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THE 
 
 CEREBRAL PALSIES OF CHILDREN. 
 
(h 
 
(h 
 
 
 ^^ ^.wCv 'fCi/V^K., Ih.V 
 
 '^. fT^f 
 
 THE 
 
 CEREBEAL PALSIES 
 
 OF 
 
 CHILDEEN. 
 
 A CLINICAL STUDY FROM THE INFIRMARY FOR 
 NERYOUS DISEASES, PHILADELPHIA. 
 
 BY 
 
 WILLIAM OSLER, M.D., 
 
 FELLOW OK THE ROYAL COLLEOE OF PHYSICIANS, LONDON; 
 
 PROFESSOR OK CLINICAL MEDICINE IN IIIE UNIVERSITY OK PE^ NSYI.VANIA • PHYSICIAN 
 
 TO THE UNIVERSITY HOSPITAL, TO THE PHILADELPHIA HOSPITAL AND 
 
 TO THE INFIRMARY FOR NERVOUS DISEASES. 
 
 LONDON: 
 H. K. LEWIS, 136, GOWEE STEEET, W.C. 
 
 1889. 
 
PRIMED BV ADLAKr AM) my, BAKTHOLOMEW CLOSE. 
 
DEDICATED 
 
 TO 
 
 S. WEIR MITCHELL, M.D., LL.D. (Hauv.), 
 
 . PRESIDEXT OF THE COLLEGE OF PHYSICrANS, PlIILADELPUI^ 
 
 IN HECOGNITION 
 
 OF 
 
 H1.S WORK IN SCIENTIFIC MEDICINK 
 
 AND IX 
 
 OKATKFUI, ACKNOWLKDOMENT 
 
 OF 
 
 INNUJMEKABLE ACTS OF FKIENDLY SEKVlCE. 
 
Note. — The material here presented forms the basis of a series of 
 Lectures which were delivered in the spring course at the 
 Infirmary for Nervous Diseases, and which appeared in the 
 ^Philadelphia Medical News,' July 14th to Aiigust Mth, 1888. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 INFANTILE HEMIPLEGIA. 
 
 / 
 
 PAGE 
 
 Introduction. LixEBATrBE. HEMiPLEorA. STNONTsrii. Ktiologv. 
 Congenital Cases; Conditions of the Mother; Syphilis; Difficult 
 and Abnormal Labour; Injury with the ForcepR; Trauma; Liga- 
 tion of Common Carotid Artery; Infection/* Diseases — Scarlet 
 Fever — Measles — Whooping-cough — CtTebro-spiaal Meningitis — 
 Dysentery — Vaccinia — Convulsions; Embolic Processes 1 — 23 
 
 CHAPTER II. 
 
 INFANTILK HEMIPLEOIA (continued). 
 
 Symptoms; Onset — Convulsions; Loss of Consciousness; Fever; De- 
 lirium ; Vomiting. The Paralysis — Face, Arm, and Leg. Itigidity. 
 Reflexes. Sensation. Vasomotor Disturbances. Electrical Re- 
 actions. Post-hemiplegic Movements — Tremor, Chorea, Athetosis. 
 Aphasia — Mental Defects — Epilepsy. 
 
 Morbid Anatomy. Embolism, Thrombosis, and Heemorrhage. Atrophy 
 and Sclerosis. Porencephalus. 
 
 Diagnosis. Prognosis .... 24—55 
 
 CHAPTER III. 
 bilateral spastic hemipleoia. 
 
 Synonyms. Literature. Definition. Symptoms. Cases. Ri- 
 
 LATEBAL ATHETOSIS— General Description. Mobbid Anato^siy iJ6 — 75 
 
VIII 
 
 CONTENTS. 
 
 CHAPTER IV. 
 
 Hl'ASTIC I'AIIAIT.KOIA. 
 
 PAOJJ 
 
 Synonyms. LiTEBATrHE. Stmptomh. Caskk. Ktioloov. Morbid 
 
 Anatomy. DiAdNosis . _ 7f»— 87 
 
 CHAPTER V. 
 
 Pathology. lIa)inorrlm;,'p. Apoplexia NeonntonMii. I'oliencephalitis. 
 Infuctious I'rocessen. I't-ii- and End-iirti'iitiB. Thrombosis of 
 Ccrcbnil Wins. Condition of tlio Cord in .Spu.stic Paniplepia. 
 
 Tkkatm knt 
 
 H8— lOM 
 
 
 
TUH 
 
 CEREBRAL PALSIES OF CHILDREN 
 
 CHAPTER 1. 
 
 INTRODUCTION. 
 
 Dividing tho motor path into an upper cortico-spinal 
 segment, extending from the cells of the cortex to the 
 gray matter of the cord, and a lower spino-museuhir, 
 exte.rling from the ganglia of the anterior horns to 
 the motorial end plates, the palsies which I propose to 
 consider have their anatomical seat in the former, and 
 may result from a destructive lesion of the motor centres, 
 or of the pyramidal tract, in hemisphere, internal capsule, 
 crus or pons. 
 
 Certain general features define sharply from each other 
 palsies of the upper and lower portion of the motor path. 
 When the latter is affected, as in the common infantile 
 spinal palsy, poliomyelitis anterior, we have the combina- 
 tion of paralysis with rapid wasting, early loss of reflexes, 
 absence of rigidity and marked changes in the electrical 
 reactions. On the other hand, in involvement of the 
 upper segment, when the lesion is cortico-spinal, any- 
 where from the motor cells of the cerebrum to the gray 
 matter of the cord, there is paralysis with spasm or 
 disordered movements, exaggerated reflexes, neither rapid 
 nor extreme wasting and normal electrical reactions. 
 
 The clinical picture presented by diseases of the upper 
 
 1 
 
 1 
 
Hi 
 
 hi 
 
 
 
 2 
 
 THE CEEEEIKIML PAL8IES OP CHILDREN. 
 
 segment is very variel, (depending' partly on the nature, 
 partly on the extent ctf the legion ; and while on certain 
 grounds it would he pm^ferable to classify and consider 
 the affections on f i amtjifiomical, or, perhaps, better still, 
 on an etiological l*a*:!J*, we may, for clearness and con- 
 venience, adhere to tm^iO'imj and classify the cases accord- 
 ing to the distribaitkuDi fof the paralysis, whether hemi- 
 plegic, diplegic, or pmiraplegic. The cases are usually 
 arranged under the jfHrTieric terms cerebral palsies — the 
 German Cerehrale Kmdf.rhihmiDig — or spastic palsies, 
 while the specific diewiOTiation indicates the distribution 
 of the paralysis, "wliifeitfiiier unilateral, bilateral, or para- 
 plegic. 
 
 Without entering mtf» historical details, it will be suffi- 
 cient to note that tibe imicMication, in 1884, of Striimpell's 
 paper^ seems to har-e anrjased special interest in the sub- 
 ject. Since then tlie msonographs of Gaudard'^ and of 
 Wallenberg,' the oojurhrifoucions of Ranke,* Bernhardt,^ 
 and Kast,^ in GernaanDj; of Jules Simon,'^ Richardiere,^ 
 Jendrassik and Maaw,* m France ; of Ross,'° Hadden,^^ 
 Wolfenden,^^ Abercronaufe,^'^ and Gowers,^* in England, 
 
 ' " Ueber die Acute EudejAiJtEirut der Kinder," ' Jahrbuch fiir Kinderheil- 
 kunde,' 1884; and Lis Tt«t'!i«iife of Medicine, by Sliattuek, New York, 
 1887, p. 704. 
 
 * ' Contribution a I'etucU- fit Krtnuple^ie cerebrale infantile,' GenSve, 1884. 
 ' " Ein Beitrag zur Ltbrf a.^oi (ieiv Cerebnilen Kinderlahniungen," ' Jahr- 
 
 bucb fur Kinderlieilkuiidf-,' a*i«?i. 
 
 * "Ueber Cerebrale KindwrluiliinnTijr/". Jahrbuch fiir Kinderheilkunde,' 1886. 
 '" " Hemiplegia Bpastica iu*;iiiinilit*," * Vircliow's Archiv,' Bd. 102. 
 
 * ' Archiv f. PBvchiatrie.' BSd. swiii, 
 
 ' "De la Sclerose cerebride diiii les enfanta," ' Rev. men. des Maladies de 
 I'enfance,' t, i and ii. 
 
 * ' Etude sur les Scleroeee trnwitphaliiiues primitives de I'enfance,' Havre, 
 1885. 
 
 8 ' Archiv. de Physiolope. W^i, 
 '" • Brain,' vol. v. 
 1' 'Brain,' vol. vi. 
 ** ' Practitioner,' vol. xxii'l 
 " ' British Med. Journa.1.' IWT, vnl I 
 
 '* 'Diseases of the Is'ervpw *y*reui,' London, 1887, vol. ii; "On Birth 
 Palsies," ' Lancet, 1888. voL i. 
 
INTRODUCTION. 3 
 
 have extended and systematized our knowledge of these 
 cases. 
 
 The valuable papers by McNutt,^ Sinkler,^ Wood,'' 
 Hatfield* Knapp,^ Billiard and Bradford/ Seibert, Caille, 
 J. Lewis Smith,^ and quite recently Lovottj^show that the 
 question has not failed to attract the attention of American 
 observers. 
 
 It is a pleasure to speak specially of the work of Dr. 
 Sarah J. McNutt, of New York, which Gowera has re- 
 cently characterized as " by far the most valuable con- 
 tribution to medical science that the profession has yet 
 received from members of her sex." 
 
 The kindness of my colleagues, Dr. Weir Mitchell 
 and Dr. Wharton Sinkler, has enabled mo to utilize their 
 cases as well as my own, and makes the material upon 
 which this study is based exceptionally lar^e, much larger 
 in fact than has been heretofore analyzed from any clinic. 
 I have also to thank Dr. Kerlin, of the Pennsylvania 
 Institution for Feeble-minded Children at Elwyn, for 
 placing at my disposal the cases under his care ; and to 
 Dr. Wilraarth, his assistant, for anatomical data. 
 
 The cases may be arranged as follows : 
 
 tr • 1 • f Infirmary 
 Hemiplogia < •' 
 
 I Penna. Inst. F. M. C. 
 
 Total 
 
 Bilateral hemiplegia 
 Paraplegia . 
 
 Chscs. 
 97 
 23 
 
 120 
 20 
 11 
 
 ' "Double Infantile Spastic Hemiplegia," 'Amer. Journ. of the Med. 
 Sciences,' 1885, vol. i ; " Apoplexia neonatorum," • Amer. J. of Obstet.,' 1885. 
 
 » •* Paralyses of Children," ' The Medical News,' 1885, vol. i. 
 
 ^ " Spastic Infantile Paralysis," ' Polyclinic,' 188* • Nervous Diseases ; 
 their Diagnosis,' Philad., 1887. 
 
 * ' Archives of Pediatrics,' 1886. 
 
 ^ ' Journal of Nervous and Mental Diseases,' 1887. 
 
 * " lleport of Proceedings of Suffolk District Medical Society," ' Boston 
 Med. and Surg. Journ.,' 1888, vol. i. 
 
 " Report of Proceedings of New Yorii Academy of Medicine," Jan. 25th, 
 1888; ' Journal of the American Medical Association,' Feb. 25th, 1888. 
 s ' Boston Medical and Surgical Journal,' June 28th, 1888. 
 
 |j 
 

 I : a 
 
 I] 
 
 4 THE CEREBRAL PALSIES OF CHILDREN. 
 
 A total of 151 cases of cerebral paralysis. 
 
 It is of interest to compare the relative frequency of the 
 cerebral and spinal forms of infantile paralysis. During 
 the period in which there have been at the Infirmary 
 about 120 cases of the former, there have been nearly 500 
 cases of the latter, so that the proportion is about one 
 to 4-16. 
 
 INFANTILE HEMIPLEGIA. 
 
 Synonyms.' — Hemiplegia spastica cerebralis (Heine). 
 Hemiplegia spastica infantilis (Bernhardt). Acute En- 
 cephalitis der Kinder (Striimpell). Die Atrophischo 
 Cerebrallahmung (Henoch). Agenese cerebrale (Ca- 
 zauvieilh). Sclerose cerebrale, atrophic partielle cere- 
 brale (French writers). 
 
 Etiology. — Of the 120 cases, fifty-seven were boys and 
 sixty-three girls. Right hemiplegia occurred sixty-eight, 
 left in fifty-two cases. 
 
 Age at onset. 
 
 
 
 
 
 
 Cnses. 
 
 Congenital ...... 15 
 
 Ist year 
 
 
 
 
 
 
 45 
 
 2nd „ 
 
 
 
 
 
 
 22 
 
 3rd „ 
 
 
 
 
 
 
 14 
 
 4th „ 
 
 
 
 
 
 
 1 
 
 5th „ 
 
 
 
 
 
 
 3 
 
 6th „ 
 
 
 
 
 
 
 3 
 
 7th „ 
 
 
 
 
 
 
 3 
 
 8th „ 
 
 
 
 
 
 
 1 
 
 9th „ 
 
 
 
 
 
 
 1 
 
 10th „ 
 
 
 
 
 
 
 1 
 
 Above 10 
 
 
 
 
 
 . 1 
 
 110 
 
 Age at oiitii 
 
 3t not 
 
 give 
 
 1 
 
 . 
 
 . 
 
 . 10 
 
 Thus the greatest proportion of cases occur during the 
 first three years of life. 
 
 Of the congenital cases, five presented no record of 
 injury during delivery, and the affection was noticed 
 
INFANTILE HEMIPLEGIA. 
 
 either just after birth, or very early, without definite 
 onset. 
 
 Case 2.— Joseph C— , set. 2i. H., 203.^ The mother, 
 when pregnant with him, had chorea from the second to 
 fifth month. When born the left arm was cold and white, 
 and the child never used the left side. A squint has 
 developed during the past six months. The left arm and 
 leg are small, stiff and shrunken. 
 
 Case 35. — Genevieve C — , a)t. 2|. I. P., 4, 38. 
 Eleventh child, birth normal ; no convulsions ; dentition 
 normal. After birth, the mother noticed that the 
 child used the left hand rather than the right, and 
 this condition has persisted. The child now walks, but 
 with a hemiplegia gait. Rigidity at the right elbow ; 
 contractures ; difficult to extend. Intellect defective. 
 
 Case 43.— Tillie N— , «t. 23 months. I. P., 3, 185. 
 One of seven children ; others healthy. Mother noticed 
 since childbirth a contraction of fingers of right hand, and 
 loss of power in arm ; also weakness in right leg, 
 especially at ankle. No history of fever. Born naturally 
 at full term. 
 
 Case 72.— Henry B— , aet. 16. H., 262. Had seven 
 spasms during the first twenty-four hours after birth, 
 followed by loss of power on the right side. Began to 
 walk at twenty-two months. Learned to talk easily. 
 Had a talipes equino-varus of right foot, which was 
 operated upon. Began early to have choreic movements 
 of the right side. Goes to school and is intelligent. The 
 right arm is apparently as well develorjed as the left, but 
 the muscles are rigid. Very little voluntary motion. At 
 rest, there is frequent spasm of the arm, the fingers are 
 thrown out into irregular movements, and the arm is 
 thrust out at right angles, or jerked behind him. This is 
 very marked on excitement. The right leg is an inch 
 shorter than the left, and not so well developed. When 
 walking the leg is very rigid, and he turns the foot out. 
 
 * The letters and numbers after the cases refer to the Hospital Case- 
 books. 
 
b THE CEREBRAL PALSIES OP CHILDREN. 
 
 The leg is frequently extended when at rest. No rigidity 
 of muscles of neck or face. 
 
 Case 73.— Minnie C — , aet. 8. H., 281. Mother 
 noticed that as soon as the child began to crawl and play 
 it seemed paralyzed on the riglit side. Cannot fix the 
 date of onset ; there have not been convulsions. The 
 right arm and leg can be moved, but they are somewhat 
 wasted, and are the seat of irregular choreic movements 
 whenever an attempt is made to use the arm or to walk. 
 There is slight irregular movement on the right side of 
 the face, when talking. 
 
 In the first three cases, the condition is stated to have 
 been observed from birth, and, in the last, there was no 
 seizure to indicate the onset, and in it, too, the paralysis 
 was probably congenital. In the fourth case, there were 
 convulsions during the first twenty-four hours similar to 
 those which, as we shall see, usher in the majority of 
 these cases. 
 
 Abnormal condUions of the mother during pregnancy^ 
 or accidents, are men*^ioned as possible causes, and, in a 
 fev, of the cases, we find a record of sudden fright or 
 unusual mental distress ; but it is very doubtful how far 
 such influences can be connected with the affection of the 
 child. In such an instance as the following, the fright of 
 the mother eurly in pregnancy cannot have had the 
 slightest effect in inducing hemiplegia. 
 
 Case 8.— Luther P— , aet. 4. H., 279. Is the fourth 
 of five children. Natural labor. Mother states that she 
 was badly frightened at the third month, and to this she 
 attributes the paralysis of the child. Had spasms while 
 teething, but, as early as the third month, it was noticed 
 that he did not use one side well. The right arm and leg 
 are stiff and contracted. Began to walk when two years old. 
 The speech is somewhat affecied. Has had only one con- 
 vulsion since teething. 
 
 Except ir a few cases, no special mention is made of 
 the existence of nervous disease in the parents, and the 
 
I 
 
 INPANTILK HKMII'LEQIA. 7 
 
 following is tho only case in which there was a marked 
 history of alcir olism. 
 
 Casw 78.— Florence H— , a3t. 7. I. P., 359. Father 
 and mother addicted to drink. Is paralyzed on left side. 
 Can get no history of its origin. L.'ft hand shows 
 marked choreic movements. Gait hemiplegic. Has 'petit 
 mal, and, occasionally, severer fits, in which she falls. 
 
 I have been rather struck with the vigorous, healthy- 
 looking condition of the mothers with hemiplegic chil- 
 dren whom I have seen at the Infirmary. 
 
 Syphilis is not often mentioned as a cause of infantile 
 hemiplegia. It was noticed in only two of GaudardV 
 series, and Wallenberg^ alludes to it, but does not give 
 any instances. In Abercrombie's^ series of fifty cases, 
 four of the children had congenital syphilis. The fol- 
 lowing is the only case on the records in which there 
 seems to be a pretty definite history of this disease. 
 
 Case 64.— Annie F— , set. 2. I. P. A., 225. Parents 
 healthy. Of nine children, only two are living. Several 
 died immediately after birth. Mother has cicatrices 
 about the mouth and nose, due to a rash which came on 
 during pregnancy. The child was well when born. 
 When eight months old, fell off a chair; was not insen- 
 sible, but that evening had " spasms." When tei. ^uonths 
 old, had spasms while cutting teeth. There were fever 
 and a great increase in the general tenderness which had 
 existed all over the body. There was no coma. About a 
 week after the convulsions the mother noticed that there 
 was complete loss of power in the left arm and leg. The 
 child gradually regained use of the leg, and, when a year 
 old, could stand on the leg, but she cannot yet stand 
 alone. There was no facial palsy. Status prscsens : A 
 pale, but plump child. Is not very intelligent ; can say 
 only two or three words. She has thirteen teeth, all be- 
 ginning to decay. The left arm is not wasted, but is 
 
 ' Gaiidiird, loc. cit. * Wallenberg, loc. cit. 
 
 •• Abei'cronibie, loc. cit. 
 
8 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 flexed and contracted, and cannot bo moved. The fin- 
 gers are clenched. The left leg is swollen and softer, 
 but there is no difference in the length. Four months 
 ago she began to have spasmodic contractions of the 
 affected arm and leg, lasting for about five minutes, and 
 occurring several times each day. The arm would be 
 jerked up, the leg twitched and the eyes become fixed. 
 No twitching of face. Just before they come on she gets 
 quiet, and, if nursing, drops the nipple. Immediately 
 after, she draws a deep breath, and is then as bright as 
 ever. The child was brought back when eight years old, 
 and note merely says, " Decidedly idiotic." 
 
 The association o^ paralysis and mental defects with 
 difficult or abnormal labor has been insisted upon by many 
 writers, and, on several occasions, Dr. Smkler^ has called 
 attention to the subject, in connection with cases brought 
 to the Infirmary. 
 
 In two cases the children were born prematurely. In 
 Case 51, the mother had a fall, and delivery occurred at 
 the eighth month. The child, however, throve until the 
 second year, when it had convulsions and became para- 
 lyzed on the right side. There was, probably, no connec- 
 tion whatever between the premature delivery and the 
 onset of the disease, but, in the following instance, the 
 affection probably dated from a few weeks after birth. 
 
 Case 6(5. — Andrew S — , aet. 1. A seven months' child ; 
 very thin when born. When three weeks old had many 
 convulsions, very severe. For six months, on and off, 
 there were fits every day. When lifted, and the legs 
 stretched, always screamed. When about five or six 
 months old it was noticed that the left arm and leg were 
 not moved. There has been no improvement, and now 
 the fingers are contracted, and the forearm flexed on the 
 arm. Can raise the arm, but does not use it. Left leg 
 
 ' Sinkler, Discussion on Dr. Parvin's paper on Injuries of the Foetus, 'The 
 Medical News,' 1887, ii ; " Palsies in Young Children," ' Amer. Journ. Med. 
 Sciences,' 1875 ; ' The Medical News,' 1885, i. 
 
INFANTILE HEMIPLEGIA. 
 
 
 
 as long as ri«iclit, but the foot seems shorter. Limb flexed 
 at knee, but he can move the leg- and toes. Does not 
 sit ahjne nor stand. Died a week after first visit. 
 
 In three of the casos^^. of bihiteral hemiplegia the cliil- 
 dren were born at the seventli month ; and in two of the 
 cases of paraplegia the delivery was premature. In 
 twenty-eight of Little^s forty-nine cases of spastic rigidity,' 
 eight of which were hemiplegias, the birth was prema- 
 ture, in either the eighth or ninth month. 
 
 hrjury rvith the forceps J^ Fissures and fractures of the 
 cranial bones, with haemorrhage or contusion of the brain 
 substance, are well recognized by obstetric writers as 
 among the untoward I'esults of forceps delivery. The 
 parietal bones ai'e most frequently involved. Unless 
 bleeding occurs, or contusion of the subjacent cortex, the 
 effect is not serious. In the special monographs relating 
 to cerebral palsies in children, we do not find many cases 
 of the kind. Thus, in Little's^ paper, which deals 
 particularly with the relation of abnormal parturition to 
 physical defects in the child, there are only four instances 
 in which the forceps was used, and there is no statement 
 of actual injury. Gaudard,* in a review of eighty cases, 
 met with no observation of the kind in the literature, and 
 Wallenberg,^ in his analysis of IGO cases, notes that in 
 only six instances was difficult labor mentioned as a cause, 
 and he says nothing about the forceps. The Infirmary 
 
 ' Little, 'Obstetrical Society's Traiisactiotis,' vol. iii, 1862. 
 
 * With the revelation of the Chainberleus' secret in the second or third 
 decade of the eighteenth century, and the general introduction of tlie forceps 
 as an aid to delivery, there was, very naturally, discussion upon the effect of 
 such a measure on the child's head ; and to this Sterne gives popular expres- 
 sion when, in ' Tristram Shandy ' (vols, i and ii of which appeared in 1759), 
 he makes the breaking of Tristram's nose by Dr. Slop's forceps the beginning 
 of all his troubles. The possibilities of injury to the " delicate and fine-spun 
 web" of the brain are discussed at length by Slumdy, sen., with the Doctor 
 and Uncle Toby. 
 
 ' Loc. cit. 
 
 * Loc. cit. 
 
 * Loc. cit. 
 
10 
 
 TIIK CEUKHRAL PALSIKS OF CHILDRKN, 
 
 records contain tho followinf'' cases, nine in number, in 
 wliich tho cliildrcn were delivered witli forceps. 
 
 CAst: 0.— Ada W— , tut :}. 11., 240. No other chil- 
 dren. The mother had a convulsion during labor and 
 the child »va8 born with instruments. Very early it was 
 noticed that she did not use the right arm and leg 
 properly, and this continues. 
 
 Case 12.— Albert McM— , a3t. 18 months. H., 295. 
 Instrumental labor; head slightly injured. Paralysis 
 noticed October, 1884, just after a fall. Whole left side 
 is affected; contractures of arm and wrist. Has no 
 convulsions. 
 
 Case IC— Alildred M— , set. 3 months. H., 326. The 
 second child. Was born with instruments. Labor 
 tedious, head locked. Has no marks ; well-nourished, 
 healthy child ; head symmetrical, a little fuller right than 
 left. Legs never affected, reflexes good. Left arm 
 paralyzed, smaller than right, three-quarters of an inch 
 less in circumference of forearm. Fingers contracted. 
 Improved somewhat under treatment. 
 
 Case 10. — Mary C — , aet. 1. I. P., 49. Parents 
 healthy ; was b< in with forceps. Baby did not use the 
 right arm. Now is unable to sit up. Right arm is 
 smaller than the left, the flexors are contracted, and the 
 fingers are contracted and stiff. Uses the left leg more 
 than the right. There is strabismus ; forehead is narrow, 
 no marks ; has never had fits. 
 
 Case 47.— Clarence H— , «t. 3i. M., 5, 314. Elder 
 of two children. Other five months old, well. Born 
 with forceps ; bears marks of deep lacerations. At two 
 years began to walk, but badly. Walked in a stooping 
 position and on his toes. Momentary spasta six months 
 ago, thought to be brought on by excitement. Fairly woU 
 nourished and very intelligent ; speaks slowly. Walks 
 with uncertain, tottering gait. Drags left leg, and often 
 falls forward. 
 
 CAf : 65.— Estella M — , aet. 3. I. P. a., 227. Was 
 delivered with forceps ahpv ^ long labor ; head slightly 
 
INFANTILK H HMll'LE(i[A. 
 
 11 
 
 cut. No convulsions, but for tlio first three months of 
 life had prolonj^ed screaming spells. ^Mother does not 
 know whether the child was paralyzed at birth, ])ut when 
 she was three weeks old, she noticed that the left arm 
 and leg seemed perfectly powerless. When one year old, 
 she began to use the leg. Has now paralysis of left arm ; 
 can lift it, but the hand is practically useless, though slie 
 can move the fingers. The left leg is very little smaller 
 than the right. Gait hemiplegic. Intelligent. 
 
 Case G7.— Kate F— , set. 4. M., G, 18. Born with 
 instruments ; bears mark on face ; small spot in skin and 
 nodular thickening on right frontal bone. Never has 
 used left hand and arm and left leg properly ; cannot 
 grasp well with left hand. Left hand smaller than right ; 
 cannot pick up small objects with the fingers ; can walk 
 and run, but not well. Left foot stiff ; flexion and 
 extension difficult. Apparent rigidity of ankle-joint. 
 Muscles well developed. Walks on outer side of foot, 
 and chiefly on the ball of foot. Knee-jerk increased 
 very little. Left leg is colder. Is bright and intelli- 
 gent. 
 
 Case 81.— Floyd S. L— , set. 6. I. P.g, 83. Sipposed 
 to have been injured at birth by forceps. Was very 
 inert during the first three months of life. After this, 
 the mother noticed peculiar spasms, first in left leg then 
 in right arm. Got well except in the right arm, which is 
 choreic and palsied. 
 
 Case 97. — Lulu H — , aet. 5 ; the fifteenth child. 
 Others born living. Four children had died, two of con- 
 vulsions. Mother in labor three hours ; forceps applied, 
 as there was some difficulty. Child resuscitated with 
 great difficulty. Bears the scars of the forceps on right 
 temporal region, just within lino of the hair, and the top 
 of the right ear is scarred. On the left occipital region 
 low down is a scar. The wounds did not bleed much. 
 On the second day child had a convulsion, lasting many 
 hours ; never has had another. When about three months 
 old, it was noticed that the left hand was not used, and 
 
 I' 
 
 : I 
 1 ■ 
 
 i 
 
 iM 
 
12 
 
 THK CKRKnUAL PALSIES OP cniLDREK. 
 
 11: > 
 
 that the face was crooked ; and at the eighteenth month, 
 when she began to walk, the left leg was seen to drag. 
 Hfdtns pr/rsens : Well-nourished, intelligent-looking child. 
 Head well shaped. 81iglit scars in above-mentioned 
 regions ; bones not apparently injured. Left face 
 atrophied, but the muscles move quite well. Left arm 
 not used ; is smaller than the right. Hand not con- 
 tracted ; fingers can be flexed. A little stiffness at the 
 elbow. Gait hemiplegic, left leg dragged ; it is a trifle 
 shorter and is smaller than the right. The reflexes are 
 not exaggerated. Knee-jerk not obtainable on either 
 side. 
 
 In six of these cases the child is said to have been in- 
 jured by the forceps, and in all the paralysis was either 
 noticed at once or a few months afterwards without defi- 
 nite onset. Only one of these cases (47) appears to have 
 had spasms. 
 
 Trauma. — In three cases there was a history of injury 
 to the head, 07ie a penetrating wound, and two the result 
 of falls. 
 
 Case 23.— J. E. K— , jet. 27. I. P.^, 13L When 
 eleven months old received a wound on the left side of 
 the head from a pitch-fork, which penetrated the skull 
 from one to two inches, causing immediate paralysis of 
 the right side of the body. Had convulsions after it. 
 In fourteen days began to recover. Was five years before 
 he could walk, and he never has regained the use of the 
 right arm, which is rigid and flexed. Leg is slightly 
 contracted at the knee and is stiff in walking. 
 
 Case 62. — Thomas McK— , a3t. 3. I. P.g, 355. 
 Parents healthy, birth normal. Several children have 
 had chorea. When six or seven months old, child fell 
 downstairs, striking her head constantly. Some time 
 after, the mother noticed that there were irregular move- 
 ments in the right hand, and the child has never used it 
 properly. The movements are much increased by 
 voluntary efforts. 
 
INFANTILE HEMli'LElilA. 
 
 18 
 
 Case 70.— Willielra S— , xt. 29 months. I. P. a, 81. 
 When born healthy. On the tenth day after birth the 
 mother fell downstairs witli him, fourteen steps. The 
 head was not cut or brulHed. For eight days he seemed 
 very ill and did not take the breast ; did not have con- 
 vulsions. The head became much swollen — " all out of 
 shape." Has never used the left hand since the fall, 
 and the muscles are now in condition of rigid sjiasm. 
 Left leg not used so well as right. The right parietal 
 region bulges, the left is flattened, which makes the 
 head very shapeless — right semi-circumference nine and 
 one-half inches ; left, eight and seven-eighths inches. 
 There is a large soft rachitic spot on right parietal 
 eminence, very tender on pressure. Fontauelles closed. 
 Has not had any convulsions. 
 
