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                   PATHOLOGY AND TREATMEST

                                OF


        THE  PARALYSIS  OF  MOTION.


               By J. P. Batchelder, M. p. New York.

                          /> .1   It l s»*
       We  do not consider the paralysis of which we are about
       to treat, a disease, but the symptom of one which mainly
       affects  the voluntary muscles, or the muscles of animal life.
       The noncommunication of the appropriate stimulus to these
       muscles by the mind, constitutes the  disease of which pa-
       ralysis  is the symptom.  The muscles having ceased to act,
       form the habit of inactivity; and the mind, acquiescing
       from necessity or otherwise, contracts the habit of not com-
       municating the necessary and appropriate stimulus to them
       through the  nerves;  so  that, by the conjunction of these
       causes, additional morbid conditions of a  secondary and
       somewhat chronic nature,  have been  induced,  of which
       paralysis is also in this connection a symptom.  As the re-
       moval  of these cures the patient, we shall endeavor to ascer-
       tain and settle their pathology, from which we hope to be
       able to deduce the proper method of treatment.  The per-
       formance of function induces a derivation of  blood to an
       organ,  which in a measure ceases when the  function ceases;
       and  the organ diminishes in  size as the  natural and  almost
       inevitable consequence.  This is a general law of the sys- 
o
 tem, to which the muscles of animal life, like all  other
 organs, are subject; hence they become atrophied in  pa-
 ralysisfc or when kept a considerable time at rest from  other
 causes.   Thus  deprived of  blood,  their capillary vessels
 shrink, and what  the capillaries of a part do, that will  the
 part as a whole do. The atrophied muscles become shortened,
 and refuse to be elongated except by force ; neither of which
 would have happened  but for this shrinking of the capil-
 laries.
   In two points of view then is paralysis to  be considered a
 symptom :  1—In relation to the function  of the affected
 muscles.   2—In respect to their physical  condition.   Re-
 garded in the former aspect, it is a sign that the connection
 between the mind and the  muscles is interrupted; in the
 latter, it is an indication of the change which the muscles
 themselves have undergone.  In the one case, it is a symp-
 tom of functional disease—in the other, of structural change,
 which consists of a  general contraction of the muscular ca-
 pillaries,  and atrophy  of the  parenchyma  of the  affected
 muscles.
   When a  person is stricken down by a shock of apoplexy
 or palsy, the power of the nerves to stimulate the voluntary
 muscles to action is interrupted, because certain changes in
 the  cerebral centre  do  not  then take place; or if they do,
 corresponding  changes  in that  portion of  the peripheral
 brain (of which we  shall presently speak), which is appro-
 priated to the muscles of volition, do not occur, and paralysis
 of motion ensues.*
   This state of things may continue after the primary cause
 of the paralysis has been removed or ceased to operate; but
 the  patient having been quiescent for a time, becomes ac-
 quiescent from habit, and will not make the  slightest effort
 to move his limbs—indeed, insists that he cannot do it__that
 it  is impossible.  He has, as it were, forgotten how to  pro-
 duce the antecedent cerebral  change as an act of the will;

 * By a parity of circumstances and reasoning, we would  account for the ex-
istence of paralysis of sensation. 
3
and the only way to  enable him to recover the power or
learn the art of doing it, is to cause the members to perform
the motions calculated to produce the changes in the brain.
The motions first and the  changes  in the cerebrum next, is
the order and method of nature.   By this expedient,  duly
performed  and persevered  in, he will at length be enabled
to re-enact the  cerebral change, and the movement of the
limbs will follow in  exact proportion to the  energy  with
which this change in the brain is effected. Both, for obvious
reasons,'will be feeble at first; but he must  be encouraged
and helped; when by repetition,  the efforts will  be  more
and more vigorous, and the results more  and more apparent
and satisfactory.
   In this way the functional disease is cured, and the struc-
tural affection is also finally removed by the same process.
Exercise, as we all know, causes the muscles to increase in
volume as  well as power.
   The paralytic, then, so far  as the paralysis is concerned,
is in much the same condition as the infant at birth ; and in
order to recover the use  of his limbs, must go through a
course of training somewhat  analogous to that to which he
was subjected when he first learned  their use—his muscles
must be  re-educated.  There is,  however, this  difference:
the infant  at  birth is an idiot, (so  far at least  as mind and
the performance of its functions are concerned,) while the
subject of paralysis has some intellectual capital  to begin
with; but very little after all, so far as  the  affected part is
concerned.  There is  another point of  difference  between
the child  and the paralytic, which savors strongly of con-
trast, and  is in  favor of the former, who is  imbued with an
instinctive propensity to  action—a restless  activity, which
nothing but  positive fatigue or  exhaustion can  restrain;
while in the latter, inertness and an indisposition to motion
prevails, which is at first very difficult and sometimes almost
impossible to overcome; but the muscles not having entirely
lost their contractility, begin  sooner or later to act  and pro-
duce movements of  the  limbs, analogous  to  those which 
4
occurred in infancy,  and which  now  as  then, awake the
attention of the patient, and at length re-endow his para-
lyzed limbs with some degree of voluntary motion, which,
without proper training, commonly stops vastly short of a
cure.
  In paralysis, the muscles are, as suggested, seldom wholly
destitute of contractility, but the patient has lost the will
and  the  power of making them contract.  The doctrine,
then, which forms the basis  of our theory and treatment
too,  is, that the paralytic must again learn to use h'is limbs
just  as he learned to use them in infancy; but as he cannot
begin, as did the infant,  to  move  them; and  as nature,
having once performed her task, refuses  to renew her labors,
we must, therefore, substitute our own  hands for  hers, and
move his limbs as she moved  them at first, and like her, in-
voke and direct  his attention to the motions thus effected.
We must indeed go further, and endeavor to induce  him to
co-operate with and assist us in the work.  While moving
his limbs, we should try to concentrate his attention upon
the principal muscles by which the motions we are causing
to be made are naturally executed, and urge him to make
those muscles contract.  A good way  of doing this is  to
place his hand  over the muscles in our  own limb which we
wish to have brought into play in his, and make them con-
tract with force.   This expedient may be likewise resorted
to in his own unaffected  members.
  It  is better to begin with the least complicated motions,
as simple flexion and extension of  the arm  at  the elbow,
which are  done  mainly by two muscles.   These motions
may  be performed by the well limb, and  the patient exhorted
to attend to the operations of his own  mind as well as  to
the movements of his  limb.   He may likewise be requested
to fix his attention on the affected  limb, and consider what
he did in relation to the movement of the well limb, and
what he  desires  and intends  to do, and what he must  ac-
tually do in order to make this limb imitate the movements
of the other. 
5
  In a paralysis of some duration, the muscles of the palsied
limbs are not all in the same predicament.  Some are pow-
erless ;  some are  too strongly  contracted;  others, neither
contracted nor powerless, are, nevertheless, quite  ready  to
act, not in obedience to the will, but in opposition to those
which can and  do  act somewhat  in accordance with its dic-
tates ; but all  the muscles, generally  speaking, concur  in
disregarding  the volitions of the patient.
  From  these different conditions of the muscles, the indi-
cations of cure  may be deduced  with strict logical and pa-
thological propriety.  They are :
  1.  To restore strength to the powerless muscles.
  2.  To overcome abnormal contraction in others.
  -3.  To obviate or  counteract the perverse action of such
as act irregularly.
  4.  To renovate the will, and reconnect it with the affected
muscles.
  The first three indications point directly to the 4th, which
is, in  fact, the ultimate object aimed at.

                         Treatment.

  First indication.— To  restore strength to the powerless
muscles.
  Second  indication.—To overcome the inordinate contrac-
tion in others.
  As  these indications are, to some extent, answered  by the
same  means, we propose to consider  them in connection,  so
far, at least,  as the sameness of treatment goes.
  The muscles, in paralysis of the arm from lead,  furnish a
tolerably  good  example of both these conditions.   The ex-
tensors are powerless—the flexors, over contracted.
  In  restoring  tone  to the powerless muscles, we  resort,
with great prospect  of  success, to an agent inherent in the
muscles themselves, denominated "passive contraction"  by
modern physiologists.  This power causes a muscle to con-
tract  and  shorten whenever its origin  and insertion have 
6
become approximated.  Muscles thus circumstanced, after
a wliile resist with great energy all endeavors  to  elongate
them, as every surgeon well knows who has had  much to
do with dislocations of long  standing.  In such and analo-
gous cases, each entire muscle accommodates itself  to the
altered condition which obtains between its origin and inser-
tion.  To enable paralyzed muscles to recover their power,
we avail ourselves of the knowledge  of these  results, and
cause their origin and  insertion to approach each other, and
keep them in this position for a longer  or shorter time, as
the case may be, or until the muscular fasciculi  have begun
to contract and adapt themselves to the change.   This is
effected by mechanical appliances—as  splints  of suitable
form, adapted and  applied so  as to maintain the parts in this
condition till the muscles recover their tone.   Take, for ex-
ample, the  paralyzed  hand,  before alluded  to.  A splint,
wide as the hand, should  be applied along the forearm, from
near the elbow to the ends  of  the  fingers.  To  this the
palm  should  be bound with a roller, which, while it keeps
the splint in place, does  not  in the least interfere with the
movements of the  wrist.  To the  loose end of the  splint
near the elbow a weight (a small  bag of sand will do), suffi-
ciently heavy to keep the hand and fingers fully extended in
spite of the contracted flexors, except when they (the flexors)
act in obedience to the will.   When they have  thus  acted,
the patient  should endeavor, by making the  extensors con-
tract, to bring  the  hand  back into a state of  full extension,
in which he will be assisted by the weight appended to the
upper end of the splint.  In order to give him fair play—in
other words, to enable him to get rid  of the uncalled for
action of other muscles—we  have found it expedient to let
the forearm  at the wrist rest in a sling, with the  splint
excluded.   In this  way all the principles we wish to have
invoked may be summoned to our aid.
   The contracted  muscles,  usually the  antagonists of the
powerless, must be elongated, and the limb put and  kept in
a  position which will  prevent the recurrence of their con- 
7
tracted  state.   The position  of the limb should be studied
as well  in  reference to the latter as  to the former class of
muscles—thus  accommodating the treatment alike to the
first as well as to the second indication.  The  splint, pro-
perly adapted and applied, is the best and perhaps the only
instrument required for  the  accomplishment of both these
purposes.  The hand and  fingers should be brought to the
proper degree of extension, and maintained in that state till
the over contracted muscles  have become fully elongated
and given  up  the contest, and  until the others also  have
recovered their power of contraction.   The splint should be
taken off several times a day, and  the  limb rubbed  and
moved slowly and gently in every direction for half an hour
or longer, and again put up in the apparatus.
   Whenever the limb is moved, the attention of the patient
should be directed to the movement and to the muscles also,
by which that movement is ordinarily accomplished, and his
co-operation likewise invoked and insisted on.  This point
will be more particularly adverted to when we come to con-
sider the 4th indication.
   Third indication.—To obviate  or overcome the  perverse
action of certain muscles.
   The muscles to which we  now allude, are neither power-
less nor over contracted, but act with considerable  force—
not in  obedience to  the will, but  in  opposition  to those
which act  according to its  dictates.
   The  voluntary action of one  set  of muscles, excites in-
voluntary  contraction in another, by simply  putting  these
last on the stretch.  Nature's design in this is to give firm-
ness and stability to the limbs while  at rest, and steadiness
to their movements when  in  action, without  requiring any
special heed on the part of the individual in order to secure
the intended  result.  Why,  in  health,  no inconvenience
springs from this arrangement of nature, is accounted for on
the principle thai;  then the  muscles, habitually active, and
prompted  by a  lively volition,  act with  more force than
those which are excited by the mere  stimulus of extension; 
8
but  in paralysis  the tables are turned.  The muscles are
then actuated by an  enfeebled will, and, inert from habit or
disease, scarcely simulate voluntary motion, or perform it so
inefficiently as  to be overpowered by those which are ex^-
cited by other stimuli. For example : whenever the patient
thus circumstanced tries to extend the hand and fingers, the
flexors will not only resist this effort, but actually bend both
hand and fingers; or when he attempts to flex the arm at
the elbow,  various other  motions  not  designed in the pro-
gramme, will be performed.  The  muscles, thus put on the
stretch, and acting  independently and in  full accordance
with their own  energetic propensities, overcome those which
act merely in obedience  to the enfeebled will of the para-
lytic.  Hence the necessity for resisting the  efforts of these
fro ward agents, until they submit, or  the former prevail,
which is  to be  accomplished  by such mechanical contri-
vances as are suited  to each particular case.
   Fourth indication.—To renovate the will and reconnect it
with the affected  muscles.
   "At birth, the  human infant," without volition, voluntary
power, or even mind, is " the very representative of weak-
ness and  imbecility," but  subsequently comes to be indued
with these and other intellectual  faculties.   In what way,
asks curiosity, is this effected ?  An interrogation of surpass-
ing interest, in which general science and  medical science,
in special reference  to our subject, are deeply concerned.
Therefore both prompt to an enquiry  into the manner in
which these faculties are acquired.
   In this investigation, we start with the declaration that
the faculties in  question are not original endowments by na-
ture, but attainments acquired by the  child itself through
the medium and instrumentality of the muscles,  with the
co-operation of the  nerves, which, like the muscles, never
perform their appropriate function, unless  excited  by some
agent, which is, in the case of both nerves and muscles, pri-
marily the same—the blood.
   The muscles  of animal life begin to contract in utero ; and 
9
their  contractions  are repeated  after birth with increased
force, and in a short time begin to be perceived  by the ulti-
mate  nerve fibres,  the peripheral  brain* whose  perceptions
are transmitted through the nerve cords to the central brain,
in  wdiich,  owing  to  its  immaturity, no very  appreciable
changes are  at first produced;  but  when its structure  be-
comes more mature, the transmitted influences excite changes
which produce consciousness.   Now, this  consciousness is
the  inception of mind—the  inauguration of intellect;  and
as often as the muscles contract, these changes in the central
organ—the organ of mind—are repeated, and consciousness
awakened, till the inchoate mind  is instinctively directed to
the  part  in which these  contractions occur.   And  it  is fur-
thermore conceded that the direction of the mind to a part,
causes a determination of blood to that  part, and  that  the
blood is the natural and  primary stimulus which excites the

