OF THE CAUSES, NATURE, AND TREATMENT PALSY AND APOPLEXY: FORMS, SEATS, COMPLICATIONS, AND MORBID RELATIONS OF PARALYTIC AND APOPLECTIC/>ISEASES. BY JAMES COPLAND. M.D., F.R.S. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; HONORARY KEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; AND OF THE ROYAL ACADEMY OF MEDICINE OF BELGIUM; FELLOW OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETIES OF LONDON AND BERLIN; LATELY CONSULTING PHYSICIAN TO QUEEN CHARLOTTE'S LYING-IN HOSPITAL ; CONSULTING, AND LATELY SENIOR, PHYSICIAN TO THE ROYAL INFIRMARY FOR DISEASES OF CHILDREN ; FORMERLY SENIOR PHYSICIAN TO THE SOUTH LONDON DISPENSARY ; ETC., ETC. ^7inP >>i- "?, 'ty LEA PHILADELPHIA: AND BLANCHARD. 1850. ClUo TO THOMAS GODFREY SAMBROOKE, ESU. EATON PLACE. My Dear Friend, I dedicate this Treatise to you with the most sincere esteem for your high-minded and generous disposition, and with grateful feelings for the kind interest you have always taken in my professional reputation and success, for the many kindnesses I have received from you, and for the confidence you have reposed in me during a long arid intimate ac- quaintance. With ardent wishes for your health, happiness, and prolonged life, I am, my dear Sambrooke, Ever yours most sincerely, JAMES COPLAND. Old Burlington Street, ^ March, 1850. 5 PREFACE. A considerable part of the following Treatise was pub- lished many years ago in the first and third volumes of the Author's Dictionary of Practical Medicine, and several of the Chapters on the connection of Paralytic and Apoplectic seizures, with other disorders, formed the Croonian Lec- tures, for 1846 and 1847, at the Royal College of Physicians. The Author now publishes the whole in a connected form, believing that palsy and apoplexy should be studied in intimate connexion not only with each other, but also with other diseases, of which they are often the consequences and terminations, and with other affections which are fre- quently associated or complicated with them. From a very early period of the Author's practice he was strongly impressed by a conviction of the importance of describing not merely the primary and uncomplicated forms of disease, but also the several associated or compli- cated states in which each malady most frequently comes under the observation of the physician, and he was not the less convinced of the propriety of recognizing alliances and connections between diseases, too often described as distinct species, extreme features of difference being chiefly or only insisted upon, and intimate relations generally disregarded. The Author, in his Lectures on Pathology and Practical Medicine, and afterwards in his Dictionary, endeavoured to supply what he considered a defect in medical works ; and was the first to attempt to point out and to describe the relations, associations, or complications of each specific dis- ease, as well as the different states or forms which such disease may assume according to the various causes, circum- 1* 6 PREFACE. stances, and combinations of causes, which either occasion it, or influence its course. The chapters of this Treatise, in which Apoplexy is more - especially considered, were first published in 1832; and the Author believes that the practical opinions he then promul- gated have received the sanction of physicians in this and other countries, as well as of recent medical writers. A more extensive and prolonged experience has confirmed his views, thus long submitted to the profession, as to the pathology and treatment of apoplectic and paralytic affec- tions; and in the present republication, although these views are exhibited in somewhat fuller detail, and in more intimate connection with one another, and with allied topics and related affections, they are not different from what he had previously furnished. "When treating many years ago of Hemorrhage, the Author referred the extravasation in some cases to disease of the smaller arterial vessels—"to disease of the coats of an artery or vein, or to atheromatous or other deposits in the coats favouring their perforation or rupture"1; and he then mentioned instances of hemorrhage having been traced in his own practice to this change in the small arterial branches. Since the publication of this, Mr. Gulliver has shown the fatty nature of those changes in the blood- vessels which were formerly described as atheromatous; and soon afterwards some apoplectic cases came before the Author, in which he had reason to believe that this change in the vessels existed not only in arterial branches but also in the smaller ramifications, and that it weakens these ves- sels and favours their rupture, thereby producing either apoplexy or palsy according to the amount of hemorrhage. Since that part of the present work went to the press in which this statement is made, Mr. Paget has published microscopic observations which fully illustrate and prove this statement. The observations of Mr. Paget and of the Author have been made independently of, and unknown to, each other ; but those of Mr. Paget have extended further than those of the Author, as respects the state of the cere- bral capillaries. ' See Art. Hemorrhage in Author's Dictionary of Practical Medicine, ho., vol. ii., p. 02. preface. 7 After the appearance of Mr. Gulliver's memoir on this change in the arteries, the Author has examined, after fatal hemorrhage, the changes in the bloodvessels more minutely than before, and he is induced, from what he has observed, to conclude that the changes formerly termed atheromatous, although more or less resembling fat, are not actually this substance, though closely allied to it, or containing it in various proportions, in connection with more or less of other animal matters. When treating of the diseases of the arteries in his Dic- tionary, the Author imputed these changes to altered nutri- tion, owing to failure of the organic nervous influence endowing the cerebral vessels, and this idea he has sup- ported in the present treatise, believing the change in the vessels to be consecutive of impairment of the functional energy of these nerves, and the effusion, softening, disor- ganization, &c, to be the ultimate results of this procession of changes—first in these nerves, next in the vessels, and ultimately in the cerebral structure and membranes. He has stated these changes, in general terms, to be athero- matous or fatty: but they are really of a composite nature, and consist of various proportions of olein, margarin, choles- terol and albuminous matter deposited in or between the coats of the arteries; the more strictly fatty deposit assum- ing the form sometimes of oil-globules, or fat-globules, or of fat granules. It is not improbable that these changes are owing not merely to impaired organic nervous power, either generally or locally, but also to the state of the blood — to a superabundance, consequent upon imperfect assimilation of these substances in the blood, and to a per- verted nutrition; and that they are