 Ligation of common cai'otid. — In Case 7 of the Elwyn 
 series there is the following remarkable history : 
 
 Mary P — , aet. 24. In 1869, when six years old, she 
 had an extensive abscess of the neck following scarlet 
 fever. Ulceration of the right carotid occurred, necessi- 
 tating ligation, which was performed by Drs. Keys and 
 Getcheil. Left hemiplegia followed and has persisted. 
 Status prxsens : Well-grown but slightly-built woman. 
 Left hemiplegia. Wrist flexed immovably at right angles ; 
 thumb held in palm ; fingers flexed, but can be moved a 
 little. Arm somewhat wasted. Drags left foot. Left 
 leg a little wasted. Face not affected. Is bright and 
 intelligent. Is not epileptic. 
 
 Infectious disease. — It is well known that both cerebral 
 and spinal palsies may follow any of the specific fevers. 
 Gaudard mentions whooping-cough and diphtheria among 
 the possible etiological factors. In Wallenberg's statistics 
 of 160 collected cases, nine are stated to have followed 
 measles ; thirteen scarlet fever j three diphtheria (and 
 croup) ; six epidemic meningitis ; three whooping-cough ; 
 four typhus (abdominalis) ; and two vaccinia. 
 
 1 
 
 ? :•: 
 
 i-,-4i^Mr*j/j<H?-<ffl«rc«<V«.Wft' * >**»■;. 
 
u 
 
 TMK CKKKIIUAL I'ALSIKS OF (1111, DRKV. 
 
 Marie^ liaa reported two cases illustrating^ tlio con- 
 nection between infantile cerei)ral liemiplegia and in- 
 fectious diseases ; one came on with w]ioopiii^-cou<^h, tho 
 otlier followed mutnps. Abereronibie lays special str(>ss 
 on the importance of this factor, which is noted also by 
 Striirnpell, Jiernhardt, Cowers and others. In our series, 
 in sixteen cases the disease came on in connection with, 
 or just after, an attack of one of tho infectious diseases. 
 
 I' i 
 
 i 
 
 Scarlet frvrr : seven cases. 
 
 Case 4.~John K — , a3t. 12. H., 231. Family history 
 pfood. Was well until July, 1880, when he had a bad 
 attack of scarlet fever ; ill for two mouths and had dropsy. 
 Became very thin after the dropsy subsided ; had 
 rotenticm of urine. Convalescence slow — had otitis media 
 and a suppurating cervical bubo. The mother noticed 
 loss of power on the right side as the dropsy disappeared. 
 This persists, and the leg is now weak. But both are 
 getting stronger. 
 
 Case 13.— Emma G— , a)t. 17. H., 300. Was healthy 
 as an infant and child. Has not yet menstruated. 
 When fifteen, had scarlet fever, a severe attack followed 
 by dropsy. Was ordered a warm bath and while in it 
 was seized with paralysis of the right side and loss of 
 speech, and was unconscious thirteen hours. Was in 
 the bath three-quarters of an hour. Had fever, which 
 lasted three days. Was in bed for a month. Gradually 
 recovered U60 of leg. Gait is hemiplegic. Arm stiff at 
 elbow and wrist, and is held flexed. Reflexes ex- 
 aggerated on right side ; speech is still a little thick ; 
 a little paresis of right corrugator supercillii. Apex- 
 beat of heart forcible ; loud blowing systolic murmur. 
 
 Case 17.— Wm. Mc— , aet. 4. M.., 37. T:ie seventh 
 child ; six years elapsed between sixth and seventh. Was 
 well until November, 1884, when he had scarlet fever ; had 
 dropsy and also a very bad throat with it. Shortly after, 
 he had convulsions and became paralysed on the right 
 1 ' Progres Medicalo,' 1885, No. 3fi. 
 
INFANTILK MKMU'LEOIA. 
 
 15 
 
 sido J recovered ptnver prndimlly, but has never spoken 
 since. Said a few words just aft(>r tlie sjiasms. Is a strong' 
 well-built child. No note as to spasm of th" rifj^lit sidr. 
 Case 24.— John \V— , jet. 4. I. P.^ 1 :?'.». Was 
 healthy when born ; otluT rliildren healthy. When ten 
 months old could walk and was (juite well ; was attacked 
 with sumnser complaint, which left him weak for several 
 months. ^Vhen two years and thi'ee months old, had a 
 scarlet rnsh, from which he recovered and was walkin<^ 
 about. Two weeks after, he arose one moriiin*^ all ri<^ht, 
 seemed well and took his breakfast. Went to sleep in 
 the morning, as usual, and the mother noticed that ho 
 began to pant and the mouth was drawn to the right. 
 For a week he had a series of convulsions and lost 
 power completely in right side and could not speak. In four 
 or five months the speech gradually returned. Began 
 to walk last spring. Convulsions have not returned. 
 Intelligence below par; talks, and his memory is good. 
 Right arm feeble and contracted, and the fingers are 
 flexed. Gait hemiplegic and the leg is stiff. 
 
 Case 28 — Cassie McA— , tet. 20. I. P. b., 85. 
 Small, thin, pale girl. When between seven and eight 
 years old had a severe and prolonged attack of scarlet 
 fever, during which she was for a time insensible. Does 
 not know if she had fits. Right-sided hemiplegia came 
 on during the attack and has persisted ever since. The 
 face has improved, but the arm and leg have not grown, 
 and there is a marked spastic condition of the muscles. 
 Muscles respond to induced current. 
 
 Case 70.— Alice R— , a3t. 20. H., 195. Was imper- 
 fect in some way at birth ; the head was bandaged as she 
 was supposed to have water on the brain. She got better ; 
 no special feebleness noticed at that time. At ninth 
 month, scarlet fever; feebleness on right side followed. 
 Did not learn to walk until three years eld ; at first 
 seemed to walk all right, but soon noticed that she turned 
 the right ankle out, for which a brace was applied. At 
 age of ten, the right tendo Achillis was cut. There was 
 
 i 
 
 t \ 
 
 ■n|M0W«Mm«« 
 
10 
 
 THE CEltEHIEAL PAtSrES OP CHILDREN. 
 
 a gradual leaning to ttSwr insrht side, with curvature of the 
 spine. The right arm. ^md leg did not seem to grow pro- 
 portionately to the left. Status prxsens : Is emotional. 
 Slight loss of power om n^ht aide of face and uncertainty 
 of movements, which airte Jerkj. Great incoordination on 
 attempting to pick up lOifivJeotH with right hand ; move- 
 ments choreic and v^^-^k. Some loss of feeling in right 
 hand. Sensation better m right leg than in right arm. 
 Temperature lower on irii,:;feit! aide than on left. Measure- 
 ments of right arm aiud Be^, from one-half to one inch 
 less than left. 
 
 Case 83. — Annie K— , att, .>. I. P.g, 187. Third child. 
 Others healthy. Famnlj Biistory good. When two and 
 a half years old, in Ocit/oifceTj the child had a mild attack 
 of scarlet fever, fo]]oiir>eii hy whooping-cough ; one day 
 the mother noticed at italblle that the child had suddenly 
 lost power in the leg ajui'l aarca. of the right side, and that 
 the face was drawn. TliiM was quite sudden, without any 
 premonition. The paraHj^M persisted, though improving. 
 Status 'praasens : Open* arnid shuts the right hand, but 
 does not use it habitudlllj, 3Iovements of the arm and 
 foi'earm good, but e^wttsatit choreic motion, and it is 
 thrown about, particularfjfct-hind her, as she walks. The 
 right foot strongly Jiiv«itK.i'i ; gait hemiplegic; toes flexed. 
 Walks on the toes and wA-ars out the nails. No special 
 atrophy of the right fc-idte. 
 
 Measles : four cases- 
 
 Case 32.— Richar<i B~, aefc. 25. Con. Dis. 2, 215. 
 Was healthy until eigiiSftisini months old, when he had 
 measles, followed by Mtiittii*, during which fragments of 
 bone came away. H^ nLea had convulsions and left 
 hemiplegia, which lattK:T lia« persisted. The arm is short 
 and stiff — the forearm rniiieh shorter than its fellow. 
 Great stiffness ; claw-iiiiainiid- Hemiplegic gait. He has 
 a little difficulty in ^^p«;tc•Sli, Intellect is pretty good. 
 The convulsions becaiae wcjif^e about the tenth year, and 
 he now has attacks at isaHCTvala of a week or two. 
 
 (^^^' 
 
INFANTILE HEMIPLEGIA. 
 
 iure of the 
 grow pro- 
 emotional, 
 ncertainty 
 ination on 
 d ; move- 
 g in right 
 ight arm. 
 Measure- 
 one inch 
 
 lird child. 
 
 two and 
 ild attack 
 
 one day 
 suddenly 
 and that 
 ;hout any 
 iproving. 
 and, but 
 arm and 
 nd it is 
 ^s. The 
 Js flexed, 
 o special 
 
 9 91 ti 
 
 he had 
 lents of 
 md left 
 is short 
 fellow. 
 He has 
 y good. 
 3ar, and 
 
 Case 82.— John C— , set. 2^. I. P.^, 55. Is the fourth 
 of five children. Cut teeth early. Was well and healthy 
 until last autumn, when he had a spasm lasting four 
 hours. Convulsion general. Next day seemed bright 
 and well. Six weeks ago the other children had measles, 
 and this one, on the second day of the eruption, had a 
 convulsion lasting six hours, after which there was right 
 hemiplegia, with loss of speech, which continued two days. 
 Then convulsions began again, with less severity ; some- 
 times more marked on one side than on the other. Ho 
 had, in all, about eighty fits. In about two weeks there 
 was improvement in the paralysis, which has continued, 
 and he has, for the past two weeks, been walking. No 
 fits since the eruption disappeared. A discharge from the 
 ear began six weeks ago ; has now stopped. Appears to 
 understand what is said, but not fully. Head large and 
 square ; slight depression at anterior fontanelle, which is 
 closed. Is irritable. There are distinct choreic move- 
 ments of right arm, which he uses only when the left is 
 held. There is evidently loss of power. Log seems to 
 have recovered perfectly. 
 
 Case 37. — Bessie K — , set. 3 years and 2 months. I. P. j, 
 73. Well until the eighteenth month ; could walk. 
 During the early stage of measles was seized suddenly 
 with spasms and was unconscious for eleven hours. Had 
 vomiting; paralysis of right side noticed immediately 
 after piid loss of speech. Has recovered use of leg and 
 can run. Arm affected. Cannot talk. Intelligence not 
 good. 
 
 Case 1 (Elwyn series). — Jennie S — , set. 14. In 
 institution five years. Was well and strong as a baby 
 until the twelfth month, when she had measles, followed 
 by paralysis of the right side. Is intelligent. Arm stiff ; 
 not much wasted. The fingers move irregularly at times. 
 Under the influence of emotion the hand gets very stiff, 
 but when she is quiet it relaxes and she can pick up ob- 
 jects. Legs well nourished ; very rigid ; drags much iu 
 walking. Knee-jerk not obtainable. No epilepsy. 
 
 2 
 
18 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 jiaii 
 
 !1) 
 
 Whoopwg-covgh : three cases. 
 
 Case 83. — Given under scarlet fever, which preceded 
 the whooping-cough. 
 
 Case 85.— Kate B— , set. 7. I. P.^, 248. Has been 
 a healthy child. Last winter had whooping-cough, which 
 lasted into the spring. In May, 1883, had a convulsion, 
 suddenly, which lasted three hours and was followed by 
 paralysis of the right side and aphasia. Did not attempt 
 to walk for two months. Right arm improved, and face did 
 not seem much affected. Gait is hemiplegic. Articulation 
 is now perfect. Can flex and extend the arm and forearm, 
 but has no power over the fingers. Thumb strongly 
 adducted ; wrist flexed. There is at times large tremor 
 of the whole arm, especially when at rest. The right leg 
 is stiff, but she drags it. The toes are turned in, but she 
 gets along pretty well. Intelligence unimpaired. 
 
 Case 6 (Elwyn series). — John D — , set. 14. Difficult, 
 instrumental labor. Well until two years old, when he 
 had whooping-cough, followed by brain fever and left 
 hemiplegia. Arm stiff and wasted ; hand flexed ; irre- 
 gular movements in fingers. Leg wasted. Gait hemi- 
 plegic. Choreic movements in left facial muscles. Is a 
 low-grade imbecile and has epilepsy. 
 
 In the following case cerehro-sjnnal meningitis was 
 stated to be the cause of the trouble, but it was most 
 probably a mistaken diagnoses, as the symptoms are just 
 those which occur in the majority of the cases. 
 
 Case 21.— Lily H— , set. 4. I. P.^, 85. Other chil- 
 dren healthy. Was normal as a baby. When nineteen 
 months old had an attack which was called cerebro-spinal 
 meningitis ; a series of convulsions for eleven days, on 
 recovery from which the left side was paralyzed. When 
 seen again, at the age of six years, there were marked 
 arrest of development of the left arm and spasm and con- 
 tractions of the paralyzed side. 
 
 In one instance the attack came on after dysentery. 
 Case 22. — Gussie H — , set. 6. I. P.j, 125. Was never 
 
INFANTILE HEMIPLEGIA. 
 
 19 
 
 a very healthy child. When fourteen months old had a 
 dysentery, after which she had two severe convulsions 
 and coma for several hours, and seemed unconscious for 
 six (l;iys. The left side was convulsed for three days. 
 When she roused, it was noticed that the left side was 
 paralyzed — face and extremities. In about three weeks 
 the paralysis began to improve. In three months she 
 began to walk, and within a year could walk alone. No 
 convulsions since on left side, but one general convulsion. 
 Talks with difficulty. Left-sided spasmodic paralysis. 
 Gait hemiplegic. 
 
 Vaccinia : There are two instances in the literature in 
 which the hemiplegia catne on during vaccination. One 
 is given by Heine in his work on Infantile Palsy} 
 
 In Wuillamier's thesis^ the following case is given : 
 
 J. L — ; well until ninth month ; vaccinated, and toward 
 the close of the process there was fever, with a general 
 papular eruption. Convulsions came on, followed by loss 
 of power on the left side. Subsequently, epileptic attacks 
 and feeble-uiindedness. 
 
 The following case I saw with Dr. Morris J. Lewis. 
 
 Case 94. — A. L — , get. 7 ; a seven months' child, 
 vaccinated by Dr. Gerhard when she was about four 
 months old. During the height of the vaccination there 
 were convulsions, chiefly on left side, which occurred very 
 frequently and were followed by deep coma. It was some 
 time before the paralysis was noticed — some months. 
 Now she has left hemiplegia. Arm wasted ; contractions. 
 Gait hemiplegic. Intelligence defective ; speaks badly, 
 but she is learning rapidly under systematic instruction. 
 
 Convulsions : In five or six cases the children had had 
 convulsions repeatedly before the onset of the hemiplegia, 
 and it is possible that they caused the lesion on which the 
 paralysis depended. 
 
 ' 'Spiuiile Kinderlahmung,' 1860, Zweite Auflage. 
 
 ' ' De repilepsie dans rHemiplegie spasmodiquc inf.mtile,' Paris, 1882. 
 
20 
 
 THE CEREBRAL PALSIES OP CIIILDKEN. 
 
 Case 20.— Bruce B— , Ect. 9. I. P.^, 207. Has liad 
 fits since the age of two years, at least once a month. 
 They were general, and he fell in them. Eighteen 
 months ago, after an unusually severe attack, with seven 
 hours of unconsciousness, he awoke paralyzed on the right 
 side ; speech not affected ; no loss of sensation. In three 
 weeks he began to use leg. Has not had convulsions for 
 a year. There is still difficulty in using the arm, which 
 is stiff, and the movements incoordinate. 
 
 Case 39. — C. M — , aet. 8 years and 3 months. I. P. 3, 237. 
 Mumps two yeai's ago ; has had spasms ever since. One 
 week before Christmas had a sharp spasm, Avhich was 
 followed by right hemiplegia. Unconscious for six hours 
 after attack. Could not walk for two or three days. 
 Has not had spasms since. Leg and arm have improved. 
 Rigidity of arm increased by passive motion. Can extend 
 
 and flex arm ; can extend but 
 
 not 
 
 flex finu'ers. Walks 
 
 lame on account of contraction of extensors. 
 
 Case 68.— John F— , rot. 7. I. P. b, 183. Mother 
 died suddedly ; six brothers and sisters, all healthy. 
 Commenced having fits at three years. Has convulsions 
 every six or seven weeks. When six, had a very severe 
 fit, lasting two or three hours. Worked all the time. 
 Fit lasted until 12 p.m. Awakened with a '* screech." 
 Lost hearing and speech. For ten days he moved his 
 whole body. Had convulsive movements and contractions. 
 When he began to improve, noticed he could not move 
 right hand. Health excellent. Mind much impaired. 
 Does not move right arm. Nutril ion about equal. Right 
 hand colder. Grinds his teeth '^jnstantly, night and day. 
 Right arm below elbow smaller than the left. Muscles 
 of right arm contracted, will yield, but immediately 
 return. Pl«ys, amuses himself. Takes no notice of 
 others. Right leg a very little shorter than left. Right 
 foot much colder than left, but muscles firm. Tendency 
 to varus in right foot. 
 
 Case 60.— S. S— , set. 12. C. D. C, 57. Family 
 history good. Healthy and strong until sixth year ; 
 
INFANTILE HEMIPLEGIA. 
 
 J 
 
 intelligence very good. Six years ago mother noticed a 
 twitching of left side of face, lasting not more than one 
 minute, and only once a day. Had h.ad no fall, no sick- 
 ness of any kind. Soon the attacks of twitching of face 
 became more frequent, two or three daily. Head always 
 drooped to left side, and he seemed unconscious, but im- 
 mediately afterward returned to play. JVIore frequently 
 attacks of twitching of face at night. Two years after 
 first attack of twitching of face, had a general convulsion 
 of left side ; was lying asleep at the time, and attack 
 lasted only a few minutes ; did not wake up. Next 
 morning early, while asleep, had another attack, which 
 lasted one hour ; got up immediately afterwards, and 
 seemed as well as ever. The attack was confined to left 
 side ; was paralyzed completely for one month after this ; 
 loss of speech. Paralysis suddenly left, and power to 
 speak returned. The convulsive attacks have continued 
 at the rate of from one to twenty per diem, and always 
 during sleep, never when awake, generally at night, but, 
 if asleep during the day, may have an attack. Face 
 flushed during attack, afterwards pale. Never bites 
 tongue nor foams at mouth. These attacks continued to 
 increase until two years ago. At this time began to 1o«g 
 power in arm ; weakness extended to legs and, finally, 
 could not move head, and lost power of speech. No 
 palsy of bladder or rectum. No loss of sensation or 
 hearing. In one year power began to return in hand, 
 and gi-adually returned to legs and head. Still speaks 
 very indistinctly. Status jirwsms : No paralysis of arms 
 or legs. Speaks very indistinctly ; mother only can 
 understand him. Mind greatly weakened; and is irrit- 
 able. Fits occur every night; generally has one to 
 three nightly, and if bromide is neglected will have a 
 greater number. Always voids urine during a fit. Fits 
 last two minutes, and are confined to left side. 
 
 Case 92.— Delia W— , a?t. 2. C. D.o, 950. Con- 
 vulsions began two hours after birth, and have continued 
 ever since. These are of long duration, and aii'ect the ri^lit 
 
22 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 side more than the left. Six months ago, after a severe 
 fit, she lost power on the right side, and it persists, but 
 is now partial. There are constant choreic movements in 
 the right hand. 
 
 These cases are of interest, as confirming Goodhart's^ 
 view that the convulsions may cause the haemorrhage, 
 which leaves permanent damage to the brain. 
 
 i 
 
 i 
 
 In the following case the hemiplegia came on after 
 violent vo'ihifinri, caused by eating pokeroot. 
 
 Ca.^e 03.— Wm. R— , jet. 13. I. P.3, 31. Was well 
 until fifth year ; at that time ate some pokeroot, which 
 made him violently sick at stomach : the attack lasted all 
 day. After vomiting fell into a profound stupor and was 
 thought to be dead. When he awoke had complete left 
 hemiplegia, entire loss of power, face as well as limbs. 
 Could not move for three or four months. Recovered 
 slowly, leg first, then arm. Status 'prsenens : Muscles 
 well developed. Has every motion of left arm and fore- 
 arm. Can flex hand, but not well, every effort to flex 
 produces more or less extension. Has also lock-spasm 
 of hand ; fingers press tightly in palm, extends them by 
 producing extreme flexion of wrist by other hand, which 
 produces reversed condition, and enables him, with aid 
 of other hand, to unlock the fingers. There is choreic 
 movement of hand resembling athetosis. Sometimes 
 hand will not close. All muscles of left arm and shoulder 
 ai'O in constant motion. Muscles rather over-developed. 
 When asleep, spasm subsides completely. Drags leg, 
 but there are no spasmodic movements. 
 
 We should naturally think that embolic processes had 
 much to do with the production of hemiplegia in children, 
 but neither in the literature nor in our records is there 
 support for this view. In the great majority of the cases 
 the lesion supervenes before the onset of those affections 
 with which endocarditis is associated. Of Wallenberg's 
 ^ • Text-book of Diseaces of Children,' London, 1887. 
 
INFANTILE HEMIPLEGIA. 
 
 28 
 
 ' 
 
 cases, only five had endocarditis and embolism. A case 
 reported by Taylor/ illustrates the condition very well : 
 A child, ast. 5, with scarlet fever, had convulsions on 
 the fourteenth day, after which a right-sided paralysis 
 remained. There was also partial gangrene of the hand, 
 and dropsy of extremities. The autopsy showed embolic 
 softening in left hemisphere, infarct in kidney and recent 
 mitral endocarditis. Here the connection is very evident, 
 and it is surprising not to find a larger number of cases of 
 this kind. The only instance of embolism on our records 
 is of a similar nature, and is given among the scarlet 
 fever cases. The girl, aet. 15 at the time, had dropsy 
 after fever, and was ordered a hot bath, in which she was 
 suddenly seized with right hemiplegia and aphasia. That 
 this was embolic is likely ficm the sudden onset, and 
 from the presence, eighteen months afterwards, of a well- 
 marked apex systolic murmur, the result, no doubt, of an 
 endocarditis at the time of the scarlet fever. 
 
 In speaking of the morbid anatomy, I shall refer to 
 the sixteen cases, of the ninety autopsies collected in the 
 literature, in which there was vascular obstruction ; seven 
 of them were embolic. 
 
 1 ' British Medical Journul,' 1880, ii. 
 
24 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 CHAPTER II. 
 
 INFANTILE HEMIPLEGIA [contillUcd). 
 
 Symptoms. — Complex and varied as are the symptoms 
 of infantile hemiplegia they fall naturally into three 
 divisions, those of the onset, those pertaining to the 
 paralysis, and the sequences ; and in this order I shall 
 consider tliem. 
 
 The period of onset is usually charficterized by con- 
 vulsions and coma, indicating serious disturbance of the 
 brain functions, but there are exceptions to the rule. 
 Thus, in three cases the disease came on stuhlenhj, in 
 apparently healthy children, without spasms or loss of 
 consciousness. 
 
 Case 9.— Nellie M— , set. 12. H. 280. Paralysis came 
 on when she was one year of age, suddenly, with pains ; 
 no spasms ; whole left side affected ; gait hemiplegic ; 
 arm and leg swollen and shorter than fellows. Right calf 
 eleven and a half inches, left eleven ; biceps, right eight, 
 left seven and three-quarters ; dynamometer, right sixty- 
 five, left thirty-five ; left side is cold. 
 
 Case 38. — William M — , ait. 4 years and 6 months. I. P.^, 
 84. Good family history ; was well until three years ago. 
 While playing he became suddenly powerless on right 
 side ; had no convulsions, but was comatose for a time ; 
 no fever. The face was included and the loss of power 
 was complete. Is a delicate child. Some mental deterio- 
 ration. Had convulsions ten days before application and 
 now cannot walk. 
 
 In Case 77, the hemiplegia came' on while the child 
 was dressing one Sunday morning, after an indisposition 
 of a few days' duration. 
 
 s 
 
INFANTILE HEMIPLEOTA. 
 
 25 
 
 A latent, gradual onset is more common and was noted 
 in ton cases. 
 
 Case 3.— Joseph D— , wt. 2}. H. 219. When six 
 months old the mother noticed loss of power on the right 
 side. This condition persists ; the hand is closed, and 
 there is talipes varus of the foot. 
 
 Case 7. — Daniel McS— , ast. 4. H. 25:3. Natural labor. 
 When one year old it was noticed that he could not sit 
 up and seemed weaker than natural. Has begun to walk 
 within the past few weeks. Has right hemiplegia with 
 contraction of flexors ; walks very badly ; does not talk, 
 but understands what is said to him. 
 
 Case 75.— Alphonse N— , iot. 14. H. 200. Is one of 
 eight children, five of whom died in infancy. AValked 
 at two years and then walking gradually became impaired. 
 There was no sudden attack. Status j)r,xsens : Right arm 
 and leg wasted ; the right shoulder-joint and blade pro- 
 ject, and the whole side looks smaller. The hand is cold 
 and there is marked mottling of skin of legs and arms ; 
 choreic movements of right arm, and at times an irregular, 
 jerky, motion of the riglit leg ; reflexes present ; the 
 superficial are exaggerated on affected side ; heart normal. 
 
 Case 53. — Frank H— , aet. 14 months. I. P.p 100. 
 Healthy and strong when born. When five months old, 
 while teething, went into a fit, at first very severe, almost 
 every hour for a week, then once or twice a week. Has 
 them now on Mondays, in the afternoon. Noticed feeble- 
 ness of left side of body ; does not know exactly when first 
 observed. There is loss of power on the left side ; with 
 contracture of the left arm and hand, with shortening 
 and contractures in left leg. Cannot walk or even stand 
 alone. Improved, particularly the arm, under treatment. 
 
 Case 52, — Henry I — , ajt. 5. I. P. b, 37. Parents 
 healthy ; healthy at birth ; never has used left hand. At 
 eight months observed that thumb was drawn across the 
 hand, fist closed ; this became worse. Began to walk at 
 two years, then noticed that left leg was weak. Had a 
 fit at eight or ten months, another a year later, none 
 
2G 
 
 TUK CKUEIIKAL 1>ALS1K8 OF CHILDREN. 
 
 Kiuce. Mind not dovelopod. (jrip good; contraction in 
 biceps, supinator longus and muscles of hand ; hand flexed 
 at ri<^ht angle, can bo easily made straight. Arm much 
 smaller than right. 
 
 Convulsion)^. — In the majority of the cases the disease 
 began with convulsions, partial or general. In fifty-two 
 of the ninety-seven cases on our records, this history was 
 given, which corresponds very closely with the figures of 
 Wallenberg : forty-three of eighty-eight cases in which 
 the history was definite ; thirty of the eighty cases collected 
 by Gaudard, and in *' more than half " of the eighty cases 
 of Gowers.^ 
 
 The following set of cases will illustrate the promi- 
 nence which this symptom deserves in the clinical his- 
 tory of infantile hemiplegia. 
 
 Case 10. — Reta O'N — , tot. 2 years and 4 months. H. 285. 
 When fifteen months old, in April, during teething, 
 had a convulsion ; perfectly well before the attack, 
 whicli came on suddenly and was confined to the left 
 side and lasted eight hours. In July she had a second 
 {ittuck, the convulsions lasting twenty hours. After the 
 April attack there was complete paralysis of left arm, leg, 
 and part of face ; no strabismus. The second attack did 
 not increase the paralysis. She had begun to recover 
 power before the July convulsions. Reflexes increased 
 on affected side. 
 
 Case 20.— Francis H— , a3t. 5. I. P.j, 81. Two 
 older children. Healthy child until eighth month, when 
 teething. He then had convulsions, four in number, very 
 violent, which were followed by left hemiplegia. The 
 fits have continued ever since at intervals of a few weeks. 
 Has never walked ; intellect feeble ; left arm and band 
 contracted and stiff, but the stiffness can be overcome ; 
 the forearm is shorter; stands on the inside of right foot. 
 
 Case 14.— Ella H— , tet. 4. H. 809. Was well until her 
 
 ' 'A Muuual of the Diseuses of the NervouH System,' London, 1888, vol. ii. 
 
INFANTILE HKMII'LKGIA. 
 
 27 
 
 second summer. One night hud u convulHion, and in the 
 niorniug was found to he ])araly/ed on the left side. 
 Gradually recovered, and can now wulk well, though 
 stiffly, and the leg assumes various positions while at rest ; 
 attempted movements of the arm will hiing on associated 
 movements of the leg and foot. In walking the arm is 
 carried stiffly, extended and pointed backward. Voluntary 
 movements of the hand are slow and perforuied with 
 difficulty ; the lingers do not grasp well ; retlexes are a 
 little increased on left side. 
 
 Cask 15. — Nellie P — , let. 5. II. JJIO. One of three 
 cliildren ; eldest child had spasms ; parents healthy ; was 
 natural when born. Convulsions when one year old, 
 while teething; they were confined to the right side and 
 lasted from 8 a.m. to 5 p.m. After this the side was 
 paralyzed. Has had no spasms since. Uses arm awk- 
 wardly with some incoordination. The right hand and 
 arm are smaller than left ; walks with an apparatus. 
 
 Case 27. — Lewis P- 
 
 let. IG. I. P.J, 2011. Born 
 
 healthy. At the age of three months was seized with 
 spasms. There is a doubt whether or not they were 
 confined to tlie right side, but they were followed by 
 partial loss of power on this side. Has never used arm 
 and leg well since, and they are now shorter and in a 
 state of rigidity. The leg is dragged and the gait is 
 hemiplegic ; arm and hand very rigid ; intellect some- 
 what impaired. 
 
 Case 29.— Elizabeth W— , a)t. 17. I. P. b, 142. Family 
 healthy ; child was healthy when born, and well up to 
 twelfth month. Had a slight fit and lay insensible all 
 night. Was thought to have water on the brain and was 
 leeched. Was ill four weeks. Paralysis then came on, 
 involving left side except the face. Leg rapidly re- 
 covered power and she walked in a month. The left arm 
 and leg shorter than the right, and the muscles are stiff. 
 Has power of movement in the arm, and the fingers are 
 flexed, and she does not use them. The left arm is two 
 and one-quarter inches shorter than the right, and the 
 
 !l 
 
28 
 
 THE cj:in:nitAL palsies op cnrLDRKX. 
 
 i 
 
 loft lo'jf ono and nno-qiiartcr inchos shorter than the ri^ht. 
 No «litHculty iti spcctih. Intellert iinpaircMl. 
 
 Cahk Jik— Joseph McC— , ji't. 2. 1. P.p 28. Mother 
 vory nervous. Attack caino on November 7th, 1882, when 
 the child was about a year old. JIo had voniitins' and 
 pur<,'inj^, convulsions and coma, after which there was 
 sudden paralysis of the left side. Face not involved. 
 The paralysis has not improved much. HeHexes increased 
 on left side. 
 
 Case 3(5. — A^nes II — , set, 6. I. P.^, 55. Healthy as a 
 baby ; dentition slow. When sixteen months old had 
 convulsions, fever, and sudden paralysis of ri<(ht side of 
 the body, involviuji^ the face. Gradual return of power in 
 face ; gait hemiplegic. 
 
