usually partial, and some mental failure. The "partio-general" paralysis of the insane, so well described by Earle, is of this character. Paraplegia, which, in the great majority of instances, arises from obvious injury or disease of the spine, has been ascribed in a few to cerebral derangement, and has occurred as a sympathetic effect of gastric or intestinal disorder, without any perceptible change in the condition either of the brain or of the spinal cord. In chorea sancti viti, paralysis vacillans (styled by some, p. agitans, incorrectly), the tremor or agitation is not constant, but exhibits itself at the moment when an effort is made at voluntary motion. The motion fails in part, and the muscles called upon act with vacillation and irregularity, perhaps feebly. There can be little doubt, I think, that the cerebellum, the organ of association of action, is here affected as well as the nerves, and when the case is severe and protracted, the whole brain may become disordered, the patient grows gradually fatuous, and there is tendency to convulsions.

HEMIPLEGIA, as I have said, is nearly allied to apoplexy, which it may either precede or follow. As the consequence of the apoplectic seizure, it occurs not rarely. Its approach may often be observed and foretold. I have more than once marked in the apoplectic, the exact moment of its occurrence, denoted by a slight quivering of the muscles of the face, trunk, and limbs, which in an instant relax, and subside into a passive condition.

It often invades gradually and independently. The patient first complains of a numbness and tingling of one arm and leg, is apt to trip or stumble, and to let fall what he attempts to hold; there is noise in the ears, and the eye of one side cannot be closely shut; there is some distortion of the mouth, and articulation is impeded. The mind is usually disturbed; the memory generally fails, though not invariably, and some terror attends the feeling of so great a calamity. When fully developed, hemiplegia implies an incapacity to stand or walk, or close or raise the hand or the eye; but the power of sensation and voluntary motion in the side affected, though greatly impaired, is seldom, if ever, totally lost, and in numerous cases the sensibility has remained, or been morbidly enhanced, while motion was impossible, and vice versa. In one remarkable instance, there was a loss of power on one side, while the feeling of that side continued, and loss of sensibility on the other, the voluntary movements of which were not impaired. These facts are explained by reference to the independent origin of the two sets of nerves.

Sometimes the case runs rapidly on into apoplexy, occupying from a few hours to a few days, the prostration of muscular power increas ing, and the mind becoming more and more disturbed, until insensibility and coma supervene.

Many patients, however, drag out a miserable protracted existence of months and years of unabated suffering. The nutritive action of the vessels of the affected limbs is imperfect; they shrink and are emaciated, their natural heat being lessened; harshness and dryness of the surface ensue, the ordinary transpiration ceasing; the fingers are

pale and waxen, and sometimes contracted, the countenance is distorted by the traction of the mouth to the sound side, the saliva escapes over the chin, the tongue is thick, and when protruded, turns to the paralytic side, and the speech is confused and indistinct. There is sometimes severe pain; sometimes spasmodic muscular contractions on the affected side. Amnesia is usually present in various degrees. The memory of words is oftener lost than the remembrance of things or facts. The names of familiar objects are sought for in vain, or incorrect names obstinately applied, and words pronounced by the tongue which the will had not contemplated. The emaciation and debility increase, until the patient sinks, worn out and exhausted by a long train of evils, in which every function has successively suffered.

In a few cases a gradual improvement takes place, and a restoration of some of the capacities for action and enjoyment; but such recoveries are rare. They are attended with formication and tingling of the limb, and sometimes painful swelling, while the power of motion increases slowly, and the mind gains strength. According to my own observation, this recovery of motive power scarcely ever takes place to any great extent, except in the lower limb; the paralytic hand is very seldom restored in hemiplegia.

The causes of hemiplegia are those of apoplexy, already enumerated -plethora, from luxury and excess among the rich, and the apparently contrasted, though closely analogous condition, arising from imperfect supply of food, in the poor; insolation and intemperance in drinking.

The prognosis is unfavorable. We know that absorption of extravasated blood, which, by its presence in the brain, has produced hemiplegia, may take place; but the process is slow and uncertain, and the constitution in the meanwhile sinks under the general impairment of the functions. Laceration and disorganization of the cerebral tissue hardly admit of restoration. Yet recoveries do occur, even after "softening"-ramollissement.

