WS 100 W516o 1871 48910200R NLfl QSESSMMl 1 T 'O'j o 'J u lj ^'C-i/U' Surgeon General's Office mxgjmuxjL a? HEX .&** N. znro m;)aj 3&Q®'jjCJ<::.i5Q®Q&C-ioo. »'■'" us ^HW'IVI LAST DATE SEP 6 8§fl B i^-^- DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD: BEING THE LUMLEIAN LECTURES DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, IN MARCH, 1871, BY L/ CHARLES WEST, 1\I.])., FELLOW AND SENIOR CENSOR OF THE COLLEGE: PHYSICIAN TO THE HOSPITAL FOB SICK CHILDREN. * |frS-0 PHILADELPHIA: IIEXRY C. LEA. 1871. nil Jt SIR JAMES ALDERSOE", KNT., M.D., F.R.S., LATE PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS, WHO DESIGNATED ME TO THE OFFICE OF LUMLEIAN LECTURER: AND TO THE FELLOWS OF THE COLLEGE, SOME MY TEACHERS, OTHERS MY COLLEAGUES, ALL MY FRIENDS, WHO HONORED ME WITH THEIR PRESENCE, AND REWARDED ME BY THEIR APPROBATION, I GRATEFULLY AND AFFECTIONATELY DEDICATE THESE PAGES. CONTENTS. LECTURE I. Page On Neuralgia and Epilepsy,........13 LECTURE II. On Chorea and Paralysis,........50 LECTURE III. Disorder and Loss of Power of Speech. Mental and Moral Peculiarities and their Disorders, 91 ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. LECTURE I. ON NEURALGIA AND EPILEPSY. Introductory.—History of foundation of Lumleian Lec- tures.—Sketch of Dr. Caldwell and Lord Lumley — Harrey one of the Lumleian lecturers.—Difficulty in choice of subject.—Circumstances which limit choice.— Reasons for selecting diseases of early life, and for choosing disorders of nervous system, with reference to —1st. Sensation; 2d Motion; 3d. Power of Speech; 4th. Mental and Moral powers.—1st. To Sensation: rarity of pure neuralgia ; risks of error in cases of brain disease; of disease of hip-joint.—2d. To Motion: im- port of convulsions; epilepsy, what is meant by it; re- lation of convulsions in early infancy to epilepsy in childhood; frequency of attacks more important than their severity; influence of epilepsy on moral character most striking in childhood; circumstances which govern prognosis; causes of epilepsy ; its treatment; influence of specifics; of bromide of potass ; importance of moral treatment; of mental occupation.—Treatment and cure of disease imply something higher than mere adminis- tration of drugs.—Conclusion. aIr. President,—Gentlemen,—Two of the faults which this nineteenth century is some- 2 14 SKETCH OF FOUNDERS times charged with are a want of reverence and a want of gratitude. We inherit, it is said, the fruit of their labors who have gone before us: we do not cherish their memories, nor re- turn them thanks. And so, while we feel the honor done to us by our contemporaries in investing us with an office such as that which, by your too partial judgment, I hold to-day, and are alive to the responsibility of fulfilling its duties well, we can scarcely feel aright either the honor or the re- sponsibilit}', unless we for a moment ask who they were that instituted the office long centu- ries ago, and who did it not so much that their own names should be held in remembrance, as that every year something might by it be added to the common treasury of knowledge. In the case of the Lumleian Lectures, the answer to this question is of no common inter- est ; for though they perpetuate the name of one man only, two concurred in their founda- tion, and both of them men who in a remark- able time were themselves most remarkable. It was in the year 1572, when Shakspeare and Bacon were boys, when Raleigh was serving his first apprenticeship to arms with the troops of the heroic Queen of Navarre ; when the strug- gle was at its fiercest between the old religion and the new, and its result seemed doubtful to Europe, struck aghast by the massacre of St. OF LUMLEIAN LECTURES. 15 Bartholomew; when, in England, the Duke of Norfolk had just expiated on the scaffold the weakness which had brought him within the reach of her spells whose fascinations served but to ruin all who yielded to their power; when the throne of this country was tottering, and dark clouds overhung the future, that Richard Caldwell, Doctor of Medicine, and some time one of the senior students of Christ Church, and John, Lord Lumley, executed a joint deed laying a perpetual rentcharge on their lands for the foundation of these Lectures. A strange time of commotion this in which to labor at a work of peace ; and it would imply on the part of one, at least, of the two, that calm trust in an overruling power which well accords with the "doctrina, gravitas, pro- bitas," said by his contemporaries to have been Caldwell's special characteristics. Lumley's share in the transaction we may, I think, look upon as probably an act of friendship sprung from similarity of tastes and literaiy pursuits, which bound together the sober Oxford scholar and the busy, intriguing, magnificent courtier. One would gladly have known more of Cald- well ; but there is little to tell of hi in beyond the fact that he was examined, approved, and admitted into this college, and appointed Censor all in one day, and that in less than six weeks afterwards he was chosen one of the Elects. 16 SKETCH OF FOUNDERS He was of middle age when he joined the col- lege, and his benefaction to it was given when in failing health; for in the same year we find that he and Caius (with whose silver rod you, Sir, have ruled us, as it imports, ''mildly and with clemency") were specially excused on that score from attendance at the college meetings, and two years afterwards he died. Lord Lumley survived his friend nearly forty years, not dying till 1609. He had seen various fortunes. Born of most noble lineage, but the son of an attainted rebel; restored in blood and to his peerage by Edward YI ; high in favor in the reign of Queen Mary—nor much less so, save for one brief interval, in that of her suc- cessor. He married a daughter of the Earl of Arundel, who was one of the most learned women and best Greek scholars of her day; and the monument to his father-in-law at Arundel attests alike his own taste for splendor and for learning. His favor with Queen Mary, his con- nection with the Howards, his share in the in- trigues for rescuing the Scottish queen and placing* her on the English throne, leave no doubt of his sympathy with the old faith. A short experience of adversity taught him, how- ever, a safer, though less noble, course; and we blush to find him on the commission for the trial of her whom he had pledged his knightly word to serve, and to meet with his name in OF LUMLEIAN LECTURES. 17 connection with some of Elizabeth's worst judi- cial tyrannies. But time, which chastens and purifies all but craven souls, so wrought on him that when at length he died, the character recorded of him by (1amden was, "that he was a person of entire virtue, integrity and innocence; and in his old age a complete pattern of true nobility." I confess, to my mind, it is a pleasure to find that the man in the lowlier state was the nobler, truer man, and that our gratitude is due to the scholar and physician who, three centuries ago, sat in your chair, Sir, rather than to the noble- man whose name alone appears as that of our benefactor. But be this as it may, I think there are but few of us who would not hesitate to give these Lectures,—who would not wish to have long- time for preparation, or would not cast about anxiously for something most worthy to be listened to, if either Uichard Caldwell or John Lumle}' were to be of the audience. And, Sir, behind them rises a far greater figure than either, for in these Lumleian Lectures William Harvey first publicly taught his doctrine of the circula- tion of the blood, and did for the art of Medicine what Newton did afterwards for the science of Astrononi}'. Pardon me, Mr. President and Gentlemen, that I have detained you with this preface; but 18 SKETCH OF FOUNDERS to hold the post that Harvey held,—to teach, as it were, from the same place, invested with the same authorit}', and to feel that one has no great truth to unfold, no large addition to make to the common store of knowledge, may well teach one humility, and make one throw one- self, as I do, most earnestly, on your indulg- ence. I have listened, during the past few weeks, in this theatre, with great interest, much profit, and sincere admiration, to the Gulstonian1 and Croonian2 Lecturers; but I have failed to gather from them any encouragement for my- self. They seem to have been admitted to nature's arcana — esoteric disciples they, to whom she has revealed her most hidden mys- teries ; and with an almost despairing feeling I can but cry, "Ars longa," and regret unavail- ingly the shadow gone down so far upon the dial. I have looked too with much anxiety at the lists of subjects which have at different times been selected by my predecessors in this office, and find that for the most part they are great subjects, such as concern the philosophy of Medicine, such as deal with the large principles 1 Dr. Gee, Assistant Physician to St. Bartholomew's Hospital and to the Hospital for Sick Children. 2 Dr. Parkes, F.K.S., Professor of Hygiene in the Army Medical School, Netley. OF LUMLEIAN LECTURES. 19 that regulate our opinions and control our prac- tice. But I cannot hope to follow into those regions ; for I have, indeed, been made to a great degree a specialist against my will, and have been compelled to limit my endeavors to the culture of but a very small part of the field of Medicine, and must, therefore, choose from it such fruits as I can gather there, and plead (an excuse which was allowed of old) the poverty of the bringer for the smallness of his offering. M3- life has been passed very much among the young. I have lived with children; their ways, their wants, their sufferings are more familiar to me than those of grown-up people; and I prefer, therefore, to take some of their ailments as the subject of these Lectures. It is on all hands recognized that the diseases of early life differ in man}- important respects from those of the adult; that not the frailness of the machineiy, nor the imperfect powers possessed b}r children of explaining their suffer- ings, nor the smaller doses of the remedies suited to their tender years, are the only points which call for special attention ; but that also diseases themselves run a different course, symptoms have a different import, the proba- bilities of death or of recoveiy are determined by different considerations in the child from 20 NERVOUS DISORDERS those which govern our conclusions in the adult. I will not, however, occupy your time with matters so trite as these; but, selecting one large class of disorders, will do my best to point out some of their special peculiarities in infancy and childhood. For this purpose I have selected the disorders of the Nervous System ; both because they are the most frequent and the most fatal, as also because their peculiarities are more remarkable than those of ai^ other class of diseases; and this, I imagine, owing to the circumstance that the nervous system is more unformed, its func- tions more rudimentary, its condition one of change and development, the like of which does not take place in the organs of respiration, circulation, or even of digestion. In the case of the respiratory, circulatory, and digestive systems, the peculiarities of early life show themselves rather in the course of actual organic disease than in mere functional disorder. Thus, for instance, valvular affection of the heart is excited by slighter causes, and becomes more speedily associated with hyper- trophy and dilatation in the child than in the adult; bronchitis is more apt to be followed by pulmonary collapse; tubercle of the lung is more generally diffused, and large cavities are rarer; or, again, disease of the mesenteric IN CHILDHOOD. 21 glands, and tubercular deposit in the peritoneum, are more frequent than in the adult; but in the main the functional disorders of these different sets of organs manifest themselves by much the same symptoms at all ages. On the other hand, however, those disorders of the nervous system which leave no trace in the body such as the anatomist can discover, are yet so peculiar in many of their manifestations as to deserve a special notice. I propose to consider them, not in accordance with any scientific arrangement—under which, indeed, they do not seem to me to admit of easy classification—but to examine in succession The peculiarities of disorders of the nervous system in early life, with reference 1. To sensation, 2. To motion, 3. To the power of speech, 4. To the mental and moral powers. In the grown person there is a large class of ailments which consist of simple pain. We call the disorder neuralgia—nerve pain—and mean thereby that such pain is independent of local disease. It is produced by the influence of malaria, it follows on loss of blood, or is asso- ciated with various altered states of the circu- lating fluid; or in other cases, it is impossible 22 NEURALGIA. to determine the exact cause to which it is due. The difficulties of its cure render it one of the opprobria of Medicine, but it does not tend in any wa}r to shorten life, and our patients at last find a sort of dreary satisfaction in the knowl- edge that the malady which renders existence so bitter is yet only neuralgia. In infancy and childhood, however, pain referred to any part signifies almost without exception that disease of some sort or other is going on there, or near at hand. The tears so profusely shed do not prove that pain is the lot of the infant more than of the grown person ; but at one time cries are the only, as they long continue the most expressive, language. Hunger, sleeplessness, fatigue, discomfort of any sort is expressed by cries; while the character of the cry goes far towards helping us to determine the nature of the suffering. But 1 have never in infancy known any instance of pain—severe, obstinate, recurrent—for which, sooner or later, a distinct local cause was not found ; and even in later childhood the rarity of real neuralgia is extreme. There are two classes of cases in which it is of especial importance to bear in mind this caution : the one those cases in which pain is referred to the head ; the other those in which it is situate in one of the lower limbs. In the former case the pain is almost invariably symp- NEURALGIA. 23 tomatie of organic disease of the brain : in the latter with almost equal certainty of hip-joint disease. And yet I have often seen it regarded for many days as purely neuralgic. The mis- take is the more likely to be committed when pain is referred to the head, owing to the un- doubted rarity of intense pain as a symptom of acute disease of the brain, while the severe suffering which sometimes attends cerebral tubercle is almost always associated with some positive symptom or other of organic mischief. But now and then I have seen cases where, after some previous failure of health, and some trivial head discomfort such as scarcely attracted attention, pain has come on, so sudden, so vio- lent as to throw all other symptoms completely into the background, so distinctly and almost completely intermittent, and for a time, even under the influence of quinine in large doses, as to mislead even the most wary. And yet time has undeceived one as to the nature of the case ; the intermissions have become less com- plete, and of shorter duration ; the influence of quinine has passed away ; the intervals between « the paroxysms of pain have no longer been times of cheerfulness, but of indifference to ob- jects around, till the indifference has deepened into stupor, and suffering has abated just in proportion as consciousness has been lessened. It is most difficult to lay down rules for the 24 NEURALGIA. avoidance of error, for while it is undoubtedly true that neuralgia may follow either on some previous ill-defined feverish attack, or may take place during convalescence from typhoid fever, it is just in such conditions that real disease of the brain oftenest comes on; and the latter is of far more frequent occurrence than the former. It may, however, be of some use to bear in mind that neuralgic pain is localized in some part of the head ; that, while it is very intense and accompanied with excessive intolerance of light and sound, it is also often attended with weeping, and the importance of tears as dis- proving the existence of real inflammatory disease either in the head or chest, first dwelt on by Trousseau, cannot be overrated. The intervals between the paroxysms are times not only of perfect ease, but of cheerfulness ; sick- ness is absent, the power of taking food is not lost, and sleep, if not interrupted by pain, is quiet and refreshing. Moreover, there is no dizziness, though there may be heat of head ; the pulse is unusually quick and feeble, and, I must add, may be irregular or actually inter- mittent, for while, as a general rule, irregularity of the pulse is one of the least invariable symp- toms of disease of the brain, there are some children with whom any disorder of the ner- vous system, especially such as is sympathetic with disturbance of the digestive organs, is NEURALGIA. 25 invariably attended with irregularity of the heart's action. Pain, dependent on real cerebral disease is rarely limited to one part of the head; or, if it be, is referred to the forehead. It is generally, though not invariably, less intense, the inter- missions of suffering are less complete, and some one symptom almost always attends the pain: it may be sickness or obstinate constipa- tion, or dislike of light or sound, even when the pain abates—some one symptom, small in itself, but enough to keep alive the anxiety of any one who subscribes to Morgagni's saying that " the habit of observation is the foundation of the art of Medicine." There is, however, one form of real neuralgic headache which is by no means rare in children after the commencement Of the first dentition, and which ceases to occur at puberty, if not earlier, though it not very rarely returns in early manhood or womanhood, and then is what we know so well as the sick headache of hysterical patients. It is essentially an ailment of development incidental to the time when the brain is first called on for the performance of its higher functions, and the whole nervous system is first stirred by the emotions, and ac- cordingly it passes away as the new duties and new feelings become familiar. It does not b}r any means always depend on 3 26 NEURALGIA. over-study, though I do not ever remember meeting with it in children who had not yet gone into the school-room ; and I have fre- quently found it dependent on too continuous application, though the number of hours de- voted to study in the course of the day may not have been by any means excessive. The child's brain soon tires, and the arrange- ment so convenient to parents of morning les- sons and afternoon play, works far less well for it than if the time were more equally divided between the two. The attacks not infrequently come on on awaking in the morning, and become rapidly worse, the pain, which is almost always referred to the forehead, though I have not observed it to be confined to one side, being attended with much intolerance of light and sound, with nausea, and often with actual vomiting. Like the vomiting of sea-sickness, however, previous gastric disorder has no necessary share in its production, and I may indeed add that it is often difficult to assign any special exciting- cause for the occurrence of the attack. The suffering is more often relieved by warm or tepid than by cold applications, and not infre- quently pressure or a tight bandage greatly mitigates it. In no case does the attack last more than twelve hours—usually not more than half that time; it passes off with sleep, and NEURALGIA. 