too lucid and distinct, and that he has not brought forward with sufficient prominence and force the difficulties which very often practically, and at the bedside, exist in defining the exact cause of the paraplegia; or, in other words, in establishing to which category a given case pertains. Being aware of the extent to which the proper adaptation of remedies in the various forms of paralysis depends upon a just diagnosis, and how pernicious treatment may prove in the absence of such diagnosis, one is not a little tantalized by the contrast between the clearness and precision, on the one hand, with which the true line of treatment is mapped out, and on the other, the consciousness that cases in actual practice of reflex paralysis are very numerous in which, (as in reflex epilepsy) the "fons et origo mali," the exact and vulnerable source of the outside irritation, fails to declare itself openly. Certainly, with regard to the majority of cases of epilepsy, we know no point in the whole range of pathology more difficult than the determination of the source of the morbid irritation. As Dr. BrownSéquard observes (p. 8), speaking of the characteristics of reflex paralysis, "An outside irritation, starting from some sensitive nerve, exists before the reflex paralysis appears." The enigma, both as regards epilepsy and reflex paralysis, is, in too many instances, to discover the spot from which it does start, as the expectation of cure depends on this discovery and on the removal of the irritation, although in very many cases, even when the cause is removed, the effect does not entirely or quickly cease. In this respect we experience a want in the author's work of more guidance, owing to the absence of specific individual cases, the relation of whose circumstances should illustrate, enforce, and render more intelligible the general propositions adduced. We naturally have our misgivings as to the direct connexion supposed to subsist between certain forms of paralysis on the one hand, and the many lesions of viscera, pleurisy, pneumonia, &c., on the other, which are described as occurring in the paraplegic patient, so difficult is it to demonstrate the "punctum" or source from which real or supposed morbid impressions (especially in inward parts) are conveyed along the nervous channels centripetally. Touching the question of treatment, the author attempts, as we have described, to show why it is that one set of remedies best suits the reflex form, and why others alone are useful in other forms of paraplegia, basing their various uses, which, indeed, are empirical (in the proper sense of the word), upon their supposed action on the capillaries of the spinal cord, dilating or contracting them, as the case may be, and thus increasing or diminishing the supply of blood to the cord. This explanation, of course, has exactly the same cogency and weight as that given of the causation of the paraplegia itself, and it would appear that our author was led to make the inferences which he did respecting the connexion between reflex paraplegia and a contracted state of the spinal capillaries, by noticing the action upon these vessels of those remedies which proved successful in given cases. This proposition suggests a question which we should like to have answered; for, remembering that reflex paraplegia is thought essentially to depend upon a "contraction" of spinal capillaries, and that the useful action of certain remedies assumed to produce contraction of spinal capillaries is attributed to the supposed fact that the excessive contraction of these vessels is followed, ex necessitatê, by their dilatation, one is unavoidably driven to inquire, how it is that the original contraction of these vessels, the conjectural sine quâ non of this disease, does not, by the same law, lead spontaneously to their reactionary dilatation, and thus subsequently to a spontaneous cure of the disease? There is one reflection which naturally arises in the mind, on considering the value of diagnostic differences between various kinds of paraplegia, and it is one which is not, we believe, adverted to by our author. It is this-viz., to what extent may certain organic changes found in the spinal cord after death, in cases of paraplegia, be the result of abnormal molecular or other conditions of the cord, ORIGINALLY BROUGHT ABOUT IN THE REFLEX VARIETY OF PARAPLEGIA, and therefore the result of morbid excentric impressions conveyed to the nervous centre by afferent nerves? This is manifestly a problem of no little significance, and one which, as far as we know, yet awaits its solution. We have ample data, it would appear, for supposing that frequent aberrations from the ordinary and healthy condition of the cerebral capillaries, such as not uncommonly exist in epilepsy of ex-centric origin, may in the course of time and in particular instances lead to organic cerebral changes. Why, then, may not such sequences occur with regard to the spinal cord, however the changes in the state of the capillaries may have been, in the first place, conditioned? Indeed, with regard to the spinal cord, a case related by Portal* is much to the purpose. It is one in which spasmodic action of the muscles of the "left" leg was for a length of time wont to take place shortly before the catamenial periods, abating when the attendant flux had ceased. Subsequently, the left leg became paralysed, and then spasmodic action of the left arm came on; the patient died of coma, and after death the spinal cord was found to be red and softened, but this structural alteration was, curiously enough, on the "right" side. It is an interesting speculation, whether or not in this case the spasm was of a reflex character originally, and the subsequent paralysis