Q8 Circular, No. 6. RIB IF1 ILEX PARALYSIS. Surgeon General's Office, March iO, 4864 Circular, ^"Jo.-O. burgeon ©cncraVjs ®ii'ut, Washington, D. C, March 10, 18G1 The following paper on Keflex Paralysis, the result of gun-shot woundi, founded chiefly upon cases observed in the U. S. General Hospital, Christian Street, Philadelphia, by S. Weir Mitchell, M. D., George K. Morehouse, M. D., and William W. Keen, Jr., M. D., is pub- lished for the information of Medical Oflleers, in the belief that imme- diate and practical benefit may be derived from it. JOS. K. BAENES, Acting Surgeon General. Since the establishment, in May, 1863, of a, Special Hospital for the treatment of diseases and injuries of the nervous system, a vast number of cases of gun-shot and other injuries of nerves have been studied by the authors of this paper. The great mass of these will be considered in a future essay, upon tne history, results, and treatment of gun-shot wounds of nerves. _ We have judged it wise, however, to report separately a class of very infrequent eases, in -which paralysis of a remote part or parts has been occasioned by a gun-shot wound of some prominent nerve, or of some part of the body which is richly supplied with nerve branches of secondary size and importance. , So far as wc are aware, the Medical Histories, which we arc about to record, stand alone as the first reports of sudden reflex paralysis from mechanical injuries. How they differ from the paralytic affections which result from disease of organs, and which have been so ably treated of by numerous authors, we shall presently consider. That they have thus far escaped notice may be easily accounted for. In the first place they are rare; among some sixty or more carefully studied instances of wounds of nerves, wo have met with only seven cases of reflex paralysis of remote organs, in which the influence was prolonged or severe In the majority of cases, the reflex effect is cither very slight or very transient, and for one or both of these reasons, unlikely to attract notice from surgeons on the battle-field, or in Division or Corps hospitals, where their brains and hands are taxed to the utmost, by the palpable misery of wounds in the early stages of treatment. Had it been other- wise, we do not doubt that numerous cases of reflex paralysis Iron* •injuries to nerves, would have been recorded. 4 the n-\i. H'.s maiin.-r iv:u excited and hysterical. He talked ineas- :-.iiulv, and his limbo were in continual agitation, with occasional twite!dug of the facial muscles. The tympanal membrane was split across in his left ear. and on the right side presented a triangular opening, lie hud no headache, but complained of the roaring, hissing, eic, which seemed to be sources of the utmost annoyance. Despite his Josire to'move about, his muscle:- were extremely feeble, and for twenty - four hour.; ho was unable to walk without aid. He recovered readily; houl membranes healing completely, and his hearing none the worse lor iho accident. The patieni, it should be noted, was not injured by his full, and as we have seen, showed no sign; of concussion. II:, as well as his medical attendant, attributed the phenomena, which he exhibited, to the shock giv;>n to the'auditory nerve. This opinion has since been confirmed by ihi eases reported by M. J)i:owx-Sequaud, and others. Further on we shall show that in rare cases gun-shot wounds cause partial or very general paralysis of grave type and prolonged duration in parts not directly injured: we shall also show that these protracted paralvoCS mu.-t be due to an equally permanent affection of the nerve ■en'a-i's. Now, if this be po-sibb, there is every reason to believe that a temporary, though general, parulvds may take place in a large number ;jf gun—hut wound i. When tin- cardiac centres feel the shock most :cvcrely, the feebleness will of course be greater; but there is much reason lo suppose that the cerebral and spinal centres in general, suffer en masse in every case of loss of consciousness from shock. As we proceed, we shall have occasion to discuss the mechanism of the more permanent forms of reflex paralysis. Hero we desire only to show that the effect of grave wounds is to cause a condition of the centres which gives rise to a general and profound feebleness, and that in rare eases the central effect is so intense as i;i some way to cause paralysis, which may last for hours, days, or month-. Another class of nerve affections demands some notice before we discuss the undoubted instances of reflex paralysis from wounds which have fallen under our notice. Thc-e are what the French writers call eases of injury from commotion. They differ from those we have described in being due to the mere mechanical effect produced upon the neighboring parts. If, for example, a ball passes near the spinal column, it Is conceivable that the roll of its motion, and the resistance of the tissues, may determine in the .-pine a. brusque and sudden oscillation of the contents, sufficient to cau.