seat of exquisite pain and sensibility, without any thing being visible externally. In other cases the pain will suddenly cease in a part, and the patient will experience a disagreeable sensation of formication rather than distinct pain in some other part, at a considerable distance. On examination, he is surprised to find a large patch of redness, with more or less tumefaction, in the new seat of the rheumatism. In this manner the complaint will sometimes travel over the whole surface of the body, and then fix itself at the extremity of a finger for a month or two, causing dreadful pain, but without the least discolouration or swelling of the part.

"I have seen this disease in the person of a medical gentleman, fix itself in the sclerotic coat of the eyes, at their outer and inner angles, and there occasion the most terrible sufferings, on the least motion of the eye-ball. Yet the sight was not in the least affected, nor was there any appearance of inflammation. At other times the rheumatalgia has seated itself in the transparent cornea, attended with indescribable sufferings, intolerance of light, insomnium, and violent ophthalmia. The same medical gentleman experiences occasionally the rheumatic pain in a single point of the minutest dimensions, in the eye-brow, and other parts of the face. An elderly lady, afflicted for several years with rheumatalgia of the deltoid muscle, lost slowly her sight. An ophthalmic surgeon discovered a cataract in each eye. The operation was performed on one of them; but scarcely was it finished, when the organ became the seat of the most excessive pain-the sclerotic became gorged-the coats red-and this state of insupportable sufferings lasted six weeks, with scarcely any intermissions. At this period, the deltoid muscle (which had been free from pain) became again the seat of rheumatism, and the ophthalmic inflammation and pain disappeared. She recovered sight in this eye. Three months afterwards the other eye was operated on, and again the pain and ophthalmia took place as violent as in the other eye. A blister was applied to the arm, and a metasitasis of pain was quickly produced, and the eye relieved.'

Of all the INTERNAL organs, our author has found the STOMACH the most liable to rheumatic affection. In some cases, this shews itself merely in languor of function, or simply a sense of cold or pain in the epigastric region, relieved by hot frictions. The digestion may be very little impeded. In this state of chronicity, the disease is difficult of removal. But, not unfrequently, it produces in the same organ much more disagreeable effects, as nausea, vomitings, indigestion, violent cardialgia, and symptoms imitating cancer or scirhus of the pylorus-all which phenomena will suddenly disappear on the commencement of rheumatic pain in some of the limbs.

"I have seen a case of wandering rheumatism, where, after attacking the stomach, the bowels, &c. it fixed itself, for more than three months, on the heart, inducing palpitations, convulsions, syncope, and other symptoms that led the attendant physician to believe there was aneurism of the heart. A blister applied to the arm dissipated the whole of these symptoms, and the patient afterwards enjoyed good health."

The author has seen the bladder affected with rheumatism, and retention of urine produced-the lungs attacked, and all the phenomena of peripneumony succeed. Parturient women are very susceptible of the causes of rheumatism, and Dr. C. avers that nothing is more common, at least in his part of the country, than rheumatic pains in the uterus and its appendices.

But we must now proceed at once to the treatment which Dr. C. has brought forward, as it is somewhat novel-at least it is a new modification of a remedy, which has long been employed, though less so in this coun

try than formerly. It is OPIUM. After remarking on the different effects of opium, according to the dose, or the repetitions of the doses, Dr. Cazenave proceeds to maintain, that the failure of opium in the cure of rheumatism is owing to the timidity with which it is administered. In the complaint under consideration, Dr. C. remarks, opium acts in three ways, according to the dose employed. Given in small quantities, it obtunds the sensibility, and brings a temporary relief-but the cure is not thereby accelerated. Administered in a somewhat larger dose, it sometimes occasions nausea, palpitations, giddiness, head-ach, &c. These effects are, of course, but momentary, and should form no solid objection to the remedy, if it is found beneficial in other respects, besides relieving pain. To the above effects of opium (if it be continued) succeed others :-the patient does not sleep; but he experiences a kind of delightful ecstacy, forgets his sufferings, &c. The action of opium is then excitant, like that of wine. In some cases, an abundant perspiration is the result-but, in both events, the radical cure of the rheumatism is effected-that is, with or without the sweating process. The quantity of opium will vary, of course, in different constitutions; but the following is the mode of administration employed by our author.

To an adult, he orders a pill containing one grain of opium-and, an hour afterwards, he gives another grain, if the pains continue. At the expiration of the second hour he gives a third grain-and, after a little time, he examines his patient. If there be a tendency to hilarity, he administers a fourth grain, and so on, a grain every hour, till a complete calm is established, or an abundant perspiration is induced. This being the case, he orders a grain to be given every two, three, or four hours, according to circumstances, solely with the view of keeping up the perspiration.