 Case 44.— Joseph H— , a^t. 18 months. I. P.^, 189. 
 Natural labor. Child healthy when born. In October 
 was taken suddenly with high fever ; no convulsions. 
 The fever subsided in a week. He continued very 
 irritable and nervous for a month. Week before 
 Christmas had convulsions, lasting for fourteen hours, 
 and he was paralyzed in the left arm and leg. The 
 following day unilateral spasm began and continued until 
 evening. He has never had any more spasms. The palsy 
 continues, with, of late, improvement in the leg. Status 
 'prxscm^ : Weakness and partial palsy of whole of left 
 side with considerable rigidity of flexors of fingers ; no 
 deviation of face now, though there was some at first. 
 Died of the unilateral convulsions just eleven months after 
 onset of the disease. 
 
 Case 4G.— Mary M— , set. 19 months.. I. P.g, 165. 
 One other child has had spasms. In July had " spasms." 
 Woke from sleep in them ; the left side was convulsed 
 and, after spasm, found to be palsied. Two days later 
 had eighteen attacks ; after this left arm and leg seemed 
 a little better. Face was drawn to the left side. After 
 a few days ceased having these violent spasms. Began 
 to walk in two months. Since then she has had moment- 
 ary attacks of unconsciousness, occurring at first daily, 
 
INPANTIl.K HEMIIM.EaiA. 
 
 29 
 
 now ovory two or tliroo days, St(tfi(s firn't^rns : Uoulthy 
 looking ; no atrophy (jf inusch's ; no cnntruotions. Left 
 arm and leg weiiker tlian right. Falls easily. Fuco not 
 drawn. 
 
 Case 40.— ^fary M— , ivt. 11 months. I. ?..„ f}:}?. 
 Yonngcst of three children. Well until Jaly Oth, when 
 she had spasms all the afternoon and evening. No fever or 
 diai'rhcca. Said to have had congestion of lungs. Faco, 
 arm, and leg right side palsied. ]k'gan to move right 
 leg at end of week. Arm still palsied. 
 
 Cask 50. — Jennie A — , mt. 14 years and 10 months. H.p 
 348. Was healthy when born. Labor natural. Enjoyed 
 good health until about a year old, when she had con- 
 vulsions, suddenly followed by conja, which lasted several 
 days, and, on recovoryj she was nc^ticcd to have lost ])ower 
 on the left side of face, arm, and leg. For several 
 mouths the palsy persisted, but she gradually regained 
 use of the leg and then of the arm, but the face has never 
 changed ; for this she now comes to the hospital. Status 
 •prsesens : A fairly well-grown girl, rather nervous and 
 timid, and the father says she worries herself and has fits 
 of despondency. There is complete paralysis of the lower 
 facial muscles on left side ; mouth is drawn to the right. 
 Can shut the eye, wrinkle and elevate the brows, but 
 there is no movement of the lips on left side, nor does the 
 ala nasi expand. Face on this side a little smaller. No 
 loss of sensation. Arm is used quite well ; no weakness 
 of hand. Dynamom.eter : R. 75 ; L. 05. Can run well ; 
 no difference in the legs. Reflexes normal. On watch- 
 ing the face it is noticed that, from time to time, there 
 .are choreiform twitchings in the muscles of the face on 
 the left side ; most marked when the muscles of the normal 
 side are in action. Quantitative, but no serial changes 
 in electrical reaction of the paralyzed muscles. 
 
 Case 54. — Thomas McR— , tut. lU. Well until eight 
 months old, when he had spasm of the left hand, and the 
 whole left side seemed weak. No statement as to 
 general convulsion. When two years old had seven cou- 
 
 • t 
 
30 
 
 THE CEKEf.lK.ftlL PAMTES OP CHILDRKN. 
 
 * ! 
 
 IM 
 
 vnlsions, and lias hwl eftylit since then. Fever often 
 precedes tlie attack*^, TBiere is contracture of the left 
 arm, and the Laud a* wK-ak, thongli the fingers can be 
 moved. There are, zn Itiimesi, slight spasmodic movements 
 in pronation. Jjtfl l6<^ drawn up by contraction of 
 gastrocnemius. 
 
 Cask 55.— Jo^ej.h D— ^ set. 11. I. P. a, 107. Healthy 
 when born. "WLeti nlupee months old had convulsions, 
 after which it wai^ tj f >irii(W<'i that he did not use the right 
 hand. Had twitchjiij;-* and spasms as an infant, and, at 
 three years, a severe <<:ioin,valsion lasting from 10 a.m. to 
 10 P.M. Has not ItaiJ Tiolent spasms since. Walked 
 when two years ol'L iff Mm* jprsci^ens : Walks badly on 
 account of coutraclai'jim <ol right gastrocnemius. Move- 
 ments of right arm lliiiiininttefl. Cannot extend the wrist ; 
 fingers flexed. Gnp Caiiiirfv srood. 
 
 Case 57 
 
 .— Uarrv .S— , »t. 3. I. P 
 
 a. 
 
 159. Well until 
 
 the tenth month wht-ni), diiaring an attack of catarrh, he 
 had a severe convuli-^iiioinii Basting seren hours, chiefly on 
 right side, and for itBuirie'e days lay in a stupid, semi- 
 comatose condition. CotojM not use the right arm after it, 
 and the right leg ■vra* weakened. The mouth was drawn 
 to the left side, but Jj^^tcame straight again. When a 
 year old had a secoinl (Ciotivnlsion while teething. Gait 
 hemiplegic ; cannot l^iit nlie toes ; right leg well nourished. 
 Contraction and spai-Tvrr crmdition of the right arm. 
 
 Case 51».— Mary H— , aec. 6. C. D. C, 80. Parents 
 healthy ; one brother hwl convulsions while cutting teeth. 
 Healthy until third jx-ar. Fit came on while in perfect 
 health. Fit begaxi '(m left; side, then became general ; 
 lasted nine hourt?:. ImiiteTisible for some hours. Could 
 not see for two daj*. I^ft side completely paralyzed. 
 Could not move left mie tor three months ; improvement 
 beginning in hand- An end of year could walk. In 
 Sei)tember had fits ajmrffi^ but was not more paralyzed. 
 Fits again in March. Tiiree attacks of fits since. Last 
 attack, one year ago, (Ciompletely palsied the left side again. 
 Ever since first attaick ammel affected ; bad temper ; bites. 
 
INFANTILE HEMIPLEGIA. 
 
 81 
 
 No atro]i1iy of left arm, no contracturo ; loft arm sooms 
 weak, lie walks ami runs. Has fits now. • 
 
 Case 80.— Christian A—, get. 8. I. P. a, 10. Ilealtliy 
 when horn. When six months old had veiy violent fits. 
 When three years of age had one day convulsions from 
 4 A.M. to 7 P.M. Had summer complaint badly during the 
 first eighteen months of life. After the first fit lost 
 power on the right side of the body and in the limbs. 
 Chorea gradually developed. Stafxs piwspns : Is well 
 grown and intelligent ; goes to school. The right arm 
 and hand are weak, and he can flex and extend the fingers, 
 but when he attempts to perform any volitional act, irre- 
 gular movements come on and prevent their successful 
 performance. The grasp of the right hand is decidedly 
 weaker than that of the left. When at rest the right 
 hand is closed and the thumb flexed across the palm. 
 The right leg is colder than the left and the heel is drawn 
 up by contraction of the gastrocnemius. The foot is 
 inverted, pes cquino-varus. There are no choreic move- 
 ments in the leg. The tendo Achillis was cut and an 
 ap))aratus applied which relieved him very much and 
 enabled hitn to walk much better. 
 
 Case GO, — Henry L — , ivt. 14. Wiien eighteen months 
 old had general convulsions Avhicli lasted ten days, and 
 left the right side paralyzed. Gradually recovered the 
 use of the leg, but the right arm is atrophied and 
 weak, and displays constant choreic movements. No 
 contractions. Walks quite well ; general health good. 
 
 Case 88. — Amanda C — , xt. 18 months. I. P.^, 375. 
 Born without instruments. In October, when seven 
 mouths old, had spasms and was unconscious from 
 Saturday to Wednesday. Spasms began in left arm and 
 right leg. On Wednesday the arm and leg were noticed 
 to be palsied. ^Status pnvsois : Is unable to sit alone ; 
 falls towards the left side. Kigidity and contractures of 
 left arm and leg, marked choivic movements. Muscles 
 not wasted. The thumb is turned into hand. 
 
32 
 
 THE CERKBRAL I'ALSIES OF CHILDREN. 
 
 Loss of consciousness almost invariably accompanies 
 tlic convulsions, and may last from a few hours to many 
 days. In a few instances coma occurred without con- 
 vulsions. 
 
 Cask 5. — Li/zio E — , ict. 21 months. 11.237. One of 
 two children. Was healthy when born and until sixteen 
 weeks agu, when, in the evening- at 10 o'clock, had a most 
 intense headache. She had seemed to have frontal head- 
 ache for about two months. 8he became unconscious 
 and did not revive until 11 o'clock. She attempted to 
 rise but fell to one side. She was able to walk upstairs, 
 and nothing wrong- was noticed in the limbs. The next 
 morning the child could not move the right arm or leg, 
 and had lost completely the power of speech. Thi'ee 
 days after could move the leg, and walked again in three 
 weeks; regained s])cech on third day. Has for the past 
 seven weeks begun to use the arm. Patellar retlex is 
 increased on the affected side. 
 
 Case 48.— Bertram T. B— , tut. 5. I P.g, 270. Family 
 history good. Ehler of two childi-en. Two years ago, 
 in July, had an attack of left hemiplegia. Unconscious 
 for six weeks ; no convulsions. At end of six weeks 
 beiran to move right arm and leir. Two months later 
 began to move left leg. Has not impi-oved nnich since. 
 Considerable wasting on left side, and the left foot is 
 somewhat smaller than the right. 
 
 
 Fever. — The records are not complete on this point, and 
 it is not often mentioned whether or not the temperature 
 was elevated. Fever may be transient or persist for 
 weeks as the following cases illustrate : 
 
 Case 45. — Lewis S — , fot. 2. I. I'.g, 11. Youngest of 
 six children ; others healthy. Parents healthy. Well 
 un'" September. While playing on floor, fell over, and 
 on examination it was found that he did not use left arm 
 and leg well. Paralysis of leg soon became complete 
 and of arm incomplete. Began to use arm in one week, 
 ami, in a month, could sit alone and draw up his leg. On 
 
INFANTILE HEMIPLEGIA. 
 
 33 
 
 day of attack had fever, was restless, did not vomit. 
 No retraction of head and no bladder trouble. Fever 
 disappeared in a day or two ; soreness to touch remained 
 for two weeks. Status prxsens : Has improved very 
 little in leg. Is a well-nourished looking child ; left leg 
 atrophied. No difference in length of legs, but left foot 
 one-quarter inch shorter. Can flex and extend leg and 
 thigh ; extends foot, but cannot flex it. Flexes and 
 extends toes. Talipes equinus ; sensation normal. 
 
 Case 41. — Jennie E — , aet. 4. I. P.g, 195. In April, 
 had fever and delirium lasting almost four weeks. At 
 about end of fourth week the mother noticed right arm 
 and leg were paralyzed. Speech was also a little affected. 
 Status -prsesens : Eight leg a little shorter, about one- 
 quarter of an inch ; and foot also. Slight atrophy of leg. 
 Has all movements of leg and arm. Arm slightly atro- 
 phied ; no change of temperature. In walking she limps, 
 
 and there is slight ** genu recurvatum." There are 
 slight involuntary movements of affected limbs, noticed 
 when excited. September 24th, 1879. — Movements have 
 ceased ; walks better, some rigidity of right arm. 
 
 Striimpell, Gaudard, and others mention fever as an 
 invariable accompaniment of the convulsions which 
 usher in the disease in such a large proportion of the 
 cases. 
 
 Delirium, which is noted by some writers as preceding 
 or replacing the convulsions, was observed in Cases 41 
 and 84. 
 
 Vomiting is especially mentioned in only four cases. 
 
 Soreness of the general surface was observed in Cases 
 45 and 64. 
 
 Screaming spells preceded the attack in one case. 
 
 Doubtless many children die in the convulsions or in 
 the subsequent coma, without reaching the second or 
 paralytic stage of the disease. 
 
 The hemiplegia, which is noticed as soon as the child 
 recovers consciousness, is usually complete. Less fre- 
 quently there is, at first, paresis which gradually results 
 
 3 
 
 II 
 
34 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 in complete loss of power, and in some instances the total 
 paralysis was only established after repeated convulsions, 
 as in Cases 59 and 85. In sixty-eight cases the right 
 side was involved, in fifty-two cases the left. 
 
 The face is not always affected ; the exact proportion is 
 uncertain as the point was not constantly mentioned. 
 As is the rule in facial paralysis of cerebral origin, the 
 superior muscles are not involved, and the child can 
 close the eyes and elevate the brows. Rapid and com- 
 plete disappearance of the facial palsy is the rule, and 
 of the cases which returned for examination, in only one 
 did the condition persist, and in this, strange to say, no 
 trace remained of the paralysis of arm and leg. The 
 child, aged fourteen and one-half years at time of obs3r- 
 vation, had been completely hemiplegic at the age of one 
 year ; the arm ai. \ ' had gradually improved, but the 
 face was drawn to II ight and there were choreiform 
 movements in the paralyzed muscles of the left side. 
 The tongue did not seem to be affected, but the uvula 
 deviated strongly to the right. Dr. Sinkler has at 
 present in the wards a girl aged thirteen, who became 
 hemiplegic in infancy, and has still complete facial palsy ; 
 and in Case 96, the last of the forceps cases, there were 
 paresis and atrophy of the facial muscles. 
 
 As with the hemiplegia of adults, the residual paralysis 
 is most marked in the arm, which displays more or less 
 wasting, and is, as a rule, useless for the ordinary pur- 
 poses of life. There may be arrest of development, 
 leaving a wasted and withered member ; more commonly, 
 there is only a moderate degree of atrophy. In extreme 
 cases the arm is held close to the side, the forearm 
 strongly flexed at right angles and in the semi-prone 
 position ; the hand flexed and the fingers contracted in 
 the palm, usually embracing the thumb. Motion may be 
 almost lost in the arm and completely lost in the fingers. 
 In a majority of the cases there is considerable power of 
 movement, and the arm can be lifted above the head and 
 flexion and extension made at elbow and wrist. The 
 
INFANTILE HEMIPLEGIA. 
 
 35 
 
 finer and more delicate movements of the hand are rarely 
 recovered, and while many of the cases possess a useful 
 limb for carrying or grasping" purposes, actions requiring 
 manipulation with the fingers cannot be effected. The 
 grasping power is often remarkably good. 
 
 The leg, as a rule, recovers more rapidly and more 
 completely than the arm, and the palsy may completely 
 disappear, an event which very rarely happens in the 
 upper extremity. The wasting is never so marked, nor 
 doeti arrest of development often occur. In only one 
 case, 6 of the Elwyn series, is the leg much atrophied. 
 But even when of fair size, and of good muscular develop- 
 ment, there is evidence of impaired power in the per- 
 sistent halt which is such a characteristic legacy of 
 hemiplegia. The patient may simply " favor " the 
 affected side, noticeable, perhaps, only on rapid walking. 
 A very perceptible dragging of the limb is more common. 
 There may be tremor of the leg while in motion. 
 
 Rigidity was present in a large proportion of the cases 
 at the time they came under observation. So marked is 
 this feature of spasm that the disease has been termed 
 spastic infantile hemiplegia. Although a very frequent, 
 it is not a constant symptom, and there are cases in 
 which the paralyzed limbs are quite relaxed, even years 
 after the onset of the affection. In Cases 4, 5, and 7 
 of the Elwyn series the arm is flaccid ; and in Case 10 
 the spasm is very slight. The rigidity disappears during 
 sleep ; it is increased by emotion and aggravated by any 
 attempts forcibly to overcome the spasm. When the 
 rigidity is extreme and has lasted for years, permanent 
 contracture may result, in which condition relaxation is no 
 longer possible, on account of the structural changes 
 which take place in the muscle. 
 
 The reflexes are almost invariably increased in the affected 
 limbs. The knee-jerk is exaggerated, and, in many cases, 
 the ankle-clonus can be obtained. As often happens in 
 hemiplegia, the reflexes may be heightened on the sound 
 side. A rectus clonus can sometimes be got, and, in 
 
36 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 several of the cases, making sudden tension of the spastic 
 fingers developed a clonus in the flexors. In three cases 
 the reflexes were absent — Cases 1 and 8 of the Elwyn 
 series, and 9 of the Infirmary patients. In the Elwyn 
 cases there is rigidity, which in the other is very slight. 
 They are not necessarily absent in the instances of flaccid 
 paralysis. 
 
 Sensation is not often disturbed ; it has been normal in 
 all the cases which I have examined, and it ia not onco 
 mentioned in the records as absent. 
 
 Vaso-motor disturbances, such as coldness of the affected 
 extremities, blueness and congestion, are not uncommon, 
 particularly when the paralysis is extreme. 
 
 The electrical reactions are usually normal ; occasionally 
 quantitative, but never qualitative changes are noted. 
 None of the recent cases examined in the electrical 
 department, by Dr. Willets, have shown alterations other 
 than slight diminution in the response. 
 
 . 
 
 Post-hemiplegic movements. — It was from this Infirmary, 
 and based chiefly upon a study of cases of infantile hemi- 
 plegia, that Dr. Weir Mitchell first described those 
 disorders of movement which are known as post-hemi- 
 plegic chorea, mobile spasm, athetosis, hemi-ataxia and 
 post-hemiplegic tremor. There were thirty-one cases in 
 the entire series which presented these movements. 
 Three varieties were noted : 
 
 1. Post-hemiplegic tremor, which was present in only 
 one case (85), and occurred in the entire arm, chiefly 
 when at rest. 
 
 2. Post-hemij)legic chorea, or, more correctly, herai- 
 ataxia. The great majority of the cases, twenty-four in 
 number, came in this division. The movements were in- 
 coordinate and choreiform, chiefly noted on voluntary 
 effort. Many instances of this have been described in 
 the report of the cases. 
 
 3. Mobile spasm, and athetosis, noted in six cases. 
 The following are good illustrative cases : 
 
 i« I 
 
INFANTILE HEMIPLEQIA. 
 
 37 
 
 Case 91.— Mary H— , aet. 11. I. P.j, 161. When two 
 years old, had "a spell of sickness'* which lasted some 
 time, and in which paralysis of the left side gradually 
 came on. She did not walk until the fourth year. She 
 now favors the left side in walking, and the arm and leg 
 are stiff. Has slight power over arm, but it and the 
 hand are in constant, irregular motion ; fingers are 
 extended in regular order, and she has no control over 
 them. She can move the arm about quite well. 
 
 Case 76.— Edith W— , set. 6. H., 301. Birth natural, 
 at full term. Father died of phthisis. At four or five 
 months noticed that the child did not use the right arm. 
 Began at two years to pull herself up by a chair, and at 
 two and a half years learned to walk, and then dragged 
 the foot. Has been improving. Face not affected. Is 
 intelligent. Choreic movements of right hand and arm. 
 January 25th, 1888, condition as follows : Is a well-grown, 
 fat child. Walks with a decidedly hemiplegic gait. Sits 
 with hands quiet in her lap, the right on the left. When 
 excited, or on attempting to make any movement, there 
 are regular choreic movements in the right hand and arm. 
 In grasping an object picks it up with the hand, not with 
 the fingers ; as the object is approached the fingers jerk 
 in various directions, are separated from each other and 
 extended in more or less orderly sequence. Some stiff- 
 ness in the arm during these movements. Very similar 
 motions are present in the foot and toes, and the leg is a 
 little stiff. Knee-jerk on right leg exaggerated ; no ankle- 
 clonus. Intelligence good. 
 
 In one case there were associated movements of the 
 paralyzed arm on attempting motion with the other arm. 
 Allied to this, doubtless, is the not infrequent irregular 
 jerking of the arm in the act of walking. Sometimes it 
 is thrown in a curious way behind the back. 
 
 Aphasia. — Speech was affected in thirteen cases, in five 
 of which the children were under three years of age. 
 The following are illustrative cases : 
 
38 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 I 
 
 Case 1, — Cecilia P — , set. 12. H., 25. Healthy when 
 born ; one of seven ; others healthy. Father has had 
 hemiplegia for three months. When two years old awoke 
 paralyzed on right side ; became comatose and remained 
 unconscious for two days. Lost power of speech for six 
 weeks. Paralysis persisted for six months ; the leg 
 gradually improved. Kigidity came on in affected side a 
 few months after the attack. Has had, at times during the 
 past three years, loss of consciousness, with convulsive 
 movements chiefly of right side. Has had two or three 
 in a day but may not have any for a week or more. Has 
 a characteristic hemiplegia gait. Leg is a little stiff ; 
 muscles somewhat wasted ; one arm smaller than the 
 other and flexed ; the fingers also flexed and contracted. 
 
 Case 11. — Robert M — , aet. 13. H., 91. No injury at 
 birth. One year ago sudden paralysis of the right side, 
 which was preceded for a day by loss of power of speech. 
 The face was also drawn. Had convulsions a few weeks 
 after the hemiplegia, but not at the time. Began to 
 walk eight weeks after the attack, and recovered speech 
 about the same time. Arm has improved but little ; is 
 stiff. Convulsions at intervals. Is improving. 
 
 Case 33. — Mathew C— , set. 10. I. P.^^, 19. Good 
 family. Well until August, 1883, when present trouble 
 began. Had vomiting, diarrhoea, great headache and 
 photophobia, which lasted four days, and on the fourth 
 day there was complete right hemiplegia, including face, 
 with aphasia. In a month the child began to get about ; 
 the aphasia was complete for one week, and then the 
 power to walk gradually returned. Walks well but slowly 
 and stiffly. Arm contracted. Right face is still smooth, 
 and the dimple is gone. 
 
 Case 58. — Ellen McC— , set. 6. C. D. C, 177. Parents 
 healthy. Healthy until three years of age. Then had a 
 fit, lasting, with intervals, for nine days, and, at the end 
 of that time, convulsive movements confined to right side ; 
 right hemiplegia followed, and also loss of speech. 
 Gradually regained power of walking; has not yet re- 
 
 -1 
 
INFANTILE HEMII'LEQIA. 
 
 39 
 
 gained power in arm. Began to speak in a year, and 
 mental condition improved. Ever since first attack has 
 had attacks of unconsciousness every day ; jumps, falls to 
 ground and immediately rises again, looking bewildered. 
 No prolonged convulsion until ten days ago. During 
 this time has had none of the lesser attacks. Has had 
 as many as fifty to sixty of these "jumps." Injures her- 
 self much by the falls. During attacks, convulsive move- 
 ments of left side of body and face, and she screams. 
 Does not bite tongue ; speech affected since second attack. 
 Status prsesens : Right arm smaller than left ; contractions 
 of flexors of forearm and wrist, not of her fingers. Right 
 leg trifle shorter than left, and slight contraction of tendo 
 Achillis. 
 
 Of these thirteen cases twelve were associated with 
 right and one with left hemiplegia. The number affected 
 is much smaller than in the collected series of Wallenberg,^ 
 whose statistics give forty-five cases of speech disturbance 
 in ninety-four right hemiplegias and seventeen cases in 
 sixty-six left hemiplegias. In Gaudard's' fifty-five right 
 hemiplegias there were twenty-five cases of disturbance 
 of speech, seventeen of which were true aphasia. There 
 were eight left hemiplegias with aphasia. Bernhardt,^ 
 who has made a very careful study of this condition in 
 children, says that in a majority of the cases of cerebral 
 palsy, no matter on what side, there is affection of speech, 
 usually transitory. In one case of our series the aphasia 
 was associated with left hemiplegia. Usually the power 
 of speech begins to return in a short time, but recovery 
 may be deferred for a year (Case 58) and in Case 17 
 the child had not spoken six months after the lesion. In 
 several instances recovery was incomplete. 
 
 In eight of the twenty-two cases at Elwyn, there is 
 absence or profound disturbance of speech, but the patients 
 are idiots or idio-imbeciles who have never acquired fully 
 the power of speech. 
 
 * Loc. cit. ' Loc. cit. 
 
 ' ♦ Viiehows Archiv,' Bd. 102 
 
40 
 
 THE CEKEBKAL PALSIES OF CHILDREN. 
 
 Mental defects. — A lesion so serious and extensive as 
 that which is associated with infantile hemiplegia may 
 seriously interfere with cerebral development, and, among 
 the most common sequences, we find various anomalies of 
 intelligence. In the Infirmary series only twelve cases 
 presented idiocy or imbecility at the time of observation, 
 but it must be remembered that the majority of the 
 cases came to the Infirmary a short time after the onset 
 of the paralysis, so that our records on this special point 
 are by no means complete. In Gaudard's series — eighty 
 cases — there were fifteen feeble-minded and nineteen 
 idiotic children, while in Wallenberg's cases (160), there 
 were fifty with mental defects, and in fifteen cases im- 
 becility followed the epilepsy, so often associated with 
 this condition. Three grades may be distinguished : 
 idiocy, which is most common when the hemiplegia has 
 existed from birth, or has come on at an early period ; 
 imbecility, which may increase with the development and 
 persistence of convulsions ; and a feeble-minded backward 
 condition, a retarded rather than arrested mental develop- 
 ment. The twen'^y-three patients at the Pennsylvania 
 Institution for Feeblfi-rQiiided Children may be classified 
 as follows : Idiots, four ; idio-imbaciles, two ; low-grade 
 imbeciles, ive ; middle-grade irabeciles, six ; high-gxade 
 imbeciles, six. 
 
 In connection with the mental disturbance which so 
 often follows infantile hemiplegia, Merklin^ has called 
 attention to the development, later in life, of psychoses, 
 even in cases which, in youth, have not shown any 
 abnormalities. 
 
 Epilepsy. — One of the most common and distressing 
 symptoms is the occurrence of convulsive seizures, 
 usually confined to the paralyzed side, but tending to 
 become general. This hemiplegic or post-hemiplegio 
 epilepsy affects, sooner or later, a considerable proportion 
 of the cases. In the Infirmary series of ninety-seven 
 
 ' • St. Petersburger med. Wochenscbrift/ 1887. 
 
INFANTILE HEMIPLEQIA. 
 
 41 
 
 / 
 
 cases there were only twenty instances. In Gaudard'a 
 list (80) tliere were eleven cases of hemi-epilepsy, and 
 sixty-six in Wallenberg's series of 160 cases. At 751 wyn 
 of twenty-three cases, fifteen had epilepsy. 
 
 The attacks begin a variable time after the onset of 
 the hemiplegia, mostly within two or three years, though 
 they may be deferred eight or ten years, or even longer. 
 In some instances the paralyzed limbs are convulsed 
 within a few weeks. 
 
 These seizures may be either (1) attacks in which the 
 child is simply dazed for a moment or two, occasionally 
 longer without any motor involvement ; (2) spasms 
 beginning in and confined to the affected side, without 
 loss of consciousness — the true Jacksonian epilepsy ; (3) 
 general convulsions which begin in the paralyzed limbs, 
 and are usually accompanied by loss of consciousness. 
 All three forms may occur in one case, but by far the 
 most common and characteristic is the hemi-epilepsy with 
 retention of consciousness. 
 
 The following illustrative cases will give an idea of 
 these attacks : 
 
 Case 96. — Patient of Dr. Mitchell, at present in the 
 house. The hemiplegia is left-sided, and dates from 
 shortly after birth. As the child sits on the floor the eyes 
 will suddenly become fixed, deviate strongly to the left, 
 the head begins to nod (the so-called nodding epilepsy, 
 E. nutans). The left arm, which is constantly stiff, may 
 be more closely retracted, but often the fixing of the eyes 
 and nodding motion of the head alone indicate that a fit 
 is present. After a few moments the child wakes up with 
 a start and resumes its play. 
 
 In Case 64 the child, aet. 2, became hemiplegic (left) 
 at the tenth month. When twenty months old s^e began 
 to have spasmodic contractions of the left arm imd leg, 
 lasting for about five minutes, and occurring several times 
 a day. The arm would be jerked up, the leg twitched, 
 and the eyes become fixed. Just before they come on, 
 she gets qniet, and, if nursing, drops the nipple. With 
 
. i 
 
 42 
 
 THE CEUKBKAL PALSIIS OF CHILDKKN. 
 
 cessation of the attack she draws a deep breath and is 
 then aa bright as ever. 
 
 In the following case tho lad had post-hemiplegio 
 movements, as well as distinct convulsions, which some- 
 times became general : 
 
 Case 74.— Charles W— , sot. 13. H., 323. Was 
 healthy as a baby. Birth natural. In August, 1881, 
 had a " sick spell " from Wednesday to Friday. While 
 dressing on Sunday, lost power entirely in left arm, leg, 
 and face. Was in bed two months. He slowly regained 
 power of leg. Since then has had fits. Status prsesens : 
 Is fairly intelligent ; no scar on head. Characteristic 
 hemiplegia gait ; drags the left leg ; left arm smaller 
 than the right ; it is wasted, and possesses very slight 
 power of movement — chiefly flexion. Spastic rigidity of 
 flexors of the wrist, so that the carpus cannot be extended. 
 Often in the day, as many as ten or fifteen times, the 
 arm will stretch out from the side, and the fingers will 
 extend, first the little and then the others in order. Face 
 muscles will also work. He has other attacks, in which 
 the movements may begin as these, and be confined to 
 the arm or extend to the entire side of the body. He 
 never loses consciousness, and never sleeps after the 
 attacks. Has as many as three or four in a day. He 
 has headache, but not worse on one side. Knee-jerk 
 exaggerated on left side. 
 
 Case 18. — Annie E — , ast. 10 years and 6 months, I. P.^, 
 157. Three other children. Was quite healthy until the 
 sixth year, and was a very bright, intelligent child. Had a 
 convulsion one night after exposure to intensely cold 
 weather. The spasms were on the right side. They 
 recurred at intervals for a year, always on the right side, 
 and she gradually began to lose power on this side. 
 When about nine years old the convulsions became 
 general, but they began on the right side. They have 
 become more numerous, and she has had as many as 
 fifteen in a day, and even four or five in an hour. Status 
 jpraesens : Dull, stupid-looking girl ; marked spastic 
 
INPANTH.E HEMIPLEGIA. 
 
 48 
 
 hemiplegia of the right side, arm and log rigid. Fingers 
 strongly flexed in the hand. Heart normal. 
 
 Morbid Anatomy. — Although the clinical features of 
 infantile hemiplegia are as well characterized as those of 
 infantile spinal palsy, our knowledge of the pathological 
 conditions on which the former depends is, in comparison, 
 still very defective. As in hemiplegia of adults, the 
 lesions are variable, and the symptoms may be produced 
 by any destructive process in the cortico-spinal section of 
 the motor tract. It is surprising how few are the obser- 
 vations made shortly after the onset of the paralysis. 
 The great majority of the post-mortems have been made 
 after the hemiplegia has lasted for months or years, when 
 all trace of the primitive lesion has disappeared. 
 