independent of inflam- matory action in the coats of the arteries. Of the imperfections of this as well as of his other works no one can be more convinced than the Author is himself; for he has neither had the time, nor has he enjoyed the opportunities or the occasions requisite to the full attainment of what he desired, or of perfecting satisfactorily to himself that which he attempted. In certain other circumstances he might have accomplished more; he could not have done much less than he has done; for that which still appears to himself but little, imperfect, and hence unsatisfactory, has been produced under no cheering influences — during the 8 preface. anxieties and interruptions incidental to the practice of his profession — chiefly during hours which are generally de- voted to the restoration of powers exhausted by the mental and physical labours of the day. Old Burlington Street, March, 1850. CONTENTS, PAGE The intimate Connection of Palsy and Apoplexy shown - - - 13 SECTION I. Of the less complicated Forms of Palsy or Primary and Simple Palsy - - - - - 15 Chapter I. Of Paralysis of Sensation - - - - 17 i. Palsy of the Sense of Smell - - - 17 ii. Paralysis of the Sense of Taste - - - 17 iii. Paralysis of the Organs of Sight - - - 18 iv. Palsy of the Sense of Hearing - - - 21 v. Palsy of the Sense of Touch—Anaesthesia - 26 Chapter II. Of Paralysis chiefly of the Function of Motion - 34 i. Of local or partial Palsy chiefly of Motion - 35 ii. Palsy of one Side of the Body, or Hemiplegia - 44 iii. Palsy of the lower Half of the Body—or Para- plegia - - - - - - 50 iv. Of general Palsy - - - - 63 Chapter III. Palsy of New-born Infants and Children - - 75 Chapter IV. Shaking Palsy—Paralysis Agitans - - - 79 Chapter V. Palsy caused by Poisons - - - - - 83 i. Palsy from Mineral Poisons - - 84 ii. Palsy from Stupefying Agents - - - 88 SECTION II. The umcomplicated Forms of Apoplexy,—or, Pri- mary and Simple Apoplexy - - 90 Chapter I. The symptoms preceding and constituting an attack of Apoplexy - - - - - 92 i. Of the Approach, or premonitory signs of Apoplexy 92 ii. The Symptoms characterizing the Attack - 93 Chapter II. Primary and Simple Apoplexy - - 95 Chapter III. The gradually increasing or ingravescent Apoplexy - 99 SECTION III. Of the Association of Palsy and of Apoplexy with each other - - - - - 106 Chapter I. Apoplexy associated with, or terminating in Palsy - 107 10 CONTENTS. Chapter II. Palsy, either partial or Hemiplegic, after an indefinite Duration passing into the Apoplectic Attack - - lid Chapter III. Of certain Phenomena observed in the simple and asso- ciated Forms of Apoplexy and Palsy - - - 117 SECTION IV. Of several Diseases often preceding, inducing, and complicating Apoplexy and Palsy - - 126 Chapter I. Vascular Determination to, Congestions and Inflamma- tion of, the. Brain or its Membranes often induce and complicate Apoplexy and Palsy - - - 12G Chapter II. Of softening of the Brain in connection with Palsy and Apoplexy - - - - - -132 Chapter III. The Connection of Apoplexy and Palsy with Epilepsy 143 Chapter IV. The Connection of Palsy and Apoplexy with Insanity 147 i. Connection of Palsy with Insanity - - 147 ii. Of Apoplexy in connection with Insanity - - 155 Chapter V. Of the Connection of Apoplexy and Palsy with Disease of the Heart - - - - - 158 Chapter VI. Of several other consecutive and complicated states of Apoplexy and Palsy - - - - 162 i. Consecutive Occurrences of Palsy and Apoplexy - 162 ii. Metastatic Attacks of Apoplexy and Palsy - 163 iii. Complicated States of Apoplexy and Palsy - 166 Chapter VII. The Relations or Alliances of Palsy and Apoplexy to some other Diseases .... 175 i. Relations to Neuralgia - - - - 175 ii. Relations of Palsy to Chorea ... 181 iii. Relations of Palsy and Apoplexy to Hysteria - 182 iv. Alliance of Catalepsy to Palsy - - - 185 v. Alliance of Rheumatism to Palsy - - - 186 SECTION V. The Diagnosis and Prognosis of Apoplexy and Palsy 188 Chapter I. Of the Diagnosis of Apoplexy - - - 189 Chapter II. Diagnosis of Palsy - - - - - 192 Chapter III. Of the Prognosis of Apoplexy - - - 196 Chapter IV. Consequences, Terminations, and Prognosis of Palsy - 200 SECTION VI. The remote Causes, or Contingent Occasions, and the Pathological States producing Palsy and Apoplexy ------ 204 Chapter I. The remote Causes or contingent Occasions of Apoplexy 204 i. The predisposing Causes of Apoplexy - - 205 ii. The exciting Causes - - - - 210 iii. The Modus Operandi of the Causes - - 213 Chapter II. The remote and contingent Causes of Palsy - - 215 Chapter III. Remarks on the Pathological Stales producing or con- stituting Apoplexy - - - . -210 i. Of the physical Conditions of the Brain and Spinal Cord - - - _ . -219 ii. The pathological States producing and constituting Apoplexy ..... 009 CONTENTS. 11 PAGE Chapter IV. Of Topics connected with the Pathology of Palsy and Apoplexy - - - - - 231 i. Of the immediate Source and Transmission of tlio Paralytic effect ----- 231 ii. Of the supposed Relations subsisting between the Lesion of the Brain and the Symptoms attending and following the attack ... 237 Chapter V. Of certain Topics more especially connected u-ith the Pathology of Palsy ----- 243 i. The remote Changes in the Seat of Hemorrhage - 243 ii. Interrupted Circulation to, or Anaemia of, a por- tion of the Brain may occasion Palsy - - 244 iii. Of the Mechanism and Functions of the Spinal Cord - - - - - - 247 A. Of the Mechanism of the Cord - - 247 B. Of Irritability in relation to the Spinal Cord 249 C. Of the state of the Sphincters in connection with the function of the Cord - - 251 D. Of the influence of the different Columns of the Cord on the sensitive and motor Powers - 252 E. Of various sympathetic Phenomena in con- nection with Palsy - 254 iv. Of the influence of Congestion of the venous Sinu- ses of the Spine in causing Paralysis - - 258 SECTION VII. Of the Treatment of Palsy and Apoplexy - 261 Chapter I. The means which should be employed when Palsy or Apoplexy is threatened - . - - 262 Chapter II. The Treatment of the different States and Complications of Apoplexy ------ 269 i. Treatment of Apoplexy unattended by depression of Vascular Action or by marked exhaustion of Nervous power—of Sthenic Apoplexy - - 270 ii. Treatment of the Depressed States of Apoplectic Seizure—of Asthenic Apoplexy - - 280 iii. Means which are admissible in certain States of either the Sthenic or Asthenic forms of attack - 283 iv. Of the Treatment of certain Consecutive and Com- plicated states of Apoplexy - - - 287 Chapter III. Of the Treatment of the several Form? and Complica- tions of Palsy - - : - ' - 292 i. Treatment of Palsy, chiefly of Sensation - - 293 ii. Treatment of Palsy, chiefly of Motion - - 294 A. Of Local or Partial Palsy - - - 294 B. Of Hemiplegia - - - - 295 iii. Treatment of Paraplegia and General Palsy - 298 A. Of Paraplegia - - - - 298 B. Of General Palsy - - - - 300 iv. Treatment of Paralysis in Children - - 301 v. Treatment of Shaking Palsy - - - 302 vi. Treatment of