A DICTIONARY OP PRACTICAL MEDICINE: COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE. WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED; A CLASSIFICATION OF DISEASES AC- CORDING TO PATHOLOGICAL PRINCIPLES; A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN of formulae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE AND A DIGEST OF MEDICAL LITERATURE. BT JAMES COPLAND, M.D., F.E.S., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ! HONORARY MEMBER OF THE ROYAL ACADEMY OF SCIENCES OF 8WEDEN ; OF TIIE AMERICAN PHILOSOPHICAL SOCIETY; AND OF THE ROYAL ACADEMY OF MEDICINE OF BEL- GIUM ; LATELY PEESIDENT OF THE ROYAL MEDICAL AND CHIRURGIOAL SOCIETY OF LONDON ; FOR- MERLY CONSULTING PHYSICIAN TO QUEEN CHARLOTTE’S LYING-IN HOSPITAL AND SENIOR PHYSICIAN TO THE SOUTH LONDON DI6PEN8ARY; CONSULTING, AND LATELY SENIOR, PHY6ICIAN TO THE ROYAL INFIRMARY FOB DISEASES OF CHILDREN, ETC. EDITED, WITH ADDITIONS, BY CHARLES A. LEE, A.M., M.D., PROFESSOR OF MATERIA MEDIOA AND GENERAL PATHOLOGY IN GENEVA COLLEGE, ETC., ETC. “ ©flails tooltie Jjc lerne anti slaTjlg tectie.”—Chaucer. IN THREE VOLUMES. YOL. III. NEW YORK: HARPER & BROTHERS, PUBLISHERS, FRANKLIN SQUARE. 1859. “ Bead, and fear not thine own understanding; this book mil create a clear one in thee; and when thou hast considered thy purchase, thou wilt call the price Of it a charity to thyself.” Shieley. “ One caveat, good reader, and then God speed thee!—Do not open it at adventures, and, by read- ing the broken pieces of two or three lines, judge it; but read it through, and then I beg no pardon if thou dislikest it. Farewell.” Thomas Adams. “Where there is much desire to learn, there will of necessity be much arguing, much writing, many opinions; for opinions in good men are but knowledge in the making.” Milton. “ Uti ratio sine experiments mendax, ita experientia sine ratione fallax.” Bkunxer. “ Antequam de remediis statuatur, primum constare oportet, quis morbus et quae morbi causa; ali- oquin inutilis opera inutile omne consilium.” Baglivi. “It is the great excellence of a writer to put into his book as much as his book will hold.” S. Johnson. “What dire necessities on every hand Our art, our strength, our fortitude require! Of foes intestine what a numerous band Against this little throb of life conspire! Yet science can elude their fatal ire A while, and turn aside Death’s leveled dart, Soothe the sharp pang, allay the fever’s fire, And brace the nerves once more, and cheer the heart, And yet a few soft nights and balmy days impart.” Beattie. “Go, little book, from this my solitude; I cast thee on the waters: go thy ways; And if, as I believe, thy vein be good, The world will find thee after many days.” Southey. Entered, according to Act of Congress, in the year one thousand eight hundred and forty-six, by HARPER & BROTHERS, in the Clerk's Office of the District Court of the Southern District of New York. A DICTIONARY OF PRACTICAL MEDICINE. PALATE.—Syn. Palatum, P. molle et durum. Palais, Fr. Der Gaumen, Germ. Palato, Ital. The fauces. 1. The mucous membrane covering the isth- mus faucium, the soft palate or uvula, may be simply relaxed, or inflamed, or ulcerated. The hard palate—the bones of the palate may be also diseased—may be inflamed or ulcerated and carious, but chiefly as a symptom of se- rious constitutional disease, especially of syph- ilis, more rarely of scurvy. 1. Relaxation of the Palate and Uvula. ■Relaxed throat—Relaxed sore throat—Catarrhal relaxation of the throat—Relaxation of the fauces. Classif.—I. Class, I. Order {Author). Defin.— Uneasiness or soreness in the fauces, often with slight cough, without fever. 2. This affection occurs primarily; but it also attends catarrhal and other inflammations of the mucous membrane covering those parts and the tonsils and pharynx. It is also symptomatic of catarrhal affections, of chronic bronchitis, of the several states of indigestion, and of numer- ous other diseases. The anterior fauces, or velum palati, appears more or less relaxed, very humid or watery, with little or no increase, or only with slight increase of vascularity, and the uvula is elongated, and hangs down upon the base of the tongue, often reaching to the epi- glottis, and is sometimes also oedematous. More or less uneasiness in the throat, somewhat in- creased on deglutition, and occasionally a dry, tickling cough, particularly when the relaxed uvula irritates the epiglottis, are complained of. Indeed, the elongation of the uvula is gen- erally the cause of the chief uneasiness attend- ing relaxation of the palate or fauces, which often becomes a chronic disorder, especially in leucophlegmatic habits, and in persons who live irregularly and intemperately. 3. This affection, when it appears primarily, is generally caused by the same influences as produce inflammatory attacks of the palate or fauces {) 6), and catarrhal affections. It rare- ly continues limited to these parts, but extends to the adjoining surfaces, to the pharynx, epi- glottis, and larynx, causing a tickling cough, with slight mucous expectoration. It is fre- quent in spring and autumn, especially during humid states of the air, and usually, with re- laxation or irritation of the Schneiderian mem- brane, constitutes a principal part of the com- mon catarrhal affection. (See Art. Catarrh, « 7.) 4. The treatment necessarily depends upon the causes of the affection, and upon the nature of the disorders of which it is symptomatic. If a part of, or connected with, the common T TT catarrh, the treatment advised for that disorder (§ 16, et seq.) should be employed, and a warm embrocation may be applied to the neck or throat. If it be a symptom of indigestion, ton- ics and astringent gargles, after biliary and intestinal secretions are evacuated, are gener- ally useful. In persons subject to dyspepsia, in those of a relaxed habit of body, and in the irregular liver, relaxation of the soft palate and uvula often becomes chronic, whatever means of cure be prescribed, especially if the li ver be at the same time torpid, or otherwise disorder- ed. In those persons the elongation is often attended by oedema of the uvula, and is produc- tive of the most unpleasant part of the symp- toms. Amputation of the part has, therefore, been often recommended, and too often allowed. Several persons who have had the uvula re- moved, have consulted me on account of disor- ders which had either continued or appeared after this part had been extirpated. The func- tion of the uvula is evidently to convey the mucus and saliva over, and thereby to lubricate the base of the tongue and epiglottis ; and when it is no longer, or is imperfectly discharged, not only those parts, but also the pharynx and glot- tis, become the seat of a chronic irritation more serious than that caused by an elongation, which a judiciously-directed treatment to the original source of disorder would remove. 5. If the elongation continue after such treat- ment, the hydrochloric or nitric acids, or both conjoined, may be given in the decoction ot baric, or in sirup with a tonic tincture, and as- tringent gargles may be employed. If these fail, the uvula may be touched by a solution of the nitrate of silver, or by a powder containing the sulphate of alumina or sulphate of zinc. II. Inflammation of the Palate.—Syn. Pal- atitis, Islhmitis, Hildenbrand. Isthmitis sim- plex ; Angina simplex; Cynanche simplex; An- gina gutturalis ; Angina mitis ; Angor Fau- cium ; Inflammatio Palati; Injlammatio Fau- cium, Auct. var. Angine simple, Palatile, Fr. Die Rachenbraiine, Halsentzundung, Entzun- dung der Fauces, Germ. Sore throat, Quinsey, Inflammatory Sore-throat. Inflammation of the Fauces. Classif.—III. Class, I. Order {Author). Defin.—Redness of the soft palate, generally with elongation of the uvula, pain on sivallowing, and slight fever. 6. i. The Causes of Palatitis are chiefly those productive of Catarrh (v lifting very heavy weights. Dr. Healy has PARALYSIS—Varieties and States of. described instances of palsy of the hand and forearm, owing to pressure caused by the head resting on the arm when asleep, which could be removed only by electricity ; and Dr. Dar- well has ascribed the palsy consequent upon over-exertion to the injury done to, or over- straining of, the nerves supplying the affected muscle. 24. Palsy of a single limb is not infrequent in children. It is often congenital, and the up- per are more liable to it than the lower limbs. It is sometimes owing to congenital disease or deficiency of the brain ; but, when it takes place subsequently to birth, it has been imputed to a loaded state of the bowels, or to disorder of the stomach ; but disease of the brain or spinal chord is probably more immediately than those connected with its occurrence. Some of these cases grow up, and present the limb of a child joined to the body of an adult. I have met with several instances of this occurrence, one in a physician, another in a medical student, both being characterized by remarkable irrita- bility of temper. An upper extremity, which contrasted remarkably in size with the sound limb, was affected in both these cases. 25. Palsy of a part, or of the whole of one limb, is very generally the commencement of a more extended malady; and instances are sometimes met with where only a few of the muscles of an extremity are affected, these be- ing, according to Sir C. Bell, muscles natu- rally combined in action, although supplied with different nerves and different blood-vessels. Sometimes all the extensor muscles lose their power, while the flexors preserve it. In rare instances, also, as in the case of a lady lately under my care, the motions necessary for wri- ting, or for any fine work, were completely lost, while the arm could be moved as strong- ly as ever. It has been supposed that the nerve in these eases is incapable of perform- ing its functions, owing to pressure or dis- ease ; and this is probably the case in some in- stances, as in those recorded by Drs. Aber- crombie and Storer, and more especially when partial paralysis follows acute or chronic neuri- tis. It is even possible that, in other cases, the palsy is caused by imperfect or interrupted circulation through the blood-vessels of the limb, owing to disease of them, as supposed by Graves, Stokes, and others. But in some instances there are no indications of disease of the nerve itself, and the circulation is perfect in the affected extremity. In the case of the lady just alluded to, who is about sixty years of age, and of a full habit of body, there was no sign of disease in either the nerves or the blood-vessels of the limb itself. I prescribed for her blood-letting, which was performed un- der my own eye, twenty-four ounces being quickly taken away without any faintness be- ing caused. After the depletion and purging, the partial state of palsy gradually disappeared. 26. e. Paralysis of the tongue and muscles of articulation, although occurring frequently in connexion with hemiplegia and apoplexy, is very rarely met with alone. I have, however, been consulted in several cases, in which it was either the chief part of the disease, or was associated with difficult or impossible degluti- tion. In a case from the country, which I re- cently attended, complete loss of the power of articulation was associated with partial palsy of the extremities, the patient being deficient chiefly in the power of contracting the muscles of the hands and forearms. Both lower ex- tremities were also weak. He returned with- out benefit from treatment, and died soon af- ter. I have not learned the particulars con- nected with his death. In this case loss of ar- ticulation was the first and chief symptom, yet the tongue could be protruded without being drawn to either side. 27. Some years ago, Mr. Winstone consult- ed me in the case of a professional gentleman, aged about fifty, who had, for many months, lost all power of uttering the most simple ar- ticulate sound, and who swallowed substances with the utmost difficulty, or not at all, unless they were conveyed over the base of the tongue. The tongue could not be protruded, and, indeed, was incapable of motion. The mouth, also, could be opened only imperfectly, but the sense of taste was not affected. He had neither head- ache nor any other ailment, and no other part was paralyzed. He attended regularly to his profession during the usual hours of business, but was obliged to write down all he wished to say. The disease was ascribed to pressure or structural change at the origin, or in the course of the lingual and glosso-pharyngeal nerves; and the prognosis of suddenly fatal apoplexy or general paralysis was hazarded, which oc- curred some months after my attendance ceas- ed. Various means were prescribed without any effect on the disease. 28. Most frequently, however, paralysis of the muscles engaged in articulation, o.r in deg- lutition, or in both functions, follows upon se- vere or renewed attacks of apoplexy, or of hemiplegia complicated with apoplexy. I have seen it occur after inflammation of the brain, and after cerebral convulsions in children, as in the case of a fine boy, respecting whom I was consulted by my friend Mr. Worthington of Lowestoft. The disease may continue for many months unmitigated by treatment; it is generally ultimately fatal, death taking place after or during a convulsive attack. 29. /. Aphonia, in the true sense of the word, can occur only when the larynx is affected, ei- ther its muscles being paralyzed, or its struc- ture changed by serous or other effusion be- tween its ligaments, tendons, or cartilages. Loss of the power of articulation depends upon paralysis of the tongue, cheeks, and lips; and this loss may be so complete as to prevent all articulate sounds from being produced ; still the power of uttering sound remains, but in its sim- plest form only. When articulation is entirely gone, the motions of the muscles of the pharynx and base of the tongue are also lost. Simple aphonia is often caused by temporary inaction or torpor of the nerves of the larynx, in hyster- ical or nervous persons. Loss of the power of articulation is a much more serious and per- manent malady than aphonia, and is either at- tendant upon, or followed by, the most general or fatal states of palsy, unless in hysterical ca- ses ; and in these the motions of the tongue are also sometimes temporarily lost. In cat- alepsy, voice and articulation are quite lost, with all voluntary motion, but they return as soon as it is restored. In incomplete palsy of the tongue, protrusion of it may generally be 15 16 PARALYSIS—Varieties and States of. eftected ; but it is generally drawn to one side, particularly if hemiplegia also exist. In other cases it is usually protruded in a straight di- rection. The tongue, even in cases of hemi- plegia, is not always drawn towards the sound side. Sometimes it is drawn to the paralyzed side. Laleemand imputes its direction to this side to the action of the genio-glossus muscle of the unaffected side drawing the base of the tongue forward, and turning the apex to the opposite side. Cruveilhier attributes the di- rection of this organ, when protruded, to feebler resistance on one side than on the other. 30. g. Paralysis of any of the muscles of or- ganic life rarely takes place to any extent, and is, indeed, incompatible with the continuance of life, unless in those viscera which are particu- larly influenced by volition, as the urinary blad- der, the sphincters, &c. A temporary state of relaxation, or loss of the contractile power, of portions of the alimentary canal not infrequent- ly occurs in the course of various diseases, and constitutes a part of the pathological conditions obtaining in inflammations of this canal, in col- ic and ileus, in lead colic, in hysteria, &c.; but it rarely continues for any considerable period, at least in a complete form, and in the same portion of the tube, without being followed by a fatal result. 31. h. Palsy of the urinary bladder, owing to over-distention, is a frequent occurrence ; it is likewise connected with paraplegia, and in both circumstances of the complaint retention of the urine is the prominent phenomenon. Hyster- ical paralysis of the bladder is often met with. Dr. Todd says that there is much truth in Sir B. Brodie’s remark that, in these cases of hys- terical paralysis, “ it is not that the muscles are incapable of obeying the act of volition, but that the function of volition is suspended.” Of course the muscles possess their capability of motion ; no one could have suspected the con- trary ; that the function of volition is suspend- ed in these cases is, however, a more doubtful proposition. The truth is, that a careful in- quiry into the phenomena of hysterical paral- ysis, in some cases which have come before me, has shown that, owing to a weakened or exhausted state of the spinal chord and motor nerves, volition is not transmitted in sufficient force to produce muscular action ; and that vo- lition is not suspended, although it may be weakened ; but that it must be made with more than usual energy to act upon, or even to be transmitted to the muscles. 32. i. Palsy, more or less complete, of the rectum, is not infrequent in aged persons, and in hysterical females. In these cases faecal ac- cumulations often form in the rectum and co- lon, owing to their inaction or want of power io overcome the resistance of the sphincter. 33. k. Palsy of the sphincters of the rectum and bladder attends most maladies in which ei- ther the brain or the spinal chord is oppressed, or has lost its power. The inability to retain the faeces, or the incontinence of urine which results, becomes one of the most troublesome and unfavourable phenomena of the disease. As, however, this form of local paralysis very rarely occurs unconnected with a more exten- sive malady, it will be more fully noticed here- after. 34. B. Hemiplegia (from r/iuav, the half, and TTAr/aacj, I strike)—semisideratio—is used to de- note paralysis of one side, extending to both the upper and the lower extremities. When the upper limb of one side and the lower ot the opposite side are affected, the palsy is usual- ly called transverse or crossed jpalsy ; but this form is comparatively rare. Hemiplegia is the most common form of the malady ; and it oc- curs more frequently on the left than on the right side, the proportion being as three to two, according to the observations of Sir G. Blane. Generally the paralysis extends to the side ot the fhce, the angle of the mouth being drawn to the sound side, and a little upward ; the tongue, also, is often more or less affected, and on the same side, as shown either by its imper- fect protrusion, or by its being drawn to one side—usually to the same side as the mouth. The pharyngeal muscles are sometimes also affected. Hemiplegia is limited exactly to one half of the body, the median line being the boundary, owing to the distribution of the spi- nal nerves. 35. The attack of hemiplegia occurs various- ly. 1st. It may appear gradually ; local palsy, affecting first the fingers or toes, leg or hand, taking place, and extending slowly and gradual- ly until the lateral half of the body is implica- ted. In some cases of this form of the disease, convulsive movements of a limb, or even of both limbs, are remarked, and continue until the loss of motion is complete. 36. 2d. After various chronic cerebral symp- toms, and affection of one or more of the senses, the speech becomes affected, the tongue more or less palsied, or protruded with difficulty, and the face distorted ; upon these complete hemi- plegia supervenes in a short period. This form is not infrequent in aged persons. In this and the preceding variety, several organic lesions, as tumours, tubercles of the brain, or its mem- branes, are often present. 37. 3d. After cerebral symptoms of a more acute and painful character ; after severe head- ache, febrile commotion, sometimes delirium or intellectual disorder, spasm or twitchings of the muscles,, pain in the limbs, occasionally spastic rigidity of some of the flexor muscles, or even convulsions, complete hemiplegia takes place. In this variety inflammatory softening of a portion of the brain is often present, and pain is complained of in the paralyzed limbs. 38. 4th. After injury of the head, at a more or less remote period, or after chronic cere- bral symptoms, and various affections of some one or more of the senses, convulsions or ep- ileptic seizures occur, which, after a more or less frequent recurrence, are followed by palsy of a limb, most frequently the arm, extending to the whole side ; or at once by complete hemiplegia. In three cases of this variety I found one or more abscesses in the brain. In these several states of hemiplegia the sensi- bility is generally unimpaired, or but partially affected. 39. 5th. Hemiplegia may occur suddenly, without any previous indication. In some of these cases I have ascertained the existence of inflammatory attacks of the brain at a re- mote period, recovery having taken place long previously to the hemiplegic seizure. This va- riety is often followed by apoplexy, but at no precise period. 40. 6th. Hemiplegia frequently immediately follows an apoplectic seizure, or attends it, or appears in its course. In this variety more especially, and very often in that immediately preceding, haemorrhage within the cranium has occurred. Generally the hemiplegia is observ- ed only when the stupor subsides ; but in many instances it may be detected at first by a care- ful examination of the state of the extremities and features. According to my experience, the sensibility is most frequently implicated in the fifth and sixth of these varieties of the seizure. 41. Although some reference has just now been made to the cerebral lesions upon which those varieties of hemiplegia individually ap- pear most frequently to depend, still no pre- cise or constant connexion between the one and the other has been ascertained, and most probably it does not exist. Nevertheless, the relation is too frequent and too obvious to be entirely overlooked. Of hemiplegia it may be remarked, in general terms, that it may pro- ceed from any one or more of the numerous organic lesions which are described in the ar- ticles on the morbid anatomy of the Brain and its Membranes, and of the Cranium. {See these articles.) 42. One fact may be relied on, viz., that the lesion exists, with very few exceptions, and these not very precisely determined, in the side of the brain opposite to the seat of palsy. Dr. R. B. Todd remarks that, according to the views of Foville and others, we should ex- pect to find the optic thalami and corpora stria- ta, or some of the fibrous radiations which pass through these bodies, the seat of disease in hemiplegia; and, in fact, in the generality of cases, those bodies, or some portion of the cer- ebral hemisphere, present alteration of struc- ture, variable in extent as well as in degree. It must be admitted, however, that cases oc- cur in which one only of these bodies is the seat of disease, or in which no appreciable le- sion can be detected in the hemisphere. Such occurrences, however, as Dr. Todd justly ob- serves, can hardly be deemed to militate against the theory of Foville, inasmuch as our igno- rance of the mechanism of cerebral action, whether healthy or morbid, is alone sufficient to make them appear anomalous to us. 43. Hemiplegia is very rarely produced by disease of the upper part of the spinal mar- row. In several cases of lesion of this part, in' which I have been consulted, the paralysis has been at first local or partial, generally af- fecting one arm, but it has soon become more general. In some instances, however, one side has been affected more than the other, or one or two limbs more than the rest. Instances, however, have been observed of loss of mo- tion on one side, and anaesthesia of the other ; but these are remarkably rare. One has been adduced by Portal, and another by Mr. Dun- das. This latter case was consequent upon concussion of the spine produced by a fall. The temperature of the side and limbs, depriv- ed of sensation, but possessing muscular pow- er, was lj3 Reaumur, below the side which retained sensation without motion, the heat on this side being rather beyond natural, and the sense of feeling morbidly increased. 44. Hemiplegia may be congenital, or may occur soon after birth. M. Cazauvieilii has PARALYSIS—Varieties and States of. shown that congenital hemiplegia usually de- pends upon an arrestor defect of development or growth in a portion of the brain. The limbs of the affected side, particularly the arm, were stunted in growth, and flexed and contracted. The opposite hemisphere of the brain was gen- erally smaller, the convolutions imperfectly developed, the capacity of the ventricle less, and the corpus striatum and optic thalamus of smaller size. Cases of this kind may attain an advanced age. Most of the instances I have had an opportunity of observing were idiotic, as well as incompletely paralyzed on the de- formed side. Cases of hemiplegia have oc eurred in which the opposite side has become similarly affected, either soon after the first attack, or during convalescence from it. In these the sensibility has sometimes either been only partially, or not at all affected. 45. The paralyzed side may be the subject of pain, the result of morbid action in the brain, or of spasm; hence designated spasmodic hem- iplegia by Sauvages and others. In these, in- flammatory irritation in the brain or its mem- branes, in the vicinity of the primary seat of lesion, often exists. Deep-seated pain or spasm may occur in a limb, the superficial sensibility of which is either impaired or altogether lost; and either or both phenomena may affect the opposite or sound limb, although less frequent- ly than the paralyzed side. I have never seen an instance of hemiplegia with spasm of the paralyzed side, to which the term of hysterical, imposed by some nosologists, was strictly ap- plicable. Hysteria very rarely occasions true or complete hemiplegia, but I have met with several cases of paraplegia caused by hysteria. 46. Intermittent hemiplegia has been noticed by Sauvages, Morgagni, Cullen, Elliotson, and Todd ; but examples of it have been rare- ly and imperfectly observed. It would seem that the congestion of, or vascular determina- tion to, the brain, during the febrile paroxysm, occasioned a condition of one of the hemi- spheres, or of a portion of it, so as to interrupt the action of volition ; but that the change was only temporary, and depended upon the state of circulation attending the febrile parox- ysm ; that it consisted neither of softening nor of haemorrhage. 47. Much variety in the symptoms are ob- served in the course of hemiplegia, depending upon circumstances that will be alluded to hereafter, and upon a partial or more complete return of sensibility when this has been also lost, and upon a slight recovery of some of the motions of the limbs, particularly of the lower limb ; but generally when the patient is able to walk a little, or with the aid of a stick, the lower extremity is usually thrown forward by the inclination of the trunk to the sound side. The foot is pointed outward when the limb is raised, and falls from its own gravity. The affected arm is applied to the trunk, and the forearm is slightly flexed on the arm, the wrist and fingers being also slightly bent inward, and occasionally somewhat {edematous. 48. C. Paraplegia (from napa, vitiose, and nlyaau, perevtio) has in modern times been applied to that form of palsy in which the low er half of the body is deprived of motion oi sensation, or of both. Hippocrates denomi- nated all paralytic affections paraplegia which 17 18 PARALYSIS—Varieties and States of. were consequent upon apoplexy ; and Are- employed the word to designate any form of palsy. Boerhaave and Van Swieten defined paraplegia to be a palsy of all parts be- low tbe neck, or viewed it as a general palsy (<5> 65, et seq.); and in this sense it has been used by Ollivier and several modern pathol- ogists. I shall, however, apply the term para- plegia to that form of palsy which affects the lower half of the body on both sides. When palsy extends to the upper and lower extrem- ities of both sides, it may be denominated, al- though it is not strictly, general palsy 49. The symptoms most characteristic of paraplegia are, loss of the power of motion in the lower limbs, with inaction of the urinary bladder and rectum, with loss of power over the sphincters, and often with impairment or entire loss of sen- sation. 50. The accession of the symptoms of para- plegia, as well as the character, range, and grouping of the symptoms themselves, varies with the pathological changes or physical caus- es of the malady, as it proceeds from injury, from inflammation and its consequences in the spinal chord or its membranes, or from organ- ic lesljons of these parts, or of the bones and cartilages of the spine. When the disease is consequent upon injury, the symptoms are gen- erally sudden in their accession and fully de- veloped, although this is not always the case, especially if the accident be slight, and serious only as regards its consequences. When it proceeds from disease of the chord or of its envelopes, some disorder of sensation or of motion, or even of both, is first experienced, which becomes more or less rapidly increased to numbness, or diminished power of motion, of the lower extremities. The patient trips when walking, is unable to stand for any time, and complains of a sense of weight in the limbs, and of pains extending to the legs and feet. He cannot walk without the aid of one or two sticks, or of another person. The urinary blad- der, rectum, and sphincters soon afterward be- come more or less affected, and various other phenomena supervene, according to the seat and extent of the organic change occasioning the affection. In some cases sensibility in the lower extremities is but slightly, or even not at all impaired, particularly when the lesion is seated high in the spine ; and when this is the case, even the patient’s power over the excre- tions and the sphincters may not be materially impaired. It is comparatively rare that sensi- bility is impaired or altogether lost in the low- er limbs without the power of motion being also diminished or abolished. 51. a. The symptoms, pi-ogress, and consequen- ces or terminations of paraplegia vary with the lesion producing it ; and it is difficult, if not impossible, to connect the symptoms, in their full extent and course, with the particular le- sion upon which they depend. The exact seat of lesion, in respect not only to the portion of the chord which it affects, but also to the roots of the nerves connected with the part implica- ted ; the nature of the lesion, particularly as regards the degree of pressure, or of irritation, it produces ; and the suddenness o-r slow prog- ress of the change, all influence very remark- ably the phenomena and course of the malady. 52. There are few diseases which have been more lucidly illustrated than paraplegia conse quent upon injury has been in the admirable paper upon the subject published by Sir B. C. Buodie ; and as injury often causes inflamma- tion and its usual consequences of the spinal chord and its membranes, the subject has both a medical and surgical bearing. Many, how- ever, of the changes consequent upon injury— even haemorrhage upon or into, and softening of, the spinal chord—and various organic lesions of these parts or in their vicinity, may occur independently of external injury, and cause par- aplegia. It will be proper to enumerate these. 53. 1 a. Concussion of the spinal chord affect- ing the intimate structure of some part of the chord, although not evidently to the unassisted eye ; 2b. Manifest laceration or division of its substance; 3c. The pressure or irritation caused by extravasated blood; *d. The pressure or irri- tation produced by displaced bone; Be. Sanguin- eous congestion, particularly of the spinal veins or sinuses; 6/. The usual consequences of in- flammation of the chord or of its membranes especially effusion of coagulable lymph, indura- tion of the substance of the chord, &c.; tg. Softening of the chord, whether it be consequent upon inflammation, or upon impaired nutrition or lost vitality ; 8h. Inflammation and its conse- quences of the vertebra, or of the intervertebral substance, as caries, exostosis, anchylosis, fc. of the vertebra ; 9i. Scrofulous disease and tuber- cles in these parts; l0k. Tubercles or tumov.rs in the chord or its membranes ; ul. Hydatids in either of these situations ; 12m. And fungoid or malignant tumours implicating the chord or the roots of the spinal nerves, are severally patho- logical causes of paraplegia ; but the symptoms of individual cases, as well as the issue, depend upon the part of the chord affected; upon the extent of the particular lesion ; upon the slow- ness or rapidity of its development; and upon the manner in which the chord or roots of the spinal nerves is implicated, whether by press- ure, loss of substance, softening, irritation, in- terrupted circulation, &c., or by two or more of these conjoined. 54. It would be inconsistent with a proper consideration of this subject were I to overlook the physical condition of the spinal chord, es- pecially in relation to the fluid surrounding it, to the membranes enveloping it, and the bony case protecting it. The physiological view here suggested materially aids the pathological con- sideration of the subject. This interesting physical condition also obviously concerns the roots of the spinal nerves, and serves to explain several circumstances connected with them, as well as with the spinal chord itself. These parts, being thus surrounded by a limpid fluid, and being protected by membranous coverings, and by a bony case and muscles, are thereby rendered much less liable to disease and injury than if they were otherwise circumstanced, as first insisted upon by Cotugno, more recently by Magendie, and most satisfactorily by Dr. Todd. Before pursuing farther this part of the pathological bearing of the subject, I will notice more fully the chief phenomena of paraplegia. 55. b. Paralysis of motion is the chief char- acteristic symptom of paraplegia, and it affects more or less all the muscles supplied with nerves from the seat of, and below, the injury or dis- ease in the chord. If the disease be slight, only one limb, or a set of muscles, may be af- fected, as above adverted to, especially if the roots of a nerve or nerves on one side only be implicated ; or one limb may be more severely affected than the other; or a slight affection may soon become severe, or the converse. Complete paraplegia may thus be gradual and slow, or it may be sudden. It rarely happens that the palsy extends to parts supplied with nerves proceeding from a portion of the chord above the seat of injury. Instances, however, of this occurrence are recorded by Mr. Staf- ford and Sir B. Brodie. In these cases, it may be presumed that the consequences of the in- jury, as softening of the chord, effusion of blood or of lymph, had extended upward from the part primarily injured. 56. Although voluntary motion is completely abolished in the lower limbs, involuntary mo- tions and spasms of their muscles are not in- frequent. When the lesion is seated high in the chord, spasmodic contractions, either of more or less permanency, or of a momentary or short continuance, may affect the abdominal muscles, as well as the muscles of the lower limbs, and these may be attended by much or by little pain, either in some portion of the spine or in the limbs. Occasionally the invol- untary motions are of a tremulous kind, and often the flexor muscles are those more per- manently contracted. The pains, involuntary motions, and spasms are manifestly caused by inflammation or irritation of the chord or of its membranes, or of the roots of the nerves at the seat of lesion, especially by extravasated blood; by pressure or irritation of tumours, displaced bone, effused pus ; by caries of the vertebrae, by malignant or other formations. 57. c. The affection of the urinary organs con- sequent upon paraplegia from injury or disease of the spinal chord varies in different cases. It may be considered with reference to the func- tions of the kidneys and the states of the blad- der. Paraplegia from severe external injury is very frequently followed by diminished secre- tion of urine, or even by complete cessation of the function; but this is often only temporary, and the urine is secreted in variable quantity and altered quality. In some cases, it is at first acid, very offensive, of a yellowish colour, and deposites a yellow, amorphous sediment. More commonly, however, especially after two or three days, the urine is ammoniacal and tur- bid when voided, and deposites on cooling a quantity of adhesive mucus. At a later period a white substance, phosphate of lime, may be detected in the mucus, which is often tinged with blood ; and subsequently blood and bloody coagula are blended in the urine and mucus. These changes generally take place between the third and ninth days from the paraplegic at- tack, when it is sudden and complete, especial- ly if caused by injury, and when the bladder becomes distended from loss of its contractile power. At the same time that this distention exists, a dribbling of urine often takes place, if the fluid is not drawn off. In other cases, es- pecially in those caused by disease seated in, or implicating, the chord, the voluntary power over the sphincter of the bladder only is para- lyzed, there being incontinence, but no reten- tion of urine. In the most severe cases, the urinary affection continues and hastens a fatal PARALYSIS—Varieties and States of. issue ; but in others, the power of evacuating the bladder, or of retaining the urine, is resto- red ; and the urine assumes a more acid and healthier character. This amelioration of the urinary disturbance is one of the chief indica- tions of restoration of the functions of the chord ; but the state of the urine often varies from time to time, before it becomes perma- nently healthy, or before the muscles of the ex- tremities obey the will. 58. In these cases, where the urinary blad- der is paralyzed, and the urine retained, a state of septic or asthenic inflammation is rapidly produced in the mucous membrane of the blad- der, ureters, and pelves of the kidneys, occa- sioning the chief changes observed in the urine, particularly the ammoniacal state, the presence of mucus and coagula of blood, &c. Sir B. Brodie has put the question, whether the inju- ry of the chord operates directly on the mu- cous membrane, or whether its first effect is to alter the quality of the urine, the mucous mem- brane becoming affected afterward, owing to the unhealthy and irritating secretion 1 Instead, however, of imputing the effect on the urinary organs to one of these causes only, I believe that it may be justly imputed to both of them : that the unhealthy and irritating secretion rap- idly induces inflammation of the surfaces with which it remains for a time in contact, owing to the marked disposition of these surfaces to become inflamed when deprived of that portion of nervous influence which they derive from the spinal chord ; and that they partake in this disposition to be inflamed and ulcerated with other parts below the seat of spinal lesion. In some instances, particularly when the lesion is seated high in the chord, or when the paraple- gia is incomplete, or the power of motion prin- cipally affected, the urinary disturbance is not considerable, and the powers of expulsion and retention but little impaired. 59. d. The bowels are generally not only tor- pid in paraplegia, but the evacuations are very dark and morbid. This latter state is the more remarkable, the higher in the chord is the seat of lesion. In a case lately under my care, the evacuations, which were procured with diffi- culty, were nearly black, or of a deep greenish black, and of a treacle or tar-like appearance and consistence. This colour is probably ow- ing to impaired decarbonization of the blood by respiration, the liver and digestive mucous sur- face performing a vicariously increased func- tion in respect of sanguineous depuration, or of removing the superabundant carbon from the blood. This explanation of the phenomenon was published by me as early as 1815, and sub- sequent observations induce me to reassert it now. 60. One of the earliest phenomena associated with paraplegia is palsy or inaction of the rec- tum and colon, the latter viscus especially be- ing unable to propel its contents. At the same time, the sphincter ani is not relaxed, but sub- sequently, or as soon as the faecal matters ac- cumulate in the lower bowels, they pass invol- untarily, owing to reaction of these bowels on their contents, and the loss of voluntary power over the sphincter. Incontinence of the faeces generally accompanies retention or inconti- nence of the urine ; while, on the other hand, it is not remarked in the same states of the 19 20 disease that are unattended by the urinary dis- turbance (§ 57). Still, although the patient has power over the faecal evacuations, particularly when the upper portion of the chord is affect- ed, or when paraplegia is consequent upon dis- ease slowly developed and implicating the chord, the stools are not the less black and of- fensive. They are often also very abundant, and the intestines are usually distended by gas- es, and are tympanitic. 61. e. The sensibility in paraplegia varies re- markably. When the palsy is caused by con- cussion or other severe injury of the chord, both sensation and motion are abolished. In slighter cases, and in diseases or spontaneous lesions implicating the chord, and occurring gradually and slowly, the sensibility may be un- affected, while motion is altogether lost. In other cases, sensation may be only blunted, or it may be impaired in one part, and perfect in another, or entirely lost. Very frequently sen- sibility of the surface only is impaired or abol- ished, while deep-seated parts retain their sen- sibility ; and often pains, more or less acute, or feelings of heat, burning, or constriction, are felt in the back, abdomen, or loins; or even in limbs or parts which are altogether insensible to touch, and even to external punctures or in- juries. Sensation is sometimes gradually, oc- casionally suddenly, lost; but, as in hemiplegia, so in paraplegia, it is restored before the pow- er of motion. 62. /. Priapism attends paraplegia from con- cussion or injury of the upper portions of the chord ; but it sometimes occurs in those cases which are caused by disease. Sir B. Brodie has not met with this symptom where the seat of lesion was below the sixth dorsal vertebra. It is observed even where the sensibility is al- together abolished. It seems to be occasioned, in some cases, by the irritation consequent upon the introduction of the catheter. 63. g. The temperature of the paralyzed parts is generally above the healthy standard. This is most manifest in complete paraplegia from external injury; but I have observed it also in- creased in cases produced by disease, although not so generally and remarkably, and where the sensibility of the surface was unimpaired. This increase of temperature appears to be chiefly owing to the dry and unperspiring state of the surface of the paralyzed parts, in con- nexion with the state of the circulation and blood. 64. h. The occurrence of gangrenous sores, upon the least injury or pressure of any of the paralyzed parts, is generally observed, and is often remarkable. It seems to be attributable to an impaired vital cohesion of the tissues, caused by a loss of that portion of nervous en- ergy bestowed on them by the spinal chord It is most manifest in cases of severe injury of the chord, and when sensibility is altogether lost. When the lesion is seated high in the chord, and is more or less chronic, a scurfy, dry, or furfuraceous state of the surface is oft- en observed. 65. D. General Paralysis.—When palsy ex- tends to both sides of the whole body—when all the limbs and trunk of the body are deprived of motion—the disease has usually been viewed as general palsy. In this very extended form of the malady voluntary motion may alone be PARALYSIS—Varieties and .States of. lost, sensibility still remaining. But the gen eral sensibility is sometimes also more or less impaired, as in cases of paraplegia, much more rarely altogether abolished. Indeed, general palsy may be viewed as a more extended state of paraplegia, as it has been by some of the older as well as of more modern writers. In some rare instances the senses, or one or more of them, have been impaired, or even lost, as well as the power of motion and sensation. In- stances of this kind have been published by M. Defermon and Mr. Davies Gilbert. In the more common states of general palsy the af- fection extends no higher than the upper ex- tremities, and depends upon some lesion im- plicating the spinal chord or its membranes be- low the origin of the pneumogastric nerves. In the rare instances, where the senses are also implicated, the lesion is generally seated with- in the cranium, or in one or more of the parts composing the base of the brain. In the case described by Mr. D. Gilbert, it was found, upon dissection, that “ the dura mater lining the basis cranii was deficient, and its place oc- cupied by a thin and transparent membrane, loosely and singularly arranged ; the tentorium cerebelli was likewise deficient, so that the pos- terior lobe of the brain rested immediately upon the upper surface of the cerebellum. All the nerves were regular.” 