ments which regulate the calibre of the vessels and their corresponding afferent nerves. If, now, we suppose there is a nerve which conveys to the sensorium the state of the muscle, and if the ordinary sensory nerve is composed of four different filaments, according to the several varieties of sensation already mentioned, we shall have described ten different kinds of fibres. I am not quite sure about the eleventh, but I think it is said that if any branches of a nerve supply a gland it is supposed that a specially appropriate filament is required for the secreting office.

These distinct filaments have never yet been demonstrated in every nerve, and there are some who think that there is no need for the supposition of their existence; that, for example, the excito-motor function of the spine is worked through the ordinary motor and sensory nerves; also that the spinal nerves may be influenced through their junction with the sympathetic without supposing that the latter sends distinct fibres to accompany them; and again, that the different varieties of sensation may be only different forms of impression conveyed through the same nerve.

The question of the compound function of nerves is of especial interest in reference to the question of their influence over nutrition. That such an influence does exist there can be no doubt, and the usual explanation is that the nerves have a controlling influence over the blood-vessels, but what exactly is the nature of these nerves and what their origin has not yet been quite ascertained. There are some physiologists and pathologists who see in chemical action all that is sufficient for the production of the changes in the tissues, whilst there are others who are content to speak of cell-growth altogether uninfluenced by nervous forces, and they enforce their statements by illustrations from the growth of plants and some lower animals, to say nothing of the growth of the human embryo itself. Admitting, they say, that nerve force may regulate or control nutrition, the latter must necessarily be independent of it in its actual operation. Those, on the other hand, who see a direct influence which almost amounts to a vital one propagated by a nerve, would illustrate the fact by cases where a nerve has been severed, and an atrophy of the parts below has resulted; or a nerve proceeding to a muscle has been injured, and the muscle has wasted. Also as showing the influence of the nerves on nutrition, there are the cases mentioned by Mr. Hilton, where an angry ulcer has healed on the division of the nerve leading to it, or where an ulcer on the face remained open until a neighbouring decayed tooth was removed. The herpetic eruption following a neuralgia would also seem to imply that the condition of the nerve and that of the tissues in the skin were inseparably connected. Dr. Addison had a notion that the chronic ulcer sometimes met with in young girls was due to nervous irritation and intimately associated with the palpitation of the heart, pain in the side, and other neuralgic symptoms so commonly met with in these patients.

In regarding the question of nutrition, we ought, if possible, to look at it in its integrity, and not, because the bent of our mind is towards one branch of science rather than another, make it either a subject of chemistry or one of physics; for we must be quite sure that the cells, the blood, and the nerves are all working in harmony, to say nothing of the lymphatics, which appear of late years to be left quite out of the question in discussing the various processes of nutrition. One great difficulty in judging of the effects of nerve-influence on nutrition has been due to the varying results of paralysis on the tissues; but this might be used as the strongest argument in favour of the compound character of a nerve, and that just as in one case the vaso-motor filaments are involved in disease, in another they might escape. If, for example, an ordinary compound nerve is divided, the totality of its functions is lost; but should that nerve contain filaments possessing different properties, and which, on reaching the spine, take their own respective destinations, it is clear that disease in different portions of the cerebro-spinal centres may involve only certain portions of the nerves, and thus the various forms of paralysis may be as numerous as there are distinct filaments and functions of the nerves. If, for example, there is loss of

motion without sensation, it is evident that the nerve is only partially paralysed, and if in one case nutrition is affected and not in another, we should suspect that a certain function of the nerve remained in the one case and was absent in the other. Now, it would be highly desirable to ascertain for certain where the vaso-motor filaments have their source, or, if there be not such in ordinary nerves, at what point of the nervous system the motor filaments receive their influence from the sympathetic. Certainly in central cerebral disease, there may be loss of sensation and motion, but nutrition is unimpaired; also in many cases of spinal disease, we observe the same, whereas there are other cases of disease of the cord where wasting of the muscles is most marked. Thus in the disease known as progressive muscular atrophy, the prime cause of the malady has been usually placed in the tissues themselves, because ordinary paralysis was not known to cause wasting of the muscle; but in answer to this, it may be said that some special part of the cord may be affected, and this will probably turn out to be the case. Waller's experiments, however, tend to show that the nutritive nerves do not altogether proceed from the spine, for if the roots of the spinal nerves be divided, the motor branch wastes away, whilst the posterior retains its integrity beyond the ganglion.