 I have analyzed the records of ninety autopsies in cases 
 of hemiplegia coming on in infancy or childhood. The 
 majority of these are contained in the articles of Cotard,* 
 McNutt, Gaudard,'' Richardiere^ and Wuillamier,* but I 
 have, as far as possible, referred to the original cases, 
 and have been able to extend the list of the forty-eight 
 autopsies analyzed in 188G by Wallenberg. The right 
 hemisphere was affected in thirty-nine cases, and the left 
 in fifty-one. It is interesting to note in seventy cases, as 
 bearing upon the prognosis, the ages at which death 
 occurs. Under two years, 4 ; between second and fifth 
 year, 10 ; from fifth to tenth, 8 ; from tenth to twentieth, 
 18; from twentieth to thirtieth, 12 ; thirtieth to fortieth, 
 4 ; fortieth to fiftieth, 8 ; above fifty, 6. I have excluded 
 all cases of hemiplegia coming on after the fifteenth year, 
 and, in the great majority, the onset dated from convul- 
 sions in the early years of life. 
 
 The lesions may be conveniently grouped under three 
 headings : 
 
 1. Embolism, thrombosis, and hemorrhage. — In this 
 group, comprising sixteen cases, the patients did not long 
 
 ' Cot^rd, ' Sur ratiophie partielle du cerveau,' Paris, 1868. 
 ' Loc. cit. * Loc. cit. * Loc. cit. 
 
44 
 
 Ifii: CESXftBAL PALSIES OF CHILDREN. 
 
 survive the attaclc, and a study of the conditions found 
 post mortem migiiu be supposed to throw considerable 
 light on the itMiwre of the initial lesion. In the cases of 
 Gibb,* Vernois, aoA fA Valleix,' the condition was con- 
 genital. The mmheTf in Gibb's case, had received a blow 
 on the abdomen, smd the child was stillborn, with rigidity 
 of the limbs on tls© left side. There was a clot in the 
 right hemispherte alcove the ventricle. In the cases of 
 Vernois and VuMmx the labor was difficult, and the 
 paralysis existed fiirom birth. The children lived for 
 forty -nine days aanii three and a half months respectively, 
 and, in boil;, ^.jAr&rm&tion existed in the neighbourhood of 
 the ganglia. Im ttlufr caaes of Wrany-Neureutter,' Taylor,* 
 Callender,^ KelJj -Jio-liin.aon,*' Barlow,^ there was heart dis- 
 ease, with emboilism of the middle cerebral artery. A 
 case of Henoch'fc* waa also embolic. In two cases of 
 Callender,* in one fA Lewkowitsch, and in one of Reimer, 
 there was haemorrJuage, In a case of Abercrombie,'° the 
 right Sylvian arteirj was plugged by a firm thrombus. In 
 Case 12 of a Beri«« fA aneurisms of the larger cerebral 
 arteries, which I reported from the Montreal General 
 Hospital^^ a boy fA m% years, with left hemiplegia, there 
 was haemorrhage anattfO' the longitudinal fissure, and lacera- 
 tion of the median jwarface of the right hemisphere, caused 
 by rupture of an amftrarism of the right anterior cerebral 
 artery. In a cam d Dulles,'' in a child of six months, 
 there was haemorriaai^ into the ventricles. 
 
 ' Gibb, ' Lancet,' l^SS^ 
 
 ' Quoted by J. Ltwi* ftnjtBy ' FMaeaaes of Children,' 4th edition. 
 
 * Quoted by Walltiuliw;;^ loc. cit. 
 
 •• ' British MedicaJ JummailT.' I8ftO, ii. 
 
 * ' St. Bartholomew'* Hnitpltal Reports,' vol. v.' 
 
 * ' Medical Tiuiee and ^iauKtUi,' 1880. (Gaudard, Reference incorrect.) 
 ' ' British Medictd Jwanutlv' I87B. 
 
 * ' Vorlesuiigen uUr KiuWkrankheiten,' Berlin, 1883. 
 
 * Loc. cit. 
 
 >" ' British Medical JwmiaW 1887, i. 
 
 >' 'Canada Med. luid *winr. Journal,' 1886; 'Trans. Path. Soc. Phila- 
 delphia,' vol. xiii. 
 
 " * Philad. Mvd. Tiuw*,- 0*7«l 
 
INPANTILE HEMIPLEGIA. 
 
 45 
 
 Thus, cf the sixteen cases, there was plugging of a 
 Sylvian artery, usually embolic, in seven, and haemor- 
 rhages in nin(?. In striking contrast to the majority of 
 the cases of infantile hemiplegia, is the significan', ''net 
 and in this group the age at onset is high. Excluding 
 the three congenital cases, there was only one cl Id under 
 three years, while ten were over six. 
 
 2. Atrophy and icierosis. — In fifty cases there was wast- 
 ing with induration, either of groups of convolutions, an 
 entire lobe, or, in some cases, the whole hemisphere was 
 affected. 
 
 The following cases from the institution at Elwyn illus- 
 trate this condition in a typical manner : 
 
 Male, aet. 16. Family history good. During measles 
 when a child, he became paralyzed on the right side, 
 and had aphasia. He regained partially the use of the 
 leg, but did not recover speech. There was complete 
 loss of power in the arm. He had repeated convulsions, 
 in one of which he died. There was no sensory dis- 
 turbance. 
 
 The only lesion found was in the left hemisphere. The 
 brain Avas of full size, and looked natural ; the membranes 
 stripped off readily, except in the Rolandic region on the 
 left side, where the pia mater was greatly thickened and 
 
 Fio. 1. 
 
 Left hemisphere, showing sclerosis in the Rolandic region. 
 
46 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 adherent. As shown in the cut, Fig. 1, which is taken 
 from a photograph by Dr. Wilmarth, there is a depression 
 in the neighbourhood of the fissure of Rolando, and the 
 fissure itself is not evident except at its upper third. So 
 far as can be made out, the ascending frontal convolution 
 in the greater part of its extent is atrophic, reaching to 
 its lower end, but above there is at least half an inch un- 
 affected. The central portion of the ascending parietal 
 is also involved. From these regions the thickened 
 membranes could not be removed without tearing the 
 brain substance. The paracentral lobule, the third frontal, 
 and the insula did not appear to he affected. The cord, 
 unfortunately, was not examined. 
 
 Sections across the sclerosed area. Fig. 2, show a com- 
 plete atrophy of the ascending frontal gyrus and of the 
 
 M 
 Ism 
 
 ASC.PAR. 
 
 tlFK. 
 
 IKR. 
 
 Section through the sclerosed area. A/tc. Fr. Ascending frontal gyrus. 
 Asc. Par. Ascending parietal. 2nd Fr. Base of second frontal. 
 F. R. Fissure of Uolaudo. 
 
 contiguous surfaces of the adjacent convolutions. The 
 pia is thickened and closely adherent, particularly where 
 it dips down to the top of the wasted convolution. In 
 the fissure of Rolando, a loosely arranged connective 
 tissue, containing numerous blood-vessels, unites the op- 
 posed pial membranes. At the bottom of the fissure 
 there is a wide sulcus, containing several large veins. In 
 the shrunken ascending frontal convolution three layers 
 of tissue can be readily distinguished, even with a low- 
 power lens: (1) Beneath the pia is a narrow layer, re- 
 
 k i 
 
INFANTILE HEMIPLEGIA. 
 
 47 
 
 sembling closely the normal first layer of the cortex, a 
 granular matrix with a few nuclei arranged centrally, 
 and, here and there, spaces, probably vascular. Blood- 
 vessels pass through this part from the meninges. (2) 
 A wider, more loosely arranged layer, with numerous 
 nuclei and distinct fibres, among which are small arteries 
 with thickened walls and dilated capillaries. In the 
 deeper portion of the gyrus there are irregular spaces, 
 some of which are large enough to be seen with the 
 naked eye. (3) A central stem, composed of a close net- 
 work of fibres, looking a little more condensed than the 
 ordinary white matter, with scattered nuclei and a few 
 blood-vessels. 
 
 The contiguous portions of the ascending parietal and 
 second frontal convolution present essentially the same 
 change. Although the entire gyrus is involved, the pro- 
 cess is chiefly cortical and has resulted in the entire de- 
 struction of the gray matter. 
 
 I have recently had an opportunity of examining a 
 second specimen at the Elwyn Institution with Dr. 
 Wilraarth, a case of right hemiplegia with idiocy and 
 epilepsy. The brain looked well formed ; the meninges 
 were normal. On the posterior part of the first left 
 frontal, about three-quarters of an inch from the fissure 
 of Rolando, there was a depression over which the mem- 
 branes appeared normal. The 1 of the first and the 
 top of the ascending frontal gyrus aad an opaque white 
 appearance, contrasting strongly with tlu' surrounding 
 tissue. On section this was seen to be an area of in- 
 duration passing into the cerebral substance for at least 
 an inch, and cutting, with great resistance. A second 
 opaque-white block existed in the hinder convo' ition 
 of the quadrilateral lobe. On the left side there were 
 two of these masses, one in the lower occipital con- 
 volution, and the other in the supramarginal. TV' • 
 masses were firm, opaque, white in colour, the pia over 
 them not thickened and the contour of the convolutions 
 not destroyed. The examination of the brain has not 
 
I 
 
 48 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 yet been completed, but the blocks correspond to the 
 description given by Boumeville and other French writers 
 of the sclerose tubereuse. 
 
 To the French writers we owe much of our knowledsre 
 of cerebral sclerosis. Cazauvieilh/ in 1827, described 
 twelve cases under the term agenese cerebrale, Boume- 
 ville'^ has recorded a number of observations from the 
 Bicetre, while Cotard,^ Jules Simon,* Richardiere,^ and 
 Delhorme*' have more recently written monographs upon 
 the condition. In clinical features the great majority 
 of the cases conform to the description of infantile 
 hemiplegia. 
 
 The skull may be flattened on the affected side, and it 
 is not uncommon to find it very broad and prominent 
 above the mastoid processes. In several of the cases 
 the bone on the affected side has been greatly thickened. 
 The dura is usually closely adherent, and osseous plates 
 have been found, which, in Bell's case,^ were so extensive 
 that the right hemisphere seemed enclosed in a second 
 bony casing. 
 
 The arachnoid is turbid and thickened, and the amount 
 of cerebro-spinal fluid excessive. The pia mater is often 
 so thickened and adherent that, on removal, portions 
 of the cortex come away, leaving a roughened surface, 
 and in these cases the condition suggests a meningo- 
 encephalitis. This localized thickening and adhesion of 
 the pia to the sclerosed convolutions is well illustrated in 
 the specimen just described. 
 
 The sclerosis is usually diffuse and involves either an 
 entire hemisphere or a single lobe, or it may be confined 
 to one or two convolutions. In a few cases it has been 
 
 ' •Archives generales de Med., 
 
 1827. 
 
 
 
 ' • Archives de Neurologic,' 1- 
 
 -5. 
 
 
 
 * Loc. cit. 
 
 
 
 
 * Loc. cit. 
 
 
 
 
 * Loc. cit. 
 
 
 
 
 • " Contribution k I'etude de 
 
 I'atrophie 
 
 cerebrale 
 
 infantile," 
 
 Pnris,' 1882. 
 
 
 
 
 ' ' Archives geiientles,' 1831. 
 
 
 
 
 Thdso de 
 
INFANTILE HEMIPLEGIA. 
 
 49 
 
 in patches — insular. Nodular projections of sclerosed 
 tissue {sclerose hypertrophique) may occur over the sur- 
 face. The affected convolutions are small, of a grayish 
 or gray-yellow color, often with a stippled, pitted surface, 
 to which the pia adheres firmly. In contrast with the 
 neighboring normal gyri, the appearance is very striking 
 and characteristic. The reduction in size of the affected 
 hemisphere may amount to a third of the bulk. In one 
 case the atrophied hemisphere weighed 169 grammes, the 
 normal 653 grammes. The tissue may be a mere shell 
 over a dilated lateral ventricle, as in the cases of Baud^ 
 and Piorry. In many cases anfractuosities and small 
 cysts have been found in and about the sclerosed tissue. 
 Some of these cysts are evidently the result of old 
 haemorrhages, as haematoidin crystals have been found 
 in the walls. This is particularly the case with cysts in 
 the neighborhood of the basal ganglia. In all of the fifty 
 cases the Rolandic area was involved to a greater or less 
 degree ; in some cases affected alone, as in the brain 
 figured ; in others, involved in a widespread process. 
 Undoubtedly the motor region, the area of the cortical 
 distribution of the middle cerebral arteries, is most often 
 affected, but this is not always the case. 
 
 Thus it is interesting to note the distribution of the 
 lesions in ten specimens of sclerosis of the brain in the 
 Museum of the Elwyn Institution. 
 
 1. R. H. Superior parietal lobule, patch i x | inch, 
 depressed meninges adherent. 
 
 2. R. H. First and second frontal. Occipital. L. H. 
 Occipital lobe almost destroyed. Superior parietal, poste- 
 rior half. Anterior two-thirds of first frontal ; second 
 frontal slightly. 
 
 3. R. H. Cuneus. First frontal, extensive ; gyrus 
 fornicatus. L. H. Gyrus hippocampus, lingual, and 
 occipital. First frontal slightly. 
 
 4. R. H. Occipital lobe, outer aspect ; supra-marginal ; 
 occipital end of first and second t^^mporals ; cuneus 
 
 ' Quoted by Gaudard. 
 
50 
 
 THE CEKEBRAL PALSIES OF CHILDREN. 
 
 ! 
 
 slightly. L, H. Temporal lobe, leaving the first un- 
 touched ; supra-marginal and the entire angular group. 
 
 5. L. H. Gyrus fornicatus almost destroyed. Cyst on 
 the middle of first frontal. R. H. Insula smooth, gyri 
 not evident. Posterior half of first temporal ; Sylvian 
 ends of both central gyri. Middle portion of first and 
 second frontal and posterior part of third frontal ; gyrus 
 fornicatus. 
 
 C. L. H. Normal. R. H. Supra-marginal and angu- 
 lar gyri, encroaching on occipital ; posterior third of first, 
 second, and third frontal. 
 
 7. Blocks of induration, sclerose tuhereuse, scattered 
 over both hemispheres. 
 
 8. L. H. Normal. R. H. Temporal, parietal and 
 occipital convolutions uniformly sclerosed ; not a normal 
 looking gyrus in any of these lobes. Frontal lobe quite 
 natural looking ; occupies more than three-fourths of the 
 hemisphere. Patient was an epileptic ; no paralysis. 
 
 9. The case given in full. R. H. Normal. L. H. 
 Sclerosis of ascending frontal and part of ascending 
 parietal. 
 
 10. R. H. Nodular sclerosis, first frontal and base of 
 ascending frontal. Patch on posterior gyrus of quadri- 
 lateral lobe. L. H. Patch on lower occipital, second on 
 supra-marginal gyrus. 
 
 Dilatation of the lateral ventricle on the affected side 
 is frequently mentioned ; the basal ganglia may be flat- 
 tened. In all the recently reported cases a descending 
 degeneration of the pyramidal tract is described. In the 
 cases of extensive atrophy of one hemisphere the oppo- 
 site hemisphere of the cerebellum has been found smaller. 
 The condition of the vessels has not attracted sufficient 
 attention. In two cases Jendrassik and Marie^ found 
 important changes in the walls of the cortical arteries to 
 which, we shall again refer. 
 
 3. Poiencephalus. — Associated as the condition invari- 
 ably is with atrophy, of which it is indeed only a final 
 
 ' Loc. cit 
 
INFANTILE HEMIPLEGIA. 
 
 51 
 
 result, to consider it separately is not strictly correct, and 
 yet precision may well yield to the manifest convenience 
 of grouping together for analysis the cases which present 
 this lesion. Porencephalus represents a loss of substance 
 in the form of cavities or cysts, situated at the surface of 
 the brain, either opening into or bounded by the arach- 
 noid, and often passing deeply into the hemisphere, 
 reaching even to the ventricle. It was present in twenty- 
 four of the ninety autopsies in hemiplegia. In eighteen 
 of these cases the onset of the paralysis ^a^ noted. In 
 six it was congenital. In eleven the hemiplegia came on 
 in very early life after convulsions. In one it appeared 
 to bo the result of a fall at the age of two years. In six 
 of the cases death occurred before the tenth year ; in 
 five between the tenth and twentieth year ; in five between 
 the twentieth and thirtieth, and in eight after this age. 
 The extent of the defect was very variable, from a few 
 convolutions to half a hemisphere. In all of the cases 
 the motor region was involved to a greater or less extent. 
 Although occurring in other parts of the brain in the 
 great majority of cases the districts supplied by the 
 middle cerebral arteries are affected. It is worthy of note 
 that this condition usually corresponds with definite areas 
 of vascular distribution. 
 
 In the recent study of this condition by Audry^ it is 
 interesting to note that hemiplegia was mentioned in sixty- 
 eight of the 103 cases. In ninety-six cases in which the 
 details were full, the defect was bilateral in thirty-two, 
 the left hemisphere alone affected in thirty-eight, and the 
 right in twenty-six. 
 
 to 
 
 Diagnosis. — The more frequent onset with convulsions, 
 the hemiplegic character of the palsy, the absence of 
 rapid wasting of the affected muscles, and the retention 
 of electrical reactions, are features of the early stage of 
 the disease sufficiently well characterized to exclude, in 
 most cases, infantile spinal paralysis. The rigidity of 
 ' ' Revue de Medecine,' Nos. 6 and 7, 1888. 
 
52 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 l[ il 
 
 the muscles, the increase in the reflexes, the gait, the 
 distribution of the residual palsy, the impaired intellect, 
 and the frequent onset of convulsions clearly characterize 
 the later stages. 
 
 There are cases, however, which present difficulties, 
 owing to irregular distribution of the paralysis. Thus the 
 following case of spastic crural monoplegia is probably 
 from its character of cerebral origin. 
 
 Case 25. — James H — , set. 5 months. I. P., 125. 
 Healthy when born and until two and a half years old, 
 when, for two weeks, he had fever, which was preceded 
 by screaming spells. He seems to have pain in the right 
 leg, and the back seemed painful and stiff. Then rigidity 
 appeared in the left leg. During the attack he was de- 
 lirious. The arms were never affected. There was no 
 loss of sensation at any time. The condition is now con- 
 fined to the left leg. The foot can neither be flexed nor 
 extended, and is shorter than the right. Cannot lift the 
 thigh. Can flex the leg slightly. Cannot stand on left 
 leg. There is a difference of one and three-quarters 
 inches in circumference of the legs, and of one and a 
 half inches in that of the thighs. The reflexes are 
 increased. 
 
 In the following case there was, at first, right hemi- 
 plegia, with the involvement, also, of the left arm, a dis- 
 tribution suggestive of spinal palsy, but the history clearly 
 shows that the origin was cerebral. 
 
 Case 86.— Mary J—, set. 2^. H., 345. The second of 
 three children ; others well. Family history good. 
 Mother fell three days before confinement, and was 
 delivered of the child prematurely at eighth month. Birth 
 norm{\l. About May 30th, when two years old, was 
 p<.< ' . !i "v^ whining for a time, and then had con- 
 vul !rt .^ :,■■ v^iici; C. T.outJ- and fac" .v«^re twisted to the 
 lefi^ /.id she uiv»vad iiauda and Tms. Both arms were 
 paralyzed ; nd the right leg after the attack. It was live 
 weeks before she began to use the left hand, and she has 
 never regained power in the right. She began to 
 
 1^' 
 
INFANTILE UKMIPLEGIA. 
 
 53 
 
 use the right foot in about two months. Status prmsens : 
 Cannot walk, but slides along" on her buttocks. Mind is 
 deficient ; cannot talk ; but understands what is said to 
 her. Cranium microcephalic ; biparietal diameter, 4*5 
 inches; occipito-frontal, 6; circumference, 17^. Slight 
 internal squint. Rigidity of right leg at knee. Right 
 hand is clenched, fingers extended with difficulty ; hand 
 seems slightly smaller than the left ; no difference in 
 forearms. Right hand gets cold and blue at times. 
 
 At the Elwyn Institution there is a remarkable case 
 which must be regarded, I think, as one of post-hem i- 
 plegic epilepsy. All trace of the hemiplegia has disap- 
 peared, but there remains slight wasting, increase of the 
 patellar reflex, and occasional attacks of Jacksonian epi- 
 lepsy, to indicate the nature of the original trouble. As 
 the fits became general, and were aggravated at each 
 menstrual period, oophorectomy was performed, with 
 relief at first, but, as might be expected, the attacks have 
 returned. 
 
 Case 23 (Elwyn series). — Annie S — , aet. 23. Inmate 
 of institution for one year. Mother is in an insane 
 asylum. When between three and four years old she 
 fell and, for a long time after, could not walk ; weakness 
 of the left side. In one history of this case it is stated 
 that the paralysis came on after scarlet fever. Had 
 spasms at the age of twelve. Always began in arm, and 
 for a long time were in the arm alone. Had the spasms 
 worse at menstrual period, usually three or four, either 
 just before or just after the period. Oophorectomy was 
 performed two years ar^^*. Fjbruary, 188G. Better for a 
 year. I& a weil-nourishiJ girl ; gives a good account of 
 herself. Left arm is smaller than right. Left forearm, 
 9 inches; right 9^. Wrist: left 6^ and right, 7. No 
 spasm, no rigidity ; movements perfect. Left leg smaller 
 than right. Calf, 12|. Right calf, 14^. Foot; length: 
 left, 8| ; right, 9. Left knee-jerk + . No ankle-clonus ; 
 no heart lesion. The fit besfins every time in the left 
 
 arm, the fingers are drawn up and the arm gets stiff. 
 
« : 
 
 i 
 
 f 
 
 54 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 She has then to lie down on the sofa, and they become 
 general ; sleeps after them ; has often vomiting. Has 
 not had an attack since February, 1888. At first, while 
 in the institution, they recurred for a number of months 
 with regularity. 
 
 In certain cases of cerebral tumour the symptoms are 
 those of spastic hemiplegia. Seeligmiiller' records such 
 an instance of tubercle of the meninges, beginning with 
 convulsions and fever, with left hemiplegia and con- 
 tractures in hand and foot ; and I have described a case 
 of glioma^ in a girl of thirteen years, who had spastic 
 hemiplegia and Jacksonian epilepsy for some years. 
 
 Paralysis of the face and of the upper extremity may 
 result from the application of the forceps ; the latter more 
 commonly from the manipulations of the accoucheur. 
 These obstetrical paralyses, as Duchenne' called them, 
 could rarely be confounded with those due to cerebral 
 causes. They are fully considered by Nadaud,* and 
 Budin^ had recently given an excellent description of the 
 brachial palsy. 
 
 Prognosis. — Parents are naturally intensely anxious 
 as to the prospects of a child attacked with hemiplegia. 
 As a rule, the younger the subject the greater the liability 
 to serious and permanent damage. The nature of the 
 lesion doubtless has an important influence, vascular ob- 
 struction being more favorable than meningo-encephalitis, 
 and the latter than tumour, but the diagnosis of the exact 
 condition is by no means always easy. Of the bodily defect, 
 about which the greatest uneasiness is displayed, we can 
 almost invariably predict great improvement, particularly 
 of the leg. Perfect recovery of the arm is rare, of the 
 face more frequent. The development of post-hemiplegic 
 movements is a bad omen, as such cases are more likely 
 
 1 < Jahrbuch fiir Kinderkeilkunde, Ud. xiii. 
 
 ' ' American Journal of the Med. Sciences,' 1885. 
 
 * ' Traite de I'electrization localisee,' 3rd edition. 
 
 * ' Des Paralysies Obstetricales des Nouveau>ne8,' Paris, 1872. 
 
 * ' Le Bulletin Medical,' No. 20, 1888. 
 
INFANTILE UEMIPLEQU. 
 
 55 
 
 to have epilepsy, which constitutes one of the most serious 
 sequences of the disease. Not only are the attacks dan- 
 gerous in themselves, but they undoubtedly tend to 
 aggravate existing mental defects. They may not de- 
 velop for some years after the onset of the paralysis and 
 may be deferred till the period of puberty. More dis- 
 tressing still to the relatives is the enfeebled mental state 
 which so often follows infantile hemiplegia. As the re- 
 cords of the Pennsylvania Institution for Feeble-minded 
 Children at Elwyu show, the percentage of the cases 
 due to this cause is by no means small. Training does 
 much for them, but for too many the outlook is not hope- 
 ful, and as Merklin states, even when in childhood they 
 escape imbecility, they are very liable in adult life to 
 become the subjects of psychoses. Quo ad life the pro- 
 gnosis is good, as shown in the post-mortem reports of 
 ninety cases in a large proportion of which the age at 
 death was over twenty years. 
 
50 
 
 THE CEREBRAL I'ALSIES OF CHILDREN. 
 
 i| I 
 
 CHAPTER III. 
 
 BILATERAL SPASTIC HEMIPLEGIA. 
 
 Synonyms. — Spastic rigidity of the newborn (Little). 
 Tonic contraction of extremities. Essential contraction. 
 Spastic rigidity. Permananter-kinder tetanus (Stromeyer). 
 Spastic paralysis of children (Adams). Spastic diplegia 
 (Gee). Spasme musculaire idiopathique (Delpech). 
 
 In infantile hemiplegia a great majority of the cases 
 occur within the first three years of life, and in only a 
 limited number is the condition congenital, either the 
 result of intra-uterine disease or of accident during 
 parturition. In bilateral hemiplegia and in paraplegia 
 the reverse holds good ; in a large proportic a of the cases 
 the trouble dates from birth, and is the result of injury 
 to the child during its passage into the world. Hence 
 the appropriateness of the term birth palsies, applied to 
 these cases by Gowers. Strictly speaking, these cases 
 should be considered together, as they depend on essentially 
 similar conditions, and we may find the arms so rJightly 
 affected that it is difficult to say whether the case is one 
 of diplegia or paraplegia ; but there is a sufficient number 
 of clearly defined cases in each group to make a division 
 advisable, and there are questions relating to the spastic 
 paraplegia of children which deserve separate considera- 
 tion. 
 
 To the orthopaedic surgeons we owe the greater part of 
 our knowledge of these cases. Heine^ understood them 
 thoroughly, and to him, I think, belongs the credit of 
 first recognizing their cerebral origin, and separating them 
 
 ' ' Spinale Kinderlahmung,' zweite Auflage, 1860. 
 
tilLATERAL SPASTIC UEMIPLEQIA. 
 
 0/ 
 
 from the ordinary infantile paralysis. He clearly dis- 
 tinguished cases of hemiplegia cerebralia spastica and 
 paraplegia cerebralia spastica, using these expressive 
 names which have since been employed with minor 
 modifications by Benedickt, Bernhardt and others. At 
 page 103 of his monograph is also to be found, perhaps 
 the first, certainly a most accurate, account of post-hemi- 
 plegic movements. 
 
 Little, the well-known London orthopaedic surgeon, has 
 contributed more than anyone to the subject, and to him 
 we owe, in great part, the accurate knowledge of the 
 relation of the cases to abnormal parturition. His paper in 
 vol. iii of the London Obstetrical Society's ' Transactions,' 
 18G2, contains an immense amount of material. The 
 clinical description which he gives at pages 301 — 303 has 
 not been excelled. In France the cases of spastic rigidity 
 are sometimes called Little's disease (maladie de Little). 
 The writings of Delpech,^ Stromeyer' and Adams' particu- 
 larly of the latter, to whom we owe the name spastic 
 paralysis of children, contain careful descriptions ; and 
 more recently Rupprecht* has considered the subject 
 from a surgical standpoint. 
 
 Symptoms. — Bilateral hemiplegia is characterized by a 
 spastic condition of the extremities, dating from or shortly 
 succeeding birth ; occasionally following the specific fevers 
 or an attack of convulsions. The legs are more involved 
 than the arms ; there is no wasting ; no disturbance of 
 sensation ; the reflexes are increased. The mental con- 
 dition is profoundly disturbed ; the patients are usually 
 imbeciles or idiots, helpless in mind and body. Ataxic 
 and athetoid movements of the most exaggerated kind 
 may occur. 
 
 » • Orthomorphie,' Paris, 1828. 
 
 ' Stroiiieyer, ' Handbuch der Chirurgie,' Bd, ii. 
 
 3 Adams, Club-Foot," London, 1866. 
 
 ■• Ilupprecht, " Ueber angeborne spastische gliederstarre und spatisclie 
 contractu ren," ' Volkmann's klin. Vortrage,' No. 198. 
 
58 
 
 THE CEClBEJtL PALSIES OP CHILDREN. 
 
 Anatomicallj tliero ia bilateral sclerosis or poron- 
 cephalous defect jc»f meAor areas of the cortex cerebri. 
 
 Ji 
 
 Case 1. — Anna S — ^. 3^. First child ; no instruments 
 used in labor ; fimlll term. An " inward convulsion " on 
 tenth day ; lay for tEree days apparently dead. First 
 teeth came at sixlli month. Child has not progressed 
 well. Head aeyemeeu and a half inches in circumference. 
 
 February 29t!», t^tf^. — Aged now six years ; says only 
 "mamma," "papa" and "no." Strabismus, no nystag- 
 mus. Has thriTtua and grown, understands everything. 
 Head long and narmow ; biparietal diameter five inches ; 
 occipito-f rental feii amd i^ quarter inches ; circumference 
 eighteen and a lialf inches. Face blank, but laughs. 
 Conjunctivitis;, tieiettlii bad. Uses hands to eat; arms 
 stiff at elbows. Ltr^ stiff in extension. Well nourished. 
 When cries gets tctj ngid. Pes equino- varus. Feet 
 cross when attesapits to stand ; cannot walk ; knee-jerk 
 + , no clonus. 
 
 Case 2. — Amelia P — , aet. 14 months. M. 5, 423. 
 Born at seven iekkmIu* ; no instrument ; reason assigned 
 for miscarriage caiinrymg heavy weight. First child. 
 Great weakness m-oittikDetfl at birth, but nothing else ; child 
 very small ; no spasm* ; has never had any serious illness ; 
 has never cut uur teeth j never walked ; never talked, 
 except for the ila*t two months to say " papa " and 
 " mamma." ComTiergent strabismus. Never has hud 
 any skin eruption- Keeps the legs crossed. Recognises 
 the parents ; does in)io« fix attention ; does not sit up will ; 
 wobbles the head aJiicwist!. Knee-jerk + +. Plantar reflex 
 + . Head microoejjkailiir, aymraetrical ; fontanelles closed ; 
 circumference of bc-awl seventeen and a half inches ; occi- 
 pito-frontal diameiitir mx inches ; biparietal diameter five 
 and a half inches ; fi>hdge of nose sunken. Arms and 
 legs stiff, moves them with freedom ; takes things with 
 the left hand, dc** a«« grasp well ; right arm especially 
 stiff at shoulder aaud elbow ; while under observation legs 
 fc.ti£tened in ext-esaskia , m the interval the legs can be 
 
BILATERAL SPASTIC HEMIPLEGIA. 
 
 59 
 
 extended and flexed easily ; stands fairly well when 
 supported. 
 