-c very grave results. We have sometimes seen this illustrated in a very interesting shape, and in a less dangerous form. Thus, in the case of a soldier wdio was shot at Gettysburg, July 3, 1860, the ball entered the cheek, and passing outside of the ramus of the jaw, was cut out of the trapezius muscle. It struck the ramus, but did not fracture it, or interfere with the act of mastication. In October, one or two very minute morsels of bono escaped from the neck, in front of, and four inches below the jaw. The only injury to the jaw-bone must have been on its exterior surface, from which the pieces of bone alluded to worked down the tissues of the neck. The shock caused complete paralysis of the inferior dental nerve, with absolute anesthesia, analgesia, and loss of sense of temperature in the lower lip and chin of the injured side. The sensation was for the most part rapidly restored by the use of cutaneous faradization, after the nerve had been allowed time to recover from the results of the shock it had sus- tained. A portion of the lip. the skin below it, and the inucou3 mem- brane within, still remain rcb:lb!ou3 to treatment. 5 The other case of mechanical shock to a nervous structure, we shall report more at length. It is one as to which there may reasonably exist some doubt, whether to call it an instance of commotion of the spinal cord, from injury of neighboring parts, or to regard it as an impression made upon the spinal centre through the injured nerves, and resulting in a paralysis, as the reflected result of the state into which the centres wero thus thrown. It is impossible to be sure that both sets of causes may not have been at work. Flesh woend or isacic oe neck; entire aphonia and paralysis OF ALL I'OUR limes; speedy recovery, the rioht arm remain- ing WEAK. Mor.oAN Emory, crt. 20, farmer, horn in New York, enlisted Septem- ber. 1801. in company "C." 9th New York Cavalry, a healthy man. August, lSliii, had typhoid fever, but recovered perfectly. On the seventh of July. 1863, he was wounded at Williamsport. The ball passed through the neck from side to side, posterior to the vertebra;, entering the left"side one-half inch below the level of the angle of the jaw, and two inches from the posterior middle line of the neck, and emerging on the right side at one-fourth of an inch lower down, and two and a half inches from the same middle line. No bone has been discharged from the wound, nor is there any evidence of injury of the spinous processes of the vertebrae. Effect of v:ounutil. Continued to faradi/.e daily. The faradization was used up to November l.-t, when he was furloughcd. At this time the electro- mu-cular contractility and sensibility of the muscles were as good on tbe ri^ht side as on the left. lie has recovered all tho motions of the elbow, wrist, shoulder and hand, but all arc more feeble than those of the left arm, which ws'Iil u littl' numb, although far less -o than when admitted. The burning pain whi<-li at lir-t annoy * him is now rarely f"lt, mvJ th^ 6 hyperesthesia of the muscles is nearly gone. On his return from furlough he was still better, and within a month was returned to duty. Tho fall upon the shoulder was incompetent to cause all of the symp- toms here described, and since, in other cases where this element of doubt was absent, wo have seen paralysis caused by commotion, therefore we see little reason to hesitate in assigning it as the producing cause of the paralysis in the present case; moreover, there was no paralysis of cerebral nerves, and tho loss of power lay chiefly in the range of those nerves over whose spinal origin the ball passed. In many of the cases of injuries of the brachial plexus which we have observed, it was quite impossible that the nerve tissue could have been directly injured by the ball, and in.some of these at least the resultant paralysis must have been duo to brief compression of their trunks during the movement of tho missile or to agitation of the nerves through the tearing of tissues more or less remote. As we shall return to this subject in a future essay, it is only necessary here to describe cases of commotion, so as lo separate them from those of true reflex paralysis with which they might easily be confounded. We have met with another and very interesting form of paralysis, which might possibly be mistaken for reflex paralysis by a superficial observer. Men who are forced to use crutches, and to bear heavily upon them, are some- times affected with numbness of one or both hands, and even with loss of motion in these members. This result is due to pressure upon the axillary nerves. It is most apt to occur in emaciated persons and those of largo frame. Where it presented itself early in the case, as it may do, it might readily be attributed to reflected irritation. It is then easily relieved by laying aside tho crutches, or by padding thern and adding a handle by which to support the weight of the body on the hands. When the cure is delayed, faradization always affords prompt relief. We have seen that in all probability the state of shock from gun shot injuries is a state of general paralysis. We have also seen that in the great mass of cases it is temporary. We have now to show that in rare instances the paralysis continues as a more or less permanent evil, after the general depression has passed away. "When, therefore, a wound occurs, and the patient surviving the first effect is found to have paralysis of a distant limb or limbs, it is impossible to deny to such cases tho title of reflex paralysis. All of the following instances seem to us to have fulfilled every condition, which would entitle them to be so considered: CASE I.