  * The nerves, from their exit  through the apertures in the skull and spinal
column, to their termination in the ultimate fibre, are enclosed in a sheath ; but
the branches into which these fibres break up are, like the primitive fibres within
the brain and spinal marrow, destitute of neurilemma.  The perceptive faculties
of these termini are so modified by the substances with which they are in imme-
diate contact, as  to render them scarcely cognizant of changes  not peculiar to
those substances.  Hence the nerves distributed to the muscles of animal life,
take cognizance of those changes only which pertain to them and to them alone.
These naked termini constitute what we denominate the peripheral brain, which,
in every part perceives and takes cognizance of changes that occur in the imme-
diately surrounding substances.  It is highly probable that the nerves are only a
continuation of the brain or  nervous centres into all  parts of the body.   This
view of the subject seems to  be fairly and fully supported by analogy.   "The so
called nerves of pure sense—the olfactory, optic and auditory nerves—may more
properly be regarded as portions of the brain itself, than as mere  nerves, for they
possess most of the anatomical characters of nervous centres. The intra-cranial
portion of the first is as distinctly compounded of vesicular and  fibrous matter
as a convolution of the brain. In the peripheral expansion of the optic nerve,
the retina, it will be hereafter shown that the vesicular elements of a nervous
centre  are as unequivocally  present as in the olfactory bulb.   As regards the
auditory nerve, there are also some grounds for the statement that the vesicles
of gray matter are deposited at its peripheral expansion in the internal ear.1'
Todd & Bowman's Lectures, p. 205.  The nerve cords, sheathed in the neuri-
lemma, form the connecting medium between the peripheral and central brain,
through which impressions are conveyed, consciousness awakened, and the man-
dates of the will transmitted  to parts subject to its control.
                  2 
                            10

 muscles to act.   Consequently, the mind repeatedly directed
 to any one or more of them, will  cause it or them to  con-
 tract.
   This process is rendered more and more easy by repetition,
 and is finally perfected  by habit, which the child sooner or
 later acquires.   He also becomes  conscious of the fact that
 when  these  changes (which directed  the mind to certain
 muscles) took place in the brain, they were uniformly asso-
 ciated with certain movements of his limbs ; and he more-
 over finds that contraction  in  certain muscles causes this or
 that limb to move.  Consequently, when this or that motion
 is desired, he directs the mind to  this or that  muscle, and
 the  desired motion immediately ensues—why or wherefore
 he cannot tell—nor is it necessary  he should. Volition,  thus
 commenced, is soon followed by the acquisition of voluntary
 power, and this  by voluntary motion.  The exercise of this
 power and its  results become more and  more  precise and
 perfect, in the paralytic  as well as in the child, according as
 the efforts are more or less frequently and judiciously made.
  That this is the  method  to  be  pursued in educating  the
 muscles, every one, we think,  may satisfy himself, who will
 take the trouble  to notice the trials made by the child while
 learning to use  his limbs; or who will try the experiment
 of educating  his  own muscles to the performance of a series
 of motions to which they have not been accustomed.
  Having acquired the power of moving his limbs,  the
 child, although he continues to exercise it, soon forgets  the
process by which it was obtained, but nevertheless continu-
ally resorts to it  in after life, whenever any new or unprac-
ticed operation is to be performed.   To restore motion to
muscles and re-educate them, as in cases of palsy (and some
other affections we  might add), and give the will* dominion

  * "That mental state which produces or resists motion, is the will. When it
exist?, it first produces motion—change of condition (motion) in the capillaries
of the brain, at the  origin of certain  nerves,  and if persisted in, produces
change of condition (motion again) in the  peripheral extremities of  those
nerves, and the movement of the limb ensues." We cannot say to whom the 
II
 over their action, we  must, we repeat,  adopt the plan of
 first  impressing passive  motion on the limbs, and  endeavor
 to keep the  patient's attention fixed on the movements, and
 also on the muscles, by which these movements  are ordina-
 rily made, and moreover put forth his mental as well as phy-
 sical energies and efforts to make those muscles contract.

                       Of Medication.

   Electricity, galvanism and strychnine are the  principal re-
 medies which  at  the present day are most relied  on in the
 treatment of paralysis.   They have  been, it has seemed to
 us, rather empirically employed, the principles on which
 their use is based not having been very plainly declared, or
 clearly illustrated.  They should, we think, be used mainly
 for the purpose of exciting motions  in the paralyzed  limbs
 analogous to the primary movements in  early  infancy, to
 which the attention of the paralytic should be  directed, and
 of which he should avail  himself in recovering the use of
 his limbs, just as he did when he first acquired a mastery
 over them.   In accordance with these principles, electricity
 and  galvanism ought  to be  employed at  first  with  great
 caution, and in the gentlest manner possible,  the  object
 being to produce  effects very like the primitive action of
 the muscles.   Like the primitive actions, these  effects may
 be cautiously increased. The motions caused by these agents
 may be beneficial by retarding or preventing the atrophy of
 the affected  muscles.  To avoid doing irreparable mischief
 as well as to obtain all the benefit to be derived  from these
 agents, we repeat with solicitude the  injunction that their
 influence should be very slight,  scarcely perceptible at  the
 beginning, and increased as the cure  progresses.  By neg-
 lecting this  precaution,  and applying these  remedies  too
 strongly at the commencement, the excitability still remain-
 above quotation should be accredited. Our doctrine is, that the primordial
 change is in the peripheral extremities of the motal nerves, and that the mo-
tions of the limbs communicated through the nerve cords to the central brain
give rise to the changes in that organ productive of thought. 
                             12

ing in the  muscles will be  extinguished, and the hopes of
the patient blasted forever.
  One important item in the use of these agents  must  not
be  omitted, which is,  that  the patient's attention be con-
tinually invoked.  Whenever an application is about to be
made, he  should be apprised of it, and prepared for it, and
exhorted to prolong the motion excited; for the influence of
concentrated  attention, when accompanied with the  expec-
tation of  change, in modifying  organic functions, is an  im-
portant agent in effecting cures in this affection.  Therefore,
the patient should be convinced of the necessity of this, in
order to secure all the benefit which may be derived from
these remedies.
  Strychnine.—This most singular drug  causes  motions in
the paralyzed limbs, which, like  those produced  by elec-
tricity and galvanism, somewhat resemble  the  primitive
movements already alluded to, and of which we should avail
ourselves in the treatment, very much after the manner sug-
gested in relation to the last mentioned agents. The patient
ought to be  admonished to prolong  these  excited actions
wdien they come ; but they cannot be anticipated; for when
slight, they are preceded by  no premonitory  sensation ;*  but
when strong,  as  when caused  by large doses, one-third or
half a grain of the drug three  times a day, they are  always
preceded by an indescribable sensation in the muscles—as
if they were  alive—or a sort of crawling, immediately fol-
lowing which is the jerk or  spasm.  We should endeavor to

  * The premonitory symptom of tetanus is a stiffness of the thighs and legs in
the  morning on first waking, which goes off in a short time—to be returned the
next morning. During this day or the next this terrible disease declares  itself
in an unmistakable manner.  A similar rigidity of the lower extremities  is in
some instances a premonition of the more general action of the strychnine, and
admonishes the reduction of the dose, or suspension, for a while at least, of the
drug.  In all cases in which tetanus is to be apprehended, enquiries should be
made every morning by the medical attendant respecting this stiffness, as it is
not  apt to be mentioned by the patient, on account of its having soon ceased to
affect  him.  He should be purged with  calomel, and put and  kept under the
decided effect of opium.  By so doing I am well satisfied that the tetanic affec-
tion may be, sometimes at least, prevented. 
13
make the same use of these as was made of the primal mo-
tions by  the child in its early infancy.   By  omitting  to
adopt  the course suggested, less benefit will accrue to the
patient from the use of this medicine than  he would other-
wise experience.
   By way of illustration, we introduce the following case:
   J. B*** aged  26 years, returned from a sea voyage about
the  middle of March 1854, enjoying good health.   A few
weeks previous, while on the  coast of South  America,  he
experienced  a strange, indescribable sensation  in his head,
mostly about the €rown  and right side, which  could not  be
called  a pain, but seemed more like dizziness than any thing
else.   For this  an  English physician was consulted,  who
prescribed cathartic pills,  and  a blister to  the  nape of the
neck, which greatly relieved him—so much so that when  he
arrived in this  country he thought  himself well, and con-
tinued so until the middle of May, when the same disagree-
able feeling returned, and kept  getting worse, till at the end
of a week he was obliged to take his bed, seemingly more
from a sense of general weakness than from  any other cause.
In a short time  (he does  not distinctly recollect how long)
he lost the use of the right arm and leg and right  side of his
face; the symmetry of which was  disturbed by the  traction
of the features  to the opposite side.   He could masticate
tolerably well, but could not swallow without danger of suffo-
cation.   To  avoid this, he adopted the expedient of holding
the morsel in the back part of the mouth till the parts seemed
to have completed their arrangements for deglutition, before
he made the attempt—a practical hint, worthy of considera-
tion in  analogous cases.*  Other complications,  as  consti-
pation and retention ensued, and were as  usual followed  by
incontinence of urine and involuntary discharge of pus.

  * The cause of the difficulty of  swallowing was the lodgment of the matter to
be swallowed in the paralyzed side of the  fauces ; and the arrangements spoken
of in the text consisted in dislodging and  transferring it to the unaffected side.
Until this was done, the unaffected muscles, in their action to cause the morsel
to pass into the oesophagus, would only force it upon the glottis and upper part
of the larynx. 
u
       He was confined to the bed about twenty-two weeks; at
     the end of which, he was taken out of bed by two persons,
     placed upon his feet, assisted to stand and step a little, and
     soon marched several times a day into the hall.   In a month
     he was able to  move  about with a cane, and shortly  ven-
     tured into the street alone.   When I first saw him, October
     1st, 1S56, he walked as  persons in his  condition  generally
     do—swaying the body to the opposite side and Swinging the
     diseased limb round in order to bring the foot forward, while
     the arm which hung loose and useless by his side,  was moved
     much in  the same way, but could be moved somewhat in
     various directions by the muscles about the shoulder; mostly,
     however, in opposition to the will.  The same was likewise
     true in relation to the movements of the forearm.  The flexors
     of the wrist and fingers were so obstinately contracted that it
     required  much  force  to  straighten either—in fact he  was
a*   obliged to take his arm in one hand near the wrist, and hand
     in the other, and place his knee against the back of the wrist
     in order to bring the hand and fingers fairly in a line with the
     forearm, or carry them backward so as fully to elongate the
     flexors.  The thigh could be only half flexed on  the pelvis,
     but not carried backward; and the leg but slightly flexed on
     the  thigh.  He could  not indeed  lift the  afflicted foot from
     the  ground, while the body was kept in  an upright posture,
     and the thigh in a line with the body.   The mouth was still
     somewhat drawn  to the left  side. The speech,,  although
     much improved, was still faulty; but pressure with the hand
     on the right  cheek enabled him to articulate much better.
     Deglutition was not quite easy, but much less difficult than
     at first.  Blowing, smiling and laughing were mostly on  one
     side of the mouth, and whistling entirely out of the  question.
     Previous to July  1851, when  he first went to sea, he  had
     lived  very irregularly—intemperately and incontinently-
     had contracted  syphilis,  which went  through  its several
     forms—primary, secondary and tertiary;  but during his sea-
     faring life he had little to do with women.  In boyhood and
     subsequently he was much in the habit of masturbating and 
15
 has now not unfrequently nocturnal emissions.  In addition
 to  all his other difficulties, this poor fellow is apparently far
 gone in consumption.
   On the 2d day of October last he came under my care for
 the treatment of the paralysis, and visited my office nearly
 every day for two  weeks, when he was attacked with  what
 proved to be an  abscess near the anus, which confined him
 to  the house three weeks, and much of that time to the bed;
 during which I did not see him, having forgotten to take his
 address.   After the  bursting  of this abscess, which  ulti-
 mately terminated in a  complete  fistula  in ano, he resumed
 his visits, and continued to  do so  until the weather became
 so  cold as to render it imprudent for him to come out, except
 on  very pleasant days.   Consequently,  I saw him a few
 times only during the  month of December.   He seemed  to
 come with reluctance,  which, with the fact that amendment
 had  almost ceased, led me  to suspect that  the  course  of
 treatment to be pursued at home had  been neglected, which
 was the fact.
  In hemiplegia and paraplegia also, the muscles arising from
 the trunk and inserted  into the  limbs below, are those  in
 which the  recuperative process first  begins  and progresses
 most rapidly; and  those of  the inferior extremities recover
 sooner than those of  the upper.*   Hence,  these patients
 generally, perhaps  always, commence walking before  they
 have regained the power of using  the arms and hands.f  The