 Case 3. — Everett A. P — , set. 5. Parents alive and 
 healthy ; no nervous diseases in family. This child is 
 the oldest of three. Born at seven months ; no instru- 
 ments ; small, very weak, jaundiced. Noticed stiffness 
 when only a week or two old, in legs and arms ; has 
 never walked. Does not know his letters. Never had a 
 spasm J had scarlet fever. Hands have always been free 
 from spasm ; elbows stiffer sometimes than at others. 
 Temper not very good. Status prsesens : Legs : color, 
 temperature, nutrition good. Knees, ankles and hips 
 stiff ; cannot walk, when supported stands on toes with 
 legs crossed. Spasm in facial muscles at times. Knee- 
 jerk +. Can use han ds well ; elbows stiff. Cremasteric 
 and abdominal reflexes present. Spine straight. Phi- 
 mosis ; teeth fair. No nystagmus. Bright, talks well. 
 Head — biparietal diameter five and a half inches ; occi- 
 pito-frontal seven inches ; circumference nineteen and 
 three-quarter inches. In bed sits with spine doubled, 
 cannot sit up straight. 
 
 Case 4. — Florence S — , aet. 4. M., 5, 137. No forceps 
 used. No trouble during pregnancy. Five older chil- 
 dren. Father and mother healthy. Nothing special 
 about child at birth ; nursed well. Spasms on the second 
 day. Has not walked or crept. Does not talk, under- 
 stands what is said. Is well-nourished, fairly well-grown 
 child ; looks bright and is fairly intelligent, though 
 expression is spoilt by the constant dribbling from the 
 open mouth. Head wobbles from side to side. Head 
 measures nineteen and a half inches in circumference, 
 and is symmetrical. Sutures closed, and a little ridged 
 in their course. Arms not well developed, and nre stiff, 
 but can be readily flexed at elbows, wrists and fiugers. 
 Gets so stiff at times that she can be lifted without bend- 
 ing. Arms stiffea in extension. Moderate grasping 
 power. Knees avid tlrighs can be flexed, abducted and 
 adducted. Like arms, they stiffen and gel hard. Cannot 
 
60 
 
 THE CEREBRAL PALSIES OF CHILDREN'. 
 
 I ! 
 
 walk. Plaptar reflexes not marked. No ankle-clonus. 
 Knee- jerk +. Teeth much decayed. No convulsions 
 now. Sleeps well, but will not sleep in the dark, and 
 awakens at once if light is removed. 
 
 February 4th, 1888. — Will be six years old in August. 
 Is small for her age. Does not get so stiff now, only 
 once or twice a day, not, as before, a dozen times. Very 
 characteristic posture of legs — feet extended and legs 
 crossed. Stands on toes, generally on right foot, with 
 the left leg diagonally across the right. Holds her head 
 better ; is not cross. Hands get stiff, and fingers separate 
 and extend when she attempts to take anything. 
 
 Case 5. — Jennie S — , a3t. 10. M., 7, 177. Labor difficult. 
 Head much flattened in birth, and child was unconscious 
 for half an hour. First child. Second died at four years 
 from accident. Mother thinks child always used arms 
 and legs with difficulty. Never learned to walk or use 
 the hands. Dentition natural. Intellect deficient, yet 
 understands ordinary conversation. Has not learned 
 anything. Knee-jerk + + ; muscles rigid; arms and legs 
 almost contractured. Color pale, appetite good, slee])s 
 well. Bowels regular. Heart normal. Lower jaw 
 retreats. Occipito-frontal diameter, six and a half inches ; 
 occipito-mental diameter, eight and a quarter inches ; 
 biparietal diameter, five inches. 
 
 Case 6. — Lydia IJ — , a)t. 2 years and 3 months. M., 185. 
 Elder of two children, other healthy. Born without 
 instruments. Head slightly microcephalic. Biparietal 
 diameter, four and three-quarter inches ; occipito-frontal, 
 five and a half inches. Fontanelles closed Forehead 
 prominent in central portion. Internal strabismuc. Mouth 
 open, no dribbling. Intelligence poor, speaks little, smiles, 
 and looks intelligent. Dentition began at six months, 
 last tooth is now being cut. Arms stiff, especially left. 
 For a time kept left hand closed. Legs stiff, slight 
 extension of feet. Tendency to talipes equinus, legs 
 flexed with difliculty, sits with legs crossed. Never has 
 used legs properly, they are thin and cold. Electric 
 
BILATERAL SPASTIC HEMIPLEQIA. 
 
 61 
 
 examination shows the quantitative change, but no reac- 
 tion of degeneration. She had a spasm soon after first 
 visit ; tendon-reflexes increased. 
 
 Case 7.— Nellie M— , aet. 6. M., 5, 291. Mother died 
 of phthisis ; one child died at eleven months, of convul- 
 sions, while teething. This child is one of twins, the 
 other born dead. Some defect noticed at birth ; teething 
 natural. Never had convulsions. Never has been able 
 to sit up or walk ; has to be fed. Right hand weak and 
 small, can take some things in it. Both shoulders stiff, 
 a little pressure relaxes them. Thighs are crossed. 
 Legs have clasp-knife rigidity ; left leg crosses right ; 
 this position is nearly constant. Legs can, however, be 
 placed side by side ; right leg decidedly larger than left. 
 Foot strongly extended on leg ; ankle-joint cannot be 
 flexed. Knee-jerk + + ; no ankle-clonus. Expression 
 idiotic ; speaks no word ; temper bad ; mouth open ; 
 constant dribbling ; does hot cry much. Head micro- 
 cephalic, supra-orbital arches marked. Face prognathous. 
 Forehead low, narrow , does not support head, but it 
 wobbles from side to side. Circumference of head, 
 seventeen and a half inches. Chest rickety, costal 
 margins everted ; sternum depressed ; antero-posterior 
 and lateral spinal curvature. Convergent strabismus, 
 nystagmus. 
 
 Case 8. — Harry B — , set. 1. M. 5, 168. One brother 
 said to have some brain trouble, one died in a convulsion 
 at the ago of three years, one died of congestion of brain. 
 Two other healthy children. Fourth child ; labor natural. 
 Was backward about walking. Since summer of 1885 
 has twitched hands and feet. Head symmetrical, measures 
 nineteen inches; expression bright and intelligent. Temper 
 good. Makes no sounds, seldom cries. Uses his hands 
 well ; at times clinches hands and folds them over heart, 
 and they get stiff. Eyes turned a little. Moves feet 
 with a slight spasmodic movement. Legs cross when at 
 rest, and wlion he is lifted they get stiff. 
 
 Cask 1>.— Wm. K— , sat. 2. M.,4, 33. Family history 
 
62 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 good. Mother had a severe fall five months before child 
 was born. Never has had any children's diseases. Is 
 moderately well nourished. Special senses perfect ; dull, 
 stupid, never says anything' except " mamma." During 
 last year has had frequent attacks, in which face grows 
 at first scarlet, then purple, and finally white. Attacks 
 last from two to three minutes, during which he works 
 mouth and twists lips. There is entire loss of conscious- 
 ness. Does not bite tongue or froth at mouth ; attacks 
 occur in daytime ; sleeps after them. Independently of 
 these attacks during the day he has repeated spasms of 
 the muscles at the back of the neck, and the head is 
 drawn into complete extension. There is a constant 
 spasm of the left thumb, which is drawn across the palm 
 of the hand. Arms stiff. Legs tend to cross when he is 
 held erect, but can be spread apart by force ; great diffi- 
 culty in flexing the legs when they are in spasm. Can- 
 not stand alone, and has never walked more than two or 
 three steps. Uses hands but little, holds objects in an 
 awkward manner, and cannot feed himself. Still nurses, 
 but takes other food. Slight nystagmus. Dribbles con- 
 stantly. Sleeps well, but starts at sounds ; is constipated. 
 Case 10.— Morris C— , set. 3. M., 4, 122. First child ; 
 labor lasted eleven hours ; instrumental. Father thinks 
 mother was frightened when half way through pregnancy. 
 Child's body was black when born. He cried continuously 
 for one week after birth. When he began to move, 
 parents noticed his movements were awkward. Cannot 
 sit up. Has no fits now. Is said to have had them last 
 fall. Appetite and sleep good ; shows signs of intelli- 
 gence. Eyes squint internally. February 15th, 1888. — 
 Returns to-day. Is now eight years old. General health 
 has been good ; no convulsions ; has not been able to sit 
 up, nor walk ; lays on stomach in cot-bed most of the 
 time ; cries very little, temper good ; can scarcely talk, 
 says a few words — e. g., " home," " all right," " hello." 
 Looks faii'ly bright and intelligent, and understands what 
 is said. Head not quite symmetrical ; left parietal and 
 
 snaagnmi 
 
BILATERAL SPASTIC HEMIPLEGIA. 
 
 63 
 
 left frontal eminences most marked. Biparietal diameter, 
 five inches ; occipito-frontal diameter, seven and one- 
 quarter inches ; circumference of head, nineteen and a 
 half inches. Eyes bright, clear, slight convergent stra- 
 bismus ; pupils medium size, react to light, vision seems 
 good. Makes irregular movements of lower muscles of 
 face ; opens mouth, and utters unintelligible sounds. 
 Has difficulty in supporting head, which wobbles from 
 side to side. There does not appear to bo distinct spasm 
 of the neck muscles. Back much turned to right. No 
 wasting ; body is thin. Hands are held closed, opens 
 tliem soiTietimes ; thumb inverted, and fingers usually 
 closed ove." it ; is unable to grasp anything. There are 
 constant, l^rge, irregular movements of arms; distinct 
 spasm in arn: ; very difficult to extend forearm. Right 
 thigh constantly drawn up in semi-flexed position ; leg 
 flexed on thigh ; \?ii leg extended, foot inverted, great 
 stiffness ; muscles of legs fully developed, but firm. 
 Knee-jerk +; no ankle-clonus. Teeth good, getting 
 second teeth. 
 
 Case 11.— Thos. McG— , aet. 4. M. 5, 195. One of 
 three children. Born naturally, and seemed healthy. 
 Measles at three months, followed by hydrocephalus ; head 
 continued to increase in size till one year old ; circumfer- 
 ence twenty-three and a half inches. Dentition normal. 
 Talked at an early age and seemed quite bright. Never 
 walked, but can kick legs ; legs spastic on standing, toes 
 extended, muscles tight, feet crossed, legs relaxed when 
 at rest. Knee-jerk + +• Hands shake and arms are 
 stiff. 
 
 Case 12. — Elsie J — , sot. 1 J. M., 5, 21G. Roxborough. 
 Youngest of two children, the other perfectly well. Labor 
 natural and not difficult. Never had convulsions ; no 
 definite onset. Head microcephalic, measures seventeen 
 and a quarter inches in circumference ; furrow in temporal 
 region ; sutures closed for some time ; transverse diameter 
 above ears four and a half inches ; occipito-frontal, six 
 inches. Dentition retarded. Has upper incisors and 
 
64 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 lower central. Seems bright and notices objects. No 
 nystagmus. Fairly well nourished. Arms stiff at elbows 
 and shoulders ; knee-jerk 4- . Legs were noticed to be 
 stiff soon after birth ; not well developed ; never walked j 
 on standing rests on toes ; (Fig. 3) knife-clasp rigidity ; 
 
 Fio. 3. 
 
 Position of child when supported. 
 
 strong adduction ; sometimes crosses legs ; some eversion 
 of feet ; attempts to walk ; seems to have more power on 
 left side. January Slst, 1887. — Supposed to have had 
 spasms about a year ago ; was three years old last 
 December. Arms and legs remain stiff. Child has not 
 developed mentally. 
 
 Case 13. — Willie L — , aet. 6. One child stillborn, one, 
 aged two weeks, died of marasmus. Born with instru- 
 ments ; had fits as soon as born, lasting for three days ; 
 moved arms and legs, but not so well as other children ; 
 
 *T 
 
BILATERAL SPASTIC HEMIPLEGIA. 
 
 never able to sit up till one year old ; began to talk at 
 two years ; sat up and held up head at eighteen months ; 
 right hand contracted till second year ; dragged the right 
 hand in creeping ; stood at three and a halt" years ; can- 
 not stand now without support. Intellect bright ; speech 
 affected, has difficulty in pronouncing words. Fits again 
 two years ago, after improper food. Healthy but small. 
 Back straight ; walks on toes ; legs small below knees ; 
 skin and tissues adherent ; contraction of tendo Achillis, 
 which can easily be overcome, l^egs cold ; in walking 
 toes of left foot turn in ; left hand rather the larger ; 
 both arms stiff. 
 
 Case 14.— -Fred H— , ret. 3. M 7, 58. Parents 
 healthy, five other children, all well. Looks bright ; 
 understands everything. Born at seven months ; no in- 
 struments ; nursed by mother. Has never sat up, 
 crawled, or walked ; is now just beginning to say a few 
 words. Restless and irritable ; constantly throws hitn- 
 self backward. Hands and arms contracted and stiff, 
 and in constant motion ; makes an offer to take things, 
 but can scarcely take anything to his mouth as the arms 
 are so stiff, left more than right ; feet are at times 
 everted, then the toes are tiexed and extended. Knee- 
 jerk difficult to obtain ; no ankle-clonus ; spasm gets less 
 when once overcome by motion ; teeth good ; no nystag- 
 mus. Biparietal diameter four and three-quarter inches ; 
 occipito-frontal seven inches ; occipital region very pro- 
 minent ; circumference nineteen and a quarter inches. He 
 has been ill lately with fever ; is now very pale ; at times 
 gets very stiff in arras and legs ; hands and fingers extend 
 and get rigid ; uses left hand most ; can scarcely grasp 
 an object. Has had two slight convulsions, limited 
 almost entirely to face and mouth, first last autumn (188(5), 
 second in March, 1887. 
 
 Cass 15. — Ralph W — , a3t. 3 years and G months. In 
 Pennsylvania Institute for Feeble-minded Children. Idiot ; 
 no history ; unable to walk or talk. Head microcephalic, 
 circumference sixteea and a half inches, with the hair ; 
 
 5 
 
66 
 
 THK I'EKKRHAL I'AI.SIK.S OF CIIILDFJF.X. 
 
 no nystagmus ; does not dribble j teeth good ; arms 
 rigid, and become more so on the slightest touch ; irre- 
 gular movements in fingers, but how much voluntary and 
 how much involuntary, it is difficult to say ; legs in 
 extreme spasm, slight equino-varus position; the feet can 
 scarcely be moved, so firm is the extensor spasm ; the 
 whole pelvis moves on attempting to flex the thighs. 
 
 A class of cases belonging to this division of bilateral 
 heniij)legia is characterized by spasm and disordered move- 
 ment. They are described in literature as chorea spastica 
 and double athetosis. The cases I refer to are simply 
 spastic diplegias, plus post-hemiplegic disorders of move- 
 fiient. The history is the same as in ordinary cases ; the 
 trouble has persisted from birth or shortly after, and 
 there is a condition of feeble-raindedness or idiocy, though 
 in some instances the intelligence is fair. Very often, 
 too, there has been a difficult labor. 
 
 Of the chorea spastica, the following are probably 
 illustrations : 
 
 Case IC. — Mary M — , xt. 4. M. 4, 429. Breech pre- 
 sentation, delay at the head, was six hours before she was 
 resuscitated. Began to talk at two years ; never walked ; 
 almost from birth she has had peculiar movements of 
 hands and arms ; the thumbs are turned in and there is 
 constant irregular motion of the arms and hands, with 
 stiffness, which is made worse when she attempts to 
 control it ; it is like a chorea. There is also some in- 
 coordination of the head. She is well nourished ; no 
 wasting. Coordination of legs good ; but she does not 
 walk. 
 
 Case 17. — Nellie P — , aet. 9. I. P. b., 55. Parents 
 healthy, five children dead, of seven. Seven years ago 
 had fits while teething, had fits constantly for twenty-one 
 days ; for nine months had seven to nine per diem ; in 
 very weak health when fits ceased. Present state : Speech 
 hesitating ; memory not affected ; unable to stand, sit, 
 feed herself, or assist herself in any way ; can move every 
 
BILATEKAL SPASTIC HKMIPLEGIA. 
 
 67 
 
 muscle in the body, but with an irregular movement 
 which prevents her using any group of muscles ; the 
 movement is choreoid ; in attempting to grasp an object 
 the fingers are thrown out in a stiff, spasmodic, and 
 irregular manner, and she is unable to close them over 
 the object. 
 
 I do not mean to infer that all cases of so-called con- 
 genital chorea come under +his designation ; there are 
 instances without spastic rigidity, as the case reported by 
 Dr. Sinkler from this Infirmary.' Certain of these cases 
 of congenital chorea iiave also had definite athetoid 
 movements.' 
 
 There are several reports of children in the Infirmary 
 records with the diagnosis of multiple sclerosis, which 
 in many respects resemble these cases, and it would 
 doubtless often be difi[icult to make a differential dia- 
 gnosis. 
 
 lo 
 
 r 
 
 [s 
 lo 
 le 
 
 Bilateral athetosis is not very uncommon ; an illustra- 
 tion may be found in almost every almshouse or home 
 for incurables. It is one of the most distressing of all 
 maladies to witness, and is usually associated with im- 
 becility. 
 
 The following cases illustrate the combination of spasm 
 with disordered movement characteristic of this condition : 
 
 Case 18. — William B — , aet. 30. In the Klwyn Institu- 
 tion for eight and a half years. History : llad jaundice 
 when eleven days old, after which the paralysis occurred. 
 Status prxsens : Intelligent looking ; head well formed. 
 Does not speak, but utters a loud, deep-toned sound 
 when he is pleased. Sits up, but in a sloping position. 
 Cannot stand. Continual grimaces, caused by irregular 
 movements of the lower face muscles. Head is turned 
 forcibly from side to side and the mouth drawn and 
 hideously distorted. Arras very stiff, not wasted ; are 
 quiet at times, but every few minutes the most irregular 
 ' ' System of Medicine,' edited by Pepper, vol. v, Fhilad., 1886. 
 ' Kau : ' Neurologisches Centralblatt,' 1887. 
 
68 
 
 THE CEREBRAL PAI-HIES OF CHILDREN. 
 
 movements ; the arms and forearms stiffen in extension, 
 the hand flexed, and the fingers in rapid, continuous spasm. 
 At times is quite quiet and can even feed himself. Sits 
 usually with his wrists strongly flexed on the bench, as if 
 helping to support himself. The motions of the fingers 
 are typically athetoid ; those of one hand will be flexed 
 on the palm while the others are in active extension. As 
 he feeds himself the spasm is very great, and it is with 
 much effort that the mouth and hand can be made to 
 meet. The index finger may be strongly flexed while 
 the middle is in extreme extension. The legs are stiff, 
 strongly adducted. The feet are in extension in equino- 
 varus position. The knee-jerk is obtained with difficulty, 
 lie is good-tempered and smiles ; knows the attendants 
 and makes signs as to his wants. 
 
 Case 19.— Laura C— , set. 21. The fifth child. A 
 hard labor, but no instruments used. When born there 
 was ** no sign of life in her," and for an hour she was blue. 
 The mother is a large well-built woman ; the family 
 history is excellent. At six months the l ild had whoop- 
 ing-cough ; seemed weak before this, but after the attack 
 grew much worse ; could not sit up and could not help 
 herself like other children. From infancy she has had 
 irregular movements of the arms and legs, with stiffness. 
 Learned to talk late ; is intelligent and good-tempered. 
 She was brought to the Infirmary when eleven years old. 
 When seen recently at home she presented the following 
 condition : a medium-sized girl, pale, but with an intelli- 
 gent face. Sits in a chair supported by cushions. She 
 answers questions in an interrupted, somewhat high-pitched 
 voice, a little difficult to understand at first. Mentally is 
 quite bright ; appreciates her condition, and said she was 
 a " little Job." Likes to be read to and to play with 
 the children. She has never walked, and is quite helpless 
 on account of the extraordinary rigidity and irregular 
 movements of the extremities, which are excited by 
 emotion or by any attempts at voluntary efforts. The 
 facial muscles move spasmodically as she speaks. When 
 
BILATEUAI- SPASTir UKMU'l.KdlA. 
 
 r.i> 
 
 pleased she laughs in a loud, rough manner, with thu 
 mouth widely opened, the jaw strongly depressed, so tlmt 
 the uvula and palate arc freely exposed. The arms are 
 well nourished and are held in strong extensor spasm ; 
 the left is rotated inward and rigid ; the forennn is so 
 strongly extended that there is almost an anterior disloca- 
 tion of the ^Ibow-joint. At the same time there is ex- 
 troui!> rotation of the radius and the hand, the fingers of 
 which aro clinched so tightly that it is impossible to 
 separate them. The right arm is less strongly contracted, 
 and with it she can make attempts to grasp objects. The 
 spasm relaxes every few moments and the limbs assume 
 new attitudes. The fingers relax and close, but without 
 that continuoup, orderly spasm seen in typical athetosis. 
 The shoulder and trunk muscles aro also affected, and 
 their irregular contraction moves the trunk about from 
 side to side. The legs are strongly extended, the feet in 
 the equino-varus position. There is not much movement, 
 but on testing the reflexes there were sudden spasmodic 
 jerkings, and at times the knees are drawn up. 'J'lie 
 muscles in spasm have an iron-like rigidity, and it is 
 almost impossible to bend the limbs. When not excited 
 she is much quieter and the muscles relax ; but the slightes<t 
 exertion brings on the spasms. She can sometimes, with 
 the left hand, pick up objects, and even carry a biscuit 
 to her mouth, but she is quite unable to feed or help 
 herself. The arm- and leg-reflexes are increased ; the 
 ankle-clonus is readily obtained. Sensation perfect ; the 
 most extreme spasm gives no pain. There are no trophic 
 changes. Her appetite is good and she sleeps well, the 
 contractions disappearing completely. The bodily func- 
 tions are well performed. 
 
 Recently a young man car.e to the Infirmary whose 
 case forms an interesting link bi^tween the comuion forms 
 of spastic diplegia and those associated with disordered 
 movements : 
 
 Case 20.— E. A—, aet. 21. Eldest child. Difficult 
 labor. The mother died in childbed with third child. 
 
 !i 
 
 t 
 il 
 
 i| 
 
70 
 
 THE CEREBIUL PALSIES OF CUILDKEN. 
 
 Hi < 
 
 Very limp and feeble as an infant. Had two fits in early 
 life and one at age of five years. Did not walk until the 
 ninth year as ** the cords at the back of his logs were too 
 tight." Has been bright and intelligent, but did not 
 learn to read until late. Status j)r!K»en8 : Intelligent 
 looking : head well formed : circumference twenty-two 
 and a half inches. The muscles of the face move irregu- 
 larly, and the lips are drawn up. Tiio speech is imper- 
 fect ; articulates with decided effort, and there are clonic 
 contractions of the facia' muscles, lie can stand and 
 get up alone ; walks with difficulty ; steps are short, and 
 the gait is very stiff. Leg muscles are not well developed. 
 Left calf measures eleven, right eleven and a half inches. 
 On attempting flexions legs get very stiff. Arms fairly 
 well nourished. Supinators are small. No movements 
 when at rest, but when excited or when attempting any 
 action, the arras get stiff and the motions are very slow. 
 He can dress himself, using the fingers in a stiff clumsy 
 manner. The reflexes are increased ; ankle-clonus pre- 
 sent. Sensation perfect. Special senses unimpaired. 
 
 In spastic diplegia some of the patients are able to 
 walk ; in all the hands are used awkwardly, or not at all. 
 The legs are most affected, usually extended, the feet 
 crossed and in the pes equinus or equino-varus position. 
 The thighs are often strongly adducted — the so-called 
 clasp-knife rigidity. When the child sits the legs cross, 
 and, if supported, there is the characteristic attitude of 
 infantile spastic paraplegia, the feet crossed and the body 
 supported on the toes. In Case 10 the right thigh was 
 drawn up ; sometimes the legs are partially flexed, but, 
 as a rule, the extension position is maintained. The 
 stiffness is in some cases constant, while in others it 
 varies greatly and is increased when the child cries, or in 
 attempts to move. It may be more marked on one side 
 than on the other. The whole body may at times become 
 rigid, and, as Little remarks, is turned *' all of a piece " 
 on the lap. The arms are usually flexed, and the stiffness 
 
 "-.laf.. Ji 
 
IIII.ATKUAL SPASTIC HK.MIIM.EOIA. 
 
 71 
 
 i8 at once apparent on attempting to extend them. It 
 may be dilHcnlt or ini])os8ible to raise the arms or to ab- 
 duct them. The hands may be clenched and the fingora 
 strongly flexed, but it ia rare to see the extreme s])asm 
 which is so common in hemiplegia ; and, as the reports 
 indicate, a majority of the children could use the hands, 
 though awkwardly ; v/hile in Case 3 the movements were 
 almost natural. There may be, as in Case 10, large, 
 irregular movements of the hands. 
 
 Spasm of the muscles of the face or tongue was rarely 
 noted. In Case 10 there were irregular movements of 
 the facial muscles ; and a condition of rigidity was at 
 times present in the facial muscles. The spasm is not 
 always fully relaxed during sleep, but disappears when 
 the patient is fully etherized. The back and neck mus- 
 cles are weak, and the child is rarely able to sit up alone. 
 The spine in some cases seems to have remnrkablo 
 flexibility, and mothers have used more than once the 
 expression that the child was as " limp as a rag." So 
 'helpless, indeed, is the condition of many cases that 
 unless in bed they must be in the lap. The feeble neck 
 muscles are unable to support the head, which rolls frotri 
 side to side or sinks on to the chest. The muscles wore 
 firm and hard, not often marked wasting. 
 
 In no case was sensation impaired. 
 
 The reflexes were increased in all these cases, particu- 
 larly the knee-jerk. The ankle-clonus cannot, as a rule, 
 be obtained. 
 
 The electrical conditions in the cases tested were 
 unchanged. 
 
 With the exception of Cases 3, 19, and 20, the 
 children were either idiots, with a glimmer of intelligence, 
 or imbeciles. The facial expression usually indicated the 
 mental deficiency. The open mouth, constantly dribbling 
 saliva, and lolling tongue were present in the majority of 
 the cases. Only two of the children could speak plainly, 
 thirteen could not talk at all, and six spoke with 
 difficulty. With the exception of two or three caj-es. 
 
72 
 
 THE CEK.EBEAL PALSIES OP CHILDREN. 
 
 they all seemei Itfc he able to understand, more or less, 
 when spoken to hj their molhers. Irritability of temper 
 was complained fA rerj much. 
 
 Microcepha]iis m a very common condition with asym- 
 metry, and IB ftfeveral of the cases the head was very 
 broad above tmd Jj»frhind the ears. 
 
 In two cats** ajstagmus existed, and in three stra- 
 bismus. 
 
 As is Bo comtmm in imbecile ch'klreri, the teeth were 
 defective, a ©omxljiBiKon to which Dr. Alice Sollior has 
 recently devoU-Ml at special monograph.^ 
 
 Only two ciiiymtTii had epilepsy, Case 9, subject to 
 attacks of f^tiJt mm, and Case 13, which had two 
 spasms in which iffue face twitched, and the child seemed 
 to lose conscioiiaMDi***, Cases 1 and 4 had had con- 
 vulsions after birtllii, and Case 10 had fits at two years 
 of age. 
 
 Of these tw^-'iDity cases the youngest at the time of 
 application yua^ (cme year and the oldest ten. Six were 
 first children ; tJiUPO* were born at seven months ; in three 
 cases the labor wai* prolonged, in two of which forceps 
 were applied ; oae was a breech case. In eight cases 
 the labor is etait*d i<^ have been natural. 
 
 In ten of xha (ca^^s the condition was probably con- 
 genital, as there wa?» no definite onset, and the stiffness 
 was noted carh*. fri Case 1 there were convulsions on 
 the tenth day, amA -Ke child was unconscious for three 
 days. In Catse itfofr head was much flattened by the 
 forceps, and the- (cliiM could not be roused for half an 
 hour. In Case I'O, aiao, the child was delivered with 
 forceps, was agpJiiTiiated when born, and cried for a 
 week. In Cat^ 11 ttft child had measles at three months, 
 which was fo]]ow(fc4 by hydrocephalus and the gradual 
 development of a »i^jjffl.»i;ic condition. 
 
 Morbid AkaI'T.imt. — 1 have been able to collect the 
 reports of sixteeia anitopsies in cases of bilateral spastic 
 
 > 'De I'etat de Is Dmsusum rhcz les Enfants Idiota et Arri^res,' Paris. 
 1887. 
 
BILATERAL SPASTIC HEHIPLEQIA. 
 
 78 
 
 hemiplegia in children ; the yoangest was two years old, 
 the oldest thirty. The anatomical condition in these 
 cases was as follows: Case 1. F — , set. 5 (Kundrat'). 
 Bilateral porencephalus, motor regions. Case 2 (Henoch'). 
 M — , 8Bt. 6. Atrophy, frontal convolutions. Case 3 
 (Heubner'). .^t. 2^. Atrophy of left central and right 
 parietal convolutions. Case 4 (Ross*). F — , oet. 2^. 
 Bilateral porencephalus. Case 5 (McNutt^). F — , act. 2^. 
 Bilateral atrophy, central convolutions. Case G (Richar- 
 diere*). F — , aot. 2^. Sclerosis of temporo-occipital and 
 parietal gyri on both sides. Case 7 (Isambert and Robin') . 
 JEt. 2. General cortical •yr'lerosis of both hemispheres. 
 Case 8 (Bourneville^) . JEt. 10. Extreme sclerotic atrophy 
 in both hemispheres. Case 9 (Bourneviilo^). /Et. 0. 
 Bilateral atrophy of convolutions, particularly the cen- 
 tral gyri. Case 10 (Blanchez'). F — , {ct. 5. Atrophy 
 of posterior lobes of both hemispheres. Case 1 1 (Simon^"). 
 .^t. 2^. Sclerosis of central convolutions. Case 12 
 (Bourneville®). JEt. 5^. Foci of sclerosis in frontal and 
 temporal lobes. Case 13 (Ashby^*). JEt. 22 months. 
 General atrophy ; surface of hemispheres smooth. Case 
 
 14 (Moore^''). JEt. 5. General cortical sclerosis. Case 
 
 15 (Gee'^). F — , est. 11. General cortical sclerosis 
 Case IG (Mierzejewsky^*). JEt. 30. Double poren- 
 cephalus. 
 
 ' Knndrat, ' Die Porencephalic,' 1882. 
 
 * Henoch, ' Lectures on DiscaBes of Children,' American edition, 1S82. 
 
 * Heubner, * Berliner klinische WochenBehrift,' 1882. 
 
 * Ross, ' Brain,' vol. v. 
 
 * McNutt, loc, cit. 
 
 * Richardi6re, loc. cit. 
 
 ? Isambert and Uobin, quoted by Wuillamier, loc. cit. 
 » Bourneviile, quoted by Wuillamier. 
 ' Blauchee, quoted by Wuillaiuier. 
 ** Simon, loc. cit. 
 
