a gentle manner, without other morbid phenomena, or lastly, if it follows local muscular pains, and remains localized in several muscles or in a U. limb, the diagnosis is easy, the paralysis is entirely muscular, and independent of the central nervous system. It is a myogenic paralysis, '!!!! very often of rheumatic origin.

If the paralysis likewise supervenes withont any appreciable cause, and shows itself under a paraplegic form without disease of the vertebrali column, the paralysis is also independent of the nervous system, and is caused by a special alteration of the muscular system.

In case of hemiplegia, if the muscles of the face do not participate in this alteration, and if there is only paralysis of the thoracic and abdominal member, without preceding acute disorder, the disease has

also its primary origin in the muscular system. It is also a myogenic paralysis.

Which is

The diagnosis becomes more difficult when the paralysis has followed one or several attacks of eclampsia. Then there is reason to believe Convulsum in some disorder of the nervous system. Yet, if the eclampsia is unattended with fever, and neither precedes nor follows an acute disease, there is reason to believe that it does not depend upon any organic cause, and that the paralysis which follows is not be referred to it. In this case the paralysis appears to be the result of exhaustion of the

muscles, and it may be supposed to be due to this change in the

primary fasciculi, which results from exaggerated movements.

But when, on the other hand, paralysis succeeds febrile attacks attended with convulsions, as in meningitis, contraction, as in meningeal hæmorrhage, or general nervous phenomena, as in hydrocephalus, it is evidently the result of more or less severe anatomical lesions of the nervous system. It is a symptomatic paralysis entirely different from that we are now considering.

The same is the case with the paralysis which follows scrofulous disease of the vertebræ, which may be at once dismissed.

Myogenic paralysis, confined to one limb, may give rise to a mistake which it is right to point out. It may be counfounded with disease of the joint to which the limb belongs, whether it be the coxo-femoral articulation or that of the shoulder. Thus, M. Rilliet has reported a very curious case of paralysis of the arm, which in every respect resembled dislocation of the shoulder. There was merely simple relaxation of the ligaments of the joints. West and Kennedy have likewise pointed out the difficulty of diagnosis in cases of disease of the hip joint amongst children who have had no other affection besides the paralysis of the inferior extremity. It is sufficient to be aware of these causes of error in order to avoid them.

I shall lastly allude to rachitis, a common disease amongst young children who are out of health and have been badly nourished, who

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Rachites

are more or less rickety, and who are behindhand in their speech and
movements, so much so that a person not warned might fancy them
attacked with myogenic paralysis. This is hardly worth mentioning;
nevertheless, I have been frequently consulted on this point by parents
who were uneasy at seeing their children incapable of walking at an age
at which they tried their first steps-they require to know the reason.
Still, what a difference between the delay caused by a disorder of nutrition
and myogenic paralysis, whether local, paraplegic, or hemiplegic. Thus
in rachitis the movements are genererally feeble, one limb does not
move more quickly than another, all of them move uniformly, especially
when the child is in bed; walking is difficult, but possible with a little
assistance; it is a general muscular weakness. In myogenic paralysis,
on the contrary, there is energetic action of certain parts and several
members, diminution or abolition of movement in the opposite limbs.
This contrast renders a mistake impossible.

PROGNOSIS.

Myogenic paralysis of young children is a serious disease. Whatever may be its origin, its result is an alteration of the nutritive functions of a portion of the muscular system, which almost invariably leaves behind it incurable deformities. It is never followed by death. In its incomplete form it is cured more easily than entire and complete paralysis. The same is observed in cases of quickly developed paralytic attacks. Slow and progressive paralysis always last a longer time. The whole of the importance of the prognosis rests on the seat and extent of ᎢᏗᎵᏓᏍᏗ . the paralysis; it is evidently more favourable when it is confined to one of the sterno mastoid muscles or to different muscles of the fore arm than when it attacks the whole of the superior extremity, or, more especially, than when it puts on the hemiplegic or paraplegic form. In these circumstances the unfavourableness of the prognosis results from the greater or less importance of the paralysed parts, and from the incurable deformity which may be the consequence of it.

TREATMENT.

At the commencement of the attack, the state of the mouth should be inquired into, to discover the state of dentition, and in case any tooth should be on the point of piercing the gum, its protrusion should be hastened by lancing. At a more advanced stage of paralysis, this operation is both useless and senseless, for it would be necessary to practise it on all the patients indiscriminately. What child is there of one or two years old which has not always some tooth ready to protrude? To enumerate this eircumstance as the cause of the paralysis is to give to a simple coincidence all the importance of a well founded etiological cause,

and it is a gross error to allow it to serve as a guide in the

treatment.

The gum should then only be incised when there is evidence of difficult, slow, and painful dentition.

If the children are constipated, and have some disorder of the cush digestive functions, it must be promptly relieved. The first means to be employed in myogenic paralysis, is to keep the bowels free by the syrup of chicory or rhubarb, manna in milk, infusion of senna in coffee, or by a small quantity of calomel.