27 leaves the patient weak and with a degree of tenderness of the head to the touch. Such attacks may occur every fortnight, ten days, or even oftener; and the exceedingly unhealthy appearance of the evacuations passed during or just after an attack, and which are often quite destitute of bile, leads to the chil- dren being dosed with mercurial and other purgatives ly those who mistake effect for cause, and who, in spite of repeated failure, still continue most powerful dosing, though it neither relieves the attack nor prevents its return. The frequent return of these headaches, which to the patient's friends is the great source of apprehension, is to us the ground on which we rest our hopeful prognosis. A first attack, indeed, may make us anxious, till we see the manner in which it passes off so speedily and completely, and when afterwards a second or a third attack comes on with the same severity of onset, the same rapid worsening, and the same quick passing awa}r, we know that the symptoms have no grave meaning. In any doubtful case, too, the ophthalmo- scope will certainly be a valuable help to diag- nosis, and I have on two or three occasions derived most useful guidance towards a right diagnosis from the report of some colleague expert in the use of that instrument. 28 NEURALGIA. I said that there was another class of cases in which intense pain has a deeper signification than we might at first be disposed to attach to it—namely, when pain, apparently neuralgic, is really due to disease of the hip-joint. In the majority of instances, pain and lameness come on together, increase slowly and usually simul- taneously, and though the pain be referred to the knee, careful examination will rarely fail to discover tenderness about the hip-joint, and thus to save from the possibility of mistake. But I have seen a few instances of the acute onset of hip-joint mischief in which the pain referred to the knee was intense, completely intermittent, and unattended by the slightest tenderness about the hip, but accompanied by some gastric disorder to which the whole ailment had for cVdys been referred. In other cases, too, the same condition has come on during conva- lescence from some tedious illness, such as ty- phoid fever, and in such conditions the risk of error is perhaps even greater from the circum- stance of the disease beginning at a time when the child was unable, from its previous malady, either to walk or to stand. I will not enlarge more on this, but I shall not think I have said too much if I do but im- press on the minds of any of my younger brethren who may have honored me with their CONVULSIONS. 29 presence, the excessive rarit}r of pain in child- hood except as a sign of local disease. But if the sympathy of the nervous system with constitutional disorder so rarely manifests itself by pain in infancy and childhood, it shows itself by disorder of the motor power with a most wonderful frequenc}'. Imperfect digestion, intestinal disorder, diarrhoea, constipation, too long fasting, too full a meal, the irritation of teething, the onset of acute inflammation, the outbreak of an eruptive fever, all may give rise to convulsive movements, often to a fit of con- vulsions. I need not, however, insist on the frequency of convulsions in childhood, or on the slightness of the causes to which they may be due, but shall occupy your time more profitably in point- ing out some of their peculiarities. First of all, I may observe that convulsions in childhood generally depend on excentric causes, not on primary disease of the brain ; or, at least, do not occur as a consequence or symp- tom of brain disease until such disease has already reached an advanced stage. They mark the irremediable mischief in a case of acute hydrocephalus, they indicate the irritation in the surrounding structure produced by tumor or tubercular deposit in the brain, they do not give the first alarm, nor warn us of the incipient danger. Acute cerebral congestion, such as 3* 30 CONVULSIONS FROM ORGANIC results from sunstroke, or from exposure to a very heated atmosphere, though not to the direct rays of the sun, sometimes sets in with convulsions ; and we not infrequently hear that convulsions in very early life have been the first symptom ushering in that accumulation of fluid in the ventricles which we know by the name of hydrocephalus. Our knowledge of the pathology of the disease would render the accuracy of this statement very doubtful, and I am certain that a careful inquiry will almost always elicit the fact that there has been a stage betokening irritation and disorder of the brain before the sudden outburst of the convulsions. He is but a careless observer whom the sickness and the headache and irregular pulse have not fore- warned of the approach of tubercular hydro- cephalus ; and, as a general rule, subject to but few exceptions, even the slow advance of tuber- cular deposit or of other tumors in the brain can scarcely be overlooked. The convulsions which occur in these latter cases, too, are usually very characteristic. They are confined to one side, frequently to one arm; and the face, though usually, is not always distorted, while the movements are not violent, are seldom of long duration, often unaccompanied by loss of consciousness. The fit is almost always fol- lowed by partial paralysis of the affected side ; and the paralysis, though very incomplete, DISEASES OF THE BRAIN. 31 seldom passes entirely away. In such cases, too, the greater dilatation of one pupil than of the other is almost always apparent, and ought to guard from error, while, in addition, it very frequently happens that the convulsive move- ment recurs at uncertain intervals of several days without obvious exciting cause; without any increase of severity, or more marked loss of consciousness than on the first occasion, but usually followed by an increase of the previous paralysis. Thus much it seems worth while to say about a mistake which it is not difficult to avoid if once we are aware of its possibilhy. Convulsive movements in early life are very frequently partial, but all partial convulsive movements have a great tendency to become general. The form which these generalized convulsions assume seems to depend to a very great degree on the age of the patient. In infancy and early childhood general convulsions are, for the most part, violent, attended by un- consciousness, and by such general disturbance of the nervous power which ministers to the vital organs, that, in spite of their usually short duration, death not infrequently takes place during the paroxysm. They have a tendency to recur at uncertain intervals without obvious exciting cause, and then receive the name of epilepsy; they retard mental development or 32 EPILEPTIC CONVULSIONS. occasion a retrogression of powers already ac- quired, and this in proportion to the frequency of their return and the causelessness of their occurrence. The same class of causes as tend to produce epilepsy in infancy and early childhood com- monly occasion chorea after the beginning of the second dentition, though I have seen chorea in an infant of eight months old, and we all know that there is no age free from the liability to epilepsy. The movements which, in chorea, begin with twitching of the mouth, winking of the e}Tes, uncertain movements of the hand, or an unsteady gait, increase, become general, de- prive the child of the power of walking or of grasping, render even swallowing difficult, and speech impossible. But they do more than this, for they weaken the mind and dull the percep- tion ; and, long after the movements have ceased, the intellectual powers are left impaired by the attack. They are chronic, however, in their course; days, weeks, months, mark their duration, while a few minutes or a few hours are the longest time during which a fit of epi- lepsy lasts, or could last without destro}ring life. Paralysis hardly ever follows chorea; and though the attacks have a disposition to recur, yet in general it is after a longer interval, and in consequence of a more obvious cause than will suffice to produce the return of an epileptic INFANTILE CONVULSIONS. 33 seizure. Unlike epilepsy, too, the attacks of which, if they do recur, generally do so with increased severity, the second attack of chorea is usually less severe than the first, and the third than the second. Partial convulsions tend to become general. It is this fact which gives its importance to the crowing inspiration, the indrawn thumbs, the twitching of the mouth in the young child. The general convulsion which has happened once is apt to recur; and its importance is to be mea- sured not by the present danger only which ac- companies each seizure, but by all that is im- plied in a child becoming epileptic. Be the cause, too, what it may by which the fit is first excited, a paroxysm of whooping-cough or the irritation of thread-worms—something which would seem most temporaiy in its character and furthest removed from any abiding influ- ence on the higher endowments of the nervous system—it yet leaves behind a mark, a stamp, a stain, not unlike what theologians tell us of the flaw which our first parents' sin has left upon our moral nature—a predisposition, in short, to a great evil. The analogy, too, holds good in this, that months and years may pass, the accident even may have been forgotten, when suddenly all comes back again. The ex- citing cause may seem too trivial to produce so grave a result. You ask whether fits have ever 31 INFANTILE CONVULSIONS. occurred before; and you learn then for the first time that they had happened once, or of- tener, months before, or longer still ; but, as the parents tell you, they fancied they were cured, and had even ceased to remember their occurrence. The exact requirements of modern medicine call on me to justify, by figures, a statement so sweeping as that which I have made, and I re- gret that the numbers which I can bring to bear directly upon it are very small. Of 42 epileptic children, not including epileptic idiots in whom the epilepsy and the idiocy might be referred to a common cause, 23 had suffered from fits in infancy, and in 14 of these the fits had contin- ued at irregular intervals of a few weeks up to the time of the patient coming under my notice at an age varying from 3 to 12 j^ears. It did not appear that hereditary predisposition played any very important part in the production of these attacks, since it existed only in 7 of the total 42, and in 3 of the 23 cases. I purposely do not go into the question of the special con- stitutional peculiarities which predispose some infants more than others to convulsions, but I will just say that while I believe most thorough- ly in the influence of the ricketty constitution, all traces of it, if it ever had existed, had passed away in many cases where the fits continued still. Again, my impression is, though I state EPILEPSY. 35 it only as an impression, that the hereditary tendency to epilepsy comes into play later in life than the age of childhood, just as does that to hysteria and to insanity. It is usually with the evolution of the sexual system that hysteria shows itself, and with the pressure of life's cares that the mind is thrown off its balance, and then it is with regard to both that the ancestral taint first displays itself; so, too, is it, I believe, to a great degree with the hereditary tendency to epilepsy. But whatever allowance may be made for the absence of the fullest proof of the views I have expressed, there still remains ground enough for the belief that epilepsy in childhood is to a very great degree dependent on disturbance of the nervous system dating back from infancy ; and on the practical importance of this belief I have no need to comment. Be the age at which epilepsy commences what it may, there is, of course, a great resem- blance between its main features in the child and the adult. Still it may be well to notice that, in the first place, no conclusion can safely be drawn from the severity of a convulsion, or from its general character as to the probability of its frequent recurrence, or of its passing into permanent epilepsy. The severity of a fit certainly affords no reason for this apprehension, nor. does its 36 EPILEPSY. recurrence, so long as a distinct exciting cause can be discovered for each return. The fits which cease in the teething child when the gum is lanced, and which on each succeeding return are equally relieved by the same proceeding, do not imply that there is any great tendency on their part to become habitual. In the same way, the attacks which follow on constipation, or on indigestion, or on some other definite ex- citing cause, may probably with care be guard- ed against, and their return prevented. Those, on the other hand, which come on without any distinct exciting cause, or those which, coming on during teething, continue to recur at inter- vals while the evolution of the teeth is going on, but are not excited by the irritation of some particular tooth or teeth, are much more likely to become permanent. Even though they should cease for a time when teething is completed, they will be likely to return with the commence- ment of the next evolution period, or, in other words, with the second dentition. In later childhood causes acting on the emotions, as, fright, or on the higher mental powers, as over- study, are more apt to be followed by perma- nent epilepsy than those which are confined in their influence to the organic system. If, on the one hand, the violence of a con- vulsive parox3^sm does not by any means impty the greater proportionate risk of its recurrence, EPILEPSY. 37 so neither can any hopeful conclusion be drawn from the slightness of an attack or from its momentary duration. This, indeed, holds good equally in the adult, with whom the petit mal is known to be no less ill-omened than the well- marked convulsion. The frequency of the attack, in short, rather than its severity, is to be taken as the measure of its importance. In the adult we are familiar with attacks of slight epilepsy—the petit mal, as it is termed— which yet we know tend none the less surely to develop into the characteristic epileptic parox- ysm, and which, indeed, we regard with perhaps even more solicitude than the regular epileptic convulsion, as far as their influence on the intellectual powers is concerned. In childhood such attacks are at least as common preludes to epilepsy as in the adult, and are the more de- serving of attention from their very liability to be overlooked. That a grown person should stand for a few seconds, his eye fixed on va- cancy, that he should suddenly stop in the midst of an unfinished sentence, or pause with no obvious reason in the act of writing, or of eating, or of drinking, at once attracts notice, its repetition excites alarm. In the child, how- ever, such things are apt to be overlooked, or to be called bad habits, or to be passed by with some commonplace unmeaning observation which consoles the friends, and with which the 4 38 PECULIARITIES OF EPILEPSY doctor too often feels himself relieved from the duty of careful inquiry and close observation. I believe, however, not only that such an onset of epilepsy is at least as common in the child as in the adult, but that an imperfect suspension of consciousness—the child knowing what passes, though unable to speak—is not very uncommon ; and, further, that it is far from unusual to have the early stage of epilepsy in childhood an- nounced by sudden incoherent talking for a few seconds, or a wild look—a cry of surprise, or a short fit of almost hysterical sobbing announcing the close of the paroxysm. And yet these attacks, as far as ni3' experience goes, pass on into epilepsy ; do not resolve themselves into any condition of hysteria. The early symptoms of epilepsy in childhood are also the more likely to be misinterpreted, from the circumstance that they are frequently accompanied with a moral perversion much more striking than any loss of mental power, and which, I believe, indeed often precedes it. AVe can judge the intellectual power of the adult; we know that a man was prompt in business, accurate in ac- counts, and so on ; and if he have well schooled his heart, the intellectual weakness will often show itself before the moral failing. With the child, however, it is just the opposite ; there are, in early life, alternations of intellectual activity and mental indolence; of quickness IN THE CHILD. 3D and comparative dulness, which all who have had much to do with education are well aware of, and which are perfectly compatible with health of body and health of mind. But changes in the moral character of a child who is still under the same influences have a far deeper meaning than is often attached to them ; a child does not suddenly become wayward, fretful, passionate, mischievous, except under the pres- sure of some grave cause, into which it behooves us to inquire, and which we shall seldom fail to discover. One other point there is also to bear in mind: namely, that the child is impelled by the vague sensation of hitherto unknown dread not to conceal the early symptoms of epileps3' as the grown person would do; longing as the child does for love and sympathy, and weakened in its moral force, it craves for more love, more sympathy, it exaggerates its S3rmptoms, it assumes some which do not exist at all. The conclusion is a natural one, but none the less untrue, that the child who is discovered to be shamming has nothing the matter with it—is simply a naughty child. In the child as in the adult, epilepsy blunts the intellect as well as weakens the moral power; and does both more speedity and more effectually in proportion as the child is younger, and its mind and will are less developed. It is 10 PROGNOSIS IN EPILEPSY. the young plant stunted and deformed, not the old tree withered. I need not say how far sadder is the former than the latter. And yet this has its compensation ; for, as the powers fade quickly, so, if the attacks cease, they re- cover with surprising rapidity, and as the moral powers are the first to suffer, so they are the first to regain—I will not say full vigor, but at least a degree which raises the children to be objects of specially tender affection, rather than of pity and compassion. I do not propose to enter into detail on the wide question of the treatment of affections of the nervous system in early life. To do so use- fully would require that 1 should go into minute particulars, that I should appeal to the evidence of figures, and that I should guard each state- ment by a reference to cases—a course right and necessaiy in a treatise, but out of place and irksome in brief lectures such as these. Still, it might seem a grave omission if I were to pass over entirely unnoticed the cir- cumstances which govern our prognosis, and the principles which regulate our treatment. We are, in cases of convulsions especially, asked with so much anxiet3r as to the prospects of the child. Will it get better ? will the fits return ? are the3* epileptic ? will they affect the mind? are questions we often have to listen to, too often without being able to return to them a PROGNOSIS IN EPILEPSY. 