convulsive seizure, in spite of most appropriate and energetic treatment, the little child died.

"The vessels of the scalp were loaded with blood, and the skull was so intensely congested as to appear of a deep blue colour; the sinuses were full of coagulated blood mixed with lymph, and all the vessels of the brain and its membranes were enlarged and turgid with blood.

"A large quantity of coagulated lymph covered the convolutions of the brain and the corpus callosum like a false membrane, and furnished a delicate lining to the lateral ventricles, whose walls were softened and in part broken down. The ventricles contained about 3 iij of turbid serum, and there was a considerable quantity of lymph at the base of the brain."

Dr. Abercrombie (On Diseases of the Brain, &c.; case x, p. 52) relates the following interesting illustration: "A child, aged two years, 21st May, 1826, was suddenly seized in the morning with a severe and long continued convulsion. It left her in a dull and torpid state, in which she did not seem to recognize the persons about her. She had lain in this state for several hours, when the convulsion returned, and during the following night it recurred a third time and was very severe and of long continuance. I saw her on the morning of the 23rd, and while I was sitting by her, she was again attacked with severe and long continued convulsion, which affected

every part of the body, the face and the eyes in particular being frightfully distorted.int

The countenance was pale and expressive of exhaustion; the pulse frequent, her
bowels had been fully opened by medicine previously prescribed, and the motions
were dark and unhealthy. Further purging was employed, with topical bleeding,
cold applications to the head, and blistering. After the attack she continued free S
from convulsion till the afternoon of the 23rd, in the interval she had remained in a
partially comatose state, with frequent starting; pulse frequent but feeble; pupils
rather dilated; she took some food. In the afternoon of the 23rd the convulsion
returned with greater severity; and on the 24th there was a constant succession
of paroxysms during the whole day, with sinking of the vital powers, and she died
early in the evening.

"On removing the dura mater, the surface of the brain appeared in many places covered by a deposition of adventitious membrane betwixt the arachnoid and pia mater. It was chiefly found above the openings between the convolutions, and in some places appeared to dip a little way between them. The arachnoid membrane, when detached, appeared to be healthy, but the pia mater was throughout in the highest state of vascularity, especially between the convolutions; and when the brain was cut vertically, the spaces between the convolutions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusion into the ventricles, and no other morbid appearance.”—P.H.B.]

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CHAPTER XVI.

ON TUBERCLES OF THE BRAIN.

There are three kinds of tubercles of the brain. Some, primarily developed in the pia mater, have encroached upon the cortical layer, and have extended to the medullary substance; others, which from the cortical layers have advanced to the pia mater, with which they

have only a slight adhesion; and lastly, those which are completely enveloped in the cerebral substance, and situated either superficially or deeply in the organ.

The tubercular matter of the brain presents the same characters as that from other viscera; only it is very rare to meet with it in a state of infiltration. It presents itself most frequently in a crude state, with a very decided greenish yellow colour.

The size of these productions is very variable; some of them are enormous. Their density differs: they gradually pass through the varied stages, from the state of the induration of tubercle to the Bf pulpiness of softened tubercle.

The cerebral substance which surrounds them preserves its ordinary characters as long as the product remains in a state of crudity. It inflames, becomes red from infiltration of blood, and softens at the same time as the tubercle. A more or less considerable effusion into the ventricles then takes place.

The meninges are often affected, and present the granulations of which we have made mention while on the subject of tubercular meningitis. These two cases must be here distinguished from each other; either the child dies in consequence of an affection foreign to the brain, of a tubercular or inflammatory nature, or it is carried off by a cerebral disease. In the first case, if tubercles are found in the brain, it is rare to meet with granulations in the meninges; yet they are sometimes there observed. In the second, at the same time that there are encephalic tubercles, there are meningeal granulations. This is a rule which offers few exceptions.

Children who have tubercles in the brain, have also very often ...tubercles in the other viscera. The tuberculization of this organ is only the extension of a general disease, already manifested in the lungs and in the bronchial glands, or in the viscera of the abdomen, in the glands of this cavity, and in the glands of the neck.