In illustrating this subject I would not attach too much importance to many examples which are constantly mentioned in proof of the importance of nervous influence on nutrition, for many of these would bear a different interpretation. Thus, there is the well-known case of the bedsore which so commonly accompanies paraplegia, and which might be used to exemplify the principle; but, on the other hand, it might be said that the inability to move for several days, and thus to relieve the pressure from a particular spot, would be sufficient for the effect, as shown by the restlessness which all people in health experience. The strongest argument in favour of such proposition is that if the patient be placed on his side the most extensive ulcer will often rapidly heal. The same remarks apply to the cystitis which occurs also in the disease. This might be referred to the removal of nerve influence; but, on the other hand, it may be said that the retention of urine causes decomposition, and if the bladder be continually washed the inflammation is prevented. As regards the oft-quoted case of ulcer of the cornea on division or disease of the fifth nerve, it is certain (as I have seen) that the ulcer will heal when the eyelid is closed, and thus all irritant substances prevented from affecting the anaesthetic surface.

The physiological connexion between the spinal nerves and the sympathetic has not yet been fully shown, for in many of the results obtained by passing galvanic currents through the body, it has not yet been ascertained what amount of result has been due to stimulation of the motor nerves or the sympathetic. Thus, in the interesting observations by Remak on what he calls diplegic contraction, the rationale of it is not very evident. He took a case of progressive muscular atrophy and applied one electrode beneath the right ear and the negative electrode outside the sixth dorsal vertebra, and then on closing the current a contraction took place in the left hand. Faradisation appears to produce the same results, and which are thought to be induced by stimulation of the superior cervical ganglion.——— Med. Times and Gazette, Oct. 10, 1868, p. 411.

13.-ON PARALYSIS WITH WASTING OF MUSCLES, ESPECIALLY IN CHILDREN.

By Dr. J. RUSSELL REYNOLDS, Physician to University College Hospital.

The causes of infantile paralysis are numerous, and some of them are well understood, inasmuch as they differ in no special manner from those which are encountered in after life; but there are some forms of paralysis, of which young children furnish the examples, that we cannot refer to the commonly recognised conditions of hemorrhage, softening, tubercle, syphilis, and the like.

[From the fact that nothing beyond the paralysis has been observed, these cases have been sometimes called Essential Paralysis." The following cases illustrate the disease.]

1. Commencement of symptoms.-A. B., a healthy girl, the youngest of three, born of healthy parents, without any premonition of disease of any kind, at the age of nine months “took cold in the head," was feverish, and heavy in manner, for nearly a week, but improved towards the end of that time, and tried to get up. It was seen, however, that she "could not put either foot to the ground," although both of the hands were moved quite freely, and there was no pain nor spasm in the lower extremities. In a very short time she moved and used the left leg as freely and firmly as before the attack of "cold," but the right leg was paralysed, and in the course of a few weeks was observed to be cooler, softer, and smaller than the other.

C. D., a fine boy, the fifth of six healthy children, at the age of four years suffered from some "stomach complaint," was "poorly" for about a week, complained of his legs being "sore," and was found, after keeping his bed for five or six days, unable to stand. At the end of a month he could walk, but, in doing so, dragged his left leg, which was then thinner, softer, and cooler than the right.

E. F., a boy who had "never had a day's illness," the youngest of eleven healthy children, when two years old became fretful, restless, sore all over, and lay on his back; "seemed to lose the use of all his limbs," and could not sit up; was distinctly feverish for a day, but for one day only; he moaned at night; but after a few days he seemed well. At the end of a fortnight he walked, but did so like a much younger child, and it was noticed that he made no use of his right arm-that the arm was thin, and especially so about the shoulder.