due to interposing histological alterations in the cord, which in the first instance were the result of functional changes, which functional ones had followed the conduction of morbid impressions along afferent nerve-fibres. We think we are justified at this juncture, especially in calling attention to the contingency which we have mentioned, because the point under consideration is that of a "contracted" state of spinal capillary vessels; and it is a contracted state of blood vessels (diminished calibre-i.e., and therefore diminished bloodsupply) which, when permanent, leads to softening and other intimate alterations of delicate nervous tissue. If we are able to recognise the possibility of such an occurrence, it is very easy to conceive that post-mortem examination may, in indivi * Cours d'Anatomie Médicale, 1803, tome iv. p. 116. dual cases, be far from helping us to the diagnosis between the reflex and the other forms of paraplegia. Before bringing our observations to a close, we cannot help referring to a lecture by Mr. Wells, on Paraplegia, which appeared in the 'Medical Times and Gazette' for November 14th, 1857. In it we find, besides a good recount of the then existing state of our knowledge on the matter, several interesting practical remarks, enforcing attention in a pointed way to the reflex form of the disease. This variety, as it occurs in connexion with disease of the urinary organs, is described “ad naturam," both as regards its etiology, mode of approach, and regular course; it appears to us, however, that in certain respects some confusion exists in this description touching the diagnostic symptoms of the reflex form of paraplegia and that from myelitis. In the matter of treatment Mr. Wells, in one respect, differs very decidedly both from Graves and Brown-Séquard, and that is as regards the exhibition of strychnia as a remedy. After enlarging on the mode of treatment, general and local, which is desirable in reflex paraplegia from urinary disease, he remarks: "As to strychnia, I have seen it tried in small doses, and I have seen it carried on till its characteristic effects have been produced; I have seen it do harm, but I have never seen it do any good whatever. Galvanism or electrogalvanism, on the contrary, I feel quite certain, is of very great utility; but it must be used perseveringly.' دو From the results of our own practice we can by no means endorse this anathema as respects the nux vomica, provided that the proper cases for its administration have been selected; and we have no doubt that in paraplegia, as in many other diseases, owing to deficient care, or impossibility by reason of complications, in duly diagnosing particular cases, good and efficient remedies have acquired, like the once naughty dog of renown, that "bad name" which undeservedly, but infallibly, sticks to it for ever after.* In considering the literary character and qualifications of the works placed at the head of this Article-and we speak chiefly of that devoted to the subject of paraplegia-we observed undoubted indication of hastiness in composition and, in consequence, some occasional obscurity in meaning- as, for example, at p. 59, where a certain amount of intricacy attends the delineation of the diagnostic difference between the forms of local myelitis. Again, in places, we experienced difficulties owing to the absence of strict separation between different subjects treated of, sections wanting here and there their appropriate * Here we must also allude to the communication read at Birmingham by Dr. W. Hinds (mentioned before at page 387), in which two cases of paraplegia, supposedly from disease of the kidney, are related. In Case I. this affection was supposed to be owing to a scrofulous state of the kidney, but unfortunately the spinal cord was apparently not examined. In Case II., the patient was suffering from hæmaturia and pain in the left loin, the left leg being more affected than the other one, and was still under treatment. Dr. Hinds has recently informed us that regarding this second case, though the health has shown a slight improvement, the paralysis has slightly increased, and both lower extremities pretty equally implicated. Towards the end of the year 1860, the patient passed blood from the bladder, a quarter of an hour before making water. The lumbar pain has not the severity it formerly had. He complains much of numbness of both hips, legs, and thighs. headings-as at p. 109, where that of treatment is not separated from that of symptoms; or at p. 42, where that of diagnosis runs into that of prognosis. We are also of opinion that more detailed and didactic guidance as to the doses of remedies required would for the purposes of many readers much enhance the value of the work. These imperfections, easily to be removed in a future edition, do not, however, in any manner, detract from the abstract value of the works, and we think that the profession is much indebted to Dr. Brown-Séquard for the able and complete manner in which, by the juxtaposition and comparison of pathological cases, and of the results of experimental research, he has illustrated the general subject of paraplegia, and especially the more limited one of reflex paraplegia. We look forward with interest to the completion of those Lectures on the Diseases of the Nervous System which are now in the course of publication by the author, and with which we hope to make our readers familiar at a future time. REVIEW VII. Mémoires de l'Académie Impériale de Médecine. Tome xxiv., I. PASSING Over M. Dubois' eulogium on Geoffroy St. Hilaire and M. Guérard's 'Report on the Medical Employment of the Mineral Waters in France during 1857,' we come to M. Trousseau's ' Report on the Epidemics observed