7. Elevating the foot of the bed at night sometimes overcomes enuresis by taking away irritation from the neck of the bladder. Hot sitz baths may be given before bedtime, and vibration along the spine and over the bladder may be applied every other day.

CONVULSIONS IN CHILDREN

Convulsions are symptomatic of some disturbance, but may be treated from the clinical standpoint as a separate affection. In children clonic convulsions are always accompanied by loss of consciousness; in adults convulsions may be simulated. Older children of neurotic environment and constitution may have tonic contractures without true loss of consciousness. We speak of tonic and clonic, general and localized, convulsions. Convulsions are common in rhachitic, neurotic, tuberculous, and syphilitic children. On the other hand, long continued profound malnutrition shows an obtuseness of the nervous system. Congenital contractures point to convulsions in utero.

Motor discharges have their origin in the nerve cells, in the cortex, at the base of the brain, in the pontobulbar region and Rolandic cortical area, in the ganglion cells of the brain, or in reflex centres in the pons and medulla. An autopsy generally shows no changes except hyperæmia, and the real changes are probably in the cells. Irritation of the motor centres may be direct, as in: Injuries at birth; hæmorrhage; tumors; abscess; thrombosis; embolism; encephalitis; meningitis; sunstroke, etc.; or irritation of the motor centres may come indirectly through the circulation, as in: Anæmia of the brain; hyperæmia or venous congestion, as in heart disease, asphyxia, laryngismus, and pertussis; uræmia; poisons, vegetable, mineral, animal; toxines, infectious fevers; autointoxication from poisons formed in the intestines, urine, or blood (paraxanthin, acetone, etc.).

Irritation of the motor centres may come as a simple reflex irritation, as from a foreign body in the nose, ear, pharynx, etc.; earache; gastrointestinal irritation, colic; fright, anger, burns, wounds; retention of urine; renal and intestinal colic, etc.

Convulsions in infectious fevers have a twofold significance. At the onset they denote overwhelming toxæmia, but do not necessarily involve a grave prognosis. When convulsions set in at the termination of a severe illness, it means some complication or circulatory failure, with inanition of the brain. During the convulsive attack the temperature may be normal or elevated. A convulsive seizure may be followed by coma, semicoma, rigidity, or paralysis, and occasionally death.

Prognosis. The prognosis is governed by a knowledge of the exciting.

cause.

Treatment. In the majority of cases convulsions in children are due. to some gastrointestinal disturbance or to the onset of an acute infectious disease. The momentary treatment is entirely symptomatic. In many instances such prodromal conditions as twitching with restlessness and high temperature will warrant the administration of a bath and an enema. A child in a paroxysm should receive an enema at once, and be put into a bath 100° F. After removing the patient from the bath, an ice cap is

CHOREA (ST. VITUS'S DANCE)

215

applied to the head and the patient put to bed and kept quiet. Should the convulsions return, the bath and enema are repeated, and chloral hydrate with potassium bromide (each, gr. 1 to 3) may be given by the mouth if the patient is conscious, or by the rectum if he is comatose. If a very high temperature is present, hydrotherapeutic measures for reducing temperature are indicated, or a single dose of antipyrine in water may be given per rectum.

In obstinate and prolonged convulsive seizures the inhalation of chloroform and the hypodermic administration of morphine (gr. s to 1) are justified. If, on the other hand, the convulsions are caused by heart failure, camphor, strychnine, whiskey, and digitalis may be given subcutaneously in connection with enteroclysis. After the child's recovery from an attack the physician will direct his attention to any underlying or predisposing cause. In obscure cases it may be advisable to tap the spinal canal for diagnostic purposes.

CHOREA (ST. VITUS'S DANCE)

It

Chorea belongs to the group of psychomotor neuroses of unknown origin, and occurs most frequently between the ages of five and fifteen. is a disease characterized by irregular and involuntary muscular movements without loss of consciousness, affecting the muscles of volition, frequently associated with systolic heart murmurs, and having some obscure connection with endocarditis and rheumatism. As the origin and pathology of chorea are still a terra incognita at the present time, its ætiology will not be discussed here beyond stating that overpressure at school and fright are important factors in its production, and that neurotic, anæmic, and ill nourished children are most liable to be afflicted.

Clinical varieties of chorea are symptomatic chorea, caused by material lesions in the brain; reflex chorea, due to reflex irritation, and idiopathic chorea, due to infectious and toxic influences, e. g., rheumatism. The last variety is the most frequent and important, and may be looked upon as an infectious disease or intoxication by the products of pathogenic bacteria.

Symptoms and Course.-Chorea may be general or partial. Its course may be acute, subacute, or chronic. It rarely affects children under five. years of age. The attack comes on gradually, as a rule. The child appears nervous and depressed, drops things held in the hand, or stumbles and falls or makes grimaces. Such manifestations may be one sided (hemichorea). The child is irritable and emotional and has difficulty in speaking. There is tongue tremor with inability to hold the hand out straight and motionless. Systolic heart murmurs are frequently heard.

In the so called posthemiplegic "chorea," the muscles are rigid and contracted and the reflexes are increased.

PROGNOSIS.-Complete recovery is the rule. Acute chorea plus endocarditis may terminate fatally. The prognosis in cases complicated by a cardiac murmur should be guarded. Relapses of the choreic condition. are not infrequent.

