treatment was modified according to symptoms as the case progressed. The patient steadily improved day by day. At the end of a week he was talking with facility; on the 23rd of the next month he walked between one and two miles two days in succession, and in February he called upon me, and reported himself quite well, and impressed me as being so both mentally and physically.

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, aud 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 his 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 staid 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, clayey-looking; 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 stagnate 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-ap

plied 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 fore

head 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 continue 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 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 redu cing 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 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 hyperesthesia, 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

The

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. 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 fore-part of the foot, it immediately dropshe 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 fore-arm always prouated. 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; and the third phalanx of the index finger, formerly paralysed, he could flex strongly. His left leg also continued to grow stronger; he could stand alone upon it without support for a considerable time; the stiffness formerly felt at the top of the calf, when he attempted to extend it, was completely gone; he could hold up the fore part of the foot when the heel was on the ground as long as he liked; he could move the toes, especially upwards much more freely, and, as he said, he walked "much better" than formerly. I ordered the extensor muscles of the fore-arm, especially those of the thumb, to be galvanized frequently; the treatment in other respects to continue the same.

The last record which I made of this case, was July 28, and was as follows: -When the hand is in a passive state it is now quite straight in relation to the fore-arm, and its grasping power is notably increased. The patient can walk on either the heel or toes of the left foot, and in ascending stairs can

bear all his weight so completely on his left toes, as to be able to go up by advancing each foot a step alternately. The bowels continue to be open daily; the left side continues remarkably warm, and during the two months of treatment headache has never been felt.

As the radial side of the fore-arm has been turned inwards ever since infancy, it is probably held in that position, not only by the pronator muscles, but by adherent tissue developed between the immobile structures. Holding this opinion, I directed the boy to make continuous efforts forcibly to supinate the fore-arm, and already the rotating power has increased. If his left tendo-Achillis had not been divided, he would now walk I believe, with only such a slightly perceptible limp as would be due to the difference in length of the two legs; there is more unevenness in his gait than that difference will account for, and I ascribe it to the operation which he underwent. Indeed he could walk better, he says, before the operation than afterwards; and he is probably right, for he also says that before the operation the muscles of the calf were fully developed, whereas afterwards they gradually wasted.

As in the treatment of cases of paralysis of long standing, medicines are, notoriously, of slight avail, and as any merely theoretical considerations which I may advance in favour of the method I am advocating will not be likely to exert much influence, I shall, I hope, be permitted to adduce, as evidence in support of that method, the reports of two other cases which were published in the Journal of Mental Science.

Case of Hemiplegia, with persistent headache; impairment of intelligence and vision; obstinate constipation; and deficient expulsive power of the blad der.-H. D. J., suffering from hemiplegia, consulted me, August 12th, 1863. He can lift the right elbow nearly as high as the shoulder, when the arm is flexed; but when extended, only as high as the mamma. The supra-spinatus muscle of the right side is considerably wasted. Can flex the fore-arm vigorously, but can extend it only imperfectly and feebly. Can flex the fingers and thumb closely, but not powerfully; cannot extend the fingers beyond a right angle with the palin; cannot extend the thumb. Cannot stand on the right leg without support; it is not wasted. Cannot extend the toes except very slightly; can flex them better, but much less than he can the toes of the left foot. The right foot and leg, as high as the knee inclusive, are habit ually cold; so cold that even now he has a fire every night to warm them before going to bed. Drags his left foot, and wears the toe of his shoe out in consequence.

Has continuous pain on the right side of the head round the ear, sometimes extending to the back and front of the same side. Has constant singing in the right ear. Has paralysis of the sixth nerve of the left side. Has a little pain in the left eye; cannot read test-type "12" with it; with the right eye can read test-type "3" with difficulty. Tongue deviates strongly to the right side; tactile power of tongue and of cheeks on each side the same. In the palin of the hand feels two points six lines apart on right side, four on left. Intelligence considerably impaired. Pulse 120, the same strength on both sides. Bowels so constipated as to be confined for a week together if no medicine be taken, the stools being very hard. Even with several strong doses of purgative medicine in succession, very often no action of the bowels is effected. The expulsive power of the bladder is "greatly impaired." He sometimes passes twenty-four hours without making water. The patient is generally very impatient and irritable.