Paralysis caused by Poison - 303 1 12 CONTENTS. / vii. Treatment of the Complications of Palsy - 305 viii. The Appreciation and Appropriation of Reme- dies for Palsy - - - - - 311 Chapter IV. The Consecutive Treatment of Apoplectic and Para- lytic Seizures, Or Treatment directed to the prevention of a return, or of an exacerbation of the disease - - 321 THE CAUSES, NATURE, and TREATMENT OF PALSY AND APOPLEXY, ETC. 1. Palsy and Apoplexy are so intimately connected the one with the other in their causes, seats, pathological con- ditions and treatment, as to render it most difficult, if not altogether impossible, to treat fully and satisfactorily of the one apart from the other. The same remote causes and contingent occasions, and the same structural changes, vary- ing only in grade, affecting often the same parts or seats, produce both these diseases. In these circumstances, there- fore, and in the great majority of cases, they may be viewed as modifications of one malady, even when unassociated. Seeing, however, that they are very frequently found asso- ciated—that, in most cases, palsy either commences or terminates in apoplexy,—when it is observed that the ma- jority of instances of apoplexy are either complicated with, or followed by palsy, the propriety of treating of them in connection with each other, and as they usually come under the observation of the physician, will be admitted. Both forms of malady thus depending upon sameness or simi- larity of pathological conditions, necessarily require also similar modes of treatment; or, at most, the means which 2 14 palsy and apoplexy. are often the appropriate to the one are suitable also to the other, with more or less modification. 2. In treating, therefore, of these two forms of disease— of apoplexy and palsy—it is immaterial which of the two should receive precedency. The fatality of the one is nearly equal to that of the other, although after different periods of duration; and the consideration of the changes producing both, and of the means most appropriate to the removal of these changes, is beset with difficulties equally great in respect of each. As, however, several forms of partial palsy are often forerunners of either complete and extensive paralysis, or of attacks of simple or of compli- cated apoplexy, I shall direct my attention, first, to the more simple and primary varieties of palsy ; next, to the uncomplicated forms of apoplexy; afterwards, to the com- plicated states of palsy and apoplexy, and to their causes, to the disorders which often precede them, and to the more important points of their pathology; and, lastly, to the treatment of their several forms and complications. SECTION I. OF THE LESS COMPLICATED FORMS OF PALSY, OR PRIMARY AND SIMPLE PALSY. 3. Palsy, or Paralysis, is characterized by a diminution or loss of the power of motion, or of the sensibility, or of both motion and sensation, in one or more parts of the body. Pathologically, or as respects its nature, palsy may be de- fined to be, a disease depending generally upon structural change, either of some portion of the cerebrospinal axis and ramifications, or of adjoining parts implicating these, so as to impair or altogether to abolish motion or sensation, or both, in a part, or more or less extensively throughout the frame. 4. Paralysis presents itself in several forms and states, according as the sensibility or the power of motion, or both, are affected; and according to the degree and the extent of the affection. It varies thus in grade, character, and ex- tent, from the numbness or weakness of a single joint or finger, or the failure of the action of a single part or organ, to a complete apoplexy, in which the sensation and motion of the whole body is abolished. These circumstances have led to the use of various terms, as respects the form and extent of the disease, that may briefly be noticed. 5. As regards the form or character of the malady, it has generally been allowed that when either motion or sensa- tion is entirely lost, the paralysis is complete as respects the lost function; if either be impaired only, or not altogether lost, the disease is incomplete. If only one function is affected, the paralysis is imperfect', if both sensation and motion are lost, the disease is perfect, as suggested by Dr. Bennett. Thus, palsy may be not only incomplete or com- plete, or imperfect or perfect; or incomplete and imperfect, or both complete and perfect; but it may even be complete 16 DIVISIONS of palsy. as respects either function, and yet imperfect inasmuch as one only is lost; or it may be incomplete and yet perfect as regards the affection of both functions. 6. Palsy has been divided, as respects its extent, into partial and general; the former has been further divided into hemiplegia, when one side or lateral half of the body is affected; paraplegia, when the inferior half is attacked; and local when a smaller portion of the frame affected. It has, moreover, been called idiopathic and symptomatic; but those who have thus divided it nave not pointed out in what its idiopathic nature consists. Palsy is generally, if not universally, a symptomatic malady, inasmuch as it depends upon lesion of the central nervous masses, or of the princi- pal nervous trunks or cords, or of parts implicating them; as it is rarely owing to an affection of the parts themselves which betray the disorder, unless in a few instances of palsy from cold or from some agents directly influencing these parts. 7. Palsy, in all the forms of loss of sensation, or of motion, or of both, and in their several grades and com- binations, is remarkably diversified, and often variously complicated with other aliments or diseases. As I shall have to show in the sequel, several disorders which have been differently named are merely modifications of paralysis, whilst many others are so intimately allied to this import- ant affection as to either approach it in grade, or to be symptomatic manifestations of organic lesions, which sooner or later produce it in one or other of its forms. 8. Paralysis has been termed continued or intermittent, fixed or moveable, according as it presents these characters. It has likewise been called plethoric, serous, bilious, febrile, &c, according to its presumed cause, or to these states of concomitant disorder. Its origin in certain metallic and vegetable poisons has also been used, and with true practi- cal advantage, to distinguish those instances which are thus produced. To these forms and characters of the malady attention will be directed in the sequel, as Avell as to the complications presented by them in practice. In describing the several states and forms of paralysis, loss of sensation will be first considered, and afterwards the several forms of loss of motion, with or without impairment or loss of sen- sation. PALSY OF SENSES OF SMELL AND TASTE 17 CHAPTER 1. Of Paralysis of Sensation.—Loss of the Sensibility of an Organ or Part.—Partial Paralysis of Sensation. 