66 under circumstances which permitted the observation of the disease during all its periods, and where there was an opportunity for witnessing the development of the paralysis. Accordingly, I have collected all the cases of diphtheria, more or less generalized (whether in the form of pharyngeal diphtheria, or of laryngeal, tracheal, or bronchial), which occurred in the wards of the Sick Children's Hospital during the year 1860. The number of these cases is 210. The cases of diphtherial paralysis observed during the same year were 36 in number; but as 5 of these cases only entered the hos pital after the cure of the primary affection, and solely on account of the paralysis, I exclude them from my calculation as to the frequency of the affection, although they will be taken into account when I come to consider the clinical history of the affection. There remain, then, 31 cases of paralysis (either general, or, as most frequently happened, limited to the pharynx), out of a total of 210 cases of diphtheria, which gives us a proportion of about one-sixth, or nearly 15 per cent. But this proportion, already considerable, must be materially augmented; because, on the one hand, some of the children who quitted the hospital as soon as convalescence was fairly established may have been lost sight of; and, on the other, in a very large number who died during the early stages of the disease there was no time for the establishment of consecutive paralysis; thus, out of 104 children in whom tracheotomy was performed on account of croup, 13 died on the day of the operation, 31 on the second, 22 on the third, consequently more than the half before the fourth day; that is to say, among the children so rapidly carried off, there was no time for the development of a secondary affection, such as a diphtherial paralysis; and it was only in a small number of the cases, where death occurred from the primary disease, that life was sufficiently prolonged to give the local phenomena of paralysis an opportunity for manifesting themselves. Although the object of my researches is to found upon statistics as the surest basis of my opinion as to the frequency of paralysis secondary to diphtheria, I conceive that, for the reasons I have given, I am entitled to assume a higher proportion than the mere numbers would convey, and that, from a calculation of probabilities, I am justified in raising it to a fourth or even a third, instead of a sixth. "I have proved in a direct manner, by facts carefully observed, that paralysis is a very frequent sequela of diphtheria; it is not sufficient to allow this to remain as a barren fact, but it must henceforth be looked upon as an important characteristic of pseudo-membranous affections; and since this paralysis has a special cause, as well as peculiar symptoms, course, and termination, a special place should be assigned to it among paralytic affections, just as, among dropsies, scarlatinal dropsy is specially recognised. I shall now show, by indirect proofs, that this really deserves to be considered a special form of paralysis. 66 The result of my statistical inquiries permits me to state in the clearest manner, that secondary paralyses are as rare after other acute diseases as they are common after diphtheria. I do not absolutely deny that paralysis may supervene during convalescence from febrile affections, and may be connected with them in some unknown manner; in the case of typhoid fever and simple pharyngeal angina, the fact appears positive, although one circumstance must be kept in view, namely, that in angina, accompanied with slight symptoms, it is easy to overlook the existence of a scanty false membrane which has soon dropped off, or which, limited to the posterior surface of the uvula and the pillars of the fauces, has escaped attention-in other words, that some cases, supposed to be cases of simple angina, are really cases of diphtheria. In the same way, in cases of typhoid fever, if the throat be invariably examined, it will be found that there almost always exists an erythematous angina of the vault of the palate and the pharynx, and which is complicated more often than is generally supposed with the secretion of a pultaceous, and even fibrinous matter-in fact, a pseudo-membrane of about the same consistence as in muguet: I am, therefore, disposed to explain, by the antecedent existence of an angina of this nature, the small ' number of cases of paralysis of the vault of the palate, and more general paralysis, which have latterly been observed to follow dothenenterite. "I admit the possibility of paralysis consecutive to acute diseases : in twelve years of private practice, I have seen four cases of secondary paralysis, one in a little girl after ataxic pneumonia, another after double pleurisy, and the other two in young women after hepatis depending upon biliary calculi; but the frequency of this phenomenon is so inconsiderable, the occurrence is so exceptional, that etiologically I attach no value to it. I again refer to statistics in reference to this point. During the same year, 1860, I took a note of all the children, boys and girls, who were admitted into my wards, with an exact indication of the diagnosis and result; in no one child, no matter whether the disease was acute or chronic, slight or severe, did I notice any paralytic phenomena, except in cases of diphtheria and well-characterized cerebro-spinal diseases. Thus limiting myself to diseases, as sequela of which paralyses are said to manifest themselves, I subjoin the figures relative to simple angina, pharyngeal or laryngeal, typhoid fever, the eruptive fevers, and pneumonia. Of simple angina, there were 61 cases; 40 of pharyngeal angina; 21 of laryngeal. Of typhoid fever, 12 cases. Of measles, 33 cases; of scarlatina, 12; of variola or varioloid, 4. Of pneumonia, 24 cases. In none of these was there any secondary paralysis. 