When the common origin of the nerves is affected, and from it all
the other parts of the body have lost their motion and sensibility,
the affection is called apoplexy, by which the leading energies are
impaired; but if the obstruction is in either side, it is called
hemiplegia and paralysis; and if the injury is seated in any one part, it
is called an affection of that part, and hence Hippocrates says, “His leg
was seized with apoplexy.”
Wherefore, in apoplectics, the respiration remains small. When, then,
it is greatly perverted from its natural energy, it will induce a
strong affection, and when but little, a weak one. Respiration is of
the worst kind when it intermits, or is performed with great exertion.
The affection arises suddenly from a cold phlegm obstructing the most
important cavities of the brain. Whenever the whole origin of the spinal
marrow is affected, all the parts below the face become paralysed, whilst
it remains unaffected, because the parts there derive sensibility and
motion from the brain; but, if one half only be affected, then is there
a paraplegia of these parts, that is to say, a partial paralysis. If
the sense of smell is affected, this arises from the anterior cavities
of the brain having contracted the intemperament, or from the pores
of the ethmoid bones being obstructed. Wherefore, apoplectics lie
speechless, motionless, and insensible, without fever. The precursors of
this affection are sudden and acute pain of the head, distension of the
jugular veins, vertigo, flashes, as it were, of light in the eyes, an
inordinate coldness of the extremities, palpitation and difficult motion
of the whole body, and grinding of the teeth in sleep. Their urine is in
small quantity, of a verdigris-green or a black colour, and containing a
branny sediment. The affection occurs in old age to those of a phlegmatic
temperament, and who use a diet of this nature. If it occur in youth and
in the season of summer, it indicates a strong exciting cause.
_The cure of apoplexy, and hemiplegia or paralysis._ Apoplexy is an
affection which is never or but rarely cured, for it threatens instant
death; and if it be relieved, it commonly leaves a paralysis of some part
of the body. Wherefore, those persons who admit of being cured should
be immediately bled, and if there be any remission of the disorder,
the operation should be repeated on the same or the following day.
The belly should be opened by a stimulating clyster, made by mixing
salt water and honey. Then let the whole body be rubbed with plenty of
sulphurated oil, but the head with the oil of chamomile, or of dill in
which cow-parsnip or calamint has been boiled. Inject honied water,
and apply strong-scented things, such as opopanax, sagapene, galbanum,
or castor, to the nose. It may be necessary to open the mouth forcibly,
and introduce a finger or feather dipped in oil to remove the matters
sticking there. Anoint the anus with applications for promoting the
discharge of flatus. Give honied water and oxymel to drink, and use
masticatories prepared by boiling thyme, or marjoram, in vinegar. When
there is a remission of the complaint, we are to have recourse to
tender, diffusible, and succulent food. When loss of speech continues,
if the strength permit, we are to apply to the back part of the head a
cupping-instrument with scarificators, and, if admissible, it should be
applied to the hypochondria also. Let them afterwards be carried about
in a chair, or couch, or suspended bed, and have recourse frequently to
sternutatories and masticatories. After the fourteenth day, we may bring
them back to the other kinds of gestation, attend to their speech, give
old apomel with pieces of bread or alica, and afterwards a small quantity
of hiera. After the twenty-first day, we may lead them to the bath,
give them old wine to drink; and otherwise we must promote recovery by
sprinkling them with warm water, by baths, and rubbing with unguents. If
possible, let them reside in places by the sea-coast.
_The cure of paresis, or resolution._ If there be paralysis of all or of
certain members, without injury of the primary energies, we must first
evacuate the offending humour, whatever it be, and then give hiera, and
a certain portion of castor, beginning with half a drachm, along with
some honey and warm water in which it has been dissolved, either alone,
or with the addition of half a scruple of pepper; then, after an interval
of four days, we may give a whole drachm, and afterwards one and a half,
then two and three. After an interval of the same number of days, we
may give four drachms, if the patient be able to take so much, adding
one spoonful of honey. To the part we may apply some of the discutient
remedies, along with rubefacients, adding to them some castor, or pepper,
or pellitory, or rosemary, or euphorbium; and, in addition to these,
we may have recourse to embrocations with oil of rue, or Sicyonian or
old oil. The food ought to be farinaceous, taken in a slop, of easy
digestion, and not excrementitious. Let cupping-instruments be applied to
the affected parts separately, if there be many of them, but to one if
there be few. After cupping, apply cataplasms containing pitch, rosin,
or manna. A most suitable application consists of calamint, fleabane,
and nitre boiled along with mugwort, and some water is to be added,
which is to be evaporated during the boiling. The belly is to be again
opened by means of aloes, polypody, scammony, or the colocynth pottage.