—Ball wound of right side of the neck, probably INVOLVING NO IMPORTANT NERVE DIRECTLY"; FRACTURE OF HYOID BONE; AVOUND OF THROAT. KEFLEX PARALYSIS OF LEFT ARM; PROBABLE REFLEX PARALYSIS OF RIGHT ARM; EARLY RECOVERY OF LEFT ARM; PARTIAL AND REMOTE RECOVERY OF RIGHT ARM. Captain R. N. Stemble, U. S. N., cet. 49. While commanding the ram Cincinnati, May 10, 18G2, the ship was attacked by tAvo rebel rams. Captain S. was aiming a pistol when a ball entered his right neck, broke the hyoid bono and traversing tho neck, emerged three and a half inches from the middle line, above and to tho right of the superior angle of the beapula, through the edge of the trapezius muscle. He fell half conscious and confused, but soon reviving, felt that both arms were paralyzed. His first impression was that he wis shot through both arms. He was carried below in great pain, and spitting blood freely. The pain in the arms was made worse by movement and by passive motion. Pressure gave pain in the. right arm and shoulder only, and in the right chest. Sensa'ion was never entirely ab.ent from.either arm. bat \va.- dell in bo'.h. His medieai attendant. Dr. Judkins, of Cincinnati, who took charge of his case on the 19 th. of May, 18b_, writes as follows: "When first seen by me the anterior wound Avas' discharging mucus and pus, with saliva. His voice was hoars-:1; deglutition, which returned in part on the third day, was still difficult and painful. He experienced severe pain in the supra hvoidean group of muscles and in the pharynx. 11 b left arm was still slightly paralyzed, lmdng rapidly improved. On the rigid side the deltoid, biceps, triceps, and brachialis anticus were completely paralyzed, and up to the date of this account. July Oth, 1862, have improved very little. The muscles of the right fore-arm are nearly as much paralyzed as those of the arm, and the sensibility of the right arm has become painfully acute. Captain S. seems also to* have lost to a great degree the use of most of the shoulder muscles on the right side.'' The left arm was nearly well in four weeks, the sensibility and move- ments of both improving'equally, so that uoav, July 18, 1863, he has no loss of function in the member, except slight want of tactile sensation in the ultimate distribution of the ulnar nerve. The right arm was but little better at this date, but the fere-arm had acquired every movement exeep'. supination, which seemed to be limited about one haif, not by paralysis, but bv contraction of tho opponent group of pronating muscles. At tibi period, sensation was entire in the right limb, but there Avas soreness on pressm-e in all the anterior arm mu-eles, and neuralgia in the arm and fore- arm. The nutrition of both arms was good, but tho right was the smaller, mei-urinw at the biceps i>;j- inches, Avhile tho left measured 10J inches. Durin" the slow progress of his case, Captain Stemble lost several small pieces of the hvoid bone, and although hoarse for many months, has rec< vered his voice, without serious change in its tone or power. His convalescence, interrupted by many accidents, and by an attack of pneumonia, continued up to the summer of 1863, and was largely due to the skill and k ire of his able medical attendant, Dr. Judkins. When placed under reatment. in Philadelphia, by Dr. Mitchell, July 18, 1863 Captain S. was still suffering from constant pain m the right arm. The left was well except as to the trifling loss of sensation mentioned above The rb'ht fore-arm, though weak, possessed every movement except supination, as did also the hand, but the arm hung at the side usele^ because there was scarce any abducting power and very little flexion at the elbow, both the biceps and long supinator being greatly enf ebh-d and the former muscle, as Avell as the brachialis anticus, almost en< bely atrophied and lost to view. Excepting the trapezius and rhom- boid muscles, all the shoulder group was nearly useless and partially ^ v.^m Julv 13 to September 9 he was faradized; at first every day, and then every "third day. Active and passive movements, which had a1 ready been cmploved, being of course continued. The result was a steady gain, ending in a cure as complete as could bo hoped for in a case so ^ve?e Ho regained every lost motion, and could raise his hand to his" chin'and abduct the arm about fifty degrees. The pronators alone i-emained intractable, despite every effort, but us the supinators and biceps developed themselves largely, even pronation gained somewhat, though not to such an extent as the other movements. The pain and hyperas - thesia diminished, but the former still exists. It is believed that a second course of similar treatment, about to be instituted, will lurthcr amend thh case, in which all other means had utterly huled. D" Jl-ekivs is of opinion that the entire paralysis was due to reflected irritation. We incline to thU belief for anatomical reasons but ev^ though we admit .hat the paralysis.,,- ,i,e r.gh- :,:■«, may have uc-n 8 caused by commotion of the brachial plexus, it is impossible to suppose that the loss of power