The symptoms of tubercles in the brain are very nearly the same as the symptoms of tubercular meningitis. The symptoms of the stage of incubation of this latter disease are here observed even much better characterized. In fact, tubercles of the brain, like the meningeal granulations, save with very rare exceptions, reveal themselves a long time in advance without occasioning fatal symptoms. How often do we observe in children transient phenomena of cerebral congestion, striking nervous symptoms which have no other cause.

I have observed in a child the appearance of a sharp pain in the cervical region, accompanied by a retraction of the sterno-mastoid muscle of the left side. The head was drawn from this side. These symptoms disappeared. They appeared again three weeks afterwards, but at the same time there was fever, nocturnal agitation, and startled

awakening. The child woke all quiet when the mother arrived. which nothing could account for.

Lase

of a sudden with a shriek, and was 7
During the day it had sudden terrors
The digestion was not disturbed, its

played willingly, and did not otherwise appear ill. A second time the
child returned to health. It had a fresh attack and rapidly died, in hai
consequence of a cerebral affection which presented the symptoms of Causes
tubercular meningitis.

I obtained permission to make the autopsy, and I found, in addition, inber to meningeal granulations, two tubercles in the cerebellum and a tubercle

in the annular protuberance, the substance of which was red and the surrounding parts softened.

In this patient there is reason to believe that the muscular retraction and the nervous symptoms were due to the encephalic irritation, caused

by the presence of tubercles. These transient congestions determined les the formation of meningeal granulations, and secondarily the meningoencephalitis, which caused the death of the patient.

The symptoms of tubercles of the brain are then at the commencement, very analogous to those of granular meningitis. When these products determine acute symptoms the similitude is still greater, and we cannot do better than refer to what has been said on the subjecteaz of this disease.

The consideration of the etiology, the prognosis, and the treament which are also applicable under these circumstances will there be found.

[MM. Rilliet and Barthez discovered tubercle in the brain in 37 out of 312 children, between the ages of one and fifteen, in some organ or other of whose body this morbid deposit existed; they consider it to be less usual before than after three years of age; but according to Dr. Green, its period of greatest frequency is from three to seven years of age; and in seventeen out of thirty-two cases recorded by Dr. Mauthner, the age of the children did not exceed three years; and the same was the case with reference to seven out of nine fatal cases that came under the notice of Dr. West. Dr. Hennis Green (Medico Chirurgical Transactions; vol. xxxv) mentions pain in the head as the most constant cerebral symptom, having met with it as a prominent feature in the disease in seventeen out of twenty cases.—P.H.B.]

CHAPTER XVII.

ON HYDROCEPHALUS.

The term hydrocephalus is applied to the effusions of serum which take place in the interior of the cranium.

This disease presents itself under many forms which it is difficult to appreciate. It offers considerable differences in its progress and on

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account of the numerous causes which determine it. It is impossible to study it conveniently without establishing several preliminary distinctions necessary to insure the clearness of the description.

The first is founded on the appreciation of the rapid or slow progress of the cerebral symptoms, or on the intensity of the frebrile reaction, whence acute hydrocephalus and chronic hydrocephalus.

The second division is based on the very nature of the disease. Thus, as hydrocephalus may depend on an anatomical alteration of the brain, or, on the contrary, may exist independently of these alterations, it is thought more correct to adopt, with respect to this disease, the generally received division of dropsies, a division in which the word essential or symptomatic specifies the absence or the presence of anatomical alterations of the tissue. We shall then have to consider separately essential and symptomatic, acute or chronic hydrocephalus.

1ST. ON ACUTE HYDROCEPHALUS.

Thuck There is, then, a symptomatic acute hydrocephalus and an essential acute hydrocephalus.

1. Symptomatic acute hydrocephalus. We often meet with children attacked by an acute disease of the meninges or of the cerebral pulp, who present at the same time a considerable serous effusion into the arachnoid or into the ventricles. In these circumstances we agree with the greater number of authors, that the formation of the fluid should be considered as the result of the lesion previously established, as a complication or as a symptom of the primitive disease.

