When both feet are affected, they are, not unfrequently, differently distorted; as, for instance, with equino-valgus of one foot, there may be equino-varus of the other.

When single muscles or groups of muscles are paralysed, it is in the following order of frequency; namely, 1st, extensor longus digitorum; 2d, tibialis anticus; 3d, extensor proprius pollicis pedis; 4th, the supinators of the wrist and the extensors of the fingers; 5th, deltoid; 6th, sterno-mastoid; 7th, the extensors of the leg.

The muscles of speech are sometimes paralysed, together with other muscles. I have lately seen as many as four cases in which this had occurred. In two of them the flexors of the foot, and the supinators and extensors of the hand and fingers, had also suffered loss of power.2

The diagnosis of myogenic paralysis is often difficult. If paralysis is more or less localized, and has been preceded by muscular pain; if it has appeared suddenly; if the secretions are not disordered, and the child has not been convulsed, the affection is of the muscles, simply, and without disease of the nervous centres. But if it has succeeded febrile action, occasioned by worms in the alimentary canal, by dentition,

'Beobachtungen über Lähmungszustände der untern extremitäten und deren behandlung,' p. 16, Stuttgart, 1840.

2 "Sir Benjamin Brodie lately mentioned to me," says Mr. Adams, “a case brought to him, in which the muscles of deglutition were paralysed in a child. The attempts to swallow were very painful to witness." (Lectures on Orthopedic Surgery, Med. Times and Gazette,' Dec. 1855.)

or other of the many causes already enumerated, incident to infancy, or dependent on other sources of irritation of the brain or spinal cord, it will have been induced by lesion of the nervous system.

SPASM.

Spasm and paralysis sometimes coexist; spasm of one limb, paralysis of the other. Spasm may terminate in paralysis, and returning power is not unfrequently marked by spastic action; indeed, the primary cause of these conditions— spasm and paralysis-is, to a certain extent, identical.

Spasmodic action is usually first developed in the upper, and later in the lower extremities. Also, the upper extremities recover power before the lower. There are many exceptions, however, to both of these propositions. But in paralysis the reverse of this usually obtains, the arm being the last to recover power.

Some cerebral disturbance usually accompanies spasmodic muscular contractions; and this may be, and, in fact, is generally repeated, a succession of slight fits following—at various periods, perhaps several times in the course of twelve hours, or three or four times in the course of a twelvemonth-the first convulsive attack. After the first attack, the limbs may remain in a state of tonic spasm, and the muscles become rigid, and give rise to fearful distortions of the trunk and limbs.

The flexors of the limbs are the muscles which especially occasion distortion in these spasmodic affections, for they are generally more powerful than the extensors. As Dr. Mason Good says, "a very slight survey of the animal frame will show us that the flexor muscles have in every

part some preponderance over the extensors;" and this is well exemplified in these diseases: for the thighs become flexed upon the trunk, and, through contraction of the powerful adductors, the knees are approximated, and crossed even, one over the other; and so rigidly are they thus maintained, that the application of considerable force may be wholly insufficient to separate the thighs: the legs are flexed upon the thighs, the feet are extended and inverted, and the toes frequently are flexed. The arms are bound to the sides by the combined actions of M. latissimus dorsi and pectoralis major; or the latter muscle alone acting, they may be crossed on the chest; the fore-arms are flexed, the hands are prone, and the fingers are flexed. The rectus oculi internus frequently is affected, producing convergent strabismus: very rarely, divergent strabismus is seen. Strabismus is always found on the same side as the rigid muscles, when one side alone is affected.

Spasm of the extremities of one side is more usual than more extensive irregular muscular action; or both lower extremities are affected, or a single limb, or a group or groups of muscles.

In spasm, the flexors and pronators usually distort the limb, but the extensors1 and supinators are most commonly paralysed. Hence, in paralysis and spasm, a similarity of distortion prevails.

The spinal column, in the cervical and dorsal regions, is occasionally, at the same time as the extremities, distorted, by the irregular action of M. latissimus dorsi, trapezius, erector spinæ, sterno-cleido-mastoideus, &c., but this is not a common complication. The bladder and rectum are also

The muscles of the calf of the leg were classed as flexors by Rudolphi, Walther, and others.

occasionally implicated; the bladder is more frequently affected than the rectum, and its contents may be ejected with great violence, after having been retained during, perhaps, an inordinate time.1

In severe forms of this affection, the countenance of the child is indicative of cerebral disturbance; the child is heavy and listless, and wears a vacant expression, and the intellect is usually somewhat torpid; but it may generally be roused to notice surrounding objects, and is more intelligent than might be supposed by a casual observer. Not unfrequently children thus affected are very excitable.

In a large number of instances, cerebral symptoms are not observable; the child has never been known to have a fit, nor shown any disposition to cerebral disturbance. Tonic muscular contractions have been induced, doubtless, by some hidden irritation, which may not sensibly affect the health of the child.

The following case will serve to illustrate a class of cases which is far from uncommon :

Towards the close of 1854, the child of a clergyman was brought to me, having double talipes equinus. She was four years of age, dark, florid, stout, and remarkably healthy in appearance. She had never had any infantile disease, nor a day's illness; the teeth were cut remarkable easily and without pain. The child was precocious, and more observant and inquisitive than I have ever before or since known.

Eighteen months before I saw her, she was observed to limp in walking, and this gradually increased until she stumbled; and at length, the heels were observed not to touch the ground, and the

1 I have lately seen an instance of this in a child, three years of age, who had suffered from spastic contractions since the age of nine months. The bladder was seldom emptied oftener than once in twelve hours, and occasionally its contents were retained forty-eight hours, causing considerable suffering.

child fell after making a few paces, or when walking she steadied herself with a stick.

The extensor muscles of the right foot were more retracted than those of the left, and consequently the right heel was more elevated than the left; the pelvis had become slightly oblique, and the spine was curved with a single curve. There was no paralysis of the flexor muscles of the foot, and no other abnormal muscular action (that of the muscles of the back, consequent on the obliquity of the pelvis, to restore equilibrium, not being considered) than that of the extensors of the feet.

During the first three years of life, children are particularly subject to convulsive affections. Spasm is occasionally developed at birth or some few days after; it may be occasioned by pressure of the head of the fœtus in its passage through the pelvis ; it may also be induced by instrumental interference. When it occurs at birth, without undue pressure having been exercised, it takes place, for the most part, in those who are puny and ill-nourished, and who have not completed the full period of gestation. These are unusually predisposed to congestion and spasmodic affections, through the imperfection of the circulatory system and of the respiratory organs.

When the child has been convulsed, some muscular weakness may result, or the limb may be paralysed, or a state of spastic contraction of muscle may ensue. Not unfrequently, any of these conditions, affecting the lower limbs exclusively, remains unperceived until the child should commence to use its feet; or being observed, it is often thought to be unimportant, and gains less attention than it deserves.

1 Vide 'Observations on Cerebral and Spinal Apoplexy, Paralysis, and Convulsions,' by Evory Kennedy, M.D., in 'Dublin Journal of Medical Science,' vol. x, art. 27.