9. A particular sense, or the feeling of a limited or even of the greater part of the body may be impaired or alto- gether lost—the palsy of sensation may be incomplete or complete in the part affected; the affection being either limited, or so extended as to be almost general; but this latter is very rarely or never observed.—Under the head of local, limited or partial loss of sensation, may be com- prised incomplete and complete palsy of the several senses. 10. i. Paralysis of TnE Sense of Smell.—Loss of Smell —Anosmia, is commonly a symptom of some disease, as a catarrh, &c. It is rarely observed as a simple affection unless it be caused by the abuse of stimulants or of irri- tants, as of snuff, &c. Dr. Todd and Dr. Good mention instances of this having been a congenital affection. It often attends coryza, or common cold, ozsena, nasal polypi, diseases of the spongy bones, &c.; and it is sometimes caused by external injuries; by prolonged irritation or ulceration of the Schneiderian membrane; and by diseases of, or tumours pressing upon, the olfactory nerves. M. Serres states that disease of the roots of these nerves, and more particularly of the external root, is not an unfrequcnt cause of defect or loss of this sense. But in its more evan- escent states it is most commonly caused by a common cold, or by discharges from the nasal surface. 11. ii. Paralysis of the Sense of Taste.—Loss of Taste—Ageustia, sometimes also attends other diseases. It occasionally accompanies palsy of the tongue, or of the muscles of the face. It is frequently observed in continued and exanthematous fevers; and is in them, as well as in some other acute diseases, partially caused by the fur and viscid mucus covering the tongue and adjoining parts, that prevents the sapid body from coming into close contact with 2* 18 palsy of sense of sight. the nerves of taste. It may be produced also by the use of tobacco, especially by chewing it, or by other acrid sub- stances. It has even arisen from want of exercise of the nerve of taste, as in a case detailed by Dr. Bobbins (Lond. Med. Gazette, vol. x., p. 175), in which, owing to an un- sound tooth, substances were usually taken and masticated in one side of the mouth without being brought in contact with the side on which the diseased tooth was situated. After the tooth was removed it was found that taste in that side of the mouth was impaired. A slight degree of ageus- tia often is associated with loss of smell in severe catarrhs and coryza ; and it is then owing chiefly to the state of the nerves of smell and taste. Marked impairment, however, of the former sense often also slightly impairs the latter. 12. iii. Paralysis of the Organs of Sight.—Palsy of Vision.—Loss of Sight.—Amaurosis (from *p*vi>o;, obscure) —the drop serene of Milton—Gotta serena, of the Italians, —or nervous blindness,—may be defined to be, "a partial or total blindness" owing to the state of the retina, or of the nerves, or of that part of the brain related to the organ of sight, caused by functional disorder, or by congestion, or by inflammation, or by any other change of these parts; or by sympathy with other organs : or, in other words, partial or total loss of sight from other causes than those which obstruct the passage of the rays of light to the bottom of the eye—or to the retina. 13. Palsy of vision is met with at all ages; but most fre- quently in the advanced epochs of life. It is sometimes con- genital: and it is then often difficult to ascertain the seat and nature of the affection. At advanced periods of life, the history of the case, of the previous habits and ailments of the patient, and of the various resulting and related mor- bid phenomena, will generally throw light upon the pathology of the disease. 14. A. Seats of Amaurosis.—Privation of sight may be owing to affections of either of the following parts;—1st. To functional or structural lesion of the retina; 2d. To the state of the optic nerves;—3d. To the functional or struc- tural conditions of the organic or ganglial nerves communi- cating with the lenticular ganglion and nerves of the eye ;— 4th. lo the state of the nerves which send branches to the eye, as the fifth and third pairs of nerves;—5th. To the PALSY OF SENSE OF SIGHT. 19 parts of the encephalon connected with the optic nerves, either at their origins or in their course;—and 6th. To st ites of the pineal and pituitary glands. 15. That impaired or abolished function of one or more of these parts will occasion amaurosis is by no means im- probable ; and that such impairment or even abolition may take place independently of organic change of an obvious kind may be admitted, although not readily demonstrated. For there are causes which will directly depress the sensi- bility or vital functions of these parts, whilst there are others which will indirectly depress or exhaust the functions which these parts severally perform. Admitting the existence, then, of functional amaurosis, it may be inferred that the impairment of function of one or more of the parts just enumerated cannot long exist unless it depend upon some degree of vascular or structural change, or without super- inducing such change; and accordingly numerous lesions have been detected by observers, in connection with loss of sight in the situations now particularized. The organic changes upon which the disease most frequently depends are very numerous, and many of them are identical with those which occasion several other forms of palsy. They will therefore be noticed in the sequel. The most important of them have been described, and the symptoms most frequently connected with each have been noticed under the head Amau- rosis, in the Author's "Dictionary of Practical Medicine." 16. B. The symptoms of Amaurosis are, 1st. Those which the patient himself experiences; and 2d. Those which the physician detects in the eyes, or in the several organic and animal functions. Each of these classes of symptoms are to be inquired into separately. Each eye should be carefully and separately examined, the light being extended from the one whilst the other is observed; the effects of gradations of light being remarked. 17. a. The loss of vision may be gradual in its accession, or remarkably sudden, and may amount to an almost total deprivation of sight. It may be more gradual in one eye, and more sudden and complete in the other. Hence, the disease has been distinguished by the epithets, slow and sud- den, incomplete and complete, or imperfect and perfect. 18. At the commencement the failure of vision is some- times only occasional for a short time, and after shorter or 20 PALSY OF SENSE OF SIGHT. longer intervals. In some cases it assumes the form of day- blindness, in others of night-blindness; and it not unfre- quently recurs for a time after great exertion of the eyes with either minute or bright objects. Sudden and transient attacks are often the consequence of disorder of the digestive organs, or rather of a state of the vital manifestations which occasions equally loss or impairment of sight as well as of the digestive functions. 