66. a. Concussion of the brain and the more severe states of apoplexy are attended by gener- al palsy, concussion of the brain especially im- plicating also the senses. These, however, oc- cur differently, and are attended by phenom- ena which remove them from the category of paralytic diseases. The relation between them, however, is intimate. Motion, sensation, and consciousness are all lost in these maladies, respiration and circulation alone continuing. As soon as the respiratory nerves are affected by direct or counter-pressure in apoplexy, or by the change produced in the intimate struc- ture of the brain, cr medulla oblongata in con- cussion, life is soon terminated. When, on the other hand, the mischief is less extensive, and the patient regains consciousness, a more or less general state of palsy may remain, at least for a time, and either recovery take place, or hemiplegia, or more partial palsy, only remain. The apoplectic Jr cerebral form of general palsy may be viewed as an indication merely of the nature and extent of the cerebral lesion. A person may be seized with hemiplegia conse- quent upon softening of a portion of one of the hemispheres, or upon haemorrhage in the brain, or upon any other organic lesion. A greater amount of the same lesion, or others concur- ring with it, may so completely subvert the powers of motion, and even of sensation, as to give rise to a general palsy, circulation and respiration alone remaining. These occurren- ces are not rare. Thus, inflammation, limited to a portion of the brain, may first occur, and be manifested by symptoms which the close ob- server will detect. At an indefinite period sub- sequent to this attack, the patient may be sud- denly seized with hemiplegia, and may contin- ue in this state for weeks, months, or even years, when a profound apoplectic seizure oc- curs, occasioning general palsy, extending ul- timately to the muscles of respiration, and causing death by asphyxia. But in rare in- stances, instead of an apoplectic seizure, the other side may become palsied, as respects the power either of motion or sensation, or of both, and either before or after the side first affected has recovered any, or much of its powers. In this case there is general palsy, incomplete, probably, as regards one or other function in ei- ther side, with certain of the senses and many of the faculties of the brain but little affected, un- til apoplectic coma or paralysis of the muscles of respiration terminates life. An instance of this kind recently occurred in the practice of my friend Dr. Babington, and upon dissection lesions were found in both hemispheres of the brain. 67. b. The forms of general palsy to which I am most desirous of directing attention are altogether spinal. They may occur suddenly, as in cerebral general palsy, or gradually, and even slowly. Severe injuries, as dislocation of the cervical vertebrae, laceration of the chord, violent concussion of the spine, haemorrhage upon the cervical portion of the chord, &c., usually occasion general palsy instantly; but disease seated in the spinal chord or its mem- branes, or implicating these consecutively, pro- duces the paralytic phenomena much more slowly. Even severe injuries may not be fol- lowed by palsy for a considerable period ; still it may be stated that the accession of general palsy from injury, as well as the phenomena characterizing it, will vary with the immediate or more remote effects of the injury upon the chord or its membranes, it being either instan- taneous or remote, according to the extent and nature of the lesion produced. A muscular man, aged about sixty years, the father of a late medical friend, when turning in bed, his head being forcibly pressed on the pillow, so as to partially raise the trunk, felt something snap in his neck. He was afterward unable to bend or to rotate the head without causing much pain in the neck. I inferred that rupture or laceration of some of the small muscles or lig- aments had occurred, and advised quietude and various means which palliate the more painful symptoms. Still the least movement of the head caused distress. Notwithstanding this, he travelled outside a coach, during the sum- mer, to Cornwall, and returned to town, and not till sixteen months after the accident he complained of numbness and want of power in the left arm. In a day or two the palsy ex- tended to both the upper extremities, but was incomplete in the right; it soon became more general, and in a short time difficulty of breath- ing, rapidly terminating in asphyxia, superve- ned. The body was examined by Professor R. Quain and myself, and the seeond cervical ver- tebra was found fractured completely across on both sides, the fraeture on one side passing close to the base of the odontoid process. Chronie inflammation had extended from the fracture to the theca and membranes of the medulla oblongata ; lymph was thrown out upon the arachnoid surfaces ; the membranes, partic- ularly the dura mater, were much thickened, and ultimately the chord at this part was press- ed upon. 68. Next to injury or concussion of the spi- nal chord, caries of one or more of the cervical vertebrae may be considered as a cause of gen- eral palsy; but the palsy rarely occurs until PARALYSIS—Varieties and States of. 21 the disease of the vertebrae has induced chron- ic inflammation of the membranes of the choid, with thickening and effusion of lymph, or such a degree of angular curvature as to affect the physical condition of the chord itself. I was lately consulted in the case of a child, twelve years of age, who presented unequivocal indi- cations of caries of one or two of the cervical vertebrae consequent upon malignant scarlatina. To these supervened incomplete palsy of mo- tion in one arm and hand, which gradually in- creased and extended to the other arm and low- er extremities, until general and complete pal- sy of motion existed; sensibility was unim- paired. The bowels were obstinately constipa- ted, and the evacuations black and tar-like. The sphincters were not paralyzed. Respiration was performed by the diaphragm, and all parts below the face were deprived of motion. The head could neither be rotated nor bent without great pain. The body and limbs were much emaciated. The skin was cool and dry, and covered with a furfuraceous scurf, particularly the scalp. The pulse was very frequent, weak, and soft; the tongue furred and loaded. Af- ter persisting for many months in a treatment hereafter to be described, this young lady re- covered the use of her limbs, the neck, how- ever, remaining stiff, shortened, and turned a little to one side. In this case, the change produced in the membranes enveloping the chord, or in the theca, was most probably lim- ited to the diseased vertebrae and their imme- diate vicinity. It is not unlikely owing to this limitation of the disease, and to the gradual accession and increase of it, that the sphincters continued unaffected. 69. c. General palsy may be only an extension of paraplegia, or, in other words, the disease may commence and continue for a time as par- aplegia, either complete or incomplete, and gradually extend higher and higher until the trunk and upper extremities are deprived of motion, sensibility being generally either not at all or but little impaired. In some of these cases, the palsy of the lower extremities, as well as that consecutively affecting the upper parts of the body, continues incomplete for a long time, the motions consequent upon voli- tion being imperfect, weak, and vacillating, and executed slowly, tremulously, and with difficul- ty. In these the patient often complains of spasmodic or severe pains in the limbs, with a sense of constriction ; of spasm and flatulent distention, with occasional attacks of painful constriction in the abdomen ; of want of pow- er over the sphincters, and involuntary dis- charges. This last symptom often varies much in different cases and different times in the same case, according to the treatment, &c. 70. In other cases, the paralytic symptoms either appear nearly cotemporaneously in sev- eral parts or limbs, soon becoming general or more complete, or extend much more rapidly from the lower to the upper extremities, than in the immediately preceding class of cases. Still the same symptoms are generally present, only varying in some subordinate phenomena, sometimes continuing nearly stationary for months or even for years, and ultimately ter- minating in a similar manner. I occasionally attended, during nine or ten years, a gentle- man somewhat above the middle age, who was affected with this particular form of general pal- sy. It was long incomplete, sensibility being but little impaired, even when the power of motion was altogether lost. Power over the sphincters was only partially retained for some years, but was very considerably increased by opiates, conjoined with stimulants and aromat- ics ; at last it was altogether lost. The intel- lectual powers were unimpaired. Ultimately cerebral symptoms, followed by coma and death, supervened. Permission to examine the body was allowed by his accomplished and highly intelligent relatives. The membranes at the base of the brain were more vascular than usu- al, and a considerable quantity of serum was effused. All the spinal arachnoid presented appearances of previous chronic inflammation. It was thickened, covered in parts with false membrane, or adherent to the opposite surfaces by means of cellular bands. The whole dura mater, or sheath of the chord, was more or less thickened throughout, and the arachnoid of the chord, where it was not adherent, was opaque and thickened. The venous sinuses, placed be- tween the bodies of the vertebrae and the sheath of the chord, were remarkably dilated and con- gested, so as manifestly to encroach upon the spinal canal and diminish its calibre, especially at the lowest part of the chord. The chord it- self was firmer than usual, particularly in this situation, was somewhat atrophied, and its gray substance was wasted and less apparent. Its vascularity also was diminished, although the spinal veins and sinuses external to the sheath were remarkably diluted, and congested with coagulated blood. 71. While I was treating the above case, a respectable tradesman, aged about fifty, came under my care, and was seen by me occasion- ally until his death, which took place three or four years afterward. The symptoms, pro- tracted course, and termination of the disease, were altogether the same as those just de- scribed. On examination after death, the le- sions found in the spinal chord were also sim- ilar to those observed in the preceding case. The chief difference was the less remarkable congestion of the spinal veins or sinuses, al- though this was considerable. The conse- quences of the chronic inflammation of the membranes, and the state of the chord itself, were nearly the same as those already descri- bed. There was, however, a more abundant effusion of serum between the membranes of the chord than in the former case ; and much fluid was found in the ventricles of the brain. The upper portion of the medulla oblongata, and the membranes at the base of the brain, presented appearances of recent acute inflam- matory action, especially increased vascularity and congestion, with a turbid serous effusion : these corresponded with the cerebral symp- toms preceding death. 72. I have occasionally seen, during the last few years, with Mr. Pettigrew, a gentleman between thirty and forty years of age, whose are nearly the same as those char- acterizing the above cases, and are most prob- ably owing to similar changes existing in the spinal chord and its membranes. In this case the loss of power over the sphincters is more re- markable than in the preceding cases, or, rath- er, appeared earlier in the course of the disease. 22 PARALYSIS—Varieties and States of. 73. The above cases of general palsy from chronic inflammation of the membranes of the chord and its consequences came before me when the paralytic symptoms were more or less fully de- veloped. I had an opportunity, many years ago, of observing the disease from its com- mencement. In 1820, a boy, aged thirteen, was brought to my house with chorea. He had rheumatism of the arms and wrists, asso- ciated with rheumatic pericarditis. After a few days the rheumatic affection subsided, and the chorea returned, with pain in the course of the spine. Leeches, &c., were applied along the spine ; but the disease passed into a state of general palsy, which was complete in re- spect only of motion, from the head downward. All power over the sphincters was lost; sen- sibility of the surface was at first acute, and, although it became somewhat impaired as the general palsy was developed, still it was not materially diminished. After death, coagula- ted lymph and turbid serum were found effused between the opposite surfaces of the arachnoid of the chord in a very remarkable quantity, and so as to press upon the chord itself. (See Lond. Med. Repos., vol. xv.) 74. d. It has been stated above (§ 52, 53) that softening of the spinal chord, whether it be the consequence of concussion of the spine, ot inflammatory action, or of some other morbid condition of the vessels, or constituent tissues of the chord, is not an infrequent cause of para- plegia when seated in any portion of the chord below the fourth or fifth cervical vertebra. When the disease is seated at or above this part, the palsy is nearly general. In a very re- markable case recorded by Dr. Webster, the spinal chord was soft and pulpy in this situa- tion, particularly the posterior columns ; the membranes were adherent to the chord ; close to the softened part the medulla was of a dusky red tinge, but above and below this part it was healthy. The subject of this case “ was for many months totally unable to move, even in the slightest degree, any muscle situated low- er than the neck, but still retained the capa- bility of feeling quite perfect throughout the surface of the body; while the other senses and intellectual faculties were unimpaired to the last moment of his existence. Indeed, the patient’s cuticular sensibility even appeared, in the latter stages of the case, to be more acute than natural.” The evacuations took place in- voluntarily, and violent spasmodic twitchings frequently affected the lower extremities. 75. e. Although general palsy as well as para- plegia is most generally caused by some mani- fest lesion seated in, or implicating the spinal chord or its membranes, when the functions ol the brain are unimpaired, still it is not to be inferred that the lesion is always of a nature which may be detected. Cases sometimes oc- cur that present no appreciable lesion, at least to the unaided eye, upon dissection ; and oth- ers recover after a treatment not obviously calculated to remove any serious lesion of the chord or its membranes. Sir B. Brodie refers to a case {Lancet, No. 1060, p. 380) which com- menced as paraplegia and terminated in gen- eral paralysis. The spinal chord and solai plexus were examined with the greatest care after death ; but they presented no change from the natural state. Sir B. Brodie justly remarks, that it is not, however, to be supposed that this is a mere functional disease because we see no lesion after death. The minute or- ganization of the brain and spinal marrow is not visible to the naked eye, and even with the microscope we can trace it only a little way. Some defect in the minute organization, some change of structure not perceptible to our senses, may exist in the part and interrupt its functions. 76. Some years ago I attended, with my friend Dr. Roscoe, a gentleman who had re- sided many years in an intertropical country. On his voyage across the Atlantic to this coun- try, in the winter season, he was seized with general palsy of the powers of voluntary mo- tion immediately after prolonged exposure to cold and wet. The functions of the brain were unaffected; and neither pain nor uneasiness was felt in the neck or in any part of the spi- nal column under any circumstances of posi- tion, flexure, rotation, or pressure. No evi- dence of inflammatory action or of congestion in the spine could be detected. Cutaneous transpiration was suppressed, and the bowels were costive and torpid; but he retained the sensibility of the surface, and command over the sphincters. He was treated, at first, upon the supposition of either serous effusion or vascular congestion having taken place in the spinal canal, but without receiving any benefit. He ultimately, however, quite recovered by having a frequent recourse to warm baths con- taining stimulating substances. 77. That form or state of general palsy in which structural lesion may be inferred to be most decidedly absent, and which consists en- tirely of functional disorder, is the cataleptic seizure. In this affection, as shown elsewhere {see art. Catalepsy), voluntary motion is alto- gether suspended ; but in two very remarkable cases, which I had an opportunity of observing attentively, consciousness and sensibility re- mained, with the senses of seeing and hearing. Yet no part—neither the muscles of the tongue or jaw, nor the eyelids—could be moved during the attacks, which often continued for many hours ; nor did the least muscular contraction take place on tickling the soles of the feet, or on pinching any part, although the sensibility was affected by these acts. Recovery from these seizures was generally sudden and com- plete, little disturbance beyond slight hysterical disorder on some occasions being observed. 78. The symptoms of general palsy vary much with the lesion occasioning it.—a. The accession of the attack also varies. In the cerebral form of the malady, particularly when it depends upon apoplectic or epileptic seizures, and when it assumes the cataleptic form, the accession is sudden or rapid. In the spinal form the symp- toms appear gradually, and generally slowly, when it is the result of disease, but often sud- denly and completely when it proceeds from severe injury. In the cerebral state, the sensi- bility, and even consciousness, are abolished or nearly lost; but in the spinal states (f) 67, et seq.) of the malady, sensibility, the functions of sense, and the intellectual powers are either unimpaired or but little affected. In a few ca- ses only is the sensibility of the general sur- face remarkably diminished, and in still fewer is it altogether lost. PARALYSIS—Varieties and States of. 79. /?. The loss of voluntary motion is most sudden and complete in the cerebral states of the disease, and in cases of injury of the cer- vical portion of the chord, or of concussion of the spine. When the palsy proceeds from dis- ease of the spinal medulla or of its membranes, the loss of motion is rarely complete at first, and often does not become complete until after several years, and until the organic lesions have advanced so far as evidently to interrupt the functions of the chord. Still, there are ex- ceptions to this, as the case noticed by Sir B. Brodie. During the protracted progress of the malady the patient often experiences spasmod- ic actions, or more permanent contractions of the muscles, particularly of the flexors ; fre- quently a sense of painful constriction around the abdomen and the thighs; and sometimes, especially when the upper part of the cervical medulla is implicated, even convulsions or complete epileptic attacks. These are evi- dently the consequence of inflammatory action or irritation in or near the portion of the chord or its membranes which is the seat of lesion. 80. A compositor, who was engaged in print- ing a work which I was editing many years ago, came to me with caries of one or two of the upper dorsal vertebrae. Matter had evi- dently formed, and was making its way exter- nally. He became paraplegic, and subsequent- ly generally paralytic ; but at a very early pe- riod of the paraplegic state fully-developed ep- ileptic seizures occurred. These became more frequent, and ultimately terminated in coma and death. On examination, a sanious pus was found collected around the second and third dorsal vertebrae, extending between the muscles, and between the theca vertebralis and bodies of the vertebrae. The membranes at, and to a considerable extent above, this part were inflamed, the arachnoid surfaces being partially covered with lymph or adherent. In- jection of the vessels and effused serum were traced thence along the membranes to the brain. The chord itself was not, however, materially changed. 81. y. Pain, even of a most severe character, is often remarked, particularly in the inflam- matory states of the spinal disease, and when the roots of the nerves, or when the nerves, as they pass through the spinal foramina, are implicated in the lesion. The pains are usual- ly deep-seated in one or more limbs, and are often not the less acute where the cutaneous sensibility is much impaired. In some instan- ces of spinal general palsy the sensibility of the surface, particularly at first, is painfully in- creased, and sometimes even perverted. Pain is often felt in the part of the spine affected, either primarily or consecutively. In some in- stances, particularly when the disease com- mences in the lower portion of the spine and extends upward, it may be confounded with lumbago ; or it may be viewed as originating in lumbago, the pain in the loins being caused ei- ther by inflammatory action or softening, or by congestion of the spinal veins and sinuses. When the disease is consequent upon mastur- bation or venereal excesses, it is often prece- ded and attended by pain in the loins, extend- ing upward with the local lesion and the para- lytic symptoms. 82. d. The bowels are remarkably torpid, and 23 24 PARALYSIS—in new-born Infants and young Children. the evacuations in the more complete states of the disease, dark, and like tar or treacle (<) 59). The urinary organs are affected in the more complete and advanced forms, in the manner already noticed (§ 57,58); but, in the less com- plete states, and when the spinal chord itself is not materially changed, the patient still re- tains more or less power over the evacuations and actions of the sphincters. In the more se- vere and sudden cases, particularly those con- sequent upon injury of any kind, and attended by marked disturbance of the urinary functions, priapism is a frequent symptom. 83. e. The external surface is always dry, often scurfy, sometimes discoloured in the ex- tremities, or presenting livid spots resembling vibices. It is generally emaciated, and colder than natural, even when the patient complains of a sensation of heat. The disposition of the surface to ulcerate or slough on pressure, so remarkable in paraplegia, is less so in general palsy, unless at the last stage or more severe and complete state of this latter form of the disease. 84. £. The cerebral functions—sensation and intellectual power—are unaffected in general palsy as well as in paraplegia, and continue un- impaired until the malady terminates either in fatal congestion of the lungs, or asphyxia, or in congestion of the brain with serous effusion. 85. II. Of Paralysis in new-born Infants and young Children.—Paralysis is sometimes met with in new-born infants. It may be the effect of injury to the nerve either in the part paralyzed or in its course after its transmission through the cranial or spinal aperture. Dr. E. Kennedy remarks that we have examples of this fact in injury to the portio dura, as in face presentations ; or where the head has been long pressed in the pelvis against the project- ing ischiatic spines ; and he adds, that several cases of this kind had occurred to him in which the disease was quite local, the paralysis being removed on the subsidence of the swelling pro- duced by the protracted pressure.—a. I have already mentioned (§ 44) that the paralysis may be the result, not merely of spontaneous lesion of some part of the nervous centres during foe- tal life, but also of arrested development or in- sufficient growth during the early periods of this epoch. In this latter case the palsy is oft- en associated with idiocy. The cerebral or spinal lesion may, however, occur shortly be- fore, as well as during the period of parturition. In the following case, recorded by Dr. E. Ken- nedy, the lesion must have existed some time before birth ; and probably, from the speedy recovery, consisted merely of congestion of one side of the brain. 86. Immediately after birth a large, soft tu- mour was observed on the right side of the head, principally on the vertex, with two or three small excoriations on the left side. The left eye was closed; the mouth drawn to the left side ; and when the child cried, the ala nasi and angle of the mouth were drawn up ; the right eye was open, and the right side of the face unaffected during crying. The left side of the body was completely paralyzed. The ex- tremities of this side were of less bulk than those of the right, and were rough to the touch; the muscles were flabby. Bpth pupils were in- sensible to light. The child was unable to suck ; but deglutition did not seem to be affect- ed. On the third day it had several slight con- vulsions, confined to the upper half of the body. A leech was applied to the vertex, followed by the warm bath : stimulating liniments were rubbed over the spine, and the child recovered. In this interesting case the portia dura of the right side, and the levator palpebra of the left side, supplied by the third nerve, were para- lyzed, in connexion with hemiplegia of the left side. 87. It is often difficult to ascertain the ex- tent of paralysis in new-born infants and very young children, as the paralyzed limbs are gen- erally either so much convulsed, or so spasmod- ically contracted, as to be removed from under the influence of volition. When the spasms cease, the paralyzed state of the limb some- times becomes more evident in the more unfa- vourable cases. The lesions which most fre- quently occasion paralysis in this class of sub- jects are, congestions of the brain and spinal column, serous effusion either between the membranes or in the ventricles, and extravasa- tion of blood. This last is much less frequent in children and infants than in adults, and very rarely occurs in the cerebral structure. When haemorrhage takes place within the cranium or spinal canal of infants, it is generally found to proceed from the surface of the membranes, and seldom causes permanent paralysis, but usually apoplectic attacks, or eclampsia, tris- mus, or convulsions, terminating generally in death. In these cases the effused blood pro- duces either coma, spasm, or convulsions, ac- cording to the quantity effused ; and ultimate- ly, if the child live a short time, inflammatory action in the parts into which it is extravasa- ted, owing to the irritation it occasions. 88. b. Paralysis, sometimes partial, at other times more or less general, accompanies the advanced progress of the disease usually called acute hydrocephalus, and of true or chronic dropsy of the brain. In the former of these maladies (see Dropsy, acute, of the Brain), I have shown that the palsy is the consequence of the softening of the more central parts of the brain, rather than of the effusion into the ventricles which either attends or supervenes on the soft- ening. The tubercles sometimes found in the brain, or its membranes, of children, either as- sociated with, or independent of, softening and serous effusion, are rarely a cause of paralysis, unless at an advanced stage of these lesions, or as a termination of convulsions or spasms, with which, however, some degree of paralysis is occasionally associated. 89. c. But palsy is sometimes met with un- der different circumstances, especially during suckling and teething; and, although not so frequently as immediately after birth, still suf- ficiently often to have procured for it, as occur- ring at this period, more attention than has been paid to it. From the first dentition to the period of puberty, paralysis is generally the consequence of scrofulous caries or disease of the vertebra, or of softening of a portion of the brain, or of tubercles within the cranium or spine. In cases of softening or tubercles in the brain or its membranes, convulsions, more or less of an epileptic character, almost always precede the paralysis, which commences gen- erally in one arm, and sometimes passes into hemiplegia. When these lesions are seated within the spinal canal of young children, con- cisions of a more limited character, often pasms or contraction of a limb, are more fre- quently remarked either before the develop- ment of palsy, or in connexion with it; although, even in these cases, the convulsions may as- sume an epileptic character, particularly when the upper part of the chord is implicated. 90. d. Infantile paralysis may, therefore, be divided as follows: 1st. The congenital, and then it is commonly a consequence of arrested development or congestion of a portion of the cerebro-spinal centres ; 2d. That caused by the accidents attending parturition, as shown above (§ 85); 3d. That consequent upon lesions or spontaneous disease, of a demonstrable nature, Implicating the brain or some portion of the cerebro-spinal axis ; and, 4th. That which pre- sents no obvious lesion in the brain and spinal chord beyond slight congestion, and from which recovery often takes place without sufficient evidence of organic lesion having been afforded. This last class of infantile palsies generally oc- curs in infants at the breast or during the first dentition. It is often sudden in its accession, and is preceded by no very apparent state of disease, beyond the usual irritation often at- tending dentition, or disorder of the alimentary canal or biliary functions. The arm is com- monly the part affected ; but the leg of the same side is sometimes either also paralyzed, or contracted and drawn up, or both palsied and contracted. Sensibility has not been, as far as I have observed, impaired in the affected limb, but, on the contrary, sometimes morbidly increased. A large proportion of the cases which I have seen of this description has re- covered after the means that will be noticed in the sequel have been employed. 91. My very learned friend, Dr. M'Cormac, of Belfast, has noticed cases of paraplegia in infants, which he considered to proceed from concussion of the spinal chord: a cause by no means unlikely to produce the disease in both infants and children, and to be followed by ei- ther haemorrhage, inflammation, softening, se- rous effusion, or other change of the parts lodged in the spinal canal. He believes, also, that injury to the sciatic nerve may produce paralysis of the limb in infants ; but this is manifestly a rare occurrence. III. Shaking Palsy.—Syn. Scelotyrbe festinans, Sauvages. Paralysis Agitans, Parkinson. Synclonus ballismus, Good. Tremor, J. Frank. Tromos (Tpopog), Swediaur. Tremblement, Fr. Zittern, Germ. Trembling Palsy. 92. This disease is characterized by a tremu- lous agitation, a continued shaking, and by great weakness of one or more parts or members of the body. Although it was described byHARscHER, Diemerbroeck, Schelhammer, Hamberger, and others, and more recently by Parkinson and J. Frank, it has not received the attention which the frequency of its occurrence and the obscu- rity of its nature should have obtained for it. Even its symptoms, its relations to other ner- vous affections, its course and terminations, have been imperfectly observed and described ; and no accounts have been furnished of the ap- pearances observed in fatal cases. 93. Shaking palsy may affect either a single part or limb, or many parts, or even the great- PARALYSIS—Shaking Palsy. er part of the body. It may continue limited to its original seat for many years, and even nev- er extend beyond it; or it may not only in- crease gradually in the part first affected, but extend to two, or to all the limbs of the body. Generally the power of motion only is affected, and usually is only partially impaired ; and it continues long in this state ; so that the com- plaint may be viewed as imperfect palsy of the power of motion, with shaking of the part. 94. The affection usually commences imper- ceptibly, and proceeds slowly. It often begins in the head, or in one or both arms, and it fre- quently is confined to these parts for a long pe- riod, or even for years. It is generally attend- ed by a feeling of weakness of the part. In two instances I have seen the complaint lim- ited to the lower jaw, \yhich was moved by a rotatory or lateral action in one case, and by a vertical action in the other. When the head is affected, it is commonly moved upward and downward; but it is in some instances in a constant state of rotation. In these situations, as well as when it affects the hands and arms, the motion often does not exceed that of tre- mour, or a gentle but quick shaking; but in oth- ers the agitation is more remarkable and vio- lent ; and even the slighter cases may be more severe when the patient is influenced by any ex- citement or marked emotion of mind. 95. The affection commences usually with a slight sense of weakness and proneness to trembling, especially on any emotion or after physical exertion, and commonly in the hands or arms, but sometimes in the head, or in the tongue or lower jaw. These symptoms grad- ually and slowly increase; and usually after one, two, or three years, but in some cases not until after a longer period, they extend to the lower extremities ; and the patient finds great difficulty in walking ; bends his body forward, and is obliged to assume a hasty or rapid pace, from the fear of falling forward. The tremu- lous agitation has now extended to his legs, and the limbs have become less and less capa- ble of obeying volition. Suspension of the agi- tation is seldom experienced, unless in some cases when the limbs are held or supported; and when it ceases from this circumstance in one limb or side, it continues in the other. Thus it sometimes ceases in the arm or side on which the patient lies or reclines, but as soon as he changes to the opposite side it be- gins in the former. Occasionally, attempts to restrain the agitation only increase it; and it is often exasperated at the sight of strangers. When the patient walks, he is often thrown on the fore part of the feet, and impelled to adopt a quick or running pace, from fear of falling at every step on his face. At an early stage, or in less severe cases, the affection ceases for a short time, or is ameliorated after a refreshing sleep; and it is often then controlled by the will or by earnest attention to the part, but it soon afterward recommences. 96. At a far-advanced stage, the tremulous motions of the limbs occur during sleep, and, particularly when the patient dreams, waken him, often in agitation. The power to convey food to the mouth ultimately becomes so im- peded as to oblige him to be fed by others. Mastication and deglutition are impeded, or dif- ficult, and the saliva dribbles from the mouth 25 26 The trunk is permanently bowed, from the gen- eral want of power in the muscles. The bow- els are costive ; are acted upon with difficulty; and sometimes require mechanical means to remove them from the rectum. Ultimately, the agitation becomes more vehement and con- stant ; and when exhaustion passes into sleep, it sometimes becomes so violent as to shake the room. The head falls down, so that the relaxed or shaking jaw meets the sternum. The power of articulation fails or is lost, and the urine and fa:ces are passed involuntarily. Slight, low delirium, passing into coma, usually terminates life. 97. I have met with this affection both as the chief and primary malady, and in connex- ion with disease in some distant organ, of which it appeared either as £ consecutive change, or as a concomitant disorder. I have seen it more frequently in males than females, and chiefly in persons about fifty years of age and upward. I observed it to a very remarkable extent in a man aged about sixty, who had valvular dis- ease of the heart, upon which pulmonary con- gestion and dropsy supervened ; but I could not obtain permission to examine the body. I observed it also in a lady in a similar form of complication, but I ceased to attend her long before her death. I was recently consulted by a gentleman from Lancashire, affected by this complaint in the arms, and in every other re- spect he professed himself to have been in good health. I have seen it both in plethoric and in thin and spare habits, but more frequently in the fair and sanguine than in any other tem- perament. I have never had an opportunity of observing the changes that existed after a fatal termination of the complaint, and I do not rec- ollect of any case being recorded where such an opportunity had been enjoyed. It is fre- quent in very aged persons in its slighter forms. 98. In rare instances hysteria assumes a form very nearly allied to, or closely resem- bling, this affection. In 1842 I attended, with Dr. N. Grant, a girl aged about sixteen, on ac- count of various anomalous nervous affections consequent upon obstructed catamenia. After passing through various phases, in which the tongue, larynx, and diaphragm seemed spasmod- ically affected, violent tremulous agitation of the head and arms supervened. UThe head was rotated from side to side without intermission for several days. She received benefit from treatment, and ultimately recovered. 99. In the absence of post-mortem examina- tions, opinions as to the origin and seat of this complaint must be viewed as suppositions mere- ly ; but it is not unreasonable to infer that the medulla oblongata and upper part of the spinal chord are the chief seat of the affection. J. Frank adduces the case of a widow, aged for- ty, who had experienced an interruption of the catamenia, had complained of pain in the spine, and had recourse to a vapour bath ; after com- ing out of the bath she was exposed to cold, and suddenly was attacked by this affeetion. Her head was in a constant state of rotation, and the arms, hands, legs, and feet were in continual motion. Blood was taken from the spine by cupping, and she recovered sooner than was expected. It is not improbably con- nected with congestion of the venous plexuses, or sinuses, placed between the sheath of the PARALYSIS—from Poisons. chord and bodies ofnhe vertebrae, particularJy in persons of a plethoric habit, and when it is consequent upon suppressed evacuations. In other cases it appears to depend more upon the states of the chord and nerves, or to be more strictly nervous. 100. IV. Paralysis from Poisons.—Paraly- sis venenata, Cullen.—Paralysis e venenis.— Palsy, varying as to seat and character, is not infrequently observed consequent upon the op- eration of several poisonous substances of ei- ther a mineral or vegetable nature, especially the former. The poisons most liable to cause palsy are lead, mercury, arsenic, ergot of rye, monkshood, thorn-apple ; and in rare instances palsy occurs as a contingent remote effect of most of the acro-narcotic poisons. 101. A. Palsy from Lead.—Lead palsy gener- ally occurs after one or more attacks of colic (see Colic from Lead) ; but it occasionally ap- pears without any severe disorder of the digest- ive organs. When the palsy is connected with colic it usually becomes manifest as the colic subsides ; but both affections may be associated or cotemporaneous. When the palsy occurs independently of colic, costiveness and indi- gestion, with or without slight pains in the ab- domen, are generally present, both before and concomitantly with it. The palsy usually pre- sents peculiar characters. It is seated chiefly in the upper extremities, and affects the ex- tensor more than the flexor muscles. It is at- tended by great emaciation of the affected mus- cles, and the loss of power is most remarkable in the muscles which move the thumb and fin- gers. The palsy is seldom complete, even in these, except in the extensors. The hands and fingers are constantly bent, unless when they hang down by the sides. The patient, in the most severe cases, is unable to raise them, and, when one arm is more affected than another, he raises the one by the aid of the other. Se- vere pains are also felt in the lower limbs and arms. Attacks of colic, severe fits of indiges- tion, and obstinate constipation are apt to oc- cur, especially after irregularities of diet or exposure, and generally carry off the patient. The palsy of the arms is sometimes associated with deafness, owing to palsy of the auditory nerves. 102. In fatal cases the paralyzed muscles have been found pale, bloodless, and flaccid; and incases of long standing they have become still more pale and fibrous. The nerves have also appeared atrophied and firmer than natu- ral. It is not improbable that the lead, in a state of oxide, has in some measure combined with these tissues. In this case, however, it ought to be detected by chemical analysis ; but, while some chemists avow that they have de- tected it, others assert that they were unable to do so. Dr. Christison’s able researches into this subject do not countenance the opin- ion that a combination takes place between the lead and tissues affected in these cases. That the metal affects the states of these tissues cannot be doubted; but whether by its actual presence, or by its indirect operation on the nerves and nutrition of the muscles, independ ently of its presence, has not been demonstra- ted. Most probably its operation is direct in the state either of an oxide or of a salt, in ei- ther of which states it may pass into the cir- culation, and act immediately upon the nerves and muscles. 103. B. Mercury, when carried into the sys- tem in the form of an oxide, or of a salt, some- times causes palsy, but generally in the form described as shaking palsy ($ 92), or incomplete valsy of motion with tremour—the tremblement me- tallique of French writers. It usually occurs in miners, in gilders, and in other workmen ex- posed to the operation of mercurial substances. It usually commences with unsteadiness of the arms, and afterward with tremours, which ex- tend more or less with the continuance of the malady, and often becomes associated with convulsions. For a fuller account of this af- fection I may refer to the article Arts and Em- ployments (<) 24). 104. C. Arsenic sometimes occasions limited or partial palsy, when it has failed of causing fatal effects in a short time, or in the advanced stage of the more prolonged cases of poisoning by it. In some cases an incomplete form of paralysis, resembling palsy from lead, and af- fecting one or more of the extremities, is caus- ed by this poison. Occasionally the palsy is preceded by cramps, tenderness, and weakness of the extremities, the palsy being sometimes attended by contractions of the joints. The affection is not confined to the power of mo- tion, but generally also extends to that of sen- sation. Dr. Falconer observed a case in which the palsy was limited to the hands, and anoth- er in which it gradually extended to the should- ers. 105. D. Paralysis from narcotic or acro-nar- cotic poisons is sometimes observed contingent- ly upon their more remote effects. I was con- sulted many years ago respecting a case of hemiplegia caused by eating the root of monks- hood by mistake. The more immediate effects had been numbness and palsy of the tongue, followed by apoplexy, and a state of the cuta- neous and mucous surfaces closely resembling that existing in fully-developed purpura haemor- rhagica. The apoplexy had been either asso- ciated with hemiplegia from the commence- ment, or the latter rapidly followed it. The patient, aged about twenty, ultimately recov- ered, and I lately saw him without any remains of the paralytic affection, which, however, had continued during two or three years. Paralysis from this class of poisons generally affects the powers of sensation more or less remarkably. 106. E. Ergot, or spurred rye, sometimes oc- casions palsy, especially of sensation ; but the effects of this substance are fully treated of in the article Ergotism. 107. V. General History of Palsy.—i. Of the various Disorders preceding and attend- ing Palsy.—From the description of the sev- eral varieties of palsy, it will be seen that the power of motion is much more frequently im- paired than that of sensation ; that either may be singly, or both jointly affected in various grades, but that, when motion is totally lost, sensation is frequently more or less impaired ; that sensibility is very rarely entirely lost in a paralyzed part, and still more rarely over the surface of the body; and that palsy is both preceded and accompanied by considerable de- rangement of the general health as well as of the nervous system, to which especial attention should be directed. PARALYSIS—General History of Palsy 27 108. A. It is impossible to notice all the pre- monitory symptoms of palsy, as the varieties and relations of the malady are so numerous as to render them both diversified and inconstant, and as they depend very much upon the nature of the pre-existing disorder and of the remote causes. Hemiplegic palsy is often preceded by the same premonitory symptoms as have been mentioned in connexion with the accession of Apoplexy (§ 4), especially by various affections or disorders of one or more of the senses, par- ticularly of hearing, sight, and touch ; by neu- ralgic pains about the face or head ; by twitch- ings, spasms, or convulsions ; by weakness ol muscles, or of a limb ; by headaches, restless- ness, sopor, lethargy, or watchfulness; vertigo, faintness, and unsteady gait; irritability of tem- per, loss of memory ; imperfect or difficult ut- terance ; flatulence, costiveness, and various dyspeptic symptoms ; more or less manifest in- dications of irritation or inflammatory action in some part of the brain ; epileptic seizures, and most frequently apoplectic attacks. (See above, $ 40, and art. Apoplexy, § 4.) 109. The paraplegic and, general stales of pal- sy are often preceded by pain in the course of the spine, sometimes resembling, and frequent- ly mistaken for, lumbago ; by spasms or cramps of particular muscles ; by pain in the neck, or wry-neck; by neuralgia or neuralgic pains; by numbness of the toes or fingers ; by attacks of nephritis ; by increased sensibility of the sur- face of one or more limbs, or of the body gen- erally ; by costiveness and colicky pains, or obstinate constipation ; by retention of, or dif- ficulty of voiding, the urine ; by chorea, partial convulsions, or various anomalous nervous dis- orders ; and by the more limited forms of par- tial palsy. 110. B. The disorders of the nervous system, and of the general health, accompanying palsy, are various in different cases, according to the seat of the malady.