in the left member could have been similarly pro- duced. The only permanent lesion on that side was the loss of feeling on the ulnar side of the palm and fourth finger. With this exception; it regained its normal functions within three or four weeks. Whatever may have been the cause of injury to the right arm, it appears to have involved more or less, nearly all the strands of the plexus, which is un- usual in cases of traumatic injury from a ball. Its results were also-more lasting than in the other arm. A year and tAVO months after the accident tho right arm was a useless member. Faradization, of the muscles affected, restored their poAver A-ery rapidly, so that the patient regained every movement of the limb, which is still improving; electricity having been temporarily laid aside in September, 1863. CASE II.—Flesh avound of right thigh, without wound of any LARGE NERVE; COMPLETE PARALYSIS OF ALL FOUR LIMBS; SPEEDY RECOVERY OF THE LEFT ARM, TARDY RECOVERY OF THE OTHER LIMBS; SUBSEQUENT ANALGESIA OF THE RIGHT SIDE. Jacob Demmutii, cet. 21, Swiss, enlisted July, 1861, company "D," 108th Ncav York Vols., a man somcAvhat beloAV the average standard of height, of lymphatic temperament, and moderate intelligence. Reports himself as healthy up to the date of his wound, which took place at Fredericksburg, December 13, 1862. He was marching at double-quick, Avhcn a fragment of shell, as large as a musket ball, struck his right thigh, at the junction of tho upper and middle thirds, directly over tho femoral artery. Tho fragment did not enter deeply, but merely lodged in tho leg, and Avas removed a day later without injury to the vessel. Effect of toound.—Ho fell half conscious, and although aAvare that ho Avas Avounded, he could not fix on the site of the injury until ho had examined the limb. He felt instantly a burning pain ji both feet, in front of the right chest and in tho right arm, and in the right thigh about the Avound. At first he Avas entirely powerless, but after a few minutes tho poAver of the loft arm returned, leaA'ing him paralysed as to motion in tho right arm and in both legs. He lay on the field twenty- four hours, the Aveather being very cold. Sensation was defective in all the parts paralysed as to motion. He had no pain in-the back, but the burning pains alluded to above continued for a long time, and Avcrc ahvays cased by cold applied to the wound. While tho wound was healing he had headache and difficult, painful micturition. The Avound closed in four Aveeks. During this period he regained the poAver to move the right arm, feebly and sloAvly although perfectly as to extent. The pain in the side and feet also diminished, and the former disappeared altogether at a later period. He could not stand, hoAvevcr, or lift his legs from the bed at the time the wound healed, but there Avas then no headache or difficulty Avith the bladder or rcetum. January 28, 1863, ho was sent to Washington, where he improved so as to be able to walk Avith tho help of a cane. His subsequent transfer to West Philadelphia caused a relapse; the pains returned, the paralysis increased, and he Avalkcd with difficulty on crutches. June 4, entered Christian St. Hospital. Present State. Movement.—-The patient is partially paraplegic. He has some power to move the thighs when lying down, 'but cannot lift the legs from the bed. Beliw the knee all motion is lost, except a slight poAver of flexing the smaller toes in both feet. Pressure upon the cicatrix causes feeble twitching of the anterior mu-ele? "f the right thigh; hoth leg- are subject 9 L<> cramp and Iwitchings, which increase at night. The left arm is strong; the right arm has all the normal movements, but all are slowly and feebly executed. Sensation.—He has shooting pains which start from the scat of the wound, and dart down the thigh to the knee. No other pain exists at present, but there is still a good deal of burning sensation in both feet alike. Localizing sensibility perfect everywhere. Tactile sensation normal, or very nearly so, in all parts of his body; no loss of sense of pain in the skin. Pressure or pinching of the muscles gives him more than tho usual pain, so the muscles (of both legs, especially below the knees.) may be regarded as affected Avith hyperesthesia of common sen-1 sation. The left arm is in all respects normal; the right arm is also free from lesions of sensibility. Nutrition.—There is no special atrophy of individual groups of mus- cles, but both legs arc slightly wasted, the right arm not at all so. The legs beloAV the knees are relaxed and cold ; the feet arc congested, but not bAVollen to any marked extent. Along the edges of both soles there are singular purple and blue mottled spots, which he says existed from the time his boots were first taken off", twenty-four hours after he was wounded. It is possible that these marks are due to frost bite. Tho muscles of the legs are about equally irritable to induced electric currents. Unfortunately.no very perfect electric examination of their condition Avas made at this period. Treatment.