  * Of this seemingly unimportant fact, a very important advantage may be oc-
 casionally taken in the treatment of paraplegia, in  many cases of which we shall
 find on close examination, that the muscles  arising from the trunk and inserted
 into the limbs  below, have to  some  extent partially recovered a contractile
 power, or were not from the first wholly deprived of contractility.  This is apt
 to be the case when paraplegia occurs in infancy or childhood. In such, and we
 are  inclined to think in all cases in which this  state of the muscles obtains,
 the patient may by the help of a suitable apparatus and other appliances and
means, be made to walk with a tolerable degree of  satisfaction and usefulness.
  t Probably this is attributable to the fact that patients are  usually soon placed
upon their feet,  and compelled, as it were, to make an effort to stand and walk;
in which case the weight of the body excites the muscles belonging to and con-
nected with the inferior extremities  to early and somewhat energetic action, 
16
truthfulness of  these  statements  was very manifest in our
case.
  To direct and fix  his attention upon the muscles  to be
brought into action, and likewise upon the motions to be
impressed on the lower limb—particularly the leg, and give
definiteness and precision to these motions, he was placed in
a position facing a door-post (the  door being open), with the
body and thigh of  the affected side in close  contact with
this fixture, and held  steadily there; thus situated, he  could
not flex the leg on the  thigh, which was slowly done by
another, while the patient co-operating, endeavored to raise
the foot from the floor by bending the  knee.   In this wray
he soon acquired the  power of raising the  limb by his own
efforts, so  long as he remained in this situation ; but the mo-
ment he left the fixture, the thigh would be flexed on the
pelvis, whenever he attempted to bend the knee.   The ex-
pedient of fixing a strip of cloth to the leg of his pants low
down,  or of putting a bandage about the ankle with a loop
in the  free part, held in the well  hand, enabled him to sub-
stitute it  for that of  another; but  as  it was  desirable to
direct  and fix the  will of the  patient as much as possible
upon the muscles and  movements of the diseased limb, and
as this plan seemed to divert  his  attention therefrom, it was
relinquished, and in the course of a few weeks he acquired
such power over the former as to  raise the foot, to kick with
force, and even run.
   To enable him  to  flex  and extend the foot, was a more
difficult  task;  for the accomplishment of which,  he was
placed in a chair,  and the  foot flexed and extended at the
ankle by another, he at the same  time using his best endea-
vors to assist.  The improvement here was  in  a short time
quite apparent, but less rapid than in the motion of the leg
on the thigh.   After  a while the experiment of  standing
upright on the affected leg only was tried; and by steadying

while those of the arms and hands are allowed to remain unexcited and idle.
The early training of the upper extremities would cause them to improve, pari
passu with their congeners. 
17
himself with a hand on  the  back of a  chair, he  succeeded
tolerably well in this difficult undertaking, and was not long-
in acquiring the  power of not only sustaining  himself, but
of maintaining his  equilibrium on this  limb alone.   In the
progress of improvement  the paralytic habit of walking
almost entirely disappeared—especially if he walked slowly,
and  took short steps, as he was  instructed to  do.  To ex-
change this awkward gait for one more natural and comely,
was  mainly accomplished by  setting the lame foot flatly and
firmly on the floor or ground, and taking care  not to move
the  other until the weight of the body was transferred to
the affected limb, when the well  foot was to be raised, car-
ried  forward and planted steadfastly on the ground.   This
done, the lame limb and foot were put in requisition to push
the  body forward upon the well  member.   At first he was
obliged to take very short steps, but soon acquired the habit
and  ability to take steps about the usual length, and to walk
so well that few would  suspect  that any  thing  ailed him.
Besides, he  even became at length able to run with  conside-
rable facility and smartness.
   In disciplining the superior extremity much difficulty was
experienced, principally from three causes—the weakness
and  inefficiency  of some  muscles,  the rigidly  contracted
state of others, and the abnormal action  of a third class.
Those obstinately  contracted—mostly  flexors—were  fully
elongated by main strength, and their recontraction obviated
and  prevented by the application of splints, which not only
resisted the contraction, but kept  them  completely  elon-
gated.* These splints  were removed from time to time, and
the  limbs exercised in the manner described.  In case the
muscles thus kept on the stretch became painful, the splints
were laid aside until the muscles became easy; and as they
prevented sleep, they were allowed to remain off  during the
night, which it was thought  somewhat  impeded the  cure,

  * The contracted state of the fingers was very successfully treated by means
of the glove and pieces of whalebone, as will be hereafter described.
                3 
18
both in regard to the restoration of strength to the enfeebled
muscles, and  the counteraction of those which were unduly
contracted.  The  irregular contraction of the muscles was
likewise resisted, in some instances, by splints, and in others,
by bands so applied as to prevent abnormal action.  It was
found that when  the action of some  of these muscles had
been successfully resisted for a short  time  only, they gave
up the contest, and became submissive.
  We have stated that the muscles arising from the trunk
and inserted into the limbs, had acquired, or seemed to have
retained more mobility than others not connected with the
trunk; and in the course of treatment, these very muscles
were found to be the most mischievous and  troublesome of
all, particularly those of the upper extremity; for whenever
an attempt was made to raise the hand to the head, instead
of permitting the  biceps flexor to act with freedom in its
own appropriate way, the deltoid would assume the right of
acting, and raise the arm from the side and  move it in all
directions so  far as its own organization would allow;  and
other muscles connected with the scapula would also join in
the melee, and like the deltoid, move the limb in various
ways, but always  in opposition to the will.   This game was
effectually stopped by fastening the arm with a long ban-
dage, closely and  almost immovably to the side, and then
having the forearm moved at first  by  another, and  then by
the patient himself; in this manner the control of the will
was acquired  and established, so that the  limb would be
flexed, extended, and indeed moved in almost any direction
and to almost any extent, by his own volitions.  The  head
also was  moved to the right  and left; farther and farther
from day to day, and likewise backward and forward, until
the power of the muscles by which these movements were
effected seemed to be quite recovered.  The muscles of the
face were in  like manner exercised, by which its symmetry
was almost entirely restored.  He could laugh  and  blow
about as well as ever, and would doubtless have completely 
19
recovered had he been more favorably situated.*   As it was,
during the short  time he was under  treatment,  strictly
speaking, a few weeks  only, he became able to  pick up a
pin  on the table or  floor;  to  button  his  shirt  bosom  and
vest;  to  split kindling wood with a hatchet; and do other
small  matters of business.  When he had so far convalesced
as to assay the use of the  hatchet, he would often try eight
or ten times before he could strike a piece  of kindling wood
two inches square;  but  in less than a month  he would,
sometimes for days together, hit a piece one-fourth that size,
at almost  every attempt, and  at others only  after  several.
When he began to use  this tool he was instructed to raise it
as high as he could well  do, and then  bring  it  down  very
slowly upon a designated  part of the stick,  which he was di-
rected to mark, and fix his eye upon.   Having acquired the
control of the muscles, he was  desired to discharge the blow
at first with only a slight  degree of force,  which  was  to be
increased, according to circumstances, until he could deliver
it with tolerable accuracy as well as efficiency—so  much so
that for two or three  wreeks before he  ceased coming to my
office, he amused himself by reducing the pieces of  kindling
wood  to a more  convenient size, and was not a little proud
of his achievements in that way.  Having never  learned to

  * Owing to the pulmonary disease and  the slight  probability of recovery, the
friends  of this unfortunate young man thought it  hardly worth  while to make
further  attempts to cure the paralysis. As this appeared to be a somewhat ra-
tional conclusion, in which the patient also concurred, the treatment was discon-
tinued.  About three months ago he called on me, looking much better than
when I  last saw him.  Having so long neglected the treatment for paralysis, he
had lost much of what he had previously gained,  but was, nevertheless, much
better in this respect than when he first presented himself to me  in October
1850.  Expressing a desire to come again under treatment, the same system
was resumed.  Through the kind-heartedness of Mr. Mongomery, the benevo-
lent superintendent of the gymnasium in Crosby street,  he has been permitted
to visit, free of expense, that institution as often as  he pleases; and has done so
almost daily, and in consequence improved very rapidly—particularly in regard
to strength  and muscular development.   Mr. Mongoraery and the young gentle-
men attending at this important and well managed establishment, have taken
great interest in this case, and have never failed to  encourage the poor fellow,
and assist him in all his endeavors, by instruction and  otherwise. 
20
write, he took a few lessons with the pencil, and succeeded,
beyond expectation, in making straight marks, 0, D, &c.
  In regard to this part of the treatment—the training of
the muscles—we deem it  important, in order to gain the
confidence of  the patient  as well  as  for other reasons,  to
begin, as has been suggested, wilh the  simplest motions—as
flexion and extension of the arm for instance, and continue
their repetition, still urging him  to co-operate in each move-
ment, when he will unconsciously make the motions almost
entirely without our help, which should  be withheld by de-
grees, and as imperceptibly as possible.  When apparent  to
the assistant that this can be done without aid, or with very
little, the attention of the patient should be called to the fact;
the truth  of which may be so demonstrated as to remove all
doubts in  regard to his ability.   When this is done, the cure
may be considered as half accomplished.
   While  these trials  are being  made,  the  patient must be
continually admonished to move the limbs at first slowly,
and always with  reference to  accuracy, but regardless  of
force.  When,  for example, he  can flex  the  forearm to an
acute angle with  the arm, and  extend it to a line with it,
he may be instructed to do so  with increasing agility and
potency—the one or the other or both  augmented and regu-
lated according to circumstances.  In the re-education of all
the muscles, this plan should be pursued.
   This system  of treatment can  be carried  out to perfection
in  hospitals and  in families only in which full and proper
assistance and  suitable appliances  can be  commanded and
applied.   For  the hands  of  an assistant,  pullies, treadles,
and perhaps other mechanical  contrivances,  may be sub-
stituted, and the patient instructed to  carry on the required
motions by the efforts of his own unparalyzed limbs.  This
may be found  difficult if not impracticable at first, not  ex-
actly on account of an actual indisposition or want of desire
on the  part of the  patient, but because of the absence  of
positive will, which must be recreated and reconciled with
the muscles.   Settled in the conviction that matters cannot 
21
be helped, the paralytic  is apt to become satisfied with his
condition, and is with difficulty induced to make an effort to
change it even for the better.  This indifference must and
will, with due perseverance, be overcome ; and as soon as he
perceives any amendment, he will enter with alacrity and
zeal into the plan and practice.

  Case  it.—Thomas Kennedy, born in Ireland, twenty-six
years of  age, and a  painter by profession, was admitted to
the New York hospital Aug. 4th, 1S5G.
  Nearly a  year before admission he had been seized with
intermittent fever of a tertian type, and suffered from re-
lapses of this disease through the entire winter.
  About three weeks  before  admission, while using  white
lead, he observed the first symptoms of his present disorder;
still however  having chills occasionally, and greatly debili-
tated by the malarious disease.   His fingers became numb,
principally on the posterior side, as did also his toes, on the
upper side; and this feeling increased until he completely
lost the use of them.
  The advance of the disease  cannot be very clearly traced.
He says  that he  has never suffered from colic, nor does he
know that any of his relatives were ever afflicted  with it,
though most of them are painters.  The paralysis has gradu-
ally gained  upon him, so that he has fallen  into his present
condition, and now has the dropped wrists  characteristic of
lead poisoning.  His fingers are curved inward, so as to rest
on  the palm of the hand, and  are so entirely useless that he
is unable to feed  himself.  His toes are bent downward in
a curious manner, the end of the  toe nail resting on the
ground.  The muscles of the arms and legs are very much
atrophied, especially those of the forearm,  the ball of the
thumb, and the calf  of the leg.
  He suffers considerably from pains of a burning character
in his arms, the palms of his hands, his legs,  and the soles of
his  feet. 
22
  He can move his arms and legs, but is unable to use his
hands, or to take a single step.  The nurse feeds him, &c.
and lifts him in and out of bed.
  In this condition, so far as paralysis is concerned, he con-
tinued until the 23d of April.

  The foregoing, furnished by Dr. Anderson, the intelligent
house physician, is an extract from the hospital records.   To
this young gentleman, as well as to several other attaches in
the same capacity, I  am much indebted for their politeness
and hearty co-operation.
  The judicious treatment to which this  patient has been
subjected since his admission into the hospital, has probably
caused  the elimination of every particle of lead  from  his
system, and also removed the primary and long continued
malarious influence beneath which, for a time, it succumbed.
The case, therefore, presents principally the secondary and
ultimate consequences  of those  poisons:  From  their  con-
joined influence, certain muscles in his limbs remaining long
paralytically inactive, have not resisted the " passive  con-
traction" of others; hence the great stiffness amounting to
rigidity, with which these last are affected, and which  no-
thing but considerable extraneous force can  overcome ; while
the former, from long continued  inactivity, have contracted
the  habit of inaction.  This being the pathological condi-
tion of  parts so far as the paralysis  is  concerned, two indi-
cations  of  cure are in the main, to be pursued:
   1.  To  elongate and  keep extended those muscles which
are over-contracted.
   2.  To excite and bring under the control of the will those
muscles which were in  the first  instance paralyzed,  but are
now inactive  chiefly from habit.  The other indications, as
previously laid down in this paper, being  less called for by
the  peculiar circumstances of the  case, were  not so parti-
cularly regarded in its treatment,
   "The dropped  wrist  characteristic of lead  poisoning" ig 
23
not now as  manifest as at  first; and a change has likewise
taken place in the condition  of  the  fingers.   The second
and third phalanges are very strongly flexed by the action of
the long flexors, (profundus and sublimis)  of  the  fingers,
while the first phalanx of each finger is almost as firmly drawn
backward by the lumbricales, which being  connected with
the tendons  of the sublimis and also with  the  aponeurotic
expansion of the extensor  tendons, act as extensors of  the
fingers, when the flexor sublimis is much contracted, and  the
fingers carried back of a line  ranging with  that of  the me-
tacarpal  bones.  Neither pronators nor supinators seem to
have been much affected.
   The state of the muscles, condition of the limbs and gene-
ral appearance do not  seem to be much different from what
they were at the time of his admission. The treatment now
(April 23, 1S57) inaugurated was in accordance  with the in-
dications stated :
   1.  To overcome the resistance  of the  over contracted
muscles, which was  done  as  fast  as the painful nature of
the operation would admit, and retain by means  of the glove
and whalebone  in  the fingers, what  had been  acquired by
force; and also  by splints, &c. to the limbs.
   May 12.—These  agencies, the glove and  pieces of whale-
bone, having accomplished about all that was to be expected
from them,  were laid  aside, and gentle, passive motion  (see
Indication 2) impressed upon the limbs, was resorted to, the
patient himself being enjoined to  co-operate and of himself
to make frequent efforts to move one limb or parts of it, by
acting on it with the  other.  Besides these manipulations,
he was several times a day lifted by two persons out of his
chair, and placed on his feet.
   In this attitude (his body and inferior extremities forming
an angle of 180°) he  was  each time  held a few  moments
only on  account of the pain occasioned by it;  but the  dis-
tress  diminished with each repetition.   In a  few days, by
putting  his hand on the arms of  his chair, he raised himself 
24
 further and further from its seat, and soon succeeded in get-
 ting entirely out of it, with little or no  help;  and holding
 on by his bed, hitched himself along its  side from head to
 foot.   He  was then placed fully on his  feet, and made to
 stand  a few  moments between two persons, holding on to
 them, and held up by them to prevent falling.  In this situ-
 ation he was compelled to bear more or less weight on his
 feet, or rather on  the  toes and plantar regions next them,
 because  the  gastrocnemii  muscles, though atrophied and
 flabby to the feel  when not in action, became exceedingly
 tense when put upon the stretch; and, contracting with all
 their  force, drew  up the  heels so that in the attempt  to
 stand, the right heel could not be made  to touch the floor
 by three  inches,  and the left  by two or  two  and a half
 inches.  Thus fixed, he would sustain the  whole weight of
 his body a short time.  From  standing  he began  to step
 and  then to  walk—first assisted  by two persons, then by
 one, and  lastly, alone  by  the side of the partition wall—
 then  a step  or two by himself, relying however upon the
 guardianship  of one  or two persons to catch  him if in dan-
 ger of falling.  Crutches were tried ; but owing to the dis-
 abled state of his hands, he could make little or no use  of
 them, and they were accordingly laid aside.   He  continued
 to improve rather rapidly under this mode of discipline, and"
 soon assayed to walk alone—and now (May 2-5) walks, by
 short  distances at  a time, all about the wTard, and has had
 but one fall.  His  gait is  far from being  easy and graceful;
 but judging of the  future by the past, we are quite sure it
 will be not only improved, but quite natural.
   June 8.—He can walk half the length  of the wTard with-
 out stopping, with his body tolerably erect, and  his legs and
 arms under good command.   Indeed, he is trying "to walk
the crack," an experiment which all the  paralytics like him
have been  required  to make and  persist in, until satisfac-
torily performed.   In this he  succeeds in bringing his feet
much nearer the mark than was anticipated.  He is directed 
25
to walk slowly at each step, and place  his foot on the floor
with  as  much precision as possible, on or near the crack.
He has been several times laid up from over-doing.
   June 23.—Went twice down into the yard from his ward
in the second  story in the hospital, and up  again, without
any one to assist him either in descending or ascending the
lofty flights of stairs.  The obstinately contracted state of
his toes, as mentioned in Dr. Anderson's report, and  an in-
verted nail,* have considerably interfered with  his walking,
and impeded his progressive improvement.
   July 30.—Has continued to improve, and now walks com-
paratively well, keeping his  body almost erect, and with
much less of that waving or swagging motion which was so
very characteristic of his gait even after he became able to
walk  about the ward,  down  stairs, and  in the grounds.
About this time an erysipelatous inflammation attacked the
dorsum of his left foot, which, with the officiousness  of one
of the patients in cutting away about half the inverted* por-
tion of the nail, has prevented nearly all attempts at walk-
ing, and has put him back some six or eight  weeks.   He is
now (September 11) beginning a little to resume his walking,
which is only  occasionally attempted on account of the pain
and inconvenience  which are excited by such efforts,  and
which accompany and follow them.  These  adverse  occur-
rences have proved a matter of stern regret to the  patient
himself, and no small chagrin to his medical  attendants—
and to the writer in particular.