Fatty inunctions are to be made with old oil in which squill has been
kept for forty days in the sun; or, if it be not at hand, you may boil
in oil two ounces of squill, and anoint with it; or the seed of rosemary
may be prepared in like manner, but an ounce of wax must be added, that
it may not be too liquid. But, if you add of galbanum, of castor, of
euphorbium, of adarce, and of nitre, of each, oz. ss, it will be a more
potent remedy. The herb crowfoot, boiled in the oil, and preserved in the
sun, is also an excellent application. Castor to the amount of a drachm,
and opopanax swallowed to the size of a bean, will make suitable potions.
But sagapene taken to the size of a tare in honied water, and castor with
opopanax, and the Cyrenaic juice to the size of a millet, are admirable
remedies. The antidote from the three peppers is also beneficial. We
may likewise use beating restoratives (_acapa_), and masticatories.
After the fourteenth day, we may give more copious food; and, when much
benefit is derived, we may lead to the bath. After the thirtieth, it
will be necessary to apply a dropax, use the bath, and afterwards put on
a cataplasm of mustard, taking care in those cases in which both motion
and sensibility are lost, lest from want of feeling they be allowed
to burn too much. Where sensibility remains, rubefacients only are to
be used. After it swells, we ought to lead to the bath, and cure with
simple cerates. They ought to take the emetic after a meal, and that from
radishes. They should be carried about in a chair, or in a car drawn by
the hand, or in one drawn with a yoke. Otherwise, let them be put into
one of the natural baths. A desiccative diet, spare drink, and friction
will be proper. Let them, therefore, eat dry food, and struggle against
thirst as much as possible.
_On paralysis with relaxation or distension._ Since paralysed parts are
either contracted or relaxed, and this proceeds either from plethora
or emptiness, it will be necessary to attend to this, and sometimes
abstract blood, and sometimes not. _Again_, to relaxed parts we must mix
astringents with the relaxing remedies, and use intense friction; but
for the contrary state we must use relaxing remedies only, along with
gentle friction. For the relaxed limbs, let the oil used for friction
have a little nitre and dried lees of wine pounded on it. Let hot water
also be strongly poured upon them, especially sea-water, in which have
been boiled bay-berries, or the shoots of the chaste-tree, or marjoram,
or the like. If it is in the summer season, let them also swim in the
sea. But rubefacients are particularly applicable to them, and therefore
the parts may be whipped with rods, or nettle branches; but if the
paralysis remain, the relaxed skin between the joints is to be drawn up,
and transfixed with small and slender burning-irons. To contracted limbs
it is proper to apply constantly a calefacient plaster.
_On paralysis in particular parts._ Paralysis occasioned by the division
of a nerve is incurable; but when occasioned by an intemperament, or a
certain humour, it is relieved by the common remedies already mentioned;
but there are certain particular remedies applicable to each of them,
which we shall describe below. Wherefore, in cynic spasms, the jaw is
to be reduced to the opposite side by means of a muzzle. Detraction of
blood from the vessels below the tongue will likewise be proper, as also
cupping-instruments applied along the first vertebra, with masticatories,
and purgatives administered by an instrument inserted into the nose.
It is necessary to know that the jaw which appears to be distorted is
not the one which is paralysed, but the opposite one. When the organ of
deglutition is paralysed, cupping-instruments must be applied to the
chin, and we must use the liniments made of castor, sagapene, and the
Parthic juice. Acrid gargles are also beneficial. When the tongue is
paralysed, we must open its veins, apply a cupping-instrument to the
chin, and use masticatories of mustard, and exercise the tongue. When
the organs of speech are paralysed, apply the remedies to the chest,
enjoin retention of the breath, and have recourse to vociferation. When
the eyebrows are affected, anointing of the eyelids in like manner is
of great use, and, at last, the operation by suture called anarrhaphé.