—Regarding the case as one of rcflez paralysis chiefly, he was ordered to have rough frictions, Avith cold' to the spine, and to tal«r the twentieth of a grain of strychnia three times n day. Under this treatment, the cramps and twitciiings increased, so that after three Weeks the strychnia was abandoned. Every future attempt to repeat its employ- ment caused the same increase of annoyance, Avithout correspondent benefit, so that it was finally laid aside as useless or worse. Aleut the middle of August a Vlster Avas placed on the cicatrix, with the effect of greatly relieving the burning in both feet. At the same lime he Avas ordered to use the hot and cold douche to the spine alternately, and faradized daily. The electricity was persistently employed during two month:, and a month later he was also treated with iron and quinine, porter and liberal diet. The electric treatment caused a rapid amelioration of his case, so that he soon left his bed and began to walk on crutches. Early in N ovember he ceased to improve, and the treatment Avas abandoned. At this time he could use his right arm Avell and quickly, and walked un- aided, although Avith a little unsteadiness of gait. ^ Xo close examination Avas made as to his sensibility until December o, 18G3, because during this time he had been able to give aid in the wards and made no complaint, except of more or less constant aching in the dorsal and lumbar regions of the spine. About December 3, he Avas closelv inspected for discharge,When the following notes Avero taken: y„>;o/>.—Good in left arm; not so perfect in right arm. Doth legs somewhat weak, so that he shuffles a little in walking, the worst move- ment being that of extension in the toes of the right foot. Sensation.—Tactile sensibility feeble in the right leg and right arm, but nowhere entirely lost; it is normal in the left leg and left arm. 1 he sense of touch is first found to be feeble below the navel on the right Bide. It lessens in perfection to the knee, and is better below that part, espocially on the inside of the calf, being worst in the foot. Tickling the sole cau-es no sensation of tickling on cither side. _ tain.—Th^a is absolute los* of sense of pain in the right, leg, belly, elv-l and arm, with o:y,rv.l>M W.wn-d sensibility to pam en the led -;,le 10 also. In many localities he was able instantly to toll by the altered sen- sibility when the needle point crossed the median line; in others, this was more- difficult. So complete Avas this analgesia, that the most intense faradization of the nails of the right hand, or of tho right nipple, caused not the least sensation. Tho penis remained sensitive, but all over the right side he could be cut or stuck full of needles without evincing the least consciousness of anything but a touch. The sense of temperature was good in the left leg, confused and uncer- tain at the upper third of the right thigh, and lost b'eloAv the knee, Avhere a heat of 110° Fahrenheit Avas felt as a touch only, when the sponge Avetted with hot Avater was applied. On the foot of the right side this degree of heat Avas unfelt in any form. Higher heat caused reflex move- ments, which did not tend to remove the limb from the irritant, but were merely conA'ulsive in their character. Intense cold also gaA'e rise to these irregular movements. Electric examination.-—There was some difficulty in determining the state of the muscles as to their electric sensibility, owing chiefly to the want of intelligence in the patient, and to the fact that he spoke an impure German patois, which made it no easy task to obtain from him a clear statement of his feelings. The electro-muscular contractility is slightly diminished in the right leg and arm; it is much impaired in the extensors of the toes on both sides; everywhere the muscles respond sIoavIj*. The patient was discharged December 14, 1863. CASE III.—Wound of right thigh, with probable commotion of eight sciatic nerve; partial paralysis of right leg; reflex paralysis of right arm; speedy recovery of arm; history* unfinished. William W. Armi.in, cct. 23, born in New York, farmer, enlisted August,-1862, in company "D," 134th New York Vols. Healthy before enlisting, and except a slight typhoid fever in the fall of 1862. healthy up to the date of the Avound, July 1, 1863, at Gettysburg. YVhile kneeling on the left knee, the right knee bent at a right angle he AAras shot in the right thigh, on a line Avith the internal condyle of the femur, ten inches above it, and a little anterior to the artery. The ball passed upwards, backwards, and outAvards, and emerged two inches below the tuber ischii, and one and a quarter inches external to it, just above the fold of the nates. Dropping his musket he fell on his lace, Aveak, but not insensible; the righ; leg violently flexed for a moment. He felt very feeble, but especially so in the right arm, with Avhich he A'ainly tried to aid himself. After a half hour the bleeding, which Avas not excessive, ceased, and he was able to stand on the left leg, but not on the right leg, and had scarcely any use of the right arm, which, it should be noted, was in no Avay hurt Avhen he fell. He managed to bind up the wound Avith a water dressing, and occa- sionally renewing it, lay two days on the field. When hit, he perceived no pain, but Avithin an hour a burning attacked his instep, and has never loft it, remaining neither Avorse nor better. Sensation, he is sure, was unaltered except on the sole; motion improved slowly, except in the flexors and extensors of the foot and toes. To his surprise, the feebleness of the rigkt arm increased after he Avas put in b^.l. and indeed notably lifter the second day. Up to October 28 it improved sIoavIv, but at this time he Avent home on furlough, and began to use a crutch, which again so Avcakencd the arm as to alarm him. and deprive him, as at first°had happened, of the power to feed hims-!f. Rejecting a crutch on this side, he u.