   Case hi.—Thomas Collins, 42 years of age,  30  years a
sailor, of good constitution, and uniformly healthy, received
a violent blow on the right side  of the head,  near the parie-
tal eminence,  which stunned  him at the time, and indeed
rendered him insensible for several hours—the next morning,
however, he found himself  quite  well, and with the  excep-

  *The inverted toe nail is being rapidly cured, by the simple method described
in the last July number of the X. Y. Journal of Medicine, p. 9.
                4 
26
tion of a wound in  the scalp, the consequence  of the blow,
and an occasional dizziness,  which  continued for 10 or 12
days, when he was attacked,  November  23,  1856, with  a
severe headache, which commenced at the point where the
blow had been inflicted, and  spread over the right side of
the head, to which  it was mostly confined.   The occasion of
this pain was accompanied with vomiting, which was almost
constant,  and very  distressing.  The night following  this
attack he  became  quite  stupid,  and in 48 hours lost his
senses—could retain nothing on his  stomach and for 8 or 10
days after, although it was tolerably quiet, could take very
little food.  One morning, on  attempting to get  out of his
berth (for he was on shipboard) he found  himself unable to
move the limbs on the right side, with no feeling in the right
arm, as high up as the shoulder.  The right lower extremity,
though  motionless   and powerless,  retained its sensibility.
The muscles of the trunk were, as is usual in cases of hemi-
plegia, not affected.*  In about six weeks  the feeling in the
arm and  hand began to return, and somewhat earlier he had
so far recovered the use of his leg as to be  able to bear some
weight on it;  and soon to walk a little by holding on by the
rails, but could not move his hand at all.

   The following extract from  the hospital record, made at
the time of his admission (February 2S, 1857) into that in-
stitution,  is corroborative of the foregoing statement made
by himself.
   " On  admission,  his  right arm was  found to be almost
completely paralysed with respect to motion—sensation was
slightly impaired.   It  was disposed to  be colder  than the
other, and very much smaller.  He can walk without much
trouble;  but on his doing so,  there is a perceptible  drag of

  * It is important to take this fact into the account when making up a differen-
tial diagnosis in relation to the degree of actually existing paralysis, because the
patient, in his attempt to move his limbs, often exerts the muscles of the trunk
in a manner which apparently gives the members range of movement that does
not properly belong to them, and which they are utterly unable to accomplish by
their own muscles. 
27
the right foot—such as is usually seen inhemiplegic subjects.
Two months previously he had received a blow on the right
side of the head."
   His present condition (April 23, 1857) is as  follows: He
can  raise  the  elbow to  within 6 or 8 inches of  a level with
the shoulder, and flex the  forearm to a right angle, or per-
haps a little more with  the arm, and slightly move the hand
and  fingers.  The latter were much flexed, and rigidly main-
tained that condition.   He can elevate the thigh to an angle
of 180° with  the trunk, but can hold the limb  in that posi-
tion only a minute  or two.  When he  attempts to bend the
leg on the thigh, he can scarcely raise the foot so as to sepa-
rate the toes from the floor, without flexing the  thigh on the
pelvis.  Speech, deglutition and the muscles of the face are
not now,  nor  have  they been  at all affected from  the  first.
   Much the same course was  pursued  in this as in the pre-
ceding case;  and being a stout, healthy man,  with a good
constitution, hardened by his  mode of  living, not at  all en-
feebled by any of its indiscretions, he  soon  began to mend.
In a week he could raise the arm and place  the hand on the
top and back of  his head, and perform various other motions,
which, wThen the treatment began, he  could neither do, nor
even be  persuaded to attempt.  0,n this account the limbs
were at first moved by others, he being urged at the time to
assist in the performance.  His efforts  in this respect were
not  much interfered with, nor resisted by  the involuntary
action of  other muscles, awakened by such  exertions—a
contingency  already noticed in the case of Batty.  In  a
short time he found that  he  had a will of his own, and
could  impress its  influence upon his  limbs.   When fully
convinced of this, he entered with spirit into the plan; but
with all  his efforts  he could not at first raise a four pound
dumb bell from the bed, but at subsequent trials would take
it  up, and wield it in  all directions  with  much apparent
ease.   In  ten or  twelve  days he was desired to  raise a small
stool from one of the beds in the ward, but after making
several trials, gave it up as impracticable. He was however 
28
instructed to make frequently repeated attempts during the
remainder of that and the succeeding day.   The  next day
the experiment was repeated with but little  success,  until
he was encouraged to make another effort, with  the  assu-
rance that he would  be helped.  The  attempt was made,
"with my finger under the seat of the  stool for the purpose
of assisting, when with very little  help from  me  the  stool
was raised about an inch from the bed.
  Another effort was made under similar circumstances, and
although no assistance whatever was rendered, the stool rose
to the  height of six  or eight inches, and in a few days it
wTas taken by the  leg or round  and  wielded  with conside-
rable facility and energy.  A large, heavy arm chair, which
weighed three or four times as much as the stool, was now
substituted, but could not be raised  from the floor at all.
The attempt was repeated with an assurance of help  as in
the former  instance, but with  no better  success.   He was
directed to repeat  the effort as often as  he could, without
producing any special inconvenience.  The next day it was
again  repeated, with  the same  proffered assistance, and the
chair  was moved,  but  not raised  from the  floor.  During
each succeeding  attempt the amount  of help was  gradually
lessened,  yet the chair continued to  be moved with about
the same degree of success, when at length it rose about an
inch from the floor.  These expei'iaients were repeated from
time to time until it was raised some six or eight inches, and
 held  so elevated for  a few seconds.  He was now informed
that the  help was only in appearance, and that his late ex-
 ploits were entirely  the result  of his own  efforts.  This
 greatly encouraged him, and  after this discovery he  expe-
 rienced no difficulty in taking up the chair and carrying it
 half across the ward.   The dumb bells were aerain brought
 into play—racing, jumping, pulling the rope with  his fellow
 paralytics, assisting the nurse, &c. &c. were  resorted to for
 exercise,  and to give strength to the muscles.
   In  this as  in  most cases of the kind,  the  flexor muscles
 being naturally the strongest, acquired and maintained an 
29
ascendancy, but  they were  elongated  by force, and  their
recontraction  prevented  by mechanical  appliances.  The
long splint with the weight was omitted, on account of a
suspicion of some disease in the wrist joint, which was not
only very stiff, but painful.  Pressing the articulating sur-
faces one  against  the other considerably aggravated the
pain, which did  not  immediately cease on the removal of
the  pressure.   The muscles of the paralyzed limbs  were
flaccid, flabby and  atrophied, yet when an extending  force
was applied to the limb, they would become quite tense,
and resist  with a power which seamed incompatible  with
their apparently  relaxed condition.

   As a post-mortem in this case is  not to be expected, we
may be allowed  to speculate a  little on  the circumstances
which seem to characterize  its  pathology.  We infer that
the lesion of the brain caused by the blow was superficial,
and primarily involved the pia mater and  cortical substance
of the  organ.  1.  By irritation and inflammation.  2. By
effusion and consequent  compression.  The vomiting  indi-
cated the first, and loss of consciousness and sensation, the
second; and the  subsequent loss of motion evinced that the
compression which  resulted from the effusion affected deeper
seated parts, as the medullary substance  or motory tracts;
but to no very considerable depth or degree.   Thus far the
paralysis is to be considered not the disease itself, but merely
a symptom, the final cause or design of which, as a symp-
tom, is identical with  that  of  vomiting; both  acting  as
depletents, were  the  medicaments of nature :  The former
prevented the reception of nutritive matter into the system;
and  the other, by keeping the patient  still, prevented the
evils which would  have resulted from exertion.   Every ex-
perienced physician knows full we'll  that nausea and vomit-
ing, taken in connection with other symptoms, are indicative
of irritation and  inflammation of the pia mater,  through
which the brain receives the blood, by which it is nourished,
and its functions sustained.   The return  of consciousness 
30
and sensation, and also the power of motion, though in part
only, showed conclusively that the disease which had occa-
sioned  their loss, had ceased ; notwithstanding the patient
did not move his limbs.  Why?   He ate, drank and slept
well—had  little or no pain, and was,  to all appearance,
quite well.   Why then,  we  repeat, did he  not move his
limbs ?  Having abstained for so long a time from the exer-
cise of his will, and the muscles, from contracting the habit
of inactivity, had acquired an ascendancy more or less com-
plete over his mind and physical  organization.  This being
the case, all  that was  necessary in order  to  effect a cure,
was to break up this habit of inaction, which was accom-
plished in the manner described.  The will was revived by
putting the limbs in motion, and directing his attention to
their movements,  and reconnected  with  the muscles, by
urging and indeed insisting  upon his  co-operation.   Very
soon he began to give his assistance.
   One  word  more.  The direction of the mind to the mus-
cles caused a determination  of blood to them; and motion,
whether  voluntary or  impressed  by the hand of  another,
produced the same result—verifying in some degree the ex-
periment of Von Humboldt, who states  that  " bending  the
thigh of an animal upon  its sciatic  nerve induced the mus-
cles to contract."
   It seems to follow as a corollary, that the more frequently
muscles contract,  and  the oftener the mind  is directed to
them, the more blood will be derived to them, and as a con-
sequence, their nutrition be increased—also their  size  and
power  augmented. In this  case, the seat of  injury  and
central lesion were on the  right side of  the head, and  con-
trary to the  usual  course,  the palsy was  likewise on  the
same side.

   Case iv.—Joseph Kanski,  a Pole, and gardener by occu-
pation, aged 4-5 years, was admitted into the New York hos-
pital April  29, with paralysis of the right leg.  Five months
ago a heavy piece of  iron fell upon the  top of his head, 
31
 which rendered him senseless for a short time.  The acci-
 dent was followed by pain of a throbbing character,  which
 has troubled him ever since.   Two months since he experi-
 enced a sense of numbness in his right foot and leg,  which
 gradually extended up to the  arm of the same side—also
 that of  insects  crawling  over  the  leg,  with  spasmodic
 twitchings of the muscles.   The temperature  of  the limb
 was natural.*   Now, on his  attempting to  walk, dragging
 the foot is very observable, though  he moves about without
 much trouble.  He moves his arm freely in every  direction.
 Sensation in the  leg is somewhat blunted—in  the arm, not
 at all.   Reflex action is very marked in the leg, the slightest
 pinch causing it  to  twitch violently.   His  bowels are in-
 clined to  be constipated, and he has some difficulty  in re-
 taining his urine.

   The above is the hospital record of this man's case, which,
 owing to the state of his  mind at  the time of  admission, was
 all that could then be gathered.  His mental faculties having
 since improved, he now  (May 13) gives the following addi-
 tional particulars : That  at the time of the accident he had
 on his  head a thick cap—notwithstanding considerable tu-
 mefaction at the  place of injury  immediately ensued; that
 he resumed his labors in  the garden in the course of two or
 three hours, and continued from day to day to  work as usual;
 that his  sleep was very much  broken, and his  rest much dis-
 turbed ;  that he felt tired and bad every morning  on  rising
 from bed.  He says that  matters  went on much in this way
 for three or four weeks, except that he seemed to be gradu-
 ally getting worse, when  he began  to experience a sense of
 coldness (usually we  believe the earliest premonitory symp-
 tom of approaching palsy) and  numbness in  the right foot,
 which gradually extended up to the arm and right side of
 the face.   Sometimes he would feel as if all this side of his

