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application of the forceps in tedious and difficult labor will have a preventive effect.

DIAGNOSIS.

Most of these patients present more or less definite clinical features, and the disease can not be overlooked by a cautious observer, but it may be masked by convulsions and consequently be pronounced epilepsy upon this superficial study, and continue under that classification. It should be said in this connection that cerebral bony anomalies and asymmetry form suspicious circumstances.

Markedly microcephalic or plagiocephalic skulls have an indicative bearing. The definite presence of paralysis, with the rigid condition of the muscles and increased tendon reflexes with convulsions, makes the diagnosis almost certain. The convulsions, as before stated, may be limited to one side and there is no involvement of sensation, and the ultimate fixation of the limb in contracted position makes it certain. It must be differentiated from epilepsy, and from acute spinal paraylsis, which affects one or both extremities and is degenerative in character with lost reflexes and occurring suddenly with high fever, vomiting, stupor, and immediately following paralysis. There are no later convulsions and no cerebral symptoms in the latter disease.

TREATMENT.

After they have reached our asylums, little remains to be done except to take care of the general health and treat any symptoms arising. Prior to this time, it may be surgical, to remove an early lesion of definite location and certain effect. Medical, to build up the child, prevent the development of convulsions, save him from the stress and strain of life, and above all not to attempt to educate him as a normal child. Preventive treatment is rarely considered, and yet, when it is remembered that so many of these cases are due to dystocia, according to Joseph Collins, it is incumbent upon every obstetrician to use every scientific means to lessen prolonged and dangerous deliveries. The forceps should be used before pressure has been productive of the lesion. After birth peo

ple should be thoroughly educated to avoid all the infections of childhood instead of courting them, as seems to be done even yet among the less educated classes. It should also be stated that every infectious or contagious disease should be treated with more care and foresight, to prevent complications.

In the acute form of the disease, rest in bed, ice bag at the head, free purgation, light diet and bromides to produce quiet. Later, if convulsions appear and a definite lesion can be found, remove it. If not, treat expectantly. For wasting or undeveloped muscles use friction, warm baths and massage. If contracture is very great the tendons should be cut, and such orthopaedic appliances used as will effect the highest degree of locomotion. After genuine epilepsy has developed, nothing is effective.

In conclusion, I desire to present to you the following illustrative

cases:

First. Post-Natal, Left Hemiplegia.-W. E., aged twenty years, parents healthy, father railroad man. Heredity good except one paternal uncle epileptic. In childhood had measles, mumps and whooping cough. There was no difficulty at the time of his birth. His mother was in labor six hours and was normally delivered. She had not had any fall, injury, shock or fright of serious character, and neither had the child up to the development of an attack of illness which produced the present condition. At eight years of age he had a severe attack of typhoid fever, which lasted six weeks. At the end of the third or beginning of the fourth week he became unconscious suddenly and developed paralysis, involving the entire left side. He could not move either arm or leg, but after his recovery from unconsciousness he could feel on that side, though sensation was weak. He had fever at the time the paralysis occurred, but was not delirious. It was thought he would die, but slowly he emerged from the difficulty. Within two or three months after the paralysis occurred the hand and leg of the affected side began to draw up. Up to this time he had never had any fits or convulsions, and had manifested no weakness of mind. His recovery from the typhoid fever was slow and he remained dull afterwards, fre