When the bladder is paralysed, there is either retention of urine or an
involuntary discharge of it. The remedies are to be applied to the bottom
of the belly and perinæum, and clysters injected by the anus, consisting
of oil of rue, or Sicyonian oil, with butter and castor, galbanum,
opopanax, or the juice of laserwort. And these things, if injected into
the bladder by the penis, will be of great service, or prove sufficient
of themselves. Clysters of centaury and colocynth, along with Sicyonian
oil, are also beneficial; and diuretics may be drunk with advantage, and
castor taken in like manner. But, above all things, we must have recourse
to the catheter when the patients cannot make water, and get them to sit
in hot baths of a relaxing nature, and use emollient cataplasms. When the
urine flows involuntarily, we must treat them upon the astringent plan
with tonic remedies, and make them use dry food and cold drink. During
convalescence they ought to use rubefacients, and natural baths in a
cold state. Cases occurring from a wound of the spine, from a fall and
dislocation of a vertebra, if there be a concurrence of fatal symptoms,
it is impossible to remedy. If the penis is paralysed, we must apply the
remedies recommended for the bladder to the same parts, and also to the
groin; and medicines which excite to erections ought also to be used.
Milk, cheese, and the other cakes are improper, likewise lettuces and the
other pot-herbs. When the rectum is paralysed, in which case the fæces
are either discharged involuntarily, or retained, the same remedies must
be used, and clysters are to be administered, sometimes of an astringent
nature, such as the decoction of cypress, of rush, or of bramble; and
sometimes emollient; such as the fat of swine and geese, and the oil of
mallows; and sometimes stimulating, such as salt water, the decoction of
colocynth, or the like. Nothing contributes so much to motion as variety
of exercise with the lever. If they complain of a sense of cold, the
restorative plaster of euphorbium, dissolved in oil, may be used for a
clyster. But, along with the ordinary treatment, the paralysed limbs
should be bent, rubbed, and stretched in the manner described; for our
greatest dependence is upon friction.
_On paralysis supervening upon colic disease._ In our times a colic
complaint has prevailed, in which convalescents are seized with complete
loss of motion in their limbs, but the sense of touch remains uninjured,
there being a critical translation of the disease from the internal
parts. Hence, in many cases, the motion has returned spontaneously in
process of time. Those of more difficult cure were remedied by using the
more simple liniments formerly described. The acopa made of poplar and
of the fir were found to be excellent applications; and many were greatly
benefited by tonic and moderately cooling applications.
* * * * *
COMMENTARY. Consult Hippocrates (Aphoris. ii, 42, de Glandulis, et
alibi); Galen (Comment. de Loc. Aff. iii, 11); Aretæus (Morb. Chron. i,
7; Cur. Morb. Acut. i, 4); Aëtius (vi, 26); Oribasius (Synops. viii,
14); Theophrastus (ap. Photii Bibliothecam); Alexander (x, 2); Actuarius
(Meth. Med. iv, 2); Cælius Aurelianus (Morb. Acut. iii, 5); Octavius
Horatianus (ii, 7); Leo (ii, 5); Nonnus (37); Avicenna (iii, i, 5, 12);
Avenzoar (i, 9, 12); Serapion (i, 24); Mesue (de Ægr. Cap. 27; de Ægr.
Nerv. 2); Haly Abbas (Theor. ix, 6, Pract. v, 22); Alsaharavius (Pract.
i, 2, 18); Rhases (ad Mansor. ix, 3.)
To so many excellent works on apoplexy, wherein the subject is treated
of fully and correctly, it is difficult to do justice within our narrow
limits. We shall give, however, a brief, though imperfect outline of
their opinions.
Hippocrates pronounces a slight attack of apoplexy to be difficult
to cure, and a severe one to be utterly incurable. He says that an
apoplectic attack is brought on by turgidity of the veins. When a person
has suddenly lost his powers Hippocrates directs that he should be
bled. (Aphor.) Apoplexy, he says, occurs most frequently between the
age of forty and sixty. (Ibid.) He says, in allusion to apoplexy (as
his commentator Theophilus remarks), that when persons in good health
are suddenly seized with pains in the head, with loss of speech, and
stertorous breathing, they die in seven days, unless fever supervene.
(Ibid.)