  * Had this patient put his limb in motion  when he experienced these symp-
toms, and continued to do so, as he did subsequently, we can  scarcely allow our-
selves to doubt that the attack which followed would have been prevented. 
32
body was dead.  When this sensation, which usually lasted
about ten minutes, wTent off*, he would walk round and round
in a circle for a few minutes, and then fall, or be thrown to
the ground, where he would lie four or five minutes, and
then get up and go to work.  These turns came  on irregu-
larly—sometimes twice a week, and sometimes oftener.  He
has had none of them or any thing of the kind the last two
or three months.  Previous to entering the  hospital, on at-
tempting to move about from place to  place, he was  often
obliged to run to prevent falling.  He  has had no difficulty
in swallowing, but much  in articulating, which is not  even
now wholly overcome.  He urinates ten  or twelve times in
the 24 hours, and discharges a larger quantity of water than
before the accident.  He has had all along and has now con-
siderable trouble in his head, as pain and dizziness, with but
little exact control over his right leg—indeed both legs ap-
pear to be somewhat affected.  His gait  is very unsteady—
so much so, that one of the patients in the ward  said, " he
walks like a drunken man."
   Treatment.—He was managed much in the  usual way, by
being placed sometimes with his back and  sometimes  his
face against the side of  the  room, or in one position or
another, had his limbs, particularly those of  the  right  side,
moved in  various directions,  he being exhorted  to co-ope-
rate, &c. &c.  He was then set to  walking—very slowly,
but with  all  the  exactness and precision  in his  power;
Having practiced in this way until  he  could use his  legs
with more certainty, he was required " to walk the crack,"
which was at first done awkwardly enough, but encouraged
to persevere, and  assisted by  his companions, who had a
better use of their legs, he soon began to improve, and con-
tinued to do so very rapidly, and in a few days performed in
a manner  very much to his own satisfaction.  He can also
stand a minute or two, with considerable steadiness on the
afflicted foot,  while  the  other is raised  from the floor—a
very difficult task for these patients to accomplish.
   May 18.—This man, although he has improved  very much 
33
so far as the paralysis is concerned, has a good  deal of trou-
ble in his head, for which a blister to the  nape of the neck
was prescribed  by Dr.  Griscom.
   May 21.—Head considerably  relieved.   He  now  walks
tolerably well, but is  evidently  quite  weak.  Suspicion  of
some indefinable trouble in the brain—ramollisment  per-
haps—has  been entertained, and it  was therefore deemed
not prudent or  expedient to push the treatment but  mode-
rately, lest  his nervous energies should be over-taxed and
exhausted.
   May 2-3.—He is  about the same  as on the 18th.   The
nurse was  directed to  make arrangements for  ascertaining
the exact quantity of  urine discharged, and the intelligent
young gentlemen in attendance,  to have it examined chemi-
cally and microscopically.   I am not aware that this  was
ever effectually done.
   This man continued to  improve,  so far as  the paralysis
was concerned, but  slowly it is  true, for the reason above
assigned.  During his  convalescence he had frequent slight
attacks of threatened paralysis, almost losing the use of his
right arm or leg.  Both wTere never affected  at the  same
time.  He was instructed to put the  limb, whichever it was
that was assailed, in motion, and keep it moving wmenever
he perceived the sense of  numbness, &c. affecting it in the
slightest degree, as the surest method of preventing a recur-
rence of the affection ;  and this he found invariably success-
ful.  For the difficulty in the head the medical  gentlemen,
Drs. Griscom  and Smith,  prescribed various remedies, by
which  he was  somewhat relieved.   Dr. Bulkley, when he
came into service, put  him  upon  a course of  mercury, which
lightly salivated and perfectly relieved him of  the cerebral
affection.  He remained in the  hospital up to the 21st of
July, when  he was discharged " cured."   Notwithstanding,
it was a matter of regret both to Dr. Bulkley and myself,
that he was  not retained in the  house a few weeks longer,
lest a relapse should  occur.
               5 
                           34


            Hospital Record of Robinson's  Case.

   Case v.—"James Robinson, aged 25, Vt. seaman, admitted
May 28th.   One year ago, while standing at the helm, he
suddenly felt a sensation in his right foot, as if it were asleep,
which soon  extended to the arm, and in  about  fifteen mi-
nutes he found that he had lost all power over the limbs of
that side.
   He says the sun was very hot at the time, and shone di-
rectly upon that side of his body.  He had no pain nor blind-
ness then nor afterwards, nor was his power  of speech af-
fected.  His general health was good.
   For a week after the attack he  was able to move about
but little;  after that time  he began to improve.
   At present he is able to walk tolerably well, but his con-
trol over the right leg is impaired.  He moves his arm with-
out difficulty, but complains of its  weakness.  It is tremu-
lous when he extends it.
   Bowels regular;  appetite good; skin  natural;  renal se-
cretion abundant."

       Additional Particulars concerning  the  Attach.

   In a week after the attack he was  able, as  stated in the
hospital record, to get out of his cot  and walk about, and
near the same time  the feeling in his leg returned; and on
the 15th of June feeling came into  his hand and arm.   In a
month or  two—he does not exactly  recollect the precise
time—he began to have  the power of motion, which com-
menced in his right thumb ; and in  two or three weeks after,
he could move the arm, first in the shoulder, and in a week or
two after this could flex the forearm at the  elbow, but could
not extend  it.  In  three  weeks more he could move the
fingers.
  It is true  that he now (June 1) walks  tolerably well, and
moves his right arm without much  apparent  difficulty ; yet 
35
it is obvious that these movements depend considerably on
the motions of the body, particularly at their commencement;
and they are likewise much influenced in their progress by
the same agency, for when the trunk is confined, the motion
of the limbs is constrained and restricted in no small degree.
The right side of his face was and is now somewhat affected—
also the right eye—so much so that he  cannot read with it.
The pupil is contracted and  scarcely movable, and through
it a slight  haziness is perceptible.  Motes  are all the while
present,  and a spectrum resembling a half  moon,  constantly
occupies a part of its field of vision on the sight.  The tongue
when protruded, inclines  slightly to. the affected side.  The
attack was at noonday, in a tropical climate (the  Gulf of
Mexico), under  a hot sun, whose fierce rays fell, as  stated
above, with unbroken violence upon the affected side, which,
from his position at the tiller, was most  exposed.
  Want of precision and  powTer of  motion constitute the
principal characteristics of this case.
  This man had previously been affected with syphilis, but
at this time seems to be free  from its contamination.  Was
this exposure to the intense heat and light  of a burning tro-
pical sun the exciting  cause of the paralysis—particularly
of the affection  of the eye ?  The central brain proper does
not appear to have been  affected.  Was it then the peri-
pheral brain only ?
  Owing to the fact that, during the whole or most of his
indisposition, he had been able to move his limbs ; there was
less muscular atrophy and rigidity  than  there would  other-
wise have been if motion had been suspended or much im-
paired.   From all the circumstances of this case we inferred
that the principal difficulty  was located in the  peripheral
brain, to which  allusion has been repeatedly made.
  Treatment.—The usual course of  training, as described in
the other cases,  was adopted  and pursued; under which he
improved for a time in a very satisfactory manner; but hav-
ing reached a certain point he became quite indifferent about 
36
 making further effort  or  progress,* and was, at his own re-
 quest, discharged on the  29th of August, considerably im-
 proved.

   Case vi.—David Lynch,  Irishman, aged 25  years, occu-
 pation  that of a farmer, experienced, in October  1856 a sense
 of weakness in the toes, more particularly the  great  toe of
 the left foot, which extended  up the leg, and by the 1st of
 January following, affected the whole limb.  In the course
 of this and the succeeding month, his legs—indeed all his
 limbs, arms as well as  legs—became affected in much  the
 same way.   The sense  of weakness in the upper extremities
 was first felt at the inner side of each forearm just  above
 the  wrist, from which  it  extended upwards,  and occupied
 the whole of both limbs, although for a while it seemed to
 take  possession of the biceps flexor muscle  in each arm,
 where  it paused and  remained  stationary for a short time,
 but soon began to  spread  in all directions over both arms.
 Of the two., the  right  was most  affected.   From the first,
 and through the whole  progress of the complaint, there has
 been no diminution of feeling.  All the functions of  organic
 life have been normally performed, and he  has  been in per-
 fect health, with  the exception of a sense of general weak-
 ness,  and an inability to move  his limbs voluntarily.

   The foregoing is the account of the case, as gathered from
 the patient himself, and his general appearance certainly con-
 firms the latter part of  the statement.  His hands and wrists
 are large, not swollen, and  appear as if they constituted parts
 of a powerful frame.   His face is  round, plump and ruddy.
 The muscles of expression,  deglutition, articulation, respi-
 ration, and of the tongue, are all  intact.  The  functions of

  * This trait exhibited by Eobinson is  not uncommon with paralytics. Satis-
fied with having recovered to a certain extent, they are apt to  decline further
effort.  They are well enough to carry on their business or enjoy life, and per-
haps too lazy to endeavor to attain more ability. Why, then, they reason, should
they give themselves any further trouble ? 
37
 the rectum  and bladder are undisturbed.  The movements
 of the head are in all directions perfect, and  entirely under
 the control of the will.  He can elevate or shrus; the shoul-
 ders with unabated force.   The intellectual faculties are un-
 affected.
    The voluntary muscles  seem to  be the only organs out of
 order ;  and they  from derangement or mere weakness  of
 function.   To the eye of  the ordinary observer he appears,
 while at rest, in good health, but when in motion the feeble-
 ness  of which he complains is manifest.  When  stripped
 the  muscular atrophy  which prevails,  particularly in the
 limbs, is quite obvious.  In the trunk  it  is  less apparent.
 The muscles about the scapuhe and along the arm, even be-
 low the elbow, are much emaciated, while the hands, wrists
 and forearms,  for two-thirds their  length,  are less  affected.
 The  muscles  of  the lower extremities are  not as much
 atrophied as those of the upper, which is  imputed to the
 fact that they had been more exercised by walking about,
 which, as he would do  nothing else, he did as much as he
 was able.  The  muscles of the trunk, which  he avers have
 fallen away, have to appearance held their own better than
 those  of the extremities;  and those which arise from the
 trunk and extend to the limbs, have suffered more than those
 which pertain exclusively to the body.
   When  he  entered  the hospital, he says  he was so weak
 that he  could  scarcely get up into the ward  without help,
 and only by pulling himself up by the balusters.  Although
 he can walk about and move his arms, yet every motion is
 performed in an awkward manner.   His  limbs, particularly
 the arms, are moved  mainly by impulses communicated to
 them by the trunk, and not  by their own  muscles—conse-
 quently very little  in accordance wTith the will—but seem-
 ingly as they listed.  When desired to bend the arms at the
 elbows, he declared, most pertinaciously, that he could not—
that it was impossible;  and wdien  it was insisted that he
should make the effort to do so, almost  every muscle  con-
nected with the trunk and arms was brought into irregular 
38
action, as were those also which belonged exclusively to the
body; for he tried with his might, but the forearm and hand
would not come up.  If moved at all,  they would be moved
in almost any other direction than the  one intended.
   The  case was certainly anomalous.   It  would hardly be
considered as one of pure paralysis, according to the strictly
scientific  meaning  of  the  term.  Is it  an  affliction  of the
brain ?   There is no dizziness—no vertigo—while the senses
of  sight,  hearing and   smell are  intact.   The  inference  is
certainly against it.  Is it a disease of the spinal marrow-—
softening  or  fatty  degeneration  of it,  or  of  the  muscles
themselves ?   Was  there a  wasting of the anterior roots of
the spinal  nerves ?   Or was that  portion of the peripheral
brain located in the voluntary muscles mainly affected?    To
this  opinion,  the  writer,  considering the  case  somewhat
analogous to that of the widow reported  by Dr. Klaatsch,*
is rather inclined.   In  her  case the peripheral brain, in its
sentient  parts,  was the seat of the  affection.   In  this of

  *"Dr. Klaatsch relates the case of a widow, aged 58, who applied to him, on
account of severe  pains in the extremities, and a powerless state of the upper
ones, which prevented her from  grasping any object firmly.  She also  com-
plained of an irrelievable sense of hunger.  In other respects, with the excep-
tion of occasional  headaches, she  was quite well; had had nine children, still
menstruated moderately, and  exhibited no symptoms of hysteria.  An examina-
tion exhibited no appearance  of paralysis, but the  sense of feeling was lost over
the entire skin and orifices of the mucous membranes, and could not he excited
by pricking with needles.  No unpleasant feeling  was excited by irritating the
nares. the conjunctivae, or the mucous membrane  of the mouth, and the  fumes
of ammonia produced no.effect upon the respiratory organs.  Boiling water and
a prolonged application of the electrical pencil alone  induced some feeling on
the surface.  The sense of contact was retained, and she was enabled to exactly
indicate the spots at which she had been pricked.  The power of distinguishing
between differences of temperature was abolished, but the muscular sense re-
mained, as she was conscious  of the position of her limbs, and could determine
the weight and size of a body, by grasping it. The senses of smell and taste
were lost, and both hearing and vision were somewhat defective, although she
had not before observed diminution in their power. The reflex excitability was
very slight, the rapid application of hot sponges exciting but slight movements.
Tickling of the fauces did not induce any disposition  to vomit. This patient
was restored by electricity.  There were  no symptoms of hysteria."—Medical
Times and Gazette, June 30,1357, from Deutsche  Klinick, No. 45.  Republished
in the Med. News, August 1S57. 
39
 Lynch, it is the peripheral brain pertaining to the muscles of
 animal life.   No definite opinions were, we  believe, formed
 by the medical faculty attached to the  institution at the
 time of his admission—at least we heard none expressed.

                      Peripheral  Brain.

