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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**»■;. 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.— RicharALS1K8 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
    " ' 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 '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 liapnic ScieD.res Corpomtion 23 WEST MAIN STREET WEBSTER, N.Y. MS80 (716) 872-4503 \ % ■^ <> ^>^ V L<$> lU I. f "'^ i ^ Oi 6 AF Q o a o (St do 60 o .a en t-H iP t', L^. VI" "d n I 'J ii dU do o u P4 |0 8 a I Cm / y 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»-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. 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THE CAUSATION OF DISEASE: An exposition of the ulti mate factors which induce it. Demy 8vo, 12s. 6d. ALFRED H. CARTEF?. m.d. lond. Member of the Royal College 0/ Physicians; Physidmi to the Qi4eeii's Hospital, Birmingham; late Examiner in Medicine for the i'niierstty of Aberdeen, &c. ELEMENTS OF PRACTICAL MEDICINE. Fifth Edition, crown 8vo, gs. L^'"' published. P. GAZEAUX. Adjunct Professor in the Faculty of Medicint 0/ Paris, &e. ANL> S. TARNIER. Professor of Obstetrics and Diseases of Women and Children in the Faculty of Medicine of Paris. OBSTETRICS : THE THEORY AND PRACTICE ; in- cludinpj the Diseases of Pregnancy and Parturition, Obstetrical Opera- tions, &c. Seventh Edition, edited and re\'ised by Robert J. Hess, M.D., with twelve full-page plates, five being coloured, and 165 wood- engravings, 1081 pages, roy. Svo, 35s. FRANCIS HENRY CHAMPNEYS, m.a., m.d. oxon., f.r.c.p. Obstetric Physician and Lecturer on Obstetric Medicine at St. George's Hospital: Examiner in Obstetric Medicine in the Uni erzity of London, ««»««.., 10 Catalogue of Works Published by H. K. Lewis. WILLIAM A. HAMMOND, m.d. Professor of Mental and Nervous Diseases in the Medical Department of the University of the City of New York, &c, I. A TREATISE ON THE DISEASES OP THE NERVOUS SYSTEM, Seventh edition, with 112 Illustrations, large 8vo, 25s. II. A TREATISE ON INSANITY. Large 8vo, 25s. III. SPIRITUALISM AND ALLIED CAUSES AND CON- DITIONS OF NERVOUS DERANGEMENT. With Illustrations, post 8vo, 8s. 6d. ALEXANDER HARVEY, m.a., m.d. Emeritus Professor of Materia Medica in the University of Aberdeen; Consulting Physician to the Aberdeen Royal Infirmary, &c. I. FIRST LINES OP THERAPEUTICS; as based on the Modes and the Processes of Healing, as occurring Spontaneously in Disease ; and on the Modes and the Processes of Dying, as resulting Naturally from Disease. In a series of Lectures. Post 8vo, 5s. II. ON THE PCETUS IN UTERO AS INOCULATING THE MATERNAL WITH THE PECULIARITIES OF THE PATER- NAL ORGANISM. In a series of Essays now first collected. Fcap. 8vo, 4s. 6d. ALEXANDER HARVEY, m.d. Emeritus Professor of Materia Medica in the University of Aberdeen, &c. AND ALEXANDER DYCE DAVIDSON, m.d., f.r.s. edin. Late Regius Professor of Materia Medica in the University of Aberdeen. SYLLABUS OP Mi.TERIA MEDICA POR THE USE OF STUDENTS, TEACHERS AND PRACTITIONERS. Based on the relative va'.ies of articles and preparations in the British Pharmacopoeia. Eighth edition, 32mo, is. 6d. K. M. HEANLEY. Matron of Boston Cottage Hospital. A MANUAL OP URINE TESTING. CompUed for the use of Matrons, Nurses, and Probationers. Post 8vo, is. 6d. GRAILY HEWITT, m.d. Professor of Midwifery and Diseases of Women in University College, Obstetrical Physician to University College Hospital, &c. OUTLINES OP PICTORIAL EASES OF WOMEN. Folio, 6s. DIAGNOSIS OF DIS- C. HIGGENS, F.R.c.s. Ophthalmic Surgeon to Guy's Hospital; Lecturer on Ophthalmology at Guy's Hospital Medical School. MANUAL OP