Tenotomy of the tensor vaginæ femoris, of the semi-membranosus and the semi-tendinosus on both sides; also of the tendo Achillis on both sides and of the peroneals on the right. Forcible extension and retention in plaster-of-Paris. Apparatus applied in six weeks. Legs still very helpless. Must walk on crutches for some time. Great difficulty in applying the apparatus on account of the lateral and backward tilting of the pelvis, which can never be cured, although extension and counter-extension while in bed has greatly helped the condition.

FIG. I.

CASE II.-W. W., fourteen years of age; infantile paralysis in childhood. Has never walked since. Legs absolutely helpless. Flail legs from hip. No voluntary action in foot or toes. Excessive lordosis from tilting of the pelvis, which was raised on the right side three inches above the left. Excessive lateral curvature with rotation of the vertebræ and prominence of the left thorax posteriorly. Arms also extensively atrophied and very helpless. Flexion at thigh to a right angle; at knee nearly the same. Right foot, equino-varus; left, valgus. The whole body greatly emaciated and from insufficient food illy nourished.

The child was so feeble that after tenotomy on one side had been performed, it was necessary to wait several weeks before the other side could be operated

upon.

Tenotomy of the tensor vaginæ femoris, the sartorius, and long head of the rectus, the hamstring tendons, and the tendo Achillis on both sides. The knees and feet were brought straight, but the thighs could not be put in normal position; nor could the pelvis be brought into its proper relation to the spinal column, because the latter was so greatly distorted. Long extension and counter-extension, however, added to the benefit obtained at the time of operation, but even after an apparatus with rigid joints was applied from the thorax to the feet, the arms were incapable of supporting the patient upon crutches. A wheel-crutch (see Fig. 2) was therefore constructed in order to support the weight of the body until locomotion could assist in giving some power to the legs. With this he was able to progress very well. A leather jacket encircled the body. Six months

CASE III.-L. C., fourteen years of age; infantile paralysis in infancy; has never walked since except with apparatus with rigid joints. Flexion of both knees; hips and ankles are in good position; lateral curvature of the spine, with left rotation. Section of the hamstring tendons. Apparatus constructed; leather jacket; movable joints in apparatus, with elastic strings to assist all weakened muscles. With such assistance, after three months he was able to walk a mile. He was kept in plaster-of-Paris dressing for four weeks.

CASE IV.-J. M., eleven years of age; absolutely helpless from infancy; has never walked. flexion of hips and knees; feet but slightly distorted, as they have never been used. Tenotomy; plasterof Paris dressing; apparatus. Walked with crutches at the end of six weeks, with cane at the end of seven months, and is still improving.

CASE V.-A. M., ten years of age; has never walked since an attack of infantile paralysis at one year of age. Hips and knees in fair condition; talipes equino-varus of left foot; equino-valgus of right foot.

Section of tendo Achillis and of the contracted fascia on the left side, and of the same tendon and of perineals on the right; plaster-of-Paris dressings; apparatus in five weeks. At the end of five months walking without cane and without fatigue for several blocks.

CASE VI.-R. C., three years old, has never walked, except upon all-fours, as shown in Fig. 3. Flexion at right angle. Section as described. Can now walk on crutches, and is gaining strength.

FIG. 3.

CEREBRAL SPASTIC CASES.

I am confident that in these cases the benefit to be derived from locomotion is not to be gained by any other means. The effect upon the physical well-being is marked; mental development occurs and is assisted by bringing the individual into contact with the world, an effect that should not be underrated.

Some may say that brain-cells cannot be replaced. This is certainly true, but, as in a case of enfeebled muscles, constant exercise tends to stimulate growth and development. This action may be described as a benefit to be derived from without inward, but it is nevertheless positive. That it can produce a fully developed mind no one claims, nor can fully developed muscles be secured, but at the same time the gain derived is positive and decided.

The most common deformity in spastic cases is flexion of hip and knee, with contraction of the gastrocnemius and soleus. Adduction of the thigh is also frequent. All the deformities increase greatly as soon as the patient stands upon his feet.

In dressing these cases, I usually over-correct the equinus, them apply gypsum bandages to retain it in this position. The knee is then rigidly fixed in a straight line, and a continuous dressing from feet to perineum is applied. This permits complete and perfect abduction, to be secured by simply separating the feet.

After myotomy of the tensor vaginæ femoris and fascia, the weight of the plaster-cast is usually sufficient to lessen the hip-flexion, but weights are sometimes necessary. The hip-flexion is the one

most liable to relapse when the upright position is resumed; hence I often use the wheel-crutch for a time, in order to take off the weight of the body.