    The neurilemma is the fibrous sheath  which  invests the
 nerve  cords from their  exit  or passage  through the bony
 casement which includes the  cerebro-spinal  axis—the cen-,
 tral brain, to their termination in the ultimate fibres.  The
 design and use of this investing membrane is to secure thej
 nerve  cord from being acted on by the parts  through which I
 it  passes, and to prevent them from being acted  on by it in
 its  transit.   The nerve  fibres, at their origin in the brain
 and spinal  marrow, and also  at their distal termination, are \
 uninvested.*  At this extremity the ultimate fibres and the
 branches  or primitive fibres into which they  break up, min- l
 gle with  the substances by which they are surrounded,  and J
 with which they are in immediate contact.  These unneuri- ]
 lemmated termini, remific or motific, according to the nerves j
 of which  they form a part, constitute what we mean by the l
 peripheral brain, which in many instances manifests itself j
 quite independently of its congener, the central brain.  For '
 example :  The heart of a frog, some minutes  after exsection, i
 is  made to palpitate,  by pricking it  with a needle—thus
 furnishing undeniable  proof that  the  portion of  nerves, in- !
 termingled with its fibres, possesses the power of feeling and *'
  * Every nerve fibre, in its course, proceeds uninterruptedly from its origin at
 a nervous centre to its destination, whether this be at the periphery of the body,
 in a nervous centre, or in the same centre whence it issued.  In the whole of its
 course, also, however long, there is no branching, or-anastomosis or union with
 the substance of any other fibres."       *       *       *       *
  " Hence the central  extremity of each fibre is connected  with the peripheral
 extremity of  a  single nervous fibre only; and this peripheral extremity is in
 direct relation with only one point of the brain, spinal cord,  or nervous centre ;
 so that, corresponding  to the amany millions of primitive fibres which are dis-
 tributed to peripheral parts of the body,  there are the same number of periphe-
 ral parts  of the body represented in the nervous centres."—Paget's Manual of
Physiology, p. 27!), 280. 
40
 also of motion.   Perception is  the  function  performed at
 the  extremity of the nerve, by  the peripheral brain.  The
 change there produced is communicated, telegraphically if
 you please, to the central brain, by which a change is there
 effected, that is  productive of thought.   The first change is
 modified by the physical or other properties peculiar to the
 cause;  which modification is likewise communicated to the
 brain  proper, in which  a  correspondent modification  of
 change is produced ; in consequence of which, an idea of
 the  character and  nature of the cause  is induced.  When
 these operations have been performed  a number of times,
 the  individual acquires the  power of reproducing, by a vo-
 luntary effort, the identical change  in the cerebrum, which
 is followed by the same change as formerly in the peripheral
 brain; and thus, by an effort  of the will, he  can  re-excite
 the idea of the agent which originally caused  the  aforesaid
 operations, &c. whether they be sensitive or motive.
   The prevailing sentiment was in favor of  the course of
 treatment which had been so successful in the' other cases,
 and the following process was adopted.   He was placed with
 his back against the wall, and held steadily  there.  Each
 hand was taken  in one of mine, and he admonished to stand
 in the most careless  manner, and make no effort of his own—
 none at all—but leave the matter entirely to my manage-
 ment:  He was  only  to observe  attentively  the procedure.
 His hands were now brought a little forward by flexing the
 elbows ; but even this per se was found to be impracticable,
 because almost every muscle would as before mentioned, be
 called into action.   To prevent this, the  arms were confined
 at the elbows and  the shoulders, and  upper part of the
 trunk,  by assistants.   Under these restraints the elbows were
 flexed—a very little only, while he was assured, in the most
 careless manner  possible, that a slight  degree of motion
 only was all that was wanted, and that we did not care about
his rendering any assistance whatever—that all  we desired of
him was merely to permit the movements to be made.   The
 object  of this was to  have his attention, inadvertently as it 
41
 were,  directed to  these motions, which were  being thus
 effected, without exciting  others which were undesired to
 accomplish certain co-ordinate actions without  calling into
 play certain others, which were any thing but  co-ordinate.
 In the course of half an hour thus spent, this point was in
 a measure gained, when it was remarked, in the same care-
 less manner, that he might assist a very little if he pleased,
 and his attention was by the application of his hand, directed
 to the movements of the  biceps flexor muscle  in my arm,
 which  took place when my hand was being raised—from
 mine to this part in his own arm his  hand was  transferred,
 and he wras desired to note whether he could perceive any
 movement there when his hand was raised, and he was not
 long in discovering the fact that motion was likewise  there.
 This was probably the first time in his life that he had been
 fully conscious that here was lodged the agent by which the
 hands  were raised.   After  this discovery he wTas desired to
 make that action a  little more effectual, and  soon found that
 by fixing his mind on  that part, and  willing to have  the
 hand ascend, it would  rise  a little  distance only, to be sure.
 He was now desired to think the matter over, and occasion-
 ally endeavor to  make this single muscle contract without
 calling any others into action, and he was not long in acquir-
 ing some  influence over it  and nearly all the muscles of his
 limbs.   Th-is influence was very feeble, and at times seemed
 to be  almost entirely dependent on  the movements of the
 trunk.   Walking very slowly and carefully  was enjoined.
 He was desired every time he put his foot down to mark the
 spot where the tread was to fall, and soon was called on " to
 walk the crack," which was at first  done very awkwardly,
 but  in  a short time  his improvement was quite evident.
 From  walking—running, jumping, hopping, balancing the
 broom, brush end up,  &c. &c. were assayed, but rather in-
 differently performed.  To  these the india rubber foot, and
 small hand ball were added; also, the rubber  parlor ball
 suspended at different  heights by a cord, was displayed, at
which  he  was to strike with the open hands as often as it
               6 
42
swung near him.  When fatigued, these exercises or amuse-
ments in which  the  other paralytics and  inmates of the
ward joined, were  to be suspended.   Being  an Irishman,
he took  much  pleasure in fisticuffing  a pillow  which was
from time  to time held up for the purpose.  His improve-
ment was very slow, and at times, especially if he over-acted,
was suspended or entirely interrupted for two or three weeks
at a  time.  He was  particularly delighted  writh the exercise
of striking  the  suspended parlor ball,  and  over-did  the
matter, and has not only not advanced, but has actually re-
trograded so far as power is concerned;  but he has now,
September 9, more  definite control over  his forearms and
hands than I have before witnessed.   He  indeed raised the
hands nearly to a  level, and almost  in  contact with his
shoulders with but very little (almost  none) of  the accom-
panying  action of other  muscles, which had hitherto been
so officious.

      Hospital Record  of the Case  of Andrew Lottimer.

   Case vii.—Andrew Lottimer, admitted  May 20.   While
lying in  bed on Sunday morning playing with his children,
he suddenly became insensible.  After he came  to himself,
his wife told him that he had been insensible for two hours—
that  he had foamed  at  the mouth.  When  he recovered his
senses, his left hand felt larger than natural, and gave him
the impression that it was another person's hand.  On at-
tempting to move it, he found it paralyzed.   His tongue pro-
trudes to the left, and is slightly coated.   The left  hand is
completely paralyzed,  but sensation is restored.  He is able
to move  the leg of that  side, but says that it  gives  way
when he  attempts to walk. His pupils are unaffected;  skin
natural;  pulse 54;  bowels constipated;  person corpulent.
He is in  the habit of  using spirituous  liquors.   Had drunk
some on Saturday.   Ordered cathartic treatment.
  July 29.—Is able to walk, but halts considerably.   Can
balance himself for  a  moment on  the  paralyzed leg.  His 
43
left shoulder hangs lower than  the other.   He can nearly
close the hand and raise the arm to a level with the shoulder.
Extends the hand and fingers with some difficulty, but says
he can use it much better in the morning  than  at night.
Tongue protruded to the affected  side.  Speech somewhat
thick.  Put under Dr. Batchelder's care for gymnastic ex-
ercise.
  August 29.—Has sufficient use of his hand to go to work,
though it  is not as strong as the otheV.  The shoulder still
drops some.  Halts some on the left leg.  Cured."
  We have gleaned the following additional particulars from
the patient himself.  For six months previous to the attack,
his left leg had  been somewhat  affected with cramps when
in bed, which went off almost immediately  -on getting up
and walking  about.  A while after the attack he  began to
experience a sensation  of increased warmth, (the earliest
sign of improvement, according to our observation and ex-
perience), in  the affected foot, but no change of feeling was
perceived in the hand or arm.  Not long after this, he  com-
menced trying to move the toes, and then the foot, and soon suc-
ceeded in both attempts, but in a moderate degree.   He was
taken out of  bed, and placed  in a chair by others, in which
he remained  until  the bed was made, and  then replaced in
it in  the  same manner.   Subsequently, when taken out of
bed, he was raised and  placed on his feet, on which he was
allowed to bear some weight, when  the nurse said to him
one  day, that " he must try to wTalk,  by taking hold of
things," Sff.  To this he replied,  " that he was going to
walk on the  4th of July, which was only two or three days
ahead."   Although  nobody believed  him,  his  own  mind
during the interim was very much occupied and exercised
with the idea of doing what he had announced that he would
do on that day, and he was as good as his word.  He got up,
or rather was gotten up, placed on his feet,  and walked the
whole length of the ward without help, and continued to
walk about more or less every day, and to improve slightly
in this mode of exercise.  Up to  this time (July 29) the im-
provement in the upper extremity had been much slower. 
                          41

  The course of treatment was much the same  as in the
other cases, which have  been given  in  detail.   He  was
placed against the wall—sometimes with the face and some-
times the back in contact with it, and  his limbs moved, &c.
The long splint and weight were applied to the arm, and re-
moved several  times in the day—with other and  various
kinds of exercise, appliances  and devices  for bringing the
muscles into various and gentle modes of action.   Although
he could  walk,  to startl and maintain a standing on the af-
fected  limb  alone,  was a  very difficult attainment, and at
first impossible, but was ere long accomplished.  After con-
siderable  training,  by short  steps, long steps,  pacing the
ward in its  length, but very  slowly, the india rubber  foot
ball was introduced, and the patient directed to kick it with
either foot wherever he could find it.   In this exercise other
inmates of the ward besides the paralytics joined with great
gusto, and it was not long in  coming to be a favorite exer-
cise with all who  could join in the sport, and a  matter of
infinite amusement to those who  from infirmity could not
take a part.   The paralytic patients were, however, directed
to quit the fun as  soon as they began to feel the slightest
fatigue.
  This man  continued to improve up to the 29th of August,
when he was discharged " cured," as stated in the hospital
report.
  September 3—He called on me  at my office this morning,
having walked  all  the  way from  home, several miles.  He
looks well, and says he  shall go to work next Monday.  He
was cautioned to be very exceedingly careful not to over-do.

       Partial Paralysis—[Written by Dr. Dubois.)

  Case viii.—Abner H. Clyde, aged 25, N. Hampshire, sea-
man, admitted  February 16,  1S57, (Dr. Van Buren,) with
slight frost-bites on ends of four  fingers of right  hand and
the three middle ones  of  left, which  he  first noticed  two
weeks ago, and probably caused by pulling in ropes at sea
which were  covered with ice.   The skin only is involved, of 
45
 a pale tallowy color, hard and insensible.  He has also pa-
 ralysis of extensor muscles of left wrist and hand, causing
 dropping of that hand exactly similar to that caused by poi-
 soning by lead.  He has not  been exposed to contamination
 by lead in any way, that can be ascertained.  Pie says that
 8 days ago he got into a fight on shore, and was struck on
 the left side of head with a piece of rope, and also across the
 loins.  He was stunned and knocked down by the blow, but
 soon recovered consciousness.  Four days after, he first no-
 ticed this dropping of left hand.   There  is partial  paralysis
 also of the flexors of the hand and  wrist, and also of the
 flexors of elbow.
    Treatment.—Ends of fingers painted with tr. iodine.
   February 22.—Ordered sol. iod. pot. fss. ter in die.  Dead
 skin has been removed from ends of fingers.
   March 1.—Not much improvement. C. T.   Fingers about
 well.
   March 10.—He can  now bend his elbow without much
 difficulty, and when his hand is  held back pretty strongly.
 Dropping of wrist continues the  same.
   March  19.—Not  much  change in  the paralysis. Takes
 now sol. iod. pot. ter in die.
   March 30.—Can now grasp with more force.  C.  T.
   April 18.—Takes  iod. pot. grs. xv,  ter in die, and  general
 stimulants.  Thinks he is gaining slightly in  power over his
 fingers.  He cannot move his  wrist.
   April 21.—Ordered T.  nucis vomi,  gtt. xl,  aq. fiv, 3ss. ter
 in die.  Stop iod. pot.
   May 11.—Since April  25, patient has  taken T. N. vomi,
 3i, aq.  iiv, 3ss. ter in die, and says that he gains slowly some
 power over  his fingers.   He cannot raise  his wrist, but can
 grasp with his hand pretty firmly.   Patient placed under Dr.
 Batchelder.
  June 2.—Patient has rapidly regained the use of his fingers
and wrist under Dr. B.'s treatment.
  May 11.—As stated above, this patient came under treat-
ment.  In my  minutes it is  stated  that the left  hand is 
46
dropped, and the fingers obstinately flexed, as in lead palsy.
No effort of his can raise the former or straighten the latter.
In his attempts to do so, various muscles in other parts of
the body, particularly in the opposite leg, near and about
the ankle and foot,  are called into vigorous  action.   The
movable splint was applied as in the other cases, which he
was instructed to keep in  motion as much as  possible, and
to have it removed  from time to time, to exercise the hand
and fingers as well when it was off  as when  in  place.   The
glove and whalebone strips were also applied.  In  less than
48 hours, signs of improvement became apparent,  and  in 3
or 4 days he could raise the hand to a level with or in a line
with the forearm, and also considerably extend the fingers,
and separate them one from the other, about half an inch at
the ends.  When raised, the hand could be maintained a few
seconds in that position.  The power of motion continued
to increase until, at the end of two wTeeks, he began to talk
of leaving the hospital, and on the 2d of June was, with the
consent of Dr. Griscom, discharged  "cured."   Since which,
he has not been heard from.
  In this case, smart percussion on the cervical vertebra.1 over
the origin of the nerves which go to the arms, or sudden and
even violent twisting of these parts gave no  pain or uneasi-
ness.  Therefore, the inference was that neither the bones
nor ligaments nor  intervertebral cartilages were  affected.
The  sense  of feeling was  not affected.   The disease could
not, it was thought, be attributed to the  blow on the  head,
as no symptoms  indicated  trouble in the brain, nor indeed
any  which  complicated the  spinal marrow.  Exposure  to
cold  was  the probable cause of the loss of motion.   The
seat  of  the affection is not in the central, but peripheral
brain—that portion of it  pertaining to  the  muscles whose
functions failed.

   Case  ix.—" Martin  Quigley, New York,  seaman,  was
admitted into the New York Hospital April IS.   Patient
comes in with partial paralysis of the left hand.  His wrist 
47
 has the peculiar  drop,  characteristic of saturnine  disease.
 He is unable to raise the hand, or to extend it on the wrist,
 though he can move his arm without any trouble.  The fin-
 gers curve slightly towards the  palm.  He ascribes his dis-
 ease to the fact of his having slept with his head resting on
 his forearm, after  having been engaged all the preceding day
 in wheeling heavy loads of coal.  He lost the use of his hand,
 he says,  from  this  cause.   Otherwise  he is strong  and
 healthy."

