special injurious effects of arsenic became apparent, when he suspended its use for a few days, resuming it again as soon as these symptoms had passed off. Dr. Radcliffe, who has employed it in this way and with success, states that he has often been compelled to discontinue it on account of the gastric disturbance which it produced, and which often became urgent before the remedy had had time to influence the chorea. In these circumstances he suggests a trial of the arsenic hypodermically, from which he has obtained good results on some occasions; and in instances of chorea rebellious to other means, this suggestion, and I may say the same about every suggestion of Dr. Radcliffe's, deserves to be borne in mind.

I have never employed strychnine as a general remedy in chorea, in the way in which I employ zinc; for notwithstanding the high recommendation of M. Trousseau, I have felt afraid of it. He himself was accustomed to push the medicine to a dose at which the physiological effects of the remedy became apparent, and speaks of head-ache, stiffness of the muscles of the neck, pains in the limbs, occasional spasms, and itching of the surface of the body as indications that the medicine has been carried to the limit of safety. But the twitching of the limbs in chorea prevents our being aware of the occurrence of spasms; while a child's inability to describe its sensations deprives us of another most important guide: and I have seen convulsions occur more than once in young children who were taking strychnine, apparently unpreceded by any of the ordinary physiological effects of the remedy.

On these accounts I have never given it in cases of severe chorea in which the dulling of the intelligence as well as the violence of the movements prevent our learning when the medicine has begun to produce its specified effects. I also very rarely use it in children under the age of seven. I begin with a small dose, increase it slowly, suspend it for two or three days at a time when its administration is long continued; and limit its use almost entirely to cases in which there is loss of power rather than violence of movement. In those conditions in which the limbs cannot be exerted without the irregular movements being at once induced, although these movements are comparatively slight so long as the patient remains quiet in bed, the strychnine has seemed to me sometimes very useful, just as it is in cases of diphtheritic paralysis. The above are the chief, I do not say that they are by any means the only, remedies for chorea. I have not dwelt on the various

indirect means (in the more chronic form of the disorder they are indeed the most important) by which you must endeavour to improve your patient's health. Residence in the country, sea-air and sea-bathing, a well-regulated but nutritious diet, and generally a careful use of stimulants, when combined with the most sedulous avoidance of over-excitement in any form, often do as much as medicine, or even more, for the restoration of your patient.

In the great majority of cases you may, as I have already mentioned, assure the friends of your patient that the disease will ultimately subside, though it may last for many weeks. Two qualifications, however, you are forced to add to this cheering assurance—the one that slight causes may occasion its return, and the other that there exists a connection between it and the rheumatic diathesis; and the development of heart disease either with or without rheumatism in the course of chorea is a hazard against which you can furnish no guarantee.

LECTURE XV.

PARALYSIS-Sometimes congenital, but this not true infantile paralysis-its characteristics-age at its occurrence-most frequent during period of dentition---Diagnosis-Identity with spinal paralysis in adults-Prognosis not very favourable -Consequences of its persistence-Treatment—aids to walking-modes of exercising the limbs galvanism.

FACIAL HEMIPLEGIA in new-born infants.

NEURALGIA in infancy and childhood.

DISTURBANCE of the nervous system shows itself in children as well by loss of the motor power as by the occurrence of involuntary movements; and such an accident as the palsy of a limb naturally occasions parents the greatest anxiety. In the adult, a paralytic seizure is generally the result of very serious disease either in the brain or spinal cord, and the sign of the commencement of a series of morbid processes which issue sooner or later in the destruction of the patient's life. Non-professional persons are aware of this fact, and often suppose that the same rule holds good in the case of the child as in that of the adult; but you may in most instances quiet their fears with the assurance that paralysis in infancy and childhood seldom betokens any peril to life, though the affection is often very slow in disappearing, and sometimes is quite incurable.