19. Palsy of sight is often at first only partial—extend- ing only to a part of the field of vision. In some cases in- tervening portions of the field are obscured: in others one- half of it is hid from view. Occasionally objects are seen only in a particular direction; some patients discern objects in a distorted form—in a crooked, mutilated, shortened, lengthened, or inverted form. Double vision is not unfre- quent; and in rarer instances the objects are doubled as well as otherwise distorted. These conditions are generally the results of disease within the head. 20. In some cases the failure of vision assumes the form of shortness or great nearness of sight, or an indistinctness of sight as respects near objects, and a clearer view of dis- tant objects. But these are not so frequent as the occur- rence of false impressions, in the form either of flashes of light, shining stars, globes of light, and various other lucid spectra; or of dark spots or motes, or other dark objects in the field of vision. False impressions of colour are also frequent in the early course of amaurosis. Luminous spec- tra are most common in plethoric persons and when amau- rosis depends upon increased vascularity or inflammation of the retina; motes, black specks, muscse volitantes, and thick mists or clouds, when the affection arises from exhaustion of the sensibility and vital energy of the organ; and when it occurs in dyspeptic subjects, or from exhausting causes. 21. As the disease advances the field of vision is ob- scured as if by a cloud or net-work; the latter appearing gray or black in a good light; but occasionally becoming light, white, silvery, yellowish, red and luminous in the dark. The patient sometimes also complains, especially early in the disease, of some intolerance of light, or of pain in the eyes when exposed to light. But, in other cases, from the very beginning, diminished sensibility of light, and a constant desire for a stronger light—a thirst of light—are present. PALSY OF HEARING. 21 Pain in the eyes and commonly also in the head is an import- ant symptom, and it should be carefully investigated. The precise seat, extent, and character of the pain, and the cir- cumstances which relieve or aggravate it should be noted. We should also ascertain whether or not it be attended by giddiness, noises in the ears, wakefulness, forgetfulness, tor- por, inability of exertion, or failure of any of the mental mani- festations ; as from the grouping of these symptoms the nature of the efficient cause of the affection may be inferred. 22. b. The general health and previous ailments of the patient require a particular investigation in this as well as in the other forms of palsy. The temperament, diathesis, and habits of the patient should be considered; and preced- ing attacks of gout, rheumatism, inflammation of the brain, fever, apoplexy, epilepsy, inquired after and duly consid- ered. We should ascertain whether the patient is of the scrofulous constitution, or whether he has had syphilis, or sustained internal injuries, or undergone long or severe courses of mercury; and, in the case of a female, whether she has been Subject to any hysterical affection, or disorder of the uterine organs. Amaurosis, occurring either in an uncomplicated or in a complicated form, presents numerous phenomena, many of which vary with the particular patho- logical condition upon which the affection depends; but these are generally either identical with, or very closely allied to, those observed in other states of paralysis. 23. PagAtion of sensation, are really thus exclusively employed. The alteration producing PALSY CHIEFLY OF SENSE OF FEELING. 33 anaesthesia may exist in the brain, in the spinal cord, or in the nerves themselves; but although the posterior roots of the spinal nerves appear to be more especially concerned in the function of sensation, it has not been fully shown that the posterior columns of the spinal cord are the appropri- ated channels for the transmission of sensation. Numerous cases are recorded in which the posterior columns have been disorganized, or even the whole cord pressed upon, softened, or otherwise disorganized, and yet the sensibility has either been unimpaired or even increased. Some of these cases have been referred to by M. Ollivier, and others have been lately published in recent transactions of societies and periodical works. To these a more particular reference will be made in the sequel. I may here, however, briefly remark, that anaesthesia has followed causes affecting chiefly the sur- face of the body, as the prolonged influence or excessive degree of cold. It has been likewise produced by torpid or interrupted circulation of blood in the part. It is sometimes a symptom in hysteria and hypochondriasis, in all which cases it is usually partial or limited as to extent; and it has occurred in the puerperal states. It has also appeared in connection with certain epidemics affecting the system gene- rally, and the cutaneous surface and extremities more par- ticularly, as that which prevailed during the summer and autumn of 1828 in Paris,—a circumstance calculated to sup- port the view of the pathology of ansesthesia which I shall have to state hereafter. 52. G. The singular occurrence of epidemic ansesthesia which took place in Paris in 1828, was described by several contemporary writers, and in the Medical Journals of that year. (See Journ. Hebdom. de Med., vols. i. and ii.) This affection began with pricking and severe pain in the integu- ments of the hands and feet, followed in some cases by inflam- matory redness, and accompanied more generally by so acute sensibility that the patients could not bear those parts to be touched by the bed-clothes. After some time, a few days, or even a few hours, a diminution, or even abolition, of sensation took place in the affected members ; they became incapable of distinguishing the shape, texture, or tempera- ture of bodies, the power of motion declined, and, finally, they were observed to become altogether paralytic. The injury was not confined to the hands and feet alone, but 34 PALSY CHIEFLY OF MOTION. advancing with progressive pace extended over the whole of both extremities. Persons lay in bed powerless and help- less, and continued in this state for weeks and even months. Every remedy which the ingenuity of the French practi- tioners could suggest was tried, and proved ineffectual. In some the stomach and bowels were deranged, and this affec- tion terminated in a bad state of health, and even in death. In another, the vital organs, cerebral, respiratory, and digestive, were in the same state as before their illness, and their appetites were good, but still they remained paralytic. At last, at some period of the disease, motion and se?isation gradually returned, and a recovery generally took place, although in some instances the paralysis was very capri- cious, vanishing and again re-appearing. In a few instances the palsy became general and complete, and terminated fatally. The nervous centres were examined for the imme- diate cause of this strange disease ; but there was no lesion found in the brain, cerebellum, or spinal marrow. That the disease was chiefly owing to an alteration of the more peri- pheral distributions of the organic or ganglial nerves appears not improbable, seeing that, in many cases, the altered sen- sibility was attended by inflammatory appearances in the extremities; and it is well known that these nerves not only evince sensitive functions, but also actuate the bloodvessels. CHAPTER, II. OF PARALYSIS CHIEFLY OF THE FUNCTION OF MOTION. 