Management and Treatment.-A child affected with chorea should be put to bed and have no visitors or excitement, but be in charge of a

competent person to entertain and nurse him. A daily bath and daily soap suds enema are to be given. Should the child not get sufficient sleep, a dose of chloral and bromide must be administered at night. A light and nutritious diet must be arranged. Palpitation of the heart with some fever may indicate the administration of

R Sod. salicyl., .
Potass. iodid., .

Tinct. aconit. rad..

Aquæ et syrup, ad.,

M. S.: A teaspoonful every two hours.

3j;
3 ss.;
gtt. xvi;
3ij.

Fowler's solution of arsenic, gtt. 2 to 5, in combination with 5 grains of bromide of potassium, may be administered in water three times a day. With a view to combating endocarditis, which is a frequent complication of chorea, an ice bag may also be placed over the chest.

After recovery the child should be sent to the country or seashore, and have mild general massage. In mild cases the children should be taken from school and given a change of air. When arsenic has been given to the point where gastric symptoms are manifested, its administration must be discontinued, and the following digestive may be given:

R Acid. hydrochloric, or dil.,

Tinct. gentian, comp.,

Ess. pepsin.,.

M. S.: A teaspoonful after eating.

3j;
3j;

3iij.

The use of arsenic may be resumed after the tongue is clean. In some cases vibration over the spine every other day for ten minutes has been followed by satisfactory improvement.

THE PARALYSES OF INFANCY AND CHILDHOOD1

Obstetrical paralysis of the face or arm is caused by injuries inflicted. during labor, and is discussed in the section of diseases of the new-born.

Little's disease is a congenital spasmodic paraplegia of the extremities, particularly the legs, capable of improvement and cure by general hygienic management and mild massage, though if syphilis is the underlying cause, mercury should be administered.

Infantile Spinal Paralysis (Acute Anterior Poliomyelitis.).—This ailment is most frequent between the ages of one and four years, and must be looked upon as an acute infection localized in the cord. The disease occurs sporadically and in epidemics. The onset is usually sudden, with fever, vomiting, diarrhoea, and prostration. Paralysis sets in shortly after the onset. When children are taken sick in the afternoon, the paralysis is generally manifest on the following day. There are no disturbances of sensation and the intelligence remains intact. One side or both sides may be paralyzed at the onset, but after a few months, even without treatment, we find the paralysis limited to a few muscles of one leg or arm. The

See also Neurological Memoranda.

THE PARALYSES OF INFANCY AND CHILDHOOD

217

muscles are soft, never rigid, and show no tendon reflex, thus contrasting sharply with the rigidity of cerebral paralysis. Atrophy in infantile spinal paralysis is also marked. The lesion affects the growth of the paralyzed limb, and the joints become lax. It has been noticed that those muscles recover which respond to the faradic current. The total absence of sensory symptoms is also characteristic of infantile spinal paralysis.

DIFFERENTIAL POINTS.-In discriminating between anterior poliomyelitis and multiple neuritis following infectious disease (diphtheria and influenza), it will be well to remember that in the latter lesion the limbs are affected symmetrically, the muscles are tender, and in fact the sensory symptoms are severe. Paralysis, atrophy,

reaction of degeneration, and loss of tendon

reflex are present in both.

TREATMENT. The object is to increase the nutrition of the limb and protect it from injury. The paralyzed limb is cold and should be well wrapped during cold weath

Massage, gymnastics, hot and cold. douches, and the interrupted or galvanic current and vibratory massage are indicated. If a brace is applied, it must be light and not cumbersome. Orthopædic surgery has been invoked to overcome the paralytic club foot and contractures by tendon grafting and shortening of tendons and nerve anastomoses, and some noteworthy results have been obtained.

Infantile Cerebral Paralysis with Retarded Development (Spasmodic Infantile Hemiplegia.)-Beginning more or less with brain manifestations, fever, delirium, convulsions, spasm, the paralysis is of the hemiplegic type, with rigidity, contracture, and exaggerated reflexes. The electrical reactions are normal, and there is no rapid or extreme wasting. Athetoid movements are noted in some cases, also posthemiplegic chorea. Protracted labor, instrumental injury, asphyxia, acute infection (scarlatina, diphtheria, cerebrospinal meningitis), cysts, and areas of softening and sclerosis are ætiological factors.

PROGNOSIS.-Facial paralysis generally disappears, the leg improves, and the arm remains disabled.

The TREATMENT is the same as in the spinal paralysis, and in cases of doubtful origin the patient should have the benefit of the doubt and be given an inunction cure.

Primary Myopathies.-Pseudohypertrophic muscular paralysis and atrophic myopathies are forms occurring in late childhood, usually beginning between the ages of two and eight and affecting both sexes. Some form of motor weakness is generally the first symptom, and the way in which the patient raises himself from the horizontal to the vertical position is characteristic of the lesion. Owing to weakness of the extensor muscles of

the knee, he places his hands on the lower part of the thighs and gradually raises himself upward by this assistance. The posture and gait are characteristic. When the patient is standing, the abdomen projects, the back is hollow, the buttocks are thrown back, the feet are planted apart, and the gait is swaying and waddling. There is feeble response to both currents of electricity.

The PROGNOSIS of myopathic disease (atrophy or pseudohypertrophy) is not favorable. After the power of standing is lost, the case is practically

hopeless, but no case should be pronounced hopeless until treatment has been persisted in on the following lines and with a view of exhausting the "specifics" before we give up all hope:

Open the bowels to eliminate autoinfection from the intestine.

Give general mild massage and baths to better the circulation.

A course of antimalarial treatment, even if the plasmodium is absent from the blood, may be given.