66 It would be easy for me to add to these figures, by giving the precisely similar results of my colleagues, but this appears to be unnecessary. Returning, therefore, to my starting point, and considering, on the one hand, the excessive rarity of secondary paralysis in the phlegmasiæ, and in fevers other than dothenenterite, and, on the other, its excessive frequency after diphtheria, I believe that it is consistent with a sound pathology to establish a special class of diphtherial paralysis, and not to allow them to be lost in a vague group of secondary paralysis." ART. 46.-On Diphtherial Nerve Affections. By Dr. E. HEADLAM GREENHOW. (Proceedings of the Royal Medico-Chirurgical Society, March 24, 1863.) The epidemic sore-throat which, under the name of diphtheria, has latterly engaged so much attention, is well known to be followed by nervous phenomena of a peculiar kind. These consist chiefly of impaired, excessive, or perverted sensibility, together with more or less complete paralysis of the muscles of the fauces, pharynx, tongue and lips, extremities, trunk, and neck; the frequency of the occurrence of these symptoms in the several sets of muscles being nearly in accordance with the order in which they have just been mentioned. The author has had the opportunity of watching the course of several cases of these diphtherial nerve affections in patients under treatment at the Middlesex Hospital, and the present paper is in a great degree based on these observations. He does not mean to infer that every attack of diphtheria is followed by some of these secondary nerve affections, for he has seen patients recover perfectly without experiencing any of them; nor to assert that their intensity is always proportioned to the severity of the primary disease, for he has sometimes seen them follow comparatively mild attacks of diphtheria. Nevertheless, as a general rule, he has certainly observed these nerve affections to be more frequent after the worst cases of diphtheria, and to bear some proportion even to the local severity of the attack; he has noticed, for instance, that the paralysis and anæsthesia are sometimes more complete on that side of the fauces which had been most severely affected by the primary disease. The author has found that a brief period of convalescence --generally not exceeding a few days, but in rare cases extending to weeks-almost always intervened between the disappearance of the sore-throat and the accession of the nerve symptoms; and cases have fallen under his notice in private practice in which patients who had recovered sufficiently from diphtheria to be sent from home for change of air, had subsequently fallen into a helpless condition from diphtherial paralysis. The fact of this interval seems to him important, inasmuch as it goes far to show that the paralysis could not be entirely attributable either to the albuminuria which so often accompanies the acute stage of diphtheria, or to the anæmia which closely follows it, as patients have often got rid of the former symptom, and even begun in some cases to regain flesh and strength before the accession of the paralytic symptoms. The author has observed that these nerve affections do not at once attain their maximum of intensity, but are progressive even in the same sets of muscles; and also that if several of the sets of muscles which he has enumerated should be attacked in the same individual, they do not become affected all at once, but in succession-the faucial or pharyngeal muscles being the first to suffer, and so on in the order in which he had placed them at the beginning of the paper-though it by no means follows that all of them should be affected in any one case. He has found the muscles of the fauces by far the most frequent, as well as the earliest, seat of nerve affections after diphtheria, and has seen them attacked in many cases in which the rest of the muscular system either entirely escaped or was very slightly affected. When the fauces are paralysed, the soft palate lost its natural action, the speech often became imperfect, and liquids regurgitated through the nostrils. These symptoms should be discriminated from the hoarseness of voice and return of fluids through the nostrils which often occur during the acute stage of diphtheria, and arise, as in ordinary quinsy, from the swollen and painful state of the fauces impeding the natural action of the parts. Anæsthesia has co-existed with the paralytic affection of the fauces in all the cases that have come under the author's notice, so that these naturally very sensitive organs became altogether callous and insensible to touch. Next to the affection of the fauces, impairment of vision, probably due to paralysis of the ciliary muscle, appears