11 satisfactory reply. To the question whether fits are epileptic, I alwa3's answer that the name of epilepsy is given to convulsions occurring at uncertain times, and without obvious exciting cause, and that therefore the less frequent the return of the attack and the more definite the cause which produced it, the greater is the ground for hope; so that, consequently, a severe fit seldom happening is of far less serious im- port than are slight seizures if frequent and apparently causeless in their return. The more definite the exciting cause of an attack, the brighter the prognosis. The fits which persist from earliest infanc3r imply the existence of some congenital cause for their occurrence, and leave but little ground for the expectation that they will ever cease. Attacks which coincide with teething have a different import according as they occur only while local irritation is pro- duced b3r some particular tooth, and cease when it has pierced the gum, returning only with the approach of another tooth to the surface; or, as on the other hand, they seem induced by the constitutional disturbance which attends the whole period of dentition, and so continue in- differently during the pauses in the eruption of the teeth, as well as during their active evolu- tion. The difference, in short, is the same as we sometimes see about the approach of woman- 4* 12 PROGNOSIS IN EPILEPSY. hood, when one girl will suffer from hysteria or headache, or other symptoms of disordered nervous system, only at the menstrual period, while another will experience these ailments during the whole time of the evolution of the sexual S3rstem. In the former case, the symp- toms will probably cease when development is complete; in the latter the3r are veiy apt to continue all through life. The convulsions which sometimes complicate the so-called spas- modic croup seem to have a much less tendency to terminate in cpileps3' than fits which come on without any previous laiyngeal spasm, even though the\' should be of far less frequent oc- currence. The explanation of this I suppose ma3* be that the fits of laryngismus are conse- quent on the spasmodic closure of the glottis, and that this spasm is due to the local irritation of special nerves by the teeth or by indigestible food taken into the stomach rather than to a more general disorder of the nervous S3'stem. This fact, too, is but an illustration of the law already laid clown as to the definiteness of the exciting cause lessening the gravity of the prognosis. The fits which become epileptic oftener come on during the cutting of the first four molars than at either an earlier or a later period of dentition, and it is seldom that den- tal irritation produces convulsions either from deca}' of the first set of teeth or during the PROGNOSIS IN EPILEPSY. 43 appearance of tlie second set, though to both of these rules I have seen occasional exceptions, especially in cases where, from the narrowness of the jaw, the teeth of the second set are ex- tremely crowded. Intestinal irritation and disorders of the di- gestive organs are at all times in eav\y life a frequent occasion of convulsions, and almost the sole removable exciting cause after the completion of the first dentition. I do not, however, think that worms are b3r an3r means so frequent an exciting cause of fits as the3' are assumed to be by the public, whether lay or medical. The nervous symptoms which are sometimes dependent on tape-worm are not only rare in their occurrence, but also seldom assume the form of epilepsjr; and though I have once or twice seen violent epileptic convulsions de- pendent on thread-worms, still, in these cases the worms were present in great numbers, and the convulsions, which ceased on their expulsion, did not subsequently recur. Intestinal disorder is sometimes erroneous^ assumed to be the cause of epileptic fits, in consequence of the ex- ceedingly unhealthy appearance of the evacu- ations voided a few hours after their occurrence. The inference, however, is often incorrect. The action of the liver and the functions of the digestive organs are arrested or disordered by the nervous shock which manifested itself by 11 PROGNOSIS IN EPILEPSY. the convulsion, and hence the vitiated secre- tions which are afterwards expelled. It is the state of the secretions before a fit, and not after it, on which our conclusions must be founded. Small unsuspected causes not seldom have to do with the occurrence of convulsions, and with their prevention; and a careful record of a child's life for weeks or months will often throw upon the case a wholly unexpected light. Hence, whenever a child is brought to me, in whom, from the apparently causeless occurrence of convulsions, there is ground for apprehend- ing epileps\', I always direct the parents to keep a tabulated statement of each day's histoiy, containing a separate column for food, sleep, evacuations, temper, medicine, if any is given, and convulsions, in which last column the hour and circumstances, of their occurrence, their character and duration are all recorded. Over and over again I have by these means dis- covered a wholly unexpected clue to the in- terpretation of a case which seemed most ob- scure. Of all cases of epileps3r, those in which dis- orders of the digestive organs pla3T a leading part are the most hopeful. These are the cases to which the principle which lies at the bot- tom of the plan of the late distinguished Ameri- can physician, Dr. Jackson, and which con- sisted in the adoption of a diet exclusively of MEDICAL TREATMENT OF EPILEPSY. 45 milk and of farinaceous substances, is applica- ble. I sa3T the principle, for that I apprehend to consist in supplying a food which is simple, unstimulating, and easy of digestion; and the withdrawing meat, the diminishing the total quantity of food, and regulating the intervals at which it is given, is sometimes followed by almost unhoped-for results. The power of di- gesting the curd of milk, which varies much in different children, of course governs the de- gree to which an exclusively milk diet can be carried out in practice. It were worse than idle before such an audi- ence as I have the honor to address to go over the commonplaces of medical practice, but I may be expected to say something as to my experience of specifics for epilepsy. I have tried all, or almost all, in favor of which any reasonable evidence could be adduced, and all have failed. The only one which has ap- peared to me to exert any specific power over epilepsy is the bromide of potass, and in a few instances its results have been most remarkable. It hardly ever fails to arrest the frequency of attacks; now and then it has seemed entirely to prevent them; and the crucial test of arrest- ing fits by bromide of potass—of suspending the remedy and seeing the fits return, and of once more putting a stop to them by the re- sumption of the medicine, has on some occa- 16 MORAL TREATMENT sions established its value beyond question. In the great majority of cases, however, the amendment has not entirely maintained itself; the system has after a time become habituated to the remedy, and after several augmentations of the close, each of which has seemed to renew the old influence, I have been compelled to dis- continue it in consequence of the depression of the pulse, the general loss of power, and the appearance of the peculiar pustular eruption which occasionally follows its long-continued use. In other cases, too, the agent which at first worked wonders, ceased to have any influ- ence. The constitution tolerated the increased dose, but so did the disease; the patient con- tinued to take the medicine, but the fits, though once controlled, returned after a time just as before. Still, with all these drawbacks, the bromide remains the only agent which, in my hands, has made the least approach to the character of a specific. I always employ it when I can find no distinct indication to guide me. I confess that I use it empirically, for I have found no means b3T which to distinguish before- hand the cases where the bromide will do per- manent good from the other apparently similar, but much more common instances in which its influence is merely tempora^. One point still remains connected with the OF EPILEPSY. 47 treatment of epilepsy to which I cannot abstain from referring. This is the influence of moral control in lessening the frequenc}' of epileptic seizures. Over and over again children are received into the hospital hopelessly epileptic; with the histoiy of attacks recurring three or four times a week, or oftener still. They remain a week or a fortnight, or even longer, in the in- stitution, and during this time not a single at- tack occurs, or perhaps one, just enough, in short, to show that the disorder is not cured, but only kept in check by the regularity of the gentle rule to which the little ones are subjected. The order goes for much in these cases; the novelty goes for something too; for almost in- variably I have found that after a time the ap- parent improvement became less marked, and, though they continued better than when the37 first came to the hospital, the children were still epileptic ; the advance of the disease had been retarded, but its progress had not been arrested. It is a common observation that the epileptic will pursue difficult and dangerous occupations with safety, like the bricklayer mentioned b3' Sir Thomas Watson, who was the only man in the neighborhood who would venture to repair the tall chimney of a manufactoiy, and who, when so engaged, never experienced a seizure. The unconscious influence of mental preoccu- pation in lessening the severity of an attack, 48 MORAL TREATMENT which it may yet not altogether prevent, receives a further illustration from the history related by M. Trousseau of the architect who was occa- sionally seized when on the scaffolding of a building, and then ran backwards and forwards, uttering a cr3r, but who never fell from the gidcty height, and soon regained his conscious- ness, and continued, as though nothing had happened, to give directions to his workmen. It is in the morning hours too, soon after waking, or on first rising, that the attacks oftenest come on; or else when undue exertion, either of mind or bod3^, has tired for a season the nervous energies. The careful regulation of exertion both of mind and body, the control of the moral feelings, the imparting self-command, the put- ting new objects of interest before the awaken- ing spirit, these are the means that we must employ if we would prove ourselves worthy of the highest meaning of our vocation. Medicus imports one who cures, and the knowledge of the powers placed by God in minerals, roots, and herbs is but a part of what we are bound to know. The Goddess of Health gave her name to the Greeks who practiced our art; and our English leech and leechcraft are terms which have no reference, as the mere sound of the words might seem to import, to bloodletting. They are found in the Gothic and cognate lan- guages with the sense of healer and the art of OF EPILEPSY. 49 healing, associated with the idea less of reme- dies administered than of supernatural powers called into play to cure. Even though we reject the supernatural ele- ment in the histories of cures wrought by pil- grimages to distant shrines, since, perchance, as one of our great historians has well said, u Man now knows too much, believes too little," there still remain the influence of moral control, of the fixed direction of the mind to one great object, the novelty of the journey, the expecta- tion of a cure, all contributing to the recovery of the patient as much as the remedy prescribed or more. "Think! could we penetrate by any drug, And bathe the wearied soul and worried flesh, And bring it clear and fair?" It was well and wisely done to separate our profession from the church ; but it were ill done and unwiseby, even for our patients, if, with what some nniy consider an antiquated faith, we also put aside our belief in all remedies which do not admit of being weighed or meas- ured, and whose names are not recorded in the British Pharmacopoeia. 5 50 CHOREA. LECTURE II. ON CHOREA AND PARALYSIS. Chorea; its study more hopeful than that of epilepsy.— Remarkable liability to it of female sex.—Apparent in early childhood, therefore independent of influence of sexual system —Proportion of sexes opposite in cases of epilepsy.— Causes of chorea various.—Reasons against universal application of theory of embolism—Rarity of hemichorea.—Analysis of sixty-six cases of chorea.— Relation of chorea, to rheumatism and to disease of heart.—Comparative rarity of emotional causes of chorea —Various modes of onset of chorea..— Nature of heart-affection which attends it. — Paralytic element in chorea.; illustrative case —Temporary impairment of intellect.—Treatment of chorea ■—Tendency to sponta- neous improvement — Mental and moral influence, and cases where it proves of service.—Oym.nastics.—Inter- nal remedies: tartar emetic; sulphate of zinc, its occa- sional power as a specific. Paralysis.—Diphtheritic paralysis —Temporary paraly- sis after long illness. — Tardy acquirement of power of walking, or loss of it.—Share of rickets in producing it.—Loss of power supposed to be paralytic, from dis- ease of spine or of hip-joint.—Paralysis of idiots, and that from cerebral tubercle. — Characters of infantile paralysis —Importance of habit of minute observation. Mr. President and Gentlemen.—The trans- ition which we make to-day from the study of epileps3r to that of chorea may be unscientific, CHOREA. 51 but it has at least the merit of practical con- venience. In the former lecture we had to do with cases in which convulsions are sudden in their onset, often violent in their manifesta- tions, generally brief in their duration, accom- panied with temporaiy loss of consciousness ; ceasing indeed complete^ for an uncertain time; but tending to recur without obvious cause, and by degrees to arrest the develop- ment of the mind, to degrade and debase the moral powers, and thus presenting to us in its hardest form that problem which philosophy blunders at and revelation does not attempt to solve—how and why is it that infinite good and almost infinite evil stand together in this world of ours ; why the coin fresh minted should have its image and superscription blurred and ef- faced so soon. But we must leave the ques- tion ; for our better knowledge denies us the solace which the poor Savoyard finds when a Cretin child is born to him, and grows up with his other little ones, among them but not of them. " It is Christ's child," sa\*s he ; " its soul has sta3red above to serve as sort of angel guar- dian to the rest on earth, to welcome them to heaven." A fond and foolish superstition it is true, but wiser perhaps than some of our philos- ophy in this, that an inexplicable riddle and an awful affliction do not shake the peasant's sim- ple faith in an overruling good, that he detects 52 RELATION OF SEXES what the wise man too often fails to hear; how "Through the thunder comes a human voice ; •"' and the sage's doubt, scarcely his hope, above his expectation, " So the All-Great were the All-Loving too," lies at the bottom of the poor man's belief; is not seldom almost the only article of his creed. To-day we deal with a less painful subject, with convulsive movements gradual in their onset, slow in their progress, unattended with any disposition to permanent impairment of either the mental or the moral powers ; little amenable indeed to treatment, but tending usu- ally to a spontaneous though gradual recoveiy. These convulsions indeed, like those of epi- lepsy, are apt to recur, but with the remarkable peculiarity that their first attack is commonly the severest; that their evil effects very rarely outlast the period of youth, and that it is unu- sual for them to occur in adult age. It was at one time supposed that these con- vulsive movements were mainly connected with the changes of approaching puberty, and their greater frequenc3' in the female sex than in the male was not unnaturally associated with the greater importance of the changes which the development of the sexual system brings about in the constitution of the girl than of the boy. IN CHOREA. 53 But though the fact of the greater liability of the one sex to chorea is undoubted, so that of 175 children suffering from it who were admit- ted as In or Out-Patients of the Children's Hos- pital, 499, or 64 per cent, were girls; still not only were all of these children under the age of ten, but 66 out of 102 of the number were under the age of 5. At the same time the dif- ficulty thus presented to us is not solved b3* what might seem to be the ready explanation that girls are on the whole more liable to con- vulsive affections than boys; since of 758 epi- leptics under the age of ten, 409 were boys, only 349 girls. The carefully compiled tables, too, of my friend and colleague, Dr. Gee, published in the Bartholomew's Hospital Reports, and which make up, by the care with which the facts have been collected for the smallness of their numbers, illustrate the same point. He found that of 48 cases of laryngismus in rick- etty children under the age of three, 34 occurred in males, only 14 in females; and out of an equal number of cases of general convulsions under the age of 3 J years, 33 occurred in boys, 15 in girls. We may therefore take the fact, I do not attempt its explanation, that as with acute hydrocephalus and all the graver forms of disease of the nervous system, whether acute or chronic, the liability of the male sex prepon- derates ; so all through life the slighter forms 5* 54 CAUSES OF CHOREA. prevail in the female sex. Neuralgia, chorea, hysteria, are the special heritage of woman from her earliest 3rears, as much as the gentle voice, the flowing hair, the graceful form. But not only does the hypothesis which would connect the occurrence of chorea of necessity with an3T of the changes which attend or prelude the period of puberty fall to the ground when carefully examined, but equalty untenable are the various other theories which would refer the occurrence of chorea exclusively to one set of causes. Digestive disorders of various kinds, debility, anaemia, variously altered states of the blood, such as exist in rheumatism ; or even actual lesion of the brain itself, such as embo- lism of the small vessels of the corpus striatum, have been put forward less as possible factors of the disorder than as invariably producing it. Now, with the most sincere respect for the dis- tinguished Eellovv of our College who has pro- pounded this last theoiy, I do not think that the clinical history of chorea at all bears out the supposition that it is dependent on any invariable organic change, any more than on disorder of- any one set of functions. The occasional suddenness of its occurrence, the more frequent tardiness of its development, its tendency to recoveiy, but nevertheless to return at long, uncertain intervals, and with the pecu- liarity of the subsequent attacks being almost CAUSES OF CHOREA. 55 nvariably milder than the first, all appear to me to tell against such a theoiy as affording a constant explanation of the disorder. More- over, it is very rare for chorea to continue limited to one side. I found it confined to the right side in one, and to the left in two, out of 66 cases; and though it generally begins on one side, whence it extends to the other, the side first affected usually, though not always, con- tinuing to be affected the more severeby, 3ret the instances are far from unusual in which both sides of the body, both upper and lower extremities, are affected from the very first. In such cases a general unsteadiness of gait and uncertainty of grasp, and strange distortions of the face under any# excitement, or even inde- pendently of excitement, are the first symp- toms which gradually deepen into chorea. The great rarity, too, of paralysis as a permanent sequela of chorea ma}T be alleged as another reason for doubting its usual dependence on any form of organic change. There is, I know, no error greater or more mischievous than that which leads one to draw too wide a conclusion from scanty data. I give, therefore, the following analysis of 66 cases rather as a contribution towards our knowledge of the subject than as adequate to establish any fact beyond dispute. Of the 66 cases, 20 were male, 46 female. 