29.-CASES ILLUSTRATIVE OF THE TREATMENT OF PARALYSIS BY THE APPLICATION OF COLD OR HEAT ALONG THE SPINE.

By Dr. JOHN CHAPMAN, Physician to the Farringdon General Dispensary.

Case of Apoplexy with Hemiplegia.-On December 3, 1864, I was called to see a gentleman, aged 55, whom I found in a state of profound stupor; he could not be roused, the right arm and leg were paralysed, the leg less completely so than the arm. When the hand was pinched severely there was no evidence of sensibility; the left hand was of a markedly dusky hue, the nails being slightly purple; the temperature of the left side was considerably lower than that of the right, and the pulse which was 82, was much feebler at the left than at the right wrist; the head was hot; both eyes were closed, the left one being protruded abnormally and slightly lachrymose; the face was drawn to the left side.

I applied an 8 inch spinal water-bag, containing water at 120° Fahrenheit, to the cervical and upper dorsal region of the spine. This bag was ordered to be refilled at frequent intervals, so that the application of heat might be continuous during the day or whenever the head should be found hotter than natural. A spinal ice-bag was also ordered to be applied at once during three-quarters of an hour to the lower third of the spine, and to be repeated the same afternoon. In less than twenty minutes after the hot-water bag was first applied, the head had become much cooler than before, and within twelve hours some degree of returning consciousness was evinced. The treatment was modified according to symptoms as the case progressed. patient steadily improved day by day. At the end of a week he was talking with facility; on the 23rd of the next month be walked between one and two miles two days in succession, and in February he called upon ine, and reported himself quite well, and impressed me as being so both mentally and physically.

The

December 3rd, 1865, exactly a year after the date of the above mentioned attack, I was called to this patient again. On the previous day he became suddenly giddy and incapable of standing. Shortly afterwards he vomited and was relieved, but his speech, which was previously perfect, had become much impaired, and immediately before I was summoned he suddenly lost the power of speech, his eyes becoming, as his wife said, "fixed and glassy." Ice was applied to the spine and benefited him considerably. I found him much better again, and his speech, though greatly impaired, was intelligible. I ordered ice to the lumbar region 45 minutes at eight p.m., a saline mixture and light food.

After passing a good night, vomiting came on at 5.30 a.m.; consciousness and the mental faculties were greatly impaired, and the power of speech was so far lost that he was quite unable to make himself understood. Ice was applied at nine a. m., and at ten a.m. I saw him, when he had somewhat improved; he was conscious, and he had recovered his power of speech to a slight extent; but bis mind was dull and confused. The face and tongue were drawn to the left side, and both arms were slightly paralysed. Pulse 76, full and fairly strong in the right wrist, extremely slight and feeble in the left. I requested ice to be applied during thirty minutes every two hours, to the lumbar region; and the water bag at 115° Fahr. to the cervicodorsal region during ten minutes, also every two hours, but alternately with the ice. The saline mixture was continued ; and the patient was nourished with beef-tea. In the course of two days he was very greatly improved in all respects; the heat and cold were then applied at more distant intervals, and on the following day (December 7), I found the head clear, the speech fairly recovered, and the pulse in the left wrist much increased in strength and volume. The use of heat was then discontinued; and I requested the ice-bag to be applied along the lower two-thirds of the spine half-an-hour, and the saline mixture to be given three times a day. By the 21st of the month the patient had quite regained his former health: his mind was clear, his speech distinct and normal; his face symmetrical, and his pulse in the left wrist as strong as that in the right. The medicine was discontinued, and the ice after being applied once daily until the 26th, was left off at the request of the patient, who, at that date, took a long walk alone.

Case of Apoplexy, with Hemiplegia.—On March 14th, 1865, I was called to a patient at Brighton, a stout woman, aged 60, who, in the afternoon of the previous day, being excessively flushed, with a dull heavy expression, staggered towards her bed and fell down senseless. The physician, who was immediately called in, said she was dying. He stayed with her until three o'clock of the following morning, and, on leaving, sent a woman to "lay her out. As stated by a spectator, "she gasped, seemed to breathe only at intervals, was blue round the mouth, clayeylooking; the whole features seemed to sink; her head, shoulders, arms, and legs were quite cold, and her face was covered with clammy sweat." She remained in this state during forty-eight hours. At the end of this time I visited her. The head and face were strikingly cold and death-like; the eyes exuded a thick gluey fluid; the left pupil was dilated and immoveable in the presence of light, the right pupil was contracted; the right side was more dusky, and somewhat colder even than the left; the face was drawn to the left side.

On tickling the soles of the feet, there was a slight movement of the left foot; none of the right.

In the treatment of this case, my efforts in the first instance were directed to produce alternate contraction and relaxation of the cerebral blood-vessels, in order to effect movement of the stagnant blood within the head. Accordingly, I applied heat on each side of the upper third of the spine for a few minutes, then removed the bag, while still hot, and shortly afterwards re-applied it. Within fifteen minutes of my first application to the spinal region, an area of about two and a-half inches in diameter in the middle of the forehead became quite warm. Before twelve hours had elapsed, the whole head and face became warm; and within twenty-four hours, or by the evening of the 16th of March, her whole body was warm. On this day she saw a cup of beef-tea in the hands of an attendant, and opened her mouth as if asking for it. The same evening she was believed to have recognised her daughter. From that date she steadily progressed in intelligence, so that by the end of the month she appeared to understand all that was said to her, could appreciate a joke, and could answer questions by monosyllables. She began to gain some power on the paralysed side, and, as the weeks passed, her improvement in intelligence and power of expression gave promise of her ultimate recovery, though, of course, with the probability that she would continne more or less hemiplegic. She lived about three months; but, unhappily, owing in part to the neglect of her nurse, sloughing over the sacrum came on unperceived, pyæmia followed, and proved fatal.