Apparatus for these cases is often very complicated and expensive, and even then insufficient. I have long tried to secure a wheeled support for these unfortunates, but all those in the market are so expensive as to place them far beyond the reach of a large number of sufferers. With the valuable and helpful assistance of Dr. George E. Shoemaker, I have now constructed such a support that is both practical and cheap. To save expense we must use material that is already in the market. The running-gear of baby-coaches, or of children's expresswagons, or buckboards are utilized. These can be procured at from four to six dollars a set. For young children, or for those so feeble-minded or feeblemuscled as to require attendants, a baby-coach running-gear frame can be utilized so that it can be guided or pushed.

The

Upon the frame is erected a crutch-support. The crutch-head can be raised or lowered by a nut and thread. Jar is prevented by rubber washers. width of the crutch-heads will vary with the diameter of the thorax. For very helpless cases a broad supporting belt of leather encircles the chest. For children who are strong and able to control themselves, the hind wheels are similar to the fore ones, but the latter are pivoted, as in rolling-chairs, wardcarriages, etc., thus permitting movement in any direction.

In hospitals with long halls a longer apparatus with self-steering gear, as seen in the illustration, may be employed, and is very useful in educating patients to walk. When an infantile paralytic, say fourteen years old, has never been up on his feet, it is not to be expected, even for a long time, that he will know how to use his feeble muscles. In spastic cases, many who cannot walk at all without this apparatus can by its aid make very comfortable progress.

The following are illustrative cases:

CASE I. Cerebral spastic paralysis from birth. Walks on tips of toes; toes inverted in position ductors flexed; moderate degree of mental impairof talipes equino-varus; knees, thighs, and adment; marked internal strabism's; cannot walk without support, and then with the usual staggering gait.

Section of the tendo Achillis and of the adductors. Knees forcibly straightened and retained by plaster-of-Paris dressing from toes to perineum; limbs widely parted and fastened; apparatus applied. In six weeks heels well down upon the floor, although still pigeon-toed.

CASE II.-G. B., nine years of age. Very low degree of mental development; unable to talk, but

Tenotomy of the hamstring tendons and tendo Achillis both sides; extension in bed. Wheelcrutch constructed so as to be pushed by a nurse like a baby carriage. In this manner patient is able to progress with much less spasm, and can bear considerable weight on his legs. No improvement in mental condition anticipated. CASE III.-L. L., one year of age. Suffered injury by forceps at birth. No decided depression discovered in skull; very feeble intellect; can only stand when supported; talipes equinus in both feet.

Section of the tendo Achillis. Put upon a wheelcrutch at the end of six weeks, and with the aid of a nurse could walk with much comfort and pleasure.

CONCLUSIONS.-I. The deformities of infantile paralysis can be prevented by apparatus, but if this has been neglected and distortion has occurred,

BY AUGUSTUS A. ESHNER, M.D., INSTRUCTOR IN CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE AND IN THE PHILADELPHIA POLYCLINIC; REGISTRAR IN THE NEUROLOGICAL DEPARTMENT OF THE PHILADELPHIA HOSPITAL.

"OF all the diagnostic problems presented to the physician," says Gowers, in his work on Nervous Diseases, "that of cerebral hemorrhage is at once the most difficult and urgent." The diagnosis is simplified if recovery from the acute manifestations occur. It is in the grave and fulminant cases that the diagnosis is most difficult, and it is just in these cases that it is most important. Nothnagel, in Ziemssen's Cyclopedia, states that "the diagnosis, of hemorrhage or of embolism or of thrombosis cannot in any case be unreservedly made." With these qualifications let us endeavor to summarize and arrange side by side the special features that distinguish cerebral hemorrhage from those conditions that may simulate it. To no con

procedures, and in some way make the patient walk.

2. Apparently hopelessly distorted cases can be put upon their feet. Even great deformity of limbs resulting from infantile spinal paralysis should not deter us from the attempt to straighten the limb and give the individual the power of locomotion.

3. Atrophied limbs can be straightened and can then be incorporated as a part of the locomotive

with emphasis the statement that there are few pathognomonic signs in disease. Among other causes, the symptoms in this condition are due to the results of pressure, suddenly induced, and to destruction of cerebral tissue. Any other state, in which like influences are active, will be attended with similar manifestations.

In a consideration of cerebral hemorrhage all the forms of intra-cranial extravasation of blood are sometimes included. All display many symptoms in common, but there are certain features that, when present, distinguish the one from the other.

Let us first briefly pass in review the more common symptoms of intra-cranial hemorrhage. The two most prominent and characteristic are loss of consciousness and impairment of motion. Either The second may be present in varying degree. may not become evident until the first has passed away. The loss of consciousness may occur suddenly-constituting the so-called apoplectic shock -or it may set in gradually. It may be transient or protracted, and of an intensity from the slightest. to the most profound. There are no true prodromata, except in cases of ingravescent apoplexy, So-called prodromata are usually due to the existin which the hemorrhage takes place gradually. ence of the conditions favorable to the production of hemorrhage or to the occurrence of minute capillary hemorrhages.