56 ANALYSIS OF In 14 cases, the right side, and in 14 the left was the first affected. In one case only did the movements remain limited to the right side ; but in eight, having begun on the right side, they continued through- out to be more severe on that side. In two cases the movements remained throughout limited to the left side, and in three more they were severer on the left than on the right side. In the remaining 38 cases the movements affected both sides from the very first, or if there were any affection of one side earlier than the other, the difference was not such as to attract the observation of friends. In eight of the 38 the right side continued throughout the more affected, and in one the left; but in the other cases there was no such predominant affection of one side as to be noteworthy. It must be added, first of all, that affection of the- arms almost always precedes that of the legs, even when both sides are equalty involved, though I do not think the arms are the first to recover ; and, in the next place, it is very rare for improvement to advance on both sides with equal rapidity, but power is commonly acquired much more quickby on one side than on the other. The above facts show a disposition, though not a ver3r marked disposition, to affection of SEVERAL CASES OF CHOREA. 57 the right side more than of the left; but at the same time they prove the cases in which the disorder involves both sides to be by far more common than those which could with any justice be termed hemi-chorea. The same cases yield results not altogether without interest as regards the causes of chorea. In 16 instances rheumatic symptoms accom- panied or preceded the chorea. In 11 of these the heart's sounds were accom- panied by a systolic bruit, which persisted after convalescence in 10 of the number. In one of the 16 cases rheumatic symptoms and heart disease, which latter was very ex- tensive, followed in the course of the chorea; but in all the other cases the rheumatism pre- ceded it, sometimes immediately, sometimes at an interval of several weeks. In nine cases, though no rheumatic symptoms were present, and though there was no history of rheumatic affection, the heart was found to be already the seat of valvular disease when the patients came under observation. In two cases chorea came on during scarla- tina. In one of these cases the heart was not affected; in the other the heart disease was so grave as to occasion the patient's death. In one instance it succeeded to measles. In 12 chorea was preceded by general failure of health ; a temporary bruit accompanied the 58 CAUSES OF heart's action, which ceased with the patient's recovery in one of these cases. In one instance it was attributed to overwork. In six it was referred to fright, and in one of these six cases there was a temporary bruit, and in one a murmur which persisted. In the remaining 19 cases no special cause was assigned for the occurrence of the disorder; the movements in each case having been the first evidence of failing health. Four of these cases, however, were secondaiy attacks ; in two of them a first attack had followed rheumatism; in one had succeeded scarlatina. In the fourth instance the first attack had succeeded to scar- latina, while the second, like the third, in which the patient came under my notice, had been apparently causeless. In this case there was a temporary bruit, which disappeared as the chorea improved; in the other there was not even temporaiy affection of the heart. I may further add that there does not seem to be any connection between the presence or absence of rheumatism or of heart affection, or of both, and either the severity of the chorea, or the tardiness of recoveiy, nor does there seem to be aii3r special disposition to the recur- rence of chorea in those whose first attacks were associated with rheumatism. But though this be true, there is undoubtedly a connection between that state of constitution CHOREA. 59 which predisposes to chorea and that which predisposes to rheumatism ; and both these tendencies predominate in the female sex. There is, I am aware, an impression that chorea is more common in the female, rheumatism in the male sex; but however the special exposure of the male to variations of temperature and other exciting causes of rheumatism ma3rmodif3r the results in the adult, before the period of puberty the preponderance of liability to rheu- matism is found to be decidedly with the female sex. Of 520 cases of rheumatism in children under the age of 12, and mostty under the age of 10 years, admitted either as in or out-patients into the Children's Hospital, only 243 were male; 277 were female children. If, for the sake of being surer of our diagnosis, we leave the out-patients out of consideration, we arrive at a total of 84 rheumatic boys to 88 rheumatic girls. But as 4357 boys were admitted to 4080 girls, we have a proportion of one rheu- matic bo3T in 51.8 to one rheumatic girl in 46.3. That a relation exists between the two con- ditions seems, then, to be be37ond doubt; but at the same time this relation is far from con- stant. It is by no means limited to cases of severe chorea, nor to those cases, on the other hand, in which rheumatism is specially severe, or in which it is complicated with heart affec- tion ; while in some instances, though but 60 VARIOUS FORMS rarely, the chorea occurred first, the rheumatism afterwards. Slight rheumatism followed by severe chorea, severe rheumatism succeeded by slight chorea, heart disease associated with chorea, or chorea followed after some time by heart disease, all point to some one fact under- lying all these its varied expressions. I hesitate only to attribute to it so universal an applica- tion as is suggested 03- Dr. Hughlings Jackson, and prefer to treasure up these facts as mate- rials towards the solution of a question as yet unanswered. One other result of some interest may be deduced from these facts, namely, the compara- tive rarity of the emotional causes of chorea to which common prejudice attaches so high an importance. M3' own impression, too, founded independently of these facts, is that emotional causes do not really come so much into play as is commonly supposed. I recall but one in- stance in which excessive mental work could fairby be put clown as the cause of chorea in a child ; and in none of them in which the dis- order was said to be due to fright was the result immediate, but sometimes a week, ten days, or even a fortnight elapsed between the supposed cause and the occurrence of the symptoms. It is, perhaps, worth while just to remark here that affection of the facial muscles is not an early s3rmptom of chorea, but comes on about OF CHOREA. 61 the same time with disorder of the muscles of deglutition and impairment of the power of speech. I refer to this in order to guard against the grave anxiety of friends which is often ex- cited by the grimacing of nervous children, the working of their eyes, and twitching of their mouth. Their apprehensions are, I ma3T say, usually unnecessary, in so far at least as the risk is concerned of the symptoms developing into regular chorea. It would ill become me, before such an audi- ence as this is, to go over all the old familiar details of the symptoms of chorea, still less, with unskilled hand, to retouch Sydenham's famous portraiture of its features. It is, how- ever, perhaps not altogether out of place to notice the veiy various modes in which the disorder makes its onset, assuming, one knows not wiry, now an acute, then a chronic form. In one case, within a week after the commence- ment of the ailment, the child ma3r be unable to stand, unable to grasp an3r object, or even to remain quiet in bed, and yet the irritability of the nervous system rmay not be aggravated b3T the disorder being complicated with an3r heart affection ; and it may not prove either extra- ordinarily severe in its character, or peculiarly rebellious to treatment. Those cases are, I think, graver in character which, having set in comparative^'' mildly, undergo after the lapse 6 62 HEART DISEASE of two or three weeks a "sudden exacerbation. In such circumstances a bruit previously un- heard has sometimes been found accompanying the heart's action, and has proved by its per- sistence after the patient's convalescence that it was due to some abiding lesion of the heart, and neither to irregular spasmodic action of its muscular fibres, nor to alteration in the blood. Hut I must add that I do not connect the worsening of the s3^mptoms and the superven- tion of disease of the heart as cause and effect. I do not, indeed, know to what to attribute it, for I have seen two cases at one time running a similar course, their s3rmptoms worsening at the same time, and equally without evident external cause, in one associated with the super- vention of cardiac mischief, in the other without it. It is true that very mild chorea is unaccom- panied b3' heart disease, and it is also true that the heart affection of chorea is in many instances non-rheumatic, and also that the rheumatic heart affection is exclusive^ endocardial. Moreover, the evidences of dilatation of the heart are not only very remarkable in some cases, but are also very rapidly progressive. The doubt has occurred to me whether the heart affection may not in some of these cases be due to the dis- turbance of the organ in its attempts at regular contraction, and to the consequent yielding of AND CHOREA. 63 its walls, rather than to the trouble produced by actual valvular disease. It would seem, indeed, to have been so in the following case: A girl, nine 3'ears of age, had suffered from chorea for about three months before she was •received into the Children's Hospital. The chorea had come on apparent^' causelessby three weeks after convalescence from a mild at- tack of scarlatina. The child, for a month be- fore admission, had been unable either to speak or to feed herself, to walk or to stand; and the weakness and loss of power were out of pro- portion to the severity of the choreic move- ments. The latter lessened still further, and there came some slight increase of the feeble muscular power ; but the distress produced by the enormously dilated heart grew worse and worse, and the heart itself, as ascertained 03^ physical examination, became rapidly larger. When first admitted into the hospital, in addi- tion to a loud prolonged murmur accompany- ing the heart's first sound, a distinct thrill was perceptible by the hand placed over the cardiac region. A month later this had disappeared. The urine became albuminous, the patient grew anasarcous, the right external jugular vein be- came blocked with coagulum, and a few weeks after admission the patient died suddenby. A post-mortem examination discovered no affec- 64 HEART DISEASE, tion of the pericardium, no valvular disease, but enormous dilatation of the auriculo-ventric- ular orifices, and an old clot in the right auricu- lar appendix. It seems to me that we have not yet learned all that it were well for us to know with refer- ence to heart affection and its relation to cho- rea. It is worth something to know that the circumstances which predispose to rheumatism predispose to chorea too, and worth still more if, with our ingenious colleague, we can follow step b3" step the way in which sometimes at least the secondary mischief is done, and the part which should preside over movement is rendered unstable in the performance of its functions. It would, however, be worth still more if we could ascertain by careful observa- tion that disease of the heart is sometimes a consequence, not invariably a cause, of chorea, and if, guided b3T this knowledge, we could suc- ceed in controlling its disordered action, and become skilled to prevent, not merely to regis- ter, its defects. But chorea sometimes begins almost imper- ceptibly, and advances by very slow degrees, being in such cases often limited for several weeks to one side, and continuing through its whole course to affect one side very remarka- bly. In such a case the movements are often but slight, perhaps almost none while the pa- PARALYSIS, AND CHOREA. 65 tient is at rest, but become obvious so soon as the muscles are called into action. The para- bytic element in such cases is often very marked, and I have seen instances of alleged hemiplegia in children avIio were really suffering from cho- rea. In some of these cases, too, the anxiety of the friends has been all the greater in conse- quence of the dulling of the intellect, which is so frequent an attendant on chorea, and which has made them entertain the gravest apprehen- sions with reference to their child's mental as well as to its bodily condition. In every case of chorea, over and above the uncontrollable movements, there is always a more or. less considerable loss of muscular power. The two conditions always stand in a certain relation to each other, but the paralytic state constantly outlasts the unsteadiness of movement; as is easily found if one asks a pa- tient convalescent from chorea to grasp one's hand. The loss of power is no doubt in some degree due to fatigue ; just as any person, who at night has suffered from cramp in the leg, feels the limb tired in the morning. I may acid, by the by, that one of the reasons for confining the limbs of a patient with severe chorea is, by les- senino- the degree of muscular movement, to lighten thereby the fatigue, and the consequent loss of power. Sometimes, however, the para- lytic condition remains throughout far in excess 6* 66 PARALYSIS of the choreic movements, and such cases are usualby particular^ tedious and difficult of cure. A boy, six and a half years old, who had never had rheumatism, and in whose family no disposition to it existed, began to have cause- less attacks of night terrors five weeks before admission into the hospital. In a week or two he complained of pain in his limbs, and began to lose his speech, and for ten days had been confined to his bed. The rheumatic pains were by no means severe, and were unattended by fever, but there was a loud systolic murmur at the heart's apex. The child was well nourished, but pale and flabb3T. He lay in bed with a con- stant twitching of the angles of his mouth and of his e3'es, and his fingers were never still. His arms moved slightly from time to time, but he had no power to raise them, nor to move them otherwise than horizontally ; while, though he could manage to stand with his legs wide apart, he could scarcety move his legs to walk. In the course of a fortnight the pains had ceased, but the loss of power was even more complete, so that the child became unable to turn in bed, and, except for the continuance of the twitching, the case had much the character of diphtheritic paralysis. Gradually the move- ments quite ceased, but left the child, at the end of six weeks from admission, still quite helpless. In two weeks more he began to move his arms AND CHOREA. 67 a little ; in another week he sat up; in a few days more he was dressed ; and ten weeks after admission, between fourteen and fifteen after the commencement of the illness, he went out quite well, except that the bruit persisted. Five months afterwards he re-entered the hospital, with a relapse of chorea; the move- ments being much more marked than before. The face twitched, articulation and the pro- trusion of the tongue were difficult, and, in short, the only respect in which the case differed from one of rather severe ordinary chorea was that, before the movements began, the child had complained of stiffness as well as of pain in the legs. Strychnine was given him, which, with- out benefiting the chorea, produced two or three attacks of convulsions, although the medicine had not been employed in an excessive dose. All remedies were suspended, and at the end of three months of gradual but stead3r improve- ment, the child went out convalescent. Four years after he returned, with acute rheumatism, the pain and swelling, however, being inconsiderable, though there was a good deal of delirium at night, and the general con- stitutional disturbance was out of proportion to the febrile movement. At the end of ten days general choreic twitching came on, and then in a few days were superadded paroxysms of un- controllable movement of the limbs, with a ten- 68 PARALYSIS deney to opisthotonos, but unaccompanied by loss of consciousness. These attacks lasted for a few minutes, and then left the boy in the same state as before, except with a lessened power over his limbs, though the paralysis never became so complete as on the occasion of his first attack. He continued at his worst for about a week, then gradually mended, and went out well at the end of three months, except in so far as his heart was concerned. That, how- ever, had become much more dilated, and its functions were performed with much more difficulty and discomfort than previous to the attack. Since that time, flow four years ago, the boy has not come under my observation. There is much that is enigmatical in chorea. To one of its peculiarities, the aphasia which often accompanies it, and which is not de- pendent on mere inability to employ the muscles which subserve articulate speech, I shall refer at the next lecture. The impairment of the intellect, however, like the loss of muscular power, deserves a moment's notice. The silli- ness of manner of the chorea patient is not ap- parent onby, or due to the unavoidable distor- tion of the features, but is veiy real, and increases with the severity of the ailment, till the state becomes one of hebetude, in which nothing is done, nor endeavored to be done, AND CHOREA. 69 the mind seeming to be wearied as the bocby is. Both, however, recover, though at uncertain rates ; one child remaining dull, and listless, and foolish, for weeks after movements have ceased, the other brightening as soon as the movements have begun to lessen, and long before power has returned to the limbs. It is, too, as one would expect, the emotional side of the faculties which suffers most, and the child who can repeat correctly, though not very in- telligibly, long passages of poetiy, will yet long remain fretful, impatient, passionate, prone to bursts of tears. But still I know no instance where the mind did not at last perfectly regain its balance, and the mental faculties show them- selves quite unimpaired. The instances, too, are of extreme rarity in which there is any permanent impairment of the muscular power. One girl who had had chorea, affecting chiefly, though not exclusively, the left side, was found, three months after the complete cessation of all choreic movements, to have but imperfect power over her left side. She dragged her left leg- slightly, which was a quarter of an inch shorter than the right, while the girth of the left arm was half an inch smaller than that of the right. One child, too, who had had severe chorea, affecting all her limbs, and who, during the acute stage of the disorder, had kept her hands firmly clenched, was found to have wasting of 70 CHOREA: the muscles of the right thumb and of the interossei—a condition, in short, of progressive muscular atrophy ; for it did advance in the hand, but it not only did not extend to the forearm, but the wasting of the muscles ceased, power gradually returned, and at the end of about five months the difference either in power or in muscular development between the two hands was very slight, and improvement was still going on. Such cases, too, are but the exceptions which, according to the common proverb, do but prove the rule which warrants us, I think, in speak- ing hopefully of the issue in all respects of chorea, except in so far as the grave complica- tion of heart disease may warn us to be reserved in the expression of our opinions. And now I will endeavor to give, in as few words as I can, the results of my experience with reference to the treatment of chorea. In estimating the value of different remedies and of different modes of treatment, it must not be forgotten that chorea is one of those affections in which there is a tendency to spontaneous recoveiy. Not only does this show itself in almost all cases where improvement has taken place up to a certain point under the influence of remedies, but very often the improvement, once advanced to this point, goes on to perfect recovery with the same rapidity, whether these ITS TREATMENT. 