-ed a liniment, 1864. CASE VII.—Wound of right deltoid; sensory and slight motor PARALYsIS OF RIGHT ARM; SPEEDY RECOVERY'. Michael Farrell, vet. 28, farmer, born in New York, enlisted, Sep- tember, 1861, company '-I.'' 20th New York Vols.; a vigorous, healthy looking man—was avoII up to date of enlistment. At Fredericksburg, De- cember 13, 1862, he AA'as shot in the left shoulder while lying denvn. The ball entered the erector spince mass of muscles on the left side, on a level Avith the lower angle of the scapula, and passing upwards and outwards, lodged under that bone; the Avound healed readily, the ball remaining. February 3, went to duty. July 1, 1863, a small ball passed through the right deltoid muscle, three inches above its insertion into the humerus. The ramrod fell from his hand, and the arm dropped. He retired to a hospital, and on examination, found that although he had all the movements of the arm he had no sensation. During tho next four days he was exposed to the sun a good deal, and thearmjjcing bare, was blistered, Avhieh, he says, to a grout extent, restored its feeling, which has since gone on improving. There is now, July 2o, 1863, some slight paralysis of motier, but all the movements are feeble, and those of the arm painful, owing l« the con tract ions about the ball track; the-arm improved, an-1 the nr.n *ve- returned to du'y O ■U-l-rc 22. 1S63. T4 f> 'fore, proceeding to discuss the causes whhfli give rise to reflex paralysis, it Avill be useful to analyze the symptoms of the preceding cases, so as to learn hoAv they difler, and in Avhat respect they resemble one another. RELATION OF THE SEAT OF THE WOUND TO THE PART OR PARTS PARALYZED. Case I.—The wound involved the muscles of the neck or throat, and tho hyoid bone. Result. Paralysis of both arms, and of the neck. Case II.—Fragment of shell; wound of muscles over and external to the right femoral artery. The injury may hav^e caused concussion of the crural nerves, and thus much of traumatic paralysis. Result. Reflected paralysis of the right arm and leg, and the left leg. Case III.—Probable injury of the sciatic nerve—(commotion.) Result. Reflex paralysis of the right arm. Case IV.—Ball wound of right testicle; paralysis of right anterior tibial muscles and peroneus longus. Case V.—Wound by fragment of shell in external side of left thigh; paralysis of tact on a corresponding part of right thigh. Case VI.—Ball wound, probably involving the crural nerves. Result. Paralysis of right arm. Case VII.—Ball wound of deltoid muscle; sensory and slight motor paralysis of same arm. There is no evidence in this case that tho ball struck the bone or directly injured any large nerves, since even the deltoid itself had nearly full poAA'er Avhen the patient was first examined by us. In three of these cases the leg Avas hit, and the arm of the same side was paralysed. In three cases the paralysis affected the opposite side of the body, and in one the paralysis of tact and pain Avas observed to haATe fallen upon a space symmetrically related to tho wounded spot as regards position. No general laAV, therefore, can be deduceel from these records, nor from what avo see in the causation of reflex paralysis from disease should Ave expect to find any inevitable relation betAveen the part injured and the consequent paralysis. The constitutional condition at the time of the wounding, as to excitement, mental and physical, may possibly have to do Avith causing the resultant paralysis. Of the seven cases aboATo reported, tAvo Avcre in active movement, two were standing about taking aim. one was kneeling, and of two Ave haATo no information as to this point. It may prove, upon examining a larger number of cases, that a man wounded when moving violently, or when excited, is more than another liable to reflex paralysis, but as yet we are not entitled to such an inference. In most of our cases the constitutional effects were instant and severe, and could not therefore have been due to the loss of blood, Avhieh in some of them Avas copious. Four of the seven cases had stinging, smarting or burning pain in the part paralysed reflectively. The pain was an early symptom which disappeared in all of them after a time. In three cases no such pains Avere complained of. The after history of these cases is extremely curious. HoAvever grave the lesion of motion or sensation, it greAV better early in the cas(T, and continued to improve until the part had nearly recovered all its normal powers. In almost every instance some relic of the paralysis remained, even after eighteen months or more from the date of wounding. In some, the part remained weak, in others, there Avas r-till left some slight loss of sensibility, and in two the loss of poAver and of sensory appreciation