 ' Ashby, ' British Medical Journal,' 1S86, i. 
 " Moore, ' St. Bartholomew's Hospital Report*,' xv. 
 '^ Oee, 'St. Bartholomew's Hospital Reports,' xvi. 
 '* Mierifjewsky, ' Archives de Neurologie,' tome i. 
 
/• 
 
 t 
 
 THK CKUKHKAl. PAI.SIKS t)F CHII.DUKN, 
 
 A more detailed aocount of Dr. Sarah J. McNutt's 
 case will illustrate the condition which exists in the 
 majority of these patients. The child, two and one-half 
 years old, had been delivered with instruments and had 
 convulsions during the first nine days of its life, and for 
 a long time did not seem to have Jiny muscular power. 
 When first observed there was paresis with rigidity of all 
 the extremities, and the child was defective mentallv. 
 Death occurred from gastro-intestinal catarrh. Tlio 
 brain was studied by Dr. William 11. W^elch, who has 
 given a very full description of the coarse and micro- 
 scopic appearances. 1'hero was atrophy in each hemi- 
 sphere of the paracentral lobule, of the central convolu- 
 tions and of the roots of the three frontal convolutions. 
 Microscopically the »;ortex of the affected convolutions 
 was replaced by a finely fibrillated tissue, rich in nuclei 
 and without ganglion-cells and nerve-iibi*es. There was 
 typical bilateral secondary degeneration of the pyramidal 
 tracts in the pons end medulla and cord. In the pons 
 most of the bundles of the longitudinal fibres were de- 
 generated, ill the medulla the sclerosis was confined to the 
 anterior pyramids, and in the cord the degeneration in- 
 volved the direct and pyramidal fasciculi on both sides. 
 The ganglion-cells of the anterior liorns were normal in 
 number, size, and general appearance. 
 
 Destruction of the motor centres of the cortex is, then, 
 the essential lesion in bilateral spastic hemiplegia. Diffuse 
 atrophic sclerosis is the most common condition ; a patchy 
 sclerosis has been found in some cases ; porencephalus in 
 others, while in Ashby's case there appears to have been 
 arrest of development, as the surface of the hemispheres 
 was stnooth and sclerotic. Descending degeneration has 
 been found in the pyramiilal tracts in the cases oi McNutt, 
 Jules Simon, and Ashby. In the majority of the cases 
 there was no report as to the condition of the cord. In 
 Ross's case the cord did not show any changes. 
 
 \'oisin\ in IHHl, communicated to the I'aris Academy 
 ' ' S)ullvtin (Ic rAcaiiiMnie de Mnderirn/ 1884. 
 
'"iinwiilllinnmna,^ . 
 
 BILATERAL SPASTIC HEMIPLEOIA. 75 
 
 o1 ^:fkf„r N?n '!"' "^^^'^ «"^^-^ ^>^ ^'- eases 
 menf W M ^^'^"^^''^ ^^^« given, merely the state- 
 Tbl^ tn fi Tl7. ""^ ^^' "'^^'''^^ ^^"- I h^^e not been 
 able to find a full report of his paper. 
 
F% \ 
 
 76 
 
 THE CEREBRAL PALSIES OF CHILDHEN. 
 
 CHArTER IV. 
 
 SPASTIC PARAPLEGIA. 
 
 '^j 
 
 Synonyms.— Paraplej[?ia cerebralis spastica (Heine). 
 Tetanoid pseudo-paraplegia (Segnin). Spastic spinal 
 paralysis (Erb). Tabes dorsalis spasmodique (Charcot). 
 
 Spastic paralysis of the legs in children is a common 
 affection, and yet it is only within the past few years that 
 the subject has attracted much attention from writers on 
 diseases of the nervous system. The orthopaedic surgeons 
 have for years past described and figured cases which in 
 reality form no inconsiderable quota of the patients at 
 their clinics. Heine, as early as in 1840, gave an admir- 
 able account of it, and expresses the modern conception 
 of the disease in the name which he applies — })araplegia 
 cerebralis spastica. Delpech, Stromeyer, Adams, and 
 more particularly Little, describe it in their works already 
 referred to. Erb^ and Seeligmiiller,^ in Germany, and 
 Gee,' in London, brought the subject to the notice of 
 physicians, and the first-named author described the cases 
 with those of spastic paraplegia of adults. Koss,* 
 Hadden,' Gowers,* d'Heilly," and Gilbert^ have more 
 recently dealt with the question, and the disease is now 
 
 ' Erb, • Virchow's Arcbiv,' Bd. Ixx. 
 
 ' SoeligmiJllor, ' JiihrbuL-;! fiir Kiiiderheilknmh',' Hd. xiii. 
 
 3 Qee, 'St. Uartholonicw's HospitAl Reports,' vul. xiii. 
 
 * IlosH, ' Brain,' vol. v. 
 
 '• Hadden, ' Brain,' vol. vi. 
 
 * ' Diseases of the Nervous System,' vol. i. 
 
 ' ' Hevue men. des maladies de I'enfance,' 1883-84. 
 
 * ' Keviie medicale de la Suisse romnnde,' 1887. 
 
SI'ASTIC PARAPLEGIA. 
 
 77 
 
 usujiUy assigned a place among the cerebral palsies of 
 children. 
 
 ^j 
 
 Symptoms. — The general features of the disease may 
 be thus defined : Spastic paralysis of the lower extremi- 
 ties dating from birth, or coming on within the first years 
 of life ; absence of wasting ; a condition of talipes equinus 
 or equino-varus ; adductor spasm, producing the " clasp- 
 knife rigidity ;'* the gait stiff, the patient walking on the 
 toes, or there may be cross-logged progression. The in- 
 tellect is usually impai?'cd, though not, as a rule, so pro- 
 foundly affected as in bilateral hemiplegia. 
 
 Case 1. — Samuel B — , ast. li. l^arents alive and 
 healthy. Three other children, one died of cholera 
 infantum. Born at term; instruments not used, labor 
 easy. " Nervous " at birth. At about nine months 
 began to cry out at nights and would draw up both feet 
 as if in great pain. Never stood alone or walked. Now 
 with assistance can walk a little. Cannot read ; mother 
 says can sing. Cannot speak at all distinctly ; voice 
 very thick. Sits bent Dver double, head hanging on 
 chest, cannot sit upright for more than a moment. 
 Moves head and body constantly. Kaoe-jerk marked. 
 Ankles, knees, hips, stiff. Feet turned out at ankle ; 
 knock-knee. In walking, puts toe to ground first. 
 Pupils equal. Expression idiotic. Neck large, circum- 
 ference fourteen inches. Trapezius and sternocleido 
 muscles much enlarged. Tongue long. Teeth, two 
 upper incisors a little chisel-shaped. Lower teeth well 
 formed. Head diameters : biparietal, five and one-quarter 
 inches ; occipito-frontal, six and one-half inches. Hands 
 strong, well developed. Heels much drawn up. Can 
 flex legs and feet. Ankle-clonus present. Muscles of 
 gs not so well developed as arms. Spine flexible, no 
 scoliosis. 
 
 Casfs 2. — Vera M — , a)t. 13. Mother living; father 
 killed. Five children living, four dead. Two boin 
 dead, one by craniotomy. This child born at eight 
 
78 
 
 T»E CEREBUAL PALSIES OP CHILDREN. 
 
 Bright mentally, but 
 
 M. 5, 312. Deformity 
 
 Has never walked, sits 
 
 Thighs look large. 
 
 nigntha ; forceps not used, but labor long and hard. 
 Nursed at breast ; spasms at four months and again at 
 six. Never could walk alone until fourth or fifth year. 
 Vrcfient ntdte : Left leg twenty-four and one-half inches 
 long. Right leg twenty-five and one-half inches long. 
 Knee-jerk + + . No ankle-clonus. Gait spastic ; cannot 
 walk without crutches. Patella drawn above condyles of 
 femur by quadriceps extensor. Dentition tardy. Arms 
 normal. Head : biparietal diameter five and one-quarter 
 inches ; occi[)ito-frontaI, seven inches ; circumference 
 twenty and three-eighths inches, 
 queer. 
 
 Case 3. — Addison D — , not. 0. 
 first noticed at fourteen months, 
 doubled up with spine curved, 
 owing chiefly to large development of fat. Thigh can 
 with diHiculty be flexed on abdomen, pelvis rises on 
 flexing thigh ; knee very stiff, but can be gradually 
 overccjme. Legs much wasted ; knee-jerk -f . Toes are 
 flexed and he cannot move them. Foot everted. Creeps 
 about and walks with assistance on the outer side of his 
 feet. Head well shaped : biparietal diameter six inches ; 
 occipito-frontal, seven inches ; circumference twenty-one 
 inches. Intelligence good, can read. Distinct nystag- 
 mus, convergent strabismus. Teeth well formed. Arms 
 normal. I'ilectrical examination : muscles respond actively 
 to faradization. 
 
 Case 4. — John P — , aet. 4. I. P. 4, 4. Parents 
 healthy. Had convulsions at ten months ; paralysis of 
 logs, which are rigid. Now creeps on knees, equino- 
 varus of both legs ; reflexes + . 
 
 Cask 5.— George N— . ®t. 5^. L P. 4, 20. Natural 
 labor, never had convulsions. Whooping-cough at four 
 and a half years. Christmas, 1883, began to get restless 
 and unoiusy. Was treated for worms, and passed a few. 
 Tlion became weak in the legs. The right leg first 
 became weak, then in January, 1884, the left. The 
 weakness steadily increased. Now the legs are rigid : 
 
 
81'ASriC I'ARAFLEdlA. 
 
 r<» 
 
 spastic contruc'tiou of muscles of feet ; talipes equiuua ; 
 walks on toes. Is bright. Keilexes increased. 
 
 Cask C. — Robert G — , a)t. 1 years and 9 months, ^f. 
 0, 18. Oiily child. Born with instruments ; cried for eight 
 hours steadily after birth. In twelve Iiours a largo lump 
 was iormed in left occipital region. This was lanced, 
 and a clot of blood removed. Intelligence good u[) to 
 fifteenth month. At two years of age said to have lia<l 
 tubercular meningitis. Intelligence impaired ever since. 
 Never had a convulsion, lias a depression at anterior 
 fontanelle, which has a hard base. Says about a dozen 
 words; not particularly fretful. Kuee-jerk + . " Lead- 
 pipe " leg ; both legs nearly equal in stiffness ; no 
 wasting. Progresses by lifting his weight on his arms 
 and throwing his body forward ; cannot walk. Arms 
 are strong. Nystagmus present. I'himosis. Teeth are 
 in a state of decay and discoloration. 
 
 Case 7.— Frank W— , a't. 6. M. 0, 100. A large 
 baby, born with instruments, very long labor. Only 
 child Mother contracted eyphilis six weeka before 
 ciiildbirth, and had a suppurating bubo. Began to walk 
 at eighteen months, but never walked well, always stiffly. 
 Teething a little tardy. Improved in walking till two 
 years ago, wlien he had several spasms in rapid succession 
 for twenty-four hours, which left him weak. The spasms 
 came on in a.m. about 3 o'clock, did not gain conscious- 
 ness until 5 P.M. Ilad much fever ; was ill a week. 
 Talked and walked more since the spasms. Has had 
 slight spasms since. Last May hud a series of very 
 severe spusnvs. No stiffness in arms. Legs both s})astic, 
 toes turned in. Falls often. Has a very pecu'iur stiff 
 gait, toes on ground ; some incoordination in hands, 
 particularly the left ; picks up objects with difliculty ; 
 fingers very clumsy. Stiffness of legs most in extension. 
 Feet extended. No nystagmus, lias headache at times. 
 Knee-jerk 4- on both sides ; no clonus. Slobbers a good 
 deal. Does not talk well, but says many words. A 
 blight internal strabismus. Biparietal diameter five and 
 
I 
 
 80 
 
 THR CKRBBRAL I'ALSIIIIS OF CHILDREN. 
 
 a quarter inches ; occipito-frontal seven inclies ; circum- 
 ference nineteen und seven-eighths inches. 
 
 Cask 8.— Stella U— , rot. 6. I. P. B., 73. Never had 
 fits ; sickly from birth ; no note as to labor. Had a fall 
 at twenty-two months. Stains prxscns : Limbs well deve- 
 loped. Ac times limbs limber, but often rigid. Leg 
 fl' xed, toes turned very much in. Can move logs, but 
 cannot stand without assistance. After some effort 
 rigidity is overcome. Arms normal. Electro-muscular 
 contractility normal. 
 
 Cask 0. — Mamie McD — , oat. 3 years and 2 months. M. 7, 
 7'). Mother died of phthisis. Born at seven months, no 
 instruments used, labor natural. Always weak ; measles 
 
 Fiu. t. 
 
 I'ohitiuu o( child in walking'. 
 
 three months ago ; very sovcro spasms and crying spells, 
 unconscious fifteen to thirty minutes. Can stand alone 
 for a miimte ; can walk when supported, cross-legged 
 progression and walks on tiptoe. No special stiffness 
 except when walking. Knee-jerk -t- -f. No ankle-clonus. 
 Ankles inverted ; movements of hip-joints normal. Hands 
 not affected. Has night terrors. Intelligence good. No 
 nystagmus. After five months' treatment nmch improved 
 and could walk alone quite well. 
 
SI'ASTIC PARAPLEOIA. 
 
 81 
 
 Case 10. — Viulet M — , mt. 1 yenrand 4 ranntlis. I. V. i, 
 40. First cliild in twenty-three years of married life. Two 
 miscarriagea. Labor natiu'al and (|nick. Cliild wei^'licd 
 four pounds at three and a half weeks. Fed from bottle. 
 Cholera infantum. No fever, no convulsions. The hands 
 and arms are thin and never have developed well. 
 Motion with them is very much impaired ; dilHculty in 
 grasping or liolding an object. Can walk with dillioulty. 
 Head brachycophalic. Intelligeneo poor. Knee-ji?rk + . 
 — February 15th, 18H8, is four years old. Has not been 
 able to sit alone ; cannot walk, (.'an say a few words, 
 " papa " and " mamma ; " understands everything ; looks 
 bright ; has intelligent smile. liad-tompered ; cries a 
 good deal ; dribbles much. Head : biparietal diameter 
 five inches ; occipito-frontal five and three-quarter inches ; 
 circumference seventeen and three-quarter inches. No 
 squint ; no nystagmus. Teeth decayed. Had a convul- 
 sion last winter. The mother says that the child is like 
 a ra<j. Arms flaccid ; hands open ; cannot pick uj) things ; 
 muscles ill-developed ; a little stiffness of right arm. 
 Legs extended, stiff, moves them about ; feet extended, 
 bent with difficulty. (Jets very stiff at times, could 
 almost bo lifted by tho legs. IMautur refluxes good. 
 Sensation good. 
 
 Case 11. — Joseph J — , ast. 20, colored. Sent to the 
 Infirmary from a distance, and no history could hi ob- 
 tained except that his parents are healthy and that tho 
 present trouble had lasted from infancy. Patient is a 
 well-grown lad, and has been arcustomed to help at farm 
 work. He is weak-minded, and cannot give a very satis- 
 factory account of his past condition. He has an intelli- 
 gent-looking face, although tho forehead is low. Speech 
 is imperfect, clips the words, and it is often hard to 
 understand him. Ho has not much education, but can 
 read a little. The arms are well developed ; uses tho 
 hands and fingers well. Tho legs are muscular, of equal 
 length. When recumbent he can flex them at tho knee- 
 and hip-joint, though they are somewhat stiff and there 
 
 (i 
 
82 
 
 THK CKREIMJAL TALSIES OF CHII.IHIEN. 
 
 ia adductor spasm, lie walks with a spastic gnit, tlio 
 legs stifT, the thighs adducted, aud the toes kept close to 
 the ground. The logs cross at each step, as shown at 
 Fig. 6. The entire foot is placed on the ground. The 
 arms are used to maintain the balance, and the body 
 sways from side to side with each step. The knee-jerk 
 is much increased, the ankle-clonus can readily be ob- 
 tained ; superficial reflexes also increased. 
 
 The condition of the logs in these cases is practically 
 identical with that in the spastic diplegias, and there aro 
 instances which link the two groups together. Thus, in 
 Case 2 there was inability to use the hands properly, and 
 the right arm at times became stiff, and in Case 10 the 
 elbows were occasionally stiff, though at the examination 
 there was no trace of it. 
 
 That in spastic paraplegia the cerebrum is less pro- 
 foundly affected is shown by the greater number of chil- 
 dren who are bright and intelligent and who ultimately 
 learn to walk. Of the eleven cases three were mentally 
 well developed ; the others presented various grades of 
 feeble-mindedncss. Six could speak plainly ; in four 
 articulation was defective, and Case 10 could only utter a 
 few words. Only one case had strabismus, and in two 
 nystagmus was present. 
 
 In many cases the history was defective. In only 
 three were there difficult labors, two requiring the forceps. 
 The pai'amount influence of abnormal conditions of birth 
 or of parturition in producing this condition is well 
 illustrated in Little's cases, of which I think twenty-four 
 can be selected as paraplegic. Of these in twenty-three 
 there was either difficult labor or premature delivery ; six 
 were first children. In only one instance were the 
 forceps applied, but we must remember that in the fourth 
 and fifth decades of this century the forceps were not used 
 so often as they are at present. In none of Little's cases 
 did the feet present, a point observed by Ross^ and others. 
 
 The stiffness of the legs may not be noted for some 
 
 Loc. cit. 
 
.SI'ASTIC PAKAi'LKGlA. 
 
 83 
 
 months after birth, but usually on washing and drossinj^ 
 the child the mother notices the rigidity. The child is 
 late in attempting to walk, and then the awkwardness 
 and stiffness of the legs become more evident. When 
 standing the attitude is most characteristic — there is 
 talipes equinus, varying from the slightest raising of the 
 heel to a position in which the child actually stands on 
 tiptoe. The heels are usually everted and the knees 
 approximated, owing to the spasm of the adductors, 
 which, with the gastrocnemii, become hard, tense, and 
 prominent. In most cases, owing to the elevation of the 
 heels, the body is supported on the balls of the tnes. 
 Fig. 5 represents the foot-marks in Case as tlio cliild 
 walked, with the soles chalked on a black surface. In 
 other instances, as shown at Fig. 6, the entire foot may 
 be set down at each step. Owing to the extension of tho 
 limb as it is being moved forward to take a step, the toes 
 do not always clear the ground, but drag, so that the 
 shoe-caps are usually much worn. The strong adductor 
 action produces a remarkable crossing of the legs, and 
 each foot is dragged over and planted in front of, or even 
 to the other side of, its fellow. This is very well illus- 
 trated in the figures. When extreme, as in Fig. 6, which 
 is taken from Case 11, the body is thrown from side to 
 side in walking, and the arms are kept apart to help 
 maintain the balance. In some instances the adductor 
 spasm is so great that the thighs rub at each step, and one 
 foot is shuffled before the other in a series of extremely 
 short steps. The trousers may be rapidly worn out at tho 
 inner aspect of the knees in consequence of the constant 
 friction. In attempting to flex the legs there is 
 marked resistance, which gradually yields, and the limb 
 can be bent, as Dr. Weir Mitchell has expressed it, like 
 a bit of lead-pipe. The term " lead-pipe " contraction is 
 often ud'id rxi the clinics to designate this condition. The 
 adducto'' spafin maybe so extreme that it is impossible to 
 separate lie .thighs — clasp-knife rigidity. When at rest 
 the spasm may relax, but any attempt at movement or 
 
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SPASTIC PARAPLEOIA. 
 
 85 
 
 1 
 
 an effort on the part of the doctor to flex the leg will at 
 once induce it. Ultimately there may be constant flexion 
 of the legs, with permanent contracture. 
 
 The reflexes are increased. The knee-jerk is almost 
 invariably present, though in very young children it is 
 sometimes not an easy matter to elicit. The ankle-clonus, 
 as a rule, is not to be obtained. It was present in Cases 
 1 and 11. 
 
 Sensation is not impaired. Trophic lesions were not 
 noticed. The functions of the bladder and rectum are 
 unimpaired. 
 
 In brief, the symptoms of this affection in children are 
 almost identical with those of adults, and the earlier 
 writers on spastic paraplegia classed the cases together. 
 Heine long ago expressed the opinion that these cases in 
 children are of cerebral origin, and this is now generally 
 accepted on the following grounds: 1. The frequent co- 
 existence of symptoms indicating cerebral defects, such 
 as idiocy, imbecility, nystagmus, and the like. 2. The 
 occurrence of cases of bilateral spastic hemiplegia, in 
 which the paraplegic symptoms are identical with those 
 of tabes spasmodique — cases, moreover, in which the 
 evidence is usually very clear of the existence of profound 
 cerebral disturbance. All gradations are met with, from 
 pure spastic paraplegia with perfect use of the arms, to 
 instances of the most extreme bilateral spasm with or 
 without disordered movements. 3. The paraplegic and 
 diplegia cases present identical histories, and a large pro- 
 portion of the cases in each group are birth palsies, the 
 result of abnormal parturition. 4. As the diplegic cases 
 have been shown to depend upon symmetrical disease of 
 the motor areas with, in many instances, descending de- 
 generation, the conclusion has not unnaturally been 
 drawn that the paraplegic form was the result of a similar 
 though less extensive lesion. Ross, Hadden, and Gowera 
 take this view ; d'Heilly thinks that there is not necessarily 
 involvement of '^^'^ brain, but that it may be a primary 
 degeneration of the lateral tracts. 
 
-'^•if^rvmrnx^rrMm 
 
 86 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 H 
 
 The Morbid Anatomy of infantile spastic paraplegia 
 remains to be worked out. In a tolerably careful review 
 of the literature, I can find but one record of a carefully 
 performed section in a case of this kind. Forster,^ in a 
 report from the Dresden Children's Hospital, among the 
 spastic palsies, gives the following case : Boy, set. 2. No 
 history of the parents or of the delivery. At the age 
 of one and a half years the paralysis was noticed, and he 
 began to use the few words of speech which he had 
 acquired. When seen at about the age of two, the arras 
 were normal, the legs stiff and with strong adductor 
 spasm. When attempting to walk he stood on the outer 
 aspects of the feet with the heels raised. Knee-reflexes 
 exaggerated. Intellect feeble. The case appears to have 
 been one of true spastic paraplegia. The post-mortem, 
 by Birch-Hirschfeld, showed a moderate grade of general 
 cortical sclerosis, with slight dilatation of the ventricles. 
 The basal ganglia were normal ; no note as to pyramidal 
 tracts in crus or medulla. The cord was firmer than 
 normal, and the lateral tracts presented a gray- white, 
 translucent aspect, which was regarded as a descending 
 degeneration, the consequence of the brain lesion. 
 
 Diagnosis. — The diagnosis of spastic diplegia and 
 paraplegia is usually easy, but there are cases from which 
 they must be carefully distinguished and which, at times, 
 closely simulate them. The condition described by 
 writers on children's disease as idiopathic contraction with 
 rigidity, [tonic contraction of the extremities, the con- 
 tractures of the French writers, is very apt to be con- 
 founded with true spastic paralysis and vice versa. The 
 confusion which exists is illustrated in several recent 
 papers, notably those of Onimus^ and Launois' and the 
 thesis of Simard*. The majority of the cases reported 
 
 1 ' Jahrbuch fiir Kinderheilknnde,' Bd. xv. 
 
 * ' Revue men. des maladiet de I'enfance,' 1883. 
 3 ' France Medicalc,' 188i. 
 
 ♦ ' These de Paris,' ir84, No. 85. 
 
SPASTIC PARAPLEGIA. 
 
 by these writers belong to the category of spastic para- 
 lyses due to cerebral disease. 
 
 The chief difference between these conditions may be 
 thus tabulated : 
 
 Pseudo-paralytic rigidify. 
 
 Spastic paralysis ; di- and 
 paraplegia, 
 Usuiilly exists from birth. His- 
 tory of lilffiiult labor, of asphyxia 
 neonatorum or of convulsions. 
 
 Arms rarely involved without lej^s, 
 and not in such a marked degree. 
 
 Usually painless. 
 
 Variable in intensity but con- 
 tinuous. 
 
 Follows a prolonged illness. Is 
 often associated mt\\ rickets, laryn- 
 gismus stridulus and the so-called 
 hydrocephaloid f.i;ate. 
 
 Begins in hands as carpo-pedal 
 spiism ; often confined to hands and 
 arms. 
 
 Spasms painful and attempts at 
 extension cause pain. 
 
 Intermittent and of transient dura- 
 tion. 
 
 The history, the limitation in many instances to the 
 arms, the existence of rickets or other constitutional dis- 
 turbance, render clear the diagnosis. The spasm in idio- 
 pathic contraction may be extreme, the arms adducted, 
 the forearms strongly flexed and the hands clenched on 
 the chest. In none of the cases of spastic diplegia have 
 I met with such inflexible rigidity of the arms as existed 
 in a rickety child which T saw with Dr. Major, of Mont- 
 real. From tetany, which in children is closely related 
 to the carpo-pedal spasm, and occurs under similar 
 conditions, the distinction would rest largely on etiologi- 
 cal considerations. In early lif : the association with 
 rickets and diarrhoea, and the greater involvement of the 
 upper extremities, are features of letai 7. 
 
 It must not be forgotten that tumors of the pons and 
 of the cerebellum may produce a bilateral rigidity when 
 the motor paths are involved or compressed. Tubercular 
 growths of the cerebellum seem specially liable to induce 
 this symptom. In the Gulstonian Lectures for 1886, 
 Sharkey^ reports four cases, in each of which the tumor 
 occupied such a position that it compressed either pons 
 or medulla. 
 
 ' ' Spasm in Chronic Nerve Disease,' London, 1S86. 
 
88 
 
 THE CEKEBRAL PALSIES OF CHILDREN. 
 
 I 
 
 CHAPTER V. 
 
 PATHOLOGY AND TREATMENT. 
 
 Pathology. — Varied as is the anatomical condition, the 
 lesions have this in common — interference with the motor 
 centres, or with the conducting paths of the cerebrum. 
 In reviewing a large number of post-mortem records, or 
 in studying such a series of brains as that prepared by 
 Dr. Wilmarth, at Elwyn, we are impressed, on the one 
 hand, with the extent to which sclerotic and other changes 
 may exist without symptoms if the motor areas are 
 spared, and, on the other hand, with the degree of per- 
 manent disability which may exist with even slight affec- 
 tion of this region. Our knowledge is so limited to the 
 appearances and states years after the onset of the sym- 
 ptoms, the final results of processes long past, that we 
 are scarcely in a position to discuss accurately, in a^l its 
 aspects, the pathology of this interesting group of cases. 
 It is something, however, to get an outline for our igno- 
 rance and to ascertain in which direction facts are needed 
 to sustain, or, it may be, to upset our theories. 
 
 A certain number of the cases of hemiplegia in children 
 are due to haemorrhage from causes identical with those 
 which prevail in the adult, and I have given illustrative 
 instances of true apoplexy with laceration of the cerebral 
 substance ; but it may be safely concluded, I think, that 
 hsemorrhage is not the common cause, and accounts for a 
 very small percentage. A small proportion of the cases 
 of hemiplegia come under the designation of birth pal- 
 sies, as there is a history of persistence of the paralysis 
 
PATHOLOGY AND TREATMEXT. 
 
 89 
 
 
 ^IS 
 
 from birth, and of the occurrence of difficult labor, often 
 necessitating the application of forceps. 
 
 In the cases of birth palsy, which result usually in 
 bilateral hemiplegia or paraplegia, the evidence points 
 strongly to meningeal haemorrhage as one of the chief 
 causes of the disorder. The great majority of these, as 
 we have seen, present, at birth, one of two conditions, 
 asphyxia or convulsions. The children are resuscitated 
 only after prolonged attempts at artificial respiration ; 
 more commonly convulsions occur, either immediately 
 after birth, or within the first ten days of life. Facts 
 have been gradually accumulated to show that haemor- 
 rhage, usually meningeal, is a very frequent condition in 
 children dying shortly after birth of asphyxia, or convul- 
 sions, and as the birth palsies almost invariably have this 
 history it seems reasonable to conclude that, in the cases 
 which recover and subsequently present signs of motor 
 disturbance, a similar, though less intense, lesion has 
 existed. 
 
 Apoplexia neonatorum is by no means an uncommon 
 event. Little fully understood its importance, and quotes 
 from Cruveilhier, Every Kennedy, Hecker, and Weber to 
 show the occurrence of meningeal baE^morrhage and 
 capillary e'^travasations in newborn children. In 1880, 
 Litzmann^ communicated the results of the examination 
 of 161 newborn children, in eighty-one of whom the 
 spinal canal was exposed. There were thirty-five instances 
 of iiieningeal hgemorrhage, in nineteen the extravasation 
 being in considerable amount. The exudation existed in 
 both cerebral and spinal meninges. 
 
 Parrot,' in thirty-four cases of cerebral haemorrhage in 
 the newborn, found five in which the blood was in the 
 cavity of the arachnoid, and twenty-six in the subarach- 
 noid space. In a large proportion of the cases the extra- 
 vasation was bilateral. This author makes no allusion to 
 the association of the lesion with abnormal labor. 
 
 1 ' Archiv f. Gynakolof^ie,' Bd. xvi. 
 
 • • Cliiiique des NouvcHU-iies,' VatU, 1877. 
 
I I 
 
 90 
 
 THK CEREBRAI. PALSIES OF CHILDUEN. 
 
 Dr. Sarah J. McNutfc has reported ten cases/ and her 
 paper is very convincing as to the frequent association of 
 this condition with abnormal labor and with asphyxia 
 and convulsions in the newborn. It may occrr when 
 the parturition has been normal, and may be deferred 
 some days, or even weeks, as in the following case, 
 which occurred in Dr. Parvin's wards at the Philadel- 
 phia Hospital, and the specimens from which I saw with 
 Dr. Stahl. 
 
 Child, get. 6 weeks, mother single ; labor normal. 
 Eemained healthy until the forty-fifth day, when at 8 
 A.M., it had a convulsion, at first on the right side, and 
 finally general. Convulsions were repeated through the 
 day and an ecchymotic rash appeared on trunk and 
 extremities. Death at 10 p.m. The post-mortem showed 
 extensive meningeal haemorrhage, a large clot over the 
 cortex, particularly on the left side. There was much 
 more blood in the left than in the right Sylvian fissure, 
 and it extended under the frontal convolutions ; it looked 
 as if the bleeding had begun here, but the most careful 
 examination of the vessels sho^.'ed no changes in the 
 arteries or thrombi in the veins. There were clots also 
 in the posterior and middle fossoB, and a uniform sheeting 
 of coagulated blood extended beneath the spinal dura. 
 
 I saw a second case, this winter, at the Philadelphia 
 Hospital, and I am indebted to Dr. Hirst, who made the 
 autopsy in both these cases, for the following notes : 
 Case of twins ; first child delivered with forceps — head 
 presentation. The second child presented the breech, 
 and there was great difficulty in the extraction of the 
 head, required much force. Twenty minutes after birth, 
 left lateral convulsions occurred and were repeated at 
 intervals. The child lived forty -eight hours, having 
 become intensely anaemic. The post-mortem showed the 
 viscera normal. The brain, in places, was remarkably 
 soft, the tissue almost diffluent. A large clot existed 
 beneath the dura mater on the right side, very thick over 
 1 < American Journal of Obstetrics,' 1885. 
 