OPHTHALMIC PRACTICE. Crown 8vo, illustrations, 6s. [Now ready. [Lewis's Practical Series.] the BERKELEY HILL, m.b. lond., f.r.c.s. Professor of Clinical Surgery tn University College ; Surgeon to University College Hospital and to the Lock Hospital. THE ESSENTIALS OP BANDAGING. With directions for Managing Fractures and Dislocations ; for administering Ether and Chloroform; and for using other Surgical Apparatus; with a Chapter on Surgical Landmarks. Sixth Edition, revised and enlarged, Illustrated by 144 Wood Engravings, crown 8vo, 5s. BERKELEY HILL, m.b. lond., f.r.c.s. Professor of Clinical Surgery in University College ; Surgeon to University College Hospital and to the Lock Hospital. AND ARTHUR COOPER, l.r.c.p., m.r.c.s. Surgeon to the Westminster General Dispensary. I. SYPHILIS AND LOCAL CONTAGIOUS DISOBDEBS. Second edition, entirely re-written, royal 8vo, i8s. II. THE STUDENT'S MANUAL OP VENEREAL DIS- EASES. Being a Concise Description of those Affections and of their Treatment. Fourth edition, post 8vo, 2s. 6d. C. R. ILLINGWORTH, m.d. ed., m.r.c.s. THE ABORTIVE TREATMENT OP SPECIFIC FE- BRILE DISORDERS BY THE BINIODIDE OF MERCURY. Crown 8vo, 3s. 6d. SIR W. JENNER, Bart., m.d. Physician in Ordinary to H.M. the Queen, and to H.R.H. the Prince of Wales. THE PRACTICAL MEDICINE OP TO-DAY: Two Addresses delivered before the British Medical Association, and the Epidemiological Society, (1869). Small 8vo, is. 6d. C. M. JESSOP, m.r.c.p. A ssociate of King's College, London ; Brigade Surgeon H.M. British Forces. ASIATIC CHOLERA, being a Report on an Outbreak of Epidemic Cholera in 1876 at a Camp near Murree in India. With map, demy 8vo, 2s. 6d. ^^wpw*m 12 Catalogue of Works Published by H. K. Lmii. I GEORGE LINDSAY JOHNSON, m.a., m.b., b.c. cantab. Clinical Assistant, late House Surgeon and Chloro/ormist, Royal Westminster Ophthalmic Hospital, &c. A NEW METHOD OP TREATING CHRONIC GLAU- COMA, based on Recent Researches into its Pathology. With Illus- trations and coloured frontispiece, demy 8vo, 33. 6d. NORMAN KERR, m.d., f.l.s. President of the Society for the Study of Inebriety ; Consulting Physician, Dalrymple Home for Inebriates, etc. INEBRIETY: its Etiology, Pathology, Treatment, and Jurisprudence. Second edition, Crown 8vo, 12s. 6d. [Jf^^t ready. RUSTOMJEE NASERWANJEE KHORY, m.d. brux. Member of the Royal College of Physicians. THE PRINCIPLES AND PRACTICE OP MEDICINE Second edition, revised and much enlarged, 2 vols., large 8vo, 28s. NORMAN W. KINGSLEY, m.d.s., d.d.s. President of the Board of Censors of the State of New York; Member of the American A cademy of Dental Science, &c. A TREATISE ON ORAL DEPORMITIES AS A BRANCH OF MECHANICAL SURGERY. With over 350 Illus- trations, 8vo, i6s. J. "WICKHAM LEGG, f.r.c.p. Assistant Physician to Saint Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the Medical School, I. ON THE BILE, JAUNDICE, AND BILIOUS DISEASE With Illustrations in chromo-lithography, 719 pages, roy. 8vo, 25s. II. A GUIDE TO THE EXAMINATION OP THE URINE : intended chiefly for Clinical Clerks and Students. Sixth Edition, revised and enlarged, w^ith Illustrations, fcap. 8vo, 2S. 6d. III. A TREATISE ON HAEMOPHILIA, SOMETIMES CALLED THE HEREDITARY H^EMORRHAGIC DIATHESIS. Fcap. 4to, 7s. 6d. ARTHUR H. N. LEWERS, m.d. lond., m.r.c.p. lond. Assistant Obstetric Physician to the London Hospital; Examiner in Midwifery and Diseases of Women to the Society of Apothecaries of London, &c. A PRACTICAL TEXTBOOK OP THE DISEASES OP WOMEN. With Illustrations, crown Svo, 8s. 6d. [Now ready. [Lewis's Practical Series.] Catalogue of Works Published by U. K. Lads. 18 LEWIS'S PRACTICAL SERIES. Under this title Mr. Lewis is publishing a Series of