Autopsy. The most common circumstance noted in the examination of hemiplegics, is the presence of a clot of blood in some part of the brain. It is usually, perhaps always, enveloped in a cyst, and has undergone more or less change from absorption. The process is slow; the clot has been found undiminished in size, and filling the cyst, two years after the attack. Sometimes the cyst is found empty, with its sides collapsed; at others, it contains serum. Tokens of inflammation. of a portion of brain are found; there is induration of substance; or softening takes place, the nature of which is not well understood. It is often, I think, a vice of nutrition. Bennett and Solly maintain that it is of two kinds, inflammatory and not inflammatory; and that these are distinguishable by the microscope, which, in the former, will always show the presence of exudation-corpuscles. Abscess or effusion of pus, of serum, various morbid growths, tumors and tubercular deposits, have been seen within the brain, or connected with the membranes. The pathology of hemiplegia is readily deducible from what has been stated above. It is the result of pressure upon some part of the brain; and the degree and kind of effect are in relation to the locality and

extent of the lesion which interrupts the sensorial function. The pressure on which it depends may be, though rarely, intravascular.

Hemorrhage, with softening of cerebral substance around the clot, is supposed to be manifested by complete relaxation of the paralytic limbs. Rigidity of any of their muscles is thought to indicate irritation of sound brain about and in contact with the clot.

The treatment must be varied, as in apoplexy, to suit the condition of the patient. If he be young and robust, the pulse full and strong, the face flushed, with pain and throbbing of the head, he must be bled largely, and cold water poured upon the head from a height. Purgatives of active and irritating character must be promptly administered, and their effect hastened by the acid of enemata.

In the opposite state of the system, when the countenance is pale, the pulse feeble, the skin cold and moist, volatiles must be applied to the nostrils, sinapisms and epispastics to the limbs and trunk, and the head sponged with vinegar and water. Enemata may be given, and leeches or cups put to the temples and back of the neck. If reaction ensues, we should deplete, but with caution.

In the protracted state of hemiplegia, the persevering employment of purgatives has done service; and some of the cathartic mineral springs are celebrated for cures effected. Determination to the head must be combated by keeping the head shaved, and occasionally ap plying a few leeches behind the ears, a blister to the back of the neck; or between the shoulders, or inserting an issue or a seton in that neighborhood. Farther revulsion is attempted by frictions with turpentine, mustard, etc., which are supposed to excite locally the enfeebled muscles and nerves. With the same view, the skin of the limbs affected is irritated with tartar emetic, rubbed with rough tow and hard brushes, stung with nettles, and burnt with moxa. Both the cold and hot baths are much eulogized. But the most useful means in my hands have been galvanism and electricity.

Dr. G. Bird affirms that "in paralysis from persistent cerebro-spinal lesion, when recent, electricity will do harm; he has known a fatal apoplectic seizure from it; and that when paralysis is attended by rigid flexure of thumb and fingers, it does no good. When in old cases the original cause is removed by time and treatment, electricity is most hopeful, especially the electro-magnetic form; we must persevere, however."

The tonics are much employed, especially the metallic-the nitrate of silver, bismuth, zinc, arsenic. Strychnine has been highly recommended, and is supposed to possess specific and peculiar properties, which adapt it to the relief of the hemiplegic. I have also seen some advantage gained by the careful use of veratrine, both externally and internally employed; the difficulty of deglutition, which so distresses some paralytics, being much diminished after frictions with the ungt. veratri about the jaws and throat.

It is not only from pressure or injury of the cerebrum that hemiplegia results; it is the consequence also of lesion of the cerebellum. It appears on the opposite side of the body from the anatomical law of decussation, which, says Romberg, "not only affects the medulla ob

longata, laterally and from before backwards, but also prevails in the cerebellum, the pons, and the peduncles. The upper extremities are more frequently paralyzed than the lower; and when the two are affected, the former suffers most. In the event of a favorable issue, the paralysis is more persistent in the arm than in the leg."

"The attempt," he goes on to inform us, "has often been made to discover detached foci of innervation in the brain, but it has invariably failed." Yet we are perpetually tempted to inquire into the connection between local or partial paralysis, and the conditions of the cerebral or inter-cranial substance with which they may be connected. Of these, the most noticed are the paralysis of the muscles of one side of the face, and the digitus semi-mortuus of Marshall Hall-both of them important, as indicative of cerebral congestion and impending apoplexy. But we have not found any constant lesion associated with them.

Next we treat of affections of the Spinal Cord.