to be the most frequent of the nervous disorders consequent on diphtheria. The author has observed that the pupil of the eye became dilated, and acted sluggishly under the influence of light a day or two before the sight became sensibly impaired, and often remained so for a time after the sight had been regained; also that patients unable to read with unassisted sight could do so with the help of convex spectacles, and hence he attributes the impairment of sight to a temporary loss of adjusting power. The nerve symptoms which he has noted in the tongue and lips were formication, or a sense of scalding, numb. ness, and impaired taste and power of movement. They began, for the most part, in the lips and the tip of the tongue, and gradually extended upwards towards the dorsum and root of the latter organ. The limbs suffered more or less in all the five cases which formed the basis of the paper, from paralysis and anæsthesia, besides tenderness and abnormal sensations, such as coldness, formication, and a feeling of constriction in the fleshy parts, as if they were tightly bandaged. These affections began either first in the upper, or at the same time in both the upper and lower extremities, and were at their commencement peripheral, extending gradually upwards from the tips of the fingers and toes towards the trunk, and in some cases affecting the lower part of the back and of the abdomen. He has found that pressure over the sciatic and median nerves was sometimes attended by acute pain, and that pressure of the instep between the finger and thumb sometimes caused convulsive starting of the leg and foot as well as pain. He has observed that the paralysis in some cases assumed a more or less hemiplegic character, but has seen no instance in which, one side being paralysed, the other remained entirely unaffected. The author has seen nerve affections after diphtheria of a graver character than any of those exemplified in the present group of cases, and several even fatal cases had fallen under his notice in private practice. In three of these latter death was caused by failure of the action of the heart, and in one by exhaustion from vomiting. He believes, however, that such cases were fortunately exceptional, and that the great majority of sufferers from diphtherial nerve affections, under good management, sooner or later recover their usual health and strength. The author has satisfied himself that these cases were best managed on sound general principles. Generous diet and a liberal allowance of stimulants, together with rest in bed, he believes to be always necessary. Tonics, especially steel and quinine, or the mineral acids, he has found useful from the first appearance of the nerve affections; and after the complete development of the paralytic symptom, nux vomica and strychnia have proved in his hands most valuable remedies. The remarks in the paper are founded on five cases. ART. 47. Clinical Remarks on Cases of Infantile Paralysis. By Dr. WILKS, Physician to the Royal Infirmary for Children. (Lancet, April 18, 1863.) The subject of infantile paralysis having of late been before the profession, the following short report of cases of this disease may be of some interest. Amongst out-patients it is almost impossible to take a very full account of their histories, and much less possible is it to watch the cases to their terminations. The following short notes, however, all refer to a question which has been lately much discussed whether there be any accompanying symptoms referable to a change in the cerebral or spinal centres. It will be seen that the cases corroborate the general professional experience, that although very often there is evidence of some general nervous derangement, yet that is by no means always the case. It is for this reason the absence of all lesion-that the name essential paralysis has been given to it by the French. In the following cases, as in others, there is sufficient to suggest some central cause, yet this must not be assumed in those where no history was obtainable indicative of such disturbance. We think it must not be assumed, in the case of a child previously in good health in whom an arm or a leg is found paralysed, that the child must have had a convulsion, followed by a general paralysis, and in whom both the attack and recovery were unknown to the mother, and only, indeed, suggested to the medical man by the remnant of paralysis which he finds. The subject is one of the most interesting in nervine pathology; but, considering that perfect recovery sometimes takes place, it is too much to assume that an organic lesion must always have occurred. A fatal result seldom takes place; and hitherto, we believe, no post-mortem examination has been made to decide the point. It is scarcely necessary to allude to the absurd popular opinion of attributing every child's malady to the teeth, whether it be nervous, cutaneous, or gastric. That great changes occur in the body about the period of dentition, every medical man knows; but that the direct process of tooth-cutting has anything to do with the disorder, there is no proof, although we are ready to admit that much may be due to reflex action. It will be seen that in some of the following cases the child has gone to bed well, and been taken up in the morning paralyzed in |