quently with pains in his head, which would last for twelve hours, and occur once or twice per week, when he would have no appetite, become irritable and depressed. He continued in this condition until three or four years ago, when he began to show slight evidences of mental disturbance; he became irritable, morose, unruly, with capricious appetite, irregular bowels, headache and unusual conduct, such as crawling under the bed upon getting miffed at any little thing. This condition gradually increased until it became necessary to admit him into the institution January 13, 1902. He had not up to this time and has not since, so far as we know, developed any convulsions. He was placed upon systemic treatment, kept quiet, dieted, regulated, given a tonic with an occasional sedative, and has continuously improved in physical condition, and his mental irritability appears now to be as well as it can ever be expected to become. Upon inspection at present it is seen that his head is not entirely symmetrical, but not markedly otherwise. Vision is apparently normal. Slight pterygium on each eye, hearing normal, rather high arched palate and a few bad teeth, but nothing special. Eye and tongue movement normal. Slight asymmetry of chin and left side of face. He presents a very marked case of left hemiplegia with contracture of the muscles. There is very little difference in size in the muscular development of the two sides, from three-eighths to three-fourths of an inch. He has slight athetoid movements in the left hand. The flexors of his hand and arm are considerably contractured, as also those of the leg, interfering seriously with his gait, producing a pes-equinus. The patellar reflex upon the afflicted side is much exaggerated, the other side is normal. Sensation in paralyzed side is normal. The superficial reflexes are also normal. The electrical response to a secondary Faradic current is quite normal upon the entire left side. He is therefore a typical case of cerebral palsy, occurring at the age of eight years and following an attack of typhoid fever, probably directly produced by a cerebral hemorrhage over the right motor cortex. He illustrates the classic features with the single exception of convulsions, which he has never yet developed, but which

may occur in the course of the disease. He has the typical paralysis, spasticity and contracture of the muscles with normal electrical response and with the mental enfeeblement characteristic of the disease.

Second. Natal, Right Hemiplegia.-E. R., age nineteen years. Father healthy, mother subject to nervous headache and indigestion. Maternal uncle suffered for years with nervous disease, at times unbalancing his mind temporarily. His maternal great aunt during childhood was subject to blind flashes, eventually going blind and dying at the age of eighteen.

His mother did not have any fall, injury, shock or disease prior to his birth that would affect him. At birth no instruments were used, though it seems they were contemplated and kept in readiness, for the labor was very long and extremely difficult, and the mother had severe convulsions before his birth, and medicine had to be administered for that purpose.

Immediately after birth it was noticed that he fretted and cried all the time, practically till three months of age. After birth, so far as known, he never had any severe shock, injury or fright, and none of the ordinary diseases of childhood have been reported. The first thing wrong observed about the child, as before stated, was his continual fretting and crying till about three months of age, when it was observed that he was paralyzed upon the right side, and that he took everything in his left hand, keeping his right hand closed. Later, when he attempted to crawl and walk, he did not seem to have good use of his right leg and foot.

His mental condition did not show any deviation from that of a growing child up till twenty months of age, when he began to have convulsions. They were light at first, and occurred upon the left side, as the history shows he was drawn to that side. This is presumably due to the paralytic condition of the right side. In about one year he had another short period of convulsions, and then they came at intervals of several months, and then they became of almost daily occurrence. He had the usual epileptic symptoms, but remained a comparatively bright child until seven or eight years of

age. He was sent to school for a short time, and learned quite well, but was forced to leave school on account of the hard convulsions. These convulsions continued, becoming more frequent, and his mental condition constantly deteriorating until he finally became turbulent and unruly, suffering from severe convulsions, attacking people about him, his speech becoming more and more difficult, and his memory rapidly failing, until it became necessary to admit him to the institution three years ago. Since which time, he has progressively become demented, and his convulsions have continued.

He has just recovered from an attack of pneumonia followed by a suppurative otitis media in his left ear, which is still quite bad. A slight inspection shows that his head is large enough, but asymmetrical. He is paralyzed upon the right side, and has suffered from failure of muscular development along the entire right side. Measurements around the right biceps on left side show 8 inches, right side 7 inches. Left wrist 6 inches, right wrist 5 inches. Around middle of left thigh 14 inches, right thigh 12 inches. Left calf 11 inches, right calf 10 inches. Patellar reflexes on both sides are exaggerated, but markedly so on the paralyzed side. Sensation is normal on the paralyzed side, and his sphincters are under control. His superficial reflexes are not quite sensitive, but I think this is perhaps due to his demented condition. His right hand is flexed at the wrist; fingers usually contracted, but no marked contracture, as they can be extended.

From the history of this case and his present appearance, I think we are safe in concluding that this is a natal case of cerebral palsy, occurring at birth, from the long continued pressure upon the child's head. Paralysis first occurred, and it was nearly two years before convulsions supervened. He has pursued a perfectly typical course, and has been all the time beyond the hope of medicine and surgery. His mind is almost extinct, and it is only a question of a short time, with his greatly reduced vitality, till an epileptic convulsion will terminate his life.

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