71 remedies are continued, modified, or altogether abandoned. Now and then, too, we meet with instances in which even the severer forms of chorea, after bidding defiance to all remedies, spontaneously improve when all have been dis- continued, and such improvement is as com- plete and as lasting as that which we ever attain by any kind of medication, or by any form of treatment. Xext, it is important to remember that there are certain forms of chorea over which mental and moral culture have the most salutary in- fluence, and in which recovery is brought about by these, wholly independent of the internal remedies employed. There are, however, two classes of cases to which this moral treatment is inapplicable. First, it is inapplicable to, and powerless to control, those forms of partial chorea that con- sist in winking the eyes, in grimacing, or twitch- ing the muscles of the face or of the neck, and which are sometimes a source of great annoy- ance and anxiety to parents. Such cases, it must be owned, are often very pertinacious, and the condition occasionally, though less fre- quently than is feared, lasts through life. For the most part, the condition is due to some temporary irritation of the nervous system— generally, I believe, to mental strain ; not of necessity to undue length of the hours of study, 72 TREATMENT or to the difficulty of the tasks imposed, but often to a child's nervous anxiety to make prog- ress, and to keep up with his schoolfellows. I may mention, in corroboration of this view, that the state is one of extreme rarity among the children of the poor, in whom, while other causes of chorea are at least as frequent as among the wealthy, mental strain of course seldom occurs. In such cases, too, lessening the mental strain is almost alwa37s followed by a cessation of the twitchings, while I have never seen any good result from calling the child's attention to the habit; but, on the con- trary, the more his consciousness is aroused to it, the more, in spite of all his endeavors, does it become aggravated. On the other hand, in cases of severe chorea there is no use whatever in attempting control, for so soon as the child is desired to execute an3T movement, or so soon indeed as it perceives itself to be the object of fixed attention, all its movements become increased in violence and completeby uncontrollable. In all cases of con- siderable severity, therefore, the child should at once be placed in bed, and if the movements, in spite of perfect rest, are still violent and con- tinuous, their severity is much abated, and the child is saved much distress and much subse- quent exhaustion by putting splints on the legs and arms, and swathing the child completely OF CHOREA. 73 in soft bandages. As the child gets better the3T may be removed, but not seldom it is wise to apply them by da3r, even though they may be removed at night, if, as is sometimes the case, the child should then sleep tranquilly. Between these two classes—the veiy partial and the extremely severe—there is a veiy large intermediate class, over which moral culture and regulated movements have a most remark- able influence. The great drawback from the success of gymnastics consists in the difficulty of arousing the child's will to activity, for it is not the mere mechanical movement of the limbs which suffices, as it does in a stiff joint, for which passive exercise is needed ; but here it is essential to success that we should be able to evoke the conscious attention of the patient. Hence it is that g3Tmnastics are of service very much in proportion to the age of the children ; hence, too, the3' are of more use when practiced in a class than b3T a child alone; and hence, too, music or aiyr simple chant, in time with which the movements are made, helps greatly to fix the attention, and so to expedite the cure. It were useless to go over the list of all the medicines which have been vaunted for the cure of chorea. There is, of course, a large number of cases in which the existence of some distinct indication leaves no room for doubt as to the 7 74 TREATMENT remedies to be employed. Such are the cases of habitual constipation, such those, too, of marked debility, in which there can be no doubt as to the propriety of administering purgatives in the one case, chalybeates in the other; and there is a period in most instances of chorea during which each of these remedies commonly finds a place. But there still remain a good many cases in which the movements constitute the disease, and in which there is no special indication to guide us. It is in these cases that we meet with the large class of anti- spasmodic remedies, each of which has been vaunted and abandoned in its turn, and from none of which have I ever seen the slightest benefit. Neither have the sedatives been more successful in ny hands, except when given in a single dose for the purpose of obtaining sleep. Henbane, conium, and belladonna have all proved equalby unsuccessful, though I have known them to be tolerated in poisonous doses, without any result either for good or evil. Chloral has also seemed to have no power apart from its action in producing sleep ; and the bromide of potass, which sometimes acts like a charm in epilepsy, has seemed to be of very doubtful service in chorea, while sometimes I have been compelled to abandon it on account of its depressing influence on the heart, though it had left the choreic movements completely OF CHOREA. 75 uncontrolled. The want of accommodation at the Children's Hospital has prevented me from giving a fair trial to the sulphur baths from which French plysicians appear to have often obtained veiy satisfactory results. I am cer- tain, however, that in maiy instances the vio- lence of the choreic movement is lessened in proportion to the degree to which the action of the skin can be excited ; and the extreme cby- ness of the skin in a large number of choreic patients cannot have escaped general observa- tion. I veiy often emplo3r the hot-air bath at night for the purpose of exciting the action of the skin, giving at the same time a diaphoretic dose of tartar emetic, and continue this for three or four consecutive nights, even though the general condition of the patient should be such as to indicate an otherwise tonic plan of treatment. I have also, in some few instances, employed, with decided advantage, large doses of tartar emetic, as first proposed b3T Dr. Gil- lette, of Paris. The cases in which I have so used it have been those of special violence of the movements, in which the condition might have been fairly called one of acute chorea, and I have given as much as nine grains of it in one day for three days together, with no sensible influence on the pulse, no sickness, and no diarrlnea, but with very remarkable abatement of the movements. The remecby, of course, 76 TREATMENT requires to be employed with caution. I am accustomed to begin with an eighth of a grain for a child of ten years old; but by doubling the quantity every four hours a very large dose is soon arrived at. So soon as the movements are distinctly controlled, I cease to augment the dose, while vomiting, diarrluea, or failure of the power of the pulse is a reason for its immediate discontinuance. I think, too, that the rule which prescribes its suspension for at least 48 hours after it has been given in large doses for three days is a wise one, for a sud- den failure of power sometimes takes place in chorea; and though I am not acquainted with any instances in which death could fairly be attributed to the antimon3T, I have had one case in which death from apparently causeless ex- haustion took place 36 hours after the discon- tinuance of large doses of antimony, which yet had produced neither vomiting nor purging, and in which the diminished power of the pulse before the child began to die was not remark- able. I have never continued the antimonial treat- ment through the whole course of a case of chorea, but have always left it off so soon as the violence of the movements was controlled ; and have afterwards resorted to whatever other medicine seemed to be the most appropriate. My experiments with sttychnine have never OF CHOREA. 77 been very satisfactorv ; the twitching of the limbs of itself prevents our becoming aware of its dose being excessive ; and a child's inability to describe its sensations deprives us of another; and I have seen one instance in which its em- ployment, while it failed to benefit a somewhat severe case of chorea, was followed b3r two attacks of violent tetanic convulsions, which nearly proved fatal. The only remedy which in uy hands has ap- peared to exert anything of a specific power over chorea, is the sulphate of zinc, given in increasing doses. Of this, again, a veiy re- markable tolerance is speediby established ; and though, as a matter of precaution, I alwra3Ts begin with small doses, it is Iry no means un- usual to find a dose of 10, 15, or 20 grains taken four times a day with perfect impunity. I have never increased the dose beyond the latter amount, thinking that if three weeks' trial—at the end of which so large a dose was arrived at —produced no result, the remedy might be con- sidered to have failed. Neither have I ever in- creased the dose mereby to ascertain how large a dose could be borne with impunity, but have continued it at whatever dose fairly controlled the movements ; and if it produced sickness have continued a smaller dose until the move- ments were controlled, or till I had become sat- isfied of its inutility. At one time I was ac- 7* 78 PARALYSIS. customed to leave off the remedy gradually, just as I had increased it; but I have since tried the discontinuance of it abruptly, and have not found any return of symptoms follow from this course. Reference has already been made incident- ally to the paralytic condition, almost alwa3rs of short duration, which sometimes follows an epileptic seizure, or is left behind by an attack of chorea; and we have seen that in the latter case the loss of power is sometimes quite out of proportion to the intensity of the muscular movements. But there are other circumstances in which loss of power over the limbs is occa- sionally met with in earhy life, and in which much anxiety is excited lest this loss of power should be permanent. I need not do more than allude to the peculiar paralysis which succeeds to diphtheria, for that is not limited to the child, but, as far as I know, ma3" be observed with equal frequency in the adult, and also in as great a degree at one period of life as at another; varying, however, very remarkably in both respects in different epidemics of the dis- ease. There is, however, one caution that may not be out of place with reference to diphtheritic paralysis in the child, and that is as to the extreme importance of sparing the patient eveiy form of muscular exertion during the DIPHTHERITIC PARALYSIS. 79 continuance of the paralytic condition. We are all familiar with the occasional failure of ner- vous power, the occasional stoppage of the heart's action during the acute stage of diph- theria; of the care necessaiy even in raising the child from the recumbent position, or in moving it from its bed. At a later period I have seen most serious, and even fatal, aggra- vation of slight paralytic s3Tmptoms after diph- theria take place from allowing a child to be up and dressed because it was fractious and diffi- cult to please if kept in bed. Until the symp- toms have for several days been steadily on the decrease, and have become comparatively slight, I am sure the onby safe and wise course is to husband the strength, the nervous force, or whatever be that power which is here so strangely wanting. But besides diphtheritic paralysis, which con- stitutes a typical form of loss of power inde- pendent of disease of nervous structure, there are many instances in which, after illness, the child who used to walk loses the power, and has once more to be carried about in its mother's arms. This inability to walk, too, is something- distinct from the simple result of extreme ex- haustion, but persists straugely long, just like that retrogression of the mental faculties which one sometimes observes, especially after fever, in children ; when the quick child becomes slow, 80 PARALYSIS the memory seems lost, as recently was the case with a little bo3% who, after typhoid fever, quite forgot his name, till suddenly, long after he had been able to sit up in bed and amuse himself with toys, his mother's voice, which he had lis- tened to mechanically for days, seemed all at once to touch the spring of a locked treasure- chest. He knew his name again, the spell was broken, and all his small store of knowledge was his own again. It is after typhoid fever that the mental affection is usually most re- markable ; but it is, as perhaps might reasonably be anticipated, in younger children than those in whom fever commonly occurs, and especialty during the long ailing of a tedious dentition, that the loss of the power of walking is most frequent. The child who used to walk pretty well holding by the nurse's hand, or who even had begun to run alone, will now begin to cry, and squat down upon the ground if set on its feet, or, if supported completely, will not make the slightest effort to put one foot before the other. It will, however, not escape notice that the infant will often draw up its feet from the ground, even though it will make no other movement. Both legs are equally affected, but there is no diminution of their temperature, or of their nutrition ; and it will be found, if the child is placed upon the lap, that every move- ment can be executed perfectly. AFTER LONG ILLNESS. 81 A somewhat similar question, and admitting of being answered by the same means, occurs sometimes with children whose backwardness in acquiring the power of walking awakes the apprehension that there is some cause which will prevent their ever attaining it. In main" of these cases the influence of the rickety ca- chexia is at the bottom of the inability to walk, but its evidence must be sought for, not in dis- torted limbs, nor in any deformity of the skele- ton, but only in the history of backward denti- tion, and of a tardy closure of the fontanelle, with perhaps a prominent forehead and large parietal protuberances, and some slight enlarge- ment of the wrists. To these are almost al- ways added the constitutional signs, either past or present, of rickets ; such as the irregular and causeless attacks of vague febrile disorder, the frequent sweats about the head, the constipated bowels, the inactive liver. In these cases, too, there often seems to be a strange morbid sensi- tiveness of the limbs—not of their surface, in- deed, but of the muscles, which, like those of a rheumatic person, are tender and painful if han- dled. This condition is not always persistent, but in many instances, it comes and goes again ; it retards the time at which the power of walking is attained, but the power is gained at last; it remains for months, but health again fails, with- 82 PARALYSIS FROM RICKETS. out any obvious cause, and the old symptoms come back again with the old inability to stand or walk, and then again disappear with return- ing strength. I have seen this form of paraly- sis, or rather of pseudo-paralysis, at as late a period as eight years old, and have seen it pass away spontaneously. I refer to the condition because I have never seen it noticed, and be- cause it seems to me to be one which will well repay further investigation. Children are sometimes said to be paralyzed when the condition is due to disease either of the spine or of one or other hip-joint. The di- minished power over the lower limbs, the signs of suffering when a child is put down to stand, are sometimes unattended b3T any complaint of pain in the back, and are often observed long before the disease has produced any deformity of the bones. In eveiy case of gradual loss of power over the lower limbs it is important to bear in mind its possible dependence on disease of the vertebra?, and carefull3r to examine the spine in order to discover any point of special tenderness, or any spot where thickening or fulness indicates the existence of disease of the spinal column. Another class of cases in which it may be dif- ficult to distinguish between real and apparent paraysis is furnished by those in which the limb is unused in consequence of pain in moving PARALYTIC CONDITIONS. 83 it, as in the case of incipient hip-joint disease. The difficulty in distinguishing between the two is sometimes considerable, owing to the circum- stance that in the earty stage of infantile paral- ysis there is sometimes much hyperesthesia of the affected limb. The fretfulness of a suffer- ing child, the impossibility of inducing it accu- rately to distinguish the seat of pain, or to say what movements occasion it most suffering, in- terpose obstacles in the way of an accurate di- agnosis which it requires some tact and much patience to overcome. The hip-joint disease will, however, be discovered by the fixed pain which is often referred to the knee, by the ele- vated temperature of the surface over the af- fected joint, by the localization of the pain in its neighborhood, by the occasional parox3rsms of intense suffering even independent of any move- ment, and by the agony produced by any such movements as bring the head of the thigh-bone into contact with the acetabulum. Two states remain to be noticed as differing from the essential paralysis of infancy and child- hood, namely, the paralysis of the idiotic and that which accompanies some cases of cerebral tubercle. I do not know on what in all cases the paral- ysis of the idiot depends. It is not simply on the degree of idiocy, so soon at least as we pass beyond the very lowest stage of that condition. 84 VARIOUS PARALYTIC I believe that the great majority of idiots walk later, and use their hands later, than other children, just because the3T awake later than other children to the perception of those wants to which the hands or feet are meant to minis- ter. But still, in many instances, when they wake to the perception of the need, the instru- ment is brought into use, and performs its du- ties fairly well. There are other cases, how- ever, in which the idiot is also paralytic, and the parabysis is so far the prominent condition that the parents and friends have taken no ac- count of the intellectual deficienc3r, but have fixed their attention exclusively on the inabil- ity to walk, or to stand, or to grasp with the hand. In such cases the muscles are often somewhat wasted, and the power of the flexors predominates over that of the extensors, so that the fingers are bent more or less into the palms, while at the same time the heels are lifted off the ground, and the child, when put down, stands upon its toes. The adductors, too, are so much more powerful than the abduc- tors that the thighs are kept close together, and it is sometimes quite impossible to separate them. In such cases, however, unlike those of essential paratysis, the wasting of the limbs is not progressive, nor is their growth retarded, and both sides of the body are almost always equally affected. Such children, and, sadder CONDITIONS. 