—a. In hemiplegia and palsy of any of the organs of sense, the memory, and, in severe or prolonged cases, even the intel- lectual powers, are more or less impaired, the palsy extending even to the mental powers. This state, however, is the most remarkable in the complication of general palsy with insani- ty, hereafter to be noticed. The temper and disposition are often changed from their usual characteristics, persons of a mild disposition becoming peevish and irritable, and those who have been irascible becoming placid ; in some cases the memory, chiefly of words or of names, is impaired or perverted, so that the patient substitutes those which either are inappropri- ate, or have an opposite meaning to that which _ he wished to convey. The powers of attention, and application, and mental energy generally, are usually impaired. 111. The action of the heart and lungs is sel- dom much excited in hemiplegia or cerebral palsy, unless when inflammation of a portion of the brain supervenes upon or attends the lesion causing the hemiplegic state. Nor is the action of these organs oppressed or impair- ed, unless effusion, so as to cause direct or counter pressure, takes place, or the medulla oblongata becomes in any way implicated. Hence the temperature of the surface of para- lyzed parts is seldom lower than natural, and frequently, owing to diminished transpiration 28 PARALYSIS—General History of Palsy. without diminution, suppression of the cutane- ous transpiration will raise the temperature of the surface on w’hich transpiration is suppress- ed ; but when the oxygenation of the blood is impaired, suppressed transpiration cannot have this effect, or only to a small amount. If the change produced by respiration on the blood be much impeded, the temperature will generally continue much below the natural standard. This appears to me to be the true cause of the different states of temperature of paralyzed limbs in different cases ; and it is preferable to account for the phenomenon conformably with established principles, upon which a sound and safe practice may be based, than to mould it so as to suit a preconceived hypothesis, and to make it subserve a doubtful or hazardous treat- ment. 118. It may be objected, however, that the rise or fall of temperature in a paralyzed or in an inflamed part may be independent, in some degree, of states of respiration ; and this is ac- tually the case ; for, although the passage of oxygen into the circulation takes place in the lungs, the oxygenation of the blood, or, rath- er, of certain elements of the blood, occurs chiefly in the systemic capillaries, under the in- fluence of the organic nervous power, the ox- ygen combining partly with these elements for the nutrition of the tissues, and partly with the carbon of the blood. The change in the capa- city for latent heat consequent upon the com- bination of oxygen with these elements in the several parts of the body is great in proportion to the extent of combination ; and, as this com- bination is strictly a vital process, or at least brought about by vitality, although conformably with chemical laws, so it takes place independ- ently of the cerebro-spinal nervous system Notwithstanding that this combination and the change of capacity for caloric consequent upon it are independent of this system, and are ef- fected chiefly by vital or ganglial nervous pow er, still they may be influenced by the cerebro- spinal system. The passions and emotions show this; but they also prove the predom- inant influence of the organic nervous system, their physical action—their operation on the circulation and the tissues—being through the medium of this latter system. Fear blanches the cheek and lowers the temperature of the surface ; sexual passion produces turgescence of the erectile tissues and heightens the tem- perature ; but these, as well as other mental emotions, change the state of the circulation and temperature by depressing or exciting, ac- cording to the nature of the emotion, the or- ganic nervous or vital power in the first in- stance, the effect upon the circulation and tem- perature being consecutive. The independence of the organic or vital nervous system of the cerebro-spinal is shown, even in those vital or- gans which are most influenced by the mental emotions and the spinal chord, in the course of paralytic cases. Thus palsy, even when gen- eral, does not extend to the organs of genera- tion. Erections take place in almost all the varieties of the disease, if no other concom- itant complaint exist to prevent them ; they are even morbidly frequent or constant when the upper part of the spinal chord is congested, inflamed, or otherwise implicated. Pregnancy proceeds in its usual course, and parturition from the surface of these parts, it is higher than in other situations. 112. Digestion and assimilation are often but little disturbed or impaired. In some cases vomiting or nausea, with or without flatulence, attends the accession of hemiplegia, but sub- sequently acidity, heartburn, or flatulence, is complained of. The appetite is but little im- paired ; it is even frequently keen or craving, and is generally too great for the amount of exercise taken, and of air consumed by respi- ration, and consequently for complete digestion and assimilation. This keenness or craving appetite I have often remarked as an indication of latent irritation in the substance of the brain. The bowels and liver are usually torpid, and often require powerful chologogues and purga- tives to act on them. 113. The nutrition of a paralyzed part is oft- en not materially affected when the disease occurs after the growth of the body has been matured. Occasionally, however, some degree of shrinking, or atrophy, exists, especially in prolonged cases, owing chiefly to disuse of the muscles. The nerves are also somewhat atro- phied. Very frequently an cedematous state of a paralyzed limb is observed, increasing its bulk, although the muscular and other soft parts may be more or less wasted or atrophied. The urinary functions are seldom much affect- ed in hemiplegia and other cerebral forms of palsy. 114. b. In paraplegia and. general palsy the attendant phenomena have been already fully noticed ($ 48, et seq.), and consist chiefly of lesion of those functions which depend upon, or are influenced by, the part of the chord which is the seat of disease. As the brain continues unaffected until the fatal termination of the dis- ease draws near, so the mental powers contin- ue unimpaired till that period arrives. 115. When the medulla oblongata, or upper part of the chord, is affected, the action of the heart and lungs is often much disordered ; and if these parts, especially the former, are press- ed on, or much disorganized, death by asphyx- ia is more or less speedily produced. In slight- er lesions of these parts, remarkable slowness of the pulse in some cases, and great rapidity of it in others, are often observed. 116. Respiration is usually performed chiefly by the diaphragm, and the quantity of oxygen consumed during the process is very small, con- sequently the heat of the surface is low, and transpiration from it much diminished. The skin is dry, becomes covered with a branny or furfuraceous substance, owing to rapid exfoli- ation of the cuticle. When the lesion is seated lower in the chord, or so as not to impede the motion of the chest, and, consequently, not to diminish the action of the air on the blood, the parts below the seat of injury experience di- minished or interrupted cutaneous transpira- tion, and, instead of any diminution of tem- perature, they present an actual rise of tem- perature, owing to the interrupted transpira- tion, the functions of respiration not being im- paired. 117. The heat of the surface of paralyzed parts depends upon the state of respiration and the consumption of oxygen, in connexion with the amount of transpiration from that surface ; for, while the oxygenation of the blood proceeds takes place in the natural way, in cases of par- aplegia or general palsy in females. 119. When the upper part of the chord is the seat of lesion, the stomach is sometimes so much disordered as to reject its contents. The bowels are obstinately confined, as above no- ticed (§ 59); the tongue is furred and loaded ; the urinary organs remarkably affected ((> 57), and the vital cohesion of the superficial and other tissues below the diseased portion of the chord is more or less impaired, disposing them readily to undergo asthenic inflamma- tion, sloughing, &c. (§ 64.) 120. ii. The Associations and Complica- tions of Palsy.—As palsy is generally a symp- tom or consequence of some lesion sustained in a part of the cerebro-spinal nervous system and nerves, it will readily be admitted that it will frequently present itself in practice as an accident or result of an immediately antece- dent and intimately related disease, and often be associated with such disease—with apo- plexy ; with inflammation and softening of the brain ; with similar lesions of the spinal chord; with structural changes of the membranes of the brain, and of the spinal medulla ; with dis- ease of the cranial and spinal bones ; with ep- ilepsy, convulsions, hysteria, and catalepsy ; with insanity, imbecility, and idiocy ; with rheumatism, lumbago, and congestions of the spinal sinuses; with neuralgic affections; with inflammation of the kidneys, or other parts of the urinary apparatus. In the progress of all these maladies, some form or other of palsy may appear whenever lesions of structure, or even congestions, take place in, or extend to, any portion of the cerebro-spinal axis, or nerves proceeding from it during their course ; or, in other words, when palsy is complicated with any of these maladies, it is a consequence of the vascular and organic lesions characterizing or supervening in the progress of such malady. The importance and danger of these complica- tions require that a brief notice should be taken of them. 121. A. Of all diseases, apoplexy is the most frequently associated with, and the most inti- mately related to, palsy, especially to hemiple- gia, and to some states of general and partial palsy. The complication of apoplexy with pal- sy is fully described in the article Apoplexy {fj 31-49). I have there shown that it general- ly presents itself as follows : 1st. The apoplexy occurs as the primary malady, and is either asso- ciated with, or followed by, paralysis. 2d. The paralysis, in some one or other of its partial states, often in that of hemiplegia, first appears, and is followed, after a very indefinite period, by an ap- oplectic attack more or less profound. 122. a. In thefirst of these complications the paralytic affection may disappear in a short time after the apoplectic seizure, or not until after several days or weeks. It may be per- manent, or continue for years, or until another apoplectic seizure carries off the patient; or it may be rendered more complete or general, or it may affect additional or different parts, those first affected being either partially restored or unchanged, by renewed seizures of apoplexy, or by coma, attended by sinking or exhaustion. In these cases death is usually produced by the ap- oplectic state, or by a comatose sinking, attend- ed by a general palsy, in which, owing, prob- PARALYSIS—Associations and Complications of Palsy. ably, either to nervous exhaustion, or to coun- ter pressure on the base of the brain, or on the medulla oblongata, or to lesions extending to these parts, the respiratory organs participate. I have described fully, in the article just re- ferred to ( 34, et seq.), the lesions usually ob- served in these circumstances; and I need not, therefore, allude to them farther than to state that, in the slighter and less prolonged instan- ces, they consist chiefly of congestion and se- rous effusion ; and, in the more severe and per- manent cases, of extravasations of blood, soft- ening of portions of the brain, and of extrava- sation and softening conjoined. In some ca- ses little or no lesion is seen, or at least lesions insufficient to account for the phenomena and for death; and in other cases, in connexion with one or more of these lesions, effusion of serum in the ventricles, or between the mem- branes ; inflammation of a portion of the brain, or of the membranes, and other concomitant or contingent lesions, are observed. (See art. Apoplexy, 36, et seq.) 123. b. In the second of these forms of com- plication (§ 121) the palsy in some one or oth- er of its more partial forms, frequently in that of hemiplegia, is the primary seizure, and is generally then caused by alterations in some part of the substance of the brain, especially by softening, haemorrhage, cysts, tumours, tu- bercles, and by almost any of the diversified lesions described in the article Brain and its Membranes, particularly when they have ar- rived at an advanced state of development. Many of these lesions are followed by inflam- mation, softening, congestion, or effusion of serum or of blood in the brain or its mem- branes, causing either a more complete or a more extensive palsy, or spasms or contrac- tions of one or more limbs, or superinducing apoplexy, which may either terminate life, or be removed, leaving the pre-existing palsy more complete or extended than before. (See arts. Apoplexy, 46, et seq., and Brain.) 124. B. Palsy may become associated with epilepsy; but it is generally a consequence, even when thus associated, of repeated returns of the epileptic paroxysms. Even in the ear- lier attacks of epilepsy, occurring in young per- sons, the epileptic fit may be followed by in- complete palsy of the limb, or of certain mus- cles, especially of an arm, or of the muscles of articulation, &c. In these cases the palsy may soon disappear, and follow the next or subse- quent attacks; and may continue without much variation, or become more complete until ei- ther hemiplegia, or even more general palsy, supervenes. In some instances the epileptic seizure may present a mixed character, or a state intermediate between apoplexy and ep- ilepsy ; or it may be viewed as apoplexy at- tended by convulsions, a form of seizure which had been overlooked until it was described in the early parts of this work. These mixed forms of seizure are not infrequently followed by palsy. It has been stated in the articles Brain and Epilepsy, that any organic lesion of the brain or of its membranes may be fol- lowed by epileptic attacks ; and these lesions, in a more advanced stage of development, may occasion either palsy or apoplexy; often both in succession, at very indefinite intervals. The slighter states of palsy consequent upon the ep- 29 30 PARALYSIS—Associations and Complications of Palsy. ileptic fit may be viewed as the result of con- gestion, more particularly affecting that por- tion of the brain that has most intimate rela- tions to the paralyzed part. Where, however, the palsy is more complete or extensive and permanent, it may be viewed as depending upon similar changes to those which have been alluded to as causing palsy in connexion with apoplexy (§ 121); and if the palsy be attended by contractions or spasms either of the para- lyzed or of the sound limbs, inflammatory ac- tion or irritation may be inferred to exist ei- ther in the vicinity of the cerebral lesion, or in another part of the brain, according to the seat and character of the spasms, &c. In rare instances, the same lesion of the brain that causes the epileptic or convulsive seizure may induce at the same time a paralytic state. These cases usually soon terminate fatally. 125. C. Inflammation of the brain may be complicated with palsy; but in this state of disease the inflammation is generally limited to a portion of the brain. Either affection may be primary, and thereby give rise to two states in which this complication presents itself in practice. 1. The changes consequent upon the inflammation may induce those farther changes upon which the palsy depends; thus, inflamma- tory softening favours cerebral haemorrhage, and this latter usually causes the paralytic state. 2. The lesion primarily causing the palsy may induce inflammation of the adjoining parts of the brain, and the phenomena usually consequent upon this state; thus, blood extravasated, or a tumour formed in the brain, will occasion pal- sy, and inflammatory action will often follow in the surrounding cerebral structure, or in the adjoining membranes, or in both structures, and give rise to the association of the chief phenomena of inflammation of the brain, or of its membranes, with the paralytic state. Both these states of association may present them- selves even in the same case ; thus, a gentle- man, attended by Dr. Paris and the author, had inflammation of the brain, and after the more acute attack had been removed, hemiple- gia supervened. The hajmorrhage, consequent upon the inflammatory softening, and produc- tive of the palsy, after a short time reproduced the inflammation, which was again subdued ; but after some months an apoplectic seizure took place, and carried off the patient. In ca- ses of this complication, the membranes may or may not be implicated, according to the seat of primary lesion, or to the nature of that lesion. 126. I). The complication of insanity with pal- sy has been very fully discussed in the article on Insanity (see <) 33-36, and 167-172); and I, therefore, need not farther allude to the sub- ject at this place than to state that the palsy generally does not appear until after the men- tal disorder ; often not until the latter has con- tinued for a considerable time, and assumed a chronic and general form. In some cases, however, insanity and palsy occur almost si- multaneously ; and in a few the paralytic af- fection precedes the mental derangement. Pal- sy thus associated is commonly general, or soon becomes such. It is usually incomplete, espe- cially in its early stages, and affects chiefly the muscular system. The sphincters, and, conse- quently, the evacuations, are uncontrolled by volition. This form or association of palsy is usually a result of chronic inflammation ol the brain, and is distinct from palsy caused by cer- ebral haemorrhage, softening, tumours, &c., which, however, may also occasion the more partial, or a hemiplegic form of palsy in the course of insanity; but these latter are not so frequent as the general palsy just alluded to, and fully described in its more appropriate place (Insanity, $ 167, et seq.). The paralysis of the insane may be farther associated with epileptic, convulsive, apoplectic, or comatose states, either of which may terminate life, or the patient may sink from vital exhaustion. The appearances observed after death from these complications are minutely described in the art. Insanity (§ 235, et seq.). 127 Palsy is not infrequently, also, associa- ted with idiocy, and with puerile imbecility (see art. Insanity, 522, et seq.). In these compli- cations the palsy may be either general or par- tial ; but when it is general, some parts are usually more affected than others, and imper- fect development of portions of the cerebro- spinal axis is often seen on examinations of them after death. 128. E. Although both paraplegia and general palsy are often produced by the more common consequences of inflammation of the spinal chord and of its membranes, still the inflammation, as well as those consequences, may still continue after the paralytic state has been produced, and thus become associated or complicated with it. The history of cases of this description, and some of those above noticed, suggests this po- sition ; and the appearances I have observed during the examination after death sufficiently confirm it. The importance of attending to this circumstance cannot be over-estimated in a practical point of view, as being suggestive of a rational treatment of these cases. The persistence of inflammatory action in the spinal chord and its membranes, particularly the lat- ter, during the paralytic states depending upon lesions of these parts, is often evinced by pain in the spine, by spasms or contractions of the muscles, by pains in the limbs, and by the va- rious phenomena usually attending inflamma- tions. In some instances, the inflammation occasions not merely spasm, contraction, or pain of the muscles supplied with nerves from the part of the spinal chord which it affects, but also more general convulsions; or, when the upper parts of the chord are implicated, epi- leptic seizures, or coma and asphyxia. 129. F. Disease of the cranial and vertebral bones, or of the periosteum, sometimes compli- cates as well as causes palsy, particularly in the scrofulous diathesis. In these cases the dis- ease of the bones extends to the membranes enveloping the brain or chord ; and inflamma- tion, with its usual consequences, when affect- ing these membranes, supervenes and inter- rupts the functions of, or extends to, the en- closed portion of the cerebral or spinal struc- ture. Thus, I have repeatedly met with in- stances of caries of the petrous portion of the temporal bone, consequent upon neglected ot- torbcea, that were followed by inflammation and abscess of the adjoining membranes and cerebral structure, and by palsy, with various concomitant and consecutive phenomena. Ca- ses of this description not infrequently occurred to me in dispensary practice, and in children at the institution for their diseases. Lesions of the cranial bones associated with, as well as causing palsy, may be the result of disease or of injury. Thus, a portion of the parietal bone was remarkably and permanently depressed in a boy by accident, and coma, with hemiplegia, was the result. The coma soon passed off, but the hemiplegia continued for a time. Ultimate- ly, the palsy also was altogether removed ; and, long before he reached the period of puberty, the paralyzed side had become as strong as the other. The depression, however, continued as remarkable as before; yet, notwithstanding this, the subject of this accident became, and still is, a most powerful and talented man, with whom I have been acquainted for more than thirty years. 130. Disease, particularly scrofulous caries of the vertebrae, is a frequent cause and concomi- tant of paraplegia, and even of general palsy, as in the case above noticed (§ 68); and not only may the palsy be associated with disease of the vertebrae, but also be farther accompanied with epileptic seizures. A young man several years ago consulted me respecting epileptic attacks, each of which was preceded by the aura epilep- lica, which proceeded from the palm of the left hand to the lower cervical vertebrae. On ex- amining the hand, the palm of it was found swollen, and obscure fluctuation was detected in it. The part was opened, and matter was discharged from beneath the palmar fascia. The fits disappeared for a considerable time; but pain and stiffness in the lower cervical and upper dorsal vertebrae were complained of, and were attended by a diffused swelling. The ep- ileptic attacks returned, and paraplegia, nearly amounting to general palsy, supervened. An abscess pointed between the scapula and spine, which was opened ; and the patient soon after- ward was carried off by an epileptic seizure. In this case caries of the vertebrae, purulent in- filtration of the adjoining muscles, and inflam- mation of the membranes of the chord, with effusions of coagulated lymph, adhesions, &c., were found after death; and the inflammation of the spinal arachnoid, with serous effusion above the seat of adhesions, had extended to the arachnoid of the medulla oblongata and the base of the brain. 131. G. Neuralgic affections of the face, head, or limbs, not only precede, but also occasionally accompany palsy. The pain sometimes ceases when the palsy takes place, especially if the muscles supplied or connected with the pained nerves are those paralyzed ; but it is sometimes only alleviated. The neuralgic pain is occa- sionally complicated with the palsy, particular- ly when they occur on different sides of the body. Neuralgic pains may thus accompany hemiplegia, paraplegia, and any of the more partial states of palsy, the latter affection su- pervening after the former has been of long du- ration (see art. Neuralgic Affections, <) 72). It is only in rare instances that neuralgia ap- pears in the course of palsy, or that the latter is the primary affection. 132. H. Palsy is sometimes associated with rheumatism, but not so frequently as might ap- pear on a superficial view of the matter. The pains, whether dull, gravative, gnawing, &c., sometimes complained of both before and du- ring paralytic affections, are often mistaken for PARALYSIS—Associations and Complications of Palsy. rheumatism, or for neuralgia, although they are the not infrequent attendants of that change of structure at the origins of the nerves supplying the pained parts that ultimately produces palsy. The pains may be even felt in different parts from those which are paralyzed ; and they are then to -be viewed as the extension of inflam- mation, or of other organic lesions, to parts differently related. The pains in the loins or back, so often viewed as lumbago, and felt more or less by persons addicted to venereal ex- cesses or to manustrupation, are occasioned either by congestion of the spinal sinuses, or by inflammatory action of the membranes of the chord; and although they are most fre- quently the precursors of palsy, particularly of paraplegia, still they not infrequently accom- pany it, and extend either to the sound or to the affected limb, or even to both. 133. I. Palsy, or palsy associated with apo- plexy, is not infrequently consequent upon or- ganic disease of the heart, particularly hypertro- phy of the left ventricle, and lesions of the valves or auriculo-ventricular orifices. The remarks which I offered in the art. Apoplexy (§ 96) on the connexion subsisting between that disease and structural changes in the heart are quite applicable to the complication of those changes with palsy, especially with hemiplegia. In this complication the disease of the heart is generally the primary malady, and more or less aids in the production of the paralytic affection, although some lesion of the vessels or sub- stance of the brain may have pre-existed, or have been cotemporaneous with the cardiac disease. 134. K. The association of palsy with disease of the kidneys and urinary organs generally has already been noticed, with reference only, how- ever, to the supervention of disease of the lat- ter upon paraplegia and general palsy (§ 57). But the complication now to be noticed is of a different kind. When the kidneys, either from intense inflammation or from a primary state of inaction or palsy, cease to perform their functions, and retention of urine from this cause results, a state of excrementitious pleth- ora is produced, not infrequently terminating in fatal coma or apoplexy. These may assume the form of general palsy ; and, in rare cases, hemiplegia may take place. In these the pro- cession of morbid phenomena is sufficiently manifest; but in others it is much less so, es- pecially in those which present the occurrence of paraplegia consequent upon the nephritic disease. Mr. Stanley, in an interesting memoii {Trans, of Med. and Chirurg. Soc., vol. xviii., p. 260), has adduced several cases, in which in- flammation of the kidneys existed in connexion with paraplegia, and appeared as the primary malady, and yet no change was observed in the spinal chord or its membranes. Some of the cases deserve a brief notice. 135. A man complained of retention of urine conjoined with paraplegia, motion and sensa- tion being lost. Tenderness on pressure was felt at the third lumbar vertebra. After death no lesion could be detected in the vertebrae, spinal chord, or its membranes. The kidneys presented inflammatory changes, with small abscesses dispersed through their substance. 136. A man had retention of urine conse- quent upon the suppression of gonorrhoea by 31 32 PARALYSIS—Diagnosis. injections. He complained of pain in the back, paralysis of the lower limbs, and of the sphinc- ters. He distinctly traced the course of the pain from the bladder upward to the kidneys and across the loins. On dissection, the kid- neys were inflamed, with minute purulent dep- ositions throughout their substance. The blad- der was inflamed, and its inner surface partly covered by coagulable lymph. The brain and spinal chord presented no disease. 137. A man, aged thirty, stated that he had been suffering for a day or two from pain in the loins, when he was seized with paraplegia extending to the umbilicus. The loss of mo- tion was complete, and the loss of sensation nearly so. The functions of the brain were unaffected. The urine flowed involuntarily, and three pints were drawn off by the catheter. In sixteen hours from the attack of paraplegia the man suddenly died. The kidneys were found gorged with blood and nearly black. The mucous membrane of the urinary passages was congested. The substance and membranes of the spinal chord and brain were sound, vascu- lar turgescence of these parts being but slightly greater than natural. 138. I believe that, if cases of the kind now adduced were carefully observed at an early stage of their course, sufficient evidence would be found of congestion of the veins or sinuses placed between the sheath of the chord and the bodies of the vertebrae. This congestion would of itself be sufficient to cause disorder of the urinary functions and inflammation of the kid- neys and urinary passages, which would react upon, and aggravate the spinal lesion. In the examinations of these cases no mention is made of the state of the venous sinuses of the spine. 139. L. Palsy is sometimes associated with hysteria, and the association has been noticed in the article Hysteria (§ 35). A remarkable case of this complication was lately attended by Mr. Flockton and myself. A young lady had experienced hysterical symptoms, with ir- regularity of the catamenia, to w'hich had su- pervened suppression of this discharge, attacks of vomiting, sometimes alternating with diar- rhoea, and complete paraplegia, as respected the power of motion. The sensibility was only slightly affected. The urine required to be regularly drawn off. There was no tenderness in the course of the spine ; and all the cerebral functions, the organs of sense, the intellectual powers, and the moral feelings seemed to be in unimpaired vigour and duly regulated. She had been long ill, and had been under the care of various eminent men both in London and in fashionable watering-places. The treatment, which will be noticed hereafter, restored her in the course of a few weeks, and after three or four months she was quite recovered. 140. It is very difficult to explain the con- nexion between hysteria, or disordered states of the female organs, and palsy. But it is not improbable that many of the symptoms, and particularly those of a paralytic character, arise not merely from irritation propagated from the uterine system to the roots of the spinal nerves, or to the spinal chord itself, but rather from superinduced congestion of the spinal veins and sinuses, the congestion being attended either by interruption to the circulation in the chord, or by compression, or even by both. This change will account for the frequent connexion also of palsy of the urinary bladder with hys- teria, even when paraplegia is not present. Yet even in these cases, pains in the limbs, with weakness and partial loss of power, are often complained of. When the remote causes of hysteria are considered, particularly in con- nexion with the effects they produce upon the spinal chord and roots of its nerves, the fre- quent supervention of congestion of the spinal veins and sinuses may be viewed as altogether conformable with the laws of the animal econ- omy. 141. VI. Diagnosis.—Palsy, in a simple and primary form, cannot be mistaken for any oth- er malady. It is only when it appears second- arily, or associated with any one of the dis- eases just mentioned, that the diagnosis re- quires attention; and even then the object is chiefly to ascertain which is the primary affec- tion, to trace the nature of the connexion be- tween them, and to form some idea as to the structural changes upon wrhich the paralytic symptoms, which are usually sufficiently man- ifest, depend. It is to this last that our chief attention should be directed ; this is the great object of diagnosis, and one which is not only very difficult to determine on many occasions, but almost impossible on some. 142. a. When palsy presents any of its more ■partial states, the question of its origin will sug- gest itself; and the chief point to determine is, whether the affection depends upon lesion at the origin of the affected nerve in the cerebro- spinal centre, or whether it proceeds from dis- ease in the course of, or in the nerve itself. If ! there be no symptoms of disorder referable to i the brain or spine ; if neither pain, disordered ! function, nor sensation can be observed; and | more especially, if disease implicating the nerve can be detected, the source of the palsy be- comes manifest. In palsy of the face, disease ! of the portio dura, and tumours or matter press- ing upon the nerve, are readily detected. When the ganglionic portion of the fifth pair is impli- cated, the affection of the eye, and the symp- toms mentioned above (§ 19-22), in connexion with the states of the other senses, and of the functions of the brain generally, will readily indicate the seat of the disease. The various circumstances of the case will also aid the di- agnosis. Previous injury, the presence of tu- mours, or of periostitis, the scrofulous diath- esis, or manifest scrofulous disease, the occu- pation of the patient, and the operation of lead or arsenical poisons, &c., severally aid the di- agnosis. 143. b. Hemiplegia is generally caused by dis- ease in one side of the brain ; but it may be produced by lesion in one side of the spinal chord, although very rarely. When it pro- ceeds, as it usually does, from the former source, it is often preceded by cerebral symp- toms, or attended by an apoplectic seizure. The chief difficulty is to determine the nature of the lesion producing it; for the several changes, upon either of which hemiplegia may depend, are not attended by determinate phe- nomena. When it proceeds from haemorrhage it is usually, as above noticed (§ 39, 40), both sudden and complete in its accession, is often not preceded by pain, and is frequently asso- PARALYSIS—Consequences, Terminations, and Prognosis. the brain, or near its base, it will be asked, How is paraplegia from this cause to be dis- tinguished from spinal paraplegia 1 In many cases, the evidence of the former is negative only. There are no circumstances nor symp- toms indicating disease in the spinal chord, membranes, or containing parts, and then we are constrained to look to the brain for it. But where, in addition to this evidence, there are indications, antecedently or concomitantly, ol cerebral affection—if any of the functions ot sense or manifestations of mind be impaired, or otherwise affected, or if headache or vertigo be present—the source of disorder may thus be conceded to the brain. 147. Where it is manifest that the paraple- gia proceeds from disease implicating the spi- nal chord or its membranes, the question as to the nature of that disease is often solved with great difficulty. When paraplegia is caused by accidents, injuries, wounds, &c., the nature, and seat, and direction of these often assist the diagnosis. The suddenness or slowness of the accession of the malady, viewed in connexion with the presence or absence of pain and ten- derness in the spine, will often suggest cor- rect views. Thus antecedent pain, tenderness on pressure, &c., and the continued presence of these, constrictive pains in the limbs or in the abdomen, spasms or contractions of the muscles, &c., will indicate congestion or in- flammation in some one or more of the con- stituent tissues of the part, particularly if the palsy supervene gradually, and if the remote or exciting causes are such as are likely to oc- casion these lesions. If pain in the back oc- cur suddenly, and is attended almost immedi- ately by paraplegia, extravasation of blood may be dreaded ; or the displacement of a previous- ly-diseased vertebras, or sudden effusion produ- ced by disease of the spinal bones, may be in- ferred. (See Spinal Chord and Membranes, Inflammation of.) 148. Debility of the muscles of the spine causing curvatures of the column is rarely at- tended by any considerable degree of paraple- gia. When this palsy is associated with dis- ease of the spinal bones, the curvature is an- gular, owing to caries and absorption of one or more of the bodies of these bones. In the for- mer case attempts to straighten the spine are not attended by pain or risk, and the patient can lie on the back or abdomen without pain. In the latter, such attempts are dangerous, or even fatal; as in a case of caries of one or two of the cervical vertebrae, for which a surgeon was consulted, and an attempt which was made to straighten the part was soon afterward fol- lowed by general paralysis. I was afterward called to the patient, who recovered after a most protracted confinement. When palsy is associated with angular curvature, as in a case now attended by Mr. Chilcote, which I occa- sionally see, any attempt to lie on the back, or to straighten the spine, is followed by pain ; and in another case just seen by me, such at- tempts produce convulsions. These attempts always interfere with those processes from which alone recovery is to be expected. (See art. Spinal Column.) 149. vi. Consequences, Terminations, and Prognosis.—A. Several of the consequences of palsy have been already alluded to (§ 56, cl 33 mated with apoplexy. If it. proceed from soft- ening, or from tumours or morbid growths of any kind (see art. Brain, § 111, et seq.), it is generally preceded by cerebral symptoms, by various nervous disorders, by pain, &c., and attended by spasms, convulsions, contractions, or pains ; its accession is usually slower, and it is at first less complete than in other cir- cumstances. Tubercles in the brain or in its membranes are not infrequently causes of pal- sy in children from one or two years of age to twelve or fourteen, as stated in the art. Brain (§ 19,115), and more recently by Dr. H. Green. 144. I may here remark, that considerable lesions, or morbid growths, may exist in or near the periphery of the brain, or implicate chiefly the cineritious substance of the convolutions without causing palsy, although coma, convul- sions, or epilepsy generally result. I have re- marked this circumstance in several cases ; but I have never seen any marked lesion of the central parts of the .brain without palsy being present. 145. c. Paraplegia has been assigned above (§ 53) chiefly to disease of, or implicating, the spinal chord or its membranes. But it was supposed by Dr. Baillie, Dr. Good, and oth- ers to arise much more frequently from dis- ease within the cranium. Many years ago I controverted this doctrine (see Lond. Medical Repository, vol. xviii., p. 522, 1822). I then took occasion to state “ that, although I admit that paraplegia will sometimes result from le- sions seated at the base, or in both sides df the central parts of the brain, still I contend that it most commonly arises from diseases of the spinal chord.” “ The chief reason of the prev- alence of the cerebral pathology of paraplegia appears to be the old physiological opinions respecting the nervous system still entertained by many ; and the circumstance of the brains of paraplegic subjects being, in conformity with preconceived notions, the only parts of the ner- vous masses which, until lately, had attention paid to them. It is by no means unlikely—and many pathologists have recorded the fact—that a patient, who has been for some time paraple- gic from lesion in the spinal chord or its mem- branes, shall die apoplectic, or shall expire from lesions subsequently developed in the brain. This latter morbid structure, instead of being consecutive, may be even co-existent; but, at the present day, I should not expect to hear a pathologist conclude, because he found lesions in the brain, that the paraplegia there- fore arose from the cerebral disease only. I would be still more surprised were I to hear the same inference drawn without any exam- ination of the spinal canal or medulla oblonga- ta having been*made. Now I do contend that such conclusions have been actually drawn from such inconclusive data as the above by those who suppose—for the inferences of those in- vestigators are but suppositions at the best— that paraplegia is generally seated in the brain.” Thus I wrote in 1822, in opposition to the then received doctrine ; and now the justice of my views, which even then were based upon tol- erably extensive observation, are almost uni- versally acknowledged. 146. Admitting, as I have done, that para- plegia may occur, in rare instances, from dis- ease in both sides of the more central parts of 34 seq), but as the affection is chiefly a conse- quence itself of pre-existing disease, it seldom induces farther change unless what becomes speedily fatal; and that change is seated chief- ly around, or in the immediate vicinity of the lesion causing the palsy. Owing to such change, the mental powers are often weakened, or al- together lost In hemiplegia, or attacks of apo- plexy or coma supervene ; a partial palsy may become more extended ; and even imperfect taraplegia may gradually increase and be more complete or be general, ultimately terminating in coma or apoplexy, or in asphyxia from in- jury to, or counter-pressure on, the medulla oblongata. The principal consequences of pal- sy, especially when the spinal chord is impli- cated, are manifested in the urinary organs, the digestive canal, and respiratory functions, and in the weakened state of vital cohesion of the tissues of the paralyzed parts ; and these have been severally noticed at length (§ 57-64). 150. B. The terminations of palsy are chiefly apoplexy, coma, sinking of the vital powers, as- phyxia, convulsions or epileptic seizures termina- ting fatally, and more or less complete recovery. Apoplexy frequently supervenes on hemiplegia or partial palsy, and either aggravates it or terminates life. A state of gradually ingraves- cent coma may also terminate these states of palsy, and even general palsy, although this last variety frequently causes asphyxia, death oc- curring sometimes gradually, at other times suddenly; gradually, from defective oxygena- tion of the blood and diminished production of carbonic acid, coma usually intervening ; sud- denly, owing to the arrest of the actions of the respiratory muscles and functions, and of the heart, consequent upon lesion at the origins, and complete paralysis of the respiratory nerves. In both these latter classes of cases the blood after death is fluid and of a dark ve- nous colour. 151. Paraplegia either passes into general palsy and terminates as stated above (§ 150), or becomes fatal, owing to consecutive changes produced in the urinary organs, or to slough- ing of the parts upon which the body rests, sinking of the powers of life, and contamina- tion of the circulating fluids arising from these alterations. When the upper portions of the chord or the medulla oblongata become affect- ed, epileptic attacks or convulsions occasional- ly occur, and even terminate existence, rather by the attending or superinduced asphyxia than by the amount of injury sustained by the brain. 152. C. The prognosis of palsy depends much upon the grade of severity, or the complete or general character of the malady, and upon its duration. In forming a prognosis, the circum- stances alluded to when noticing the conse- quences and terminations of the disease should be taken into account. When the palsy is lo- cal, and independent of lesions in or near any part of the nervous centres, or where it is caused by any of the metallic poisons, hopes of recovery may be reasonably entertained. But when the disease depends upon organic change of these centres or of their envelopes; when it is complete and extensive; when a whole side of the body is affected ; and when it has been of considerable duration, perfect recov- ery rarely takes place. I have met with this favourable result only in two or three cases. PARALYSIS—Causes of. Yet, although perfect recovery so rarely oc- curs, the state of the patient may be ameliora- ted, and the patient may live many years with- out the occurrence of any of the unfavourable consequences or terminations of the malady, if a suitable diet and regimen be pursued. In all cases, the causes of the attack, and the na- ture of the antecedent disorders and attendant symptoms, should be considered. When the palsy is attended by great disorder of the di- gestive organs, when the urinary organs are re- markably affected ($ 57), and when the sphinc- ters are relaxed, when spasms or contractions of the muscles are present, or convulsions su- pervene, and when the nature of the organic lesion implicating the brain, spinal chord, or their envelopes is manifestly such as cannot be entirely removed, the most unfavourable opinion may be formed of the result, although the ultimate issue may be deferred for a con- siderable time. 153. The complications, also, of palsy should influence the prognosis. The most unfavour- able of these are the associations of hemiplegia with apoplexy or coma ; with inflammation of the substance of the brain, as indicated by spasms, contractions, and pains of the limbs ; with neuralgia of the nerves of the face or head ; with epilepsy or convulsions; with in- sanity, imbecility, or idiocy; with disease of the heart or of the liver; with lesions of the cervical spine ; and with inflammation of the kidneys. If the palsy supervene in the course of these, it may be generally assumed as the result of severe, if not irremediable, organic change in the brain or spinal chord. 154. Palsy of the muscles of articulation, of the tongue, or of deglutition, whether appear- ing alone or in connexion with hemiplegia, is a most dangerous state of the malady, and oft- en precedes more complicated and severe forms of the disease, that will soon pass into fatal convulsions, or apoplexy, or asphyxia. Fully- developed shaking palsy is rarely materially ameliorated by treatment, although patients af- flicted with it may live many years without much increase of the symptoms. 