In respect to regimen during this mode of treatment, it is indispensable, of course, to keep the patient in an even and mild temperature, with flannel next the skin, and on the simplest liquid food. Perfect quietude is necessary during this treatment. In this way, Dr. C. assures us that he speedily cures rheumatism, whether acute or chronic, or in whatever part of the body it may be seated, without any bad consequences ever ensuing. When the disease is complicated with any other complaint, particularly with derangement of the digestive organs, it will be necessary to attend to the adventitious disorder. If the fever in acute rheumatism run very high-and particularly if any thoracic or abdominal organ be oppressed in function, or labouring under pain, it will be proper to draw blood from the general system, and to put in force the other items of the antiphlogistic

treatment.

We think the plan of Dr. Cazenave is not unworthy of attention, in the management of a disease which so often baffles the medical practitioner, and brings no small degree of odium on his art.

IX.

MEDICO-CHIRURGICAL TRANSACTIONS.

1. Mr. EARLE on Paraplegia.

In the last volume of the Medico-Chirurgical Transactions, Mr. Earle bas occupied nearly 50 pages with the subject of paraplegia, respecting the pathology of which there has been a good deal of discussion, since Dr. Baillie's paper appeared, about 7 or 8 years ago, in the College Transactions. It is well known that Dr. B. believed paraplegia to be most commonly dependent on disease of the brain, when happening in adults, and when not evidently connected with outward violence to the spine. Dr. B. was not aware that Mr. Earle had published some cases, five years previously, in the Edinburgh Journal, showing that paraplegia does sometimes depend on cerebral, and not on spinal disease. When we remember that sense and motion are lost the moment that an interruption takes place in the nervous communication between the brain and the part paralyzed, whether the interruption be seated in the medulla oblongata, the spinal marrow, or any portion of the nerves leading to the muscle or skin, we see no occasion for these prolonged discussions respecting the seat of the obstructing cause, nor any reason for pride in finding paralysis of the lower half of the body in people who have organic disease of the spine. It is strange that these controversialists should not dream, that the immediate cause of the paralysis may be a change in the nerves of the part paralyzed, without any disease in either brain or spinal marrow. Does the circulation never fail, unless there be disease of the heart or of the aorta? We see paralysis, for example, in both the feet, or in both the hands, while the muscular power and sensibility remain in all other parts of the body. How, we would ask, can this depend solely on disease of the brain or of the spinal marrow? Can the brain or the spinal marrow say to the nerves going to the lower extremities, you shall carry our motive commands to the muscles of the thighs; but whenever you pass the knee-joint, you shall no farther be the bearers of our despatches? Or, can they say to the other constituents of these nerves, we will acknowledge the receipt of all impressions made on the thighs, but if you bring impressions from the legs or feet, we will not receive them? The thing is preposterous. But, if we allow that those portions of nerves which are below the knees are incapable, from some morbid change in themselves, of transmitting the will from above, or sensation from below, then all is clear and intelligible. What, after all, is the spinal marrow, but a prolongation of the brain? What are the nerves, but prolongations of the spinal marrow? Ergo, what is the minutest and most invisible point in which a nerve terminates, but a portion of the brain? It is so with the vascular system. The minutest capillary is as much entitled to the appellation of a sanguiferous vessel as the great aorta. Disease in any branch of the

immense tree of circulation will disturb the vascular function of the partand disease of the heart or aorta will disturb the whole. But, it will be said, we have found a tumour in the brain, where there was paralysis of the feet-ergo, the former was the cause of the latter. We would answer, that tumours in the brain are every day seen without paralysis-and local paralysis is often found without any appreciable lesion of the brain or spinal marrow. Besides how can a tumour in the brain cause paralysis in the legs and not in the thighs, seeing that the same nerves go to both parts ?—The causes, then, of local or partial paralysis, we maintain, are often extremely obscure, and by no means to be always accounted for by cerebral or spinal diseases.

"Paraplegia dependent on the existence of disease in the brain, generally occurs at the middle or more advanced period of life than is usual in diseases of the bodies of the vertebræ, or their intervening fibro-cartilages. Its progress is more rapid than the slow insidious approach of symptoms from the latter diseases; the affection is more general, occasioning more or less paralysis of the upper and lower extremities, and this will often take place in a very few days from the occurrence of the complaint. This disease happens much more frequently in men than women. The gait of persons suffering from cerebral affection is peculiar, and very different from that attendant on affections of the spine. It very nearly resembles the vacillating steps of a drunkard. Such paralytic persons are incapable of walking in a direct line; the limbs are loose, and thrown forward with an exertion of the whole body; there is a great consciousness of feebleness in walking, and the greatest difficulty in turning round. The appearance of the eyes often much resembles those of a drunkard, particularly when the patient is at all excited or anxious. The above analogy to the staggering steps of intoxication is readily understood, if we consider that it is the temporary disturbance of the brain, from the congestion of its blood-vessels, that deprives the drunkard of the power of directing his steps, and for the time induces a state bearing the closest resemblance to paraplegia.