85 still, such adults, we sometimes see, walking on tip-toe, their fore-arm held up nearly against the arm, their hands dangling from the wrists, their mouths half open, with a constant silly smile, and indistinct utterance, and a vacant laugh; and 3'et, in spite of their shaky gait, getting tolerably rapidly over the ground, hold- ing objects firmly in their uncertain hands, grimacing like a patient with St. Titus's dance when making an extra effort, showing plainly by each gesture that the nervous power is wanting to the limbs, just in the same wa3r as it is wanting for the exercise of the faculties of the mind. It is in the young child only that mistakes are possible; care will avoid it here, and will preserve the little one from the mistaken orthopaedic surgeiy, which, in spite of its brilliant results in suitable cases, would here be out of place—could here only worsen, could never benefit. The paralysis of cerebral tubercle varies much in its characters, according to the seat of the deposit, and its size. In most cases its form is hemiplegic ; it is often limited to the arm and hand, and invariably affects the upper more than the lower limbs. Its occurrence is usually preceded b3T a convulsion ; and this con- vulsion is limited to one side, often to one limb, the part convulsed at first being that which is 86 PARALYSIS. afterwards parabyzed. The convulsions which sometimes precede essential paralysis are al- ways general, and hardly ever recur, and the loss of power is greatest at first, and afterwards lessens in some degree, even in those cases where no complete recoveiy takes place. The convulsions produced by cerebral tubercle, on the other hand, not seldom return, affecting the same limb, and leaving it after each recurrence more powerless than before. Moreover, there is often some degree, even though slight, of fa- cial paralysis ; the pupils of the two eyes are almost always unequally dilated, and there is, besides, usually a history of previous loss of flesh, of headache, or, at any rate, some symp- tom which would attract the notice of the at- tentive observer. But there are also other cases, though very rare ones, where, owing, I imagine, to the central position of the tumor, the above-men- tioned symptoms are not observed, but the signs of impaired power come on by degrees, and consist at first of an unsteadiness of gait rather than of paraplegia, and resemble the characters of locomotor atax3T more than those of actual disease of the brain. And 3Tet I be- lieve that even in such doubtful cases we may lay it down as a rule without exception that the continued presence of any one symptom of cerebral disease, be it habitual dilatation of the CONDITIONS. 87 pupils, headache, or even causeless sickness, points unerringly to mischief in the brain. I the less regret that I have left nyself so little time to speak of what is commonly called the essential paratysis of infancy and childhood since I have nothing new to say with reference to it, nor aiy fresh theoiy to propound as to its nature. I prefer, in the present state of our knowledge, the term infantile paralysis to any other, because it commits us to nothing be3Tond the indisputable fact that this is the form of paralysis which occurs more frequently than any other in infancy and early childhood; and also because, in so far as my limited experience of the diseases of adult life enables me to judge, it does not occur in the grown person. I think that Duchennes' appellation of " paralysie atro- phique musculaire graisseuse " is unsuitable, for it predicates of all cases that which is true only of some, and which, even when it does occur, does not take place at a uniform time, nor bear a uniform relation to the loss of power. Neither do I think that there is any adequate reason for separating cases into two classes, and regarding those in which recoveiy takes place speedily, and which some have called Kennedy's Paralysis, as essentially different from others in which recoveiy takes place slowby, partially, or not at all. 88 INFANTILE PARALYSIS. The characteristics of infantile paralysis ap- pear to me to be— 1. The suddenness of its occurrence. 2. The absence in most cases of any previous sign of disorder of the cerebro-spinal S3'stem, and the fact that when such disorder does occur, there is no proportion between its severity and the extent or completeness of the paralysis. 3. The continuance of unimpaired sensation, and the absence of all rigidity or contraction of the paralyzed limbs in the early stage of the affection. 4. The occasional existence of exaggerated sensibility in the earl3T stage of the affection, and the direct proportion existing between it and the subsequent loss of power. 5. The tendenc3r of the affection to assume the hemiplegia form in the first instance, though in the course of the subsequent improvement which almost always takes place, one limb (and that usualby the upper extremity) often recovers either altogether or to a much greater degree than the other. 6. The direct relation which subsists between the early date at which improvement begins and its completeness. 7. The comparative rarity of absolute recoveiy even in the most favorable cases, for not only does a degree of weakness remain as the result of the shock, but in man3r instances one or two INFANTILE PARALYSIS. 89 muscles of a limb, and those apparently arbi- trarily selected, remain almost powerless, even when the others have regained much of their former vigor. 8. The tendency to retarded growth and im- paired nutrition in the permanently paralyzed limb, to which there is usually superadded a greater or less degree of fatty degeneration of the muscular tissue. The wasting of the limb, however, does not bear a uniform relation to the degree of pa- ralysis ; nor even if the paralysis does not im- prove is it continuously progressive, but remains stationary at an uncertain stage; as also does the degeneration of the muscular fibre. 9. The invariable tendenc3T in all cases to the production of deformity in the affected limb, in occasioning which the mere weight of the limb, and the—for it disproportionate—load which it has to support or to move, bears, as Volckmann1 has pointed out, a more important share than mere antagonism between the paralyzed and non-paralyzed muscles. And here, Sir, I stop for to-cla3r, having occu- pied your time with common things, eveiyday matters, such as some may consider fit only for the 3roung student—beneath the dignity of this 1 Sammlung klinischer Vortr'dge, Heft i, Leipzig, 1870. S* 90 PARALYSIS. learned body. Pardon me, Sir, if it is so. We know the Eastern apologue which tells us how the dervish found that an old lame camel had crossed the desert, and how he learned also the burden with which he was laden. The unequal footprints proved the camel lame; the scanty grass cropped unevenly showed the teeth worn with age ; the grain found here, and the drip- pings from the gourd which held the honey on the other side, told the rest, and the story has for ages served to point a nursery moral still worth remembering now our hair is gray. But, to pass from the region of fable to fact, I re- member reading once how the elephant-hunters in Ceylon, when tracking that sagacious beast through his native forests—since, on account of his acute sense of smell, " it is indispensable to go against the wind in approaching him— when the wind is so still that its direction cannot otherwise be discerned, will suspend the film of a gossamer to determine it, and shape their course accordingly." And so, in the practice of our art, things which seem almost as slight as the gossamer film serve often to decide points of great moment; and the detection of the real nature of disease is as often, or even oftener, the result of minute, well-schooled observation * as of acute reasoning or of great mental power. SPEECH. 91 LECTURE III. DISORDER AND LOSS OF POWER OF SPEECH.-- MENTAL AND MORAL PECULIARITIES AND THEIR DISORDERS. Speech—the highest human power; its occasional tardy development.—Deaf and dumbness.—Power of speech: in the idiot; in the backward child.—Starnmering.— Affection of speech in course of chorea not always depen- dent on severity of muscular movements; associated with intellectual disorder; eventual recovery of such cases.—Other instances of loss of speech: after typhoid fer.er ; after other ailments.—Rarity of abiding apha- sia ; case in illustration of it.—Imperfection of our knowledge concerning these cases. Mental and moral peculiarities of childhood; importance of appreciating them.—Ext nil to which child lives in the present; need for sympathy in sick child; care in impressing on it religious dogmas.— Vividness of child's perceptions: dreams; ocular s]>ectra ; subjective sounds; night terrors; sleep-walking.—Intensity of child's sen- sibilities : heart-break; suicide of children.—Children's likes and dislikes, and their craving for sympathy.— Reasons for dwelling on moral rather than on intellec- tual peculiarities and disorders of childhood.—Difficul- ties of suffering of children insoluble except by Chris- tian faith. Mr. President and Gentlemen,—I find the subjects which I have undertaken grow upon my hands. It seemed to me, when first you honored me with your commands, that the 92 SPEECH. difficulty would be to find any theme within the reach of my capacity which could be so drawn out as to occupy the hour ; and now I find nyself beginning the last lecture with the con- sciousness that much must remain unsaid that I should have wished to dwell on ; and that I must select a small part only of what might well interest us in connection with disorders of the nervous S3'stem in childhood. A portion of our time to-day I purpose to devote to the subject of the tanty development, the impairment, and the loss of the power of speech in childhood. I select this subject, because as the power of speech is the highest endowment of our race, so all that concerns it, and its loss or its impair- ment, is of supreme interest to us, not as mem- bers of one common profession onby, but as bound together by the ties of a common hu- manity. " We cannot tell as yet what language is. It may be a production of Nature, a work of human art, or a divine gift. But, to whatever sphere it belongs, it would seem to stand unsurpassed—nay, unequalled in it—by an3'- thing else. If it be a production of Nature, it is her last and crowning production, which she reserved for man alone. If it be a work of human art, it would seem to lift the human artist almost to the level of a divine creator. If SPEECH. 93 it be the gift of God, it is God's greatest gift; for through it God spake to man, and man speaks to God in worship, prayer, and medita- tion." So says one of the most learned men of our day;1 and it is in keeping with this highest estimate of what articulate speech is that we find the mother rejoicing over the first word her baby utters, more than over the appearance of the first tooth which pierces its gums, or than over its first successful attempt to stand alone. Each of these events makes the day a red-letter day ; but the first time the child calls on its father or its mother is high festival in the little world of home. And, on the other hand, few things cause so much anxiety as when the time passes at which the infant usually begins to talk, and the mother waits on in mournful expectation for the sounds which are to prove her little one's right to full citizenship. The date at which children begin to talk varies veiy greatly, and varies without its being possible, in many instances, to assign a reason for it. First children usualty talk later than those born into a large family, for they have no little teachers to instruct them ; while the fact that girls generally talk at an earlier age than boys is but an additional illustration of 1 Professor Max Mailer. 91 SPEECH. the greater intellectual quickness which the female child, especially in its earlier years, displays. It by no means constantly follows, however, that tardy acquirement of the power of speech implies a deficiency of intelligence; so far is this from being the case that a very active intelligence often makes a child an excellent pantomimist, and its resources in this way render the exercise of speech superfluous to a later age than that to which it would have been deferred with a child of slower intellect. I have seen children between two and three 3Tears old who had not yet begun to speak, and have allayed their friends' anxiety by pointing out the little one's mimetic skill; and, by calling attention to the modulation of the tones of its voice, have removed their fear lest, though its intellect might be perfect, the child might 3^et be deaf and dumb. It is not eas3T in early childhood to ascertain the existence of congenital deafness. Almost unconsciously nurse and parent accompan3T their words with signs, the child learns their mean- ing and obeys, not the sound which it does not hear, but the movements which it notices. The deafness isolates the child, however, and thus retards very considerably its mental develop- ment. The question, therefore, which usually comes before us is whether a child is dumb be- SPEECH. 95 cause it does not hear, or dumb because its in- tellect is deficient. The decision, too, is some- times rendered still more difficult by the circum- stance that the deafness may not be complete, the child perceiving loud sounds but not gentle tones ; and in both cases—that of either com- plete or of partial deafness—the infirmity which cuts off the child from free commerce with others almost always renders it wayward, dis- obedient, and passionate, and gives rise to a causeless apprehension that the child is an idiot. Imperfect hearing, however, is now and then, though I believe but rarely, associated with imperfect intelligence. (Dr. Howe1 observed it only in 12 out of 571 idiots.) And when this is the case, the difficulty of determining how much of the child's peculiarities, and how much of its backwardness in speech depends on the one cause and how much on the other is greatly increased. I mention all these difficulties, not because I have any special rules to lay clown for their avoidance, but because they are often not rec- ognized, and a hasty and erroneous opinion concerning a child's condition is expressed which a little care and patience would have avoided. 1 In his Report upon Idiocy, Sj-c, to the Senate of Mas- sachusetts. Boston, TJ. S., 1818. 96 SPEECH IN THE IDIOT. With the exception of cases of the lowest degree of idiocy, inability to talk and to use language for the expression of ideas is a rare attendant on that condition. Representing the skill of ordinary persons in the use of language by the figure 10, Dr. Howe estimates it at 5 in the idiot, while he estimates the reflective facul- ties at only 3.50. Ceaseless chatter is much more the characteristic of the idiot than diffi- culty of speech. He has more words than ideas, as Shakspeare knew when he spoke of " A tale told by an idiot, Full of sound and fury, signifying nothing." But there is one class of children to be well distinguished from the idiot, to whom the power of speech comes late. These are the backward children, ules enfants arrieres," as the French call them ; and it is concerning them that pa- rents oftenest come to us for advice and com- fort. Their history is sometimes that of having had convulsions soon after birth, or during den- tition, and of the mental progress having been retarded since then, and the bodily progress too. Or else, without aii3' special assignable cause, the3r have advanced but slowly; they noticed later than other children ; they had no power to hold up their heads long after other children could support theirs ; they were late before they could sit up, late before the3T could SPEECH. 97 stand. At eighteen months or two 3*ears old such children do not attempt to talk, and their parents become very anxious about them, and fear that the3r will never talk at all. But such fears are needless ; sooner or later almost every child who is not deaf will talk. Long before articulate speech begins, the voice shows 03' its modulations, if there be aiy intelligence at all, that the ear perceives sounds, while not infre- quently a few simple musical notes will awaken the evident attention of a child who would scarcely heed a complex tune. In such cases if we find that the child, though far behind the ordinary attainments of its age, yet corresponds in its condition with what we might expect at an earlier period of life—that it.grasps with its hands, for instance, carries objects to its mouth, notices light, or sound, or bright colors, or tries to stand, or, supported by the nurse, endeavors to walk, and expresses pleasure, or pain, or desire in tones variously modulated, though not articulate, we ma3r give the assurance that speech will certainly follow. In such cases intelligence will improve to a de- gree which it is not possible to limit, but the animal endowments will almost certainly pre- cede in their development the intellectual gifts ; the child will probably walk long before it makes an attempt at talking. But the power of speech once acquired may 9 98 LOSS OF SPEECH be impaired,—may be lost partially or alto- gether, and this either for a few hours, or days, or weeks ; or once lost it ma3' never be regained. Before passing to graver affections of the power of speech I must say one word about stammering. I never heard a veiy young child stammer. It may speak indistinctly, because it has not 3'et learned to articulate all sounds ; it simplifies them as it simplifies grammar, but it does not stammer. The children of the poor scarcely ever stammer; the infirmity is one which comes with self-consciousness, with men- tal culture, with the highly wrought nervous s3Tstem. 1 never knew a child stammer before the commencement of the second dentition. Stammering is to speech what chorea is to movement; and chorea is seldom dissociated at some period or other from imperfect speech. To a great degree, indeed, the imperfection of the speech is a gauge of the intensity of the chorea. Nor is there anything to wonder at in this. The muscles of deglutition are veiy often affected in severe chorea; the child swallows with difficulty, protrudes its tongue quickly, and for a moment only, and is quite unable to keep it protruded, and swallows its food in a succession of hasty gulps. The difficulty natu- rally extends to speech, for to a great extent the same muscles subserve both functions; while with the choreic child, just as with the IN CHOREA. 99 stammerer, observation, or aiy cause howsoever trivial which excites the child's emotions, ag- gravates its trouble. But if this were all I have to say, I should not be justified in occupying your time, Sir, and that of this learned audience with the repetition of commonplaces familiar to every one. The power of speech, however, is sometimes affected in chorea in a degree quite out of proportion to the severity of the muscular movements gener- ally, and it seems sometimes as if not only the power of articulation, but the memory of words for a time were gone. Since the subject was first noticed by M. Marce, the occurrence of temporary weakening of the mental faculties in the course of chorea has been recognized by practitioners of medi- cine, though by no means so generally as its importance demands. The impairment or the loss of speech in the course of the disorder is dependent almost or quite as much on affection of the mental powers as on disturbance of the organs of speech themselves. Not long ago I had charge at the same time of two little girls, of eight and nine years of age respective^', both suffering from chorea, both, as a mere accident, staying in the same house, though there was no relationship, nor even an3r acquaintance, existing between them. In both the chorea was of some mouths' dura- 100 LOSS OF SPEECH tion before they came under my care; in both it was severe, and neither child could walk with- out difficulty, even when supported, while all effort was followed by aggravation of the move- ments in both. In both the power of vocaliza- tion had been early affected, but while the one tried to speak, knew what she wished to sa3', but failed in the saying it because the disordered mechanism no longer obeyed the will, the other had lost the power of speech altogether. The one labored hard to pronounce the words, and though we could not distinguish their meaning, various sounds were uttered, approaching more or less nearby to the sounds of the words which would have embodied the answers to the ques- tions put to her. The other, if asked her name, said " dah !" if her age, "dab!" if she had had her dinner, still "dah!" and she continued to do so at a time when her tongue was protruded steadily, when deglutition was well accom- plished,, and when the child had acquired command enough over her muscles to play with t03Ts, to feed herself, and even to string beads. It would have been interesting to have had a careful daily record of the steps b3T which speech came back. It came slowl3T at first, and "papa," the first word spoken, was but a little step from the old monosyllable "dah!'' and one which did not need a different play of the IN CHOREA. 