155. Recovery often takes place from the hysterical or uterine complications of palsy, al- though even in these the absence of all organ- ic lesion of the nervous centres or of their en- velopes ought not to be generally inferred, for irritation of the uterine organs, or suppression of the catamenia, may be followed by inflam- mation and its usual consequences in these parts, particularly in the spinal chord, or by congestion, especially of the venous sinuses of the spine, sufficient to produce interruption of the act of volition from the brain to the nerves of the extremities, owing to the jrressure which such congestion may occasion. 156. Recovery from the less complete and least complicated states of palsy from the me- tallic poisons is sometimes brought about by careful treatment and suitable precautions and regimen. A case of complete hemiplegia con- sequent upon apoplexy caused by monkshood, respecting which I was consulted many years ago, quite recovered after a protracted treat- ment. 157. VII. Causes.—i. The remote causes of palsy are more strictly the causes of those mal- adies in the course of which alterations of the 35 nervons centres most frequently occur, and are so entirely the same as those which I have ad- duced in the articles Apoplexy, Epilepsy, In- flammation of the Brain, &c., as to require merely to be enumerated at this place. 158. A. The predisposing causes are chiefly hereditary predisposition, advanced age, the male sex, mental labour, luxurious habits, and sexual indulgences. I have observed a great- er frequency of palsy in the children of those who have died of diseases of the brain than in others. Palsy is much less frequent in chil- dren and young persons, or in those under thir- ty years of age, than in persons farther advan- ced. According to the registrar-general’s re- port, the deaths in the metropolis in two years from palsy were 33 under fifteen years of age, 514 from fifteen to sixty, and 932 at sixty and upward; and from the same authority it would appear that the number of deaths is as great ;n females as in males. Palsy is most fre- quently observed in persons whose habits are sedentary, and in those of feeble constitution, ft is said to be more frequent in the sanguin- eous and nervous than in other temperaments; out this is not established. There can be no doubt of mental labour, depressed and anxious states of mind, luxurious habits, and venereal indulgences being most influential causes of predisposition to palsy. Indeed, the various circumstances which I have assigned as pre- disposing to Apoplexy ($ 77), have a similar influence in respect of palsy. Among these vascular plethora may be mentioned ; and when this state is present, hemiplegia, either alone, or complicated with, or consequent upon, ap- oplexy, is the form of palsy most frequently observed. 159. Various arts and employments (see that article) remarkably predispose to palsy, espe- cially all those in which lead, arsenic, and mer- cury are much used, as painters, plumbers, glaziers, &c., &c.; and in persons thus expo- sed, the disease occurs at earlier epochs of life than in other circumstances. It is least frequently observed in those who lead a sober and active life, and are much in the open air. It is rarely met with in sailors and soldiers, but this is partly owing to comparatively few of them being far advanced in life. The influence of the seasons, or of weather, in favouring at- tacks of palsy has not been shown with any precision; but cold and moist seasons and weather, and cold, humid, and miasmatous lo- calities are certainly more productive of para- lytic affections than other seasons, weather, or situations. 160. B. The exciting causes of paralysis are, 1st. Physical, mechanical, and external agents ; 2d. The mental emotions ; 3d. Pathological states, or pre-existing lesions ; 4th. Poisonous substan- ces. These may act (a) directly upon the ram- ifications or trunks of nerves; (b) or directly or mediately upon the cerebro-spinal axis. 161. a. Of the physical agents the most influ- ential is certainly cold, particularly when se- vere in grade, or long applied to any part, or to the general surface. Cold directly depresses the nervous power, and benumbs sensation, thereby affecting the nerves themselves ; it may also occasion congestion of the nervous centres, and particularly of the veins and si- nuses of the spine, and, consequently, more or PARALYSIS—Causes of. less complete forms of paraplegia, or general palsy, as in the cases already alluded to.* All applications to the surface of a part that con- duct either the animal heat or the electricity from it may excite paralysis of it, particularly when long continued, as sleeping, sitting, or lying on the ground, or on stones ; wet or damp clothes ; the continued contact of metallic or earthen substances, &c. Pressure of any kind upon a nerve, whether produced by external substances or by tumours, abscesses, aneu- risms, dislocations, or other lesions in the vi- cinity of the nerve, or by disease of the nerve itself, or of its neurilemma, and wounds, con- tusions, or other injuries of one or more nerves, are occasional causes of local palsy.f Causes of a similar kind, implicating the brain or spi- nal chord, especially depressions or displace- ments of the cranial or spinal bones ; concus- sions or other injuries of the cerebro-spinal axis; depending or constrained positions of the head or spine ; congestions, tumours, mor- bid depositions, or other changes in the ner- vous centres, their membranous envelopes, or bony cases, occasion hemiplegia, paraplegia, or general palsy, according to the seat of lesion as above assigned. To these may be added intemperance, fatigue, or exhaustion, changes of temperature and of the atmosphere, inani- tion, &c. 162. b. The influence of the mental emotions in causing palsy is undoubted ; but it is not so directly manifested on the brain in all cases as may be at first supposed. The emotions, wheth- er exciting or depressing, act primarily upon the heart and circulation, and through them upon the brain and spinal chord. Undue ex- citement of the imagination, sudden mental shocks, fits of anger, and venereal excesses, or masturbation, are not infrequent causes of pal- sy. Indeed, the several states of paraplegia and general palsy are oftener produced by the last of these causes, or by masturbation, than by any other. 163. c. Pathological states, or lesions occur- ring in the course of pre-existing disease, as already stated and sufficiently insisted upon, not only in this article (§ 34-53), but also un- der the heads Apoplexy (<) 34, el seq.) and Brain (§ 50, et seq.), are the most frequent and immediate exciting causes of the several vari- eties of palsy in their primary and associated forms. These, in fact, constitute the chief mor- bid appearances furnished by paralytic cases, and consist chiefly of exostosis, tumours, or morbid growths, in the cranial bones (see art. Cranium) ; tumours, effusions of blood, or of serum, fungoid productions, congestions, and the more common consequences of inflamma- * The celebrated Scarron was deprived of the use of his limbs by prolonged exposure to cold during a lit of dis- sipation. His mental faculties were, however, unaffected, as in most instances of paraplegia, and of general palsy caused by lesion of the spinal chord. The fascinations of his wit were unimpaired, and he became the husband of the beautiful and witty Mademoiselle D’Aubigne, after- ward the famous Madame de Maintenon. Scarron lived twenty-three years in a paralyzed state. t [See an account of a poculiar form of paralysis in New- York Journ. of Med., vol. ii., p. 34, by William P. Buel. It affected the nerves and muscles of the forearm, the hand, the thumb, and the fingers, producing loss of muscular power, and loss of sensation, partial or complete, from the bend of the elbow to the tips of the fingers. The cause is ascribed to long-continued pressure of the weight of tho body upon the nerves of the forearm in sleep.] 36 tion of the membranes of the brain ; congestion and inflammation, extravasations of blood, ef- fusion of serum, abscesses, softening, indura- tion, atrophy, ulceration, apoplectic cysts, tu- mours, tubercles, morbid or malignant produc- tions, aneurisms, hydatids, watery cysts, slough- ing or gangrene consequent on severe inju- ries in parts of the brain; effusions into the ventricles, or between the membranes ; disease of the blood-vessels or aneurismal tumours, os- sification of the coats of the arteries, varices or dilatations of the veins or sinuses, and co- agula, or fibrinous, or other concretions in these vessels, are the chief lesions which have been found in cases of hemiplegia, and of partial pal- sy of the senses. The changes just particu- larized, affecting the spine, or the membranes or substance of the spinal chord, or medulla oblongata, are the usual causes of the sponta- neous cases of paraplegia and general palsy, or those cases which occur independently of the more direct effects of external injuries. The occurrence of these forms of palsy in the course of caries of one or more of the vertebrae, owing either to the extension of inflammation to the membranes, to effusion of lymph, or of serum, or to pressure on the chord, owing to the acute angle formed by the consequent cur- vature, is sufficiently familiar to physicians. But cancerous or malignant disease of the ver- tebrae, consecutive of cancer of the mammae, or occurring primarily in these parts, may also occasion paraplegia. Mr. Caesar Hawkins has adduced three interesting cases of paraplegia from this cause, and my friend Dr. Abercrom- bie, of Cape Town, has communicated to me a similar case to two of those observed by Mr. C. Hawkins, which had occurred in his prac- tice. In this instance, the breast was greatly enlarged, was quite adherent to the ribs, and its lower surface ulcerated. A prominence was observed in the situation of the second and third dorsal vertebral, with tenderness on pressure ; paraplegia, followed by its most un- favourable consequences, shortly afterward took place. 164. Periostitis, especially scrofulous perios- titis, is not infrequently productive of partial palsy, and of paraplegia, or even of more gen- eral palsy, when affecting portions of the ver- tebral column. In these cases, as far as my observation has enabled me to state, the blad- der is more or less paralyzed, the urine soon becoming alkaline, and neuralgic pains of the limbs are often present to a distressing degree. 165. d. Sufficient notice has been already taken (<) 100, ct seq.) of the poisonous substances which occasion palsy. The slow introduction of mineral poisons, as lead, arsenic, mercury, &c., sometimes is followed by this effect; and in some cases, at least, their influence is ex- erted as much, if not more, upon the nerves supplying the paralyzed limb as upon any part of the nervous centres. The poisonous effects consequent upon the vegetable or acro-narcot- ic poisons are owing more to contingent le- sions sustained by a part of these centres, ivhile they and the circulation in them are under the influence of the poison, than to any effect pro- duced by them on the nerves themselves. 166. VII. Of certain Points in the Pathol- ogy of Palsy.—It is obvious that palsy may arise from two distinct conditions of the ner- PARALYSIS—Pathology. vous centres, viz.: 1st, from the suppression or diminished evolution of the cerebro-spinul ner- vous power and of volition, owing to interrupted circulation, to depressed vital influence, or to other alterations, in that part of the cerebro- spinal axis which is chiefly concerned in pro- ducing or originating that power ; and, 2d, from whatever may prevent the transmission of cerebro- spinal nervous power and volition from the parts concerned in producing them to the limbs and organs which they actuate. 167. (a) If it be conceded that the gray sub- stance of the brain and spinal chord be chiefly concerned in originating volition and the other cerebro-spinul functions, we may readily admit that, when this substance becomes manifestly diseased throughout the convolutions of the brain, a general state of palsy, more or less complete according to the extent of change ex- perienced by it, may be anticipated; and this is actually observed in all cases where the gray structure is extensively changed, more partic- ularly in those cases of general palsy complica- ted with Insanity, as shown in that article (<$ 235). In these the cerebro-spinal functions— the emotions, intellects, volition, &c.—are more or less impaired, and the gray matter of the brain and spinal chord is generally found atro- phied, indurated, or otherwise changed, and the structure especially concerned in the mani- festations of these powers is no longer in a state capable of originating or developing them. 168. (5). The transmission of cerebro-spinal ner- vous power and volition may be prevented, al- though they are produced by injury, disease, or pressure of the medullary substance of the brain or spinal chord, or of the nerves. Most of the lesions adduced when describing the sev- eral forms of palsy and their efficient causes act chiefly by arresting or interrupting the trans- mission of volition ; although, even in these or in other cases, many alterations of structure both interrupt the transmission, and prevent the evolution or the production of nervous power and volition ; as when the lesion implicates both the gray and the medullary substance, both the origins and the course of certain nerves. 169. The well-known fact that disease on one side of the brain causes palsy of the oppo- site side of the body, has been attributed to the decussation of fibres in the medulla oblongata. This decussation was supposed to be confined to the anterior columns only. But, although it might account for the crossed paralysis of mo- tion, it could not equally explain the circum- stance of paralysis of sensibility following the same law. Sir C. Bell has, however, shown that the middle columns decussate as well as the anterior, and thus accounted for the crossed effect in both cases. 170. It has, moreover, been objected that le- sions of the cerebellum also produce a crossed effect, although this organ is seated above the point of decussation ; and that paralysis of the face follows the same law, and arises from dis- ease in the opposite side of the brain, although the nerves distributed to this part also arise above the decussation. As to the first objec- tion, it may be remarked that the dissections of Mr. Solly have demonstrated that numer- ous fibres run between the spinal chord below the corpus olivare and the cerebellum, which he believes to decussate with their fellows of the opposite side, forming, in fact, part of the apparatus of decussation. But this discovery establishes merely a direct communication be- tween the cerebellum and spinal chord in the immediate neighbourhood of the decussation, without proving the fact of the crossing of these fibres. As to the second objection, it may be answered in the words of Dr. Bennett, that Sir C. Bell has shown that the fifth pair of nerves arise below the decussation, and Mr. Solly has traced one of the origins of the por- tio dura from the fibres he has described, which run between the spinal chord and cerebellum. Thus the sensitive and motor branches of the face ought to follow the same law as the other spinal nerves, which is consonant with what actually takes place. 171. Cases have been recorded, however, in which paralysis has occurred on the same side as the lesions in the brain. Mr. Hilton has endeavoured to explain this exception by refer- ring it to a disposition of fibres in the decussa- tion ; but, as Dr. Bennett has justly argued, there is strong reason for doubting whether disease in the brain ever causes a direct influ- ence ; for of the many thousand cases of cere- bral haemorrhage, tumours, &c., which have been recorded, we are acquainted with twenty- one only in which paralysis is said to have re- sulted from disease in the same side of the brain as the palsied side of the body, and, on analysis of these, more than one half are im- perfect and doubtful. As the instances, there- fore, of this occurrence are so few, may we not consider that the palsy even in them was produced in the usual manner, and that the le- sion which attracted attention had no reference to the complaint! Numerous instances have occurred of abscesses, softening, and other al- terations of the brain having been found, but in which no paralysis had been observed during life ; and a still greater number are on record in which there was well-marked paralysis, but no appreciable lesion of structure after death. It is by no means improbable, therefore, as pa- ralysis may be induced without leaving any tra- ces, that, in those few cases where the palsy and the lesion in the brain were in the same side, it was really caused by undetected chan- ges in the opposite hemisphere of the brain; and, as is sometimes the case, that the disease found in the hemisphere of the paralyzed side had not occasioned the loss of motion. 172. Lesions in the vertebral portion of the spinal medulla produce not a crossed, but a di- rect effect; and when they interrupt the func- tions of this part of the nervous system, all the parts furnished with nerves arising from be- neath the seat of lesion are affected. Hence the paralysis is the more general, the nearer the disease of the chord is to the brain. But disorganization has sometimes gradually pro- ceeded to a considerable extent in the spinal chord as well as in the brain, while such fibres or portions of the former as remained unaffect- ed appeared sufficient to perform the limited extent of function which the state or exertions of the patient required. Cases have even been recorded in which individuals have performed voluntary movements of the lower extremities almost up to the time of death, and yet, on ex- amining the chord, it has been found entirely destroyed. Such statements should, however, PARALYSIS—Pathology. 37 I be received with distrust; for, although the presence of sensibility in tire lower limbs may be explained in these circumstances (see § 181, et seq.), the transmission of volition, so as to act upon the extremities, cannot be accounted for. It is much more probable that the lesions ob- served had taken place chiefly after death, and had only commenced shortly before it; for the spinal medulla when inflamed, and even in health, often undergoes rapid changes after dis- solution. We know, also, that when the spinal chord is inflamed, or is undergoing softening, involuntary, spastic, and automatic movements are produced in the muscles and extremities, that may be mistaken for voluntary motion, and it will hereafter be shown that, even when ex- tensively diseased and incapable of transmitting the usual acts of volition, various reflected movements of sympathy may be made by the paralyzed limbs. Several cases have been re- corded, where the spinal chord has been said to have been softened throughout, disorganized, quite diffluent, or even entirely divided, and yet sensibility, and even voluntary motion, have been preserved or but very slightly impaired. The case of Dessault, that recorded by M. Rullier, and others, are of this kind ; but they are related with insufficient precision for im- plicit confidence, and they may, moreover, be explained as just stated, and thus furnish no basis of argument. 173. (c) The physical conditions of the brain and spinal chord ought to be taken into consid- eration in estimating the influence of lesions of these parts of the nervous system, or of their envelopes, in producing paralysis. These con- ditions are, 1st. The bony and unyielding cases enclosing them ; 2d. The membranes interpo- sing between them and these cases ; and, 3d, The fluid interposed between the membranes, especially between the arachnoid and pia mater. 174. a. The unyielding cases enclosing the cer- ebrospinal axis give rise to several accidents and changes consequent upon external injury, notwithstanding the influence of the mem- branes, of the processes of the dura mater, and of the fluid interposed between the membranes in preventing them. The pressure, laceration, &c., caused by fractures, depressions, &c., ot portions of these cases; the concussions, counter-strokes, shocks, and succussions pro- duced by falls on the back, shoulders, feet, and extremities ; the direct pressure following the extravasation of blood, or of serum, the devel- opment of tumours, or venous congestion and interrrupted return of blood ; the counter-press- ure consequent upon these changes, and ex- erted chiefly on parts distant from, or opposite to, the seat of lesion or effusion ; and the shock sustained by the vitality and nervous power of the frame, upon severe injury of the nervous centres, should all be taken into account when we attempt to explain resulting phenomena; inasmuch as they complicate the effects, and render their causes or sources more obscure and doubtful. 175. (3. The physical influence of the membranes in preserving the nervous masses they enclose from injury and disease is obvious. They sup- port, secure, and protect their contents ; while they interrupt or prevent the extension of inju- ry or disease from the external cases to the contained vital parts. Still, when they are 38 themselves the seat of disease, particularly of tumours or of inflammation, the pressure or ir- ritation, or the extension of the disease and its more remote consequences, affect more or less the nervous centres and interrupt or disorder their functions, although the interposed fluid tends to prevent or to lessen these effects. 176. y. The cerebro-spinal fluid interposed be- tween the arachnoid and pia mater is not mere- ly requisite to the healthy discharge of the func- tions of the brain and spinal chord, as shown by Cotugno, Magendie, and Todd, but is also most serviceable in preventing the extension of injury and disease from the bones and mem- branes enclosing these organs. The motions alone of the spine would be productive of se- rious consequences, if this fluid, which is more copiously interposed in this part of the nervous system, did not prevent them from materially affecting the chord itself, and the roots of the nerves which it transmits. When we consid- er the effects of this fluid upon the functions of the cerebro-spinal axis, it is impossible not to infer that the quantity of it will vary with the states of the nervous masses and of vascular determination to, or congestion of, them and their membranous envelopes. It may reason- ably be concluded that, when these structures and the blood supplying them do not sufficient- ly fill the unyielding cases of the cranium and spine, the fluid interposed between the arach- noid and pia mater will supply the defect, and prevent the existence of any vacuum, and that, on the other hand, when the states of these centres and of the circulation in them are such as give rise to much fulness, the quantity of this fluid will be diminished. Anaemia will thus be attended by an increase of the cerebro-spinal fluid, and vascular turgescence by a diminution of it, the included masses being thereby pre- served from much diminution of pressure in the one case, and from much increase of it in the other. Thus, also, in cases of atrophy, partial or general, of the brain or spinal chord, the quantity of this fluid is increased, showing the importance of it to the functions of these parts, while in cases of hypertrophy it is diminished or almost wanting. 177. It is obvious that in health the presence of a considerable portion of the cerebro-spinal fluid is always necessary to protect the nervous centres with which it is in immediate contact. It is very justly remarked by Dr. R. B. Todd, that by the interposition of a liquid medium be- tween the nervous mass and the wall of the cavity in which it is placed, provision is made against a too ready conduction of vibrations from the one to the other. Were these centres sur- rounded by one kind of material only, the slight- est vibrations or shocks would be continually felt; but when different materials on different planes are used, the surest means are provided to favour the dispersion of such vibrations. The nervous mass floats in this fluid, being maintain- ed in equilibria in it by its uniform pressure on all sides, and the spinal chord is farther secured by an additional mechanism, preventing its lat- eral displacement. The abundance of this fluid at the base of the brain and medulla oblongata protects these parts, the nerves, and vessels, from unequal or excessive pressure and coun- ter-pressure during disease, or from accidents ; while a diminution of it favours or even indu- PARALYSIS—Pathology. ces most serious consequences, as shown by the experiments of M. Magendie. 178. From what I have now adduced it may be inferred that the effects often imputed to the abundance of this fluid, particularly in the spinal canal, by several pathologists, when de tailing the morbid appearances after death from diseases of the nervous system, have been im- puted to a wrong source ; that the serous effu- sion in these cases, as I have elsewhere argu- ed, is neither the cause of pressure upon, nor of induration of, the nervous centres, nor the source of the palsy sometimes observed in these cases ; but that it is a result of those changes of the nervous structure and of the lo- cal circulation with which it is found associa- ted, in connexion with, or aided by, the un- yielding state of the surrounding parts. 179. (d) Of the Influence of the different Col unins of the Spinal Medulla and Roots of the Spi- nal Nerves upon the Sensitive and Motor Powers. —Since the researches of Sir C. Bell and M. Magendie on this subject, it has generally been supposed that, while the antero-lateral columns of the chord convey the motor power, the pos- terior transmit sensations. Several pathologi cal facts, independently of the experiments of some physiologists, have, however, made it ap- pear doubtful whether or not the power of mo- tion and sensation are severally conveyed through these channels only, and in the pre- cise manner just assigned. There can be no doubt, however, that volition is transmitted along the anterior columns of the chord, the anterior roots of the nerves and the corre- sponding nervous fibrils, to the muscles which are acted upon; and that sensation generally is conveyed in an opposite direction, namely, from the surface of the body along the sensory nervous fibrils, the posterior roots of the nerves, and the posterior columns of the chord, to the brain. But, although it seems satisfactorily proved that the acts of volition cannot be fully and precisely performed unless the channels by which volition is transmitted continue sound, or not materially injured, together with the corre- sponding portions of the fibrous structure of the brain, still it is very doubtful whether or not the posterior columns of the chord are as exclusively devoted to the conveyance of sensa- tion as the anterior are to the transmission of volition. Indeed, the cases recorded by vari- ous writers, and especially those by Stanley, Webster, and others, prove either that the le- sions observed in the posterior columns of the chord have taken place at the moment of, or immediately after, dissolution, or that sensa- tion may be transmitted through other chan- nels besides these columns, or even independ- ently of the spinal chord itself. That the for- mer of these alternatives cannot be the cause, at least to any considerable extent, is shown by the history of the cases and the nature of the changes which have been observed. It should, however, be admitted that, where soft- ening of the chord is observed greater doubt may be entertained; for this change, when it has commenced before death, particularly as a consequence of inflammation, will often pro-; ceed and extend very rapidly immediately af- terward, so as to be both complete and exten- sive at the time of inspection. Still, conceding all that may be inferred from this circumstance, PARALY SIS—Path ology. 182. The indirect character of this channel may appear an argument to some against the accuracy of this inference ; but we know that, in cases of obstruction to the usual channels of circulation in the vascular system, very circu- itous courses are developed in order to preserve an organ or limb, and the nervous system pre- sents many points of analogy with that system, especially a transmission of sensation from the periphery of the body, and from the several or- gans and structures to the more central ner- vous masses, and a similar circulation or return of nervous agency in the form of motion and determinate muscular contraction. The anal- ogy may be farther pursued, but the several points are so obvious that they require not even enumeration at this place. Moreover, it should be considered that, in respect of sensa- tions excited in any of the abdominal or other viscera, it is very doubtful whether the spinal chord is the channel by which the impressions or changes in the viscera are transmitted to the brain, or whether the sympathetic nerves and communicating branches between the gan- glia are the courses which are pursued. In- deed, there appears little doubt of the latter be- ing the actual channel of conveyance ; for im- pressions on or changes in the viscera, espe- cially those of digestion and assimilation, are as vividly and as rapidly conveyed to, and made objects of consciousness in, the brain, in cases of injury, or even of complete division of the chord, as in sound health. 183. The above considerations may serve as reasons wherefore sensation remains unimpair* 39 pathology furnishes sufficient proofs that sensa- tions may he conveyed to the brain by other channels in addition to the spinal chord, espe- cially when the alterations in the chord, ren- dering it incapable of discharging this function, take place slowly or gradually. 180. Experimental proofs of the existence of these other channels, and evidence respect- ing them, cannot be furnished with the force of demonstration, as, however conclusive ex- periments performed on the higher animals with the view of furnishing such evidence may appear in the eyes of the experimenter, they will admit of other, and often very different, conclusions, and the phenomena observed in the lower animals, particularly those which cannot audibly express their feelings, may be ascribed to other causes, or differently explain- ed. We can, therefore, in the present state of our knowledge, only infer from the history of diseases implicating the spinal chord, and from what we know of various inconclusive and not always truly or correctly observed ex- periments, that changes produced in parts or surfaces of the body may become objects of consciousness, in certain circumstances at least, without the intervention of the spinal medulla ; but as this cannot take place unless the sensation be transmitted by a different channel, it remains to inquire what that chan- nel is, or whether or not various parts of the nervous system may, in certain circumstances, or to a certain extent, perform this function. 181. When we recollect that communicating branches run between the ganglionated or pos- terior roots of the nerves and the great sym- pathetic on each side ; that ganglial nerves may be traced in their course from the sympa- thetic into the spinal ganglia and chord on the one hand, and from the latter into the sympa- thetic and ganglia on the other, we cannot but infer, not only that sensation may be transmit- ted, or, more correctly, that impressions on the surface may be conveyed to the brain, so as to excite consciousness, by a different route than that of the spinal chord, especially under cir- cumstances of gradual change in the chord, rendering it ultimately incapable of dischar- ging this function, but that this other route is through the sympathetic nerves and their com- munications with the posterior roots of the nerves and spinal medulla.* functions. For nearly the same period the bowels had to be relieved by enemata. Returning sensibility was experi- enced in the skin about the fifth day, and an imperfect use ot the limbs about the fifteenth. The patient first commenced locomotion on his hands and knees, then by pushing a chair round, and afterward by means of crutches; but sensibility in the skin and power of motion in the inferior extremities returned very slowly, so much so that, four years and sev- en months after the accident, he burned his knee very se- verely, without feeling any pain or being conscious of suf- fering, by sitting too near a hot fire. Recovery eventually took place, without any curvature of the spine or spinal weakness, the patient being able to get into and out of a carriage and mount a horse without any assistance. The case is an important one, as it goes to establish the fart that the spinal marrow is the sole channel for the transmission of sensations, and that it may unite, and its functions be restored, after complete division.—(New York Journ. of Med., vol. v., p. 166.) Two cases of fracture and dislocation of the spine, which have fallen under our care, were also attended with total loss of sensation and motion below the seat of the injury. Dr. H. A. Potter relates (N. Y. Journ. Med. and Col- lat. Sci., vol. iv., p. 174) the case of Mr. E., who was struck by the limb of a falling tree on the back, by which he was rendered insensible, with stertorous breathing, &c. He partially rallied from this state in about forty-eight hours, when it was found that there was no sensation nor motion below the upper part of the thorax. “ The patient could not tell when he was pricked nor handled, unless moved so as to stir his neck; in that case the sensation was very great.” “ He continued for more than three months una- ble to move a finger or toe, or to tell, by feeling, when he was handled.” At the end of this time, Dr. Potter, by a surgical operation, removed parts of the four inferior cervi- cal and the two superior dorsal vertebra. Four of the ver- tebra were fractured so as to produce compression of the spinal chord. Ossification of the broken fragments had ta- ken place. “Before the operation ended, the patient said he felt as though we were pricking him all over. Sensa- tion appeared to return almost instantaneously, and for the first time that he was conscious of it, below the compres- sion, after the receipt of the injury.” In five hours after- ward sensation was nearly perfect. The patient lived eigh- teen days after the operation, and died of disease of the lungs (loc. cit.). The opinion of our author, however, is doubtless correct, so far as it relates to those organs that are supplied with nervous influence by the ganglionic sys- tem of nerves.] * [The following remarkable case would seem to prove that sensibility is entirely owing to the integrity of the spi- nal chord ; and that, contrary to the opinion of our author, the intervention of the medulla spinalis is necessary to the transmission of sensations from parts below the seat of in- jury : By an accidental fall, Mr. I. S. S. pierced the spinal marrow by a chisel one inch in width, which passed in to the depth of five inches in that space opposite the spinous process of the lower dorsal vertebra on the left side. The wound, at its superior extremity, was half an inch from the spinous process, and one inch at its inferior extreniity ; so that a line drawn parallel to the spinous processes of the vertebra, and three fourths of an inch to the left, would have intersected it in the middle. The direction of the instrument was upward, at an angle from the surface of twenty to twenty-five degrees, and to the right of about twelve degrees, penetrating the spinal column, and un- doubtedly entirely dividing the chord. The immediate consequence was total insensibility below the wound, with complete paralysis of the lower extremities, bladder, and rectum. The shock that the system received produced great prostration for some forty hours, when reaction took place, and was followed by fever for ten or twelve days. The urine was drawn off by a catheter for about one week after the accident, when the bladder began to resume its 40 ed, or but little affected, in very many cases where the chord is diseased or injured so as to be incapable of transmitting the impulses of vo- lition, particularly when the lesion is high in the chord, and when it has advanced slowly or grad- ually. They may also account for the rare oc- currence of entire loss of sensation in any form of palsy of motion. 184. (e) Congestion of the venous sinuses seated between the theca of the chord and the bodies of the vertebree has been already assigned as a patho- logical cause of palsy, or one of the most im- portant changes upon which the paraplegic states of palsy depend. It seldom is found un- associated or alone after death and in the most complete states of the disease, as it generally superinduces more or less extensive changes in the chord and its membranes before dissolu- tion takes place. Several of the more remote causes of palsy act by producing, in the first place, congestion of these sinuses, which were even imperfectly described by anatomists until M. Breschet directed more particular attention to their structure and connexions. But the pathological relations of congestion and of ob- structions by fibrinous coagula or concretions in these sinuses have been entirely overlooked. 185. It will soon become obvious to those who make the early phenomena of disease ob- iects of observation and study, that whatever depresses organic nervous power will soon be followed by venous congestion ; and when this depression—whether primary or consecutive of nervous or vascular excitement—has been pre- ceded or is attended by circumstances produ- cing increased determination to, or fullness of blood in, the capillaries of the chord or its mem- branes, this consecutive congestion of the spi- nal sinuses is the more prone to occur. In its primary or uncomplicated states, it seldom pro- duces more serious effects than pain, stiffness, or weakness of the back, loins, and lower ex- tremities, sometimes amounting to incomplete palsy of motion of the latter; often with pain and constriction around the abdomen ; and when the weakness or imperfect power of mo- tion is associated with pain, this state is gen- erally confounded with rheumatism or with neuralgia, if the pain is severe and follows the course of a nerve, or with an attack of gout, when it occurs in the gouty diathesis. 186. Congestion of these sinuses occasions, first, retarded circulation in the chord and its membranes; subsequently, an increased serous secretion or effusion between the membranes. Unless the congestion be very great, it can hardly be expected that it should act injurious- ly on the chord by pressure, or counter-pressure of it against the posterior parietes of the spinal canal. Still, one injurious effect may be pro- duced in this way, particularly when the con- gestion has superinduced distention of the cap- illaries of both the chord and the membranes, with increased serous effusion between the latter. 187. In these more extreme cases, when ul- terior changes have taken place, it is not un- likely that the roots of the nerves will also suffer from unaccustomed pressure, and in those ca- ses the posterior or gangliated roots are the more likely to experience it, and paralysis of sensation will be present in a greater or less degree, and even be the more complete, inas- PARALYSIS—Pathology. much as the lesion implicates those parts ot the roots of the nerves which communicate with the sympathetic, as insisted upon above (() 181). In cases, also, of caries and angular curvature of the spine, where not only conges- tion of the vertebral sinuses, but also pressure and counter-pressure of both the chord and the roots of the nerves, and even of the nerves themselves, as they pass through the spinal foramina, are apt to take place, palsy of sensa- tion is then present, but only in degree propor- tionate to the extent of pressure on the roots of the nerves, and only in those cases where the nerves or their roots, especially the poste- rior, are implicated. 188. Congestion of the spinal sinuses, with more or less of the consequences now men- tioned, is a frequent attendant upon fevers, particularly the more adynamic and congestive forms of fever, occasioning not merely pains and weakness of the back and limbs, and in- complete palsy of motion of the lower extrem- ities, but also more or less of the affection of the urinary organs already mentioned (<) 57). Many of the cases described as spinal irritation, of hysterical neuralgia, of uterine irritation, &c., actually are instances of congestion of the spinal sinuses, occasioning remote or sympa- thetic phenomena in addition to those which are more strictly local. These are often re- moved or partially relieved for a time by the natural recurrence of the catamenia ; but when more extensive or severe, or when associated with suppression of this discharge, they some- times lapse into paraplegia or partial palsy, es- pecially when neglected or injudiciously treat- ed, owing to an increase of the congestion or of its consequences. 189. (/) Various sympathetic phenomena occur in connexion with paralysis, especially with the paraplegic states of the disease, that require particular notice. Some of these admit of differ- ent explanations, and thus have been differently accounted for, both by former and by contem- porary writers. Of these, the reflex motions, which sometimes are observed upon irritating the surface of a paralyzed limb, have attracted most attention, and have directed the research- es of physiologists more particularly than here- tofore to the structure and functions of the spi- nal chord. These researches are fully noticed in the article on the pathology of this part of the nervous centres, with my opinions respect- ing them ; and I therefore need no farther ad- vert to them at this place than to remark that the phenomena which Dr. M. Hall has assign- ed to a reflex function of the spinal chord were fully recognized by Whytt, but not explained by him as occurring independently of sensa- tion. He, however, believed that the power of feeling was not limited to the brain, but was extended to the spinal chord. Prochaska af- terward more correctly appreciated the true source and relations of these phenomena ; and in the articles Cholera, Chorea, Convulsions, &c., in this work, the characteristic symptoms of these maladies were explained, and ascribed to reflex actions excited in the voluntary mus- cles by irritations transmitted to the roots of the spinal nerves and spinal chord. Subse- quently to the publication of these articles, Dr. M. Hall’s researches appeared. He referred these phenomena to a special organization of PA R A L Y SIS—Path o l o g v. the chord; and his opinion received the sup- port of Mr. Grainger, Mr. Newport, and oth- ers, although opposed by some eminent anato- mists. The structure of the nervous system in the class articulata is the chief circumstance that can be adduced in favour of the existence of a spinal organization for reflex actions in the higher animals. But reflex actions—phe- nomena which I denominated, many years ago (1824), “ reflex sympathies”—are performed not only by the spinal chord, but also by the brain, and by the organic or ganglial nervous system. 190. a. As respects the brain, no sooner are the impressions on the senses made objects of sensation or consciousness than they are re- flected upon, or treasured in the memory, and, either instantly or at some future period, ex- cite to action. The manifestations of life through the medium of an encephalon are the phenomena to which the term mental has been usually applied which consist chiefly of im- pressions on the senses, rendered objects of consciousness and of reflection by this organ, and \j*hich subsequently are recombined, com- pared, &c., and thus often become causes of volition. Many of the impressions on the sen- ses are so strong as instantly to impel to ac- tion, without any intermediate state of reflec- tion ; or, in other words, the actions or voli- tions are so instantaneously consequent upon the impressions and impulses, that the inter- mediate reflections are not made objects of consciousness, or are not remembered. This is especially the case when the impressions on the senses excite the passions, and when the individual has been habituated to act upon them without allowing, or being capable of, in- termediate reflection. These reflex actions, even when not directly proceeding from im- pressions on, or reports of, the senses, are nevertheless the results of such impressions or reports, received, remembered, or reflected upon at some antecedent period. 191. (3. The reflected actions of the spinal chord may occur, as Dr. M. Hall has shown, independently of sensation, although sensation often attends, or is excited by the impressions which occasion them. They may even be so morbidly strong as not to be controlled by the will, when the individual is most conscious of their presence, as in tetanus. The reflected actions of the ganglionic nervous system are only objects of consciousness when they are excited by powerful stimulants or irritants.* 192. Thus there may be said to be three class- es of reflected, actions, viz.: 1st. That class ot actions which may he denominated psychical, or cerebral, or which results either directly from impressions made upon the senses, or in- directly or reflectively from these impressions. 2d. That class which may be termed animal, or spinal, which proceeds from impressions or ir- ritations transmitted to the spinal chord or roots of the spinal nerves, and is reflected thence by the motor nerves to voluntary mus- cles, and which may occur independently of the brain.. 3d. That class which is organic or vital, which takes place in parts supplied only or chiefly by the ganglial system, and which is independent of both the brain and spinal chord. 