   The foregoing is the hospital  record of Quigley's case at
 the time of admission.
   On the 23d instant, five days after admission,  the following
 course of treatment was adopted: a splint was applied to the
 forearm, reaching  from  near the elbow to the ends of the
 fingers, which kept them and the wrist extended in a  line
 with the forearm.  As this splint while in place prevented
 motion, it  was laid aside, and another contrivance substituted,
 which consisted of a kid glove drawn upon the  hand ; be-
 tween the digits of which, and  the palmar surface of each
 finger (forcibly straightened) a narrow piece of whalebone six
 inches long was passed.  The thumb was treated in the same
 way.  These whalebone splints kept the fingers completely
 extended, without interfering in the  least with the move-
 ments of the  hand at the wrist.  To bring and keep  the
 origin and  insertion of the extensors of the wrist and fingers
 nearer to each other and enable the muscles to e;ather streno-th
 from the passive contraction  already alluded to, and also to
 bring them under  the control  of the will, a wooden splint, as
 before described, was bound rather firmly upon the palmar
 surface of the hand, by  passing a roller two or three times
 round the fingers, and once or twice round the hand, between
 the thumb  and wrist, in such a manner as not to interfere
 with the motions of either the hand or wTrist.  To the upper
 end of this  splint was appended a weight by means of a large
 wire bent in the form of an S, one end of which was hooked
into a hole  in the splint,  and  upon the other was hitched a 
48
weight sufficiently heavy to keep the hand back in a direc-
tion approaching a  right  angle with  the  forearm.  This
weight did not prevent the contraction of the  flexors when
subjected to the influence of the will; the patient was there-
fore directed, by contracting them, to keep the hand in mo-
tion as much as he could well do.  The moment the flexors
ceased to contract, the weight at the end of the splint would
bring the  hand back to the position described.  The  arm
was now placed in a sling, which  excluded  the  splint, and
the patient desired to allow it to remain resting therein as
carelessly  as possible.  The design  of the sling was to  pre-
vent fatigue,  and  more especially to favor the influence of
the splint  and weight in persistently  resisting the excessive
action of the flexors, which militated so much against the
cure,  and likewise to accomplish the objects in view, with-
out exciting other muscles to contract, whose action was not
wanted.
  Notwithstanding this arrangement, and all  our injunctions
to the contrary, these muscles would act  whenever he at-
tempted to extend the  hand and fingers with  any decided
voluntary  effort.  In consequence of this condition of things,
he was desired to keep the hand in motion, in an easy care-
less way,  so little under the influence of the will as not to
bring other muscles into play, and to keep his attention to
the movements thus going  on, particularly those by which
the hand was extended.
  May 23.—Discharged " cured."

  Case x.—Matthew Farrell,  31 years of age, a baker by
trade, received  on the  27th of last May a heavy blow from
an axe on the middle of the left parietal bone, which frac-
tured the skull, and knocked him down.  He was unable to
speak for some time, and has had trouble in articulating  ever
since, but  is  now much improved  in this  particular.   The
right arm  and leg were rendered motionless, and continued
so for a short time.  He  can now  (June  8th)  readily move
them, with the exception of the right hand and fingers, the 
49
present seat  of  the  paralysis.   Flexors and extensors are
both affected—the former much  less than the latter—conse-
quently the  fingers  are continually bent and cannot  be
straightened, or  indeed rarely  affected by  the  extensors.
The hand  also drops, and  cannot be raised to a level with
the forearm.  When  he makes  a strong effort to  raise it,
almost  all the muscles of  volition, not immediately con-
cerned in that effort, take on vigorous abnormal action, while
those whose  contraction should  elevate  the hand, are  most
provokingly  quiet.
   June 9.—He came under treatment yesterday, and thinks
he has improved  a  little.   Spent more than half  an hour
with him in trying to teach him how to cause the extensors
of the wrist  and fingers to  act, and finally succeeded in get-
tinsf him to move the hand backward  about half  an inch.
   D
As the supinator longus does not appear in such cases, and
especially in the  drop hand from lead, to be much affected,
the thought  occurred that if this muscle could be made to
act, the two radial extensors, which are much in the habit
of  acting with the  supinator longus, might be induced to
renew their former habit of acting co-ordinately, which was
found to be as true in practice as plausible in theory.  Pro-
fiting  by this  piece of strategy, and  persuading Farrell,
when  making extension to supinate the hand strongly, it
was soon apparent that its extension would  be increased an
inch or more, without exciting  other muscles in the arm or
other parts of the body to efforts not called for or desired.
Although  aware that the supinator longus was  generally
exempt or not  applied in  paralysis  from lead  poisoning, it
had never until now occurred that this  fact could be turned
to account in the education of these muscles.
   June 13.—Discharged "cured."

   This man  continued to improve very  rapidly till the  13th,
when he left the hospital.   Since which, no information in
relation to him has been obtained.  I have not been able to
                7 
50
get the hospital record of his precise condition at the time
of his leaving that institution.*

  Case xi.—Thomas McCuen,  aged 30, by trade  a boiler
maker, was, on the 22d of March 1857, thrown from a rail
road car with great violence upon the ground—was stunned,
and remained in a state of insensibility for a  considerable
time—he does not know exactly how long—but when con-
sciousness returned, found he could not move  the limbs on
the right side—they were motionless, but not insensible.   In
about four weeks he began to move  the limbs a little—the
legs first, and then the arm.   When lifted up and placed on
his  feet, he could stand  alone.   In a few days  he began to
step a little, when supported, by two  assistants.   He  can
now (May 16, 1857,) walk tolerably well on a  level surface,
but finds it difficult to raise his feet, particularly the right
one, but a few inches  only from the floor.  During the first
week after the accident his water was drawn off", but now he
can empty the bladder without the assistance of the surgeon.
His bowels are costive, and have not been moved since  the
accident, except by cathartic medicines.  Although he  can
move the arm in almost  any direction, he cannot extend the
hand and fingers, neither can he close them, particularly the
fingers, but very imperfectly.   When thrown from the cars
the right side of his body and  head came in contact with the
ground.  On the latter, two wounds were made—one on the
middle of the left parietal bone, and the other over the sagit-
tal suture, about midway between the anterior  and posterior
fontanels.
  Treatment—Much the same as that practiced in other cases.
The glove and whalebone splints, and splint with the weight,
were principally employed for the recovery of the hand, with
the happiest effects.   He came under treatment on the 16th,
and was discharged " cured"  on the 29th.

  * Not succeeding in getting a report of this man's case from the books of the
hospital, the foregoing account of his case was taken from his own lips. 
51
   I have not been  able  to  get a copy of the record of this
man's case, as it was entered upon the hospital books.  The
foregoing account of his  case was gathered from himself  on
the 16th of May, and subsequently.   I have no doubt of  its
correctness and accuracy, for he, as well as the others, was
cross-examined with a good deal of closeness and care.

                 Additional Remarks.

                      Time  of Attack.
                                               *
   Paralysis, like apoplexy  and  epilepsy, not unfrequently
attacks during the night, while the  patient is in bed, and
after sleep.  The recumbent posture,  and the consequent
distention of the cerebral capillaries, and the pressure which
they make on the nervous  centres (the proximate cause of
sleep, we think), seem to favor  and invite the attack; and
we shall  often  find,  on  enquiry,  that if the subject  be a
male, the accession has been preceded by masturbation or a
coitus.
                   Particular Symptoms.

   Sense of coldness—taken in connection with other premoni-
tory symptoms, is particularly significant—indicating a tole-
rably certain and near approach of the disease;  and when it
begins to abate or  be exchanged for  a  sense of warmth, it
presages a favorable termination.  Either way, it is a symp-
tom of prognosis—otherwise, it is not particularly  impor-
tant.   It seems to be somewhat idiopathic; for  it obtains as
well when the paralyzed  limb is red and tumid as when it is
pale and  shrunken.  In  the  first instance, when  the  hand,
for example, begins to grow warm, the tumefaction and red-
ness likewise begin to subside, and entirely disappear when
the member assumes its natural temperature.   In the se-
cond instance, when the  warmth  returns, the limb resumes
its natural size and color.
   The sense  of numbness is the most common of all the pre-
monitory  symptoms.  It  is  indeed seldom  absent, and  is 

 sometimes attended with a  sense of fullness, and occasion-
 ally with some degree of tumefaction.   It  generally affects
 the patient when at rest—warm in bed—towards morning.*
 As a premonitory symptom, it primarily affects the periphe-
 ral brain, and indicates that the  ultimate nerve fibres, in the
 part where it is experienced,  are  compressed.   This com-
 pression is induced in the following manner:  The capillary
 vessels of the part, having from  some cause  or other become
 less susceptible to the stimulus (that of distention only, per-
 haps,) of, the fluids which they circulate, do not  resist;  but
 yield  to the ingressive  impulse of those fluids  until they
 (the vessels)  become so distended as to compress these ter-
 mini (ultimate  fibres); by which compression this numbness
 or obtuseness of feeling is occasioned.  The remedy is exer-
 cise, which transfers the fluids from the sentient  papillae to
 the muscular tissue, and affords relief as prompt as it is cer-
 tain.  Like other premonitory symptoms, it frequently pre-
 cedes a storm or falling weather.  In this respect an analogy
 obtains between these symptoms and the  pains and aches, of
 which patients, subject to gout or rheumatism, or who have
 suffered from severe accidents, are so apt to  complain.   Un-
 der such circumstances, the cutaneous capillaries,  and also
 those of the fibrous  structures, unsustained  by the pressure
 of the  atmosphere (15 lbs. to the square  inch), become pre-
ternaturally distended, and complain—the former discover-
ing numbness, the  latter, the language of fibrous  tissues in
trouble.  Now, in all these cases, no matter to what cause
the pathological changes are owing, they may be speedily
removed by exercising the muscles—often for a  short  time
only.   Almost every individual affected in this way has fre-
 quently found these feelings cease as soon as he got well  en-
gaged in the active business of  the day.   To  such patients
our advice has  invariably been, to put the limbs  in motion,
and thus have seldom if ever been disappointed in obtaining
the desired relief.
  * In this emergency, the patient should immediately leave the bed, and put his
limbs in motion. 
53
  The analogy  between this sense of numbness and that
which is premonitory of age, is remarkable in two respects.
Both  are aggravated by atmospheric changes, and are like-
wise effectually  relieved  by exercise.   Closely allied  to the
foregoing is
   The sense of drowsiness.—The predisposed to apoplexy or
palsy are liable  to  fall asleep.  The  tendency to do so is
sometimes  so strong as not  to be resisted even in company.
In the midst of lively conversation, perhaps in a half finished
sentence, the unfortunate patient loses his consciousness for
a moment.   This sense of drowsiness, like the other premo-
nitory symptoms, commences in the peripheral brain.   This
position, we admit, accords  not with the generally received
opinion,  which is, that sleep results from changes first oc-
curring in the encephalon or brain proper.  As the postulate
which we have assumed has an important bearing upon our
theory, wTe deem it of consequence to have it settled on cor-
rect principles.  To ascertain them, let us examine the phe-
nomena  of sleep.   When drowsiness  approaches, the face
becomes flushed, and the eyes red; a sense of heaviness set-
tles on the brows, and extends over the whole head, as the
disposition  to sleep increases.  Presently the eye-lids close,
the mouth  opens, the saliva drivels, the jaw drops, and the
head  falls upon the breast.  The process, more and more in-
tensified, extends throughout the system, reaches and com-
pletely asserts its  sway over that  portion of the peripheral
brain appropriated  to the muscles of animal life, when the
subject reclines, or sinks  into the recumbent posture.  But
wdiy,  it may be significantly asked, does  the  central  brain
cease to act ?  We  answer, simply because it has nothing to
do—the  avenues of thought and volition are shut and sealed.
But this does not answer  the question pathologically.  What
is it that renders sleep necessary?   Activity—action of mus-
cle and of mind—especially the  former—which implies  a
contraction of the  capillaries—not of the organs of motion
only,  but also of those of sense; which contraction  is fol-
lowed by a spontaneous  relaxation, usually commensurate 
54
with  the previous contraction.   When  this  relaxation has
gone  on to a certain extent, the senses, closed against sensa-
tion,  take  no cognizance of changes, and consequently send
no missions to the central brain, in which a similar condition
has been subsequently, perhaps simultaneously effected, by
which the functions of animal life are suspended.  This state
may constitute perfect sleep only;  or more—profound coma.
The first link in the chain of causation is, as  has been  sug-
gested, an unequal distribution of blood to the ultimate or
distal nerve fibres (peripheral brain) which compresses them;
and  the next, compression of the proximal extremities of
the fibres of the same nerves.*  If any of the capillary ves-
sels, meandering in the vesicular substance f-of  the encepha-
lon,  give way, hemorrhage and apoplexy result.
  This relaxation is an ultimate law of nature, and therefore
inevitable.   Hence  "exhausted by watchings, the soldier
slumbers at the cannon's  side—the slave under the whip,
and the criminal in the midst of torture ;" and  "sleep, tired
nature's sweet restorer," must be had;  but it  is widely diffe-
rent  from the premonitory drowsiness of  which  we  are
speaking—which  is removed or counteracted  by exercise.
Every body is familiar with the utter incompatibility which
exists between these two conditions—exercise  and  drowsi-
ness.