Paralysis in childhood occasionally dates from so early a period that there seems every reason for believing it to be the result of some original defect of conformation. In such cases the power over both extremities of one side is greatly impaired, and the limbs. on that side are much smaller and less well nourished, and sometimes the defective growth and want of power are evident on the whole of the same side of the face and body. Some years ago, I saw a girl, 18 years old, in whom not only were the left extremities much shorter and smaller than the right, but the left half of the face and body was so likewise. The parents of the girl stated that this inequality in size of the two halves of the body had existed from earliest infancy, and that the defective power over her

limbs had not succeeded to a fit, nor to any other indication of acute cerebral disease. The left side was weak, and motion imperfect, but sensation seemed to be unimpaired. The patient in this case was rather deficient in intellectual endowments. In another instance the body was well formed, but the patient, a girl of 8 years of age, had had from her earliest infancy but very imperfect use of her right side. She limped with her right leg as she walked, always treading on her toes, with the heel raised considerably above the ground, and turning the foot inwards at every step. She had but very incomplete power over her right arm; the fingers of that hand were constantly flexed and drawn into the palm; and though by a great effort she could extend them, yet the moment her attention was withdrawn they returned to their former flexed position. Sensation was as perfect in the right limbs as in the left, but their wasted condition and smaller size, as compared with the left extremities, showed that their nutrition had been but very imperfectly carried on.

It is almost needless to observe, that in cases such as these there is no room for treatment other than the employment of whatever mechanical means may be best calculated to relieve inconvenience or to diminish deformity.

1

Real congenital paralysis, however, apart from idiocy, is a much less frequent accident than the occurrence of partial or complete loss of power over certain limbs or muscles at a subsequent period. Such sudden loss of power unattended by any symptoms which endanger life is so frequent an occurrence in infancy and early childhood as to have received a special designation; and the terms Infantile Paralysis, Spinal Paralysis of Infants, Essential Paralysis, Atrophic Paralysis, Atrophic Fatty Paralysis, all apply to the same affection, either designating one of its special features, or expressing some theory as to its nature. On this one point all are agreed, that there is a form of paralysis frequent in early life, but which differs in its symptoms and its course from any that we commonly meet with in the adult. In many instances its commencement can be traced to some attack, though often a very brief one, of cerebral disturbance, which showed itself, perhaps, by nothing more than a single convulsive seizure, or by an unusual heaviness of the head that lasted for a day or two, and then subsided of its own accord. In the majority of cases, indeed, the cerebral disturbance that preceded infantile paralysis is neither severe nor long-continued; and only two instances have come under my notice in which there seemed to be reason for supposing

INFANTILE PARALYSIS.

239

that it was associated with abiding mischief in the brain. It is therefore of importance to examine an infant carefully, even after a very mild convulsive seizure, in order to make sure that it moves its limbs as freely as before, or that, if its power over them is impaired, appropriate treatment may be at once adopted.

Paralysis sometimes comes on independently of any evident cerebral disturbance, seeming to be induced by the irritation of dentition, or supervening on the long continuance of a constipated state of the bowels, or appearing in connection with all the indications of general debility, or succeeding to a short feverish seizure which came on suddenly when the child was in bed at night, and left it with one limb palsied in the morning. I believe, indeed, that in cases even of the most sudden attack of paralysis, there have almost always been some previous indications of disorder of the general health; the few instances only excepted in which the immediate action of cold, as from a child sitting on a stone step has been followed by paralysis of one or of both legs.

The whole subject of paralysis in early life calls for, and would well repay, a thorough investigation. Unfortunately, however, the difficulties which beset any enquiry into the subject are numerous; and are the less easy to overcome, since they arise in great measure from the chronic nature of the ailment, which renders it almost impossible adequately to test the value of remedies, or to estimate the changes which time may bring about, either in improving or deteriorating the patient's condition. Of the large number of cases which I have seen, few have continued for more than a few weeks under my observation; so that I am unable to answer, with reference to them, more than a few of the questions which suggest themselves as deserving a reply.

I have spoken of Infantile Paralysis as peculiar in its characters; and I think that it is important before entering on its special study that we separate from it all other forms of palsy which may be observed in childhood; but which with few exceptions are far more frequent in the adult.

First, then, we leave out of consideration all instances in which the loss of power as in the two cases which I mentioned at the commencement of this lecture is actually congenital; and next those cases, too, most of which date from birth or from very early infancy where the paralysis is associated with idiocy; and nervous power is wanting to the limbs just in the same way as it is wanting for the exercise of the faculties of the mind. Neither do cases of simple Facial Paralysis belong here, for they either depend on