PATHOLOGY AND TREATMENT. 
 
 91 
 
 the cortex. It dipped into the fissures and sulci and 
 extended down the cord. About the middle of the 
 longitudinal sinus there was an irregular laceration, 
 several lines in length. 
 
 The extravasatioii. has in many cases been thickest 
 over the motor areas, and from what we know of the 
 changes which time may effect in effused clot, there is 
 nothing inconsistent in the belief that sclerosis from com- 
 pression or porencephalus from destruction might ulti- 
 mately result. Gowers advocates this view in the case 
 of the birth palsies, which, indeed, he considers in his 
 work under the heading of " Infantile Meningeal HaBmor- 
 rhage." Probably all the cases cannot be assigned to 
 this cause, and I think, with Jacobi,^ that certain of 
 them may be due to fcetal meningo-encephalitis. Cer- 
 tainly in Ashby's case,'' in which, in a child twenty-two 
 months old, the cortex was smooth, without a trace of 
 convolutions, the sclerosis must have begun during em- 
 bryonic life. 
 
 The frequency of spinal haemorrhage renders it not 
 improbable that some of the cases of spastic paraplegia 
 may be due to this cause ; and Ross suggests that as 
 severe traction in feet presentation has been known to 
 tear the cord, slighter degrees might injure the pyramidal 
 tracts, and lead to a sclerosis. 
 
 We have then in the spastic diplegia, and in a few 
 cases of hemiplegia — the true birth palsies — information 
 which enables us to assign to haemorrhage an important 
 role. More positive knowledge may ultimately be ob- 
 tained by the dissection of cases at different ages after 
 the onset. 
 
 When we turn to the cases of infantile hemiplegia, 
 which come on during the first two or throe years of life, 
 we are met at once with conflicting theories. It is well 
 to bear in mind that we are called upon to explain the 
 
 * Discussion at the Academy of Medicine, New York, January 25tb, 1888. 
 ' N. Y. Med. Record,' 1888, i. 
 
 * Loc. cit. 
 
92 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 Il^il 
 
 ' 
 
 mode of origin of sclerosis and porenceplialus, the two 
 conditions present in the great majority of the cases. A 
 certain number of cases of infantile hemiplegia are due 
 to haemorrhage, to embolism and aneurism, a few to 
 tumour, as glioma or chronic tubercle : but, as we have 
 seen, these form a fractional part. We require to know 
 the pathological process lying at the basis of the con- 
 vulsive attacks with coma, which come on suddenly, or 
 after a slight febrile movement, frequently succeed an 
 infectious disease, and leave a hemiplegia with too often 
 its disastrous sequences — epilepsy and imbecility. In a 
 large proportion of the cases the disease is such a clinical 
 unit, with symptoms as marked and definite as those of 
 infantile spinal paralysis, that we might expect a corre- 
 sponding uniformity in the anatomical lesion. Unfor- 
 tunately we are, so far as I can ascertain, entirely without 
 information upon the state of the brains of children dying 
 during or shortly after the attack ; and the question re- 
 solves itself into an explanation of the conditions most 
 co»-<r'-'>nly met with years after the onset, viz. sclerosis 
 ai' rencephalus. 
 
 ■X lew years ago Striimpell^ suggested that the lesion 
 was the cerebral counterpart of the infantile spinal palsy, 
 a poliencephalitis of the motor areas of the cortex, analo- 
 gous to the poliomyelitis of the anterior horns. The 
 two affections are very similar in the mode of onset, in 
 the age affected, and in the liability to follow one of the 
 infectious diseases. The more frequent occurrence of 
 convulsions and the more prolonged coma might be ex- 
 pected from the seat of the disease. This very plausible 
 and suggestive view has not met with much favor, not so 
 much, I think, as it deserves. Against it has been urged 
 the absence of anatomical facts, but this defect it shares 
 with several theories. I see no improbability in the 
 view ; and it is possible that we shall have, ere long, the 
 necessary anatomical facts to support it. The forms of 
 encephalitis which we know : Virchow's encephalitis of 
 
 * Loc. oit. 
 
PATHOLOOY AND TREATMENT. 
 
 03 
 
 tlie newborn ; the miliary encephalitis due to septic 
 causes, such as has been found in diphtheria and in 
 aphthous stomatitis ; and the steatosis of Parrot, arise 
 under different circumstances, and do not present the 
 symptoms of these cases of infantile hemiplegia. J. Lewis 
 Smith has suggested* that certain of these cases of infantile 
 hemiplegia are due to cortical encephalitis, set up by the 
 poison of cerebro-spinal fever. 
 
 The frequency with which the disease is associated 
 with or follows one of the infectious diseases is sugges- 
 tive. Endocarditis is not rare in scarlet fever, measles 
 and diphtheria, the affections which most commonly 
 precede the hemiplegia, and embolism may account for 
 a certain number of these cases. In diphtheria there 
 may be plugging of the smaller cerebral arteries with 
 micrococci, without the occurrence of endocarditis. There 
 is another way in which the relation of the infectious 
 diseases may be regarded. We know that in certain 
 fevers, typhoid particularly, changes have been met with 
 in the smaller arteries leading to anasmic necrosis in the 
 corresponding districts. This has been worked out in 
 the heart by Landouzy and Siredey,' and if it occurs in 
 limited areas of this organ it might also take place in the 
 brain. From what we know of sclerosis in other organs, 
 notably the heart, the role played by the blood-vessels in 
 the process is all-important. Kundrat has already sug- 
 gested that porencephalus results from an anaemia of 
 definite areas corresponding to arterial distribution, but 
 without arterial lesion. It is difficult to conceive of such 
 a condition, but a widespread endarteritis, similar to, but 
 more extensive than, that which is known to induce 
 anaemic necrosis of the heart-muscle might initiate a 
 soierosis ; or, if the obstruction was suddenly effected, and 
 large vessels involved, produce a rapid necrosis, the final 
 changes of which would represent porencephalus. That 
 this latter conditio., results from vascular obstruction we 
 
 » ' Medical Record,' 1887. 
 ' ' Revue de Medecine/ 1885. 
 
94 
 
 TllK CKKKIIRAL I'ALSIES OF CHILDREN. 
 
 have evidence iu the large defects which are occasionally 
 found in brains of adults, and in the one organ there 
 may be regions of softening in all stapes of regressive 
 change. Less abrupt processes in smaller vessels may 
 account for certain of the cases of sclerosis, and the 
 changes which Martin, Salourin, and other French writers 
 have found in the smaller arteries in cirrhotic regions, 
 make it by no means improbable that the cerebral counter- 
 part has also a vascular origin. 
 
 Jendrassik and Mario^ ^ave described vascular lesions 
 in cerebral sclerosis, which they believe to be primary. 
 The change is in the perivascular region, which is greatly 
 increased in size and intersected by connective-tissue 
 growth, which is in intimate relation with the vessel wall 
 and with the neuroglia. While regarding the periarte- 
 ritis as the primary cha.ip-^ in the cerebral paralysis of 
 children, these authovs do not exclude embolic and throm- 
 botic processes in the smaller vessels. They refer also 
 to the connection of these v/ith infectious processes. 
 
 In a third way, too, on infectious disease might induce 
 hemiplegia, by causing changes in the cerebral motor 
 centre similar to those which occur in the disseminated 
 myelitis f ollo\. ing measles and scarlatina. We have not 
 had until recently much positive knowledge of the latter, 
 but such a condition as Barlow* has described in the cord 
 shows the direct influence of the specific poisons on the 
 elements of the gray matter. May not this occur in the 
 motor cells of the cortex as well as in those of the cord ? 
 But here we return to Striimpell's view. The changes in 
 the gray matter are, in most of these instances, necrotic, 
 rather than inflammatory, and the vascular lesion is the 
 primary one. In his researches in sclerosis Adam- 
 kiewicz' found the destruction of the nerve elements the 
 first step in the process, to which the proliferation of the 
 neuroglia was secondary. 
 
 ' ' Arcliiv do Physiologic,' 1883. 
 
 * ' Medico-Chirurgical Trnnsai-tiDns,' vol. \x\, l!s87. 
 
 a < 
 
 Ncurologisclies CeutrulbLitt,' 188G. 
 
PATUOLOOY AND TREATMKNT. 
 
 05 
 
 *> 
 
 e 
 
 e 
 
 e 
 
 In favor of the embolic theory it may be urged that 
 the affected areas correspond with definite territories. 
 Of porencephalus this is to a great extent true, but not 
 always of sclerosis, which may be most irregularly dis- 
 tributed. I purposely noted, when discussing the morbid 
 anatomy of sclerosis, the districts involved in the ten 
 specimens in the Museum of the Elwyn Institution. The 
 involvement of two or three regions, far apart from each 
 other, and the frequency with which the territory of the 
 posterior cerebral artery is the seat of the sclerosis, are 
 against embolism as a cause. 
 
 Gowers has suggested that !1, lesion in these cases is 
 throvibosis of the cerebral veins, a wtU-recognized condition 
 in children, which sets in wuh convulsions. Usually 
 there is also sinus thrombrsis. Certainly, there are no 
 veins in the body so favorably situated for the coagulation 
 of blood ; " they are roomy in proportion to the amount 
 of blood they carry, they are tortuous and abundantly 
 anastomosing, so that the current of blood is almost 
 reversed at some points and can easily stagnate '* (Edes).^ 
 Gowers quotes a case of Money's in which the thrombosis 
 occurred after scarlet fever. Handford' has reported 
 the case of a boy aet. 5, in whom the cerebral veins 
 were like whip-cords, and there was haemorrhage on the 
 surface cf both hemispheres. There was also sinus 
 thrombosis. The symptoms, however, were not those of 
 infantile hemiplegia. Parrot' states that this condition is 
 very common, and in plate iv of his work there is a 
 beautiful illustration of thrombosis of the surface veins 
 with haemorrhage. The advantage of this view is that 
 we are dealing with recognized lesions, of common occur- 
 rence in infancy, capable of explaining satisfactorily the 
 symptoms ; and yet the proof is lacking, the demonstra- 
 
 1 ' System of Medicine by Aiueriean Authors,' vol. v, p. 982, Pliiladelpbia, 
 1886. 
 
 ■» ' British Medical Journal,' 1887, i, p. 10'J8. 
 ' Loc. cit. 
 
9G 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 sion of its existence in one of these cases of infantile 
 hemiplegia has still to be made. 
 
 To sum up : Infantile hemiplegia is probably the result 
 of a variety of different processes, of which the most 
 important are : 
 
 (1) Haemorrhage, occurring during violent convulsions 
 or during a paroxysm of whooping-cough.^ 
 
 (2) Post-febrile processes : (a) embolic ; (6) endo- and 
 peri-arterial changes ; and (c) encephalitis. 
 
 (3) Thrombosis of the cerebral veins. 
 
 There are several problems of interest in connection 
 with the pathology of infantile spastic paraplegia. Of 
 special importance is the condition of the pyramidal 
 tracts in the cord, and the attention of future observers 
 should be directed to this point. In three cases of spastic 
 diplegia, and in the one case of spastic paraplegia, there 
 was descending degeneration. In Ross's case the cord 
 was normal. In Ashby's case was the change in the 
 pyramidal tract truly a degeneration, or was it not rather 
 arrest of development ? Most probably the latter, in con- 
 nection with a brain the cortex of which was smooth and 
 presented no trace of convolutions. In Ross's case, 
 though the cord was said to be normal, yet the anterior 
 pyramids were not more than half the normal size, and 
 the lateral columns were smaller. Alexandra Stein- 
 lechner^ has reported the case of a lad named Post, aet. 6, 
 helpless from birth. The legs were in equmo-varua 
 position, but as there was no note of the condition of the 
 arms, I did not know in which category to place the case ; 
 it was probably one of spastic diplegia. Post mortem, 
 bilateral porencephalus was found ; the lateral tracts were 
 undeveloped and did not contain more than one half the 
 normal number of nerve-fibres. Hervouef' has recorded 
 
 ' Dr. Samuel West reported a case of this kind to the Clinical Society of 
 London last year (' Medical Press and Circular,' 1887). 
 ^ ' Archiv fiir Psychitttrie,* Bd. xvii. 
 '■* ' Archives de Physiologie/ 3e serie, tome iv, 1884. 
 
PATHOLOGY AND TREATMENT. 
 
 pre 
 
 he 
 
 led 
 
 of 
 
 the case of an idiotic child, set. 3^, without spasms or 
 contractures, in which there was a condition of micro- 
 cephalus with complete absence of development of the 
 pyramidal tracts in the cord. The motor strands in the 
 cord do not attain their full development until after birth, 
 according to Hervouet not until the third or fourth year. 
 It is a question of no little interest to determine the exact 
 condition of these tracts in cases of diplegia and para- 
 plegia of children. Sharkey^ states that in cases of con- 
 genital absence of the whole or pi.rt of the motor centres 
 of the brain, which are accompanied by contracture, the 
 pyramidal tract has proved to be deficient. And yet in 
 Hervouet's cases these strands were undeveloped without 
 any spasm of the muscles. It would really appear then 
 that actual sclerosis of the lateral tracts is not an essential 
 condition of spastic rigidity though T)resent in a great 
 majority of the cases. In the adult, in the cases of 
 Schultz,^ Striimpell^ and Anna Klumpke*, the pyramidal 
 tracts have been found normal in spastic paralysis, and 
 Blocq^ in his recent monograph acknowledges that con- 
 tractures may exist without affection of these parts. The 
 problem of rigidity is by no means an easy one to solve. 
 The over-action of the spinal centres seems the most 
 reasonable view, at one time conditioned by the suppres- 
 sion of the functions of the pyramidal tra,cts, the absence 
 of inhibition, the " let go " theory of Hughlings Jackson, 
 at another possibly excited reflexly, even when the motor 
 strands in cords are intact. 
 
 We shall need in future *dtopsies on cases of spastic 
 paraplegia in children specific details as to the condition 
 of the lateral tracts, and particularly as to degeneration 
 or absence of development. The two conditions might 
 
 ' Loc. cit., p. 11. 
 
 ' * Deutsches Archiv f. klin. Med.,' Bd. xxii. 
 
 ' ' Archiv f. Psychiatrie,' Bd. x. 
 
 * ' Dictioanaire Encyclop^dique,' art. " Tabe« Spasmodique " Raymond, 
 1885. 
 
 * ' Les Contractures,' Parig, 1888. 
 
98 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 readily be confounded as can be gathered from an exami- 
 nation of the plato which illustrates Hervouet's paper. 
 
 Treatment. — In the majority of the cases the physician 
 is called at the onset to treat an attack of convulsions or 
 of coma, developing suddenly or after a few days* indis- 
 position, or following, perhaps, one of the fevers. The 
 paralysis is not apparent until the active symptoms have 
 subsided, though if the convulsions are severe and uni- 
 lateral it may be anticipated. These symptoms demand 
 the bromides with chloral, a calomel purge, cold to the 
 head, and, if necessary, leeches. The cases resemble so 
 closely the ordinary convulsions of infancy associated 
 with teething that the development of so serious a con- 
 dition as hemiplegia is a great shock to the parents, who 
 are very apt to blame the physician for having done too 
 much or too little. In such an accident following vaccina- 
 tion the doctor is fortunate indeed if he escape unjust 
 criticism. In the birth palsies, unless there are marks 
 of the forceps, the condition of the limbs of the child 
 does not attract attention, and it may be weeks or months 
 before the disability is discovered. 
 
 The traumatic cases, such as the three reported, sug- 
 gest surgical interference, two of them at any rate, as 
 they were doubtless due to haemorrhage ; but it is well to 
 remember, in these days of safe surgery, that in children 
 traumatic hemiplegia may sometimes disappear completely 
 in a few days. I reported an instance some years ago^ 
 of a child, aet. 23 months, who had fallen from a balcony, 
 and was admitted to my wards with a large haematoma of 
 the scalp, left hemiplegia and coma. The symptoms 
 gradually disappeared and the child made a complete 
 recovery. A case was narrated to me by Dr. Murray 
 Cheston of a child who was tripped by his brother and 
 fell on his head. There was no external wound and no 
 fracture. Hemiplegia developed, which in a few days 
 disappeared completely, and the boy is now quite well. 
 > ' Canada Medical and Surgical Journal,' vol. viii. 
 
PATHOLOGY AND TREATMENT. 
 
 99 
 
 )letely 
 Is ago^ 
 llcony, 
 >ma of 
 Iptotus 
 iplete 
 uurray 
 pr and 
 kod no 
 days 
 lell. 
 
 When the paralysis is established medicines are rarely 
 called for, and the indications are to favor the natural 
 tendency of the hemiplegia to improve and to lessen the 
 rigidity and contractures, and, if necessary, overcome 
 them by mechanical or surgical measures. 
 
 While it is impossible to predict, in any given case, 
 to what extent the original palsy will disappear, we can 
 usually expect a return of powor in tlie leg and face, in- 
 complete in the former, often perfect in the latter. In 
 rare instances, two only in the series of one hundred and 
 twenty cases, did the paralysis entirely disappear. The 
 residual palsy is most marked in the upper extremity, 
 and even when the arpi is tolerably useful the fingers do 
 not regain the power of delicate movements. Temporary 
 arrest of growth and some degree of atrophy follow 
 invariably, but as the child grows up we rarely see the 
 great discrepancy in size of members which is common 
 after the spinal infantile palsy. To maintain tne nutri- 
 tion of the paralyzed parts we employ warmth, massage, 
 and electricity. The temperature of the affected mem- 
 bers is usually lowered and the circulation sluggish, so 
 that the limbs should at first be wrapped in cotton-wool, 
 and when the patient begins to make efforts at walking, 
 flannel underclothing should be used. Attention to this 
 apparently minor point should be impressed upon the 
 mothers ; it is too often neglected. Massage of the 
 paralyzed muscles should be practised daily. Simple 
 directions should be given to the mother or nurse, in the 
 absence of a professional rubber. The chief point is to 
 manipulate the muscles thoroughly, and I usually order 
 the rubbing to be done with sweet oil, morning and even- 
 ing, for twenty or thirty minutes. I have strong belief in 
 the efficacy of this treatment in keeping up the nutrition 
 of the enfeebled muscles. To be of any service the 
 applications must be continued for months. 
 
 Electricity is probably of no service in the original 
 lesion, which may be left to nature, undisturbed by gal- 
 vanism, which has been recommended by some authors. 
 
100 
 
 THE CEREBRAL PALSIES OP CHILDREN. 
 
 Of positive benefit is faradization of the paralyzed mus- 
 cles, which must, however, be carried out persistently for 
 months. Next to the rubbing, it is the most important 
 agent upon which we rely to prevent atrophy and main- 
 tain the nutrition of the parts. It is not often that we 
 find hospital patients able to spare the time for the pro- 
 longed treatment needed in these cases. Fortunately, 
 the wasting is not extreme, and even without the treat- 
 ment the leg and face recover more or less completely. 
 
 A considerable number of the cases come under ob- 
 servation when there is marked rigidity and contractures. 
 For this condition in the palsied arm of hemiplegia not 
 much can be done, but in the cases of spastic diplegia 
 and paraplegia manipulations and surgical measures will 
 often enable a crippled patient to walk. Persistent mas- 
 sage with strong flexion and extension of the limbs, as 
 recommended by Dr. Weir Mitchell is of great service. 
 Case 9 of the spastic paraplegia cases could not walk 
 when brought to the Infirmary, and after about a year's 
 persistent treatment — frictions with oil and forcible flexion 
 and extension — she can now get about the house quite 
 well. Sooner or later the majority of these cases come 
 under the care of the orthopaadic surgeons who were 
 dealing with this condition — and some indeed, as Heine, 
 knew upon what it really depended — several decades 
 before physicians had recognized that it was primarily 
 an affection of the nervous system. The woodcuts and 
 plates given in the works of Heine, Little, and Adams 
 show how well they dealt with these cases, and we have 
 many illustrations at the clinics of my colleagues, Drs. 
 Morton, Hunt, and Goodman, of the good results of 
 division of tendons and of the application of proper 
 apparatus. 
 
 There are one or two special symptoms calling for 
 comment. The aphasia, as we have seen, usually disap- 
 pears, but it may be helped by systematic education, and 
 these cases do better and recover more promptly thp,n 
 aphasia in the adult. 
 
PATHOLOGY AND TREATMENT. 
 
 101 
 
 Its of 
 
 [roper 
 
 for 
 
 lisap- 
 
 , and 
 
 thftn 
 
 Epilepsy is a distressing symptom for which many of 
 the cases seek relief. It is well to recognize clearly the 
 cortical nature of the atacks, and let the parents know 
 that a cure can rarely be anticipated. It is encouraging, 
 however, to note that the seizures may lessen greatly, 
 and prolonged periods of quiescence are not uncommon. 
 The attacks of hemi-epilepsy without loss of consciousness 
 may persist for years before a general convulsion with loss 
 of consciousness occurs. In some instances the attacks 
 are repeated with extraordinary frequency, twenty or 
 more daily. In the transient attacks of petit mal the 
 bromides do good ; but, as a rule, in the true Jacksonion 
 fits, unless there is much irritability and excitement, I have 
 not found them very beneficial. 
 
 An important question of practical moment has arisen 
 in connection with the propriety of surgical interference 
 in these cases. Jacksonian epilepsy has now its surgical 
 aspects, and there have already been several successful 
 cases of removal of tumors from the motor areas of the 
 cortex. Infantile hemiplegia offers some of the most 
 typical instances of cortical epilepsy, and it may be well 
 to consider how far it is likely that surgical interference 
 can here be successful. As we have seen, in the review 
 of the morbid anatomy, the conditions to be dealt with are 
 (1) apoplectic, embolic or thrombotic foci, which are as 
 frequently in the territory of the central as of the cortical 
 arteries ; (2) sclerosis ; and (3) porencephalus. I do not 
 think that, in any of the cases which I have reviewed, the 
 anatomical condition offered the slightest possibility of 
 relief from surgical interference. I except the case of 
 glioma of the paracentral lobule to which I referred. This 
 girl had had Jacksonian epilepsy for many years and the 
 tumor could have been readily removed. In the second 
 autopsy of the Elwyn cases, in which there were blocks 
 of sclerosis, the mass causing the hemiplegia might have 
 been removed, but there were several other areas. 
 
 There have been two cases of operation in the cortical 
 epilepsy of infantile hemiplegia. Bradford, of Boston, 
 
102 
 
 THE CEREBRAL PALSIES OF CHILDREN. 
 
 operated on a case of Bullard's^. A boy, aet. 4, forceps 
 delivery, idiotic, and in a state of right spastic hemiplegia. 
 There was a scar and depression on the right parietal 
 bone, due probably to the forceps. The trephine was 
 first applied over this part, but the brain-substance 
 beneath was found normal. The left side was then 
 trephined and a porencephalous condition of the Rolandic 
 region found. The child died the next day. No autopsy 
 was allowed. The other case was operated on in the 
 Infirmary by Dr. Morton. I have referred to it when 
 speaking of the symptom of epilepsy (Case 97). Dr. 
 Mitchell, under whose care the child was, believed there 
 was a possibility that the lesion might be a localized area 
 in the motor zone, which could be removed, and in this 
 opinion Dr. Sinkler and I concurred. Accordingly Dr. 
 Morton exposed the Rolandic region and found an cedema- 
 tous condition of the membranes, but no focal disease. 
 Whether the portion removed is sclerotic has not yet been 
 determined. The child recovered perfectly from the 
 operation, the dressings were removed on the sixth day. 
 The spasm of the arm has lessened and the attacks of 
 epilepsy have reduced in frequency. 
 
 There are several circumstances which militate against 
 the probable success of operations of this kind. The 
 nature of the lesion is such that not much can be antici- 
 pated. When sclerosis exists the area is usually too large 
 for removal j when porencephalus is present, we are not, 
 as Dr. Morton Prince said in the discussion on Dr. 
 Bullard's case, " likely to improve a pure paralysis due 
 to a hole in the brain, by making the hole bigger." But 
 a more serious objection was raised in the same discussion 
 by Dr. J. J. Putnam, viz. the existence in these long- 
 standing cases of descending degeneration. The paralysis 
 in such instances could not be benefited, and it is only 
 in exceptional instances that we could expect the epi- 
 lepsy to be relieved. Time alone will determine how 
 far in the removal of centres for cortical epilepsy the im- 
 ' * BuBton Medical and Surgical Journal,' ib88, vol. i. 
 
 
PATHOLOGY AND TREATMENT. 
 
 103 
 
 ainst 
 The 
 
 atici- 
 
 arge 
 
 not, 
 
 Dr. 
 
 due 
 
 But 
 
 Ussion 
 ong- 
 
 alysis 
 only 
 epi- 
 how 
 e im- 
 
 provement is temporary or permanent, and how nuch 
 less iritating the scar of a surgical wound will be than 
 the cicat.ix of an accidental trauma. 
 
 More serious in many respects, and more distressing 
 to friends and relations, are the mental defects so apt to 
 be associated with these cerebral palsies. The subjects 
 of bilateral hemiplegia are usually imbecile, often idiotic ; 
 the spastic paraplegic cases offer greater hope of mental 
 improvement, and many of the patients are intelligent 
 and learn to read and write. They rarely suffer from 
 epilepsy, so potent a factor in inducing mental deteriora- 
 tion. A large percentage of the cases of hemiplegia 
 grow up feeble-minded, a larger percentage than indi- 
 cated in our list. Much depends, no doubt, upon the 
 area and regions of cortex involved, but even in such 
 localized lesions as that shown at Fig. 1, there may 
 bo serious mental deficiency, showing that the actual 
 damage is more than is apparent. The injury to the 
 brain is usually done at the very time when the faculties 
 are developing and the education of the senses is prepar- 
 ing the way for the higher intellectual processes. It is not 
 surprising that in so many cases the damage is irreparable 
 and that idiocy or imbecility results. A few years ago 
 these cases were neglected and thought incapable of 
 education. The results which are attained by Dr. Kerlin 
 and his staff, at the Pennsylvania Institutions for Feeble- 
 minded Children, and in other public and private establish- 
 ments, demonstrate that the lesson which Dr. Seguin, Sr., 
 and others labored so hard to teach has been well 
 learned — the lesson that with patient training and kind 
 care many of these poor victims may be rescued from a 
 condition of hopeless imbecility and reach a fair measure 
 of intelligence and self-reliance. 
 
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 Ophthalmic Surgeon to Guy's Hospital; Lecturer on Ophthalmology at Guy's Hospital 
 
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 MANUAL OP OPHTHALMIC PRACTICE. 
 
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 BERKELEY HILL, m.b. lond., f.r.c.s. 
 
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 THE ESSENTIALS OP BANDAGING. With directions 
 
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^^wpw*m 
 
 12 
 
 Catalogue of Works Published by H. K. Lmii. 
 
 I 
 
 GEORGE LINDSAY JOHNSON, m.a., m.b., b.c. cantab. 
 
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 [Lewis's Practical Series.] 
 
Catalogue of Works Published by U. K. Lads. 
 
 18 
 
 LEWIS'S PRACTICAL SERIES. 
 
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 The volumes are written by well-known Hospital Physicians and Sur- 
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 MANUAL OF OPHTHALMIC PRACTICE. 
 
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11 
 
 Catalogue of Works Published by 11. K. Leiris. 
 
 DR. GEORGE LEWIN. 
 
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 THE TREATMENT OP SYPHILIS WITH SUBCUTA- 
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Catalogue of Works Published by H. K. Lewis. 
 
 15 
 
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 ANNALS OP CHOLERA PROM THE EARLIEST 
 
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 BATH, CONTREXEVILLE, AND THE LIME SUL- 
 
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16 Catalogue of Works Published hy R. K. Lewis. 
 
 PROFESSOR MARTIN. 
 
 MARTIN'S ATLAS OP OBSTETBICS AND GYNiECO- 
 
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 PRINCIPALLY WITH REFERENCE TO DISEASES OF THE 
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Catalogue of Works Published by H. K. Lewis. 
 
 17 
 
 J. F. MEIGS, M.D. 
 
 Consulting Physician to the Children's Hospital, Philadelphia. 
 
 AND 
 
 W. PEPPER, M.D. 
 
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 GENERAL FABALYSIS OF THE INSANE. 
 
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 ON INSANITY IN RELATION TO CARDIAC AND 
 
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 KENNETH W. MILLICAN, b.a. cantab., m.r.c.s. 
 
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 THE STUDENT'S TEXTBOOK OF THE PRACTICE 
 
 OF MEDICINE. Fcap. 8vo, 6s. 6d. [yust Published. 
 
 II. 
 
 TREATMENT OF DISEASE IN CHILDREN: IN- 
 CLUDING THE OUTLINES OF DIAGNOSIS AND THE 
 CHIEF PATHOLOGICAL DIFFERENCES BETWEEN CHILD- 
 REN AND ADULTS. Crown 8vo, los. 6d. 
 
 [Lewis's Practical Seribs.] 
 
 E. A. MORSHEAD, m.r.c.s., l.r.c.p. 
 Assistant to the Professor of Medicine in University College, London, 
 
 TABLES OF THE PHYSIOLOGICAL ACTION OF 
 
 DRUGS. Fcap. 8vo, is. 
 
i ^ 
 
 18 
 
 Catalotjue of Works PublMied by II. K. Lewis. 
 
 A. STANFORD MORTON, m.b., p.r.c.s. end. 
 
 SurgtoH to the Royal South London Ophthalmic Hospital, 
 
 REFRACTION OF THE EYE : Its Diagnosis, and the 
 
 Correction of its Errors. Third Edition, with Illustrations, small 8vo. 
 38. 
 
 C. "W. MANSELL MOULLIN, m.a., m.d. oxon., f.r.c.s. eno. 
 
 Assistant Surf^ton and Senior Demonstrator of A natomy at the London Hospital ; formerly 
 Haddiffe Travelling I'tlluw and Fellow oj I'embroke College, Oxford. 
 
 SPRAINS; THEIR CONSEQUENCES AND TREAT- 
 MENT. Crown 8vo, 5s. [Now ready. 
 
 PAUL F. MUNDE, m.d. 
 
 Professor of GynecoloRy at the New York Polyclinic ; /'resident of the New York Obstetrical 
 Society and Vice-President of the British Gynecological Society, &e. 
 
 THE MANAGEMENT OF PREGNANCY, PARTURI- 
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 ABNORMAL. Square 8vo, 3s. 6d. [yust Published. 
 
 WILLIAM MURRELL, m.d., p.r.c.p. 
 
 Lecturer on Materia Medica and Therapeutics at Westminster Hospital; Examiner in 
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 I. 
 
 MASSOTHERAPEUTICS, OR MASSAGE AS A MODE 
 
 OF TREATMENT. Fourth edition, with Illustrations, crown 8vo, 
 4s. 6d. ly^it published. 
 
