necessity of putting it to his face or neck, or upper part of his arm. His skin seemed to be unusually affected by heat. His hands were never free from blisters, which he could get by inadvertently placing them too near the fire.

The power of motion existed in the muscles of both hands and feet. He could grasp pretty firmly, but in holding anything he was apt to drop it if his attention was at all called away. The susceptibility of impressions generally, as well as the muscular power, seemed to be diminished.

The result of the case is no further given than that the patient was not benefited by the treatment. He left England again for the West Indies. I cannot but regard this as the result of injury to the cutaneous nerves, arising, in the first instance, from exposure whilst heated.

In enumerating the apparent inconsistencies of anæsthesia, Abercrombie says that a gentleman who was under the care of the late Dr. Hey, of Edinburgh, had two paralytic attacks at the distance of eight months from each other. In the first there was perfect loss of feeling with only partial loss of motion; in the second there was perfect loss of motion with only partial loss of feeling. He recovered perfectly from the first attack after a short time; but after the second, though he recovered partially, he continued to drag his leg, and, after a year or more, died of apoplexy. The different results of the two attacks precisely agree with the principle I have been endeavouring to establish. I believe there is yet a source of many functional diseases of the nervous centres which, in modern medicine, has been too much neglected. I refer to the interweaving of the sympathetic with the nerves, and, as we have reason to believe, entering into connection with the nervous centres themselves. States of the brain produce functional disorders of the stomach and liver, and these in their turn produce strange nervous conditions; amongst the most important of which to be here named are numbness of the fingers or face, pain over the eyebrow and on the occiput, partial paralysis of the retina, giving rise to hemiopia or indistinctness of vision, with vertigo, all of which often vanish at once by good exercise or an active purgative. Although this attempt to generalise and classify nervous affections is

necessarily very defective, yet should it hereafter be found that a careful attention to the degree in which sensation is affected in relation to paralysis may serve to inform us whether the disease be local or general, functional or organic, as indeed I think it will, the object of these lectures will have been attained.

CASES OF PARAPLEGIA.1

PARAPLEGIA FROM TUMOURS COMPRESSING THE CORD.

TUMOURS growing in the cord, or from its membranes, are among the more rare causes of paraplegia. With the exception of scrofulous deposits, these formations are most frequently seated in the loose tissue under the visceral layer of the arachnoid, or grow from the inner surface of the dura mater. They have generally been regarded as malignant, but their microscopical characters, their indisposition to invade or infiltrate surrounding parts, and their non-occurrence simultaneously in other organs, refer them to a simpler class of tumours, the fibro-nuclear or fibro-cellular. The cord and its membranes appear to be extremely rarely affected primarily by cancerous growths. When malignant disease attacks these parts it is generally by secondary diffusion, or by extension from the bones or other structures adjacent.

In paraplegia from compression of the cord by tumours, pain is, with but rare exceptions, a prominent and characteristic symptom. Some writers have expressed an opinion that it is present only when the membranes or surrounding structures are implicated, and not when the disease is strictly limited to the cord itself. This does not appear to be a well-founded distinction. In a case recorded by Mr. Shaw, in the Transactions of the Pathological Society' (1848-9), paraplegia was produced by two scrofulous tubercles occupying the interior and lower part of the spinal marrow, and invested all round by a thin layer of medullary Reprinted from the 'Guy's Hospital Reports,' 1856, p. 143.

1

matter; yet the patient complained so much of pain in the lumbar region that it was thought her symptoms might arise from caries of the vertebræ. After death the membranes and bones were found healthy. The character of the pain appears to be very variable. In one case, quoted by Abercrombie, the first symptom was neuralgic pain in the arm, which diminished as paralysis came on. In another the patient had sciatic pain extending to the toes.

Mostly the pain is referred to the back, and more or less correctly indicates the seat of the disease, from which it radiates in the direction of the nerves whose roots are invaded. Where there is no actual pain there may yet be other modifications of sensation, as coldness, or heat, or sudden alternations of these, and many other varieties of impaired feeling.

Next to pain is the frequency of muscular contractions in the affected limbs, followed as the case progresses by flexion and rigidity, and attended by a great susceptibility to the excito-motor stimulus. These phenomena are most apparent where the cord is merely stretched or compressed, and where no other change has occurred in it beyond atrophy, the communication with the brain being at the same time not entirely destroyed. If there be inflammatory softening of the substance of the cord, then these more characteristic symptoms may be absent, as they are also in compression of the cord from fracture when its structure is bruised and softened. Spasmodic contractions of the muscles of the extremities occur whether the fibres of the cord are compressed by tumours on its surface or stretched by tubercle deposited within it. At one stage of a case there may be rigid extension, which may be gradually followed as the case progresses by as rigid flexion, though the muscles at the same time may become atrophied and flaccid.

The vagueness of the early symptoms, in these as in other cases of paraplegia, deserves especial consideration in a practical point of view. In the first case here recorded, the early symptoms, cough and slight dyspnoea, and some pain in the back and shoulders, were referred to tubercular disease of the lungs. In the second, the spasmodic action of the limbs was so great that for a time the case was regarded as one of hysteria. In fine, the symptoms of neu

ralgia, hysteria, lumbago, rheumatism, phthisis, colic, renal calculus, pleuritic and hepatic affections, may rise like so many phantoms, to delude us at the onset of most paraplegic affections, and the errors they are apt to lead to can be avoided only by a rigid inquiry. Of the diseases of the nervous system in general, and of paraplegia in particular, it may be said that there is no symptom or single group of symptoms which, taken alone, can serve as a secure basis of diagnosis; the whole particulars included in the clinical history and present state of the patient must be viewed in their relation to each other and to time, before we can discern the truth they indicate.

CASE 1.-PARAPLEGIA.-Tumour growing from the inner surface of the dura mater of the cord. Early symptoms, simulating incipient phthisis; subsequently rheumatism.

Francis H, æt. 30, a married man of temperate habits, by trade a baker; admitted into Guy's Hospital January 30th, 1850, with symptoms supposed to be due to incipient phthisis. He had had cough and shortness of breath for two months, lost strength and flesh rapidly, and had frequent perspirations. The cough was accompanied by pain in the upper part of the back and in the right shoulder, but the complaint he made of it was not such as particularly to arrest attention. The heart's action was normal; respiration 24. He was ordered to take cod-liver oil. There was nothing specially noticed in his symptoms until the 4th of February, when he suddenly found himself unable to empty his bladder; he was relieved by the catheter, and was not for some time again troubled in that way. A week subsequently the report says, "He is improving under the use of the oil." On the 20th the pain in the right shoulder became much more severe, and he complained of feeling very languid, though up to this date he was able to walk about a good part of each day. He had occasional rigors and profuse sweatings. The increase of his symptoms at this time was attributed to his having taken cold. The next day the knees were painful, and the legs weak, he could not support himself, though he had the power of moving freely in bed. The character of the affection of the joints was such as to induce the belief that he was now labouring under rheumatism, and he was treated accordingly, apparently with good effect. At this time the inability to pass water returned, and decided symptoms of paraplegia came on, with impairment of sensation as high as a line round the chest, corresponding to the third rib; the boundary of the anesthesia was not, however, sharp and defined. The arms were slightly enfeebled. The paralysis of motion in the lower extremi. ties and sphincters became complete, but he retained the power of distinguishing the seat and direction of superficial impressions on the skin, though no amount of pinching or pricking gave rise to pain. The spinal column was straight, and no tender spot could be discovered on percussion, nor by the