193. y. There are several circumstances con- nected with the voluntary actions as involving consciousness, to which farther allusions may be made. The actions which occur during sleep, when the mind is incapable of perceiv- ing impressions made on the senses, unless they be inordinately intense, to which the terms somnambulism, sleep-waking, sleep-walk- ing, &c., have been applied, are merely the re- sult of suggestions arising out of previous or recollected impressions and reflections ; these suggestions and reflections giving rise to voli- tions which excite the voluntary organs to ac- tion without awakening the senses, or permit- ting the perception of external objects in a distinct manner. Somnambulists may perform any of the common occupations of life, or may even execute difficult intellectual tasks with much ability. I have seen them compose, sing, play on musical instruments, &c., according to their respective tastes or occupations, and be still unconscious of the various surrounding objects of sense. Consciousness, however, of the act, which the somnambulist is performing, and of objects connected with it, undoubtedly exists for the moment, to the abstraction of every other sensation. In this state, the sug gestions, mental operations, and the resulting actions are often perfectly performed, as re- spects the ability of the individual; but, as they commence and are continued during a state of the brain unfavourable to sensation and perception, they are faintly, or not at all recollected. The concentration, also, of the mind on the subject engaging it, still more completely prevents other objects from being perceived. The somnambulist, in fact, acts his dream, and often in such a manner as to ena- ble him to shun the dangers attending the ac- tion as completely as if he saw them distinctly, and thus avoided them. And yet there is rea- son for believing that they are not seen by him, but avoided from the circumstance of his having followed an accustomed and well-re- membered track, each successive part of which is suggested to him as he proceeds, just as a person passes through a room in the dark, avoiding all impediments in his way from his recollection of their positions. 194. d. Many of the above remarks apply to 41 * [Dr. B. Dowler, of New-Orleans, has recently attempt- ed to disprove the theory of the reflex function by a series of ingenious experiments and reasonings, which may be found in the 6th vol. of the New-York Jour, of Med., p. 305. These experiments fully establish the post-mortem contractility of the muscles, and that too, in many cases, for many hours after death. Dr. D. denies that experiments on the frog, and other inferior animals, are at all conclusive in establishing the com- plicated physiology of man ; and he shows very conclusive- ly that post-mortem contractility in the human cadaver has no connexion with, or dependance on, the spinal marrow. The following are selected from a large number of cases, il- lustrating the general phenomena of post-mortem contrac- tility: “ R. C., aged 25. In two hours after death, when the arm was extended to an angle of 45° from the trunk, and was struck with the hand, or side of a hatchet, it was carried to the epigastrium ; but when the arm was extend- ed upon the floor, so as to form a right angle with the body, he slapped himself upon the mouth and nose. The con- tractility began to decline in the third hour, and by the fourth hour all motions of the limbs ceased, although the pectoral muscles assumed the ridgy or lumpy form when percussed. An hour after death the thigh was moderately contractile. The leg hung down near the floor; its flex- ors, after being struck, drew up the heel against the but- tock. Heat, for seven hours, from 101° to 102°. Five hours after death, contractility ceased, and rigidity prevail- ed.”—Loc. cit., p. 319. Dr. D. also shows, from a number of well-conducted ex- periments, that the muscles possess the same power of con- tractility when entirely separated from the trunk, as in the arm and leg.] PARA LYSIS—Pathology. dreaming, and in part also to the motions of the body in sleep. Dreaming may, or may not, be attended by movements of the body ; but these are generally imperfect or partial, if observed at all, and have reference to the idea passing in the mind. In this case the mental sugges- tion either fails of exciting precise and corre- sponding actions and expressions, or excites them so partially or imperfectly as not to amount to somnambulism. The chief differ- ence between dreaming and somnambulism is, that the individual during a state of sleep, or while the senses are closed against perception —or, rather, while the brain is incapable of perceiving the impressions made upon the sen- ses in their usual states of intensity—not only dreams, but also actually executes what he dreams, without awaking from the state of which I have just defined sleep to consist. 195. But the motions of the body during sleep are often independent of dreaming, or of those sensations and suggestions which pass through the mind during sleep, and which are faintly remembered afterward ; for obscure sensations may be excited for the moment by external objects or physical causes during sleep, although they are not at all recollected. A person turns or moves while asleep, owing to a feeling of uneasiness, which, although not remembered by him when awakened, has nev- ertheless been produced so as to cause the change of position. These movements have recently been adduced as instances of reflex actions occurring independently of sensation ; but that momentary sensation has not been excited is not established. Even in experi- ments showing the occurrence of motion after the removal of the cerebral hemispheres, the non-existence of sensation is not demonstra- ted, inasmuch as sensation has not been proved to be limited to these hemispheres, nor even to exist in them ; they have to perform other functions, of which the sentient principle, pre- siding, most probably, in some other part, as in the medulla oblongata or in its vicinity, takes due cognizance.* * The following observations on the Forms and M,odes of Sensibility were published in 1824, among my Physiological Notes, already referred to in various parts of this work. They may serve to elucidate many of the phenomena which occur in several states of paralysis. The phenomena considered by several authors as evin- cing the existence of sensibility are referrible only to con- tractility, with which all classes of animals are endowed, and which, in the lowest orders and in some vegetables, assume the appearance of sensibility. In these latter, how- ever, we have no reason to infer the presence of sensibility merely because they contract under the influence of a stim- ulus ; for the contraction may take place without the exist- ence of this property, from the effect produced by the stim- ulus upon the organization of the contracting part. Indeed, we cannot suppose that sensibility is present where the parts generally observed to be instrumental in its production are not found to exist. A sensation cannot be supposed to lie produced where there is neither an organization suitable to receive, nor a channel to convey, nor an organ to perceive, an impression. We should, therefore, limit this term to those phenomena which the mind perceives or is conscious of when in a state capable of exciting perception or con- sciousness. With this limitation, sensibility may be called the func- tion of sensation, and a property peculiar to the animal kingdom. The sensations are derived through the medium of the senses, and of the nerves which communicate with the encephalic centre. On this centre the existence of sen- sibility chiefly depends, the ramification of its nerves, or the subordinate portions of it, being also parts of the apparatus requisite, but not giving rise to this property. As we as- cend in the scale of creation, and as the senses and organs of volition present a more intimate connexion with this nervous mass — the encephalon — so sensibility becomes 196. e. Catalepsy is a state altogether op- posed to the foregoing—is the most complete more perfect, until in man it reaches an extent greatly sur- passing that of other animals. In man, and perhaps in the more perfect animals, the modes of sensibility seem to vary. These modes may, how- ever, be divided into two conditions, as they are more or less active, namely, conscious or active sensibility, and in- conscious or passive sensibility : the former relates to those impressions, either from within or from without, which give rise to perceptions or ideas; the latter to those that are frequently produced upon the senses and upon the ramifi- cations of the nerves, and, owing either to habit or the want of due attention to them, are not perceived by the mind. In this latter mode of sensibility, the organ receiv- ing, and the channel conveying the impression, perform their offices; but the mind either is not, at the time when the impression is made, in a state to receive it, or receives it so imperfectly, from its weakness or its transient nature, as not to give rise to consciousness. This mode does not necessarily imply a difference in the degree of sensibility, but the condition in which this prop- erty exists, owing either to its being more excited by oth- er impressions, or to its being exhausted at the time when the impression is made. This condition is one to which the highest manifestations of sensibility as well as the low- est may be occasionally subject; it is, however, merely a relative mode of this property ; and the relation subsists entirely between the state of the cerebral organ which per- ceives, and the force and duration of the impression made upon the organ of sense. Thus, when the sensibility is actively occupied with a particular object, and an impres- sion is made at the same time upon a different organ from that through which the perception with which the mind is engaged was conveyed, the second impression may af- fect the senses in an evident manner, and even so as to in fluence volition, yet we may be unconscious of its opera- tion, and no active perception may result from it. If, how- ever, the second impression be stronger or more vivid than the first, or if, from various other circumstances, it should excite the cerebral functions, active sensibility or con- sciousness is the result. As sensibility, according to this view of the subject, is, in its active state, a term merely expressive of consciousness ; and as this faculty is evidently dependant upon the cere- bro-spinal nervous system, especially on that more complex part of it which holds relation with surrounding objects ; and, also, as we have no reason to attribute the possession of this part of the nervous system to the very lowest or- ders of animals, particularly to the class Radiata, so we must conclude that, although sensibility is a property of animal life, its higher grades are not possessed by all ani- mals. It may be also stated, that active sensibility, being thus considered as expressive of, or comprising conscious- ness of sensations, and of the intellectual and moral opera- tions, varies in its extent throughout the animal kingdom according as those manifestations are more or less numer- ous and perfect. How far the passive mode of sensibility, or that unattended by consciousness, may be a property of the lowest orders of animals, is difficult to say. We may, however, infer, that as this latter condition of sensibility may take place without an active exertion of this property in the highest animals, so it may result from a less perfect endowment of sensibility in the lower; and as this mode may require a less complex apparatus for its production, inasmuch as its relations are more simple, so it may be possessed by animals whose organization and manifesta- tions do not permit us to conclude that they are capable of evincing sensibility in its more perfect and active condi- tions. The relations which this form or mode of sensibility holds with the numerous instincts of animals must be ev- ident to all who consider the subject. The relations, how- ever, which evidently subsist between that form of sensi- bility called organic sensibility by Bichat, and the animal instincts, are much more numerous, more intimate, and more apparent. Organic sensibility refers to those sensations which are produced in different degrees of intensity, owing to the ex- istence of certain conditions of those viscera which are im- mediately subservient to the preservation of the individual and the species; to nutrition and reproduction, and which are not immediately subjected to the influence of volition. The conditions of the parts exciting organic sensibility are very various, and are the result of irritations arising from the presence of a stimulus, of unnatural actions supervening in particular systems or textures, and of the deficiency of that stimulus or influence to which particular viscera have been accustomed. Many of the changes preceding this class of sensations seem to interest, in the first instance, the ganglial class of nerves ; but, owing to the intimate re- lation subsisting between this part of the nervous system and the voluntary or sentient part, the impression or change is propagated to the brain. This is the only essential dif- ference which exists between this and the other forms of and general state of palsy of motion that can exist without terminating existence ; but it rarely continues longer than some hours, al- though it may recur after short intervals, last- ing on some occasions for many hours. In this state, the muscles of voluntary motion— even those of the face and the eyelids—will not contract upon irritating them, nor will they be influenced by the will of the patient, which is generally attempted to be exerted when con- sciousness is not altogether abolished. The sensibility, indeed, is generally not lost during the attack, although it is more or less obscured in most cases. In a patient who is liable to attacks of this complaint, and whom I have often seen during their continuance, the eye- lids and all the voluntary muscles retain the positions in which they are placed, but not the least appearance of contraction is manifested upon the most energetic irritation. Still, this lady feels, sees, and hears during the contin- uance of the seizure. She even wills the ac- tion of the muscles, but volition is not trans- mitted to them. The voluntary muscles of respiration are generally the first to act upon the return of voluntary power. In another case which I had an opportunity of observing during the attack, the sensibility was some- what more diminished than in the foregoing ; but I have not met with an instance of its en- tire abolition. The sphincters are always un- affected in this disease. The respiratory move- ments are slight, and perceived with difficulty ; the impulse of the heart is weak, and the pulsations generally accelerated and soft, but sometimes slow or irregular. 197. (g) Mechanism and Functions of the Spi- nal Chord.—There are other phenomena besides those already mentioned, which occur in para- lyzed limbs, and which deserve a brief notice at this place. Dr. M. Hall and Dr. Budge PARALYSIS—Pathology. 43 have shown that, in cases of paraplegia where sensibility as well as motion is lost, convulsive motions are produced in the paralyzed limbs by tickling the soles of the feet, and even on defecation and micturition. But it is doubtful whether sensibility is entirely lost in these ca- ses, the occurrence admitting of explanation in the manner stated above (§ 181, et seq.), and still more readily, if the minute anatomy of the spinal chord, according to the researches of Stilling, Van Deen, and Budge, be taken into the account. The chord, according to these re- searches, consists, first, of perpendicular fibrils, forming the white substance of it; secondly, of transverse fibrils, and of very delicate Ion gitudinal fibrils, constituting the cineritious 01 gray substance of the chord, the traverse fibrils crossing at right angles, and forming a net- work with the longitudinal both of the gray and of the white substances ; thirdly, of corpuscles, of an angular form, with nucleated or projecting processes, scattered in groups through the an- terior gray matter only, and most numerous at the origin of the anterior roots of the nerves; fourthly, of transverse fibres, passing directly from the posterior to the anterior gray sub- stance of the chord. 198. The roots of the nerves are direct pro- longations of the gray substance. Fibrils pass from the gray, through the white substance, into the roots of the nerves. Dr. Stilling traced fibrils from the posterior roots to the anterior gray masses ; and fibrils, almost as soon as they enter the chord, run between bundles of fibrils of white substance to join other bundles of fibrils from adjoining nerves. Others, in fasciculi, form loops with fibrils com- ing from the next nerve ; and others appear as continuations of the transverse ray-like fibrils of the posterior gray substance, while the con- nexion of the anterior roots with the anterior gray substance is still more distinct. The nu- cleated processes, or corpuscles of this sub- stance, are in immediate connexion with the primitive fibrils of the roots of the nerves. 199. The afferent properties of the posterior, and the efferent properties of the anterior di- visions of the chord, are rendered more mani- fest by the above results, at which the above- mentioned anatomists have arrived. But, ac- cording to Dr. Stilling’s experiments, the lon- gitudinal fibrils of the anterior white substance do not transmit volition to the nerves, this of- fice being performed by the longitudinal fibres of the anterior gray substance. As the trans- verse fibrils are prolonged into the nerves, and as we know that the posterior nerves are ne- cessary to sensation, so it may be inferred that the posterior transverse fibrils are excitors of the posterior longitudinal fibres of the gray substance, and that a sensation, or rather the sensative impression, is transmitted by the posterior transverse fibrils, and by the longitu- dinal fibres, to the sensorium ; the same rela- tions, mutatis mutandis, being conceded to the anterior gray fibres. As centripetal impressions pass from the sensitive nerves along the trans- verse and longitudinal fibres of the posterior gray substance to the brain, so centrifugal im- pressions may pass in a contrary direction, that is, from the brain along the longitudinal and transverse fibrils of the anterior gray substance to the roots of the motor nerves. sensibility. It is the brain which perceives in them ail; and although stimuli, or the defect of stimuli, may give rise to certain phenomena possessing the characters of the higher manifestations of this property in the organs appro- priated to the preservation of the organic system, independ- ently of the sensorium, consciousness, or the more perfect form of sensibility, cannot form part of the results. Organic sensibility may also be active or passive ; it may or it may not be attended with consciousness ; and even the unconscious mode of it may indirectly impel to action, or give rise to many of the manifestations or instincts which characterize the lower animals, owing to the ganglial cen- tres, either from their organization or connexions, or from both, performing a greater extent of function than usually falls to their share. If, therefore, the passive form of or- ganic sensibility may propel to action without conscious- ness, or the sensorial sensibility being excited in those an- imals, we may also account, in the same manner, for many of the instinctive functions being performed when we can- not trace them to the influence of a cerebral organ. Of all the conditions of sensibility, the active organic form is the least under the control of the mental powers. It also, in all its modes of existence, more intimately interests the exist- ence of the individual than the other forms of sensibility ; organic sensibility involves a feeling in all its active mani- festations instinctive of life or death. From this it will be readily seen bow close a connexion exists between organic sensibility and the animal instincts ; it does not, however, belong to my plan to trace the cou- nexion in all its relations. Of sensibility generally we may observe that, in the hu- man species, it is very variable, even in health ; in some persons it is very much exalted, in others very obtuse. It is vivid in early life and in youth; after the age of man- hood it gradually diminishes; as old age advances it de- creases rapidly ; and in persons who have attained a great- er age it is present in the lowest grade in which we find it in the species. Its morbid conditions—in respect both of grade and kind—form or characterize many of the most im- portant diseases of the human economy. 44 PARALYSIS—Pathology. Bichat, but since so much overlooked, that mental emotions powerfully affect the ganglial and sympathetic nerves, and, through them, the spinal chord and the nerves proceeding from it, the sympathetic nerves communicating freely with the chord and roots of the spinal nerves, and contributing numerous fibrils to the latter to be distributed with them to the parts they supply.* That volition, when con- tinued or energetic, exhausts the irritability of voluntary muscles, is admitted, and hence the sense of fatigue, lassitude, and even of sore- ness or pain, which often follow such exertion. 203. (A) The relaxation of the sphincters occa- sionally observed in palsy, especially in para- plegia and general palsy, has been viewed as a phenomenon of more general occurrence than it really is. The fact is, that the sphincters are not so frequently relaxed, as they are im- perfectly influenced by the will, or are not at all affected by it. They still retain much of their tonicity, but volition is not so energeti- cally exerted on them as to counteract the ac- tions of the hollow viscera when these viscera are excited by an accumulation of their respect- ive contents, or by medicine. The tonicity or power of the sphincters has been attributed en- tirely to the spinal chord, and without reference to any influence they may derive from the or- ganic or ganglial nervous system. But al- though they derive a share of their power, more especially the voluntary increase of power, as circumstances may require it, from the cerebro- spinal axis, their continued state of tonicity is chiefly to be attributed to the organic system of nerves. This is shown in paraplegia and in general palsy, in both which the sphincters very often retain a natural condition of contraction ; but that contraction is frequently not increased by volition so as to resist the action of the bow- els or urinary bladder. In some cases of these states of palsy, the sphincters are not much affected, especially when the palsy is incom- plete, or seated high in the chord. Pathologi- cal evidence, indeed, clearly leads to the infer- ences, 1st. That the power of the sphincters is attributable chiefly to the organic nervous sys- tem, but that it is increased by volition exerted through the medium of the spinal nerves, es- pecially in circumstances requiring such in- crease, as when the disposition to the actions of the bowels or bladder has to be resisted; and, 2d. That it is chiefly this latter influence, or that which is exerted through the spinal chord, that is either lost or impaired, in cases where the voluntary contractions of the sphincters are insufficient to prevent the passage of the excre- tions when the patient wishes to retain them. It is not, therefore, to be inferred that where there is insufficient control over the evacua- tions, the sphincters are either relaxed or ma- 200. Such being the mechanism of ordinary sensation and motion, according to the recent researches of Stilling, Van Deen, Budge, and others, it can be no longer difficult to account for those involuntary movements which are produced in a paralyzed limb when the surface of it is irritated, pinched, or tickled, and which have been termed by Dr. M. Hall reflex ac- tions, depending, according to him, upon a re- flex function of the spinal chord, which func- tion he refers to a distinct mechanism in the chord. It has already been contended by the author that no such mechanism exists, and that these actions are sympathetic, and result from the conformation of this part of the nervous system, transverse fibrils passing, as shown by the anatomists just referred to, directly from the posterior to the anterior gray substance, to convey impressions from the sensitive fibrils, and to excite the roots of the motor nerves. That no appropriate and peculiar structure ex- ists in the chord for the purpose of performing these sympathetic or reflex movements, be- yond what has now been noticed, is the opin- ion not only of the author, but also of the wri- ters already mentioned, as well as of many oth- ers who have investigated the subject. 201. Dr. M. Hall has contended that the spi- nal chord is the source of muscular irritability, and that this irritability is exhausted by voli- tion. In proof of this position, he states that paralytic limbs are more readily agitated by galvanism and strychnine than sound limbs when the cause of palsy is in the brain, the paralyzed muscles being in such cases more ir- ritable than natural, while they are less irrita- ble when the palsy proceeds from the state of the chord. The irritability is thus considered to be increased in the former case, owing to its not being exhausted by volition, and to be diminished in the latter, owing to the lesion affecting its source. But experience shows the inaccuracy of this inference, for the paralyzed muscles, in cases of cerebral paralysis, are not more irritable than the sound muscles, but, on the contrary, less so, as tested by Voltaic elec- tricity ; and Dr. Pereira has come to a similar conclusion. In the article Irritability, I have adduced my views, as promulgated many years ago, respecting the source of this property— have stated that it proceeds from, and depends upon, the organic or ganglial nervous system ; and have contended that it does not arise from the spinal chord and nerves, although it is ren- dered more energetic and perfect in the volun- tary muscles by the supply of nerves which they receive from the chord. The truth is, that the tone, rigidity, and irritability of all par- alyzed muscles are more or less impaired, the less so when the lesion is in the brain and high in the chord. Still it cannot be doubted that strychnine or nux vomica affect these muscles more readily and more remarkably than the sound muscles. These facts may be explain- ed partly by referring to the minute structure of the chord, and partly by the circumstance of this substance being rapidly absorbed and act- ing energetically on the structure of the chord and origins of the spinal nerves. 202. The fact that mental emotions often excite parts which are paralyzed is also ex- plained by the mechanism of the chord, and by the circumstances so strongly insisted upon by * The views published by the author in 1822, in the London Med. Repository, and, in 1824, in his Physiological Notes- &c., respecting the independent and distinct constitution of the organic or ganglial class of nerves, as to the functions and relations of this part of the nervous system, and as to the in- fluence exerted by this system on the vascular system on the one hand, and on the cerebral system on the other ; in short, the positions thus taken, from researches in various classes of animals, that all organs and parts which are necessary to the life of the individual animal, and to the perpetuation of its species, are supplied by ganglial or organic nerves in proportion to the importance of each organ, and to the ac- tivity of the several organic processes, have been recently fully, confirmed by the researches of Stilling, Biddkk, Volkmann, Wallach, IIannovee, R, Lee, and others. teriaily deficient in power; but that they are only insufficiently influenced by volition, rela- tively to the power which overcomes their nat- ural tonicity. 204. VII. Treatment op Palsy.—There is no disease which more requires an intimate study of its nature and relations before a de- termination should be formed as to its treat- ment than the one now under consideration. The seat, grade, pathological condition, and constitutional peculiarities of paralytic mala- dies are so diversified, that each case should be made a separate study, and such means only as are appropriate to existing pathological condi- tions ought to be employed. I shall endeavour, 1st. To point out the plans of treatment which are most serviceable in the principal forms, states, and complications of palsy; and, 2d. To appreciate the character and value of the numerous medicines and methods of cure which have been recommended for this disease, and their applicability to the several conditions in which it comes before the physician. 205. i. Of Paralysis of Sensation.—The means to be employed in this form of the dis- ease should be selected with strict reference to the remote causes, to the pathological con- ditions inferred to exist in each case, and to the particular circumstances of the individual. If this affection occur in a spare habit of body, if it be unconnected with general or local vas- cular plethora, and if it have been caused by cold or other depressing agents, the means about to be recommended for the more chronic states of paralysis of motion (§ 213, 214.) may be em- ployed, especially local stimulants and irritants, internal excitants, external derivatives, galvan- ism, &c. In all cases, however, the strictest attention should be paid to the several digest- ive, secreting, and excreting functions. 206. If the senses of sight, smell, or taste are singly or generally affected, the same princi- ples of treatment should be adopted as are here espoused in respect of anaesthesia; the several means being selected or modified according to the peculiarities of the case, and the organ es- pecially disordered. 207. Local congestions are concerned in pro- ducing many, probably the majority of cases of anasthesia. If thff loss of feeling be associated with hesitation or other affection of the speech, these conditions may be more confidently in- ferred ; and if the aneesthesia be hemiplegic, a limited congestion, haemorrhage, or softening of some part of the brain probably exists. When anaesthesia occurs in plethoric and robust habits of body, in persons who have lived fully, or of sedentary habits, or consecutively of sup- pressed evacuations or discharges, then these pathological states most probably exist, and the affection, if not quickly removed, will often soon be followed by paralysis of motion. In these circumstances, the treatment advised for the acute states of palsy of motion, especially general and local vascular depletions, cholo- gogue and other purgatives, and derivatives, is that which is most appropriate. Subsequently, external excitants, as sinapisms, vesicants, ur- tieations, &c., or the other means noticed for the more chronic states of palsy (§ 213, et seq.), may be prescribed. When aneesthesia is asso- ciated, as it generally is, with loss of motion, the treatment is in all respects as about to be PARALYSIS—Treatment of. 45 stated with reference to palsy of motion, which is then the most important phenomenon, and the one which should chiefly engage attention as respects its immediate cause. 208. ii. Treatment of Palsy of Motion, &c.—When the faculty of motion is paralyzed either alone or conjointly with partial or more complete palsy of sensation, the treatment should be directed with the same intentions as have been just mentioned, viz., 1st, with the view of removing the morbid states or the structural lesions inferred to exist in each case which may present itself; and, 2dly, with the object of restoring the transmission of nervous influence to the paralyzed muscles. 209. A. When the palsy is strictly local or par- tial, the treatment should necessarily depend upon the peculiar features of the case. In this state of the complaint (§ 21) the lesion may be either in the origin or in the course of the nerve supplying the paralyzed muscles; but it may also be limited to the ramifications of the nerve, as when the affection is caused by the continued influence of cold, &c. If the lesion be inferred to exist at or near the origin of the nerve, local depletions, derivatives, alteratives, especially a carefully regulated course of mer- cury or of the iodides, with sarsa, &c.; exter- nal irritants and drains ; and a due promotion of the several secretions and excretions, com- prise the most efficient means of cure. 208. If the nerve have its functions inter- rupted by changes in any part of its course, as by thickening of the periosteum, by abscesses, tumours, &c., alteratives, particularly the io- dides, with the solution of potash and sarsa- parilla ; various external applications, particu- larly the tincture of iodine, or solutions of the iodides, the plaster of ammoniacum with mer- cury, &c., and other means suited to the na- ture of the case, may be resorted to, if the ram- ifications of the nerve be chiefly affected ; and particularly if colds have been the cause of the disorder, sinapisms, blisters, or applications con- taining capsicum or mezereon, may be pre- scribed, and if these fail, the part may be stim- ulated by either of the means hereafter to be mentioned (§ 249, et seq.). 210. B. The hemiplegic form of palsy, whether occurring primarily and simply, or associated with apoplexy or convulsions, or appearing con- secutively of these, is the most common form of the disease, and requires the greatest dis- crimination in estimating the pathological changes and in prescribing the means of cure. —a. In the acute or early period of the malady, prompt and decisive measures are generally re- quired ; yet these should be varied according to the mode of accession and character of the attack, as already noticed 35-40). If the complaint approach in the gradual manner above noticed (§ 35, 36), alteratives and derivatives are chiefly indicated with the view of removing or arresting the lesions which may be inferred to be the causes of the complaint, and of allay- ing the irritation they may be supposed to oc- casion. Local depletions, especially by cup- ping on the nape of the neck; sinapisms or blisters in this situation and behind the ears; purgatives and alteratives ; setons in the nape, and mustard pediluvia, are severally indicated. In this form of palsy, vascular depletion, unless local and moderate, is seldom of much service. 46 Purgatives are generally required ; and mercu- rials, in alterative doses and combinations, es- pecially Plummer’s pill with soap, or the bi- chloride of mercury, in small doses, taken ei- ther soon after a meal, or with preparations of sarsaparilla, sometimes either ameliorate the symptoms, or arrest for a time the farther prog- ress of the disease. It is in this form of hemi- plegia that the iodides are more particularly in- dicated. I have given the iodide of mercury, or Plummer’s pill, nightly, and the iodide of potassium, with solution of potash and com- pound decoction of sarsaparilla, during the day, with manifest advantage, a seton being kept open in the nape of the neck. 211. When the attack of palsy seems conse- quent upon inflammatory softening of a portion of the brain, &c. (<) 37, 38), local vascular de- pletions, or even general blood-lettings, are manifestly required. Active purgatives and mercurials are also requisite; and, in the in- tervals between the exhibition of purgatives, the bichloride of mercury should be given in small and frequent doses, until the gums be- come affected, external derivation being also produced by the usual means, while the head is kept cool and elevated. In this form of the disease, I have not seen any advantage accrue from the iodides, especially in the early or acute stage, or while inflammatory action continues to exist. In other respects, the treatment in this variety of the disease should be conducted as advised for inflammation of the brain. (See art. Brain, <) 191, et seq.) 212. If hemiplegia occur in a sudden manner (() 39), the treatment should be as prompt and energetic as in cases of apoplexy. In many ca- ses, particularly in robust and plethoric per- sons, copious general or local blood-letting, or both general and local, is required ; and either one or the other, or even both, may be again necessary some days after the accession of the attack, owing to the vascular reaction conse- quent upon it and the previous depletions, or attending the inflammatory action produced by the extravasation of blood causing the seizure. In this form of palsy the pulse should be care- fully watched during the first fourteen or twen- ty-one days after the accession of the symp- toms ; and as soon as it acquires fulness or hardness, blood-letting, according to the cir- cumstances of the case, should be repeated. But, in order to prevent the necessity of recur- ring to depletions, purgatives, external deriva- tives, and refrigerants or cooling diaphoretics, should also be prescribed at the commencement of the attack. In this variety of the disease I have seen much benefit derived from the bi- chloride of mercury, either alone, and taken soon after a meal, or with sarsaparilla, until the system became affected by it; but vascular de- pletions should be premised, and the secretions and excretions duly promoted. In this state of the malady, as well in that which is associa- ted with, or immediately follows, the apoplectic seizure (<) 40), the treatment in the early or more acute stage is in every respect similar to that which I have recommended in the article Apoplexy, when that malady is attended or fol- lowed by hemiplegia. (See art. Apoplexy, <) 146, et seq.) 213. b. The chrome or persistent state of hemi- plegia is seldom altogether removed. The in- PARALYSIS—Treatment of. jury received by the fibrous structure of the brain, in the great majority of cases, is such as admits not of the restoration of the complete power of volition over the paralyzed limbs In this state, setons or issues may be tried; but they should be kept discharging for many weeks before much advantage can be expected from them. At the same time, the iodides, particular- ly the iodide of potash, may be exhibited either alone or with liquor potassae, or as already rec- ommended ; and the bowels should be kept free- ly open by means of chologogue purgatives. 214. During this period of the disease, various internal and external stimulants and irritants have been advised, with the view of accomplish- ing the second indication of cure (§ 208); but the selection of them requires great discrimination as regards their respective properties and the existing pathological conditions. The prepara- tions of nux vomica, strychnine, &c., have been recommended in this state of hemiplegia, but I have rarely or never found them of service in this form of palsy; but, on the contrary, pro- ductive of more or less mischief, especially whenever increased determination or fulness of blood in the head was present. They are indi- cated only when an opposite state of the cere- bral circulation is inferred to exist, and in some other forms of the disease. The same may be said of the use of other internal stimulants, when a disposition to increased vascular action or effusion exists in the substance and mem- branes of the brain ; for in such cases the prep- arations of iodine, aconite, cantharides, ser- pentaria, phosphorus, camphor, electricity, gal- vanism, &c., of which more particular notice will be taken hereafter, are very rarely of use, but often injurious. The remarks which I shall have to offer respecting certain modes of cure, and various medicines more or less praised for this complaint, apply so entirely to this period of hemiplegia, that I shall add no more at this place as to the means which may be farther em- ployed in the treatment of it. 215. C. The treatment of paraplegia so entirely depends upon the nature of the lesion producing this form of palsy, that a continual reference to such lesions must be had in the observations which I shall have to offer on this subject. I have stated above (§ 53) the several changes causing paraplegia ; and it will be seen that these require a treatment appropriate to each individually.—a. It is obvious that the means re- quired for paraplegia consequent upon concussion or fracture of the spine, or upon laceration of, or pressure on the chord by displaced bone, are chiefly surgical at an early period ; and that the selection of these means should depend upon the peculiar features of the case, and the extent of local injury. At a later period, when the palsy still continues, the treatment will neces- sarily hinge upon the physical condition of the parts, and the presumed consequences of the lesions immediately resulting from the injury. In such cases the paraplegia sometimes per- sists, although the physical condition of the spine appears but little or not at all altered. In these it may be presumed that softening, effu- sion, or some other consequence of inflamma- tory action is present in the chord or its mem- branes ; and, consequently, these cases come under the same category as others about to be considered (§ 216). PARALYSIS—Treatment of. 216. b. In cases of paraplegia which com- mence with severe pains or tenderness in the spine or loins, or with a sense of heat or burn- ing, followed by spasms, numbness, and loss of power, indicating an acute or inflammatory char- acter ($ 56), a decided antiphlogistic treatment is requisite, especially at an early period. In these, cupping on each side of the spine near the seat of pain or tenderness, repeated accord- ing to circumstances, mercurial purgatives and terebinthinate enemata, are the most efficient remedies, especially when these symptoms have not been of long duration. If pain or spasms still remain after a due recourse to these means, calomel, or other mercurials, should be given with opium until the mouth is slightly affected, attention being paid to the states of the urinary bladder and bowels, and of their excretions. 217. In cases of paraplegia of a more insidi- ous character—in those which occur gradually and slowly, or which are consequent upon ex- posure to cold, or are attributable to congestion of ihe spinal sinuses, to increased serous effu- sion, or to chronic lesions affecting the chord, or to scrofulous changes in this part, its envelopes, or vertebrae, the bichloride of mercury as ex- hibited above ($211, 212), or conjoined with the compound tincture of bark ; or the iodide of po- tassium with liquor potassae and the fluid extract of sarsa, or an alternation of these ; stomachic purgatives, warm salt-water baths followed by active friction of the trunk and limbs, and strict attention to the excreting functions, and to the states of the discharges, are the measures which have proved most beneficial in my prac- tice. The bichloride of mercury, or Plummer’s pill, should be exhibited until the gums are af- fected, or until recovery takes place ; and, when the motions are tar-like, and are procured with difficulty, calomel should be given with active cathartics, such as the compound extract of coiocynth, scammony, &c., sometimes quicken- ed with a drop of croton oil. Blisters, or rube- facient applications, may be placed on the back, and be repeated according to circumstances. The liniments prescribed in the Appendix (Form. 308, 311) may be applied as embrocations in the course of the spine, from time to time, or be rubbed assiduously in this situation. 218. Setons or issues on each side of the spine have been advised, and in some instan- ces have proved serviceable, particularly when aided by a judicious internal and constitutional treatment, but they require discrimination in respect both of the pathological causes of the paraplegia, and the general health of the pa- tient. When the disease appears to have pro- ceeded from exhausting causes, as masturba- tion, venereal excesses, &e., or to have been aggravated by these, then setons or issues are generally injurious, especially when the consti- tutional powers are much exhausted. Stimu- lating and invigorating measures are required in all such instances. In these and similar cases, I have found the tincture of the sesqui- chloride of iron with the tincture of canthari- des ; the compound galbanum pill with the sul- phate or oxide of zinc ; the aloes and myrrh pill with the resinous extract of nux vomica ; and the valerianate of zinc lately introduced by Mr. J. Savory, of more or less service. Sir B. Brodie recommends a grain of sulphate of zinc to be given three times a day, increasing the dose, and to be washed down by a draught con- taining twenty minims of the tincture of can- tharides. In cases of this nature, the prepara- tions of iodine, particularly a weak tincture, or the compound tincture of the pharmacopeia ; or small doses of the bichloride of mercury in the compound tincture of cinchona and tincture of capsicum, or an alternation of these, have been of essential benefit. Sir B. Brodie takes fa- vourable notice of the bichloride of mercury in doses of one sixteenth of a grain three times a day, with a moderate dose of the tincture of can- tharides. I have tried this mode of exhibiting the bichloride, but the effects should be watched. The compound tincture of camphor will be con- joined with these two medicines with advantage. 219. The treatment of general paralysis in most instances is much the same as that just recom- mended for paraplegia ; for the former gener- ally depends upon similar lesions to the latter, or is merely an extension of it.—a. When the general palsy is a symptom of the more violent states of apoplexy, the means appropriate to these should be prescribed (see art. Apoplexy, $ 135, et seq.). When it is the result of concus- sion of the brain, or of the spinal chord, or of fracture or other injury of the cervical vertebra, the treatment must depend upon the violence of the shock, on the presence of the primary symptoms, or the supervention of reaction—on the state of the heart’s action and of the circu- lation, both locally and generally, and on vari- ous circumstances which will influence the ex- perienced physician. The intentions of cure should, therefore, be not only varied, but differ- ent, or even opposite in different cases and cir- cumstances. 220. b. In cases of general palsy from caries of the cervical vertebra, after the acute symp- toms have been removed by local depletions, blisters, mercurials, &c., issues, setons, or moxas, &c., should be placed a little distance from the seat of lesion ; and an embrocation, consisting chiefly of the compound camphor and turpentine liniments, placed from time to time along the spine. In the case of caries of two of the cervical vertebra referred to above ($ 68) the treatment consisted of active mercurial and other purgatives, of an alternation of a short course of the bichloride of mercury dissolved in the compound tincture of bark, with a more prolonged course of the iodide of potassium and solution of potash, with the fluid compound ex- tract of sarsa. A protracted discharge was procured by means of blisters and savine oint- ment, applied to each side of the neck just be- low the occiput. The recovery has been com- plete. The neck, however, is shorter and much stiffer, obviously owing to absorption and an- chylosis of the diseased vertebrae. 