Galen states that apoplexy arises from a cold, thick, and viscid humour
obstructing the ventricles of the brain. He remarks that, in severe
cases, all voluntary motion is lost while respiration is performed as in
persons asleep. The reason which he assigns for this is, that the nerves
which are distributed upon the respiratory muscles are all derived from
the brain itself, and these often escape being injured, unless the attack
be of a particularly serious nature. His account of cases of partial
paralysis is highly interesting. (Loc. Affect. iii, 14.)
Celsus’ brief account deserves to be given in his own words: “Attonitos
quoque raro videmus, quorum et corpus et mens stupet. Fit interdum
ictu fulminis, interdum morbo ἀποπληξιαν hunc Græci appellant. His
sanguis mittendus est: veratro quoque albo, vel alvi ductione utendum.
Tum adhibendæ frictiones, et ex mediâ materiâ minimè pingues cibi,
quidam etiam acres; et a vino abstinendum.” Respecting the treatment of
paralysis he delivers the following aphorism: “Si omnia membra vehementer
resoluta sunt, _sanguinis detractio vel occidit vel liberat_: aliud
curationis genus vix unquam sanitatem restituit, sæpe mortem tantum
differt, vitam interdum infestat.” His other remedial measures are such
as our author’s, namely gestation, the application of cupping-instruments
or rubefacients to the affected part, the warm salt-water bath, and a
restricted diet.
According to Theophrastus, paralysis is occasioned by a deficiency or
loss of the pneuma, i. e. vital heat.
It is impossible to admire too much the brief but comprehensive account
of apoplexy and paralysis given by Aretæus. He states decidedly, that
there is sometimes a loss of motion alone, and sometimes of sensibility;
the reason of which he supposes to be, that the sensatory and motory
nerves are distinct from one another. This is the germ of the theory
fully expanded afterwards by Galen. It appears, indeed, from the
anatomical works of Ruffus, that the famous Erasistratus had attempted a
similar classification of the nerves. Galen, however, has the merit of
fully establishing the truth of the theory; and all subsequent writers on
physiology stated it in nearly the same terms that he does, until ancient
authority in medicine and its cognate sciences came to be despised.
Aretæus states it as a general rule, that when one side of the brain
is affected the opposite side of the body is paralysed; but, when the
disorder is in the spinal marrow, that the affection of the spine and
the paralysis are on the same side. This arises, he supposes, from the
decussation of the cerebral nerves; and this explanation must be admitted
even now to be tolerably correct. The causes of paralysis, as stated by
him, are falls, blows, cold, _indigestion_, debauchery, intoxication,
and violent emotions of the mind. His treatment is as follows: He
inculcates, in the strongest terms, that the great remedy for apoplexy is
venesection; and that the only difficulty, in general, is to determine
the extent to which it is to be carried. He forbids the operation,
however, when the senses are oppressed with much cold and torpor.
When venesection is contra-indicated the belly is to be evacuated,
in order to relieve congestion there, and to produce revulsion from
the head. For this purpose acrid clysters are to be given, containing
nitre, euphorbium, colocynth, turpentine-rosin, and the like. He also
recommends hiera as a purgative; and if nausea be present, he advises us
to encourage vomiting. He praises castor strongly as a remedy for the
nervous affections. The food is to be light and of easy digestion. When
the disease is protracted, cupping-instruments are to be applied to the
back part of the head. When the parts concerned in deglutition, namely,
the fauces and œsophagus, are paralysed, food is to be conveyed into the
stomach by a suitable instrument. (By the way, Dr. Friend is mistaken
in stating that Avenzoar is the only ancient author who recommends
this practice. It will be remarked that our author makes mention of
introducing food into the stomach by means of an instrument passed by the
nostrils.) When the bladder is affected, he recommends injections, but
forbids the use of the catheter, for fear of occasioning convulsions or
gangrene. He approves greatly of the bath of oil in this case.
Aëtius, Oribasius, Alexander, Actuarius, and Nonnus treat of the disease
in much the same terms as our author. Alexander, in particular, properly
recommends moderate purging with the hiera and such like medicines. He
restricts venesection to those cases in which the disease is occasioned
by fulness of blood.