Avas A-cry considerable. In a case of reflex paralysis from a Avonnd we have, therefore, some right to expect that th^ i:» patient will recover rapidly up to a certain point; then in most cases a small amount of loss of poAver or sensation may remain. The future history of our own or other cases may determine hereafter, whether the recovery is ever quite complete. In ease 1, the more prominent results were only the continued lesion3 which had been noted early in the case. In case 2, the permanent lesions were chiefly of secondary character, and were at all events additions to those which Avere first observed. In no other case were similar phenomena noticed. In Iavo of the seven cases there were lesions of sensation and motion. In three, motion alone was lost, and in two the sense of tact and of pain avcto affected without other loss of function. The extent and duration of the induced paralysis have already been considered. Of the treatment we haA-e very little to say. In Captain Stembel's case the left arm recovered without treatment in four Aveeks, leaving only a slight loss of touch in the terminal distribution of the ulnar nerve. The right arm, which we also regard as reflectively paralyzed, recovered sensation early, but Avas useless as to motion, until it Avas treated and cured by faradization, eighteen months after it was first injured. Demmuth, case 2, came under our care seven months after he was Avounded; as to his previous treatment we know nothing. In our hands strychnia not only failed to aid him, but did harm. " ne was rapidly relieved by faradization, active and passive movement, and the douche, with iron, quinine and liberal diet. Armlin, case 3, used a liniment on the paralyzed arm, with somo improvement. Faradization has restored it completely. Cases 4. Relieved by faradization. Ca— 5. No treatment; lesion of sensation only. Case 6. Kent. A stimulating liniment applied upon the arm secm3 to have been of use. As in case 3, the employment of crutches caused a relapse. Case 7 seems to haA-e been accidentally benefited through the blistering to which the arm was subjected after exposure to the sun—a useful hint in like cases. No other treatment was employed. Although long periods had elapsed in every case before avc examined them, in only one, that of Armlin, case 3, Avas there any very notable wasting. And even in this patient the loss was generally throughout the member, and may be readily ascribed to mere lack of use. In none AA'as there' atrophy, such as characterizes lesions of nerves, and ccrtainrheu- matic and other palsies, save, perhaps, in the doubtful instance of the right arm in case 1. The electric examination was made at periods so variable in the several cases, as net to permit of any useful comparison of results, and has been stated in each case merely for future use and reference Avhcn more cases have been reported. In only one case did the muscles display great loss of contractility when faradized, and in this No. 1 of the series, the limb in question Avas the right arm, as to whicli alone, some doubt may exist "one ruing the cause of the paralysis. The ultimate causation of these very singular and hitherto undescribed afi'eetions is the last point which we shall consider. Tho problem before us may be simply and briefly stated; its solution is a task less easy. A gun shot wound occurs, involving large nerves or not, and we have instantly a paralysis of motion and sensation, or of either alono in some part of tho body more or less remote. Hotv shall wo oxpjain this? Although we have long been aware that certain forms of disease are capable of causing paralysis of distant organs, of altering excretions and 16 liifeciin/ nutrition, we have had no plausible theory of the causation of these effects until M. Brown-Sl\juard attempted to account for them in a manner equally simple and ingenious. Recalling the fact that irrita- tion of the vaso-motor nerves is capable of producing contraction of the bloodvessels, no inferred that Avhen an external nerve is violently or permanently excited, it may be able to produce contraction of the capillary vessels of tho nerve centres, and thus give rise to paralysis. It seems unlikely, even if avo admit his explanation, that the capillaries could remain contracted for any great length of time. But it is possible that the alteration of nutrition, which this temporary anaemia causes, may give rise to one of tAVO results, either a continued disturbance of nutrition, which, howeA'er slight, would occasion grave results if it existed in a nerve centre, or secondly, to a paralysis of the capillaries of the nerve centre involved. We suppose, first, the existence of an exterior nerve lesion; secondly, a consequent irritation of the vaso-motor nerves in a limited part of the spine; contraction of its capillaries, anaemia, nutritive changes, and finally, a relaxation of these vessels, Avhieh Avould be more apt to be a lasting condition, and Avould in fact constitute congestion. Such a series of consequences may very possibly occur, and Avould no doubt be com- petent to cause a paralysis, Avhose site, extent, and character Avould depend upon Hie jDart of tho nerve centres affected by the excitation. With so satisfactory an hypothesis before us