In both these cases the great therapeutical efficacy of the spinal hot-water bag was signally manifested. One of the sons of the first of the two patients, a very intelligent young gentleman, who sat up at night with his father, expressed himself much astonished by the power of the water-bag in reducing the heat of the head, and volunteered the statement that when his father's breathing was stertorous, the application of the bag speedily caused it to become quite tranquil. I may add here that, in the case of a patient under my care, who is liable to become unconscious by reason of a great and sudden afflux of blood to the brain, the application of this bag at a temperature between 115° and 120° Fahrenheit, will invariably cause the hot head to become cool, and simultaneously consciousness

returns.

It will be observed that I applied heat to the upper portion of the spine, and cold below, at the same time, in the first of the two cases just reported; and I may add that, in the second case, I often had occasion to do the same. The simultaneous application of heat above and cold below, or the reverse, so far from

resulting in the neutralization of the effects of the one by the other, actually augments greatly the force of each. For example, while heat to the upper third of the spine effects the contraction of the cerebral arteries, and so lessens the amount of blood in the brain, cold along the lower third of the spine, by causing the dilatation of the arteries of the pelvis and lower extremities, increases the amount of blood in those parts, and, therefore, to a proportionate extent, derives it from the chest, upper extremities, and brain. Hence, if I wish to exercise only to a moderate extent a sedative influence on the brain, I apply the lumbar ice-bag; but if I wish to act more vigorously, I apply the double-column hot-water bag to the upper third of the spine; if more vigorously still I use the two simultaneously. The two cases just described afford most satisfactory illustrations of the unprecedentedly great remedial power in cases of apoplexy which this method of treatment affords. Of course, the sooner after the "stroke" treatment is adopted, the greater will be its efficacy. My experience, however, enables me to say, that in cases of paralysis of several years' standing, great good may be often be done by means of these spinal applications. In the appendix to my pamphlet on "The Functional Diseases of Women," I published a case, the chief features of which are as follows:

Case of Chronic Hemiplegia, with rigidity of the left upper extremity, coldness of the paralysed side, headache, dorsal hyperaesthesia, and constipation.-A boy, aged 13, afflicted with hemiplegia (left side), was brought to me June 1, 1863. At this date I made the following notes of his condition :-Has a florid complexion, looks healthy, and is very intelligent. Complains chiefly of being unable to use his left arm. He cannot raise it above his head, as he can the right one-being unable to lift the hand higher than the face. The fore-arm cannot be completely extended, and is firmly fixed in the prone position. The wrist and hand are not only powerfully drawn to the ulnar side, but so firmly flexed on the fore-arm as to resist whatever extending force the patient can apply with his right hand. If by additional external force they be brought into a straight line with the fore-arm, immediately they are released from it they return to their abnormal position. The metacarpal bone of the thumb is strongly adducted and held (immovable by the patient's will) in the palm of the hand. The four fingers are permanently bent inwards, the middle one being flexed over the end of the thumb and deeply indented by the thumb-nail. The third phalanx of the index finger bends backwards on the application of the slightest pressure, and is incapable of offering any resistance that fasciculus of the flexor profundus digitorum, which converges into the tendon of this finger, being paralysed.

The whole upper extremity of the left side is considerably shorter and smaller than that of the right. The left leg is also shorter and thinner than the right, although the arrest of growth has been less in the leg than in the arm. The patient cannot stand on the left leg, and when he attempts to extend it completely, he feels a stiffness at the top of the calf. If he places the heel on the ground, and then lifts up the forepart of the foot, it immediately drops-he cannot sustain it. He can bear no weight on the fore-part of the foot, and cannot bend his toes either upwards or downwards, except in a very slight degree. The tendo-Achillis has been divided. The right pupil is slightly the largest; the tongue deviates to the left side. The patient suffers from frequent and long-continued headache, on an average three times a-week; if he gets up with it, it lasts all day. His back is peculiarly sensitive; he bursts into hysterical laughter the moment it is touched. The whole of the left side is habitually cold. Bowels constipated: not opened oftener than every other day. The patient's malady originated, his father says, in a fall on his left side when he was six months old. From this time the elbow was observed to be slightly bent, and the forearm always pronated. In his twelfth month the weakness was first noticed in the leg. In his third year he was taken to L'Hopital des Enfants Malades at Paris; then to "a private doctor," who bandaged the arm and hung a weight to it; he subsequently attended the Orthopaedic Hospital in London, where, in addition to other treatment, by galvanism, &c., the tendo-Achillis was divided; and, finally, he was a patient during two years at another Metropolitan Hospital.

My treatment of him consisted mainly in the application of ice along the spine, the only other measures adopted were, washing him all over every morning in cold water; clothing him in flannel down to the wrist and ankles; rubbing the back and paralysed side; galvanism as mentioned below; and making frequent efforts to supinate the fore-arm.

The patient's headache ceased from the time the ice was applied. By the 8th of June, the left arm and leg became quite warm; by the 15th, the bowels had become open daily, the preternatural sensitiveness of the back had ceased, and when the left heel was placed on the ground, the fore part of the foot could be held up during at least five minutes.

As early as July 14, the power of the whole left arm, either for movement or lifting objects, had greatly increased; the hand was much less flexed and drawn to the ulnar side than formerly; the metacarpal bone of the thumb, which even a fortnight before needed a good deal of external force to draw it from the palm, could then be abducted by the will of the patient himself; he could open the fingers, and extend them completely;