  * "Every nervous filament (and this is a fundamental point of anatomy) has
its central extremity in the cerebro-spinal axis and its peripheral extremity at
its point of termination."
  ******       *       *
  "Hence the central extremity of each fibre is connected with the peripheral
extremity of a single nervous fibre only; and this peripheral extremity is in di-
rect relation with only one point "of the brain," &c.  *  *  " So that, corres-
ponding to the many millions of primitive fibres which are distributed to the
peripheral part:? of the body, there are the same number of peripheral points of
the body represented in the nervous centres."—Kirk # Paget, p. 279-80.
  (The reader will please excuse this repetition.)
  t The vesicular nervous substance gives to the part, wherever located, the
grayish or reddish appearance.  It in fact constitutes the cineritious matter of
the brain, &c. in which it is probable the nerve fibres terminate when they en-
ter a nervous centre, or from which, in common  anatomical parlance, they
originate. 
55
   Vertigo and dizziness is often a premonitory symptom of
apoplexy or palsy of much importance.  Taken in connec-
tion with others, likewise present, its import cannot be easily
misapprehended.  When it occurs, the patient either  falls
or inclines  to fall—does  so, or instinctively lays  hold on
some object for  support.  Having done this, and retaining
his hold, he should put one or another of his limbs in motion,
which we believe invariably removes the difficulty.   More-
over, this symptom, like the others, is prevented by suitable
exercise;  which should be practiced by those much afflicted
by it, a short time  before leaving  the  house, because they
are most liable to experience it when abroad, especially in a
street  or  crowded thoroughfare.  This  is owing to the fact
that people are in the habit of maintaining their equilibrium
and perpendicularity by the sense of vision; and dizziness
results when the sight is impaired, or rendered indistinct \>y
a multitude of objects in motion.  Upon the same principle,
this symptom is often experienced  when the perceptive'
powers of the retina are becoming less active.  In  which
case, it should be regarded merely  as a  sign of general  de-
clension, incident to age.  In such instances, individual per-
ceptions are too indistinct to enable the patient so to adjust
the action of the muscles in other  parts as to maintain his
equilibrium.
   As these afflictions  may be induced by various causes—by
inordinate use of tobacco  and other narcotics, by anemia,
sudden change  of  posture, &c.—they are  not, therefore,
always or even generally premonitory of palsy or apoplexy;
yet their pathology (a deranged condition of a portion of the
peripheral brain belonging to some one or other of the organs
of sense, or pertaining to the  muscles of animal  life, or in-
volving both) may in every instance be somewhat analogous.
Accompanying sensations or circumstances  will,  it  is be-
lieved, enable the  experienced  and skillful practitioner to
discriminate and affirm that they are or are not premonitory
of disease.
  Pain in the head—Especially if accompanied by vertigo, 
5G
coming on in advanced life, and unattended with other affec-
tions  commonly  associated with  it, is  ever a portentous
symptom, and demands  the  closest attention.  It may be
only an equivocal sign of cerebral affection, or it may  be,
as it is exceedingly apt  to be at this  time of life, the  pre-
cedent of grave  disease  of its locality,  whether within or
without  the  cranium, or in a particular part or extending
over the whole head with other symptoms, as nausea,  consti-
pation, sense of  numbness, &c. &c. should be taken  into
consideration  in  order to settle the question whether it is
premonitory or not.  If  premonitory,  it is like the  others
removed by exercise, which should be  gentle at first,  and its
effects, particularly in respect to its increase or continuance,
be strictly watched.
   Difficult  mastication, deglutition, Sfc.—In  hemiplegia,  the
action of the symmetrical muscles belonging to the face,
tongue, fauces and glottis, is disturbed,  and the  parts with
which they are connected, drawn to  the well side; hence
the  difficulty of mastication, deglutition,  articulation and
respiration.   In the performance of most of these functions,
and particularly  that of  deglutition, if the  attention of the
patient be directed to the subject, he will soon discover that
the  difficulty is  mainly  on the affected side; because  the
muscles  on that side, having lost  the power of motion, and
in some  degree that of sensation, do not  therefore resist  the
action of those on the well side.   Consequently,  when  the
attempt to swallow is made, the matter to  be swallowed is
forced over upon the disordered parts.  Hence the assistance
which is so generally derived from the application and pres-
sure of the hand on the  side of the face and neck, when the
patient wishes to facilitate these operations.  Deglutition,
when  premonitory of cerebral  affection, of paralysis in par-
ticular, is often attended with a gurgling noise.
   Constipation and retention,  like those just mentioned, are
symptoms which in paralysis arise from loss of sensation as
well as from loss of motion.   The  primary sensation which
naturally prompts the bladder and rectum  to employ them- 
57
selves,  is experienced at the terminal outlets  of these vis-
cera, and of course belongs to animal life.*  It produces the
conviction  that  it is occasioned  by something  which the
economy of the system requires to be removed, and also that
these viscera  are the organs by which its removal is to be
effected; i. e. by the passage of their contents.   But if this
sensation be not experienced, they will make no  effort for
the removal of a cause, the existence of which, so to speak,
they are not aware.t   The rectum and bladder  are organs
of a complicated structure.   Each has  striated and non-stri-
ated  muscular fibres and also nerves  in its composition,
which belong to both animal and  organic life, and are there-
fore  organs whose functions,  like  their structure, are of a
mixed nature—partly animal, partly organic.   In their nor-
mal state, they respond to two kinds of stimuli, the mechani-
cal and chemical, which may  act either conjointly or sepa-
rately,  each per  se.\   The susceptibility to these stimuli is
modified by the condition of the organs at the time as it is
healthy, irritable, insensible,  or  merely obtuse.   Nowt, the
cause which in this affection deprives the patient of the sen-
sation to which  we have alluded, also  paralyzes the striated
and in  some degree the  non-striated muscles, and  constipa-
tion and retention, as necessary results, soon follow and con-
tinue for a time, when  they  are succeeded by involuntary
discharges of urine and  fasces.   These  phenomena, and the
succession in which they occur, we  explain  in this way:
The contents of the bladder and rectum, probably somewhat
altered in their consistence and chemical properties, continue
to accumulate, unconsciously to the patient, until the mus-

  * I cannot call to mind a single case of paralysis  of motion, with unimpaired
sensation, in which there was incontinence of urine, or unconscious discharge of
fasces.
  t " The intestinal ganglia do not give out the nervous force necessary to the
contractions of the intestines, except when  they receive through their  centri-
petal nerves the stimuli of substances in the intestinal canal."
  t " The contents of the rectum and bladder acting as stimuli, produce a cer-
tain impression on the nerves of those  viscera, which impression is conveyed
through them to the adjacent ganglia of the  sympathetic."
                 8 
58
cles, supplied with nerves  from the  ganglionic system, are
put upon the stretch and  stimulated to contract, expel the
contents of these organs, without the control or even know-
ledge of the patient.*
  These events, and  the  order in which they happen, are
more remarkable in  cases  of paraplegia than in those  of
hemiplegia.  In both, the retention, &c. are equally certain;
but  in  the  latter  (paraplegia), the  involuntary discharges
usually take place sooner than  in the  former; and the ex-
planation requires to be somewhat modified.  In hemiplegia,
the muscles  controlling the outlets of  the rectum and blad-
der are  affected like the muscles of  the  face.  Consequently,
when these  organs contract,  analogous  results ensue—the
muscles of one  side  only are affected, while  those of the
other side are intact.   The consequence is readily under-
stood.  The parts, as in paralysis of the  face, are drawn  to
the \vell side,  and the apertures are  either opened, or afford
no  resistance whatever on the  diseased side to the passage
of the contents of the viscera, which come  away unresisted
and unheeded  by  the unfortunate  patient.t  Sometimes,
however, in  hemiplegia  these  involuntary discharges are
preceded by a  complete obstruction, while in paraplegia the
involuntary  discharges  generally  commence almost imme-
diately without being preceded by either retention or con-
stipation.  When retention of urine  results from  an injury
of the  spinal  marrow,  it is commonly removed by one  or
two introductions  of the  catheter;  bat  incontinence  soon
intervenes.  When the palsy is  caused  by a mineral poison,

  *" Ordinarily, the contents of the rectum and bladder, acting physically on
the mucous membrane, or mechanically,  i. e. by distention of their muscular
coats, make an impression, which prompts them  to contract and expel the con-
tained matters."
  t The inconvenience from these involuntary discharges may be in some mea-
sure obviated or lessened, by keeping the  inferior extremities extended in a line
with the  trunk, and the nates drawn together by  the application of long and
broad strips of adhesive plaster, or by the uniting bandage skillfully applied.
These mechanical appliances give the support which would be derived from  the
muscles were they intact. 
59
 as lead, or by malaria, incontinence of urine and involuntary-
 discharges from the rectum seldom if ever occur—a circum-
 stance which should be taken into the account when making
 up a diagnosis in obscure cases.
   It may be well to remember that only the fore mentioned,
 and nearly all the positive as well as premonitory symp-
 toms of apoplexy and palsy, whether of sensation or motion,
 have their seat in the termini which constitute the periphe-
 ral brain; and that the premonitory symptoms of these for-
 midable diseases—as sense  of  coldness,  numbness, drowsi-
 ness, pricking,  formication, and lastly, twitches,  cramps and
 spasms—invariably occur first  in these termini.  The five
 first mentioned are sent by way of admonition, and the last
 three as preventives, and also  as a solemn intimation that
 the' real attack is near at hand.  These involuntary move-
 ments  are, moreover, the suggestions of nature  as to what
 ought  to  be done; that the patient should  without delay
 have recourse to exercise; that whenever any of these pre-
 monitions are present, he should exert the limb with energy,
 instead of rubbing or having it rubbed, as is usually done.
 He should be  advised of his danger, and assured  that the
 course suggested will not only put a stop to the unpleasant
 feelings, but prevent the accession  of the disease of which
 they are the precursors and heralds.
  This method was adopted  and practiced by Kanski, when
 threatened, as he frequently was, by other attacks; which
 were always obviated, as we assured  him they wTould be, by
 this expedient.   We desire to speak of  this method of treat-
 ment somewhat  emphatically  and  positively, because we
 have, for a long and tolerably  extensive practice, found  it
 uniformly successful, when connected with other proper hy-
 gienic  measures.  But  what has impressed   us the more
 deeply in favor of its importance,  is our own personal expe-
rience, having been at  one time or another affected with all
the premonitory symptoms—even the cramps and spasms—
 which were invariably and  certainly removed  by strenuous
 and persistent action.   The cramps and spasms to which we 
GO
have alluded  sometimes terminate in  epilepsy instead  of
apoplexy or  palsy;  in  which case, the preventive remedy
(exercise)  is the same,  and  is  equally efficacious  and  suc-
cessful.*
   These  affections of the  muscles, like convulsions, consti-
tute  the  efforts of nature; the design of which, by driving
blood to the muscles, is to relieve the brain or nervous cen-
tres from the imminent  danger with which they are menaced.
The principle is the same in disease as in health.   In taking
this view, we must not  forget that the exercise of the mus-
cles,  both in  health and disease, may be carried so far as to
increase the circulation  in  both force and  frequency, and so
produce or aggravate the very evil which it was intended to
prevent.   Hence the necessity of caution.   Depletion,  ab-
stemious  diet, &c. may  sometimes be  with great propriety
superadded.

                       Decline of Life.

   " As age steals on, all the functions are performed  more
languidly than in earlier life.  The energies of the ganglial
system decline, as evinced  by the digestive, circulating and
secreting functions which it actuates.   The sensibility of the
cerebro-spinal system, and its dependent  organs ; the acute-
ness  of our intellectual  powers,  our  moral  emotions and
affections;  and the activity and strength of the locomotive

  * A medical gentleman, extensively engaged in the practice of his profession,
but subject to frequent attacks of epilepsy, informed the writer that, conscious
of the danger of having a fit when riding in his carriage or on horseback, he
always sprang from the one or  the other whenever he had the slightest intima-
tion of the accession of a paroxysm, and sought a convenient place in which he
could go  through the struggle with safety, but that he had never been attacked
when thus prepared for the assault—the demon never came!  The explanation
is, that the vigorous effort made to procure the place of safety, prevented the fit
This, I believe, will generally prevent the fit in cases in which the aura gives
timely notice, and the patient has the resolution to put it in practice.  When
the fits are periodical, they should be anticipated by exercise—and particularly
when they occur during sleep, towards morning, the patient should be aroused,
and made to exercise. 
61
 organs—all experience diminution, great in proportion to the
 advances of age."—Copland.
   The premonitory symptoms which have been mentioned,
 are not unfrequently signs of approaching age, as well as of
 disease, and are then almost as certainly and effectually met
 bJ gymnastic  exercises, as they  are when  premonitory of
 disease.  In connection with exercise, they are, in this point
 of view, worthy a more extended and thorough consideration
 than  we can give them, except in  illustration of our subject.
 With the symptoms and phenomena of approaching age all
 are familiar.   We therefore beg leave to state that observa-
 tion and experience have forced upon us the conviction that
 most of them may be obviated and prevented, to a certain
 extent, by persevering in  a consistent course of gymnastic
 exercises.  It will  prevent the rigidity of the fibrous struc-
 tures, also their ossification, and add to the muscles what is
 lost by the areolar tissues in the decline of  life.  By giving
 strength to the muscles, it prevents the slow, vacillating and
 embarrassed movements of the aged.  By often contracting
 the dorsal muscles, which curve the body backward, stoop-
 ing is resisted and prevented ; and also likewise the consoli-
 dation and thinning of the fibro-cartilaginous substances, in-
 terposed between the bodies of the vertebras, by which this
 proclivity  of  the body forward and downward is  favored.
 Determining more blood to the brain and quickening its cir-
 culation, increases its  nutrition, and consequently prevents
 the atrophy of this organ,  wmich results from age, and  also
 sustains its functional  powers, both mental  and  physical.
 By throwing more blood upon the heart, it  keeps up its vo-
 lume, consistency, tone and action,  and on the same principle,
 continues to invigorate the stomach and preserve the viscera
 in healthy and vigorous performance of function.
  There is, in advanced age, very much the  same  indispo-
 sition to muscular effort as  in paralysis, and is the more diffi-
 cult to overcome when paralysis and age concur in the same
individual.  The aged, like the paralytic, instinctively loves
to be  quiet, and consulting his ease, foregoes exertion of 
G2
body and mind.  Remiss in attention to objects of sense,
his organs lose their acuteness of perception, and languish
and fade from inactivity.   The eye grows dim, the ear heavy,
the touch benumbed and the muscles shrink and stiffen, for
want of exercise.  When the joints become rigid and mo-
tion irksome or painful, especially in the morning, or indeed
at any time of day, instead of giving up or  yielding to the
promptings of inclination, we should immediately commence
upon a system of gymnastic exercises,  and continue them
for the time being, till the joints become supple and the
muscles cease to complain.  If  this advice be taken  and
followed to the letter, the matutinal dose will probably suf-
fice for the day.   But, we add, whenever the contingencies
mentioned recur, the remedy should be repeated, by which
we are quite certain the ordinary infirmities of age may be
obviated or postponed for years.

   P.  S.—The  cases  related in  this  paper were all, except
the first, treated at  the New York hospital, under  the daily
supervision and  approbation of Drs. Griscom, J. M. Smith
and Bulkley, who constituted the medical staff in attendance
while these patients were under treatment.  To these -gen-
tlemen, and also the governors, I am under special  obliga-
tion for the liberality and efficiency with which they seconded
my views and  efforts.  I am  likewise much obliged  to the
gentlemen on the surgical side of the house, for sending to
me several cases, in which it will  be seen surgical practice
was not a little interested.   I have  preferred, in this publi-
cation, cases treated in a public institution, to  those which
have occurred in my private practice, for the reason that the
former were subjected, in the progress of cure, to the daily
inspection and observation of the  attaches, and many others
who visited the hospital in  the  capacity of either  practi-
tioners or students.   The first case having  gained consider-
able notoriety by being exhibited to several of our  public
institutions, is not regarded as forming an exception. 
EHRATA.
Page 13, line 32, for "pus," read "faeces."
Page 14, line 16, for " he," read " I."
Page 14, line 17, for " hand," read " his hand."
Page 14, line 18, for "his," read " my."
Page 14, line 23, for " afflicted," read " affected."
Page 20, line 36, for " reconciled,"  read " reconnected."
Page 26, line 6, for " occasion," read " occurrence."
Page 32, line 35, for " afflicted," read " affected."
Page 39, the whole paragraph, beginning at "Peripheral
  Brain," italic head, should have  been quoted, in a foot
  note.
Page 39, line 19, for " remific," read " sensific."
Page 49, for " affected," read " applied."
Page 50, line 11, for " leg," read " legs,"