Monographs, em- bracing the various branches of Medicine and Surgery. The volumes are written by well-known Hospital Physicians and Sur- geons, recognized as authorities in the subjects of which they tttat. The works are intended to be of a thoroughly practical nature, calculated to meet the requirements of the practitioner and student, and to present the most recent information in a compact and readable form. tES )IS. MANUAL OF OPHTHALMIC PRACTICE. By C. HIGGENS, F.R.C.S., Ophthalmic SurReon to Guy'* Hiwphal ; Lecturer on Ophthalmology at Guy's Hospital Medical School. With llltutralioiiii, crown 8vo, 6s, [Now ready. A PRACTICAL TExTbOOK OF THE DISEASES OF WOMEN. By ARTHUR H. N. LEVVERS, M.D. Lond., M.R.C.P. Loni., Assistant Ob- stetric Physician to the London Hospital ; Examiner in Midwifery and Diseases of Women to the Society of Apothecaries of London, etc. With Illustrations, crown 8vo, 8s. 6d, iKtady. AN/ESTHETICS THEIR USES AND ADMINISTRATION. By DUDLEY W. BUXTON, M,D., B S., M.R.C.P.. Administrator of Anxsthelics in University College Hospital and the Hospital for Women, Soho Square. Crown 8vo, 4s. [Ready. rftEATMENT OF DISEASE IN CHILDREN: INCLUDING THE OUT- LINES OF DIAGNOSIS AND THE CHIEF PATHOLOGICAL DIFFER- ENCES BETWEEN CHILDREN AND ADULTS. By ANGEL MONEY, M.D., M.R.C.P., Assistant Physician to the HoBpital for ChiUreo, Great Orraond Street, and to University College Hospital. Crown 8vo, JOs. 6d. ON FEVERS: THEIR HISTORY, ETIOLOGY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. By ALEXANDER COLLIE. M.D. Aberd., Member of the Royal College of Physicians of London ; Medical Superintendent of the Eastern Hospitals; Secretary of the Epidemiological Society for Germany and Russia. Illustrated with Coloured Plates, crown 8vo, bs. 6d. HANDBOOK OF DISEASES OF THE EAR FOR THE USE OF STUDENTS AND PRACTITIONERS. By URBAN PRITCHARD. M.D. Eiin., F.R.C.S. Eng., Professor of Aural Surgery at King's College, London ; Aural Surgeon to King's College Hospital ; Senior Surgeon to the Royal Eai Hospital. With Illustrations, crown 8vo, 4s. 6d. A PRACTICAL TREATISE ON DISEASES OF THE KIDNEYS AND URINARY DERANGEMENTS. By CHARLES HENKV KALFE, M.A.. M.D. Cantab., Fellow of the Royal College of Physicians. Lnnion; Assistant Physician to the London Hospital ; Examiner in Nledicine to tbe University of Durham, etc., etc. With Illustrations, crown 8vo, los. 6d. DENTAL SURGERY FOR GENERAL PRACTITIONERS AND STUDENTS OF MEDICINE. By ASHLEY W. BARRETT, MB. Lond.. M.R.C.S., L.S.D., Dental Surgeon to, and Lecturer on Dental Surgery and Patiiokigy in the Medical School of, the London Hospital. With Illustrations, cr. bvo, jt. BODILY DEFORMITIES AND THEIR TREATMENT: A HANDBOOK OF PRACTICAL ORTHOP/EDICS. By H. A. REEVES, F.R.C.S. Edin., Senior Assistant Surgeor. and Teacher of Practical Surgerv at the London Hospital; Surgeon to the Koyal Orthopsdic Hospital, &c. With nameroos Illustrations, cr. 8vo, 8s. ed. Further volumes will be announced in due counc 11 Catalogue of Works Published by 11. K. Leiris. DR. GEORGE LEWIN. Pro/esior at the Ft. Wilh. University, and Surgeon-in-Chief of the Syphilitxc Wardi and Skin Disease Wards of the Chariti Hospital, lierlin, THE TREATMENT OP SYPHILIS WITH SUBCUTA- NEOUS SUBLIMATE INJECTIONS. Translated by Dr. Carl Prcegle, and Dr. E. H. Gale, late Surgeon United States Army. Small 8vo, 7s. LEWIS'S POCKET CASE BOOK FOB PRACTITIONERS AND STUDENTS. Designed by A. T. BRAND, M.D. Roan, with pencil, 3s. 6d. nett. LEWIS'S POCKET MEDICAL VOCABULARY- Over 200 pp., 32mo, roan, 3s. 6d. T. R. LEWIS, M.B., F.R.S. ELECT, ETC. Late Fellow of the Calcutta University, Surgeon-Major Army Medical Staff, &c, PHYSIOLOGICAL AND PATHOLOGICAL RESEAR- CHES. Arranged