in this modified shape, it Avould seem needless even to suggest any other explanation. But in a region of research so little explored, it may be allowable to point out the fact, that another mode of explanation is at least possible, and the more so, since there exist certain objections to M. Brown-Sequard's manner of vicAving the subject. It is to our minds improbable that contraction of the capillaries can continue for any great length of time. There is no experiment on record to shoAV that this can be, or that it ever occurs in a nerve centre. Wo have therefore added the suggestion of consequent, and Avhy may Ave not say primary paralysis of these vessels. Here we have firmer ground for opinion, since it has been most distinctly shoAvn that in section of the sympathetic nerve this result does take place, and is singularly persistent. But Avhether tho bloodvessels remain contracted or dilated nutritive changes would occur, and these the pathologist has failed to find. If iioav avo ask ourselves the question, whether it may bo possible to blight or exhaust utterly the poAver of a nerve centre, Avithout the interA-ening mechanism of contracted or dilated bloodvessels, avo are tempted to think that such a result may bo producible. It appears to us possible that a A-cry severe injury of a part may bo competent so to exhaust tho irritability of the nerve centres, as to giA-o rise to loss of function, which might prove more or less permanent. A strong electric current, frequently interrupted, is certainly able to cause such a result in a nerve trunk, Avhilo a general electric shock, as a stroke of lightning, is, as avo avcII know, quite competent to destroy tho irrita- bility of every excitable tissue in tho economy. Noav if tho former of these results can occur in a nervo so insulated, as practically to have no circulation, tho loss of irritability cannot bo set down as due in such a case to a defect of circulation. Reflecting then upon tho close correlation of tho electrical and neural force, it does not seem improbable that a A'iolent excitement of a nerve trunk should bo able to exhaust completely tho power of its connected nerve centre. The central change thus brought about would no doubt involve the consequent or immediate occur- rence of chemical nutritive changes, Avhieh Avould gradually yield as 17 time went on. While this view seems to us adequate to explain the facts, the notion of vaso-motor irritation and capillary contraction (Brown- Skquard) does not appear to be competent to cover all the facts. We have pointed out that no one has ever shoAvn that capillary con- traction can exist as a permanent state in a nerve centre. While on the other hand, it has been proven that section of a sympathetic nerve involves permanent dilatation of bloodvessels; but in the brain, which is supplied by the sympathetic of the neck, division of this nerve gives rise to no disturbance, although the side of tho brain on which the section occurs grows warmer. However, it is probable that the whole supply of vaso-motor nerves to the brain does not come from the neck, Avhile other organs, whose whole supply Ave can cut off, as the kidneys, do certainly suffer nutritive changes as a consequence of such sections. One or other of the tAVO theories Ave have offered must therefore be called on to explain the central changes which give rise to reflex paraly- sis. Either the shock of a wound destroys directly the vital power of a nerve centre, or it causes paralysis of the vaso-motor nerves of the centre, Avith consequent congestion and secondary alterations. But there is no reason Avhy if shock be competent to destroy vitality in vaso-motor nerves or centres, it should be incompetent so to effect the centres of motion or sensation. Until the causation of these cases is better under- stood, it is vain to speak confidently as to treatment founded on a con- ception of the mode of their production. Experience has shown that the removal of the first cause, and in some instances the application of altera- tives, as blisters to the cicatrix, provo valuable in relieving such induced pain as may exist. Further, that stimulating liniments or blisters to tho affected member are useful, and that tho local application of induced electric currents to the muscles is of the utmost service. The question of the use of internal remedies has yet to bo decided by larger clinical experience. We, ourselves, have been unfortunate in that no chances have presented themselves of treating these cases in their early stages, Avhen the causes Avhieh first produce the paralysis are present and before those later nutritive changes occur Avhieh, as Ave presume, are essential to the* continued existence of the state of palsy. We have endeavored to shoAV in this report that the condition called shock is of the nature of a paralysis from exhaustion of nerve force; that it may affect one or many nerve centres, and finally, that it may be so severe as to give rise in certain cases to permanent central nerve changes, pro- ductive of paralysis of sensation and motion, or of cither alone. S. WEIR MITCHELL, GEO. Ll. MOREHOUSE, W. .W. KEEN, Jr., Act. Aist. Surgeons, U. S. Army. (J. S. General Hospital, Christian St., Philadelphia, Penn., February 15, 1864.