53. As already observed, either of the functions of sensa- tion and motion may be more or less impaired or entirely lost, whilst the other is unimpaired; or both maybe im- pairedm different degrees, or both may be lost. The func- tion of motion is, however, more frequently affected than ?nTlU,EenSatl0n; but When either is completely abolished paired °r m°re Senerall?> th* other is more or less im- 51. Under this head are comprised those varieties of the PALSY CHIEFLY OF MOTION. 35 disease which affect a part only of the body. They are divided, as already noticed, into—1st Local paralysis;— 2d. Hemiplegia;—3d. Paraplegia;—and 4th. General palsy. i. OF LOCAL OR PARTIAL PALSY CHIEFLY OF MOTION. 55. Local paralysis implies loss of motion, or of sensa- tion also, in some part only of the body, and to a small extent. Although sometimes a limited form of the disease, it is more frequently the commencement of a more extended malady. It is occasionally an evanescent or slight affec- tion : but it is as frequently ingravescent or permanent, or followed at some indefinite period by a much more severe shock or attack, as coma, apoplexy, &c. 56. a. Paralysis of motion of particular muscles and parts is not infrequent, occasioning affections, to which certain names have been applied according to their seats. Strabismus, or Squinting, is often caused by palsy of one or more muscles of the eyeball, although not by this in all cases; for it may be produced, but much more rarely, by spasm of one or other of the muscles attached to the side of the eye to which the pupil is drawn. In either case, it is often symptomatic of a lesion of the substance or membranes of the brain of a serious or dangerous nature. It may, how- ever, be congenital, or be the result of injury during birth; or it may be caused by disease in infancy or childhood—the symptomatic affection remaining after the lesion which pro- duced it has been removed. It may, moreover, result from habit contracted in childhood.—Squinting may be associ- ated with other forms of palsy—with palsy of the muscles of the face, or with hemiplegic ansesthesia, or with hemi- plegic loss of motion, or with a combination of both in various grades. It is a common symptom of scrofulous softening of the more central parts of the brain. 57. b. Ptosis, or falling of the upper eyelid, often arises from an atonic or paralytic state of the levator palpebrce superioris muscle, owing to some alteration implicating the nerve which supplies it; although it may arise also from a spasmodic action of the orbicularis palpebrarum muscle. A slight examination, or the degree of resistance opposed to raising the eyelid, will immediately show the nature of 36 PALSY CHIEFLY OF MOTION. the affection, Ptosis from local palsy is often associate£ with squinting, showing that the third pair of nerves is palsied It is always a serious affection particularly when thus associated; and is often indicative of cerebral disease, being frequently a precursor of hemiplegia or even of apo- plexy- and it often attends complete hemiplegia (§§ 75, et sea ) It is a common and most unfavourable symptom of the advanced stages of diseases of the brain in children. It is, however, sometimes caused by a tumour pressing upon the nerves in some part of their course. 58. c. Lag ophthalmia, or gaping of the eyelid, the eye being generally open or imperfectly closed, sometimes pro- ceeds from paralysis of the orbicularis palpebrarum muscle, owing to disease of, or implicating the portio dura nerve. When this is the case, the affection is associated with a state of partial palsy about to be noticed. 59. d. Palsy of the muscles of the face is not infrequent, and is generally caused by pressure, injury, or disease of the portio dura and fifth pair of nerves. If loss of motion is complete, the portio dura and motor branches of the fifth pair are affected; if sensibility also be abolished, then the sensitive part of this nerve is implicated. Where the portio dura only is paralysed there is little evidence of palsy until the muscles supplied by this nerve are called into action. As long as the patient neither speaks nor smiles the countenance presents nothing remarkable; and the sensibility of the face is unimpaired. But when laugh- ing, coughing, sneezing, crying, or any of the actions of excited respiration are produced, the deformity of the coun- tenance is apparent. The mouth is drawn to the sound side; the derangement of the features being remarkable in proportion to the intensity of the respiratory act. The affected check remains motionless, while the other is thrown into unusual action, is flaccid or swells out at the moment of expiration, or wThen the patient attempts to pronounce a word with emphasis, and appears broader and more promi- nent than the sound one, which is more contracted or wrinkled. The muscles moving the jaws and used in mas- tication, which are supplied by the motor portion of the fifth, still perform their functions. Owing to the palsy of the lips on the affected side, the labial consonants are im- perfectly articulated; and saliva, or even aliments some- PALSY CHIEFLY OF MOTION. 37 times escape from the palsied side of the mouth. The patient is unable to spit out his saliva, or to blow fully, or to snuff up with the nostril of the affected side. Lagoph- thalmia generally accompanies this state of the disease, the eye appearing more prominent, and, being exposed to constant irritation, generally becomes inflamed. In pro- tracted cases the muscles are wasted; and hence the face acquires a peculiar expression. 