221. c. When the general palsy is of an acute character, or is caused by inflammatory con- gestion, or by any of the more immediate con- sequences of inflammation of the membranes or substance of the chord, then local depletions near the seat of pain, and the prompt use of mercurials, of blisters, or of the terebinthinate embrocation in the course of the spine, and of the other remedies recommended above ($ 216; for paraplegia, should not be neglected. 222. d. When the disease is chronic, or has been neglected, or has not yielded to these j means, then the bichloride of mercury, the sul- 47 48 phate or the valerianate of zinc, the iodide of potassium, the tincture of cantharides, the tinc- ture of capsicum, &c., may severally be em- ployed as already advised (§ 218). Indeed, the treatment of general palsy, in its several forms, is in every respect the same as that advised for paraplegia. 223. iii. Paralysis in Children should be treated according to the principles above de- veloped, and with strict reference to the pre- sumed pathological condition. If the palsy be •partial or hemiplegic, and be inferred to have arisen from injury during parturition, or ap- parently acute, the application of a leech behind the ear (of the unaffected side in the hemiple- gic variety), and repeated doses of calomel, should be prescribed. Minute doses of the iodide of potassium may be given subsequently, and the bowels ought to be kept freely open. If the palsy be congenital and independent of injury, the iodide of potassium or the iodide of mercury, or the bichloride of mercury, may be tried in minute doses and with due caution. In the more chronic cases of infantile paralysis, these constitute the chief remedies, but they should be continued for a considerable period and gradually increased, a course of the one being alternated with that of the other, as al- ready advised. 224. If the infant be able to take the breast, recovery to some extent may be expected, al- though it may not be complete. I have at pres- ent under my care a patient in a fit of gout, aged between forty and fifty years, who was hemiplegic from earliest infancy, but he is un- able to state whether it was congenital or caused by injury during parturition. The limbs of the paralyzed side are considerably smaller than those of the sound side, and their move- ments weak, difficult, and constrained. The imperfect growth of paralyzed limbs in infancy is owing chiefly to the very imperfect use made of them during the epochs of development. 225. iv. Treatment of Shaking Palsy.— Amendment has not followed any mode of cure which I have tried, and I have tried the most energetic means for this form of pal- sy, when it appears gradually and in a chronic form. When, however, the tremour occurs in a more acute form, or consecutively of sup- pressed evacuations, in strong or plethoric pa- tients, as in the case adduced from Frank (§ 99), or when it is attended by pain in the head or in the course of the spine, then antiphlogis- tic remedies, particularly local depletions, blis- ters, or the terebinthinate embrocation in the course of the spine, purgatives, mercurials, &c.A followed by the iodides, the bichloride of mer- cury, or the valerianate of zinc, and a seton in the nape of the neck, may be severally employ- ed, according to the peculiarities of the case, or other energetic means about to be noticed may be tried. 226. In all cases of paralytic tremour, the ex- istence of an arthritic or rheumatic diathesis should be ascertained, and the treatment mod- ified accordingly. In such instances, tonics, opiates, and antispasmodics, with ammonia or other alkaline substances, may be prescribed. When the disease has probably arisen from masturbation, or excessive sexual indulgence the most frequent cf its causes—then the prep- arations of iion with the tincture of cantharides, PARALYSIS—Treatment of. or of capsicum, or with camphor, or with the nitro-hycirochloric acids, or the extract of nux vomica, or opium conjoined with aromatics, may be tried, according to the peculiarities of the case, and to the effect produced ; and they may be aided by stimulating embrocations, or plas- ters applied on the spine, as the liniments in the Appendix (F. 308, 311), or the emplastrum thuris comp., &c., &c. 227. v. Paralysis caused by Poisons re- quires a treatment appropriate to the nature of the deleterious agent.—a. When the affection is caused by the preparations of lead, the state of the digestive organs first requires attention. (Sec art. Colic from Lead.) After the alvine secretions and excretions are more or less im- proved, and their discharge is rendered more regular and healthy, the preparations of nux vomica or strychnia may be exhibited, but their effects should be carefully watched. In this disease I have preferred the resinous extract of nux vomica to strychnia, and have generally prescribed it in combination with the purified extract of aloes. In aid of these, the external stimulants, hereafter to be mentioned, suitable exercise of the paralyzed parts as far as they may admit of it, and the application of splints, extending from the elbows to the fingers in cases of palsy of the wrist or arm, should not be overlooked. In addition to friction with various stimulating substances, electricity and galvanism, warm salt-water bathing, and warm baths containing stimulating substances, may be employed. Cleanliness and the removal of the cause always should be enforced. During the treatment the regular discharge of the al- vine functions ought to be promoted, and the patient should be allowed a generous diet. 228. h. The states of palsy caused by other poisonous substances should be treated con- formably with the principles already explained —with strict reference to the states of vascu- lar action and vital power, both general and lo- cal. The tremulous form of palsy sometimes caused by mercury (see Arts and Employments, § 23, et scq.) requires similar means to those just recommended for palsy from lead. This observation also applies to the palsy of the ex- tremities sometimes produced by arsenic. In all these, internal stimulants, tonics, and resto- ratives ; attention to the digestive and defaeca- ting processes ; external excitants, electricity, &c., and nutritious diet, are requisite. 229. Palsy consequent upon narcotic poisons should be treated according to the states ol vascular action and nervous power. After due recourse to their respective antidotes, &c., local depletions, purgatives, external deriva- tives, &c., in order to remove congestion of the nervous centres, should be prescribed, and, if the malady still persists, the several altera- tive, restorative, and stimulating remedies rec ommended for the chronic states of palsy ought to be employed, according to the peculiarities of the case, and the circumstances of the pa- tient. 230. vi. The Treatment of the Complica- tions of Palsy requires but few remarks, as the most important of these complications is duly considered in the articles on the diseases of which palsy is a part, or of which it is con- secutive. Under the heads Apoplexy,Inflam- mation of the Brain, and Insanity, the asso- PARALYSIS—-Treatment of. 49 ciations of paralysis with these are fully dis- cussed.—A. I have already noticed that palsy may either follow or precede inflammation of the nervous centres, and have explained how this may arise ($ 125). Hence it is requisite to watch carefully all cases, especially of hemi- plegia, where it is inferred that the palsy is caused by extravasation of blood, particularly during the first three or four weeks of the dis- ease ; and, upon the first indication of inflam- matory irritation, to have recourse to antiphlo- gistic measures co-ordinately with the indica- tions for their use. The evidence of inflam- matory action in the vicinity of the lesion pro- ducing paralysis, at whatever period it may ap- pear, as described above ($ 128), is a sufficient reason for the having recourse to local deple- tion, purgatives, external derivatives, and al- teratives, and for relinquishing tonics, stimu- lants, or excitants of any kind, should those have been resorted to. 231. B. The complication of insanity with gener- al palsy admits of little or no hope, even of par- tial benefit. Still, the alteratives already no- ticed, combined with tonics and restoratives, should be prescribed, particularly the iodide of potassium with sarsa, or with bitter infusions ; the extract of nux vomica with aloetic or oth- er aperients; the bichloride of mercury with the compound tincture of cinchona; the va- lerianate of zinc, and other means already no- ticed (see art. Insanity, $ 444-446). In the association of palsy with puerile imbecility or idiocy, the case is hopeless, for the reasons as- signed above ($ 127). 232. C. The treatment of disease of the cra- nial bones, or of the vertebra, associated with pal- sy, may be said to have been already noticed ($ 217), since the same means as have been advised for the more chronic cases of paraple- gia, or of general palsy, are also appropriate to this complication. In the more common cases of this kind, namely, in those where the ver- tebras are diseased, but little can be done with rational hopes of success beyond what has been recommended above ($ 217, 220). But in the course of treatment, the intercurrence of in- flammation of the membranes, or even of the chord itself, should be guarded against and watched for, and be promptly opposed by the means already indicated ($ 216, 221). 233. D. The association of palsy with neural- gia or rheumatism, or with pains resembling these affections, should always lead to the sus- picion of congestion, or inflammatory action, of or near to the origins of the nerves which are the seat of pain, or which supply the pained parts ; and when the palsy is, moreover, com- plicated with spasms or cramps, the same le- sions should be inferred, and a treatment based upon the inference be prescribed. 234. E. I have already contended that the association of palsy with disease of the kidneys and urinary organs is most frequent and im- portant ; and that the latter morbid condition, even when it is apparently the primary one, is generally only the consequence of congestion of the vertebral or spinal sinuses, causing press- ure on the chord, or increased effusion into its sheath ($184, et seq.). In these cases the urinary functions may be disordered to a mogl. serious extent, or even for a long symptoms of paraplegia are ot the movements of the limbs are materially affect- ed. When the spinal congestion interrupts or otherwise changes the functions of the kid- neys, the consecutive excrementitious plethora may occasion either hemiplegia, or coma with general palsy. In some cases the congestion of the spinal veins and sinuses is soon followed by acute congestion, or inflammation of the kid- neys, or by suppression or retention of urine, paralytic symptoms not appearing until the re nal malady is far advanced. In these circum stances the treatment is obvious. Cupping on the loins, or near the part of the spine chiefly affected, according to the severity of the at tack and the habit and constitution of the pa- tient, should always be directed, and afterward terebinthinate embrocations ought to be applied to the loins and spine. 235. F. The nature of the occasional con- nexion of palsy, especially paraplegia, with hys- teria, has been already noticed ($ 140, 188). The irregularities often observed in the urina- ry functions of hysterical patients may often be attributed to the irritation propagated from the uterus and ovaria, either directly by the ganglial nerves to the kidneys and bladder, or indirectly to the spinal chord, and thence to the urinary organs along the nerves communica- ting between them and the chord. In those cases where the protracted irritation of the uterine organs, in connexion with exhaustion of nervous power, disorders not only vascular action in these organs, but extends itself and its effects upon the vascular system, not only to the spinal chord, but also to the urinary or- gans, pain or aching in the loins, and even ten- derness on pressing the spinous processes of the vertebrae, are often observed; and if the vascular disorder consequent upon the local excitement or irritation advances far, so as to occasion certain of its most prominent effects, numbness, cramps, or spasms of the lower ex- tremities; retention or suppression of urine, sometimes alternating with an unusually large secretion or flow of it; occasional nausea, vom- iting, and irregularity of the bowels ; irregu- larity, or difficulty, or suppression of the cata- menia ; and, ultimately, even more or less com- plete paraplegia may result. Several cases of this kind have occurred to me, and have long resisted treatment until they were submitted to energetic courses of the alterative medicines above advised (217), particularly the bichloride of mercury, or the iodide of potassium, vari- ously combined, aided by terebinthinate ene- mata and embrocations, by the extract of nux vomica, and by such of the remedies already mentioned as were most appropriate to the pe- culiarities of the case. In the remarkably se- vere and prolonged instance noticed above ($ 139), for which all the usual means had been exhausted, in pddition to several of the means now noticed, a pea-issue was made in the in- side of each thigh, and kept freely discharging until the amendment was complete. The re- covery was rapid in this instance, and the lady is now in the enjoyment of good health. 236. G. I have met with several instances of palsy, and especially of hemiplegia, associated with visceral disease. The connexion between . organic, disease of the heart and hemiplegia, as former and apoplexy, is suf- ficiently obviotTs\and neither it nor the treat- 50 PARALYSIS—Treatment of. ment of the complication requires much com- ment, inasmuch as our remedial measures should be directed primarily to the cardiac le- sion, and subsequently or collaterally to the paralytic affection ; the states of these lesions, in connexion with the age, habit of body, &c., of the patient, controlling the plan of treatment and the choice of means. 237. H. The complication of palsy with hepatic disease has been observed by me on several oc- casions, the palsy being generally hemiplegic, and the right side being that affected in nearly all the cases I have seen. Although in some cases the liver has appeared to have been pri- marily affected, still it is very probable that the loss of power in the voluntary nerves and muscles of the right side may have in some degree affected the functions and circulation of the liver, and, in prolonged cases, ultimate- ly induced disease of it. In these associations the principles of treatment and the choice of medicines will readily suggest themselves to those who have perused the foregoing remarks, and what I have adduced on the treatment of diseases of the liver. 238. Palsy may, moreover, be associated with scorbutus, and it not unfrequently occurs in the gouty or rheumatic diathesis, more especially af- ter irregular, displaced, or suppressed gout. In these circumstances, the treatment should be varied according to the diathesis. In the gouty association ofthe malady the usual means should be employed to develop the gout in the lower extremities. [Paraplegia not unfrequently occurs in this country in the course of continued or remit- tent fever, perhaps more often in chronic than acute cases, and where repeated relapses have occurred. If not speedily fatal, it is of diffi- cult removal, and generally obstinately pro- tracted. The most successful treatment con- sists in rest, repeated applications of cups to the spine, and mild purgatives during the pe- riods of the disease, in which there is often considerable febrile excitement, and afterward moxas. The treatment is, therefore, essential- ly the same as that of inflammatory affections of the medulla spinalis. In the non-inflamma- tory stages of the disease, strychnine or gal- vano-magnetism will be found useful. Suffi- cient attention is far from being paid to those violent pains in the back, indicative of spinal congestion, in the commencement of our con- gestive, and even our common continued fe- vers. External revulsives, cups, leeches, and the warm bath may all he brought into requisi- tion with much advantage in a large proportion of these cases.] 239. vii. The Appreciation and Appropria- tion op Remedies for Palsy.—In discussing the treatment of the several forms of palsy, it has been, as will be seen above, g principal ob- ject to advise the use of such means as appear the best calculated to remove the morbid changes upon which these forms severally de- pend ; and mention has been made chiefly of those remedies which seem to me most likely to produce this effect, and of which I have had more or less experience.*' It is necessary, how- ever, to a full exposition of the treatment of palsy, to review the application of the more energetic means to certain states of the dis- ease and of the constitution, and to notice oth- er medicines which have been favourably men tioned by writers of reputation. 240. After devoting due consideration to the scat and nature of the lesion of which palsy is the prominent and most manifest phenomenon, it next is of importance to estimate correctly the states of vascular action and of nervous and vital power ; to ascertain, as nearly as may be, how far the affection may be consid- ered, from these states, in connexion with its cause and duration, to be acute or chronic, and sthenic or asthenic. These terms, it is true, are merely conventional; but they neverthe- less assist us materially in our attempts at briefly indicating the conditions of the patient, which powerfully influence the operation, and which should, therefore, guide our choice of medicinal agents for this malady. 241. a. Of hlood-letling, general and local, it may be briefly stated that it is generally re- quired early in attack, especially in acute and asthenic cases, and more particularly in the hemiplegic or sanguineous form of the disease. In the paraplegic and partial states of the mal- ady local blood-letting is commonly to be pre- ferred to general; and in all cases the quantity, as well as manner and repetition of the deple- tion, should depend upon its effects, the state of the pulse, and habit of body of the patient, as well as upon the predisposing and exciting causes of the attack. We must not, however, inconsiderately prescribe either venesection or cupping in all cases, even of hemiplegia, be- cause we find them to have been advised by Celsus, Zacutus Lusitands, Home, Abercrom- bie, and many other eminent writers. The most recent of these writers recommends it too profusely, too generally, and too exclusively, at least as regards the inhabitants of large cit- ies and manufacturing towns, wherein the causes of the malady and the asthenic states of a very large proportion of those attacked either admit not of depletions, or require very different or even opposite means of cure. Dur- ing the treatment of both hemiplegic and para- plegic palsy, intercurrent inflammatory action may appear, and require, generally, depletions by cupping or leeches; and the physician should be alive to such an occurrence when he has re- course to stimulating medicines, in doubtful circumstances, and in young persons. 242. h. Of evacuants, purgatives and diuretics are the most appropriate ; and of the former of these, the most active should be selected, and such as influence most energetically the princi- pal secreting viscera, as calomel, colocynth, jalap, scammony, &c. In paraplegia, and even in hemiplegia, the bowels are very torpid, and require repeated and full doses of these, and even of still more energetic cathartics, as cro- ton oil or elaterium, in some obstinate cases. In many, recourse should also be had to pur- gative enemata, particularly to those in which the oleum terebinthina; is an ingredient. It is not merely necessary regularly to evacuate fae- cal matters by means of these, but to employ them so as to derive from the cerebro-spinal axis any increased flow of blood to it which may have occasioned or prolonged the attack. Indeed, with these conjoined objects, they are advised by Halle, Dalberg, Brodie, and oth- ers who have insisted on their use. 243. The ancients advised a recourse to diu- fetics in palsy, and some of the medicines pre- scribed by modern physicians, and considered by them to influence the disease merely as stimulants, owe no small share of their good effects to their operation on the kidneys. Of these, the most efficient are the tinctura lyttae, the preparations of iodine, and spirits of tur- pentine—substances of which farther notice will be taken hereafter—which require caution in their use, and which are suited chiefly to chronic and asthenic cases, and to the paraple- gic states. 214. c. Of alteratives, the most beneficial and most generally appropriate are mercurials, iodine, and the iodides and sarsaparilla.—a. Mercurials, employed so as to affect the system, and chief- ly by inunction, have been recommended for palsy by Schenck, Schneider, Cavallini, and J. P. Frank ; and, both internally and exter- nally, by Vallisneri, Burger, and many oth- ers. I have seen them of service, when judi- ciously prescribed, in both hemiplegic and par- aplegic palsy. J. P. Frank prescribed them more especially for saturnine palsy, in which he has seen them of great service. In acute and sthenic cases, calomel given with antimo- ny, after blood-letting, until the pulse is suffi- ciently reduced, should be preferred ; afterward, the milder mercurials may be substituted ; and, in chronic and asthenic cases, the bichloride may be given in the decoction of bark until the gums are slightly affected, especially in scrofu- lous and rheumatic constitutions. I lately attended a patient in hemiplegia (Mr. G., of Watling-street), for whom I prescribed the bi- chloride of mercury, in this combination, a fre- quent recourse to purgatives, and a seton in the nape of the neck, with the best results. His right side was affected, and he now can walk unaided, and writes letters and checks as usual. 245. (b) I have prescribed iodine and the io- dides in several cases of the various forms of both partial and general palsy ; but in no case of the disease have I ventured to employ them otherwise than in very small doses at first, carefully watching their effects, and cautiously increasing the doses. Dr. Manson was the first who published cases of palsy in which io- dine had been employed ; and these cases show not only the good effects of this substance in certain states of palsy, but also its injurious in- fluence in the more acute and sthenic cases, and when prescribed in too large doses. Dr. Manson employed only the tincture of iodine ; but, both before and after the publication of his cases, I had used both this and the iodide of potassium for this disease, as well as for some others, in public and private practice ; and more recently the iodides—the iodide of potassium and the iodides of mercury—-more frequently than the pure iodine. These preparations, es- pecially the last, are best suited to the more chronic and asthenic cases, or after depletions and other evacuants have been pushed suffi- ciently far. Even then the doses should at first be small, and the effects upon the pulse be carefully watched. The occurrence of head- ache ought to cause an interruption in the use of these medicines. The iodide of potassium may be conjoined with liquor potassae and sar- saparilla, commencing only with one or two grains, and gradually increasing it. I have PARALYSIS—Treatment of. even given only one grain in the twenty-four hours with advantage. 246. d. Stimulants and tonics were employed internally for palsy much more frequently by the older writers than by physicians of the present day, who are more conversant than they generally were with the true seat and na- ture of the lesion causing the paralytic attack. These substances are contra-indicated in all acute and sthenic cases of palsy, and whenever there is reason to infer the existence of inflam- matory irritation, haemorrhage, or vascular ex- travasation, or even of active congestion, while they may be employed with reasonable hopes of benefit in chronic and asthenic cases, and when the disease has appeared after exposure to cold or to other depressing influences, or has followed exhausting causes. 247. (a) Of this class of medicines the resin- ous extract of nux vomica and strychnine have been more frequently employed than any other in recent times. Of the two preparations, my experience induces me to prefer the former as more manageable than the latter, and equally efficacious. I have usually prescribed it in con- junction with purgative or aperient extracts. It, as well as other internal stimulants, should never be given in palsy, especially hemiplegia, when the pulsation of the carotids or the tem- perature of the scalp is at all increased ; and if the pulse become strong or frequent, or the face flushed during its use, it should be discon- tinued, and local depletions, with an antiphlo- gistic treatment and regimen, instantly adopted. It is most serviceable in paraplegia and in lead palsy. 248. (b) The flower of the Arnica montana was much praised, and is still much used in Germany and Denmark for paralytic cases. It has received the commendations of Angeli, De Meza, Conradi, Aaskow, and others ; but I am not aware of any other British physician besides Home who has given it a trial, and his evidence is not much in its favour. The Rhus radicans, or Toxicodendron, has been recommended in this disease by Brer a, Desgranges, VanMons,Kok, and Alderson ; but Zadig considers it quite in- efficacious. A decoction of the Chenopodium ambrosioides has been advised by Rudolphi, Baldinger, and Lentin ; serpentaria and capsi- cum by Falconer ; guaiacum by Fothergill and Johnston ; ammoniacum by Bourget ; py- rethrum, internally, by Oxley ; cajeput oil, both internally and externally, by Pereboom and Thunberg; naphtha byRAMAzziNi; camphor dis- solved in turpentine by Schumacher ; this sub- stance dissolved in naphthaby Reichsanzeiger ; musk by Truener, Lceffler, and others ; cas- tor by Pauli ; the tinctura lytlx, internally, by Vaughan, May, Brisbane, &c. ; phosphorus dis- solved in ether, internally and externally, by Brera and Gaultier-Claubry ; and the nitrous oxyde gas by Beddoes, Hill, and Pinel. It is very probable that these may severally prove of service when judiciously prescribed, espe- cially in those circumstances of the disease to which I have above (§ 246) limited the use of stimulants and tonics. In the same category aconite may also be noticed, it having been recommended by Stcerck and Greding ; also, opium and belladonna, which have severally been used by Stoll, Thomann, and others, in palsy from lead. [The ergot, or sccalc cornutvm, has 51 52 been found very useful in the treatment of para- plegia. It is believed to stimulate the lower portion of the spinal chord, to which, perhaps, its influence over the bladder and uterus is ow- ing. It may be given in daily doses of from fifteen to sixty grains.] 249. The circumstances which admit of the internal use of stimuli also allow a recourse to electromotive agencies in the several forms in which they have been employed ; and in no dis- ease have they been more generally and more empirically resorted to than in this. Electricity, in the form of shock, hath, sparks, &c., although chiefly prescribed by persons ignorant of medi- cine, has received the eautious sanction of Van- der Belen, Hart, and others, in the most chronic and asthenic cases. Meyer, Bang, and Percival advise it chiefly for paraplegia and lead palsy; and they, with Stoll, De Haen, Quakin, and Falconer, doubt its efficacy in other circumstances. The electro-galvanic in- fluence wTas first recommended by Volta in this disease ; and it was soon afterward adopted by Walther, Halls!, Marcus, and Grapengeisser for those cases in which powerful stimulants seemed to be required. [We have derived sig- nal benefit in many cases of local palsy from the employment of electro, or galvano-magnet- ism, applied to the paralyzed muscles in cur- rents of moderate intensity, and gradually in- creased in force. Although many cases will not be materially benefited by it, there are others which will at once yield to the repeated and judicious application of this remedy.] 250. e. The numerous means which may be strictly called external, and which have been so generally resorted to in this disease, operate either (1) by rousing the circulation and exci- ting the nervous influence in the part, as simple or medicated friction ; (2) or by deriving irrita- tion or other morbid action from the nervous centres to superficial parts, as issues, setons, &c. ; (3) or by a combination of these modes of operation, as blisters, sinapisms, urtication, &c. These means are severally appropriate to most of the forms of palsy ; and, when judici- ously selected, they may be safely used in the various states and relations of the disease. 251. (a) Frictions in a simple form, although advised by Stoll and Hilscher, are seldom employed ; for some medicinal substance with which frictions may be used is requisite to im- part confidence to the patients in their efficacy. However, they may be advantageously employ- ed by means of the hair-glove, or of the khee- sha, or Indian glove. Frictions of the palsied limbs with various stimulating substances, as with phosphorus dissolved in oil or ether; with camphor, soap, and turpentine; with cajeput oil, camphor, olive oil, &c., have been often ad- vised, and may in a few instances prove of service. [Dr. Graves recommends very highly a lini- ment of strong acetic acid, jss. ; spirit of tur- pentine, fiij.; rose water, fijss. ; essential oil of lemons, x drops ; and a yolk of egg in suf- ficient quantity to suspend the turpentine. This is to be applied by means of a sponge ; after a few applications, it produces an eruption of small pimples, and proves very efficacious.] 252. (b) Issues and setons are, upon the whole, the most efficacious modes of permanent exter- nal derivation in palsy, and the most generally PARALYSIS—Treatment or. adopted, especially in this country. The for- mer may be made in the scalp itself, by incisions in or near the occiput, pease being afterward in- serted ; the latter may be worn in the nape of the neck. They have been praised by Pott, Appleton, Latour, Schreger, Prichard, and Loder ; and I have had several occasions of witnessing their good effects. Moxas, which have been for ages employed in the East as the usual mode of external derivation, have been strongly insisted upon by Larrey and others in this and other diseases, and have been much employed on the Continent of Europe ; but their superior efficacy to issues or setons is very doubtful. [Moxa is a remedy by no means to be neglected in paralysis. We have known cases of general paralysis where moxa, applied on each side of the spine, near the second dor- sal vertebra, procured immediate benefit.} The actual cautery, mentioned by Paueus HiIgineta, and others of the ancients, has been recom- mended, also, by Richter, Portal, and J. P. Frank. Neri Nerii, a Neapolitan physician of the sixteenth century, directed it to be applied to the occiput in hemiplegia. Among the usual means of derivation, dry-cupping, mentioned by Celsus and others in this disease, should not be overlooked. 253. (c) Blisters, kept discharging for a con- siderable period, or frequently repeated, as ad- vised by Boerhaaye, Fordyce, and Dickson; or artificial eruptions, produced for a longer or shorter period, by means of tartarized antimo- nial ointment, or by croton oil, are also frequently of service both in acute and chronic cases ; but in the former especially, after local depletions and evacuations have been freely practised. The same remark is applicable to the use of sinapisms, and to a frequent recourse to urtica- tion, which has been advised by Paulus H2gi- neta, Muys, Home, Hufeland, and many others, or to embrocations containing capsicum, or its tincture, or pyretlirum, all which exert the dou- ble effect noticed above (<) 250), when applied to the paralyzed limb, as they should generally be applied, unless in cases where the sensibil- ity and temperature of the paralyzed limb are morbidly increased, as sometimes observed; and then they may even prove injurious, espe- cially in asthenic cases. In these, also, blisters applied to the palsied limb may be followed by sloughing. 254. /. Simple, and medicated, and mineral warm baths have been much praised in palsy ; but it is obvious, from the nature and forms of the disease, that, although they may be of ser- vice in some instances, they may be injurious if inappropriately or indiscriminately employed. I have seen them of service in chronic and as- thenic cases, and in those states of the disease caused by exposure to cold. Medicated warm baths—with warm and aromatic substances— were most beneficial in a case of general palsy arising from this cause that came under my care. J. P. Frank notices favourably simple and sulphureous warm baths, and states that those of Baden have been of service in some obstinate cases of chronic palsy. In recent, acute, or sthenic cases, he justly dreads the use of warm baths, whether simple, mineral, or medicated, as he has known apoplexy super- vene where they have been injudiciously pre- scribed. The sulphureous thermal baths of Baden were recommended by Stoll, chiefly in lead palsy, after electricity had been employed. It may be noticed, farther, that the warm min- eral springs of Bath, Toeplitz, &c., have been frequently resorted to by paralytie patients, and sometimes with more or less advantage, when neither general nor local plethora or conges- tion exists, or when opposite states of the vas- cular system obtain; that sulphuieous warm baths have been favourably noticed by Baker, Summers, Tolberg, Waitz, and Hufeland ; that aromatic and spiced warm baths were rec- ommended by Riedlin ; warm salt-water baths by Reil ; and even warm chalybeate-water baths by Graefe, in this malady. 255. g. The diet and regimen in palsy should depend entirely upon the peculiarities of the case. In most cases of hemiplegia, in all acute and sthenic cases, or whenever general or lo- cal plethora is inferred to be present, both the diet and regimen should be strictly antiphlogis- tic ; a farinaceous and vegetable diet, with sim- ple diluents only, being adopted. In chronic, asthenic, and anaemic cases, light, digestible animal food may be allowed ; but in every in- stance the predisposing and exciting causes should be viewed in connexion with the patho- logical conditions, and all these should be duly estimated before either the treatment, or the diet, or the regimen is assigned. The chief part of the regimen in all cases is the careful avoidance of the causes (<) 157, et seq.) of the disease. [The treatment of palsy in this country, as in every other, has been very generally empiri- cal, owing to the extreme difficulty of ascer- taining in all cases its true pathology. Prof. Geddings, of Maryland, has reported several highly interesting cases which yielded to the influence of strychnine. The late Dr. Barton employed internally, with much success, in the Pennsylvania Hospital, mustard seed and horse radish Dr. Delafield, of New-York, has recorded several very interesting cases of par- tial paralysis of the face, in which cupping, leeching, and blistering over the region of the portio dura, mercurial purgatives, and a seton in the neck were instrumental in effecting a radical cure.—(N. Y. Med. and Phys. Journ., Dec., 1824.) We succeeded in curing a chron- ic case of hemiplegia of several years’ stand- ing, in an old lady of 60 years of age, by an al- terative course of mercury, which produced very copious salivation. There is a form of paraplegia, not particular- ly noticed by our author, owing to ramollisse- ment of the spinal marrow, from retrocession of gout, which, so far as we have seen, is gen- erally incurable. The symptoms come on very insidiously, and it is often not until irremedia- ble disorganization has occurred that the true pathology becomes clearly established. We have derived most benefit in these cases from an open issue on each side of the spine, with oc- casional aloetic and mercurial purges, with al- terative doses of the iodide of mercury. Where local paralysis has occurred from pressure on the nerves of the part, as in the arm, from sleeping upon it, or carrying a weight upon it for a considerable distance, of which we have seen several cases, we have derived most ben- efit from moxas, or stimulating embrocations to the limb, with an occasional cathartic and PARALYSIS—Treatment of regulated diet. In the paraplegia supervening on visceral disease, we have found local rem- edies, as frictions, blisters, &c., to the legs and thighs, more beneficial than applications over the spine itself. Great benefit will often result, both in hemiplegia and paraplegia, from the free internal and external use of sulphur, especial- ly in the form of the natural sulphur waters ol our country, as those of Avon, Richfield, and of Western Virginia. Cases of paraplegia, fol- lowing the remittent gastric fever of children, are often unconnected with spinal disease, es- pecially in those of a scrofulous temperament, and as a general rule, they are very obstinate under the most judicious treatment. In that form of paraplegia connected with disease of the kidneys, our attention should be partly di- rected to the first link in the chain of morbid action, or we shall be disappointed in the re- sults of our remedial measures. Dr. Eberle reports two cases of hemiplegia in which he employed, with unequivocal benefit, the satura- ted tincture of the Rhus toxicodendron (Prac. of Physic, vol. ii.). Doctor Calhoun, of Philadel- phia, has proposed the use of the tourniquet for restoring the power of muscles debilitated by long-continued inactivity (Philad. Journ. of the Med. and Phys. Sci., vol. i., p. 131). Dr. Det- mold, of New-York, has recommended a pecu- liar apparatus of his own contrivance for a paralysis of the lower extremity commonly called “weak ankle,” together with the ex- ternal application of a spirituous preparation of strychnine (N. Y. Journal of Medicine, vol. iv., p. 305). Dr. Zabriskie, of Queen’s coun- ty, has published a well-written essay on pa- ralysis from visceral disorders (Am. Journ. of Med. Science, vol. ii., N. S., p. 360), in which he recommends general and local bleeding to subdue the phlogosis, followed by mercurials, when these symptoms abate, and counter-irri- tation, to divert the inflammation. After the inflammatory symptoms have somewhat sub- sided, he enjoins the use of strychnine, which he thinks is most useful in that form of the disease which is symptomatic of visceral irri- tation. Doctor B. F. Joslin, of New-York, has given a history of two cases of paralysis of the face (American Journ. of Med. Science, vol. iv., N. S., p. 322), cured by the local application of strychnine (3 grs. to jj. alcohol) to the part three times a day. In the treatment of palsy we are always to be governed by a due regard to its causes, its pathology, and those various circumstances which modify therapeutical in- dications. In applying galvanism or electrici- ty to the treatment of paralysis, “ It is neces- sary,” says M. Matteucci, “ to bear in mind two electro-physiological facts. The first is, that an electric current, if transmitted through a nerve for a certain period of time, destroys the sensibility of the nerve, or, in other words, paralyzes it. If allowed to remain in repose, the nerve, after a certain interval, recovers its excitability.” It has been discovered, howev- er, by Matteucci, that the excitability may be restored in a much shorter period by passing a second current through the nerve in an oppo- site direction. The second fact to be borne in mind is, that if the nerves of a living animal be submitted to the passage of the electric cur- rent, renewed at short intervals, tetanic con- tractions are excited ; and if the experiment 53 54 be continued for some time, the nerves entire- ly lose their excitability. “ These are the facts,” says Matteccci, “ which, independently of all theory or hypoth- esis, should guide us in therapeutical applica- tion of the electrical current to palsies. We may, in fact, admit, that in some cases of pa- ralysis the nerves of the affected limb are in a condition similar to that produced by the con- tinued passage of an electric current. We have seen that, to restore the excitability to a nerve which had been deprived of it by an electric current, it is requisite to conduct the current in the opposite direction. Hence, to cure the paralysis, the current should be passed in a contrary direction to that which has produced it. In a paralysis of motion the inverse cur- rent should be employed ; while, on the contra- ry, in a paralysis of sensation, the direct cur- rent should be used. In a case of complete paralysis, that is, of both motion and sensa- tion, there is no reason to induce us to prefer the one current to the other. “ Theory also teaches us a rule in its appli- cation, never to continue the passage of the current too long, lest we augment the disease we wish to cure. The more intense the cur- rent, the shorter should be its duration; and as we have seen that the passage of the elec- tric current in the nerves, repeated at short in- tervals oftime, considerably enfeebles their sen- sibility when continued for a long time, we must take care and not pass from one extreme to another. Theory advises us to apply the electric current of an intensity which should vary with the degree of the malady, and con- tinue its passage for two or three minutes, at intervals of some seconds. After these two or three minutes, during which we shall have communicated from twenty to thirty shocks, we should leave the patient at rest for some time, and then renew the treatment.”—(Med. Chirurg. Review, April, 1845.) The same prin- ciples, doubtless, should regulate the applica- tion of galvano-magnetism, as of ordinary elec- tricity.] Bibliog. and Refer.—Celsus, L. iii., c. 27.—Pliny, L. xxviii., c. 16.—Paulus JEgineta, L. iii., c. 18.—Oribasius, Synopsis, 1. viii., c. 14.—Avicenna, Canon., 1. iii., fen. ii., tract, i., c. 2.—Zacutus Lusitanus, Med. Pract. Hist., 1. i., No. 45; et vii., obs. 13, 14, 15.—Morgagni, De Sed. et Caus. Morb., Ep. ii., art. 11, 14 ; Ep. iii., passim.—J. Sum- mers, A short Account of the Success of Warm Bathing in Paralytic Disorders, 8vo. London, 1751.—B. Franklin, On Electncity in Paralytic Cases, Phil. Trans. Lond., 1757. —G. Cavallini, Storia d’una Paralisia curata con l’Unzione Mercuriale, 4to. Venez., 1769.—R, Charlton, An Inquiry into the Efficacy of Warm Bathing in Palsies, 8vo. Oxf., 1770.—J. N. Marquet, Traitd de Apop. Paral., &c., 12mo. Paris, 1770.—R. Charleton, Three Tracts on Bath Waters ; 2d. On Palsies, 8vo. London, 1775.—Haller’s Disput. ad Morbos, &c., vol. l, p. 17, 97, 115.—Pereboom, in Schlegel, Thes. Patholog. Tlierap., vol. i., p. 243 —B. Chandler, An Inquiry into the Theories and Methods of Cure of Apoplex- ies and Palsies, 8vo. Cantar., 1784.—Hart, in Philos. Trans., vol. xtvm., p. 786.—P. Pott, Remarks on Palsy of the Low- er Limbs found to accompany Curvature of the Spine, &c., 8vo. Lond., 17/9 ; and I arther Remarks on the same, 8vo. Lond., 1782. J. Jebb, Select Cases of the Disorders com- monly called Paralysis of the Lower Extremities, 8vo. London, 1782.—C. Cramer, De Paralysi et Setaceorum ad- versus earn eximio usu ; in Sandifort, Thesaur TIissertnt vol.i.,p. 127.—Narrative of the Efficacy of Bath Waters in various Paralytic Disorders, 8vo. Lond., 1787. J. Alder- son, An Essay on Rhus Toxicodendron, showing its Efficacy in Paralysis, &c., 8vo. Hull, 1793.— Vaughan, in Mem. of the Medical Society of London, vol. i., art. 28, 8vo. Loiid — Falconer, in Ibid., vol. ii., art. 20.—Fothergill,'in Med" Observat. and Inquiries, vol. v., p. 394.—T. Kirkland A Comment, on Apoplectic and Paralytic Affections, &c., 8vo. Lond., 1792.—Rahn, in Museum der Heilkunde, b. iv., p! PARALYSIS—Bibliography and References. 397.—L. V. Brer a, Riflessioni sul’ Uso del Fosforo nelP Emiplegia, 8vo. Pavia, 1798.—Louyer Villermay, in M6m. de la Socidtd M6d. d’Emulation, t. v., p. 440.—Latour, in Ibid., t. vi., p. 57; Memoire sur la Paralysie des Extrbmi- t£s Inferieures, &c., 8vo. Paris, 1805. — Portal, Cours d’Anat. Med., t. i., p. 303 ; t. iv., p. 118.—Reil, Memorab. Clin., fasc. iv., No. 4.—J. P. Frank, De Cur. Horn. Morbis, 1. ii., p. 46 ; et 1. v., 2, p. 497 ; 1. vi., 1, p. 260 ; et Interp. Clinicae, vol. i., p. 145.—Pinel, Nosograph. Philosoph., t. ii., p. 93.—Marcus, Magazin fiir Therapie und Klinik, b. i., p. 325.—F. Frank, Nuovo Giornale di Milano, t. iv.—Gaultier de Claubry, in Journ. G6n. de Med., t. xvi., p. 18.—Hufe- land, Journ. der Pr. Heilk., p. 78, 1811.—M. Baillie, Med. Trans, of Roy. Coll, of Phys. Lond., vol. vi.—R. Powell, Observat. on some Cases of Paralytic Affection, 8vo. Lon- don, 1814.—T. Copeland, Observat. on the Symp. and Treat, of the diseased Spine, &c., with Remarks on the consequent Palsy, 8vo. Lond., 1815.—Mollie, Recueil d’Observat. sur I’Apop. et la Paral. gueris sans retour, &c., 8vo. Paris, 1816.—J. Parkinson, An Essay on the Shaking Palsy, 8vo. Lond., 1817.—J. Copland, in Lond. Med. Repos., vol. xvii., p. 379 ; vol. xviii., p.523.—Merat, Diet, des Sciences Med., t. xx., art. Hemiplegie.—Chamberet, in Ibid., t. xxiv., art. Paralysie et Paraplegie.—J. Cooke, A Treatise on Nervous Diseases, vol. ii. ; on Palsy, 8vo. Lond., 1823.—D. A. G. Richter, Die Specielle Therapie, &c., b. viii., p. 821.— Rostan, Recherches sur Ramollissement du Cerveau, &c., 8vo. Paris, 1823, passim.—Rochoux, Diet, de MOd., t. xv., art. Paralysie.