"Sensation is more impaired than in spinal affections, when it will often remain perfect after a total loss of the locomotive powers. This impaired sensation is often peculiar, imparting an idea of some foreign body, as a leather glove or stocking, being interposed. The patient appears to feel, if I may use the expression, through a false medium; the limbs are more wasted and flabby, without any spasmodic rigidity of the muscles, which so often occurs in affections of the spine. Although often accompanied with a torpid state of the bowels, aggravated no doubt by the impaired muscular power of the abdominal parietes, there has not, in any instance that I have witnessed, been any train of gastric symptoms similar to those which so constantly attend affections of the spine, especially of the dorsal region. In some instances there is the additional confirmation of an impaired state of some of the external senses, accompanied with vertigo, a sense of weight on the head, and a general disturbance of the cerebral functions. As disease advances, the power of the brain in transmitting its influence to the extremities becomes more and more circumscribed. Thus I have known a tubercular affection of the pia mater, in the first instance, cause a numbness and loss of feeling in the feet, which has gradually extended until all four extremities were completely paralysed, and the muscles concerned in respiration at length refusing their office, death ensued."

A very similar train of symptoms occurs in other diseases of the brainespecially in membranous inflammation and effusion, of the chronic kind. Whenever disease has proceeded the length that has been described, one or more of the mental faculties generally suffer; but in slighter cases it is difficult to form a correct diagnosis, and yet, as Mr. Earle observes, it is of importance to know whether the disease be seated in the head or the

spine, that we may not unnecessarily subject the patient to the sufferings arising from the application of caustic issues and setons to the spine, when the disease is in the head. Our author thinks that attention to the following circumstances has materially assisted him in forming a correct diagnosis. He is, therefore, inclined to lay considerable stress upon it.

"It is well known that when a nerve is stimulated or injured in any part of its course, the painful sensation is referred by the percipient mind to the sentient extremity of such nerve; the familiar instance of the pain referred to the extremity of an amputated limb, may be adduced in proof of this. The exact reverse of this takes place when there is a partial paralysis arising from morbid affection of the cerebral organs. Here the centre of the sensorial functions being impaired, it appears to be incapable of transmitting its influence to the extreme parts of the body, and thus the feet and hands gradually lose their sensation or power of motion, or both; and in such cases if the nerves supplying the limbs be irritated, they will convey the impression of such injury only part of the distance down the limb, about as far as the commencement of the paralytic affection. I have repeatedly examined cases of paraplegia from affection of the spine, and in no one instance have met with the same phenomenon, which I have therefore been induced to consider as diagnostic of the paralytic affection being dependent on disease of the brain or its membranes, which opinion has in several instances been confirmed by examinations after death, in which both brain and spinal marrow have been carefully investigated."

Curvature of the spine, combined with structural diseases of the brain, tends to puzzle the practitioner, where there is also paraplegia, as it induces him to suspect the spinal marrow as the seat of the injury. Simple curvature of the spine, however, is a very different disease from the angular curve produced by disease of the bodies of the vertebrææ. In the former case, the whole spine is curved in the form of a half-hoop, in consequence of the debility of the muscles of the back, which are no longer capable of sustaining the weight of the trunk and viscera, and maintaining the erect posture.

"The test by which I have been in the habit of trying these cases is at once simple and satisfactory. If a person with such a stooping or incurvated state of the spine be placed on a horizontal plane, the back will immediately and spontaneously be restored to its proper form without causing any pain or distressing symptoms, which would certainly be produced by any attempt at extension of a diseased spine The state of the back in these cases is similar to what occurs during sleep or after death. It takes the direction influenced by the gravitation of the viscera and upper part of the body; for be it remembered that the strength of the spine and of most other joints depends on the power of the muscles: this is readily shown by dividing the tendons which pass over a joint, which will immediately become pliant and flexible. The same occurs in acute rheumatism, when the muscles are no longer under the control of the will, and the joints are consequently loose and powerless."

A great number of cases are adduced by Mr. Earle, but several of them, we think, are very unsatisfactory. Thus, in the first case, that of a gentleman, there were unequivocal symptoms of cerebral disease, as intense headach, &c. Paralytic affections extended from the feet and hands towards the trunk of the body. "On stimulating the median and ulnar nerves, he was not sensible of pain much below the elbow." How did Mr. Earle