60. Palsy of the portio dura maybe occasioned by severe or protracted cold, or currents of air, giving rise to what was usually termed a blight: but it is probably more fre- quently caused by an inflamed or enlarged state of the parotid gland, or a tumour in the vicinity of the stylo-mas- toid foramen, or inflammation or abscess of the internal ear, or by disease of the petrous portion of the temporal bone, or by a tumour or abscess compressing the nerve at its entrance into the internal auditory foramen; by disease of the brain at the origin of the nerve; or by one or more tubercles, or ulceration implicating the nerve in some part of its course; or, lastly, by a wound or injury of the nerve. It is thus a not infrequent consequence, at some more or less remote period, of chronic inflammation of the ear occurring either primarily or in the course of scarlet fever; the disease having extended to the bones of the ear, to the temperal bone, and ultimately to the membranes and sub- stance of the brain. Several instances of this occurrence have been mentioned in my work on Practical Medicine, when treating of diseases of the brain and of scarlet fever. It often accompanies concussion of the brain or fissures of the base of the cranium, especially when attended by hemor- rhage from the ear. 61. When the motor portion of the fifth pair of nerves only is palsied, there is generally slight loss of sensibility of the parts supplied by this nerve ; but the motions of the jaw on the affected side are impaired. Mastication is im- peded, and is not performed on that side owing to the palsy of the muscles which convey the morsel to the opera- tion of the teeth, and to the lost action of the masseter and temporal muscles. There are still, however, command over the countenance, little or no distortion of the features, and no loss of expression. The jaw is in some cases a little depressed; but this disappears when the patient smiles or 4 38 PALSY CHIEFLY OF MOTION. laughs, a circumstance distinguishing this variety of palsy from that caused by disease implicating the portio dura nerve. This state of disease may exist alone; but it is commonly associated with loss of sensibility (§ 36, et seq.), and is usually further complicated with hemiplegia. The disease of the motor portion of the fifth pair may be seated in the course of the nerve, or in or near the origin of it in the brain. 62. As Dr. Bennett has very justly remarked, it is rare that the lesions are confined to the fifth or to the seventh pair of nerves. In general, the symptoms of disease of the one and the other are conjoined; although they seldom in- dicate an equal affection of both nerves. Commonly the disease appears first in the one, and then in the other; and when the muscles on which the nerves first affected ramify are completely paralysed, the muscles supplied by the second are partially affected. In some of these cases, also, the paralysis is accompanied with neuralgia of a very acute description. Palsy of either of these nerves is very rarely met with in both sides in the same case. Dr. Abercrombie met with an instance of palsy of the fifth pair on one side of the face, and of the portio dura on the other, occasioned by a tubercle in the brain. 63. e. Palsy of particular muscles or of a single limb is not uncommon. Temporary palsy is not infrequently pro- duced in these by casual pressure of the nerves supplying them. It may arise, also, from overstraining the nerves or the muscles themselves by over-exertion, as by lifting very heavy weights. Dr. Healy has 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. Darwall has ascribed the palsy consequent upon over-exertion to the injury done to, or overstraining of, the nerves supplying the affected muscles. 64. Palsy of a single limb is not infrequent in children. It is often congenital; and the upper 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 cord is probably more immediately than PALSY CHIEFLY OF MOTION. 39 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 case. 65. 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 being, ac- cording to Sir C. Bell, muscles naturally combined in action, although supplied with different nerves and difierent blood- vessels. Occasionally, even when the lesion is seated in the brain, one limb, especially one arm, is chiefly or solely para- lysed—generally as respects its movements, but sometimes also as regards its sensibility, which, however, is less com- pletely lost. 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 writing, or for any fine work, were completely lost, whilst the arm could be moved as strongly as ever. I was lately consulted by a gentleman, who, after complaining of headaches, experienced a partial loss of power of his fingers, preventing him from writing and the more delicate move- ments of these parts. His arm was strong, and he could grasp with the fingers with considerable power : there was nothing wrong locally that could be detected. It has been supposed that the nerve in these cases is incapable of per- forming its functions owing to pressure or disease ; and this is probably the case in some instances, as in those recorded by Drs. Abercrombie and Storer, and more especially when partial paralysis follows acute or chronic inflammation of a nerve. It is even possible that, in other cases, the palsy is caused by imperfect or interrupted circu- lation through the bloodvessels of the limb, owing to disease of them, as supposed by Graves, Stokes, and others. But, in some instances, as in the two just adduced, 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 40 PALSY CHIEFLY OF MOTION. age, and of a full habit of body, there was no sign of dis- ease in either the nerves or the bloodvessels of the limb itself. I prescribed for her bloodletting, which was per- formed under my own eye, twenty-four ounces being quickly taken away without any faintness being caused. After the depletion and purging, the partial state of palsy gradually disappeared. 66. f. Paralysis of the tongue and muscles of articula- tion, although occurring frequently in connection with hemi- plegia and apoplexy, is rarely met with alone, or without more or less impairment of motion in some other part. In- stances, however, occur of thickness of speech, want of dis- tinct articulation, and even of almost complete inarticula- tion, without any other attendant paralysis; but either of these states is usually followed, at some indefinite period, by more general palsy, or by apoplexy. In some cases the paralysis of the faculty of speech has at its commencement been accompanied by apoplexy, or by palsy of other parts, which have been removed by treatment, the impairment or loss of articulation alone remaining. I have been con- sulted in several cases in which loss of the power of articu- lation was either the chief apparent disease, or was asso- ciated only with difficult or impossible deglutition. Some- times palsy of distant parts attends the loss of speech, or of deglutition also. 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 without benefit from treatment, and died soon after. I have not learned the particulars connected with his death. In this case, loss of articulation was the first and chief symptom, yet the tongue could be protruded without being drawn to either side. 67. Some years ago, Mr. Winstone consulted me in the case of a professional gentleman, aged about fifty, who had for many months lost all power of uttering the most simple articulate sound, and who swallowed substances with the utmost difficult, or not at all, unless they were conveyed over the base of the tongue. The tongue could not be pro- truded, and indeed was incapable of motion. The mouth, PALSY CHIEFLY OF MOTION. 