Such is symptomatic acute hydrocephalus. It is met with in meningitis or encephalitis, cerebral tubercles, &c. It does not constitute, then, a special pathological state, and cannot be separated from the diseases to which it owes its origin. Its history entirely belongs to the description of the diseases which have engendered it.

2. Essential acute hydrocephalus. This term belongs to those effusions of serum which are formed in the interior of the cranium, in the absence of any alteration of the brain or of its envelopes.

It is a very rare disease, of which few well authenticated examples are to be found in authors. MM. Abercrombie, Andral, Bricheteau, Martin Solon, have published several cases of this kind. Three are to be found in the work of MM. Rilliet and Barthez; two with effusion into the cavity of the arachnoid, and one with effusion into the ventricles. As we cannot multiply facts of this nature too much, I will relate a recent case which occurred in the practice of M. Trousseau, at the Necker Hospital.

Acute hydrocephalus — pulmonary tubercles. A boy of ten months old: has always been well up to the age of seven months, has already had descrete smallpox. He has been ill three months. He had at first several distinct attacks

of some cerebral phenomena; two, three, and even four convulsions in a day; they returned at ten or twelve days' interval; for three weeks he has not had any convulsions, but he has had a very strong fever of a remittent character; no diarrhoea nor constipation; no vomiting; a little cough, but at rare intervals. The appetite is deranged, he does not eat, and sucks very little. Naturally gay, he has become serious; he cried and wept while the pain lasted; since three weeks he no longer weeps-he is continually whining.

He was a patient at the Cochin Hospital, where leeches were applied (two to the abdomen, one to the anus); but he went out not cured, and he was admitted into the Necker Hospital, St. Julie Ward, No. 10.

A very plump child, very white, pale face, large head, blue eyes, haggard, expression of heaviness and sadness, continual groaning, sleep frequent and of short duration, waking takes place by a start, which appears very painful, and is accompanied by a sharp cry.

Cough unfrequent, a little sibilant ronchus in the chest, no dyspnoea. Abdomen large, slightly distended; stools soft, without diarrhoea; no vomitings; skin moderately warm; pulse 140.

April 2. Face pale, puffy, remarkable expression of heaviness; the expression of suffering (contraction of the eyelids and the nostrils) is also remarked; continual groanings, little sleep. The sleep only lasts a short time, wakes with a start and a sharp cry like that of fear; at the same time the face is slightly convulsed and there are spasmodic movements in the limbs.

The child sucks well, and often nothing is given him to eat; no motion; skin natural; pulse 138.

Antispasmodic draught; two doses of calomel of grain each.
April 3. Nothing new.

Antispasmodic draught; two doses of calomel of grain each.

April 10. State of remarkable suffering, characterized by the alteration of the features, groans, sharp cry, and continual movement. The face, pale and puffy, becomes slightly coloured during the cry, and redness is perceived on the forehead and temples, and then the veins are observed to swell. The sleep is frequently interrupted by wakings with a start followed by convulsions of the eyes, trembling and contraction of the limbs. The child sucks often; he eats nothing; skin warm; pulse 162.

Two doses of calomel.

April 15. This child was found in the same state at this morning's visit. Towards noon, vertigo seized him, and in the midst of cries and agitation, a convulsion appeared; the eyes were fixed, slightly diverging; the limbs stiffened, the face became bluish black, and in a few minutes he died.

Autopsy, ten hours after death. Although the head and the body of this child are very large for the age to which he is arrived, there is yet a very marked relative predominance of the volume of the head over the volume of the trunk. The dimensions of the cranium are in relation with those of the face. The bones of the head are not at all altered. There is no separation of the sutures. The brain is firm and consistent; the convolutions are not at all flattened. There is slight serous infiltration at the superior and anterior part of the hemispheres. The membranes in the rest of the brain are healthy. The cerebral substance is white, without injection, and contains no accidental production. The only lesion observed, is the dilatation of the lateral ventricles by a reddish serum. These cavities, the exact extent of which could not be appreciated, were of about twice the capacity of the normal state. They each contain about 3 ij of clear, limpid serum, without false membranes. The walls are firm, pale, in no way altered. The other ventricles are not at all dilated.