and edited by Sir Wm. Aitken, M.D., F.R.S., G. E. DoBSON, M.B., F.R.S. , and A. E. Brown, B.Sc. Crown 410, portrait, 5 maps, 43 plates including 15 chromo-lithographs, and 67 wood engravings, 30s. nett. [ytist Published. J. S. LOMBARD, m.d. Formerly Assistant Professor of Physiology in Harvard College. EXPERIMENTAL RESEARCHES ON THE REGIONAL TEMPERATURE OF THE HEAD, under Conditions of Rest, In- tellectual Activity and Emotion. With Illustrations, 8vo, 8s. II. ON THE NORMAL TEMPERATURE OF THE HEAD. 8vo, 58. WILLIAM THOMPSON LUSK, a.m., m.d. Professor of Obstetrics and Diseases of Women in theBellevue Hospital Medical College, &c. THE SCIENCE AND ART OF MIDWIFERY. Third Edition, with numerous Illustrations, 8vo, i8s. Catalogue of Works Published by H. K. Lewis. 15 RAWDON MACNAMARA. Professor of Materia Medica, Koval College of Stirgeoim, Ireland; Senior Surgeon to the Westmoreland (Lock) Government Hospital; Surgeon to the Meath Hospital, etc. AN INTRODUCTION TO THE STUDY OF THE BRITISH PHARMACOPCEIA. Demy 321110, is. 6d. [Just pubVnhal. JOHN MACPHERSON, m.d. Inspector-General of Hospitals H.M. Bengal A rmy (Retired). A uthor of " Cholera tn its Home," &c. ANNALS OP CHOLERA PROM THE EARLIEST PERIODS TO THE YEAR 1817. With a map. Demy 8vo, 7s. 6d. II. BATH, CONTREXEVILLE, AND THE LIME SUL- PHATED WATERS. Crown 8vo, 2s. 6d. DR. V. MAGNAN. Physician to St. Ann Asylum, Paris; Laureate of the Institute, ON ALCOHOLISM, the Various Porms of Alcoholic Delirium and their Treatment. Translated by W. S. Greenfield, M.D., M.R.C.P. 8vo, 7s. 6d. A. COWLEY MALLEY, b.a., m.b., b.ch. t.c.d. PHOTO-MICROGRAPHY; including a description of the Wet Collodion and Gelatino- Bromide Processes, together with the best methods of Mounting and Preparing Microscopic Objects for Photo- Micrography. Second Edition, with Photographs and Illustrations, crown 8vo, 7s. 6d. PATRICK MANSON, m.d., cm. A moy, China. THE PILARIA SANGUINIS HOMINIS ; AND CER- TAIN NEW FORMS OF PARASITIC DISEASE IN INDIA, CHINA, AND WARM COUNTRIES. Illustrated with Plates and Charts. Svo, los. 6d. 16 Catalogue of Works Published hy R. K. Lewis. PROFESSOR MARTIN. MARTIN'S ATLAS OP OBSTETBICS AND GYNiECO- LOGY. Edited by A. Martin, Docent in the University of Berlin. Translated and edited with additions by Fancourt Barnes, M.D., M.R.C P., Physician to the Chelsea Hospital for Women ; Obstetric Physician to the Great Northern Hospital ; and to the Royal Maternity Charity of London, &c. Medium 4to, Morocco half bound, 3 IS. 6d. nett. WILLIAM MARTINDALE, f.c.s. e Pharmaceutical Society, and late Teacher of Ph strator of Materia Medica at University Cotltgt. L ate Examiner of the Pharmaceutical Society, and late Teacher of Pharmacy and Demon ■ ■ Ollft W. WYNN "WESTCOTT, m.b. lond. D'puty Coroner for Central Middlesex. THE EXTRA FHARMACOFCEIA with the additions in- troduced into the British Pharmacopoeia, 1885, v,x\\ Medical References, and a Therapeutic Index of Diseases and Symptoms. Fifth Edition, revised with numerous additions, limp roan, med. 24mo, 7s. 6d. WILLIAM MARTINDALE, f.c.s. Late Examiner of the Pharmaceutical Society, Src. COCA, COCAINE, AND ITS SALTS: their History, Medical and Economic Uses, and Medicinal Preparations. Fcap. 8vo, 2S. MATERIA MEDICA LABELS. Adapted for Public and Private Collections. Compiled from the British Pharmacopoeia of 1885. The Labels are arranged in Two Divisions: — Division X. — Comprises, with few exceptions. Substances of Organ- ized Structure, obtained from the Vegetable and Animal King- doms. Division IZ. — Comprises Chemical Materia Medica, including Alco- hols, Alkaloids, Sugars, and Neutral Bodies. On plain paper, los. 6d. nett. On gummed paper, 12s. 6d. nett. *;f* Specimens of the Labels, of which there are over 430, will be sent on application. S. E. MAUNSELL, l.r.c.s.i. Surgeon-Major, Medical Staff. NOTES OP MEDICAL EXPERIENCES IN INDIA PRINCIPALLY WITH REFERENCE TO DISEASES OF THE EYE. With Map, post Svo, 3s. 6d. 