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the aid of medicines, resemble those who shake an hour glass in order to hasten the invariable and regular progress of the sand it encloses. 139. The cause of the eclampsia must be especially ascertained in order to be enabled to prevent its return.

CHAPTER XIV.

ON SYMPTOMATIC CONVULSIONS.

The convulsions which depend upon anatomical changes in the nervous centres, or in their coverings, are not included under the title of eclampsia; they are termed symptomatic convulsions. They are are sym connected with the following lesions: serous or sanguineous congestion of the coverings of the brain or spinal cord; acute or chronic inflam- Coms mation of these membranes; inflammation of the brain or spinal cord; and, lastly, with accidental productions developed in these different

organs.

It may here be observed that the convulsive phenomena lose all the individuality which essential convulsions presented. They are here the expression of a morbid anatomical condition of the nervous centres. They depend on these alterations in the most absolute manner; they are attacks which are secondary to these alterations.

Essential couvulsions have been previously described as one of those diseases the nature of which is unknown, and which it was necessary to particularize. The same cannot be the case with symptomatic convulsions, since their cause is evident and their nature apparent. The diseases in the course of which they appear must first be described. These attacks will then find place in the midst of the symptoms of these various diseases.

The history of the diseases of the nervous centres of young children, in the course of which convulsions are observed, will be described in succession. Meningitis, acute and chronic hydrocephalus, will be first studied; then encephalitis and tubercles of the brain will be considered, diseases seldom separate, nearly always combined with meningitis, if not primarily at least towards the termination; and we shall finish by meningeal hæmorrhage, and by that condition, so frequent amongst the newly-born, to which the name of apoplexy or apparent death of infants has been applied.

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CHAPTER XV.

ON MENINGITIS.

The term meningitis is applied to inflammation of the membranes which envelop the brain, and separate it from the dura mater and cranium.

This disease is seated both in the pia mater and arachnoid. It has been very often confounded with certain diseases of the encephalon. It has hitherto been described under the names of phrenitis, hydrocephalus, arachnitis, &c.: terms at the same time too vague or too precise, which have been discarded by the best part of medical men.

The inflammation is seldom confined to the membranes of the brain. It is frequently accompanied by inflammation of this organ, by accidental productions, which are usually of a tubercular nature, and by a considerable effusion of serum into the ventricles. The complications described by the terms encephalitis and acute hydrocephalus offer only a secondary interest, and do not merit a place in the first rank in the description of meningitis.

Meningitis has for a long time been regarded as a decidedly inflammatory disease, the nature of which was always identical. Its anatomical characters have been described by a great number of authors with a constant uniformity. Some only, having been struck with the frequency of serous effusion into the ventricles, fixed their attention upon this phenomena, to which they wished to attribute too much importance in regarding it as the principal phenomena of the disease. They described it, consequently, under the name of acute hydrocephalus; but they were in error, for in these cases, although the changes in the meninges may be inconsiderable, they are still not the less well #t4t characterized. These are only cases of meningitis, and the effusion is but a secondary symptom.

More recently, when pathological anatomy became the object of a study, fruitful in proportion to its minuteness, several important characters were discovered in the disease we are considering, which began to modify the medical opinion on the subject of its intimate nature. Already Willis had observed that the cerebral symptoms were as easily caused by inflammation and by the suppuration of the meninges as by the nodosities and by the tubercles they enclose (Nec minus a phlegmone et abcessu, quam hujusmodi meningitis et tuberculis nonnumquam cephalalgia lethales et incurabiles oriuntur).

Bichat, in the preliminary observations of his treatise on general anatomy, speaking of diseases of the serous tissue, has observed"Although the serous tissue is connected with the brain by the arachnoid, with the lung by the pleura, with the heart by the peri-ingle cardium, with the abdominal viscera by the peritoneum, &c., it is a

matter of indifference. It is in most parts inflamed in the same manner, neverthe in every part dropsies uniformly come on, &c.; every part is subject 24 to a kind of eruption of small whitish tubercles, as if miliary, of which no mention has, I believe, been made, and which yet merits great atten- proutian tion." These remarks had been forgotten. M. Guersant, struck with the remarkable coincidence which existed between the usual affections (ch of meningitis and the presence of granulations in the meninges, offent, I

tubercles in the bronchial glands and in the lungs, look on these children as phthisical who died from disease of the brain. But he declares* that he had no idea on the nature of these granulations, and that he dare not consider them as true tubercles. Other more enterprising individuals allowed themselves to be led by analogy, and compared these granulations with the miliary tubercles of the pleura and peritoneum. Dance, Rufz, Gérhard, Constant, Piet, supported this opinion; and more recently, M. Becquerel, in an excellent monograph, MM. Valleix, Barrier, Rilliet and Barthez, in their researches have given him the support of their talent, so as to cause it to be accepted in a definite manner. They have all erred, for microscopical analysis has shown, in an indisputable manner, that these granulations of the serous

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membranes and of the pia mater, are only composed of fibro-plastic suleciontur !

tissue, and not of tubercular matter.