These three cases are sufficient to illustrate the ordinary manner in which the paralysis I am describing makes its appearance. The febrile symptoms were slight, and only of short duration; the constitution was good; there was no recognised cause of disturbance-no fall, no blow, no exposure to cold, no obvious external influence nor internal derangement which could account for the phenomena. The age at the onset of symptoms ranged from nine months to four years, and dentition did not appear to have exercised any influence in the production of the malady. In some cases, that have come under my notice after several years' duration, it has been affirmed that there were no febrile symptoms at the commencement, but that the child was suddenly, or accidentally, found to be unable to move any of its limbs, or even to sit up; but it must be remembered that slight accessions of fever are sometimes disregarded at the time, and are wholly forgotten afterwards. The child is put to bed because it is not well, and when it is "better" the paralysis is recognised. Laborde (in an excellent treatise entitled “De la Paralysie dite essentielle de l'Enfance ") states that fever was present in four out of five cases that came under his observation; and where I have been able to learn accurately the previous history there has invariably been some period of distinct but slight and transient illness. I therefore beg you to remember this febrile mode of onset; the fever being of only one or two days' duration, being feebly marked, but continues in type so long as it lasts, and unaccompanied by the vomiting and marked nervous disturbances which, under other circumstances, so frequently characterise its presence in early life. Sometimes, but not more frequently than once in five cases (Laborde), convulsions mark the onset of infantile paralysis; and there is occasionally nothing in their actual phenomena which will enable you to distinguish between them and the fits which may arise from dentition, from worms, and from organic disease of the brain. But usually there is an absence of those symptoms which pertain to organic diseases of the brain; there is no vomiting, no headache, no strabismus, and no spasm of the face. Commonly, the limbs are found rigid after the fit has passed away; sometimes there is but one fit, but more frequently there are two, three, or four. When convulsions are present there is no fever, and vice versa, when febrile symptoms constitute the commencement of the malady there are no convulsions.

The

2. General paralytic symptoms.-When first observed the paralysis is usually at its maximum, both of intensity and extent. It is often generalnot only the muscles of all the limbs, but even those of the trunk are affected; the child can neither stand nor sit up, nor use its arms. lower limbs are more distinctly and more frequently affected than the upper, and it is very rare to find paralysis of the sphincters. Paraplegia is the most common form observed at an earlier period, and this form of paralysis may become persistent; but more frequently the "clearing up," if I may use the expression, of the paralytic state extends beyond the arms, and in a very short time-viz., from three to fifteen days, only one extremity remains affected. One of the lower limbs is more often paralysed than one of the upper; sometimes the right arm and the left leg are weakened; sometimes, but very rarely, there is hemiplegia.

The electric irritability of the muscles is distinctly diminished at the onset, and coolness and wasting of the limbs set in almost immediately.

There is no constant change in the sensibility of the skin, or of the organs of special sense; but reflex movements are sometimes, although not always, abolished in the affected limb.

Paralysis of the kind now described I have occasionally seen in the conition of pregnancy, having its onset in a precisely similar manner-i. c., appearing as general palsy after two or three days of slight febrile disturbance, and then becoming localised in one limb. Apart, however, from pregnancy-which condition bears some strong resemblance in regard of pathological tendency to the state of infancy,—I do not know of any disease in the adult which exhibits the clinical history now detailed. Ordinary wasting palsy, which is unfortunately but too well known, differs widely in its mode of onset, and in the distribution of its symptoms.

3. Stage of limited paralysis.-The paralysed limb wastes, it fails to grow at the same rate as the healthy limb, and thus it often remains withered, smaller, and shorter than its fellow. But long before any difference can be detected in length, or even bulk, there is distinct coolness, flabbiness, and softness. The rapidity with which wasting occurs is remarkable; in the course of a few weeks it is appreciable not only by the hand and the eye, but by the measuring tape. In this disease, as in all others which affect the size of limbs, there is often an amount of malnutrition, that may be quite obvious to the sight and to the touch, which measurements fail to represent; and surprise is frequently felt when a disparity, very obvious to the eye, is recorded in small fractions of an inch. But in the wasting paralysis of children the amount of inequality is often very great, and may be recognised. at once and to the full, by measurement. Thus in C. D., the calf of the right leg was 10 in. in circumference, that of the left only 8 in.; and here there was no shortening of the limb. That the failure of nutrition was mainly in the muscles was indicated by the fact that the right ankle was 74 in. in circumference, the left 7 in. Where the muscles were involved the diminution on the paralysed side was of the circumference; where the muscles were not included the difference was only of the circumference. In the same case there was obvious wasting in the left gluteal region, but it is impossible for me to tell you how much wasting there was in this unmeasurable locality. A similar difficulty prevents me from telling you exactly how great was the wasting in E. F., for here the malnutrition was most obvious in the deltoid muscle, in the pectoralis major, the supra-spinatus, and infra-spinatus scapula. It is so evident, however, to the eye that no other measurement is needed to tell you that it is very great. The head of the humerus may be seen and felt almost as distinctly as if it were removed altogether from the soft parts; for the bone appears and feels as if covered only by the thin and flexible skin of childhood. Again, in G. H., whom you have seen recently in Ward 3, and whose early history was similar to those I have described, it was impossible to represent fairly in figures the amount in wasting, for both lower extremities were affected, and that to about an equal degree. The girl was generally thin, but the malnutrition of the legs, as compared with the arms, was most obvious to all who saw her.

