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How can a progressive superintendent follow the dictates of his conscience when he so carefully prepares an annual budget to meet the demands of the people and keep abreast of the times, then have it trimmed down by the inexperienced, so that the expense of the government should not exceed the revenue, thereby forcing an imperative necessity for the public service of many State hospitals to be deprived of means that are so necessary to its proper management in all of its details. Banquo's ghost arises and frightens those who have future political aspirations, if they conceive the idea of providing more revenue. Self-preservation, the spirit of politics, pervades his innermost soul.
CEREBRAL PALSY OF CHILDHOOD.
M. L. GRAVES, M. D.,
SAN ANTONIO, TEXAS.
Perhaps the spinal paralysis occurring in childhood and known as acute anterior polio-myelitis and producing paralysis of one or both lower limbs, has attracted more attention on the part of the general practitioner than those paralyses of cerebral origin. This is due to the more definite course, the shorter duration, the more exact clinical history and the want of psychical symptoms, which leaves the disease almost entirely in the hands of the general practitioner, while the cerebral cases sooner or later find their way to the specialist and usually to the public institutions.
The cerebral paralysis of childhood, however, is not so restricted either in pathology or symptomatology as those of spinal origin, and it is frequently marked by convulsive seizures and these are often considered purely epileptic.
When the disease occurs in the newly born it is not infrequently unrecognized for several months. It need scarcely be added that every disease producing such mental obliteration and such unhappy physical effects as cerebral palsy should be familiar to all practitioners.
According to Sachs, our very best authority on this subject, the disease has three periods of development, viz.: First. Pre-natal, that is, any time before the birth of the child. Second. Natal, or at any time during the prolonged and difficult passage of the child's head through a narrow pelvis, where great compression, unequally distributed, is brought to bear upon the soft, bony and cerebral tissues, not infrequently resulting in a large meningeal hemorrhage. Third. Post-natal, which means any time after the birth of the child, but is usually within the first decade of its life.
The fact that nearly all of these cases develop convulsions sooner
or later in their history, at first unilateral, but later general, and partaking of the character of genuine epilepsy, makes the accurate observation and early treatment of this trouble of great import
The clinical history, especially in the early states, is frequently obscure and may be entirely overlooked, or, if the symptoms are pronounced, it may be considered a totally different disease. Sometimes the child is taken with fever, followed by delirium, and in some cases stupor and vomiting also occur. Aphasia and convulsions may likewise mark the initial stage of severe cases. Within
a short time the following unfortunate features present themselves and are characteristic of the trouble.
First, paralysis; second, contracture of muscles; third, spasticity; fourth, idiocy, imbecility or insanity, according to the time of its development and the character of the cerebral irritation or destruction; fifth, convulsions, sometimes on one side, involving an entire lateral half of the body and later becoming general. The motor agitation may possibly be confined to one extremity. The paralysis usually manifests itself in the form of hemiplegia more or less complete, which is said to be the usual form in post-natal cases. Next in frequency occurs paraplegia, due to pre-natal conditions, and third, diplegia, or the simultaneous paralysis of each lateral half of the body. In other words, a double hemiplegia. Some authors include a monoplegia, affecting but one extremity, but this is said to be rare.
The hemiplegia may be complete or partial, involving the complete loss of motion of an entire side, including the face, though it is more usual for the face to escape serious involvement. The tongue is sometimes involved, but not seriously and not constantly.
Some of our writers have asserted that babies have been born not only with the paralysis, but with the contracture of the limbs, which had occurred in utero.
My own personal experience has enabled me to observe only the hemiplegic forms of this disorder, and the experience is largely confined to hemiplegia, of which we now have under observation
a number of cases. If the hemiplegia occurs at birth from pressure by the natural channel, or the improper application of forceps, the paralysis may not be detected for some months, until the child's growing of the other side of the body makes it noticeable. The arm and hand are the greatest sufferers from the paralytic and contractural influences. The leg and foot usually recover much of their usefulness by persistent practice, but the arm usually remains flexed at the elbow, deeply flexed at the wrist, with the fingers either stiffly extended or flexed in irregular position and the entire arm adducted and folded upon the chest.
The deep reflexes upon the paralyzed side are more or less exaggerated. Sometimes so keenly sensitive that ankle clonus is easily produced. The reflexes upon the sound side are not disturbed. There is no paralysis of sensation on the paralyzed side and no difficulty with the sphincters. The arm may become useless and the leg may be so shortened and so stiff that locomotion is seriously impaired.
Athetoid and choreic movements frequently occur in the paralyzed extremities. Asymmetry of the face and different sides of the body occurs from the failure of development of the muscles from disuse, but there is no trophic atrophy. The body may be well nourished and the patient do well in all other respects. Such children, however, are apt to be irritable, morose, unstable, dull, inattentive to their school duties, unteachable, capricious and willful.
The most important symptom is the motor disturbance or convulsions, when the lesions are distinctly localized in the superior motor centers. It may manifest itself in convulsive twitchings at irregular intervals, of a hand or foot, or even a smaller segment of the motor circle. Indeed, it may appear to be a true Jacksonian epilepsy.
If the lesion is large enough or sufficiently distributed to affect the entire motor zone of one side of the body the convulsions may occur at first and for years upon that side, but in nearly all cases with the progress of the disease the convulsions become bilateral and general and the patient is afflicted with genuine epilepsy.
The pathological findings of this disorder, while diverse in different cases, are fairly frequent in the aggregate. They consist of, first, cerebral hemorrhages; second, cerebral cysts; third, cerebral sclerosis; fourth, cerebral atrophy; fifth, meningo encephalitis according to Strumpell; sixth, focal softening, according to Oppenheim; seventh, porencephaly or defective formation of the brain; eighth, hydrocephalus, and ninth, according to Sachs, a well defined agenesis of the cortex, or a failure of cortical development. These lesions are usually found upon the surface of the brain but some have been known to develop in the basal ganglia. Their location and extent determine the character of the motor disturbance and paralysis. It has been definitely stated that large effusions of blood have been found over the cerebral cortex in newly born infants, due to the prolonged pressure and blood stasis and tearing of the sinus veins. If the patient survives, this clot will be more or less organized into a dense membrane and the original character of the lesion overlooked.
The most important effect of this pathological condition is upon the development of the mental faculties. Such children are either idiots, imbeciles or dements.
In addition to prolonged confinement and personal shocks to the pregnant mother, infectious diseases of childhood, measles, scarlet fever, diphtheria, pneumonia, smallpox and typhoid fever have been strong factors. Injuries to the child after birth are also causative. Syphilitic infection or heredity plays some part. Oppenheim considers premature birth an important factor. Acute inflammation of the brain and its membranes from infections are causative, and likewise embolism and thrombosis of cerebral blood vessels from the same causes are important.
It is claimed that the improper use of forceps has also a positive causative effect, but on the contrary it is believed that the proper