—Burder, in Lond Med. and Physical Journ. for June, 1827.—Hufeland, in Journ. des Progres des Scien. Mddicales, t. iii., p. 254.—Lcuret, in Ibid., t. xi., p. 167.— Duges, Archives Gdner. de M6d., t. xx., p. 258.—Cazau- vieilh, in Ibid., t. xiv., p. 5.—Pelletier, in Ibid., t. xviii., p. 200.—Bayle, in Revue M0d., t. i., p. 33 ; t. ii., p. 143, 1825 ; et t. ii., p. 247, 1826.—Calmeil, de la Paralysie chez les Alidnds, 8vo. Paris, 1826.—Taliaferro, Am. Jour, of Med. Sci., vol. vi., p. 99; et Ibid., p. 227; et t. viii., p. 236.—Al- bers, in Johnson’s Med. and Chirurg. Rev., No. 43, p. 227.— S. D. Broughton, Cases Illust. of the Distinct Functions of the Nerves, in Lond. Med. and Phys. Journ., vol. lvii., p. 413 ; Trans, of Prov. Med. Association, vol. ii., p. 300; and Lancet, Oct. 1,1836, p. 34.—L. F. Calmeil, De la Paralysie, considerde chez les Abends, 8vo. Paris, 1626.—J. Aber- crombie, Pathological and Practical Researches on Dis. of the Brain and Spinal Chord, 3d edit. Edinb., 1834.—T. Chevalier, in Trans, of Med. and Chirurg. Soc., vol. iii., p. 102.—Shaw, in Ibid., vol. xii., p. 105.—H. Earle, in Ibid., vol. xiii, p. 516.—E. Stanley, in Ibid., vol. xviii., p. 260.— Seymour, Medical Gazette, Oct. 29, 1836, p. 151 ; and Dec. 24, 1836, p. 445.—R. Graves, in Ibid., May 20, 1837, p. 257. —Chandler, Dublin Journ. of Med., March, 1837, p. 164.— Craigie, Edin. Med. and Surg. Journ., Oct., 1836, p. 318. —Todd, in Cycl. of Practical Med., vol. iii., p. 240.—B. C. Brodie, On Injuries of the Spinal Chord ; in Trans, of Med. and Chirurg. Soc. of London, vol. xx., p. 118.—W. Budd, in Ibid., vol. xxii., p. 153.—M. Hall, in Ibid., vol. xxii., p. 191 ; et vol. xxiii,, p. 121-182; and vol. xxiv., p. 83.—E. Stanley, in Ibid., vol. xxiii., p. 80.—C. Hawkins, in Ibid., vol. xxiv., p. 51.—J. Webster, in Ibid., vol. xxvi., p. 1.—J R. Bennett, in Lib. of Pract. Med., vol. ij., p. 274. Paralysis from Poisons.—Borellus, Cent, iv., obs. 32, —Hoffmann, De Nerv. Resolut., opp. iii., p. 203.—De Haen, Ratio Medendi, vol. iii., p. 113.—Bang, in Acta Reg. Sog. Med. Ilann., vol. i., p. 102.—Stoll, Rat. Medendi, part ii., p. 416.—Falconer, Mem. of Med. Society of Lond., vol. ii., p. 224.—Brandis, Ueber die Wirkung der Eisenmittel, &c., p. 150.—Percival, Essays, vol. ii., p. 290.—Murray, in Edin. Med. and Surg. Journal, vol. xviii., p. 167.—Bateman, in Ibid., vol. viii., p. 376 ; and vol. ix., p. 180.—Berat, Bei- trftge zur gerichtlichen Arzneikunde, b. iv., p. 221.—Bur- ger, in Horn’3 N. Arehiv., b. ii., p. 340.—Merat, Traitd de la Colique Metallique, p. 275.—R. Bright, Reports of Med- iral Cases, &c., 4to, vol. ii., p. 495.—R. Christison, A Trea- tise on Poisons, &c., 3d edit., 8vo, p. 290, 386, 515. Edin., 1836. Paralysis of Infants and Children.—Cazauvieilh, in Archives Gdndr. de MOdicine, t. xiv., p. 5, 349.—E. Ken- nedy, in Dublin Medical Journ., vol. x., p. 430.—R. Doher- ty, in Ibid., vol. xxv., p. 82.—H. Kennedy, Dublin Medical Press, Sept. 29, 1841.—M’Cormac, in Lancet, May 27, 1843. —C. West, in Med. Gazette, vol. xxxii., p. 829.—Calmer, in Ibid., April 21, 1843. (See, also, the Bibliog. and Refer, to arts. Apoplexy, Brain, Structural Lesions of, and Spinal Chord.) [Ad. Bibliog. and Refer.— Wm. T. Taliafero, Paraly- sis successfully Treated with Moxas, in Am. Jour. Med. Sci., vol. vi., p. 99.—J. H. Miller, in Am. Jour. Med. Sci., vol. xiv., p. 321, On Galvanism in Paralysis.—IF. E.Hor ner, A Treatise on Pathological Anatomy.—J. R. Lucas, in Am. Med. Recorder, 1826, p. 239.—Boston Med. and Surg. Jour., vol. xxviii., p. 362.—S. B. Tobey, in Bost. Med. and Surg. Jour., vol. xxvii., p. 415 (Case of partial paralysis of the face in a child cured by galvanism, applied by means of “ Page's Revolving Armature for Shocks”).— W. J. Barber, in Bost. Med. and Surg. Journ., vol. xviii., p. 263.—B. B Strobel, in South. Med. and Surg. Jour., 1836.—H- Chand- PAROTID GLANDS—Functional Disorders of. 55 hr, in Bost. Med. and Surgf. Jour., vol. xv., p. 91.—S. H. Dickson, Essays on Pathology, Therapeutics, &c., 2 vols. Charleston, 8vo, 1845.-— R. Dunglison, The Practice of Med- icine, 2 vols., 8vo. Philad., 1844.—W. P. Dewees, A Prac- tice of Physic, &c., 8vo. Philad., 1833.—H. A. Potter, in New-York Journ. Med. and Collat. Sci., vol. iv., p. 174.— W. P. Buel, in New-York Journal Med. and Collat. Sci., vol. ii., p. 34.— R. J. Graves, Clinical Lectures, with Notes, by W. W. Gerhard. Phil., 1842, 8vo.—John Eberle, A Trea- tise on the Practice of Medicine, 2 vols., 8vo. Phil., 1835. —J. Bell and W. Stokes, Lectures on the Theory and Prac- tice of Physic, 3d ed., 2 vols. Philad., 1845, 8vo.—Samuel Annan, in Am. Jour. Med. Sci., vol. ii., N. S., p. 99.—J. B. Zabriskie, in Am. Jour. Med. Sci., vol. ii., N. S., p. 360.— Detmold, in New-York Journ. of Med., vol. iv., p. 305.—S. Calhoun, in Phil. Jour, of the Med. and Phys. Sci., vol. i., p. 131.—Edward Delafield, in New-York Med. and Phys. Jour., Dec., 1824.—B. F. Joslin, in Am. Journ. Med. Sci., vol. iv., N. S., p. 322.—Alban Goldsmith, Case of paralysis from fracture, in which the spinous processes of two verte- brae, half of the third and the whole of the fourth, were re- moved by an operation, with partial success, in Am. Med. and Surg. Journ., 1829.] PAROTID GLAND — Diseases of.—This gland is often the seat of inflammation, of con- gestion, of scrofulous enlargement and inflam- mation, and of several other structural lesions. It is liable to be variously affected by the in- gesta, whether alimentary or medicinal; and it is often the seat of symptomatic disease, par- ticularly in the course of those maladies which reduce vital power or contaminate the blood. The,diseases of the parotid may be divided into, 1st. The functional; 2d. The inflammatory; and 3d. The structural. I. Functional Disorders of the Parotid Gland. Classif.—I. Class, I. Order (Author). 1. These disorders have received but little attention from medical writers ; for, unless in a few prominent cases, they seldom attract at- tention, and even in these they are generally symptomatic of some more important malady to which a primary and principal attention should be paid. The functional disorders of the parot- id consist chiefly of excessive and diminished se- cretion. Doubtless, an alteration of the quality as well as of the quantity of the secretion often obtains, but the latter change is more obvious, while the former can be inferred chiefly from the deposites formed from the salivary fluid, either in the ducts or upon the teeth ; or from the action of chemical re-agents, which, accord- ing to M. DonnA, evince more or less of acidity in inflammatory diseases, with an increase of the animal elements. (See art. Saliva.) 2. i. Deficient Secretion of the Parotids arises from numerous circumstances and agents affecting the digestive organs or the constitu- tional powers. Great mental anxiety ; heating articles of food, condiments, and beverages ; general vascular excitement; and morbid states of the blood, may diminish or altogether arrest the action of the parotids and other salivary glands. Irritation or inflammation of the stom- ach, or of other digestive organs, sometimes has a similar effect; and numerous stimulating, astringent, and anodyne medicines impair the action of these glands, although in a very un- certain and capricious manner. Deficiency of the salivary secretion also generally attends most fevers and inflammatory diseases, more especially those fevers in which the blood is early contaminated ; and in the more malig- nant maladies, when the action of the parotids is arrested, the glands themselves become swol- len and tender. The secretion of these glands is generally diminished in diabetes and dis- eases of the kidneys. (See arts. Saliva and Salivation. 3. ii. Increased Action of the Parotids often arises from the ingestion of various arti- cles of food, condiments, and medicines ; but when it is caused by food or condiments, it is generally transient and slight. It is often very remarkable and prolonged when caused by med- icine, especially by mercurials ; and it is usually more moderate and irregular when it is symp- tomatic of other diseases, as of affections of the pancreas, or of the stomach or duodenum, &c. Seeing, however, that the functions of the parotid are generally affected co-ordinately with those of the other salivary glands, whether quantitatively or qualitatively, they will be more particularly considered in relation to diagnosis and prognosis, under the heads Saliva and Sal- ivation. II. Inflammation of the Parotid Glands. Synon.—IIapung (from uapa, near, and ovc the ear), Galen. Parotis, Vogel, Sauvages, Pinel. Parotitis, Darwin. Cynanche Paro- tidcea, Cullen, Parr. Angina externa, Russel. Empresma parotitis, Good. Cauma paroti- tis, Young. Oreillons, Parotide, Ourles, Fr. Entzundung der Ohrdruse, Germ. Parotite, Ital. Mumps, Branks, Inflammation of the Parotid. Classif.—lsi Class, 2d Order (Cullen). 3d Class, 2d Order (Good). III. Class, I. Order (Author). Defin.—Pain, tenderness, and swelling in the situation of one or both parotids, with symptomat- ic fever, occurring either sporadically, endemically, or epidemically. 5. i. Causes and History.—A. Parotitis is most frequently observed in children, and about the period of puberty, and but rarely after twenty-five or thirty years of age, in an acute form, although it sometimes occurs in advan- ced life as a chronic disease. M. Begin thinks that it is more frequent in children of the male than of the female sex. It proceeds, sporadi- cally, from cold conjoined with humidity, and from currents of cold air. It is sometimes so prevalent in cold and humid localities, espe- cially during the colder months, as to be en- demic ; and it is occasionally epidemic in exten- sive districts. When thus prevalent, it has ap- peared in many instances to have been propa- gated by infection, particularly in schools and in ships, &c., where a single case has frequent- ly been followed by very many; but in these circumstances the propagation of the com- plaint may be imputed to exposure to the same physical agents and atmospherical states; al- though the removal of a boy from a school in which the disease prevailed to a locality where it was unknown, and the subsequent infection of other children by the one removed, militate against these agents having been the cause, and evince an infectious property. I have seen two instances of the disease appearing in nurs- es while attending on persons affected with erysipelas of the face and scalp, and in both these the adjacent cellular tissue was much implicated. One or both glands may be affect- ed ; and when the disease is epidemic, the max- illary glands are often similarly diseased. The accumulation of morbid secretions or of faecal matters in the prima via evidently favours or predisposes to an attack of the complaint. Ep- PAROTID GLANDS—Inflammations of. 56 idemic parotitis very rarely attacks the same individual a second time. In scrofulous per- sons, simple or sporadic parotitis often assumes a modified character, and becomes chronic or prolonged. It not infrequently follows scarlet fever and other exanthematous fevers, and then assumes a very severe and troublesome form, particularly after scarlatina, the inflammation often extending far into the adjoining cellular tissue and to the lymphatic glands of the nec-k 6. B. Symptoms.—a. The invasion of the com- plaint is usually indicated by irregular chills or rigours, followed by lassitude ; pain and tender- ness, with stiffness in the neck ; frequency of pulse ; heat of skin ; difficulty of mastication, owing to swelling and pain in the situation oi one or both parotids ; occasionally a somewhat increased flow of saliva; slight difficulty of deglutition, more or less increased when the adjoining glands are affected, and by the usual attendants on symptomatic fever, as thirst, loss of appetite, costiveness, headache, &c. 7. In some cases the symptoms are even milder than now stated. The swelling, pain, tenderness, and tension are slight; the pulse is but little affected ; and the organic functions are not materially disturbed. From this state of extreme mildness every grade of severity occurs, until the disease assumes much more intense characters, both locally and generally. In these latter the swelling is great, not mere- ly in the situation of one or both parotids, but extends to the sub-maxillary glands, some- times also to the tonsils, and to the adjoining cellular tissue. In these cases there are gen- erally much heat and sensibility of the parts, often with more or less redness, and always with difficult mastication and deglutition, ow- ing to the great tumefaction. There are also acute symptomatic fever, with urgent thirst, loss of appetite, severe headache, flushed coun- tenance, &c. 8. b. The duration of the complaint varies much in the simple and sporadic form of the dis- ease ; beginning to subside in four or five days in some cases, and continuing to increase du- ring a longer period, or passing into suppuration in others. When it follows the eruptive fevers, especially scarlatina, or when it occurs in the scrofulous diathesis, as it frequently does, it is often of longer duration than in other circum- stances, or when it appears epidemically ; and it more readily passes into suppuration of a chronic kind, the matter being discharged ex- ternally, and but rarely by the external meatus auditorius. In the epidemic disease, perspira- tion usually breaks out on the fourth or fifth day, commencing and becoming more copious about the neck, breast, and head, but often ex- tending more generally. The pain, tension, and swelling of the parotids afterward diminish, and the affected parts return to their natural state. 9. c. Suppuration, which is more frequent in the simple, in the consecutive, and in the scrofulous states of the disease than in the epidemic, is commonly indicated by a greater intensity of the local symptoms ; by marked redness of the more swollen part; by a more central and cir- cumscribed elevation ; by the pain being less acute and more throbbing ; by the more ele- vated part of the tumour becoming softer, and ultimately betraying more or less evident flue- tuation. The cellular tissue surrounding the gland or connecting its lobules is generally the seat of suppuration. Bichat and others have supposed that the lymphatic glands surrounding the parotids are more affected than the parotids themselves ; and this may be the case, espe- cially in the consecutive (§ 11) and scrofulous va- rieties of the disease. Probably, also, in the epidemic form, these parts, with the glands them- selves, and the adjoining cellular tissue, are more or less implicated. 10. d. of disease from the parotids to the testes, mamma;, or even to the brain or its membranes, has been often observed and no- ticed by writers as one of the terminations of the disease, especially when appearing epidemically. When this occurrence takes place, the swelling under the ears rapidly subsides, and either the testis or the mamma on the same side with the affected parotid becomes painful and swollen. When both parotids have been affected, the metastasis has in rare instances taken place to both testes or to both mamma;. I have not met with a case in which suppuration has occurred in these parts after metastasis from the parotids. In some instances the parotids have become again affected upon the subsidence of the en- gorgement of the testicle. I have observed but few instances in which the brain or its mem- branes have been affected consecutively upon the sudden disappearance of the disease of the parotids ; and these recovered under the treat- ment about to be noticed. 11. C. The nature of inflammations of the parotids, in their several modes of manifesta- tion, requires more consideration than has hith- erto been devoted to it. That the epidemic state of the disease is different in many respects from the primary and simple form is shown by vari- ous circumstances, to which I will more par- ticularly allude.—a. Simple parotitis, whether oc- curring primarily from cold or any other cause, or consecutively of eruptive fevers, or of other affections implicating the throat or mouth, is more distinctly an inflammatory disease, and is more strictly local than the epidemic malady. It is also more prone to assume all the charac- ters of inflammation of glandular parts, and to pass into suppuration, than the latter form. 12. b. Epidemic parotitis is less strictly inflam- matory, at least in a large proportion of cases, and is more manifestly congestive ; consisting rather in active congestion, or an engorgement of the parotids and adjoining glands, than the simple form of the disease. It is also less a local than a constitutional malady ; and this, as well as its more congestive character, is shown by its originating in infection, by its disposition to metastasis, by its definite course, and by its frequently terminating by a distinct crisis. The simple or sporadic complaint is attended by fever, which is merely symptomatic of the local inflammatory action ; while the epedimic is char- acterized by fever, which is less a symptomatic than a primary or idiopathic malady, and of which the swelling of the salivary glands is an attendant or local feature, consisting of con- gestion or engorgement of these glands rather than of actual inflammation. In the epidemic or specific form of the disease, the fever is rarely sthenically inflammatory, but generally is either mild, or partakes more of an adynamic or asthenic character, and requires a different PAROTID GLANDS—Inflammations of. treatment from the truly inflammatory or sim- ple form of the complaint. 13. c. From this it will be seen that I consid- er Parotitis, or inflammation of the parotid, to consist of the following varieties and slates : namely, 1st. Simple or Common Inflammation, occurring, a. primarily, or independently of pre- existing disease ; and, b. consecutively, or follow- ing eruptive fevers and affections of the mouth and throat, in both which states it usually pre- sents an acute character; 2d. Scrofulous In- flammation of the parotids, or parotitis affecting the strumous diathesis, and usually assuming a chronic or indolent form ; 3d. Epidemic Paro- titis, or that proceeding from a specific cause, and presenting a specific or distinct and regular course. Indeed, it is doubtful whether this last should be arranged as a local inflammation, or rather as a specific form of fever caused by infection, and characterized by congestion or engorgement of the salivary glands, and a tendency to metastasis to the testicles, and thence to the brain. 14. ii. Treatment.—The treatment of in- flammations of the parotid should vary with the severity of the local symptoms, and with the character of the attendant fever.—a. In the simple form of the disease, when primary and slight, moderate warmth, sustained by the ap- plication of flannel locally, and cooling aperi- ents and diaphoretics, are generally sufficient to promote resolution. I do not believe that cold applications are beneficial in this com- plaint; they may even prove injurious. In more severe cases, where inflammatory action is unequivocally manifested in the gland and its vicinity, blood should be taken away locally, and a more strict and antiphlogistic treatment and regimen adopted, as in other cases of in- flammation. If suppuration commence, it should be promoted by the usual warm applications, and an early outlet be given to the matter which is formed. 15. b. In the consecutive form of parotitis, par- ticularly that following the anginous states of eruptive fevers, even local depletion should be cautiously prescribed, and with strict reference to its effects. Diaphoretics, stomachic aperi- ents, warm baths, and diuretics are generally required in these circumstances; and if the swelling become sub-acute or indolent, small doses of the iodide of potassium, with liquor potassae, may be given in the compound decoc- tion of sarsaparilla. If suppuration take place, the matter should be early evacuated, and the iodide and solution of potash may be given in the decoction of cinchona, &c., and change of air, especially to the seaside, advised. 16. c. The scrofulous, sub-acute, and chronic states of parotitis sometimes require the appli- cation of a few leeches to the parts, or to their vicinity, and the means just recommended (§ 15) firmly persisted in for a considerable peri- od. Brandish’s alkaline solution may be sub- stituted, in many cases, for the solution of pot- ash. When there is some degree of anaemia, or when the affection occurs in females about the period of puberty, with delayed or scanty menstruation, the iodide of iron may be takeij in the sirup of sarsaparilla, and warm salt-wa- ter bathing, or warm salt-water hip baths re- sorted to. 17. d. The epidemic form of the complaint is so slight in some cases as to require merely pro- tection from cold and humidity, and attention to the state of the secretions and excretions. The affected parts ought to be kept moderately warm, and the excretions from the bowels and skin promoted. When the local affection is more decidedly inflammatory, the swelling of the neck being considerable, and the surface generally red, febrile action being also great, a number of leeches may be applied, and their op- eration promoted by warm fomentations. Cold applications are especially hazardous in this form of the complaint, as favouring metastasis to the testes ; and this risk may even be incur- red by active purgatives. Antimonial diapho- retics and gentle aperients are the safest means which can be employed in most cases of this af- fection. If metastasis to the testicles or to the mammae occur, these are also the best reme- dies, in connexion with the horizontal posture. In these secondary states of disease, the appli- cation of leeches, followed by warm fomenta- tions and poultices, is generally necessary. An- timonial emetics are often of service in inflam- mation of the testes ; but when this disease occurs suddenly upon the disappearance of parotitis, the subsequent metastasis of the mal- ady to the brain should be dreaded, as it some- times takes place ; and it may be favoured by the active operation, and consequent perturba- tion of emetics, and by the application of cold to the diseased testicles. 18. It is possible that parotitis, caused by cold and humidity, may assume an endemic form, or may affect a number of persons who are exposed to these causes, or exist in a par- ticular locality. It has thus affected a consid- erable number of a ship’s crew, and it has then manifestly arisen from the once general prac- tice of daily, and even more frequently, wash- ing the decks, now happily abandoned. The cold and humidity produced in a confined space by this practice were the sources of more mal- adies, especially of rheumatism, erysipelas, fe- vers, &c., than were recognised in those days. Mr. Noble, in his account of parotitis endemic in a ship of war, states that the swelling and redness of the neck suddenly subsided on the fourth and fifth days, and were in all the ca- ses rapidly followed by metastasis to the tes- tes, the epididymis and spermatic chord not be- ing affected. In two instances a second me- tastasis took place from the testes to the brain, the cerebral symptoms being well marked and severe. In no instance did the disease return to the parotids. This remarkable frequency of metastasis was probably favoured by the per- sistence of the cause originating the disease, and by the use of cold applications and drastic purgatives. 19. e. In some instances, especially in aged persons, or in females about or soon after the change of life, the complaint assumes a chronic state, obscure inflammation extending to the adjoining cellular tissue, and giving rise to the formation of matter, and even to indolent ulcer- ation, if a suitable treatment be not employed. In these, a few leeches should be applied, and sometimes repeated, and an antimonial emetic exhibited. Subsequently, antimonial diapho- retics may be given, and, if matter form, fo- mentations, poultices, and an early outlet to the matter are requisite. If the disease become 57 58 indolent, or if swelling and hardness remain, the iodide of potassium, with liquor potassee and sarsaparilla, should be prescribed. The external application of a weak tincture of io- dine, or of the iodide of potassium, in the form of ointment, may also be tried ; but I have sel- dom seen this ointment beneficial unless the proportion of iodide has been much smaller than that usually prescribed. Dr. Neumann (Edin. Med. and Surg. Journ., No. 93, p. 452) applied a plaster, consisting of eight parts of mercurial ointment, and one of the iodide of potassium, to the swollen gland with great success, during an epidemic parotitis which prevailed in Silesia, having premised an emetic. When parotitis, either simple or epidemic, occurs about the pe- riod of puberty, and previous to menstruation, it is apt to become obstinate and chronic, par- ticularly in scrofulous habits. In these cases* the iodides combined according to the peculi- arities of the case ; local depletion, emmena- gogues, horse exercise, warm salt-water bath- ing, stomachic aperients, See., are most ser- viceable. III. Organic Lesions of the Parotids. Classif.—IV. Class, I. Order (Author). 20. Structural lesions of these glands, both the consequences of inflammation and inde- pendent of this state of disease, are sometimes observed. The most frequent and important of these are enlargements, scrofulous disease, scirrhus, and open carcinoma. To these may be added the congestions and asthenic inflam- mation, sometimes terminating in sphacelation, occasionally observed in malignant fevers, and frequently in the plague. 21. A. Chronic enlargement of the parotid, without pain, heat, or any other indication of inflammatory action, is sometimes met with. In some cases the gland increases to three or four times its natural size. It is difficult to determine how far hypertrophy is owing to change in the lobular structure, or minuter granules composing the gland, or to deposites of lymph in, or change in the nutrition of, the interlobular and surrounding cellular tissue. Most probably both orders of structure, and even the surrounding lymphatic glands, are more or less implicated ; and this seems the more likely, since the researches of Murat and others have shown the granules and minute lobules of the gland to be affected in parotitis. A very remarkable case of chronic enlargement, first of one parotid, and afterward of the other, the first having become much reduced after a considerable time, lately came under my care. The history of this case, as well as of others which I have seen, led me to infer that the en- largement was consequent upon obstruction or obliteration of the canal of the duct. After having had recourse to a variety of means, the enlargement was at last entirely removed by a prolonged course of the iodide of potassium in minute doses with conium. In this instance, from half a grain to a grain only of the iodide was given in the twenty-four hours, a larger dose occasioning uneasiness and febrile excite- ment. 22. The symptomatic enlargements, conges- tions, asthenic inflammations, softenings, lind even gangrene, sometimes observed in malig- nant fevers and the plague, were imputed by Bichat and others rather to alterations in the PAROTID GLANDS—Inflammations of. connecting and surrounding cellular tissue and lymphatic glands than to change in the gran- ules of the gland itself. But the researches of Murat and others have shown that these gran- ules are affected from the commencement of simple parotitis, while those of Bulard and Clot-Bey have evinced that the surrounding lymphatic glands are more especially implica- ted in the plague, and in other sympathetic en- largements in the region of the parotids. 23. B. Tumours of various kinds are some- times seated in the parotid, and scirrhus and open cancer, commencing either superficially or in the gland itself, or in the lymphatic glands surrounding the parotids, are occasionally met with. These have been the themes of pro- longed surgical disquisitions, as well as the subjects of surgical operation. But in this last resource the dexterity or daring of the opera- tor has been oftener displayed than the pro- priety and success of the undertaking. Com- paratively few cases admit of this procedure— in very few ought it to be attempted when the disease is malignant; and in none of a non- malignant nature, without having previously duly tried the means already indicated both in this article and in those on Scrofula and Tu- mours. (See arts. Saliva, Salivary Ducts, and Salivation.) [It is very important, in the treatment of tu- mours situated in the parotid region, as well as other parts of the body, to allay all mental anxiety, as it is found that disquietude of mind and perturbation of spirits are powerful causes in promoting morbid growths. As they gener- ally have their origin in mal-assimilation, or faulty secretion and excretion, it is of the first importance to shape our remedies with these ends in view; for, without attending to these functions, local applications will be altogether useless; and even should the tumour be re- moved, similar deposites will take place in oth- er parts of the body. If the healthy functions of the various secreting organs can be main- tained, there is every probability that morbid growths will eventually disappear ; at any rate, they will rarely become malignant, or call for a surgical operation. We have for several years been in the habit of treating tumours med- ically rather than surgically, and we have met with but very few cases in which extirpation was called for. Where a tumour is so situated as seriously to disturb the functions of parts essential to life, as over the trachea, or within the mouth and about the jaws, its removal be- comes not only justifiable, but absolutely ne- cessary. It may be that the presence of the tumour, although not malignant, is the cause of continual apprehension on the part of the pa- tient, which cannot be allayed except by its re- moval ; here it will be in vain to attempt to check its growth by local or constitutional means, and it may, therefore, with propriety be extirpated. By strict attention to hygienic regulations, air, food, exercise, and bathing, with a mild, alterative course of iodine and sar- saparilla, we shall succeed, in a large majority of cases, in allaying the pains and checking the 'growth of tumours, if we do not succeed in ef- fecting their entire removal by absorption. We agree with our author that a surgical operation in the first resort is never advisable, except un- der the circumstances above detailed]. Btbliog. and Refer. — 0. Valentini, Discorso Med. Chirurgico intorno alle Parotidi nelle Febbri. Perug., 1736. —E. G. Schmidt, Abhandl. von den Geschwulsten am Halse, &c. Brauns., 4to, 1755.—Rochard, in Journ.de t. vii., p. 379, 1754.—M. Stoll, Rat. Med., p. iv., p. 263.— Mariotti, Delle Parotidi ne’ Mali Acuti, 8vo. Perug., 1785. —it. Hamilton, Account of the Mumps, Trans, of Roy. Soc. of Edin., vol. ii., 4to. 1790.—J. B. Siebold, Hist. Systematis Salivalis Physiol, et Pathologice considerati, &c., 4to. Jena, 1797.—A. L. Murat, La Glande Parotide consid. sous ses Rapports Anatom., Physiolog., et Patho- logiques, 8vo. Paris, 1803.—J. Noble, in Edin. Med. and Surg. Journ., vol. iv., p. 304 {Endemic).—A. Duncan, in Edin. Med. and Surg. Journ., vol. vii., p. 431 {Epidemic). —Murat, in Diet, des Sciences Med., t. xxxviii., art. Ore- illon; et t. xxxix., art. Parotide.—E. Gendron, M6m. sur les Fistules de Glande Parotide, 8vo. Paris, 1820.—Hammers- ley, in New-York Medical Repository, July, 1822, p. 443.— Rochoux, Diet, de M6d., t. xvi., art. Parotide.—Begin, Diet, de Med. et Chir. Prat., art. Parotide.—W. Kerr, Cyclop, of Pract. Med., vol. iii,, p. 260.—A. Duplay, Observat. de Parotides survenus dans le Cholera, in Archives Gener. de M6d., t. xxix., p. 365. 1832. [For an account of American operations for the removal of the parotid gland, see Reese’s edition of Cooper’s Sur- gical Dictionary, p. 259]. PELLAGRA.—Synon. Dermatagria, Titius. Scorbutus Alpinus, Frank. Ichthyosis Pella- gra, Alibert. Tuber Pellagra, Parr. Lepra Lombardica, Swediaur. Elephantiasis Italica, Good. Pellagre, Fr. Pellarella, Pelagra, Mai di Miseria, Malattia della Miseria, Mai del Sole, Mai Roso, Ital. Classif.—3d Class, Alh Order {Good). IV. Class, IV. Order {Author). 1. Defin.—A squamous eruption, chiefly on those parts of the body exposed to the sun or air, preceded and attended by disorder of the digestive organs and nervous system; accompanied with general cachexia ; a sense of burning pains in the trunk and limbs ; ennui and melancholy ; intermit- ting at first, afterward more continued; endemic and hereditary. 2. The antiquity of Pellagra has been a sub- ject of doubt. Moscati and others consider that the disease has not been known much be- fore the middle of the last century, while Strambio, who was physician and director of the hospital established near Milan for the re- ception of pellagrosi, states, in his treatises pub- lished in 1784-7, that he had seen many pella- grosi in the hospital, who assured him that their fathers and grandfathers had died of the malady. Dr. Holland adds, that F. Frapoli, physician to the hospital at Milan, in his trea- tise on the disease, published in 1771, also con- tends for its antiquity, and supposes it to be the same disorder as the one called Pellarella, which is casually noticed in the records of the Milan Hospital for the year 1578. It is certain, however, from the concurrent testimony of all writers on the malady, that pellagra has been rapidly increasing itself since the middle of the last century. Dr. Holland, who has investi- gated the disease more closely than any Eng- lish writer, remarks that, at the time when Strambio wrote (in 1784), the pellagrosi form- ed about one twentieth part of the population in the districts principally suffering under the disorder, namely, in the Alto-Milanese, where the country rises towards the Alps. In these districts, Dr. Holland believes, at the time when he wrote (1817), the pellagrosi to be one m every five or six of the population. He adds that the disease prevails in some districts much more than in others; that it appeared first in the higher parts of the Milanese territory, and that its ravages there are still greater than in any other part of Lombardy. Some time elaps- PELLAGRA—Symptoms and History of. 59 ed before it was said to have appeared in the Venetian provinces and near the shores of the Adriatic Sea. At the present time it is increas- ing in every part of Lombardy, as well on the plains as among the hills which rise on their northern border towards the Alps. It also ex- ists in the province of Friuli, the district inter- vening between the foot of the Carinthian Alps and the northern shore of the Adriatic.* 3. I. Symptoms.—Pellagra is almost exclu- sively confined to the lower orders, and chiefly to peasants, and those engaged in agricultural employments.—a. Its first distinct appearance is that of a local cutaneous eruption, generally preceded by languor, debility, and indications of constitutional disturbance and cachexia. The lo- cal symptoms usually first appear early in spring, when the midday heat is increasing, and when the peasants are most actively engaged in the fields. The patient first perceives on the backs of his hands, on his feet, and more rarely on oth- er parts of the body exposed to the sun, certain red spots or blotches, which gradually extend themselves, with a slight elevation of the cu- ticle, and a shining surface, not unlike that of lepra. The colour of the eruption is a more obscure and dusky red than that of erysipelas : it is attended by no other uneasy sensation than a slight pricking or itching, and some ten- sion in the part. After a short time, small tu- bercles are frequently observed in the inflamed surface. The skin always becomes dry and scaly, forming rough patches, which are exco- riated and divided by furrows and rhagades. Desquamation takes place gradually, and leaves behind a shining, unhealthy state of the affect- ed surface. Towards the close of the summer, or occasionally earlier, the parts have nearly resumed their natural appearances; and but that the farther progress of the malady is fa- miliar to all, the patient might suppose that the mischief had disappeared. 4. With this local affection are connected from the first, general debility, vague and ir- regular pains of the trunk and limbs, especially in the course of the dorsal muscles and spine ; vertigo and headache; irregular appetite and depression of spirits. The bowels are usually relaxed, and continue so throughout the dis- ease. There are no febrile symptoms, and the catamenia of females are generally continued without irregularity ; but there are frequent ex- ceptions ; febrile symptoms occasionally ap- pearing, and menstruation being more or less obstructed from the commencement; but these occur chiefly in the more advanced course of the malady. 5. The patient obtains a remission, more par- ticularly of the external eruption, during the autumn and winter of the first year; but he al- most always experiences a recurrence of the symptoms in the following spring under a more severe form, and with much greater disorder of the constitution. The cutaneous affection spreads, yet still affecting chiefly the hands, neck, feet, and legs, and other exposed parts. The skin becomes callous and deeply furrowed ; large rhagades appearing, especially near the [* M. Gibekt considers the pellagra of Lombardy to be merely an ichthyosis dependant on a chronic affection of the digestive organs. As it is a disease to which the inhabi- tants of onr country are fortunately strangers, we shall add nothing to the very full and complete history of the disease given by our author-.] 60 articulations of the fingers. The cutaneous af- fection now resembles an inveterate degree of psoriasis, or of lepra vulgaris, and, in some re- spects, ichthyosis, with which Alibert has classed it. 6. The debility is greatly increased in the second year, often rendering the patient inca- pable of pursuing his active labours, and ren- dering him susceptible of all changes of tem- perature. Partial sweats break out, especially on any exertion. Cramps, spasmodic affec- tions, and pains are frequently complained of; and the mind is despondent and depressed. All the symptoms are aggravated as the heat of summer advances, especially in those most ex- posed to the sun. They begin again to decline, as in the preceding year, towards the middle or end of autumn ; but the remission, as well of the local affection as of the general disorder, is much less complete than before ; and the pa- tient continues to suffer during the winter from debility and other constitutional symptoms. 7. The disease may continue for several years thus to remit during winter, and to pre- sent increasing or varying grades of exacerba- tion during the spring and summer, but gener- ally in the third year, or in the fourth or fifth, in some instances, or even later, every symp- tom is renewed at an earlier period of the spring, and in an aggravated degree. The de- bility now becomes extreme ; the patient is hardly able to support himself; and he is af- fected with pains in his limbs. All the consti- tutional phenomena indicate universal cachexia and lesion of the nervous and voluntary pow- ers ; the general symptoms now have a close analogy to those of scorbutus. The diarrhoea continues, and augments the debility; and ul- timately it assumes much of a dysenteric char- acter, particularly in the latter stages of the malady. The evacuations are offensive and morbid, and preceded by abdominal pains. Aphthae, thirst, pains at the stomach, &c., are also frequently complained of. The odour of the breath and of the perspiration is extremely offensive. The appetite and digestion are ir- regular ; but they are often less affected than most of the other functions. Dropsical effu- sions frequently appear at this stage, generally in the form of anasarca, occasionally of ascites. Vertigo, tinnitus aurium, double vision, are now usually present; and all the senses are much impaired. Spasmodic affections, irregular con- vulsions, involuntary movements of the head and body forward, and even complete epileptic attacks, often occur. 8. b. The nervous system presents remarka- ble disturbance, and the manifestations of the mind are more or less disordered. The pella- grosi complain of a sense of heat in the head and spinal chord; of tingling or darting pains in the course of the nerves ; of heat in the limbs, palms of the hands, and particularly in the soles of the feet; of great weakness of the limbs, with trembling when attempting to stand; and sometimes of contractions of the lower limbs. Their looks become sombre and mel- ancholy. Ennui, depression of spirits, and men- tal imbecility increase with the progress of the malady. Dr. Holland states, that pellagrosi afford a melancholy spectacle of physical and moral suffering at this period. They seem un- der the influence of an invincible despondency; PELLAGRA—Symptoms and History or. they seek to be alone ; scarcely answer ques- tions put to them ; and often shed tears with- out obvious cause. Their faculties and senses are impaired; and the disease, when it does not carry them off from exhaustion of the vital powers, generally leaves them incurable idiots, or produces attacks of mania, soon passing into utter imbecility or idiocy. The public hospi- tals of Lombardy are incapable of receiving vast numbers of the pellagrosi; the greater propor- tion perishing in their own habitations, or lin- gering there wretched subjects of fatuity and decay. Where extreme debility and cachexia are the causes of death, as is usually the case, they are attended with colliquative diarrhoea, spasmodic affections, coma, and extreme ema- ciation. 9. c. Mania and delirium, consequent upon pellagra, are either acute or chronic. The acute state sometimes proves fatal in a few days; but the more chronic form seems to retard, in some degree, the progress of the malady, the strength of the patient declining less rapidly. In this state there is always loss of memory and of the powers of attention. Religious mel- ancholy frequently characterizes this form of delirium, with a desire to commit suicide, and usually by drowning. Hence Strambio denom- inated this morbid disposition by the name of hydromania. 10. d. Although the disease has been de- scribed above as proceeding in its course three or four years, yet it is generally of longer dura- tion. Several intermissions, or remissions, usually occur in its progress. It occasionally remains stationary; and certain of its phe- nomena sometimes predominate over the oth- ers at one time, and others at another time Thus some relief of his sufferings is experi- enced by the patient from time to time, although he can entertain little hope of ultimate recov- ery. Occasionally the cutaneous eruption forms the principal indication of the complaint for sev- eral years, it being renewed every spring and disappearing in the autumn. The constitutional symptoms may also continue for some years comparatively slight; and, if the patient be re- moved to a different locality and to another mode of life, the disease may be farther pro- tracted, or altogether arrested in its progress. It is rarely, however, that these means can be adopted; and the constitutional malady is gen- erally so firmly established in the third or fourth year, that few hopes of benefiting the patient by treatment or by change of climate and occu- pation can be entertained. 11. e. Some cases of the disease assume a more acute and more rapid form, particularly in respect of the constitutional symptoms. In these the disease proceeds as rapidly as above de- scribed, with all the more severe symptoms ; and, although the pulse is often very slow and weak, especially in the more chronic cases, it is sometimes frequent and hard in the more acute. This, however, only occurs when fever takes place in the progress of the malady. This consecutive fever is connected either with a state of gastro-intestinal irritation, or of as- thenic inflammation, or with predominant af- fection of the brain and spinal chord; and is generally attended, at first, by heat of skin and irregular remissions, followed by offensive per- spiration. These states of febrile excitement PELLAGRA—Symptoms and History of. generally hasten the fatal termination of the malady, usually with all the concomitant symp- toms of the last stage of adynamic fever. 12. /. In infants and children the symptoms of the malady are not materially different from those characterizing it in more advanced life. The cutaneous affection of the hands, arms, feet, and legs is the first to appear ; is renewed and augmented in successive years, and at- tended by the various symptoms indicative of a cachectic state of the body. The malady, as in other cases, has in them a fatal termination, unless a change of climate be obtained in an early period of its progress. 13. g. Some anomalies have been observed in the progress and succession of the symptoms of pellagra. During its first appearance in Italy, the disease was remarkable for the in- tensity of the cramps and spinal pains, and the trifling extent of the cutaneous affection. At a more recent period this affection became a prominent feature, while disorder of the di- gestive organs and mania appeared chiefly as secondary symptoms. Different phenomena have also sometimes predominated ; in certain years ptyalism, and in others it has been dis- placed by aphthae, desquamation of the lips, &c. Very recently the various cramps, spinal pains, and convulsions, insisted on by former writers, have been less noticed than previously, while pellagrous mania and delirium are very com- mon, and gastro-intestinal affections are gen- eral. 14. h. Pellagra may be complicated with other diseases of the skin, such as lepra, psoriasis, erysipelas, eczema, purpura, syphilitic erup- tions, &c.; and with intermittent and remit- tent fever, scrofulous affections, phthisis, peri- tonitis, white swellings of the joints, &c. 15. II. Appearances on Dissection.—Le- sions are found chiefly in the digestive canal, nervous system, and skin.