There are then two kinds of meningitis; one, long since recognized, the anatomical characters of which resemble those of inflammation of the serous membranes, is known by the serous or purulent injection and infiltration of the arachnoid and pia mater; the other, recently discovered, presents with these characters a greater or less quantity of small, whitish granulations, situated on the pia mater by the side of the vessels. These two kinds of meningitis are entirely different. The first bears the name of simple meningitis, the second that of granular meningitis.

CAUSES.

1ST. ON GRANULAR MENINGITIS.

Most authors have made exclusive researches in order to discover the causes of granular meningitis; but no important discovery has resulted from them. No single circumstance accounts in a decided manner for the production of granulations in the meninges. The concurrence of two of them is at least necessary, one which

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predisposes, the other which produces. In other words granular meningitis is not an accidental, local disease; it is a disease of the entire economy, which, in these particular cases, attacks the membranes of the brain.

The constitution of children labouring under granular meningitis is then the principal point which it is necessary to consider. The greater part present a more or less decided disposition tó tubercles. They are born of tubercular parents; they have tubercles in the cervical or bronchial glands, in the lungs, or in the interior of some viscus. M. Guersant declares, as the result of his observations, that all the

Edly children who are attacked with this disease are more or less tuberculous,

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and he adds, that as yet he has only seen one exception to this general rule. This is a result of observation long since admitted in science, and adopted by all authors who have studied the diseases of children. This circumstance is of much interest to the physician; it explains to him why granular meningitis appears to be sometimes hereditary, like the general strumous disposition which is the origin of it. There are certain families which cannot succeed in rearing their children; they nearly all fall victims to tubercular meningitis, or to tubercles of the brain. If we refer back to antecedents, it is discovered that several brothers or sisters of the father or mother of the child have died of the same disease, and probably that the latter are tuberculous to a greater or less extent.

We do not pretend to maintain that this general disposition is sufficient for the development of granular meningitis. It requires, in addition, the combination of circumstances capable of determining the congestion or the inflammatory attack of the encephalic membranes. Then the causes which would have been without result in a healthy and vigorous infant, become, in the case we are now considering, the source of the most serious cerebral symptoms. We daily meet with children who present, with a marked febrile attack, unequivocal symptoms of cerebral congestion, characterized by fretfulness, cries, restlessness, congestion, and heat of the face and scalp, without any alteration capable of explaining these phenomena. We wait, ready

to seize on new indications more characteristic of cerebral fever; then these symptoms disappear, and it is found impossible to give a name to the phenomena which have been observed. Yet are we aware Aof the consequence of this flow of blood to the brain? Who can say that it will not be the cause of the development of some fibro-plastic # granulations of the same stamp as amongst other tubercular children? Pulmonary or pleural congestion become the sources of granulations of the lung or pleura; but no one attends to this, and yet this constitutes the whole of what is interesting in the etiology of granular

de meningitis.

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It is very probable, if not certain, that granular meningitis and granular pneumonia make a similar progress. Granulations are formed in consequence of repeated congestions of the meninges or of the lung; they are perfectly developed when those acute symptoms appear which terminate the life of the patient. In fact, transient morbid phenomena, similar to that of which we have just made mention, are observed in the antecedents of those who die of granular meningitis, as in children who die of granular pneumonia; the disposition to bronchial catarrh has been proved. Lastly, post mortem Which examinations permit us to establish the presence of granulations in eas act children who, carried off by another disease, have died of any other affection but that of the brain, an additional analogy with the granu- issé

lations of the lung, which are so frequently observed in children who have died of a disease foreign to the thoracic organs. They are infinitely more rare in the pia mater than in the lung. There ulterior action is the same; they act as foreign bodies, and at last bring on inflammation of the tissues, which enclose them.

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(Thus then it is established, first, that granular meningitis is especially developed in children who are already labouring under the tubercular Aud cachexia; second, that in these cases a latent inflammatory action is at work-an action capable of determining the formation ofic granulations; third, and lastly, that an acute inflammatory attack, occasioned by these granulations, or by any other cause, of no value considering their existence, becomes added to the established alterations,e dis and puts an end to the life of the little patient.)

From what has preceded, we may observe that the different circum-shih stances relative to the age and sex of the children, those which are attached to the influences of temperature and to some more special causes, are of a secondary interest. We should be mistaken in their value if we believed they possessed some influence on the development. of the disease we are considering, without the existence of the strumous disposition of which we have spoken. This important disposition has been just adverted to; let us now approach the second part of our subject.

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Hereditary predisposition. I shall first speak of hereditary predisposition. Granular meningitis, like all the affections of a tubercular nature, is undoubtedly hereditary: only, there is one distinction to be made. The children of tubercular parents are observed to die after cerebral diseases of this nature. Last year, I had under my charge a little girl four years old, born of tubercular parents, who was carried off by granular meningitis at least as far as I could judge from the 2 duration of the premonitory symptoms, for the post mortem examination was not made. This year, in the same family, I attended another child, three years old, who presented a fresh instance of the same disease.

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