 II. 
 
 WHAT TO DO IN CASES OF POISONING. 
 
 Sixth edition, royal 32010. [In the press. 
 
 NITRO-GLYCERINE AS A REMEDY FOR ANGINA 
 
 PECTORIS. Crown 8vo, 3s. M. 
 
 i 
 
 DR. FELIX von NIEMEYER. 
 
 Late Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the 
 
 University of Tiibingen. 
 
 TEXT-BOOK OF PRACTICAL MEDICINE, WITH 
 
 PARTICULAR REFERENCE TO PHYSIOLOGY AND PATHO- 
 LOGICAL ANATOMY. Translated from the Eighth German Edi- 
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 M.D., and Charles £. Hackley, M.D. Revised edition, 2 vols, 
 large 8vo, 36s. 
 
Catolotjue of Works Puhlished by II. K. Lewis. 
 
 10 
 
 GEORGE OLIVER, m.d., f.r.c.p. 
 
 THE HARBOQATE WATERS : Data Chemical and Therapeu- 
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 ON BEDSIDE UBINE TESTING : a Clinical Guide to the 
 
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 and enlarged, fcap. 8vo, 3s. 6d. 
 
 SAMUEL OSBORN, f.r.c.s. 
 
 Assiitanl-Surgeon to the Hospitul/or Women ; Surgeon Royal Naval Artillery Voluiiteen 
 
 AMBULANCE LECTUBES : FIBST AID. With Illus- 
 trations, fcap. 8vo, IS. 6d. 
 
 II. 
 AMBULANCE LECTUBES : NUBSING. With Illustrations, 
 fcap. 8vo, IS. 6d. 
 
 ROBERT W. PARKER. 
 
 Surgeon to the Eoit London Hospital for Chiltiren, and to the Grosvenor Hospital /or 
 
 Women and Children, 
 
 TBACHEOTOMY IN LABTNGEAL DIPHTHEBIA, 
 
 AFTER TREATMENT AND COMPLICATIONS. Second Edition. 
 With Illustrations, Svo, 5s. 
 
 II. 
 
 CONGENITAL CLUB-FOOT; ITS NATUBE AND 
 
 TREATMENT. With special reference to the subcutaneous division 
 of Tarsal Ligaments. Svo, 7s. 6d. 
 
 JOHN S. PARRY, m.d. 
 
 Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical and Pathologi- 
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 EXTBA-UTEBINE PBEGNANCY ; Its Causes, Species, 
 
 Pathological Anatomy, Clinical History, Diagnosis, Prognosis and 
 Treatment. Svo, 8s. 
 
20 
 
 Catalot/He of Works Published bi/ II. K. Lewis, 
 
 E. RANDOLPH PEASLEE, m.d., m..d. 
 
 Late Professor of Gyii(rcolnf;y in the Medical Department of Dartmouth College ; President 
 of the New York Academy of Medicine, &rc., &c. 
 
 OVARIAN TUMOURS : Their Pathology, Diagnosis, and 
 
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 Professor of Medical Jurisprudence, University College; Assistant Physician to, and Physi- 
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 THE MOUTH AND THROAT. With an Appendix of Cases. 8vo, 
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 Physician Extraordinary to H.M. the Queen; Physician to the Middlesex Hospital and 
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 DISEASES OF THE LUNGS AND PLEURiE, INCLUD- 
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 URBAN PRITCHARD, m.d. edin., f.r.c.s. end. 
 
 Professor of Aural Surgery at King's College, London ; Aural Surgeon to King's College 
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 HANDBOOF OF DISEASES OF THE EAR FOR THE 
 
 USE OF STUDENTS AND PRACTITIONERS. With Illustra- 
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 [Lewis's Practical Series.] 
 
 CHARLES W. PURDY, m.d. (queen's univ.) 
 Professor of Genitu-Urinary and Renal Diseases in the Chicago Polyclinic, &c., &c, 
 
 BRIGHT'S DISEASE AND THE ALLIED AFFECTIONS 
 
 OF THE KIDNEYS. With Illustrations, large Svo, 8s. 6d. 
 
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 Assistant Physician to the London Hospital; Examiner in Medicine to the University of 
 
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 A PRACTICAL TREATISE ON DISEASES OP THE 
 
 KIDNEYS AND URINARY DERANGEMENTS. With Illustra- 
 tions, crown 8vo, los. 6d. 
 
 [Lewis's Practical Series.] 
 
 li 
 
Catalogue of Works Published by H. K. Lewis. 
 
 21 
 
 AMBROSE L. RANNEY, a.m., m.d. 
 
 ProfesMr of the Anatomy and Physiolo/^y of the Nervous System in the New York Post- 
 
 Graduate Medtcal School and Hospital ; Professor of Nervous and Mental Diseasis 
 
 in the Medical Department of the University of Vermont, 
 
 THE APPLIED ANATOMY OP THE NERVOUS SYS- 
 TEM. Beiiit; a Study of this portion of the Human Body from a 
 stand-point of its general interest and practical utility in Diaj^nosis, 
 designed for use as a text-book and a work of reference. Second edit., 
 238 Illustrations, large 8vo, 21s. [7"^' published. 
 
 H. A, REEVES, f.r.c.s. edin. 
 
 Senior Assistant Surgeon and Teacher of Practical Surgery at the London Hospital ; 
 Surgeon to the Royal Orthopctdic Hospital. 
 
 BODILY DEFORMITIES AND THEIR TREATMENT: 
 
 A HANDBOOK OF PRACTICAL ORTHOP/EDICS. With 
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 [Lewis's Practical Series]. 
 
 RALPH RICHARDSON, m.a., m.d. 
 
 Fellow of the College of Physicians, Edinburgh. 
 
 ON THE NATURE OP LIFE: An Introductory Chap- 
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 W. RICHARDSON, m.a., m.d., m.r.c.p. 
 
 REMARKS ON DIABETES, ESPECIALLY IN REFER- 
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 )NS 
 
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 Fellow of University College, London. 
 
 PRACTICAL ORGANIC CHEMISTRY; The Detection 
 
 and Properties of some of the more important Organic Compounds, 
 i2mo, 2s. 6d. [y«"< published. 
 
 Ies.] 
 
 E. A. RIDSDALE. 
 
 Associate of the Royal School of Mines. 
 
 COSMIC EVOLUTION ; being Speculations on the O igin 
 
 of our Environment. F'cap. 8vo, 3s. [Just pub i Jied. 
 
SYDNEY RINGER, m.d., f.r.s. 
 
 Professor of the Principles and Practice of Medicine in University College ; Physician to 
 and Professor of Clinical Medicine in, University College Hospital. 
 
 I. 
 
 A HANDBOOK OP THERAPEUTICS. Twelfth Edition, 
 
 thoroughly revised, 8vo, 15s. IJust published. 
 
 II. 
 
 ON THE TEMPERATURE OP THE BODY AS 
 
 A MEANS OF DIAGNOSIS AND PROGNOSIS IN PHTHISIS. 
 Second edition, small 8vo, 2s. 6d. 
 
 FREDERICK T. ROBERTS, m.d., b.sc, f.r.c.p. 
 
 Examiner in Medicine at the University of London; Professor of Therapeutics and of 
 Clinical Medicine in University College ; J'liysieian to University ColUi;c Hos- 
 pital ; Physician to Brompton Consumption Hospital, &c. 
 
 I. 
 
 A HANDBOOK OP THE THEORY AND PRACTICE 
 
 OF MEDICINE. Seventh edition, with Illustrations, in one volume, 
 large 8vo, 21s. [y»st published. 
 
 ♦,♦ Copies may also be had bound in two volumes cloth for is. 6d. extra. 
 
 II. 
 
 THE OPPICINAL MATERIA MEDICA. 
 
 Second edition, entirely rewritten in accordance with the latest British 
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 ■'I 
 
 R. LAWTON ROBERTS, m.d., m.r.c.s. 
 
 Honorary Life Member of, and Lecturer and Examiner to, the St. John Ambulance 
 
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 ILLUSTRATED LECTURES ON AMBULANCE WORK. 
 
 Third edition copiously Illustrated, crown 8vo, 2S. 6d. \_.<ow ready. 
 
 D. B. St. JOHN ROOSA, m.a., m.d. 
 
 Professor of Diseases of the Eye and Ear in the University of the City of New York; Surgeon 
 to the Manhattan Eye and Ear Hosj-ital. 
 
 A PRACTICAL TREATISE ON THE DISEASES OP 
 
 THE EAR, including the Anatomy of the Organ. Sixth edition, 
 Illustrated by wood engravings and chromo-lithographs, large Hvo, 25s. 
 
Catalogue of Works Publinhed by H. K. Lewis. 
 
 28 
 
 ROBSON ROOSE, m.d. 
 
 Fellow of the Royal College of Physicians in Edinburgh. 
 I. 
 
 GOUT, AND ITS RELATIONS TO DISEASES OP 
 
 THE LIVER AND KIDNEYS. Sixth Edition, crown 8vo. 
 
 {In the press. 
 II. 
 
 NERVE PROSTRATION AND OTHER FUNCTIONAL 
 
 DISORDERS OF DAILY LIFE. Crown 8vo, ids. 6d. 
 
 [jfust published. 
 
 J. BURDON SANDERSON, m.o., ll.d., f.r.s. 
 
 Jodrell Professor of Physiology in University College, London. 
 
 UNIVERSITY COLLEGE COURSE OP PRACTICAL 
 
 EXERCISES IN PHYSIOLOGY. With the co-operation of F. J. M. 
 Page, B.Sc, F.C.S. ; W. North, B.A., F.C.S., and Aug. Waller, M.D. 
 Demy 8vo, 3s. 6d. 
 
 W. H. O. SANKEY, m.d. lond., f.r.c.p. 
 Late Lecturer on Mental Diseases, University College, London, etc. 
 
 LECTURES ON MENTAL DISEASE. Second Edition, with 
 coloured plates, 8vo, i2s. 6d. 
 
 JOHN SAVORY. 
 
 Member of the Society of Apothecaries, London, 
 
 A COMPENDIUM OP DOMESTIC MEDICINE AND 
 
 COMPANION TO THE MEDICINE CHEST: Intended as a 
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 EMIL SCHNEE, m.d. 
 
 Consulting Physician at Carlsbad, 
 
 DIABETES, ITS CAUSES AND PERMANENT CURE ; 
 
 from the standpoint of experience and scientific investigation. Trans- 
 lated from the German by R. L. Takel, A.M., Ph.D. Demy 8vo, 6s. 
 
 [yust published. 
 
■'H ;-.'?i? T^-iS,V.TiJ''ir/CSi-'JI.^-Til 
 
 24 
 
 Catalogue of Works Published by H. K. Lewis. 
 
 DR. B. S. SCHULTZE. 
 
 Professor of Gynecology; Director of the Lying-in Hospital, and of the Gynecological 
 
 Clinic at Jena. 
 
 THE PATHOLOGY AND TREATMENT OP DIS- 
 PLACEMENTS OF THE UTERUS. Translated by J. J. Macan, 
 M.A., M.R.C.S. and edited by A. V. Macan, M.B., M.Ch., Master of 
 the Rotunda Lying-in Hospital, Dublin. With 120 Illustrations, medium 
 8vo, I2S. 6d. \_Now ready. 
 
 JOHN V. SHOEMAKER, a.m., m.d. 
 
 Professor of Skin Diseases in the Medico-Chirurgical College and Hospital of Philadelphia ; 
 Physician to the Philadelphia Hospital for Diseases of the Skin. 
 
 A PRACTICAL TREATISE ON DISEASES OP THE 
 
 SKIN. Coloured Plates and other Illustrations, large 8vo, 24s. 
 
 WM. JAPP SINCLAIR, m.a., m.d. 
 Honorary Physician to the Manchester Southern Hospital for iVomen and Children, and 
 
 Manchester Maternity Hospital, 
 
 ON GONORRHCEAL INPECTION IN WOMEN. 
 
 Post 8vo, 4s. [y«s< published. 
 
 A. J. C. SKENE, M.D. 
 
 Professor of G"necology in the Long Island College Hospital, Brooklyn, New York. 
 
 TREATISE ON THE DISEASES OP WOMEN, POR 
 
 THE USE OF STUDENTS AND PRACTITIONERS. Nine 
 coloured plates and 251 engravings, large 8vo, 28s. 
 
 ALDER SMITH, m.b. lond., f.r.c.s. 
 Resident Medical Officer, Christ's Hospital, London. 
 
 RINGWORM : Its Diagnosis and Treatment. 
 
 Third Edition, enlarged, with Illustrations, fcap. 8vo, 5s. 6d. 
 
 J. LEWIS SMITH, M.D. 
 
 Physician to the New York Infants' Hospital ; Clinical Lecturer on Diseases of Children 
 in Belltvue Hospital Medical College. 
 
 A TREATISE ON THE DISEASES OP INPANCY 
 
 AND CHILDHOOD. Fifth Edition, with Illustrations, large 8vo, 21s. 
 
Catalogue of Works Published by H. K. Lewis. 
 
 25 
 
 FRANCIS W. SMITH, m.b., b.s. 
 
 THE SALINE WATERS OP LEAMINGTON. Second Edit., 
 with Illustrations, crown 8vo, is. nett. 
 
 JOHN KENT SPENDER, m.d. lond. 
 
 Physician to the Royal Mineral Water Hospital, Bath. 
 
 THE EARLY SYMPTOMS AND THE EARLY TREAT- 
 MENT OF OSTEO-ARTHRITIS, commonly called Rheumatoid 
 Arthritis, with special reference to the Bath Thermal Waters. Sm. 8vo. 
 2S. 6d. [3^"^' published. 
 
 JAMES STARTIN, m.b., m.r.c.s. 
 Surgeon and Joint Lecturer to St. John's Hospital for Diseases of the Skin. 
 
 LECTURES ON THE PARASITIC DISEASES OP 
 
 THE SKIN. VEGETOID AND ANIMAL. With Illustrations, 
 crown 8vo, 2S. 6d. 
 
 W. R. H. STEWART, f.r.c.s., l.r.c.p. edin. 
 
 Aural Surgeon to the Great Northern Central Hospital; Surgeon to the London Throat 
 
 Hospital, &c. 
 
 EPITOME OP DISEASES AND INJURIES OP THE 
 
 EAR, with a Chapter on Naso- Pharyngeal Diseases causing Deafness. 
 Demy 32mo, 2s. 6d. [y«i^ published. 
 
 LEW^IS A. STIMSON, b.a., m.d. 
 
 Surgeon to the Presbyterian and Bellevue Hospitals ; Professor of Clinical Surgery in the 
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 A MANUAL OP OPERATIVE SURGERY. 
 
 Second Edition, with three hundred and forty-two Illustrations, post 
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 ADOLF STRUMPELL. 
 
 Director of the Medical Clinic in the University of Erlangen. 
 
 TEXT-BOOK OP MEDICINE FOR STUDENTS 
 
 AND PRACTITIONERS. Translated from the latest German edition 
 by Dr. H. F. Vickery and Dr. P. C. Knapp, with Editorial Notes by 
 Dr. F. C. Shattuck, Visiting Physician to the Massachusetts General 
 Hospital, etc. Complete in one large vol., imp. 8vo, with in Illustra- 
 tions, 28s. 
 
26 
 
 Catalogue of Works Published by H, K. Lewis. 
 
 JUKES DE STYRAP, m.k.q.c.p., etc. 
 
 Physician-ExtranrUinary. late I'hysuiiin in Ordinary, to the Salop Infirmary ; Consulting 
 Physician to the South Salop and Montj^omcryshire Infirmaries, etc. 
 
 THE MEDICO-CHIRURGICAL TARIFFS PREPARED 
 
 FOR THli LATE SHROPSHIRE ETHICAL BRANCH OF THE 
 BRITISH MEDICAL ASSOCIATION. Fourth Edition, fcap. 4to, 
 revised and enlarged, 2s. nctt. 
 
 C. W. SUCKLING, M.D. LOND., m.r.c.p. 
 
 Professor of Materia Medica and Therapeutics at the Queen's College, Physician to the 
 
 Queen's Hospital, Birmingham, etc. 
 
 ON THE DIAGNOSIS OP DISEASES OP THE 
 
 BRAIN, SPINAL CORD, AND NERVES. With Illustrations, 
 crown 8vo, 8s. 6d, 
 
 JOHN BLAND SUTTON, f.r.c.s. 
 
 Lecturer on Comparative Anatomy, Senior Demonstrator of Anatomy, and Assistant Surgeon 
 
 to the Middlesex Hospital; Erasmus Wilson Lecturer, Royal College of 
 
 Surgeons, England. 
 
 LIGAMENTS : THEIR NATURE AND MORPHOLOGY. 
 
 With numerous Illustrations, post 8vo, 4s. 6d. 
 
 HENRY R. SWANZY, a.m., m.b., f.r.c.s.i. 
 
 Examiner in Ophthalmic Sutgery in the Royal University c.f Ireland, and to the Conjoint 
 
 Board of the King and Queen's College of Physicians and Royal College of 
 
 Surgeons, Ireland ; Surgeon to the National Eye and Ear 
 
 Infirmary, Dublin, etc. 
 
 A HANDBOOK OF THE DISEASES OF THE EYE AND 
 
 THEIR TREATMENT. Second Edition, Illustrated with wood- 
 engravings, colour tests, etc., small Svo, los. 6d, [^ust published. 
 
 EUGENE S. TALBOT, m.d., d.d.s. 
 
 Professor of Dental Surgery in the Woman's Medical College ; Lecturer on Dental 
 Pathology and Surgery in Rush Medical College, Chicago. 
 
 IRREGULARITIES OF THE TEETH AND THEIR 
 
 TRE.\TMENT. With 152 Illustrations, royal 8vo, los. 6d. 
 
 JOHN DAVIES THOMAS, m.d. lond., f.r.c.s. eng. 
 
 Physician to the Adelaide Hospital, S. Australia, 
 I. 
 
 HYDATID DISEASE, WITH SPECIAL REFERENCE 
 
 TO ITS PREVALENCE IN AUSTRALIA. Demy Svo, los. 6d. 
 
 II. 
 HYDATID DISEASE OP THE LUNGS. Demy Svo, 2s. 
 
Catalogue of Works Published by H. K. Lewis. 
 
 27 
 
 HUGH OWEN THOMAS, m.rx.s. 
 
 DISEASES OF THE HIP, KNEE, AND ANKLE 
 
 JOINTS, with their Deformities, treated by a new and efficient method. 
 Third Edition, 8vo, 25s. 
 
 11. 
 
 CONTBIBUTIONS TO SURGERY AND MEDICINE :- 
 
 Part i. — Intestinal Obstruction ; with an Appendix on the Action of 
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 , 2. — The Principles of the Treatment of Joint Disease, Infl-^mma- 
 tion, Anchylosis, Reduction of Joint Deformity, Bone Set- 
 ting. 5s. 
 „ 3. — Fractures, Dislocations, Diseases and Deformities of the 
 
 Bones of the Trunk and Upper Extremities. los. 
 „ 4. — The Collegian of 1666 and the Collegians of 1885; or what is 
 
 recognised treatment ? Second Edition, is. 
 „ 5. — On Fractures of the Lower Jaw. is. 
 
 „ 6. — The Principles of the Treatment of Fractures and Disloca- 
 tions. lOS. 
 „ 8. — The Inhibition of Nerves by Drugs. Proof that Inhibitory 
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 (Parts 7, 9 and 10 are in preparation). 
 
 [R 
 
 J. ASHBURTON THOMPSON, m.b-c.s. 
 
 Late Surgeon at King's Cross to the Great Northern Railaay Company. 
 
 FREE PHOSPHORUS IN MEDICINE WITH SPE- 
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 to Materia Medica and Therapeutics. An account of the History, Phar- 
 maceutical Preparations, Dose, Internal Administration, and Therapeu- 
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 referring to nearly 200 works upon it. Demy 8vo, 78. 6d- 
 
 lE 
 
 J. C. THOROWGOOD, m.d. 
 
 Asiistant Physician to the City of London Hospital for Diseases of the Chest. 
 
 THE CLIMATIC TREATMENT OP CONSUMPTION 
 
 AND CHRONIC LUNG DISEASES. Third Edition, post Svo, 38 6d. 
 
28 
 
 Catalogue of Works Published by H. K. Lewis. 
 
 FREDERICK TREVES, f.r.c.s. 
 
 Hunterian Professor at the Royal CoUei^e of Suri^eons of Enf;land ; Surgeon to and Lecturer 
 on Anatomy at the London Hospital. 
 
 THE ANATOMY OP THE INTESTINAL CANAL AND 
 
 PERITONEUM IN MAN. Hunterian Lectures, 1885. 4to, 2S. 6d. 
 
 D. HACK TUKE, m.d., ll.d. 
 
 Fellow of the Royal College of Physicians, London. 
 
 THE INSANE IN THE UNITED STATES AND 
 
 CANADA. Demy 8vo, 7s. 6d. 
 
 LAURENCE TURNBULL, m.d., ph.g. 
 
 A tiral Surgeon to Jefferson Medical College Hospital, &c., Src. 
 
 ARTIFICIAL ANESTHESIA : A Manual of Anaesthetic 
 
 Agents, and their Employment in the Treatment of Disease. Second 
 Edition, with Illustrations, crown Svo, 6s. 
 
 DR. R. ULTZMANN. 
 
 ON STERILITY AND IMPOTENCE IN MAN. Translated 
 from the German with notes and additions by Arthur Cooper, L.R.C.P., 
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 trations, fcap. 8vo, 2S. bd. 
 
 "W. H. VAN BUREN, m.d., ll.d. 
 
 Professor of Surgery in the Bellevue Hospital Medical College. 
 
 DISEASES OP THE RECTUM : And the Surgery of 
 
 the Lower Bowel. Second Edition, with Illustrations, Svo, 14s. 
 
 RUDOLPH VIRCHOW, m.d. 
 
 Professor m» the University, and Member of the Academy of Sciences of Berlin, &c., &c. 
 
 INFECTION - DISEASES IN THE ARMY, Chiefly 
 
 Wound Fever, Typhoid, Dysentery, and Diphtheria. Translated from 
 the German by John James, M.B., F.R.C.S. Fcap. Svo, is. 6d. 
 
Cataluyue uf Works Published by II. K. Lewis, 
 
 29 
 
 ALFRED VOGEL, m.d. 
 
 Pro/eisor of Clinical Medicine in the University of Dorpat, Russia. 
 
 A PRACTICAL TREATISE ON THE DISEASES OP 
 
 CHILDREN. Third Edition, translated and edited by H. Raphael, 
 M.D., from the Eighth German Edition, illustrated by six lithographic 
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 A. DUNBAR WALKER, m.d., cm. 
 
 THE PARENT'S MEDICAL NOTE BOOK. Oblong post 8vo. 
 cloth, IS. 6d. 
 
 JOHN RICHARD WARDELL, m.d. edin., f.r.c.p. lond. 
 
 Late Consulting Physician to the General Hospital Tunbridge Wells. 
 
 CONTRIBUTIONS TO PATHOLOGY AND THE PRAC- 
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 "W. SPENCER WATSON, f.r.c.s. eng., b.m. lond. 
 
 Surgeon to the Great Northern Hospital ; Surgeon to the Royal South London Ophthalmte 
 
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 DISEASES OF THE NOSE AND ITS ACCESSORY 
 
 CAVITIES. Profusely Illustrated. Demy 8vo, i8s. 
 
 II. 
 
 i^YEBALL-TENSION : Its Effects on the Sight and its 
 
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 III. 
 
 ON ABSCESS AND TUMOURS OP THE ORBIT. Post 
 
 8vo, 2S. 6d. 
 
 FRANCIS H. W^ELCH, f.r.c.s. 
 
 Surgeon Major, A.M.D. 
 
 ENTERIC PEVER : as Illustrated by Army Data at Hon:e 
 
 and Abroad, its Prevalence and Modifications, i^tiology, Pathology ard 
 Treatment. 8vo, 5s. 6d. 
 
80 
 
 Catalogue of Works Published by H. K. Leins. 
 
 W. WYNN WESTCOTT, m.b. 
 
 Deputy Coroner for Central AlidUlesex. 
 
 SUICIDE; its History, Literature, Jurisprudence, and 
 
 Prevention. Crown 8vo, 6s. 
 
 E. G. WHITTLE, m.d. lond., f.r.c.s. eno. 
 
 Senior Surgeon to the Royal Alexandra Hospital for Sick Children, Brighton. 
 
 CONGESTIVE NEURASTHENIA, OB INSOMNIA AND 
 
 NERVE DEPRESSION. Crown 8vo, 3s. 6d. 
 
 [yust published. 
 
 JOHN ^^'^ILLIAMS, M.D., F.R.c.p. 
 
 Professor of Midwifery in University College, London ; Obstetric Physician to University 
 College Hospital ; Physician Accoucheur to H.R.H. Princess Beatrice, etc. 
 
 CANC33B OP TH'M UTEBUS : Being the Harveian Lec- 
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 E. T. WILSON, B.M. OXON., F.R.c.p. LOND. 
 Physician to the Cheltenham General Hospital and Dispensary. 
 
 DISINFECTANTS AND 
 
 Packets of one doz. price is. 
 
 HOW TO USE THEM. In 
 
 DR. F. W^INCKEL. 
 
 Formerly Professor and Director of the Gynecological Clinic at the University of Rostock. 
 
 THE PATHOLOGY AND TBEATMENT OP CHILD- 
 BED : A Treatise for Physicians and Students. Translated from the 
 Second German edition, with many additional notes by the Author, 
 by J. R. Chadwick, M.D. Svo, 14s. 
 
 BERTRAM C. A. WINDLE, m.a., m.d. dubl. 
 
 Professor of Anatomy in the Queen's College, Birmingham. 
 
 A HANDBOOK OP SUBPACE ANATOMY AND LAND- 
 MARKS. Post 8vo, illustrations, 3s. 6d. 
 
Catalogue of Works Puhlished by H. K. Letvh. 
 
 81 
 
 EDWARD WOAKES, m.d. lond. 
 
 Senior Aural Surgeon and Lecturer on Aural Surgery at the London Hospital ; Surgeon 
 
 to the London Throat Hospital. 
 
 ON DEAFNESS, GIDDINESS AND NOISES IN THE 
 
 HEAD. 
 
 Vol. I.— POST-NASAL catarrh, AND DISEASES OF THE NOSE 
 CAUSING DEAFNESS. With Illustrations, cr. 8vo, 6s. 6d. 
 
 Vol. II.— on DEAFNESS, GIDDINESS AND NOISES IN THE 
 HEAD. Third Edition, with Illustrations, cr. 8vo. [In preparation. 
 
 II. 
 
 NASAL POLYPUS: WITH NEURALGIA, HAY-PEVER, 
 
 AND ASTHMA. IN RELATION TO ETHMOIDITIS. With 
 Illustrations, cr. 8vo, 4s. 6d. 
 
 DAVID YOUNG, m.c, m.b., m.d. 
 
 Licentiate of the Royal College of Physicians, Edinburgh ; Licentiate of the Royal College 
 
 of Surgeons, Edinburgh, etc. 
 
 ROME IN WINTER AND THE TUSCAN HILLS IN 
 
 SLIMMER. A Contribution to the Climate of Italy. Small 
 8vo, 6s. 
 
 HERMANN VON ZEISSL, m.d. 
 
 Late Professor at the Imperial Royal University of Vienna, 
 
 OUTLINES OP THE PATHOLOGY AND TREAT- 
 
 MENT OF SYPHILIS AND ALLIED VENEREAL DISEASES. 
 Second Edition, revised by M. von Zeissl, .M.D., Privat-Docent for 
 Diseases of the Skin and Syphilis at the Imperial Royal University of 
 Vienna. Translated, with Notes, by H. Raphael, M.D.. Attending 
 Physician for Diseases of Genito-Urinary Organs an ' Syphilis, Bellevue 
 Hospital, Out-Patient Department. Large 8vo, i8s. ij list published. 
 
 Clinical Charts For Temperature Observations, etc. 
 
 Arranged by W. Rigden, M.R.C.S. 50s. per 1000, 28s. per 500, 
 15s. per 250, 7s. per 100, or is. per dozen. 
 
 Each Chart is arranged for four weeks, and is ruled at the back for making notes of 
 cases ; they are convenient in size, and are suitable both for hospital and private practice. 
 
82 
 
 Catalogue of Works Published by 11. K. Leivis. 
 
 THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. 
 
 President :—W. T. Gairdner, M.D., LL.D. 
 
 Honorary Secretary : — Jonathan Hutchinson, Esq., F.R.S. 
 
 Treasurer: — W. Sedgwick Saunders, M.D., F.S.A. 
 
 Annual Subscription, One Guinea. 
 
 The Society issues translations of recent standard works by continental authors on sub- 
 jects of general interest to the profession. 
 
 Amongst works recently issued are " Spiegelb;rg's Midwifery," " Hirsch's Historical and 
 Geographical Pathology,' "Essays on Micro- Farasites," works by Charcot, Duchenne, 
 Begbie, Billroth, Graves, Koch, Hebra, Guttmann, etc. 
 
 The Society also has in hand an Atlas of Pathology with Coloured Plates, and a valu- 
 able and exhaustive " Lexicon of Medicine and the Allied Sciences." 
 
 The Annual Report, with full list of works published, and all further information will be 
 sent on application. 
 
 PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. 
 
 THE BRITISH JOURNAL OF DERMATOLOGY. Edited by Malcolm Morris and 
 H. G. Brooke. Published monthly, is. Annual Subscription, 12s. post free. 
 
 THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medicine. Annual 
 Subscription, One Guinea, post free. 
 
 THE THERAPEUTIC GAZETTE. A Monthly Journal, devoted to the Science ' 
 Pharmacology, and to the introduction of New Therapeutic Agents. Edited by Drr 
 C.Wood and R. M. Smith. Annual Subscription, los., post free. 
 
 THE GLASGOW MEDICAL JOURNAL. Published Monthly. Annual Subscription, 
 208., post free. Single numbers, is. each. 
 
 LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Proceedings of 
 the Liverpool Medical Institution. Published twice yearly, 3s. 6d. each number. 
 
 THE INDIAN MEDICAL JOURNAL. A Journal of Medical and Sanitary Science 
 specially devoted to the Interests of the Medical Services. Annual Subscription, 24B 
 post free. 
 
 TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA 
 
 Volumes I. to VI., 8vo, los. 6d. each. 
 
 MIDDLESEX HOSPITAL, REPORTS OF THE MEDICAL, SURGICAL, AND 
 Pathological Registrars for 1883 to 1886. Demy 8vo, 2s. 6d. netl each volume. 
 
 %♦ Mr. Lewis is in constant communication with the leading publishing 
 firms in America, and has transactions with them for the sale of his pub- 
 lications in that country. Advantageous arrangements are made in the 
 interests of Authors for the publishing of their works in the United States. 
 
 Mr. Lewis's publications can be procured of all Booksellers in any part of 
 the world. 
 
 London: Printed by H. K. Lewis, 136 Gower Street, W.C. 
 
Annual 
 
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