PARAPLEGIA, the spinal paralysis of Romberg, is one of the most hopeless of human maladies. The muscles of the lower extremities and of the pelvis are paralyzed, usually relaxed, sometimes, though rarely, contracted. It is curious to observe that although we ascribe the affection to exclusive spinal derangement, yet that "conscious sensation" is generally impaired. Cases have occurred in which the limbs, however, have retained their sensibility intact. In some instances, micturition and defecation have continued under the control of the patient; in many, the bladder has lost its contractility, and the sphincters are relaxed. Marshall Hall has drawn our attention to the fact that the irritability or spinal sensibility, and the reflex action, are exalted in the paralyzed limbs; in some they twitch convulsively and spontaneously; in all, or almost all, twitching and convulsive movement are readily excited by any modes of irritation. Paraplegia may, of course, exist in various degrees-from a mere dragging and numbness of one or both limbs, to the total incapacity of voluntary motion or voluntary restraint just described.

Pathology. It is possible, perhaps, that paraplegia may arise from cerebral lesion or disorder; but it must be extremely rare. "It consists in the loss of motor conduction in the fibres of the anterior columns of the spinal cord, which are given off at and below the point of injury" or disease. The posterior columns are usually more or less implicated, as I have said, and sensation in corresponding degree impaired. There is always, too, some impairment of the nutritive functions in the parts, which suffer more or less atrophy, and sometimes, indeed, become gangrenous.

Autopsy usually exhibits some spinal lesion. Caries of the vertebral column, inflammation and hemorrhage of the cord, induration, atrophy, softening, are all occasionally found. A gray degeneration of substance is described, and tubercular tumor and deposit. But there are instances in which no palpable change in the condition of the medulla spinalis has taken place. I was consulted in one such, a dyspeptic subject, who for many years before his death was entirely

paraplegic. Examination post mortem showed both renal and intestinal change; but the spinal marrow seemed perfectly normal.

The causes of spinal paralysis are not always clear. I have seen it follow a tedious attack of typhoid fever. Sensual excesses have produced it. Falls and blows on the spine, not immediately impressive, are accused of giving rise to a progressive myelitis or meningitis, which results in this terrible disease.

Treatment. If there be tenderness at any part of the spine, leeches or cups should be repeatedly applied to relieve it. The bowels are apt to be constipated, and require the employment of laxatives. The condition of the bladder must be inquired into, and the urine drawn off as often as necessary. The paralysis of the bladder is one of the most tormenting of the annoyances of advanced life. Day recommends the use of ergot in free doses-3j of the strong tincture ter die in an effervescing draught of citrate of ammonia. Gerard, of the Hôtel Dieu, Marseilles, eulogizes it as curative in paraplegia, even of long standing. He recites three cases successfully treated with it, one of which had been paraplegic four years. He gave ergot, gr. x per diem, gradually increasing the dose to gr. xl. They were restored within two and three months. Iodine and its combinations have been confided in by some; strychnine by others. Electricity, galvanism, and electro-magnetism, in various modes applied, are said to have been serviceable. I am disposed, however, to conclude, with Romberg, that "all attempts at a cure directed against an assumed morbid state of the spinal cord, whether exudation or inflammation, and the application of leeches, issues, nux vomica, electricity, etc., are apt to prove fruitless," unless we assiduously apply also "those remedies which tend to encourage nutrition," and bring the system of the patient up to the highest attainable point of tone and vigor.

CHOREA.-Paralysis Vacillans.-This strange malady has many names, and has been arranged under both heads of convulsion and palsy. From certain fanciful associations, it is known as St. Vitus's dance, the dance of St. Guy, and has been confounded, improperly, with the tarantula of Italy and the hysterical affections of fanatic enthusiasm, which, however, have occasionally given rise to it.

Chorea does not by any means consist in a simple loss of power in the muscles affected; but essentially depends upon the impairment of the control of volition over the voluntary motions. It is sometimes. unilateral, but usually general, nay universal, the whole voluntary motive system being disordered; though the affection of one portion may be more prominent than that of others.

The obvious diagnostic of true chorea, is this: that in all cases at first, and in a majority throughout, the cause of involuntary or irregu lar contraction of the muscles acts upon them only at the moment when the will is directed upon them, and when they dispose themselves to respond to volition, leaving them at other times tranquil. In the most violent cases that I have ever seen, I have always been able to succeed, in greater or less degree, by soothing language and gentle repression, in restoring comparative tranquillity to the patient,