In the attack, the breathing is usually slow, labored, noisy, but it may be rapid and shallow. The face is apt to be flushed, but it may be pale. The pulse is often slow, hard, and full, but it may be weak, rapid, and irregular; the carotids

1 Read before the Northern Medical Association, June 12, 1891.

may pulsate. The pupils may be dilated or contracted, perhaps unequally, but they are usually sluggish or immobile. Perhaps even during the coma some difference between the muscular tone on the two sides of the body may be detected. The reflexes may be absent or exaggerated, but they are likely to differ on the two sides. Control of the sphincters may or may not be lost. Convulsions may occur, but are uncommon. There may have been nausea and vomiting. The head and eyes are usually turned from the side on which the paralysis occurs and toward that on which the lesion exists. The patient may die without emerging from the

coma.

Should consciousness return, the loss of muscular power becomes more evident. The temperature during the initial stage was perhaps subnormal, but now rises several degrees above the normal. The general symptoms gradually ameliorate, and in the course of several months there remain only those dependent upon the direct injury that the brain has suffered. The paralysis is usually of the hemiplegic type. The leg, arm, and face are paralyzed on the side opposite when the lesion is situated above the decussation of the fibers of the facial nerve, at the middle of the pons. The tongue, protruded, deviates to the paralyzed side. The lower part of the face is affected. The orbicularis palpebrarum and the occipito-frontal muscles are not involved. The face is drawn to the unparalyzed side, the angle of the mouth droops, and saliva dribbles. If the lesion is situated in the lower half of the pons the facial fibers are affected on the same side as the lesion, and the leg and arm on the opposite side. The asymmetry is evident when an attempt is made to pucker the lips, as in whistling, or in showing the teeth. Emotional movements, however, are symmetrically performed. Gradually there is some restoration of function, greatest in degree in least specialized parts and in those that participate in bilateral movements. The knee-jerk is exaggerated. Associated movements occur. Mental deterioration sets in.

The diagnosis would be easy if every case presented such a complete clinical picture; but in individual instances the symptoms are present in varying degrees of completeness. Again, cases are not always seen from the onset, and the history is frequently wanting.

In making the differential diagnosis cases of cerebral hemorrhage are to be separated: 1, from disorders due to intra-cranial lesions; 2, from conditions due to remote pathological changes. The distinction is further to be made from affections that for the want of a recognized lesion are called functional, such as epilepsy and hysteria. Probably in all of these conditions the symptoms arise from influences acting upon the cerebral cells and structure, but, on

the one hand, the impression is direct and local, while, on the other, it is transmitted through the circulation as a result of changes extraneous to the cranial cavity. Let us first consider the latter.

Uremia may set in with convulsions, followed by coma. Convulsions are not common in cerebral hemorrhage. If they occur at all, they are more apt to appear late rather than as the initial symptom of an attack. As a rule, the coma in uremia is not so profound as in hemorrhage, though, as already stated, in the latter it may be of any degree of intensity. The existence of Bright's disease may have been known prior to the attack, or albumin and tubecasts may be present in the urine, but as the conditions present in Bright's disease are predisposing factors in the causation of cerebral hemorrhage, too much stress cannot be laid upon these points; besides, it is recognized that albumin appears in the urine in cases of cerebral hemorrhage uncomplicated with disease of the kidney. The temperature is at first apt to be low in uremia, as in hemorrhage, but there is no secondary elevation, unless there be a complicating inflammation.

Cerebral edema may be associated with a uremic attack, and give rise to motor symptoms, but, should the patient rally, these prove but transitory. Ophthalmoscopic examination may reveal the existence of an albuminuric retinitis. In uremia, the writer has observed that the breath and body have a peculiar musty odor, not encountered in cerebral hemorrhage.

In diabetic coma, in contradistinction to cerebral hemorrhage, the loss of consciousness is not abrupt. It may set in with somnolence. The pulse is weak

and rapid. There is no paralysis. The breath may exhale an odor resembling chloroform. Then, an examination of the urine reveals the presence of sugar, while other manifestations of diabetes may also be evident.