Cælius Aurelianus enumerates nearly the same causes of apoplexy and
paralysis as Aretæus, namely, excessive heat, cold, indigestion,
debauchery, and injuries of the brain. The season of winter is justly
said to predispose to the disease. It is seated, he says, principally in
the head. His treatment is nearly the same as that of the followers of
Hippocrates and Galen, namely, emollient applications to the head and
limbs, venesection, abstinence, clysters, cupping the back part of the
head, and the bath of oil. Of paralysis he treats at greater length, and
with much precision and judgment. He mentions nearly the same causes of
it as of apoplexy; and remarks that it produces loss of sensibility,
or of motion, or of both. He observes, in particular, of the tongue,
that it may retain the power of deglutition although that of speech be
lost. He details all the phenomena of partial paralysis with surprising
accuracy; and, at the present day, we do not know a work on the subject
that contains so much information. He distinctly and accurately
describes paralysis of the œsophagus and fauces. His treatment is, upon
the whole, not very different from our author’s; but his directions for
the application of his remedies are exceedingly minute and judicious.
In the first place, he approves generally of venesection, calefacient
applications to the extremities, a spare diet, and afterwards of cupping
with scarifications. When the tongue is affected, hot gargles of mustard
and vinegar are to be given; and, when there is paralysis of the bladder,
the catheter is to be used. When the disease is obstinate, he approves
of hellebore as an emetic, and of calefacient plasters, depilatories,
cupping with much heat, embrocations of mustard, and such things as will
produce a papular eruption, namely, flour of salt, nitre, and the like.
He blames Praxagoras for recommending emetics indiscriminately, and
Erasistratus for omitting venesection. He finds fault with Themison for
being in too great haste to apply stimulants to the affected parts, and
for having recourse to cupping before the disease had begun to subside.
Though he permits the occasional use of hellebore, he disapproves of
purgative medicines in general. For paralysis of the œsophagus he
recommends us to apply a cupping-instrument, leeches, or cataplasms to
the neck.
Little additional information is to be got from the Arabians; and yet
Avicenna, in particular, has treated the subject in a very masterly
manner. The causes of apoplexy, he says, are either obstruction or
repletion; and these are produced either by blood or a pituitous humour.
We need scarcely remark that this accords with the modern division into
sanguineous and serous apoplexy. Even in pituitous apoplexy he admits
of venesection. He approves of vomiting when it can be produced easily.
Neither Serapion nor Avenzoar makes mention of venesection. Serapion
commences his treatment with an emetic. When connected with plethora,
Alsaharavius recommends general bleeding, opening the temporal veins,
cupping the legs, restricted diet, applications to the head, such as
oil of roses and vinegar, and acrid clysters. Haly’s account is minute
and judicious. He attributes the affection to obstruction within the
brain occasioning a loss or diminution of the powers of sensation or of
voluntary motion. It is produced, he says, by phlegm mixed with bile
or blood; and sometimes arises from repletion with wine, which case
generally proves fatal. He justly remarks, that one of the most common
symptoms is stertorous breathing. If the face be ruddy or livid, he
directs us to open the cephalic vein, or vena saphena, and abstract
blood according to the patient’s strength; to apply ligatures to the
extremities, vinegar and rose-oil to the head; and to give clysters.
He also approves of emetics. When the disease has partly subsided, he
approves of the bath. He treats separately of paralysis, describing
many varieties of it. In paralysis of the face he recommends stimulant
liniments, ligatures, gargles, and sternutatories. According to Rhases,
apoplexy arises from congestion of blood or of viscid phlegm in the
brain. He remarks correctly, that when attended with stertor it is
difficult to cure. When the memory is affected, he directs us to apply a
sinapism to the occiput.
The paralysis of the extremities after colic, mentioned by our author,
and after him noticed by Avicenna and Haly Abbas, was, no doubt, the same
disease as the palsy after colica pictonum described by modern authors.
De Haen has given a masterly description of this disease. (Rat. Med.)
Rhases states decidedly that the skin of paralytics may retain its
sensibility, although the muscular motion be lost. In a word, he
maintains that the nerves of sensibility and motion may be affected
separately. He remarks, however, that a part can scarcely retain its
powers of motion when the sensibility is entirely gone. He says that he
had known several cases of paralysis cured by a natural diarrhœa. His
general remedies are bleeding, purging, and rubefacient applications. He,
and several of the authorities referred to by him, recommend the warm
salt-water bath for the cure of paralysis.