41 also could be opened only imperfectly, but the sense of taste was not affected. He had neither headache nor any other ailment; and no other part was paralysed. He attended regularly to his profession during the usual hours of busi- ness ; 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 occurred some months after my attendance ceased. Various means were prescribed without any effect on the disease. 68. Most frequently, however, paralysis of the muscles engaged in articulation, or in deglutition, or in both func- tions, follows upon severe or renewed attacks of apoplexy, or of hemiplegia complicated with apoplexy. I have seen it occur after inflammation of the brain and after cerebral con- vulsions 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. 69. g. Loss of voice, or aphonia, in the true sense of the word, can occur only when the larynx is affected—either its muscles being paralysed, or its structure changed by serous or other effusion between its ligaments, tendons, or carti- lages. 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 simplest 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 hysterical or nervous persons, and is thus a complaint of comparatively little importance. Loss of the power of arti- culation is a much more serious and permanent malady than aphonia, and is either attendant upon, or followed by, the most complete or fatal states of palsy or apoplexy, unless in hysterical cases; and in these the motions of the tongue are also sometimes temporarily lost. In catalepsy, voice and articulation are quite lost, with all voluntary motion, but they return as soon as the cataleptic attack ceases. In 4* 42 PALSY CHIEFLY OF MOTION. incomplete palsy of the tongue, protrusion of it may gene- rally be affected; but it is usually drawn to one side, parti- cularly if hemiplegia also exist. But if this form of palsy be not also present it is protruded in a straight direction, or it is protruded imperfectly. The tongue, even in cases of he- miplegia, is not always drawn towards the sound side. ^ Some- times it is drawn to the paralysed side. Lallemand 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. Cruveil- hier attributes the direction of this organ, when protruded, to feebler resistance on one side than on the other. 70. h. Paralysis of the respiratory movements when complete causes death in a few seconds; but these move- ments may be incompletely paralysed, especially those of the intercostals, and life continue for a time varying with the degree of loss of power. Several diseases attended by organic lesion, extending to the base of the brain and medulla oblongata, or upwards from the spinal cord to these parts, terminate life by the asphyxia consequent upon palsy of the respiratory muscles, the nerves of respiration being implicated at, or in the vicinity of, their origins, or as they pass through these envelopes and the foramina of the bones which protect them at their sources. Thus, injuries extend- ing to the base of the brain or the medulla oblongata, or the changes and products of inflammation of the sheath, or membranes, or substance of the medulla, or of parts in the immediate vicinity, produce paralysis of the respiratory muscles in either an incomplete or complete form, according to the extent and seat of lesion, and to the slowness or rapidity of the organic change. Paraplegia, especially when passing or having passed into general palsy (§§ 124), most frequently terminates fatally, owing to the extension of the paralysis to the muscles of respiration. Dr. Schoen- lein of Berlin has recorded a case in which a large fibrous tumour involved the first cervical ganglion of the sympa- thetic nerve on the right side, destroying the natural struc- ture of the ganglion, and altering that of the communicating cerebral, spinal, and ganglial nerves. The patient, a female, complained of palsy of the upper extremities, with numbness and tingling, palpitations of the heart, oppression and suf- focating sensations in the chest, and threatened asphyxia, PALSY chiefly of motion. 43 of which she died. (M. Lebert, Physiol. Patholog., £c, vol. ii., p. 179.) 71. i. Paralysis of any of the muscles of organic life rarely takes place to a considerable extent, and is, indeed, incompatible with the continuance of life, unless in those viscera which are more or less influenced by volition, as the urinary bladder, the rectum, the sphincters, &c. A tem- porary state of relaxation or loss of the contractile power of portions of the alimentary canal not infrequently occurs in the course of various diseases, and constitutes a part of the pathological conditions obtaining in inflammations of this canal, in colic 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. An incomplete state of palsy of the muscular coats of the digestive tube, attended by remarkable torpor of these coats and great flatulent dis- tension of this tube, often accompanies the more severe cases of hemiplegia and of paraplegia, especially as they advance to a fatal issue. 72.7k. Palsy of the urinary bladder, owing to over-dis- tension, is a frequent occurrence: it is likewise connected with paraplegia ; and in both circumstances of the com- plaint retention of the urine is the prominent phenomenon. Hysterical paralysis of the bladder is often met with. Sir B. Brodie remarks that, in these cases of hysterical para- lysis, "it is not that the muscles are incapable of obeying the act of volition, but that the function of volition is sus- pended." Of course, the muscles possess their capability of motion ; but a careful inquiry into the phenomena of hyste- rical paralysis in some cases which have come before me, has shown that, owing to a weakened or exhausted state of the spinal cord and motor nerves, volition is not transmitted in sufficient force to produce muscular action; that volition is not suspended, although it may be weakened; and that it must be made with more than usual energy to act upon, or even to be transmitted to the muscles. 73. I. Palsy, more or less complete, of the rectum is not infrequent in aged persons and in hysterical females. In these cases, faecal accumulations often form in the rectum and colon, owing to the inaction or want of power of these parts of the alimentary canal to overcome the resistance of 44 PALSY OF ONE SIDE. the sphincter. But in many of these cases, the paralysis- extends also to the sphincters, especially to that of the rec- tum, the accumulation taking place more or less throughout the colon and rectum, the faeces being indurated in conse- quence of absorption of the more watery parts, and the sphincter ani being equally paralysed with the rectum. 74. m. Palsy of the sphincters of the rectum and bladder attends most maladies in which either the brain or the spinal cord is oppressed or has lost its power. The inability to retain the faeces, or the incontinence of urine which re- sults, becomes one of the most troublesome and unfavoura- ble phenomena of the disease. 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