Sometimes particular muscles, or groups of muscles, are especially affected; thus, in the upper limb the muscles around the shoulder, and in the lower extremity the extensor muscles lying outside the tibia. Of the former, E. F. afforded an excellent example; of the latter you have seen several illustrations, observing sometimes that instead of the natural roundness there was distinct hollowing external to the tibia.

The degree of paralysis varies from slight weakness to absolute immobility. If the leg be affected a child may simply "drag its foot" in walking, or it may be unable to do anything but crawl upon the floor. When G. H., who is now quite well, came into the hospital she could not stand, for in her the affection was paraplegic, and the wasting and weakness of the glutei were carried to an extreme degree.

The electric contractility of muscles is peculiar and interesting. In some cases it is entirely lost, but in others it is only diminished, exhibiting, except in the fact of diminution, its ordinary characters. But what is very remarkable is the following fact, that in certain medium cases, where the loss of voluntary power may be complete, but the failure of nutrition by no means extreme, the muscles respond at once to the application of an interrupted battery current of low intensity, and at the same time exhibit no action when an induced current of high power is directed upon them. This has now been observed so frequently that it must be regarded as a common-not an exceptional-fact in the history of such cases; and it may be displayed very readily by a comparison of the paralysed with the healthy limb. An induced current which causes violent contraction in the muscles of the healthy side awakens no movement in the wasted limb; and vice versa, an interrupted battery current, which is too feeble to cause any contraction in the healthy muscles is sufficient to produce distinct action of the wasted muscles. There would appear, therefore, to be an exalted readiness of response to one form of electricity, a diminished readiness of action to the other. This condition is not limited to the paralytic state I am now describing. It has been observed in other diseases by myself, and by my friend, Mr. John Netten Radcliffe, who will, I hope, furnish the results of his large experience in this matter in a collected form.

The sensibility of the skin in the paralysed limbs I have examined very carefully, and have found it to be normal, when tested by the compasses, by the application of heat or cold, by pinching, pricking, and the electric brush.

The reflex motility has been, so far as I have seen, utterly abolished in those limbs which have been completely paralysed to the will.

The temperature of the paralysed extremity has been reduced in all the cases that I have seen. This reduction has been obvious to the hand, and has been verified by the use of the thermometer. I have found a difference varying from five to nine degrees Fahrenheit between the limbs of the same patient, and this after taking the utmost care to avoid sources of fallacy.

The state of mind, and of the general bodily health, may be, and usually is, that of perfect health; and it is almost infinitely rare to find anything like bedsores, or localised malnutrition of the skin.

4. Consequences of paralysis.-These are either simple uselessness, and all the discomforts which may follow therefrom in paralysis of any kind; or they are certain deformities which arise from the peculiar distribution of the paralysis and wasting. It is not my purpose to give you any description of these deformities, but you will at once see that they are the most marked when the paralysis is limited to particular groups of muscles; for then the antagonists of those muscles are thrown into overaction, and distortion of the limb is the result.

5. Anatomy.-The muscles and bones are small, and the former often lose all their characteristic structure; and, until recently, it has been affirmed that beyond these changes in the limbs nothing abnormal was to be found. You may read descriptions of post-mortem examinations in which it is stated that the brain, spinal cord, and nerves were in their natural state; and it is only of late that, by a process of more minute investigation, the real nature of