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. Lecturer on Clinical Medicine in the University of Pennsylvania. A FBACTICAL TBEATISE ON THE DISEASES OF CHILDREN. Seventh Edition, revised and enlarged, roy. 8vo, 28s. Wm. JULIUS MICKLE, m.d., f.r.c.p. lond. Medical Superintendent, Grove Hall Asylum, London, &c. GENERAL FABALYSIS OF THE INSANE. Second Edition, enlarged and rewritten, 8vo, 14s. II. ON INSANITY IN RELATION TO CARDIAC AND AORTIC DISEASE AND PHTHISIS. Crown 8vo, 3s. 6d. KENNETH W. MILLICAN, b.a. cantab., m.r.c.s. THE EVOLUTION OF MORBID GERMS : A Contribu- tion to Transcendental Pathology. Cr. 8vo, 3s. 6d. ANGEL MONEY, m.d., m.r.c.p. Assistant Physician to University College Hospital, and to the Hospital for Children, Great Orinond Street, &c. 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- TION, AND THE PUERPERAL STATE, NORMAL AND 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 Materia Medica to the Royal College of Physicians of London, etc. 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- tion by special permission of the Author, by George H. Humphrey, 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- tical, with notes on the Climate of Harrogate. Addressed to the Medical Profession. Crown 8vo, with Map ui the Wells, 38. 6d. ON BEDSIDE UBINE TESTING : a Clinical Guide to the Observation of Urine in the course of Work. Third Edition, revised 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- cal Societies of Philadelphia, &c. 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 Treatment, especially by Ovariotomy. Illustrations, roy. 8vo, i6s. G. V. POORE, M.D., F.R.C.P. Professor of Medical Jurisprudence, University College; Assistant Physician to, and Physi- cian t»i charge of the Throat Department of, University College Hospital. LECTURES ON THE PHYSICAL EXAMINATION OP THE MOUTH AND THROAT. With an Appendix of Cases. 8vo, 38. 6d. R. DOUGLAS POWELL, m.d., f.r.c.p., m.r.c.s. Physician Extraordinary to H.M. the Queen; Physician to the Middlesex Hospital and Physician to the Hospital for Consumption and Diseases of the Chest at Brotnpton. DISEASES OF THE LUNGS AND PLEURiE, INCLUD- ING CONSUMPTION. Third edition, entirely rewritten and en- larged. With coloured plates and wood engravings, 8vo, i6s. 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 Hospital ; Senior Surgeon to the Royal Ear Hospital. HANDBOOF OF DISEASES OF THE EAR FOR THE USE OF STUDENTS AND PRACTITIONERS. With Illustra- tions, crown Svo, 4s. 6d. [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. CHARLES HENRY RALFE, m.a., m.d. cantab., f.r.c.p. lond. Assistant Physician to the London Hospital; Examiner in Medicine to the University of Durham, etc., etc. 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 numerous Illustrations, crown 8vo, 8s. 6d. [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- ter to Pathology. Second edition, revised and enlarged. Fcap. 4to, los. 6d. W. RICHARDSON, m.a., m.d., m.r.c.p. REMARKS ON DIABETES, ESPECIALLY IN REFER- ENCE TO TREATMENT. Demy 8vo, 4s. 6d. )NS SAMUEL RIDEAL, n.sc. (lond.), k.i.c, f.c.s., f.g.s. 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 Pharmacopoeia, fcap. 8vo, 7s. 6d. ■'I R. LAWTON ROBERTS, m.d., m.r.c.s. Honorary Life Member of, and Lecturer and Examiner to, the St. John Ambulance Association. ILLUSTRATED LECTURES ON AMBULANCE WORK. Third edition copiously Illustrated, crown 8vo, 2S. 6d. \_.