101 vocal organs ; but after a week or so came other words, not similar in sound, and seeming as if chosen at haphazard, as though it were the drawing of a lottery, and prizes and blanks— important words, and words of little moment —came out by chance. When a small vocabu- lary had thus been gained, the ke3'-note seemed to have been struck, and the whole melocty re- covered ; not words only, but complete sen- tences were framed ; forgotten memories came back again, and the little one no longer found difficulty in uttering all that she had to say. Still more remarkable was the loss of speech and its return in a little girl, eight years old, who was received last summer into the Chil- dren's Hospital. Eight months before she had been attacked by chorea, produced by fright, and after the lapse of some months (one knows how vague are the statements of the uneducatd poor) speech first became difficult, and then was lost altogether ; twitchings of the hands still continuing; not the violent jactitation of se- vere chorea, but such as was obvious enough when the child stood or walked, though it did not interfere either with standing or walking. For some weeks before she came into the hospital the child uttered no words except 'tyes " or " no," and was unable to protrude her tongue, but did as little children do who have never learned the lesson how to do it, and ap- 9* 102 LOSS OF r-PEECII plied the tip of her tongue to the inside of her lower teeth. She was able to swallow per- fectly. While in the hospital the child seemed happy; she attached herself to her nurse, and played with her toys, but the whole month long she said no more than " yes " or " no," and could never be induced to protrude her tongue. At the end of this time she was sent to the Convalescent Hospital at Highgate, and for the first ten days there was no sign of improve- ment in her condition. At the end of nine weeks, however, she left Highgate, not quite free from twitching, and paler than a child should be in perfect health, but speaking with fluenc3'. When the child first went to Highgate, prom- ises of reward if she would endeavor to speak produced for a time no effect. As she had learned to read, however, she was at length in- duced to make the attempt to read to the nurse. At first she did it so indistinctly and in a tone of voice so low as to be almost inaudible, and quite incomprehensible ; but the nurse made as though she understood her. Thus encouraged, . the powers of speech improved ; and here and there in each sentence a word was distinctly uttered; and then, as in the other case, all came back again rapidly, and the child once IN CHOREA. 103 more talked as she had done before her illness, though some degree of choreic movement was still present. Cases such as these are worth remembering, for they enable us at once to dissipate much needless anxiety, and to assure the children's friends that the mind, though weakened for a time, will regain its former powers, and that the lost gift of speech will certainly be recovered. It is, howrever, after fever and other protracted illnesses that such anxiety' is oftenest felt, and that our positive assurances of recovery have to be most frequently repeated. .And repeated they may be almost unhesitatingly, for I have only twice known the assurance to be falsified. In one of these cases hearing was lost, though not as the result of any obvious disease of the ear; but the patient, a boy of eight 3Tears old, was found, after a severe attack of typhoid fever, to be stone deaf; and speech was lost Ly degrees, because the accustomed sounds were entirely unheard, and the lesson, like many a lesson of childhood, was forgotten for want of repetition. I advised the child to be placed under the care of an instructor of the deaf and duml), but as he came from a remote part of Scotland, I do not know whether his condition, which had already existed a year when I saw him, became much ameliorated. In the other case the loss of speech took 101 LOSS OF SPEECH place iii different circumstances, and was a part only of the result of shock caused by fever, and which disordered hopelessly some of the mental powers, while others it left untouched. A healthy boy, a farmer's son, was attacked by typhoid fever, which, though severe, was un- attended ly aiy very special disorder of the brain, when ten years old, in November, 1850. He was taken to Brighton in Januaiy, I860, and as he slowly regained his strength his man- ner became strange; he talked irrational^', and at length he would not dress himself, nor would he take aiy food. His refusal to take food re- duced him to a state of extreme weakness, and in April, 1860, he was brought to the Children's Hospital. He was much emaciated; his man- ner was sullen ; but as his mother left the*ward he exclaimed, "Don't leave me, mother!" and from that time to the present he has never ut- tered another word. At first he was fed for- cibly ; after a time he allowed himself to be fed without resistance, and in the course of 3'ears has resumed the habit of feeding himself with a spoon, though he will not use a knife and fork. He would not dress himself for maiy 3rears ; but by degrees, as he grew older, a sense of decency apparently has led him partly to dress himself. He puts on his shirt and trous- ers, he washes himself, but never dresses him- self completely. He looks after the poultry and AFTER FEVER. 105 pigs, harnesses the horse and drives his mother to market, imitates the sounds of animals, laughs if any ludicrous occurrence happens, or even if some stories are told which amuse him. I said to him a year ago, " If you won't talk 3rou will never get married, for you must ask the young woman, or she certainly will not have you." He seemed highly amused, and laughed heartily; but he still observes the same silence. Sometimes, indeed, he is morose in manner, but usually tractable; and one would fanc3r, but for the 3'ears during which this silence has lasted, that it was but the vagary of a way- ward fanc3r, and that some sudden surprise or keen emotion would awaken his utterance again. I do not know where to class this case; whether with the mutism of the insane, to which it seems rather to belong, or with the special loss of the power of articulate speech which, within the last few years, has been the subject of such careful investigation. One case, and but one, of aphasia, such as Trousseau de- scribes it in the grown person, has come under my notice, and this, on account of its rarity, I will presently relate. But it has happened to me now and then to observe temporary loss of speech follow on the cure of some compara- tively trivial local ailment, such loss being accompanied with more or less disorder of the 106 TEMPORARY nervous system, and the subsidence of the latter preceding somewhat the return of the former. A girl, seven years old, who had often suf- fered from eczema, and since the age of three had been liable to attacks of strumous ophthal- mia, any considerable improvement in which was alwa3Ts attended with a deterioration of her general health, was affected with fever, exces- sive restlessness and irritability, with loss of power of speech ten days after complete re- coveiy from ophthalmia. This state continued for three weeks, when the child began to mend, and was discharged convalescent from the hos- pital in 61 days. The attack set in with head- ache, and on the next day the child was mute, though she understood questions and did as she was bid, and swallowed perfectby well. From time to time she moaned as if in pain ; her gen- eral condition seemed one of extreme depres- sion ; sordes collecting on her teeth and lips; and now and then she refused, rather than seemed unable, to swallow. During this time her temperature varied without obvious cause, rising to 103°, sinking for short periods even down to 91° ; strange signs of disorder of the nervous S3'stem occasionally showed themselves; the muscles of the face sometimes twitched, the bocby arched slightly backwards; but at the same time, though the child grew thinner, there APHASIA. 107 was no extreme emaciation. About the 19th day she appeared quieter and more attentive to external circumstances; and four days later, when spoken to, she shaped her lips as if to re- ply, but, with a pained expression of face, kept silence still. On the 28th clay her mother came to see her. She knew her, tried to talk, but no sound came. She seemed much distressed, and, for the first time since her illness began, she shed tears. On the 30th she spoke short sen- tences, screaming them out passionately, with no modulation in her tones, and as though she had no patience to wait for her wants and wishes to be attended to. On the 36th da3T she had recovered strength enough to stand if sup- ported, and to try to walk, lifting her legs in doing so as if walking upstairs. Slowby all these peculiarities subsided, and on the 64th day she was discharged well, but with slight dragging of her left leg. A year afterwards she returned to the hos- pital suffering from a return of eczema of the ears and strumous ophthalmia, from which, however, she recovered, with no return of ner- vous symptoms of any sort. Cases of this kind are, on the whole, so un- usual, and have been so little noticed, that I will very brietlv relate one more history—that of a little girl, 6^ 3rears old, who, while in her ordinary health, had a small superficial stru- 108 TEMPORARY nious sore form on her left cheek, and this was accompanied with a little swelling behind the ear. At the end of three months the sore somewhat suddenly healed, and a few days afterwards she lost her appetite, became dull and heavy, and complained of pain at the back of her head. At the end of a week slie took to her bed; in another week she ceased to speak, though she recognized her friends; and had been speechless for a week when she was brought to the hospital. She was then in a state of great excitement, shrieking aloud fre- quently, though not speaking; and with a fre- quent and feeble pulse, and much dilated pupils. An opiate in no measure quieted her. During the next three days her excitement b3r degrees diminished, and her consciousness in- creased ; though her pupils remained dilated, her nights restless, with occasional outcries; and she seemed painfully alive to her inability to speak. I found her, on the fourth da3' after her admission, sitting up in bed, playing with a doll. I spoke to her; she gazed at me most wistfully, opened her mouth, but no sound came, onby a loud unintelligible cry ; her face was drawn as if she were going to weep, but she could not; and she threw herself clown upon her pillow, her countenance half vacant, half despairing. The next day the same state con- tinued ; the effort to speak seemed still more APHASIA. 109 resolute, but still no speech, still the same agony at failure. # On the seventh da3', after a restless night, speech came back all at once—the words sometimes misplaced or wrong—but her utter- ance voluble, and she never talked nonsense. It was like a little bird learning a song again. On the ninth (by some childish disappointment was followed by a genuine fit of crying, and from that hour she was herself again, and her face when I next saw her was all radiant with happiness. I heard of her a 3Tear after, and she was still well. I have seen but one case of aphasia in the child obviousy connected with cerebral affec- tion, and where the loss of speech was of long duration, if I except the lad whose history I have already related. This case occurred in a little girl, five 3'ears old, who had sunstroke, followed b3^ coma of a fortnight's duration, and attended with hemiplegia of the right side, and with loss of speech. The right leg, to a great degree, recovered power, and the facial paraly- sis disappeared in a few weeks, but the right arm remained quite powerless, and the fingers firmhy clenched into the palm for a long time. The intellect was perfect, and the child was tractable and good tempered, but could not speak. Her only sound in answer to every ques- tion was '• dah." In three months she learned 10 110 APHASIA to say "here" and "oh," but uherev cost her a great effort, and often, in spite of all her efforts, she would fail, and say "oh" or "dah" instead. At the end of four months her mother an- nounced with great glee that her little one could chant a line or two of some nursery songs, but all she did was to modulate the tone in which she sang the same old monosyllable "dah." At the end of a year all trace of facial paral- 37sis had disappeared, the right leg was a little weaker than the left, but that was all; the power over the right arm was still very imper- fect, and the fingers, though the3r could be par- tially extended, were still drawn habitualy into the palm. Her mother pleased herself again with the idea that speech was returning, though the sounds she uttered when asked the names of things seemed to be mere modulated tones, and not articulate words. Now and then she did imitate words uttered by another person, but even then she did it very imperfectly, and often did not succeed in the attempt at all. A fortnight since, another year from her at- tack, I saw the little one again. She had grown, looked healthy and intelligent. She went to school, had learned to sew, though her right hand, still partially paralyzed, interfered with her dexterity. She had acquired a small vocabulary; said 'yes," "no," "father,'' "mo- FOLLOWING SUNSTROKE. Ill ther," "brother," "sister," and uttered some other simple words correctly. Many others she could repeat after another person, but often failed to use them correctly, saying one for the other, and not seeming aware of her mistake, nor distressed when it was pointed out to her. I relate the case vety much because hers is the earliest age at which, as far as I know, aphasia, accompanied with paralysis of the right side, has been recorded. My concern, however, is more with cases of temporary loss of the power of speech, and with illustrating their greater frequency in the child than in the adult. I do not pretend to know what happens in these cases. I have no theoiy about t. The power is lost absolute^ for a time ; it returns completey—just as the old traveller Mande- ville tells us of a country where the winters are so severe that the words freeze upon people's lips, and half the long 3rear it is a realm of si- lence ; but with returning spring, the congealed sounds are unlocked again, and all is vocal with " aiiy tongues that syllable men's names." And we ma3', to the unspeakable comfort of our patients' friends, assure them of the com- plete return of the power of speech in these cases of its sudden loss in childhood, of its in- dependence of an3^ grave disorder of the intel- lectual powers ; in short, we may promise them 112 MENTAL PECULIARITIES that the silent winter will most certainly be suc- ceeded by a voiceful spring. But, it may still be urged, is there indeed no theoiy by which we may be better helped to the understanding of this state of temporary aphasia? I know of none, and it is therefore that I shrink from the use of scientific phrase- ology, which seems to explain, but which in reality pays us only with words that do not rep- resent distinct ideas. Such phraseolog3r is like fairy mone3T—it seems, but it is not; it glis- tens like the ruddy gold," and in the moonlight of imperfect knowledge it appears to us a treas- ure, but it vanishes with the dawn, or is found by those who look at it in broad da3:light to be but dross. Scientific terms are but counters at the best; they may perhaps be serviceable to mark with, but the3' are worse than valueless if we try to pass them as if the3r were current coin. It still remains to say a few words about the mind and its disorders in childhood, a subject which might fill a big book, and your Lecturer " Aestuat infelix, angusto in limite." The mental and moral peculiarities of child- hood engage far less than the3" deserve the at- tention of most practitioners of medicine, and hence it comes that the treatment of the dis- OF CHILDHOOD. 113 orders of early life is to so large a degree a matter of unintelligible routine. The strongs-marked individuality of the adult forces itself on the notice even of the least observant. The cares which oppress him, the misfortunes which have soured his temper, the anxieties to which he is looking forward in the future, the ambition which renders him un- quiet, or the selfishness which leads him to wrap himself up in his own sensations, to study, —generally to exaggerate his ailments—are borne in mind, and modif3' the conduct of all who are at all fit to practice our profession. In the case of children, however, individuality is far less marked, and hence the mental and moral peculiarities of the state of childhood are little thought of; and the child is treated as though he were in mind, as well as in body, a miniature man, feebler in intellect, as he is smaller in strength, but differing in degree only, not in kind. Now the child differs essentially from the adult in these respects; that 1st. He lives in the present, not in the future. 2d. His perceptions are more vivid, and his sensibilities more acute, while the world on which he has just entered surrounds him with daiby novelties. 3d. He has less self-consciousness, less self- dependence, lives as a part of the world 10- Ill MENTAL PECULIARITIES by which he is surrounded—a real prac- tical pantheist. The child lives in the present, not in the fu- ture, nor much even in the past, till the world has been some time with him, and he b37 de- grees shares the common heritage of retrospect and anticipation. This is the great secret of the quiet happiness which strikes almost all visitors to a children's hospital. No one can have watched the sick-bed of the child without remarking the almost unvarying patience with which its illness is borne, and the extremity of peril from which, apparently in consequence of that patience, a complete re- coveiy takes place. Much, indeed, is no doubt due to the activity of the reparative powers in early life, but much also to the unruffled quiet of the mind. No sorrow for the past, no gloomy foreboding of the future, no remorse, disap- pointment, nor anxiety depresses the spirits and enfeebles the vital powers. The prospect of death, even when its approach is realized— and this is not so rare as some may imagine— brings in general but small alarm. This may be from the vagueness of the child's ideas ; it ma3^ be, as the poet sa3's, that in his short life's journey "the heaven that lies about us in our infancy" has been so much with him that he recognizes more clearly than we can do OF CHILDHOOD. 