Careful inquiries must then be made into the mode of the children's living, the sleeping apartment, their clothing, their physical education, and if there is not some circumstance which, by favouring the action

hild

of cold upon the limbs, has not been the cause of the paralysis, p In fact, children are often prematurely put into short clothes, and are thus carried into the open air; often, also, they go to bed without sufficient covering, and the imperfectly closed bed allows the cold to act over the whole of one side of the body. These are sufficient causes to bring on the paralysis which we consider to be durm. rheumatic. Nothing is more evident than this fact when the loss of motion is preceded by pain, as in torticollis, and several other paralyses of the limbs. It is necessary to be careful, therefore, not to clothe young children too lightly, nor to bring them up without long clothes during the first months of life. Whatever may be said of it, swaddling the child is good in one point, if it is only to prevent the young infants from becoming cold; but fashion has banished it, and it would be difficult to defend it gainst the strong feeling of the present time.

At the commencement of the paralysis, if muscular pains exist, they must be treated by baths of bran water, of elder water, vapour baths, and narcotic applications, such as frictions with a liniment composed of equal parts of oil and laudanum, frictions with old balm, and with warm flannels moistened with different substances. Still later, salt water and sulphurous baths ought to be frequently made use of. Dry frictions, either aromatic or stimulant, practised upon the diseased parts, morning and evening, will materially assist the beneficial action of these baths. It is especially advantageous, in this singular form of paralysis, to act upon the capillary circulation, so as to prevent the special alteration of the muscles. To this end, the cutaneous rubifaciants, frictions with croton oil every morning and evening for several days, and frequently repeated after the cure of the vesicular erruption; small flying blisters, &c., may be made use of to arrest the progress of the paralysis. If paraplegia exists, these means should not only be employed on the inferior extremities, but also to the lumbar region, so as to stimulate the nervous influence of the spinal cord.

Electric baths, frictions with metallic brushes charged with electricity, cutaneous galvanism, by means of electro magnetic apparatus, in short sittings of from ten to twelve minutes, according to the strength of the child, may be advantageously used, and should on no account be neglected.

If the paralysis continues, and has produced atrophy of the limb, the electro galvanic puncture must be applied as well as external electricity; it should be done by means of platinum needles, pushed into Juleuthe muscles, and charged with a current of electricity of a strength unu proportionate to the vigour of the children. The needle should be of

very small diameter, so as to produce as little pain and flow of blood as possible.

Shampooing gently practised upon the diseased limb, and gymnastic exercises, when they are possible, are proper means to employ, and have furnished good results in the hands of some physicians.

The employment of special medicines, remarkable for their property of exciting the muscles, has, up to the present time, very rarely proved successful. Heine recommends the employment of the tincture of nux vomica, in doses of twelve, twenty, or at most, twenty-four drops; and he believes that he has remarked, at the end of several weeks, an appreciably improvement. He has also had recourse to the sulphate of strychnine in doses of from one-hundreth to one-fiftieth of a grain, 7 and he has seen this medicine almost invariably restore the heat and moisture of the paralysed parts.

The rhus toxicodendron has also been used, but nux vomica and strychnine are infinitely preferable to it.

Lastly, when the muscular atrophy has arrived at such an extent as to produce the articular deformities we have mentioned, chiefly cases of club foot, we must wait until the age of six or seven years, without discontinuing local remedies, before having recourse to the special orthopedic operations which are sometimes useful.

[It is not at all necessary, as here advised, to wait until the age of six or seven years for the performance of orthopedic operations; sections of the tendons for club foot may be performed as early as six weeks, and probably after the age of two or three months; the earlier it is performed the more effectual is the cure.-P.H.B.]

APHORISMS.

118. The paralysis of one or several muscles of the trunk or limbs, painful from the first, always depends upon a local affection of the muscular system.

119. The paralysis of one or several muscles, following eclampsia, has its seat in the muscles.

120. The partial or general paralysis, which succeeds febrile convulsions, results from a lesion of the nervous centres and cords.

121. Amongst infants, paralysis leads to atrophy of the muscles. and contraction of the limbs.

CHAPTER XIII.

ON CONVULSIONS OR ECLAMPSIA OF CHILDREN AT THE BREAST.

The term convulsion is applied generally to all the involuntary disordered movements which are observed in the muscular system of animal life. It seems to designate affections, very different in their nature, but identical in their manifestations, which constitute the convulsive state.

Convulsions are principally observed in the muscles of the face and

limbs.

These nervous affections are also described under the names of infantile eclampsia and puerile epilepsy, in consequence of the close resemblance between them and the confirmed epilepsy of adults. shall see further on what is to be thought of this opinion.

Wel

Convulsions are especially observed amongst children, but theed!

youngest are those most particularly predisposed to their development. The extremely exquisite sensibility of the brain at an age when the sensations, whatever they may be, are fresh, and consequently dangerous if they are a little excited, explains this. Everything in nature progresses by degrees, and the organs should also become gradually accustomed to external impressions. The veil thrown upon the pupil at the moment of birth, is only dissipated by degrees, and the infant, which is just from its mother's womb, does not at once perceive the light; it could not support the brilliancy of it, and would sink under the painful impression. The light is gradually manifested, and only! becomes brilliant when the organs of vision are accustomed to it. It is necessary that the centre of the sensations should become familiarized a with the physical impressions, and that the first should also be the 4074 most feeble. When the contrary is the case, a violent agitation, a disturbance in the action of the brain, a perversion of the motive functions, the only thing which can exist amongst children at the breast, thence result. Pain is sometimes then the occasional cause of the convulsive state; little matter where it may be seated, even if it should be in the midst of the nervous centres or in quite an opposite part of the body, the consequence and the result are the same.

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