In alcoholism the diagnosis may be embarrassed by many doubts. Examination of the urine may detect the presence of alcohol. Anstie's test consists in the production of a bright emerald-green color by the addition to fifteen minims of urine of one part of a solution of one part of chromic acid in three hundred of sulphuric. The patient, however, may have been drinking when the hemorrhage occurred, or stimulants may have been administered with the onset of the attack. The absence of the odor of alcohol in the breath and the absence of alcohol in the urine are more significant, and strengthen the probability of the existence of hemorrhage. Irdulgence in alcohol, too, is an exciting cause of hemorrhage into the brain. In the stupor from alcoholism, however, the patient can be aroused by appropriate stimuli, as by ammonia or by shouting. The pulse is soft and rapid,

there is muscular relaxation, but no paralysis, and the reflexes are not altered from the normal. The pupils are dilated, the conjunctivæ injected. The temperature may be subnormal, but there is no secondary fever. Recovery, should it take place, is comparatively rapid, and may be facilitated by inhalations of ammonia or by evacuating the contents of the stomach and bowels. Edema of the brain may be present, as in uremia, increasing the difficulty of diagnosis.

In opium-poisoning the coma occurs gradually, the pupils are small, but equal, the breathing is feeble, shallow, and infrequent, and there may be vomiting. The patient, however, can be aroused, and he responds to stimuli. There is no paralysis, no elevation of temperature. If no complication exists, under appropriate treatment the return to the normal condition is rapid.

In poisoning by chloroform or by hydrocyanic acid, the odor of the breath is distinctive. In the first the heart's action is rapid and tumultuous, the pupils are dilated, and there is general anesthesia. In the second, inspiration is peculiarly short, and expiration is prolonged and labored. In the case of both, the sequelæ of cerebral hemorrhage are wanting.

In asphyxia, from whatever cause, the breathing is embarrassed, and there are all the evidences of respiratory obstruction. The face is livid and congested. Convulsions and coma ensue, and if the cause be not removed death follows. The symptoms are general, not local or unilateral.

In syncope and in cerebral anemia the conditions are much alike. The face is pallid, the pulse is rapid, feeble, fluttering, the respiration is sighing, the extremities are cold, and there may be nausea and vomiting-all of which may be improved by the exhibition of stimulants.

Cerebral congestion may be owing to fulness of the veins due to obstruction, or to deficient vis à tergo, or to fulness of the arteries from cardiac overaction. Should loss of consciousness occur it is of but brief duration, or only partial. Loss of power is slight or absent, and not lasting, while there are no variations of temperature and the symptoms are speedily recovered from. Most probably there have also been previous attacks of the same kind.

The facial palsy resulting from cerebral hemorrhage is to be distinguished from paralysis of the muscles supplied by the facial nerve as a result of disease of the nerve or of its nucleus, by the escape of the orbicularis palpebrarum and the occipitofrontal muscles; by the fact that associated and emotional movements of the face are symmetrically performed, and that atrophy and degenerative reactions do not follow.

Hemorrhage into the cord or spinal apoplexy also

occasions paralysis, but usually in the form of paraplegia. It is most apt to occur in the young, with a history of syphilis. The patient feels a sudden, sharp, stinging pain in the back. There is no loss of consciousness, or should there be it is but passing. If the hemorrhage is into the membranes, there will be tonic convulsions of a tetanic character.

Epilepsy ought not to be confounded with cerebral hemorrhage, but, seen in the stage of unconsciousness, some doubt may arise. The diagnosis of convulsions symptomatic of intra-cranial disease is intimately connected with a recognition of the exciting cause. In so-called idiopathic epilepsy convulsions precede coma, the tongue is apt to be bitten, there is no paralysis, the temperature may be elevated, but it is not at first depressed, and there is a history of previous attacks.

Sunstroke occurs at a particular season of the year, during the heated term. If cerebral hemorrhage shows any preference for season, the larger number of cases in this climate occur in the spring. In sunstroke the temperature is from the outset high, at times exceedingly so, and the skin is dry and burning. Coma is ordinarily not protracted or profound. Headache and vesical disorders may be sequelæ paralyses never.

It can be readily enough conceived that symptoms of cerebral hemorrhage may develop in an hysterical person; but one ought not to be deceived if he bear in mind the age of the patient, the sex, and perhaps a known menstrual derangement. A discriminating eye will be able to distinguish the feigned attack from the genuine one. On the other hand cerebral hemorrhage may occur in an hysterical individual, and the man festations of the one should not be permitted to obscure the more grave condition.

The distinction of cerebral hemorrhage from other pathological intra-cranial conditions divides itself into the differential diagnosis of the various kinds of hemorrhage, with some reference to their location, the separation from vascular obstruction and that from other varied conditions.

Should abscess of the brain give rise to loss of consciousness, this is apt to have been preceded by other symptoms. A cause for an abscess may be found in some previous injury or contiguous inflammation, or a general pyemic condition. Chills, fever, and sweats are apt to have occurred, perhaps. with symptoms of pressure. Hemorrhage may take place into an abscess, adding its own peculiar symptoms to those previously existing.

Hemiplegia or local palsies may result from tumors of the brain.. These are most commonly gliomata, gummata, or tuberculomata. Their favorite situation is at the base. They are marked by intense headache and papillitis, the symptoms are slow