When the attacks follow a convulsive seizure they may be accompanied by a temporary paralysis, such as is a not uncommon consequence of eclampsia (see page 280). Sometimes the contractions are more exten sive. Thus the muscles of the trunk are occasionally affected. Rilliet refers to the case of a delicate little girl, aged twelve years, in whom the tonic rigidity of the extremities was accompanied by opisthotonos with extreme retraction of the head, and at times intermittent contractions limited to the back were noticed, closely resembling tetanus in character ; but the jaws were not affected, as they invariably are in that disease. The disorder lasted for a month. In other cases, according to the same au thority, the spasms may be more limited and affect the hip or one side of the neck. The disease appears to be more severe upon the continent of Europe than it is in England. In the milder form common in this coun try the contractions are invariably bilateral, and affect the corresponding muscles of the two sides. As long as they continue, walking is impossible, and the child can hold nothing in his hand. In the slighter forms the contractions are remittent, and occasionally cease completely. In severe cases little variation is seen in the rigidity, and it persistA during sleep. Even complete anEesthesia from chloroform produces no relaxation of the tonic spasm. Sensation is unaffected ; reflex excitability is normal ; the temperature is natural or even below the level of 'health and the child's intelligence remains perfect. In Dr. Cheadle's case the muscles responded well to both the continued and interrupted current. The tonic contractions are rarely the only nervous symptoms present. Often they alternate with other forms of nervous spasm. The child may be subject to laryngismus stridulus, or may be readily thrown into convulsions by any passing irrita tion. In many cases, as has been said, the contractions succeed to some such form of nervous seizure, and sometimes an intermittent squint is noticed.
In most cases, in addition, symptoms of intestinal or other derangement are present. Diarrhoea is one of the commonest of those symptoms ; and, indeed, the nervous disorder has been known to disappear as the condition of the bowels improved. The duration of tetany is very variable. It may last a few days or persist for weeks. It usually becomes intermittent before it finally disappears. After ceasing for a time it not unfrequently returns.
Diagnosis.—This form of nervous spasm is readily recognised. Tonic contractions occur in a child whose nutrition is impaired either from inju dicious management, from gastro-intestinal derangement, or from the re cent presence of acute disease. Often he is the subject of rickets, and has already shown a tendency to other forms of nervous derangement. Tetany is bilateral and symmetrical. It occasions no elevation of temperature and is accompanied by no clouding of the intellect. These qualities, combined with the tendency to nervous spasm, and the evident connection of the attack with some form of peripheral irritation, will serve to exclude cerebral dis ease. In the severe form, which is accompanied by opisthotonos and tetan oid spasms, the history of the attack, the normal temperature, and the en tire absence of stiffness of the jaws will be sufficient to exclude tetanus.
Prognosis.—Tetany is merely a symptom which has no gravity what ever ; and the prospects of the patient's recovery of health depend upon causes quite independent of the nervous spasm. As the children in whom tetany occurs are often the subjects of a chronic intestinal derangement, and are in many cases distressed by frequent attacks of laryngismus stridu lus, they may possibly succumb ; but in estimating the patient's chances of recovery the tonic rigidity of the extremities may be quite excluded from our calculations.
Treatment.—Our first care in the treatment of this complaint must be to attend to any disordered condition which may be present interfering with nutrition, and acting as an irritant to the nervous system. Gastro intestinal derangements must be checked ; constipated bowels must be re lieved ; the diet must be regulated to suit the needs of the system (see Infantile Atrophy, Chronic Diarrhoea, etc.) ; and if rickets be present, meas ures must be taken at once to arrest its progress. In all cases, indeed, the general treatment recommended for laryngismus stridulus and rickets, viz., fresh air, good food, cleanliness, and the administration of iron wine and cod-liver oil, is of equal service in this disorder. Frictions and warm baths seem also to have a beneficial influence.
In obstinate cases special steps are required to relieve the tonic rigid ity. This form of spasm will often refuse to yield to measures which have the power of readily controlling the nervous disorders with which tetany is allied. Chloroform puts an immediate stop to an eclamptic seizure, but has no power of relaxing the rigidly contracted muscles of tetany ; and chloral which is so valuable in arresting the spasm in laryngismus stridulus is given in this neurosis without any beneficial result. Bromide of potassium and musk appear to be equally useless. In Dr. Cheadle's case, before referred to, chloroform, chloral, and bromide of potassium were given without any success ; but the contractions yielded after the treat ment had been changed to Calabar bean with cod-liver oil and iron wine. One thirty-sixth of a grain of the bean was given three times a day. The dose was gradually increased to one-eighth before any effect was produced. A notable diminution in the stiffness was then observed. Afterwards the dose was increased to one-fifth, later to one-fourth, and lastly to one-third of a grain three times a day. The boy was well seven weeks after begin ning to take the remedy.
Although the bean appears in this case to have had a decided influence over the spasm, it must be noted that the child began at the same time to take iron wine and cod-liver oil ; and that although the principal improve ment occurred after the dose had been pushed to one-sixth of a grain, it followed two days after the important addition of pounded raw meat had been made to the child's diet. The Calabar bean, no doubt, deserves a more extended trial in these cases of tonic rigidity. Still, in the interest ing case referred to it is doubtful what degree of improvement can be cor rectly attributed to this remedy ; for the alcohol, the cod-liver oil, and the improved diet must have taken a sensible share in bringing about the child's recovery of health.