—a. In the five bodies examined by M. Brierre de Boismont, the mu- cous membrane of the stomach was red, inter- sected by bluish or daik vessels, soft, pulta- ceous, and easily removed. The redness was greatest at the large end of the stomach; the mucous membrane was thinner in some cases, and thicker than natural in others. The valves of the duodenum, and the mucous membrane of the small and large intestines, were of a light- er or deeper tint, in some approaching to brown. This membrane was generally softened and hy- pertrophied ; it was likewise studded with ir- regular or round ulcers, surrounded by a red- dened base. The subjacent cellular tissue and muscular coat were hypertrophied. The in- testines, in all the cases, contained lumbrici. Dr. Carswell, in addition to the usual signs of chronic inflammation of the stomach and intes- tines, found perforations of the stomach from softening in two cases. 16. b. The membranes of the brain, particu- larly the arachnoid and pia mater, in these ca- ses, as well as in those examined by Strambio, Fantonetti, and others, were injected, thick- ened, and opalescent. The pia mater adhered to the cerebral convolutions, which were slight- ly atrophied. The substance of the brain was in some cases diminished, in others increased in consistence ; the gray substance was inject- ed and deeply coloured ; the white substance Jotted with vascular points. The cerebellum was slightly injected and somewhat softer than natural. The arachnoid and pia mater of the spinal chord were also injected. The gray sub- stance of the chord was somewhat indurated and injected. The white substance was much softened. 17. c. The skin of the backs of the hands and feet was like leather, and, when examined with a lens, presented a number of irregular cracks, crossing at acute angles, and placed closely, and sometimes implicating the whole thickness of the corion. Small, thin, yellow crusts, and furfuraceous lamellae of a dirty white, inter- posed in some of these small fissures, and ad- hered firmly. The epidermis was six or eight times thicker than natural, brownish, friable, and dry, and was firmly attached. The sub- epidermic layers were much thickened. The radial nerves were softened, reddish, and infil- trated with serum. The most frequent lesions to the above were the usual signs of recent or of old, general or partial peritonitis. Indica- tions of bronchitis and pulmonary tubercles were also often observed. Enlargements of the spleen and of the liver, in some cases also of the mesenteric glands, and effusion of serum in the shut cavities, have been occasionally noticed. 18. III. Asturian Pellagra—La Rosa— Mai de la Rosa — Asturian Leprosy, Thierry, Sauvages, &c.—Elephantiasis Asturiensis, Good —is, according to the descriptions of Thierry and others, merely a variety of pellagra, and, in its local and general characters, still more nearly approaches the leprosy of the Middle Ages than the pellagra of Lombardy. Thierry states that this disease generally appears at the spring equinox, on different parts of the body, with redness and harshness of the skin. It after- ward degenerates into rough, dry, blackish crusts, intersected by deep cracks and fissures. These dry and fall off in summer, leaving red- dish, smooth, and shining marks, devoid of hair, and depressed below the level of the sur- rounding skin, resembling the cicatrices of burns. They remain through life. In the spring of every year they are covered anew with crusts, which become more and more painful, offensive, and disgusting to the sight. They often appear on the fore, or most exposed part of the neck, extending to the clavicles and top of the sternum. 19. To these eruptions are added a constant shaking or trembling of the head and upper parts of the body, heat of the mouth, vesicles on the lips, foulness of the tongue, extreme weakness of the whole body, with a feeling of heaviness, and disorder of the digestive organs Through the night, burning heat, insomnia, groaning without obvious reason, dejection of spirits, melancholy, &c., are complained of. Several suffer slight delirium or hebetude of the senses, particularly of .touch and smell. To these are sometimes added slight mania, erysipelas, ulcers, and irregular fever. This malady is often attended, in its advanced sta- ges, with a tranquil state of mania or melan- cholia. The patient sinks into a state of de- jection, in which he forsakes his home, seeks solitude, and is reduced to utter despair. This mental depression usually appears about the summer solstice, and proves fatal sooner or later. A fatal issue is often, also, preceded by 61 62 marasmus and dropsical effusion. The local and constitutional symptoms place this malady in a position intermediate between the pellagra of Lombardy and the leprosy of the Middle Ages, although more closely to the former than to the latter. 20. IV. Diagnosis.—Pellagra is manifestly allied, in many of its features, to the leprosy of the Middle Ages on the one hand, and to scurvy, with which, however, pellagra is some- times complicated, on the other hand. But still, there is an alliance only in certain points. The resemblance, also, which it bears to ery- sipelas, led Titius to define it as a chronic, pe- riodic, and nervous form of that disease ; from which, however, it differs widely in its whole history—in local and constitutional symptoms, in its nervous characters and terminations. 21. M. Mayer observes that certain epidem- ics which have occurred in the north of Europe during the last three or four centuries, and which have been generally attributed to want and to the use of unripe, spurred, and damaged grain, closely resemble pellagra. The resem- blance is certainly close in many features, but the difference is great in others. There can be no doubt that local, external, and constitu- tional diseases, peculiar in kind or anomalous in character, yet varying in numerous modes, grades, and phases, appear in certain localities and at certain epochs, as the several circum- stances and agents occasioning them are dif- ferently combined, in respect both of the num- ber, grade, and quality of these agents ; for it is only reasonable to infer that as causes, agents, and influences are variously associated in number, intensity, and quantity, so will the effects be different, and hence present inde- scribable forms, varieties, states, and phases, which admit not of distinct or specific limita- tions as to character, nor of consistent, con- stant, and uniform manifestations. 22. a. It will appear in the sequel (see Causes) that many of the circumstances in which the Italian and Asturian pellagra originate are the same which gave rise to the leprosy of the Mid- dle Ages, and to certain epidemics which have appeared in several countries during the fif- teenth and sixteenth centuries. Still, the fea- tures of each vary, or even differ. In the true leprosy, the face, roots of the hair, palate bones, nose, are more affected, and the cutaneous dis- ease is more decidedly tubercular ; the affec- tion of the skin, of the extremities and face, in- creasing with the other symptoms, and the mind being less disordered than in pellagra. In the Italian pellagra, the mental, nervous, and intestinal affections predominate with the prog- ress of the malady. 23. b. In the Asturian malady, the affection of the skin is greater than that of the Italian, and approaches more nearly the severity of leprosy ; the affection of the mind is less acute than that of true pellagra, but the termination of all these is nearly equally unfavourable, al- though their duration is very variable, not only in regard of the respective maladies, but as re- spects individual cases of each. 24. c. The history of pellagra sufficiently dis- tinguishes it from other diseases of the skin. Chronic erythema is never attended by the se- rious nervous, mental, and digestive disorders characterizing pellagra ; and lepra and psoriasis PELLAGRA—Diagnosis—Prognosis—Causes. are removed to an equally great distance from the Italian malady, even without taking into account the different characters and forms ot the eruption in each, and the ultimately fata issue of pellagra. 25. d. M. Rayer attempts to establish a sim- ilarity between pellagra and the epidemic of Paris and its vicinity in 1828, to which the name acrodynia has been given. But, although the season of the appearance of the latter was the same as of the former, and although the eruption on the extremities, the pains in the feet and difficulty of walking, the disorders of the digestive organs, closely resembled the same phenomena at an early period of pellagra, yet the absence of the mental disorder, the non- recurrence of the malady, and the general re- covery of the attacked, indicate a total differ- ence between the two maladies, the points of resemblance being probably the results of a concurrence of certain causes contributing to the production of pellagra. 26. V. Prognosis.—The circumstances which render the prognosis of pellagra particularly un- favourable are the unequivocal operation of those causes to which this malady is attribu- ted ; the circumstance of one or other parent of the patient having died of it; an advanced period of its course ; the poverty and agricul- tural occupation of the affected ; previous dis- ease, and the severity of the constitutional symptoms, particularly of the disorder of the digestive organs ; general cachexia; emacia- tion, and mental disturbance; severity of the nervous symptoms, and especially the occur- rence of mania, delirium, partial, or general pa- ralysis ; and, at an early stage, the impossibili- ty of removing the subjects of the malady to a different climate, or to other occupations. Pregnancy and lactation also exert an unfa- vourable influence on its course and termina- tion. 27. VI. Causes.—The hereditary tendency of pellagra is fully admitted by all writers who have observed the progress or traced the ori- gin of the malady. There can be no doubt of the disease being continued in succession through families, even the children of pella- grosi becoming affected, when much exposed to the sun and air, or early occupied in the fields. Writers have differed as to the respect- ive liability of sex ; but there seems to be no difference in this respect beyond what may be imputed to occupation and exposure. That these latter circumstances are chiefly produc- tive of the disease cannot be disputed, inas- much as those only who are subjected to them are affected by it. Doubtless, however, other causes co-operate; but the influences to which persons thus occupied are alone exposed should he viewed as the chief agencies in developing the mal- ady. Some writers have supposed the climate to be the chief cause ; but if this were the case, other persons besides agricultural labourers would become affected. This disease has also been attributed to the use of maize ; but we do not find that maize has any similar effect in other or similar climates, where it is exten- sively employed as food. It has likewise been imputed to a rice diet ; but the same remark applies also to this opinion. The imperfect and sometimes unwholesome nourishment; the want of animal food, and due proportion PELLAGRA—Treatment. 63 of condiments and stimuli; the insufficient use of salt and other antiseptic substances; and the general wretchedness, privations, and filth of the field labourers in this part of Europe, to all which the malady has been attributed, may certainly concur, in some degree, in develop- ing it; but even these conjoined cannot rea- sonably be inferred to be the real exciting caus- es of it, inasmuch as these causes are equally influential, and concur in similar grades of ac- tivity in other localities, without pellagra being the result. 28. After considering the various causes and their combinations to which this malady has been imputed, I infer that they may tend to aggravate its severity or to increase the pre- disposition to its appearance, but that other peculiar and endemic agencies are chiefly con- cerned in generating it. What these agencies are has not been demonstrated, nor do they, perhaps, admit of precise demonstration, but they appear to me to proceed from the soil and water of the locality. The use of water filtra- ting through certain or peculiar geological for- mations, or certain alluvial deposites ; the la- bours of the peasants in fields which are satu- rated with moisture, or which have been inun- dated during the preceding winter; and the cir- cumstance of those parts of the body which are most exposed, or most commonly immersed in the water and soil or earth which these labour- ers cultivate, must readily suggest themselves to the minds of those who reflect on the sub- ject as the obvious exciting causes of the dis- ease. That the influence of the sun is neces- sary to develop the Cutaneous affection, may be admitted, and may be explained by the ef- fects produced by its rays, or by the drying ef- fects of the air upon the surfaces covered by the moisture of the soil in which the peas- ants are employed. It has been objected, par- ticularly by Strambio, that, although the sun and free exposure to the air tend to develop more completely the cutaneous affection, still the constitutional symptoms appear and pro- ceed their course, even when no such exposure is incurred, and when the eruption is either im- perfectly or not at all developed. 29. Viewing, therefore, the nature of the wa- ter of the localities in which pellagra occurs, together with the state of the soil and the wa- ter saturating or inundating the soil, as the chief causes of the malady, it may be admitted that the other agencies, to which so much in- fluence has been imputed by various writers, may in some degree contribute to develop and to aggravate the disease, especially the use of unwholesome food, as of sour or diseased rye bread, or of unripe maize or rice ; dirty and ill- ventilated apartments ; hereditary predisposi- tion ; the depressing passions; privations, mis- ery, and exhausting indulgences. M. Spessa attributes considerable influence to the habit of the poorer inhabitants of passing the even- ings, and even parts of the day during winter, in the dirty and unhealthy cow-houses and sta- bles, by way of escaping from the cold. The effluvium, also, proceeding from the accumu- lated exuviae of the inhabitants and cattle at the commencement of spring and of warm weather; and when these exuviae are exposed and spread upon the soil as manure, and to which the field labourers are more particularly exposed, may not be without its influence, and even exceed that insisted upon by M. Spessa. But, seeing that those persons who are alone affected with pellagra are those only who are much exposed to the agencies to which I have attributed the malady,* the inference that these agencies are the principal causes of it becomes inevitable. 30. It may be further added, that similar causes to those which obtain in Lombardy ex- ist also in the Asturias, where a similar mala- dy prevails. These are extreme poverty, with its attendants, bad and insufficient food ; filth ; crowded and ill-ventilated apartments ; and agricultural pursuits in the deep and swampy valleys of the country. 31. That the malady should first appear, and be aggravated during spring and summer, can be accounted for by the exposure of the sub- jects of it at this season to its chief exciting causes, and to the influence of labour, conjoined with increased temperature, in exciting the cir- culation, and in throwing out, by means of the cutaneous excretion, the morbid materials ac- cumulated in the blood, and disordering vascu- lar action in the digestive organs, in the ner- vous centres, as well as in parts of the cuta- neous surface. 32. VII. Treatment.—It is obvious that the chief means of remedying, or even of checking the progress of this malady, are change of the habits and occupations of those who have be- come subjects of it; change of climate, and re- moval of the several causes and influences to which it has been imputed, and particularly of those upon which I have above insisted on. The circumstances in which those are placed who become the subjects of pellagra very generally preclude the adoption of these measures, which, however, can be but of little avail at an advan- ced stage and confirmed state of the malady. When the nervous and constitutional symptoms are fully developed ; when the cutaneous erup- tion is constant, extensive, and severe, and is attended by a peculiar, offensive effluvium or perspiration ; when affections resembling or ap- proaching to those of either chorea, convul- sions, tetanus, epilepsy, palsy, mania, or mel- ancholia appear ; or when severe diarrhoea, or dysentery, or marasmus, or dropsy, or pulmo- nary disease occur, then removal or change of occupation, or medical treatment, is very rarely of avail; and even at an early stage medicines can produce but little benefit while the patient continues to be subjected to the several circum- stances and influences originating the malady. In addition to wholesome and nutritious food, alterative, tonic, and antiseptic articles should be prescribed, aided by warm bathing and di- aphoretics. The alkaline carbonates taken in tonic infusions, or in demulcent and bitter de- coctions, or with emollient and narcotic sub- stances, are generally of service ; but the treat- ment should vary according to the various prom- inent affections which complicate the advanced stages of the disease. 33. For the affections of the digestive canal the decoction of Iceland moss ; various emoll- ients, with or without opiates or Dover’s pow- der ; fomentations and embrocations on the abdomen, and emollient and anodyne injections are requisite. 34. Affections of the brain and nervous sys- 64 tern, during the progress of this malady, admit not of a recourse to lowering means. In but few cases can local depletions even be prescri- bed with advantage ; but, while tonics, anti- spasmodics, and alteratives, conjoined with anodynes, as circumstances may suggest, are administered, blisters may be applied to, or is- sues or setons inserted in, the nape of the neck ; or even small bleedings in the more acute ca- ses may be directed from this situation or be- hind the ears. In most of the nervous affec- tions appearing in the course of pellagra, the preparations of opium, taken with camphor, or ammonia and aromatics, are of essential ser- vice, but chiefly as palliatives. 35. For the cachectic habit of body and cu- taneous affection, alkalies and alkaline carbon- ates with sarsaparilla, particularly the compound decoction, in large quantity, or with antimo- nials ; sulphureous warm baths, followed by frictions ; milk diet, and attention to the sev- eral secretions and excretions, using those means which are most serviceable in improving and promoting them, are the measures which promise the greatest amount of benefit, which, however, can rarely be attained without the re- moval of the causes which occasion the disease. Even in an early stage of the disease, while these continue to operate, and at an advanced stage even, when these are removed, medical treatment is generally of little or only of tem- porary avail, at least as far as it has been em- ployed by the Italian physicians. Biblioq. and Refer.—F. Frapoli, Animadversiones in Morbum vulgo Pellagram appell., 8vo. Mediol., 1771.— Odoardi, D’ una Spezie particolare di Scorbuto, &c., 4to. Venet., 1776.—M. Gherardini, Della Pellagra Descrizione, 8vo. Milano, 1780.—G. M. Albera, Trattato delle Malattie dell’ insolato di Primavera, volgarmente dette della Pella- gra, 8vo. Varese, 1781.—C. Strambio, De Pellagra, Ob- servat. in Nosocomio Pellagrosorum faette, 4to. Med., 1785 ; «t Dissertazione sulla Pellagra, 8vo. Milan, 1794.—Jansen, in Frank, Delect. Opusc., t. ix.—F. Fanzago, Memoria so- pra la Pellag. del Territ. Padovano. Padov., 8vo, 1789.— J. Videmar, De quadam Impetiginis Specie, vulgo Pell, nun- cupata, 8vo. Med., 1790.—P. Dellabona, Discorso Compar- ative sopra la Pellagra, l’Elefantiasi, e lo Scorbuto, 8vo. Venet., 1791.—L. Soler, Osservazioni che formano la Sto- ria estatadi Pellagra, 8vo. Venet., 1791.—M. Thierry, Ob- servations de Physique et de Mddeeine en Espagne, 8vo. Paris, 1791.—S. C. Titius, Oratio de Pell. Pathologia, in Frank, Del. Opusc., t. xii.-—C. Allioni, Ragionamento sopra la Pellagra, 8vo. Turin, 1795.—Leraches de la Freutrie, Recherches sur la Pellagre, 8vo. Paris, 1805.—G. Cerri, Trattato della Pellagra, 8vo. Milauo, 1807. — J. II. G. Schlegel, Briefe einiger Aertze in Italien, ueber das Pella- gra, 8vo. Jena, 1807.—G. B. Marzari, Saggio Medico-po- litico sulla Pellagra, 4to. Venez., 1810 : et Lettere al Dr. Thierre sulla Pellagra, 4to. Treviso, 1812.—A. Boerio, Storia della Pellagra nei Carnovese, 8vo. Torino, 1811.-— G. Cerri, Osservazioni intorno all’ Saggio sulla Pellagra di Marsari, 8vo. Milano, 1811.—V. Chiarugi, Saggio de Ri- cerche sulla Pellagra, 8vo. Firenz., 1814.—F. Fanzago, Memorie sulla Pellagra, 8vo. Pad., 1815; et Istrusione Catechistica sulla Pellagra, 4to. Venez., 1819.—H. Hol- land, in Transact, of Med. and Chirurg. Society of Lond., vol. viii., p. 317.—G. M. Zechinelli, Aleune Riflessioni sullo Statodello Pell., &c., 8vo. Pad., 1818.—G. Di Filippi, Me- moria sulla Pell., 8vo. Nap., 1819.—Jourdan, Diet, des Sci- ences Medicales, t. xl., art. Pellagre.—G. B. Marsari, Della Pell, e della Maniera di estirp. in Italia, 4to. Venez., 1819.—/. C. Strambio, Natura, Sede, e Cagioni della Pell., 8vo. Milano, 1820.—Lagneau, Diet, de Mdd., t. xvi., art. Pellagre.—A. A. Spessa, in Annali di Omodei, t. lxiv.—/. Johnson, Change of Air in pursuit of Health. An Excursion through France, Switzerland, and Italy, in 1829, &c.., 8vo. Bond., 1831, p. 75.—Briere de Boismont, De la Pellagre at de la Folie Pellagreuse, 8vo. Paris, 1834.—W. Kerr, Cy- clop. of Pract. Med., vol. iii., p. 262.—Rayer, Diet, de Med. et Chirurg. Prat., t. xii., art. Pellagre; and Theoret. and Pract. Treatise on the Dis. of the Skin. Trans, by R. Wil- lis, 8vo. Lond., 1835, p. 1162. [Am. Bibliog. and Refer.—American editions of Caz- enave, Rayer, and Plambe; also, Worcester on Diseases of the Skin.] PEMPHIGUS—Description of. PEMPHIGUS.—Synon. IIeptpilj, rreptpcyog (a small blister or bubble), nvperoc Hippocrates and Galen. Pemphigus, Sauva- ges. Febris Bullosa, Vogel. Bulla, Bullosa Febris, Morton. Hidroa, Piso. Pompholyx Willan and Bateman. Typhus vesicularis, Young. Emphlysis Pemphigus, Good. Febris vesicularis, Febris Pemphigoi- des, Auct. Fi'evre Bulleuse, F. vesiculaire, Fr. Wassenblasen, Blasenfteber, Germ. Penjigo, Ital. Vesicular Fever. Classif.—3d Class, 3d Order (Good). 4th Order (Willan). IV. Class, IV. Order (Author). 1. Defin.—An eruption of transparent or yel- lowish bulla of considerable size appearing in cir- cular or oval erythematous patches, nearly corre- sponding in diameter with their bases; termina- ting by effusion of the fluid they contain, and by the formation of lamellar incrustations, or by exco- riations. 2. I. Description.—The various appearan- ces assumed by this eruption have led to vari- ous divisions and denominations of it, according to the mode of its eruption (Pemphigus simul- taneus, P. successivus)—to the number of the bullag (P. solitarius, P. confluens)—to the great- er or less rapidity of their course (P. acutus, P. chronicus)—to the existence or absence of fe- ver (P. pyreticus, P. apyreticus)—and to the age of the patient (P. congenitus, P. infantilis). I agree, however, with Rayer, Cazenave, and Wilson, in the propriety of considering this eruption under the two heads of acute and chronic. 3. i. Acute Pemphigus.—P. acutus, Febris bullosa, F. Pemphigoides, F. Synocha cum vesic- ulis, Auct.—This is a rare disease. The bullae almost always stand apart, or are distinct. They are rarely confluent, and they usually ap- pear in succession. They may be partial or more or less general, and may occur on any part of the body, but most commonly on the lower extremities ; occasionally, however, also on the arms, the trunk, and the face ; most rarely on the soles of the feet, hairy scalp, and genitals. 4. a. The constitutional symptoms vary from a slight degree of languor and listlessness, sometimes of sickness and general uneasiness, followed by quick pulse and mild fever (Pom- pholyx benignus of Willan), to chilliness or rig- ours followed by a dry and hot skin with pru- ritus, by pains in the head and limbs, nausea, thirst, anorexia, tenderness at the epigastrium, very rapid pulse, sore throat, and even slight delirium. In some cases the fever is attended by irritation of the mucous surface of the di- gestive, respiratory, or genito-urinary organs. 5. b. The eruption usually appears the second or third day from the commencement of the constitutional disorder, or even later, in the form of small red spots, preceded and attended by pruritus, and a parched and hot sensation. The spots increase to circular or oval erythema- tous patches, varying in redness from a pale to a vivid or dusky tint. In the course of a few hours a vesicle arises in the middle of each patch, and becomes rapidly distended by a lim- pid serum, and increases to the size of a hazel- nut, or even of a large walnut. The bullae, or blebs, which thus arise are usually circular oi oval, and slightly flattened at their summits PEMPHIGUS—Description of. 65 They generally correspond with the breadth of the patches on which they appear, and thus conceal them ; or they are somewhat smaller than the patches, which thus show around them as a narrow zone, more rarely as a complete areola. The bullae usually break in a day or two, and expose an excoriated surface, secre- ting for a few days longer a serous fluid, which concretes into a thin, yellowish scab, and be- comes gradually browner and dark ; but they sometimes do not burst, and in this case the serum contained in the bullae assumes an am- ber or yellowish tint, subsequently turbid and opaque, diminishing in quantity by evaporation, shrivelling and drying up, in the course of a few days, into a thin, dark scab. The rupture of the bullae, and the time when it occurs, depend upon the situation of their eruption. In about three weeks the scabs fall off, leaving the skin beneath of a dusky red hue, but sound. 6. Bullae are occasionally imperfectly devel- oped, and appear in the form of circular or oval patches, slightly red and prominent. On pass- ing the finger over their surface, the cuticle is felt loosened by a slight effusion of serum be- tween it and the dermis. The cuticle is de- tached after a few days, exposing a red spot, covered by a thin and shining epidermic layer. 7. The duration of the disease depends upon the mode of eruption ; if this takes place at once, it is no longer than just stated, or from seven to fourteen days ; but if the bullae appear successively, it is longer accordingly, or from three to four weeks. Mr. Wilson remarks that, in the progress of the cutaneous eruption, vesicles are not unfrequently observed on the mucous membrane of the mouth. 8. When the disease is confluent, two or more of the bullae unite and form a bleb as large as a hen or a goose egg. In these cases the con- stitutional symptoms are more severe, and are sometimes attended by irritation of most of the mucous surfaces. 9. c. This disease sometimes affects children —Pemphigus infantilis—P. gangrenosus of some writers—and sometimes assumes a very seri- ous or even fatal appearance. But this severe form occurs chiefly in lying-in hospitals, or in the crowded, dirty, and ill-ventilated dwellings of the poor. In the cases which I have seen in infants the bullae were numerous, more frequently dis- tinct than confluent, and, in a few instances, presenting many of the characters of rupia es- charotica, but assuming much more acute fea- tures, and even terminating fatally in four or five days. When it occurs in lying-in hospi- tals, it may present a mild form in some cases, and a very acute and dangerous form in oth- ers, even in the same ward and at the same time. It then manifestly proceeds from local causes: from the states of the beds and bed- clothes, and the air of the wards. 10. d. Solitary Pemphigus—P. solitarius of Willan—is very rare. I have seen only one case of it. The bulla rapidly attains the size of an orange. It is preceded by disagreeable sensations of tingling and smarting. The bul- la breaks in about forty-eight hours, and is suc- ceeded by a superficial excoriation, passing into slight ulceration. One or two days after the disappearance of the first bulla another arises in its vicinity, and pursues the same course as the preceding. In this way, two, three, or even more may appear in succession, the dis- ease being prolonged to several days’ duration. Willan says that this variety very rarely oc- curs, and seems only to affect women. The case I saw was in a man, and occurred on the lower extremity. Biett and Cazenave men- tion a chronic state of this variety. 11. e. Acute Pemphigus may occur as a com- plication or sequela of eruptive fevers, or be as- sociated with other eruptions, as with herpes, and more rarely with prurigo. Mr. Wilson re- marks that the small bullae of pemphigus bear considerable resemblance to the vesicles of herpes phlyctenodes ; and the likeness to her- pes is still farther increased by the occasional appearance of the smaller bullae of pemphigus in the form of rings. [The following case of pemphigus, from Gi- bert, gives a very correct idea of the acute and accidental form of the disease : “A man of sanguineous temperament, 21 years of age, in the habitual enjoyment of good health, went out hunting on the 8th of Septem- ber, 1811, in the marshes of Bresse, and got, several times, up to his knees in water, being exceedingly fatigued, and in a state of great perspiration. On the following evening a gen- eral heat manifested itself, preceded by shiver- ing, and accompanied by pain in the head, and thirst, increasing towards night. The second day, after a remission in the morning, the fever became greater towards the afternoon. The third day the face was more highly coloured, the skin burning hot, the pulse hard, quick, and incompressible. Pricking and itching sen- sations in the inferior extremities, which ap- peared slightly swollen, and of a deeper colour than the rest of the body. During the night, restlessness, extreme agitation, heat, and lan- cinating pains in the legs. The fourth day, the inferior extremities, swollen from the knees to the toes, were covered with red patch- es, upon which were raised vesicles (bullae), transparent, of a yellowish white, full of serum, some the size of nuts, others that of almonds, and many merely that of pease, unequally scat- tered, smaller and more numerous on the feet and malleoli, larger and fewer upon the upper part of the legs. All the red patches are not yet covered with vesicles ; on some the epider- mis is scarcely, or not at all, raised. They formed a slight prominence, their colour not disappearing on pressure. Those which had vesicles in their centre were surrounded by a red areola, w'hich became narrower as the ves- icle extended itself. Between each of these patches the skin preserved its natural colour. The pulse, full and incompressible, beat less quickly than the previous evening; the eyes became painful, slightly red and watery ; the tongue dry and whitish; the bowels costive ; the urine high-coloured, and scalding. The other functions were unimpaired. Passed a comfortable night, and slightly perspired. The fifth day many of the vesicles increased in size ; some on the calves of the legs became confluent. The sixth day, the larger eleva- tions became less full; the epidermis shrivel- led, and the fluid which they contained accu- mulated in the most depending part, when it dried up on their spontaneous or accidental rupture. During the seventh and eighth days, most of the vesicles, faded and shrivelled, 66 spontaneously opened, and poured out a quan- tity of yellow, inodorous, limpid serum, leav- ing their bases exposed, which formed large, red, and painful excoriations, and continued to ooze out a serous fluid for some period. The smaller vesicles did not break, but faded and dried up, becoming wffiite and opaque. The red areola, at the same time, became obscure, and at length disappeared. From the eighth to the tenth day all the scales dried up, and were replaced, some by large, thin, yellowish scales, others (those which were not evacu- ated) by more thickened crusts. On the falling off of these concretions, which took place in two or three days, there remained upon the skin bright, shining, wine-coloured patches, but without any depth of cicatrix. The se- verity of the fever was arrested after the de- velopment of the eruption ; it then became very slight, and returned no more after the sixth day. The urine then became turbid and deposited a considerable sediment. On the seventh day the bowels were relaxed, the stools being thin and frequent; they soon, however, became natural. For the first six days the patient did not leave his bed ; on the seventh he left it, and made a good meal with- out any inconvenience resulting therefrom.”] 12. ii. Chronic Pemphigus.—-Pompholyx di- utinus■, Wii.lan — Phlyclenoide confluente, A li- re rt—is met with much more frequently than the acute, and appears much oftener in adults and aged males than in females. It is either limited to a small surface, or spreads more or less over the body. It is painful and tedious in its course, always successive in its appear- ance, and affects chiefly persons advanced in age and of debilitated constitutions. It often continues for many months or even years, and in some cases appears at a particular season for several successive years ; for instance, in the autumn and winter, and declining in the spring. 13. a. The constitutional symptoms of chronic pemphigus are slight compared with those of the acute ; some degree of sickness and lassi- tude, with pains in the head, back, or limbs, precede the eruption during several dayst and these symptoms generally vary in degree with the severity or extent of the eruption. The cutaneous disease is often associated with considerable gastro-intestinal irritation ; and in aged persons, and in cachetic habits, it is sometimes attended by dysuria or haimaturia. 14. b. The eruption appears first in the form of small red spots, attended by slight itching. The epidermis soon becomes elevated in the centre of each patch. The base of the eleva- tion of the cuticle gradually extends ; and of- ten in a few hours an irregularly shaped bullae, the size of a filbert, or even of a walnut, is thus formed. Sometimes the bullae attain the size of an egg. At the end of three or four days some of the bullae burst, discharge their con- tents, and leave an angry-looking excoriation of the dermis. In others of them, the serum becomes reddish and turbid, decreases, and dries up,, forming a dark scab covered by the shrivelled epidermis. As one crop of bull® is thus changed, another is produced near to the first; and the disorder thus may be seen in all its stages at the same time, and be prolonged, by successive eruptions, almost indefinitely! PEMPHIGUS—Description of. The bullae are occasionally confluent, especially when they appear on the face ; but this seldom occurs. They sometimes attain the size of the palm of the hand, the epidermis peeling off and exposing an unhealthy-looking excoriated surface, which seems difficult to heal, or which heals in two or three days, new bullae forming and pursuing the same course as the former. In some severe cases the patient is confined to bed, but there is rarely any fever. 15. c. Chronic pemphigus may be complicated with prurigo—Pompholyx prurigenosus of Wil- lan—and with various chronic diseases of the viscera, and in such cases may terminate fa- tally. It sometimes supervenes on chronic in- flammation of the digestive organs, and on partial or general dropsy. When complicated with prurigo, it is often a most distressing af- fection, and in old persons especially may hasten a fatal termination, particularly if vis- ceral disease be also present, as commonly ob- served. [The following case from Gibert was called eczema in the first edition of his work, on the “ Special Diseases of the Skinit is a good example of pemphigus diutinus, or the chronic variety of the disease : “On the 26th of August, 1818, a woman 33 years of age was entered at the Hopital St. Louis, tainted with a general cutaneous mala- dy, which developed itself without any appre- ciable cause, and had lasted for 19 months. The commencement of this disease had been characterized by a bullous eruption, accom- panied with itching; but for some time pre- vious to her admission it had resembled the form of squamous dartre, herpes squamosus ma- didans of M. Alibert. The patient, whose skin constantly exhaled a fluid which pene- trated and stained her linen, experienced no pain in a state of repose, except in the parts on which the weight of the body rested ; but walking was impossible on account of the pain- ful friction which it occasioned. For many months past the catamenia had not appeared. The whole surface of the body, with the ex- ception of the palms of the hands and the soles of the feet, was covered with large, round, yellowish squamas, under which the skin was rose-coloured, or even of a bright red. There was an abundant secretion of a slightly yel- lowish fluid under the squamae, in many points. The hairy scalp was the seat of a desquama- tion which formed drier and more delicate scales; the sub-cutaneous cellular tissue of the neck was swollen, the skin being red, cracked, and shrivelled ; the eyelids were red and deprived of their lashes. The mouth was dry, the tongue very red; it presented in the centre a slight coat of yellowish brown ; nev- ertheless, the appetite and the digestive func- tions appeared unaffected. The pulse was slightly accelerated, the patient felt very weak, and had a slight cough. Laxative drinks hav- ing been exhibited for some days, gave rise to a slight purging; fever broke out, though in a very slight degree ; the marasmus and weak- ness gradually increasing, the patient sank into an adynamic state, after 19 days of treat- ment and about 20 months of disease. “ On opening the body we found old adhesions in the chest, and some miliary tubercles in the tw'o lungs (in other respects sound); a secre- tion of calcareous matter in some of the bron- chial glands. Two pints of a citron-coloured serum were effused into the peritoneal cavity, which, besides, presented some old filamentous adhesions, between the parietal and visceral portions of the membrane. The external sur- face of the large intestines, near their concave border, was studded with miliary tubercles. The internal surface of the intestinal canal was, generally, sound, with the exception of some slightly vascular injections in the stom- ach and colon. There was a quantity of yel- lowish-white fluid contained in the intestines, and particularly in the colon. The whole ca- nal w'as shrunk and contracted, and the liver had assumed the fatly appearance: the gall- bladder contained a very small quantity of scarcely-coloured bile. The skin, covered with whitish squamae, had quite lost its redness. This discoloration had already much dimin- ished during life, since the intestinal affection and general debility had made so marked a progress.’’] 16. d. The contagious variety of pemphigus mentioned by Willan — P. contagiosus — is merely the symptomatic occurrence of bullae in certain epidemic and endemic maladies de- scribed by authors. Its endemic occurrence has been observed by me on two occasions among infants in a lying-in hospital, on each occasion nearly all the infants in the institu- tion becoming affected ; but this prevalence was attributable to local causes, and not to contagion. [M. Alibert has given, under the name of dartre phlyctenoide, the following description of chronic pemphigus: “There was, at the Hdpital St. Louis, a commissioner, named Pierre Roger, about 60 years of age. He was attacked with a dartre phlyctenoide. It showed itself under the form of scattered pustules (bullce) of the size of a nut, upon the trunk, also upon the anterior and posterior parts of the right shoulder, as though a scarf had been worn. The inner side of the arm was equally affected ; the neck also, and the hairy scalp. These vesi- cles, filled with a transparent fluid, shrank, shrivelled up, and spontaneously broke, leav- ing the reticular tissue exposed. Some days after the drying up of the eruption the skin presented red patches, as if it had been burned with fire or with concentrated nitric acid. The itching was not very urgent, but there was a most uncomfortable feeling of tension over the whole skin. I noticed that all this super- vened on a discharge of blood from the rec- tum. This man had been for a long time ex- posed to the vicissitudes of the season, and had been unable, owing to his distress, to pro- cure himself even the necessaries of life. “ The same author has described under the same name a fatal case of pompholix diutinus. “ Anne Brundomy, 57 years of age, presented herself at the H6pital St. Louis for treatment. She had suffered violent grief at the loss of her husband. One day, after having experi- enced some digestive disturbance, she was attacked with a spontaneous vesicular (bul- lous) eruption, which gradually extended over the whole surface of the integuments. These vesicles (bullae) were oval, and multiplied so rapidly that they soon became confluent: they PEMPHIGUS—Diagnosis and Prognosis of. were not surrounded by any inflammatory are- ola. The eruption was accompanied by a gen- eral feeling of intolerable smarting and burn- ing, which became less after it assumed a fa- tal aspect. Phlyctcence formed on the mucous membrane of the mouth, aesophagus, and whole intestinal tube. The patient had a sensation of burning coals moving about in the intes- tines : she remained in this wretched state for 19 months, and at last sank, presenting for the last 15 days of her life all the symptoms of continued adynamic fever.”] 17. e. The morbid appearances found in fatal cases are entirely those constituting the com- plications, and usually causing the fatal issue of this affection. M. Biett and Cazenave have often met with fatty liver in their exam- inations of these cases, with effusion of serum into the chest and other shut cavities. [It has been stated that blebs, or bullae, have been met with on the mucous membranes, and particularly on that of the pharynx of those persons who have died of this affection, hut this is of very rare occurrence. On the.con- trary, these membranes will be generally found pale.] t 18. II. Diagnosis.—The bullce which occa- sionally appear during the progress of erysip- elas are accidental, and are to be distinguished from those of acute pemphigus by the latter being distinct, the surfaces between them be- ing neither tumid, nor red, nor painful. The isolated form of the bulla? and the laminated crusts which they form generally distinguish pemphigus from other eruptions. The bullae of rupia simplex are exceedingly few, and ter- minate in ulcerations and in thick prominent scabs. In ecthyma the epidermis is sometimes raised by puriform fluid to a certain extent; but the purulent nature of the containe.d mat- ter, the brownish appearance of the apex of the elevations, and the presence of pustules of ecthyma at an earlier stage, will sufficiently distinguish the eruption. In herpes the vesicles are always formed in groups upon a red and inflamed surface; while the bulla? of pemphi- gus are generally isolated, and free from sur- rounding inflammation. Even wrhen the bul- lae of pemphigus are small and confluent, so as somewhat to resemble herpes phlyctenodes, they are always larger than those of herpes, and some of them present their distinctive charac- [It is generally easy to recognise pemphigus, if we except the chronic form of the disease, which somewhat resembles chronic impetigo, or even pityriasis, in its foliaeeous desquama- tion. When it is chronic, and the bullae are imperfectly developed, and particularly when there are nothing but squamous vestiges, or even consecutive stains, to establish a diagno- sis, it requires some care and experience to distinguish the disease. In some instances it has even been simulated by placing small quan- tities of powdered cantharides on the limbs.] 19. III. The Prognosis of acute pemphigus, when occurring in adults, and without any com- plication, is always favourable. When met with in infants, in the circumstances above no- ticed (§ 9), it is often a serious or even dan- gerous disease. The prognosis of chronic pem- phigus should depend upon the constitution of the patient, and upon the existence of visceral 67 68 disease. When it is extensive or frequently developed, and affects those debilitated by dis- sipation or poverty, or when it is complicated with visceral disease, an unfavourable opinion of the result should be entertained. Its sever- ity usually corresponds with the cachectic state of the body affected by it. M. Rayer adduces a case in which chronic pemphigus of the legs, following attacks of haemoptysis, appeared to exert a salutary influence. Where there is ob- vious visceral disease complicated with this eruption, the cure of the latter will aggravate and increase the danger of the former. Mr. Wilson remarks that he has seen several ca- ses which have induced him to u believe that this eruption is an effort of the system to rid itself of some morbid disposition.” I may add, that I have hardly seen a case in which there was not reason to infer, what I have elsewhere so much insisted on. a more or less morbid state of the circulating fluids, owing either to impaired elimination and excretion, or to im- perfect assimilation. 20. IV. Causes.—Acute pemphigus attacks infants, children, and young persons most fre- quently. ,It has been said to be congenital and hereditary. It is most prevalent in the sum- mer, and in those exposed to the sun’s rays. I have often seen it in sailors who have exert- ed themselves under a tropical sun without any covering to the upper parts of the body. It is usually referred to teething ; to improper or unwholesome food ; to gastric and intestinal irritation; to over-feeding; to mental emotions; and to amenorrhcea and dysmenorrhcea. It has sometimes resulted from the constitutional ir- ritation caused by vaccination. The endemic sources to which infants are sometimes expo- sed have been already noticed (