After the treatment, consisting chiefly of ice to the spinal region, varied from time to time according to the requirements of the case, had continued until September 24th, the following was the condition of the patient:

He can now raise his right arm vertically above his head; can extend his fore arm vigorously, and all the fingers and the thumb completely. Can balance himself on the right leg without support. Can extend and flex the toes of the right foot very considerably, much more than formerly. The right leg decidedly warmer than before using the ice. In walking he can now put his left foot flat, there being no dragging of it as formerly. The pain of the right side of thehead and the singing of the right ear, though not quiteg one are

markedly lessened. The pain in the left eye is still felt at times but it is also much lessened. The paralysis of the sixth nerve of this eye continues about the same. Can now read test-type "14" with the right eye, and "84" with the left. Feels two points at five lines apart in each palm. Intelligence very greatly improved. The bowels are now easily acted on by a slight dose of aperient medicine, and are thus open at least every other day. The expulsive power of the bladder is much greater than before treatment; in fact, quite normal. Urine is now voided about three times in the twenty-fourhours. Case of Paralysis of the muscles of the tongue and throat.-September 13 1863, I was consulted by Mrs. who, about four years ago, lost the power of her right hand for a time, but recovered it. A year later she had an attack of paralysis of the right arm, lasting only for a few days. The face was drawn to the right side, and the speech became "thick." She has never walked so strongly since this attack as she did before it. She had a third attack about thirteen months ago, when, having gone to bed well, she rose in the morning, and went to call her daughter, but found herself unable to speak. The arm was not affected at all this time. Both legs are now very weak, the right one being much the worst.

The tongue is still paralyzed, but its sensibility is normal. She can now protrude it slightly, and move it from side to side, but cannot speak at all. Formerly the tongue was stiff, and could not be protruded.

During the last two months, she has become able to swallow fluids with difficulty, only a teaspoonful at a time. Has all her food minced, being unable to chew it, because she cannot guide it in her mouth. Uvula straight. Pupils equal, and sight fairly good. Forehead, face, submaxmillary region, decidedly cool; upper extremities habitually cold. Sleeps well; appetite good; bowels regular. Goes out daily to walk, but feels a great stiffness in the limbs, particularly in the right leg and arm. The patient writes on a slate—“My nerves are greatly shaken; the most trifling thing makes me laugh or cry without any cause. I cannot account for this attack in any way. I have tried blisters, strychnine, galvanisin, and homoeopathy, without any effect. I have no headache nor pain of any kind, but often feel as if a band were bound round my head and throat (more round the throat than the head); and going up or down a single step, I fancy I must fall, though I know it is only a nervous feeling." I requested her to apply ice, until it melts, along the upper half of the spine twice a day.

September 20th. The patient looks better; the hands have been always warm since the treatment began, becoming so in three minutes after the use of the ice. Her expression is improved; she looks healthier, stronger. Pulse 92; tongue clean, bowels regular. R. Ammonii bromidii gr. v.; potassii iodidi gr. iiss, ter die.

September 27th. Feels very well: arms, but not hands, warm, bowels regular. Face often flushes while the ice is on. Can eat better, and can say "Helen" and "No." To make the hands warm by putting them in hot water, by friction, and by warm gloves. To continue the medicine already prescribed, once daily, and to take of ferri carbonatis cum saccharo gr. x, bis die.

October 3rd. Much the same, but has a little more power in the tongue. Can say "nothing." Bowels regular. Pulse 104. Continue the ice and the pills, and keep a roll of cotton wool beneath the lower jaw.

11th. Is generally better. Can say "Yes" and "Fire" and all the letters of the alphabet except "w" and "y." The wool beneath the jaw has much increased the temperature there. Is always warm, except just after dinner; she has not the ice on then. To continue the pills, to put the ice-bag next the skin, and to suck jujubes in order to exercise the tongue. 17th. Can now say "Bacon, finger, apple, paper, Mary, box." Hands warm, feet also. Pulse 100. Bowels regular. Tongue deviates to the right. Swallowing improved; takes a wine-glassful of porter daily. B. Potassii iodidi gr. iij, bis die. Continue the ice and the jujubes, and make continual efforts to speak.

I never saw this patient again.