in France during 1858.' The complaints of the neglect or inefficiency of the official reporters, which we noticed in our last review of the 'Transactions of the Academy,' are reiterated again by M. Trousseau. Fortunately, there seems to have also been less to report upon during 1858; even typhoïd fever, that standing scourge of the French provinces, having proved far less prevalent than usual. Still, one affection took on a great extension, and alone caused more deaths than all the other epidemic diseases of the year combined. Diphtheria, which had begun to manifest itself in 1857, spread rapidly and extensively in 1858, so that few departments were exempted. Unfortunately, the statistics which have been obtained cannot be regarded as exactly representing the mortality, and still less the numbers, of those attacked. Such as they are, those received from thirtyone departments represent 1568 adults and 7474 children (i.e., under sixteen years of age) as having been attacked by the disease, 165 of the former and 3384 of the latter dying. M. Trousseau thus describes some of the peculiarities in the mode of invasion of this epidemic : "The invasion of diphtheria has not taken place simultaneously throughout France. Already in 1857 several departments were invaded, the disease appearing in a certain number of localities along the sea coast, from Boulogne to Havre, and beyond. At the same time it appeared in England, where the extent of its propagation has excited extreme solicitude. Frequent communications between the places affected would seem to explain the almost regular progress of the disease, taking Boulogne as a starting point; but an examination of the facts is far from confirming this supposition. Not only other centres existed simultaneously, but these were situated in the most distant provinces of the Pyrenean chain; and even with respect to the littoral departments, it will be found, by inspection of the dates, that the invasion did not take place through places in proximity. The same was observed in 1858. Diphtheria did not traverse France more or less rapidly from one point to the other; but it prevailed at the same time in countries situated at great distances from each other, not having followed the progressive course analogous to that of which the first invasion of cholera, for example, furnished so striking an example. When epidemics explode, in the absence of a single impulsion a greater or less number of partial centres may become established, whence the disease radiates to the environs. This is the case with some of the epidemics of typhoid fever. The disease is found, spontaneously developed or imported from a distance, fixing itself in a centre of population, whence, after having been developed for some time, it extends to the neighbouring communes, sparing some, and implanting itself in others, but always the prodect of an importation which may be traced. Diphtheria does not obey this law. One, two, or three centres of population in a country are attacked with various intensity, without its being possible to seize the origin of the contagion or to trace any relation between the affected localities. "If in place of studying its propagation at great distances, we content ourselves with following the mode of communication of the disease in each local centre, we are met with no less difficulties. Sometimes the family in which the first case is observed, or, so to speak, the 'parent-house' of the epidemic, is almost entirely subjected to various degrees of the diphtheritic intoxication; while, at others, a single child alone is affected, the rest of the inhabitants of the house remaining entirely exempt. Sometimes we may follow the succession of the early cases in neighbouring houses, but in general even small villages do not furnish such a series. Isolated farms, having no communication with the affected hamlets, are attacked, while the cases occur in the village at hazard, or at all events without any ascertainable affiliation. Must we, then, renounce the investigation of the mode of propagation of this disease, and confine ourselves to the registration of contradictory facts? Not so. Even presumptions, providing they be advanced with extreme reserve, may serve as a starting-point for ulterior researches. The "The first question is this: Is diphtheria contagious? We do not hesitate to reply, yes. It seems to us incontestable, and the epidemic of 1858 would furnish numerous examples, that the contact of a healthy individual with a diphtheritic patient is one of the causes of the development of the disease. For transmission to take place, cohabitation is often necessary. more carefully cases have been observed, the more they have confirmed the existence of centres of contagion. If it be true that the disease once produced has an indisputable tendency to extend in the house in which it has appeared, its mode of importation is far from offering an analogy. In some cases it is known for certain by whom the disease has been imported; but, in general, ignorance prevails with respect to the antecedents, or it is known that the child first attacked has never left the village, and has been placed in no possible relation with any one suffering from it." (pp. xxxvi-xl.) In other circumstances of its history, diphtheria is no less irregular. We are unable to fix its mean duration, nor does it exhibit during its invasion the periods of increase and decline like other epidemics. It is thus evident that its period of incubation cannot be determined. The disease is as insidious in its progress amidst a population, as it is in its course in individual cases. A first case may or may not be immediately followed by others, and then a fortnight or more may elapse 58-XXIX. .9 |