115 " the glories he hath known, And that imperial palace whence he came." I dwell on this truth because it is of great practical moment that we should bear in mind to how very large an extent the child lives only in the present; because it follows from it that to keep the sick child happjT, to remove from it all avoidable causes of alarm, of suffering, of discomfort—to modify our treatment so as to escape a possible struggle with its wayward- ness, and even if death seems likely to occur, to look at it from a child's point of view—not from that which our larger understanding of good and evil suggests to our minds—are duties of the gravest kind, which weigh on the physician, on the parent, on the nurse, and which it behooves us none the less to remember because they are not dwelt on in the lecture- room, or in the medical treatise. One word, and but one, I would add here, and I trust I may do so without incurring the suspicion of want of respect for religion, or of want of faith in its doctrines. Some of the most painful death-beds which I have ever wit- nessed have been those of children whose over- anxious friends have striven to force upon their minds the deepest verities of our faith, in that definite form in which they are embodied in catechisms and formularies. It is easier to 116 MENTAL PECULIARITIES frighten than to console;—the dark grave is re- alized, or, at least, imagined more vividly than its conqueror; and the little child, driven to look within for the evil which it does not know, and cannot find, but vaguely dreads, and would be sorry for if it knew it, has moved me to compassion only less than that I felt for its broken-hearted torturers, who have failed to learn that the little children—of whom our Saviour said that of such was his kingdom— were not called on to recite any creed, to pro- fess an3r faith ; but, just as they were in their helpless ignorance, were deemed fit to be folded in his embrace, and to be held up to us as our example. But not only does the child live in the pres- ent far more than it is possible for the adult, but there are, besides, other important mental differences between the two. Not merely is the mind of the child feebler in all respects than that of the adult, but, in proportion to the feebleness of his reasoning power, there is an exaggerated activity of his perceptive faculties, a vividness of his imagination. The child lives at first in the external world, as if it were but a part of himself, or he a part of it, and the glad- heartedness which it rejoices us to see is as much a consequence of the vividness with which he realizes the things around him as of that ab- sence of care to which it is often attributed. OF CHILDHOOD. 117 This peculiarity shows itself in the dreams of childhood, which exceed in the distinctness of their images those which come in later life, and shows itself, too, in the frequency with which, even when awake, the active organs perceive unreal sounds, or, in the dark at night, conjure up ocular spectra; and these not merely colors, but distinct shapes which pass in long proces- sion before the eyes. This power fades away with advancing life, except under some condi- tions of disease, the occasional appearance of luminous objects in the dark remaining the only relic of this gift of seeing visions, with which, in some slight degree at least, most of us were endowed in our early years. The child who dreads to be alone, and asserts that he hears sounds or perceives objects, is not expressing nierety a vague apprehension of some unknown danger, but often tells a literal truth. The sounds have been heard ; in the stillness of its nursery the little one has listened to what seemed a voice calling it; or, in the dark, phan- tasms have risen before its eyes, and the agony of terror with which it calls for a light or begs for its mother's presence, betrays an impression far too real to be explained away, or to be met b3r hard words or by unkind treatment. Impressions such as these are not uncommon in childhood, even during health. Disorder, direct or indirect, of the cerebral functions, 118 MENTAL PECULIARITIES more commonly the latter, greatly exaggerates them ; and I have known them both to outlast for man3r weeks all other signs of ailing health after convalescence from fever. The unreal sights are far more frequent than the sounds. The sounds are usually of the simplest kind— as the tinkling of a bell, of which we all remem- ber the exquisite use made by Hans Andersen in one of his nursery tales ; or the child's own name at intervals repeated, just as the little watchful boy heard it in far-off Judaea, when it was the prelude to a wondrous communication from the unseen world. It came to him as he woke from sleep, before the early morning dawned, while the lamp, lighted over night, was burning still; and still it is so far the same that these occurrences, which suggest to us problems that we cannot attempt to solve, mostly take place at times of transition from the sleeping to the waking state. The ocular spectra are usually far more vivid and detailed. Those which occur in the wak- ing state are by no means always painful, though their strangeness not infrequently alarms the child, and his horror of the dark is due not to his seeing nothing, but to his seeing too much. Some imaginative children amuse themselves with these phantasms, and then, if encouraged to relate them, will constantly transgress the OF CHILDHOOD. 119 boundaiy line between truth and falsehood, and weave their little romance. When they happen on waking they are usually preceded by fright- ful dreams, but the image which the child sees then is not the mere recollection of the dream, but a new distinct, though painful impression, general^ of some animal, to which the child points as now here, now there. These night terrors, from the veiy circumstantial character of the hallucinations which attend them, often occasion needless anxiety as to the importance of the cause on which they depend. Sleep-walking, in its smaller degrees of get- ting out of bed at night, is b3r no means unu- sual in childhood ; but the greater degrees of somnambulism are certainly rare; and I have always found them dependent on undue mental work: not always, indeed, on the tasks being excessive, but sometimes on the over-anxiety of the child to make progress. I have not yet known a poor person's child a somnambulist. But, not onty are the perceptions more acute in childhood than in adult life, but the sensibil- ities are more intense. The child's emotions, indeed, are often transitory—generally, indeed, veiy transitory; but while they last the3' pro- duce results far greater than in the grown per- son. In the case of the latter, recollection of the past, anticipation of the future, or even the duties of the present, control the overwhelming 120 INTENSITY OF EMOTIONS sorrow, or call forth the energies needed to bear it. The child lives in the present, and this pres- ent is but the reflection of the world around, its impressions uncontrolled by experience, tin- governed by reason. The broken-heartedness of a child on leaving home is not the expression only of intense affec- tion for its friends or relations ; it is the shock of separation from the familiar objects which have surrounded it; and I have not un frequently seen children inconsolable when removed from homes that wore most wretched, or from rela- tions who were most unkind. Fvery now and then, indeed, we are compelled to send chil- dren back from the hospital because no love nor care can reconcile them to the change from home; and they have refused to eat, and spent their nights in weeping. The feeling is an un- reasoning one, like the home-sickness of the mountaineer. I remember a little girl, ten years old, who was received into the Hospital for Sick Children with diabetes in an early stage, with slight indi- cations of tubercular mischief about the apex of the left lung, but who was not passing any very excessive quantity of urine. She was sad and somewhat listless for the first two days of being in the hospital. On the third day her friends visited her. Their visit greatly- excited her, and when the3' left depression followed the pre- IN CHILDHOOD. 121 vious excitement: she became sick, and vom- ited several times, her pulse rose to 150, her skin was cold, sordes collected around her teeth, and she lay calling for her mother. On the fourth day she vomited in the morning dark, coffee-grounds like fluid, but did not seem either better or worse in other respects than on the previous day. Her mother came to her, and her presence seemed to be a comfort to the child, as shown by signs rather than by words. The same afternoon she was taken home, a distance of four miles, and seemed no worse for the short journey. She never rallied, however, but grad- ually sank, and the next afternoon she died. It may be said that in this case the child was afflicted with a grave disease, though not in a far-advanced stage; and that, therefore, the shock of removal from home produced an effect on her which otherwise it would not have occa- sioned. But sudden shock may sometimes overthrow the whole moral equilibrium, and disarrange the balance of the nervous system so seriously as to cause the death of a child previously free from any important ailment. A little boy, five years old, whose health had previously been delicate, was taken on Oct. 23 to his father's funeral. There had never been any special tie between his father and himself, but the strange sad scene overcame him : he 11 122 INTENSITY OF EMOTIONS shivered violently, became very sick, complain- ed by signs of pain in the head, but had lost the power of speech, and was unable to protrude his tongue. He was brought home, and lay listless and indifferent to surrounding objects all da3r, but resting in the night, able to swal- low, but refusing food. On the third day he was admitted into the Children's Hospital, when his expression was dull; his pupils were unnaturally dilated ; he could not close his right eye; his mouth was drawn to the left side, and the saliva dribbled from his mouth ; power over the right arm was impaired, and the head was drawn to the left side. These symptoms did not persist; power over the right side returned by degrees, as did the power of speech, and that of protruding his tongue; but no corres- ponding improvement took place in his general condition. On October 28 he had for a few hours a gleam of cheerfulness, sat up, and pla3^ed with to3rs, but this soon passed awa3« His days were spent in a drows3r, apathetic condition, varied only by calls for his mother, which did not always cease even when she was by his side; and the nights were, without ex- ception, restless and excited. On November 3 convulsions occurred, and the3r were followed by deep drowsiness. The drowsiness deepened, the convulsions from time to time returned, and eary on November *7 he died, just sixteen days IN CHILDHOOD. 123 after his father's funeral. A little fluid in the ventricles of the brain, a little congestion of its vessels, was all that the anatomist could find. 1 suppose his mother was right: she said his heart was broken. It behooves us to bear in mind that the heart may break, or the reason fail, under causes that seem to us quite insufficient; that the griefs of childhood may be, in proportion to the child's power of bearing them, as overwhelming as those which break the strong man down. In France, during the ten years from 1835 to 1844, 134 children between the ages of five and fif- teen committed suicide, or, on the average, nineteen every 3rear. "In the greater number of the instances," sa3's M. Durand-Fardel,1 to whose researches I am indebted for the figures I have just quoted, "in which the cause of the suicide is mentioned, one sees that they have killed themselves in consequence of punishment, or of reproofs, or of ill-usage. These facts deserve special at- tention ; they prove how much more the sus- ceptibility and sensitiveness of children need to be taken into consideration than is com- monly done." This keenness of the emotions in children 1 Etude sur le Suicide chez les Enfants; in Annates midico-ptychologiques. 121 INTENSITY OF EMOTIONS displa3's itself in other ways, and has constant- ly to be borne in mind in our management of them. The child loves intensely, or dislikes strongly; craves most earnestly for sympatly, clings most tenaciousy to the stronger, better, higher around it, or to what it fancies so, or shrinks in often causeless but unconquerable dread from things or persons that have made on it an unpleasant impression. Reason as 3'et does not govern its caprices, nor the more in- telligent selfishness of later years hinder their manifestation. The waywardness of the most wilful child is determined by some cause near at hand; and he who loves children, and can read their thoughts, will not in general be long in discovering their motives, and seeing through their conduct. One word more I have to say with reference to that intense craving for sympatly so charac- teristic of the child. It is this which often un- derlies the disposition to exaggerate its ail- ments, or even to feign such as do not exist, and in such attempts at deception it often per- sists with almost incredible resolution. Over and over again I have met with instances, both in private and in hospital practice, where the motives to such deception were neither the in- crease of comfort nor the gratification of mere indolence, but the monopolizing the love and sympathy which during some b37gone illness IN CHILDHOOD. 125 had been extended to it, and which it could not bear to share again with its brothers and sis- ters. This feeling, too, sometimes becomes quite uncontrollable, and the child then needs as much care and judicious management, both bodily and mental, to bring it back to health, as would be called for in the case of some adult hypochondriac or monomaniac. A caution may not be out of place as to the importance of not ministering to this tendency to exaggerated self-consciousness by talking of children's ailments in their hearing, or by seem- ing to notice the complaints they make, as though they were something unusual or out of the common way. It probably has occurred to those who have done me the honor of listening to me, that in speaking of the affections of the mind in child- hood I have referred more to disorder of the moral faculties than of the intellectual powers; and I have done so because I believe them to be the more common, and the more important, if we leave out of consideration—as for want of time we are compelled to do—the cases in which idioc3r or mental weakness is congenital, and the child has never been able to claim its place in the scale of being. But the moral ele- ment seems to me to assert its superiority in this, that it is the most keenly sensitive, the soonest disordered— 11* 126 MORAL PECULIARITIES " Like sweet bells jangled, out of tune and harsh," and the discord is first perceived in the finest notes. But some may say this is no more than we should expect. Cases such-as these do but re- semble in the moral world what in the physical we are familiar with as instances of atavism : the qualities induced by culture, by the upward striving of the artificial man, are those first shaken, first abolished; the ungovernable self- ishness, the uncontrollable temper, the violent passion which disease develops, do but point to the parent stock, from which we are separa- ted only by centuries of training, and which the identity of the hippocampus minor in man and monkey proves beyond a doubt. But what, if in proportion to our sympatly with these so-called accidental, adventitious qualities, is our success in the treatment of dis- ease, and especially of such diseases as present themselves in the simplest, least complicated forms amongst the 3'oungest of our race ? "Nihil humani a me alienum puto," said the Roman, in words which have been quoted till the3^ have sunk to be a schoolboy's theme; but these words are to be used no longer; it seems we have read our lesson wrong, man's gene- alog3T is not what we thought— " Os hoinini sublime dedit Et erectos ad sidera tollere vultus," IN CHILDHOOD. 127 was a mistake of the old pagan. God made us not in His image, nor formed us in His likeness; we are no heirs of immortality, redeemed by no Atonement; but from time to time we may learn, I know not whether humility or pride, from a visit to a lineal descendant of our ances- tor in the Zoological Gardens. Pardon me, Sir, I should be sorry to trans- gress the rules which govern the topics I have a right to refer to here, but I shall probably never again have the opportunity of expressing before an audience like this what I understand as religio medici; and of making the confes- sion of faith of one who for many 3'ears has been engaged in the active practice of our profes- sion. I have lived among children, I have loved them as we all learn to love the objects by which we are all daiby surrounded. I have seen their suffering and sorrow, and no explanation but one could ever in an3^ degree solve the problem which it suggests. I have found it in the belief that He whom an old book speaks of as the Hohy Child Jesus allows the 301mg children, " whom in Palestine he had blessed, once and forever, to pass through this, onty that they might meet the sooner." The mys- teiy of the suffering, indeed, is still in large measure incomprehensible, but an end is seen to it all; not the extinction of the weak for the 128 SUFFERING IN CHILDHOOD. sake of the strong, themselves to yield in turn to the stronger; the race being all, the individ- ual nothing, but the perfection of each individ- ual of the race ;—a perfection to be attained not here, but higher. The last words of the gospel of the dreary creed to which I have referred, written by one whose intellectual gifts go far, whose moral ex- cellences go further still to disprove his own theories, and before whom, in both respects, I bow in earnest admiration, are, " Man still bears in his bodiby frame the indelible stamp of his lowly origin." So be it, but we find it also written, "The Lord God breathed into his nostrils the breath of life, and man became a living soul." The humility of our origin we allow, the ex- ceeding bitter cty of tortured humanity we above all other men have to listen to, but to our joy we know the prayer, and we believe it has been answered: " 0 Dux domus Israel, 0 Rex gentium, et Desideratus earum, veni et salva hominem quern de limo formdsti ! " INDEX. PAGE Antimony, in chorea,......75 Aphasia, in chorea,.....68, 99 temporary, from various causes, . . . 103 after sunstroke, ...... 109 Brain, pain dependent on disease of, . . . 24 paralysis from tubercle of, . . . .85 Children, mental and moral peculiarities of, . 112 Children's diseases, peculiarities of, . .19 Chorea,........50 and epilepsj*, contrasted, . . . .32 relation of sexes in, . . . . .53 causes of, . . . . . . .54 an analysis of sixty-six cases of, ... 55 relation of, to rheumatism and heart disease, 51, 62 its various modes of onset, .... 61 paralytic element in, . . . . 65, 69 affection of speech in, . . . . 68, 98 affection of intellect in, . . . (58,99 treatment of, . . . . . . .70 Convulsions generally due to eccentric causes, . 29 tend to recur, ...... 33 terminate in epilepsy, ..... 34 Emotions, vividness of, in children, . . . 120 130 INDEX. Epilepsy and chorea, contrasted, succeeds often to infantile convulsions, relation of sexes in, prognosis in, . influence on moral character, treatment of, . Gymnastics in chorea, . Headache, neuralgic, . Heart-break, Hip-joint disease, pain dependent apparent paralysis from, Idiots, paralysis of, Infantile paralysis, Intellect, affected, in chorea, overtasked, a cause of epilepsy, of chorea, Lumleian Lectures, founders of, . Mental and moral peculiarities of childhood, Moral peculiarities of children, their importance Nervous system in children, disorders of, . Neuralgia in childhood, rare, Ocular spectra in childhood, Paralysis, diphtheritic, after long illness, . connection with rickets, disease of spine, or of hip, PAGE 32 34 53 36 39 40 INDEX. 131 Paralysis, connection with idiocy, in chorea, from cerebral tubercle, . essential or infantile, Potass, bromide of, in epilepsy, . PAGE . 83 65, 68 . 85 . 87 . 45 Religious dogma, care needed in enforcing on sick child, ........ 124 Revelation only clue to reason of suffering in childhood,.......127 Rickets, paralytic state connected with, Somnambulism, ...... Sounds, perception of subjective, in childhood, Speech, importance of power of, . tardy acquirement of, . . in the idiot, ...... loss of power of, in cases of chorea, fever, or other illness, . ' after sunstroke, power almost always regained, Spine, paralysis dependent on disease of, Stammering, ....•■ Suffering in childhood, how explained, Suicide of children,..... Sympathy, child's craving for, 81 119 118 92 94 96 98 103 109 111 82 98 127 123 124 Zinc, sulphate of, in chorea, 77 WS 100 W516o 1871 48910200R NLM DSESEMMl 1 NATIONAL LIBRARY OF MEDICINE NLM052524419