IV. CEREBRAL APOPLEXY.

From the consideration of cerebral congestion it is natural to pass on to that of apoplexy, which is one of the occasional, though rare results of that condition.

From the Registrar General's report for 1866 it appears that the total number of deaths from apoplexy in that year was 5121 males, and 5176 females, of all ages; of these, 390 of the former, and 280 of the latter occurred under 5 years; the numbers in each year are given in this table:

In London alone the figures were, of all ages, 935 males, 928 females of these there were,

These figures are remarkably suggestive of the causes of apoplexy when it is remembered that, owing to the larger size of male than female heads, the births of the former are generally more tedious and difficult than those of the latter.

Two forms of apoplexy are usually described as occurring during childhood: one of which is designated cerebral apoplexy, where the blood is effused into the substance of the brain; while the other is known as meningeal apoplexy, in which the hæmorrhage takes place between the dura mater and cranium, or into the cavity of the arachnoid membrane, or beneath the arachnoid into the meshes of the pia mater. Both varieties are rare, the cerebral form being the least common; while in by far the greater number of instances of meningeal apoplexy, the effusion is found in the cavity of the arachnoid rather than in either of the other situations.

There are these differences to be noted between the apoplexy

which occurs in children and that met with in the adult; in the former it is more often meningeal, in the latter cerebral; in the former the hæmorrhage mostly comes from the rupture of the minutest capillaries, in the latter it more often takes place in somewhat larger vessels; in the former it is due primarily to congestion of the cranial contents, in the latter, to disease of the blood vessels; in the former the brain itself is usually healthy, in the latter it is generally diseased, and in a state of red or white softening. Dr. West has described what he calls a cachectic form of cerebral hemorrhage, in which a diseased state of the blood seems to be the fons et origo mali; in the cases mentioned by him the effusion occurred into the arachnoid space.

Symptoms.-The symptoms of cerebral apoplexy are much the same in the child as in the adult: there is an arrest of volition and sensation taking place suddenly, collapse with coldness of the surface, partial convulsions, unequal action of the pupils, slow and frequently stertorous breathing, and a small slow pulse. Dr. Richard Quain has reported an interesting example, occurring in a boy aged nine years, which was characterized by coma, convulsions, paralysis, and death in seven hours from the time of seizure-previous to which he was in the enjoyment of good health: after death, a large clot of blood was found in the right hemisphere of the brain, and the left ventricle of the heart was much hypertrophied. Billard also mentions the case of an infant only three days old and apparently quite healthy, who suddenly presented the ordinary symptoms of well-marked apoplexy, and died: a clot of blood was found in the substance of the left hemisphere of the brain, immediately outside the corpus striatum.

The distinction between cerebral and meningeal apoplexy was first pointed out by Serres; who believed that whereas the former was always accompanied by paralysis, the latter did not produce this result. In some cases of meningeal apoplexy, occurring in infants at the breast, M. Legendre says, that after one or two vomitings, and in some instances without precursory vomiting, the children were seized with fever and with some convulsive movements, commonly of the eyes, producing strabismus; the appetite was lost, and the thirst considerable; the evacuations were natural, or perhaps somewhat relaxed. Soon a permanent contraction of the feet and hands were observed, which was quickly followed by tonic or clonic convulsions; during which, sensibility and consciousness were abolished, and the face-always injected-assumed a deeper tint. In the interval of these attacks, there was drowsiness, which gradually

became more marked; but the fever continued during the whole course of the disease, and became stronger in proportion as the fatal termination approached. Then the convulsions, separated at first by longer or shorter intervals, grew more and more frequent; until in the last moments they became almost continuous.

The duration of the symptoms in all cases of apoplexy is very irregular, varying from a few hours to many days; they may end in permanent hemiplegia or paraplegia, or in death, or in complete recovery. When the hæmorrhage is considerable a fatal termination will be the result.

Treatment. We can say but little upon this head: for in the first place we have never seen a case of apoplexy in the young child; and secondly, the symptoms are so obscureespecially in the meningeal form that it is to be feared a correct diagnosis will seldom be formed sufficiently early to be of much value. But, it may be readily imagined, that the best rule to follow is that laid down by Cullen for the relief of apoplexy in the adult-viz., to obviate the tendency to death. If this tendency be towards death by coma, if the pulse be full and hard, if the face be flushed and turgid, and especially if the external vessels of the head and neck are visibly distended, then active purgative enemata, ice to the head, the application of sinapisms to the lower extremities, and perhaps blood-letting, will be called for. On the contrary, when-as is the case in the majority of instances-the patient appears to be dying from the mischief which has been done and the general shock to the system, when the pulse is feeble or almost imperceptible, and the skin cold and clammy, then antiphlogistic measures of any kind will only insure a speedily fatal termination; and we must endeavour to maintain life by the use of warmth to the feet and trunk, sinapisms to the chest, and by the cautious administration of wine.

V. TUBERCULAR MENINGITIS.

Acute inflammation of the brain is a not very uncommon disease of early life; that is, of children under five years of age, as is shown by the following tables.

The total number of deaths of all ages in England from "cephalitis" in the year 1866 was 2338 males, 1808 females, and the numbers for each year under five were as follows:

In London alone the figures were of all ages, 415 males, 287 females; and the numbers in each year were:

Inflammation of the brain rarely occurs in children previously healthy; when it does so, it may be regarded as simple phrenitis or encephalitis, as will be shown in the following section. When it is the result-as it frequently is-of tubercular deposit in the brain or its membranes, when it occurs, in fact, in tuberculous children, it is then known by the terms, "tubercular meningitis" or "acute hydrocephalus;" the latter term is evidently badly chosen, since it refers only to one of the results of the disease, not to the disease itself, which is distinctly and accurately described by the former title. But, provided that the physician understands the nature of the affection, it may be thought that it does not much matter whether he speaks of it as acute hydrocephalus, tubercular meningitis, or tubercular encephalitis. For ourselves, however, we cannot quite subscribe to this, and, though willing to allow that there is some difficulty and perhaps temporary inconvenience in abolishing a term which has been so generally used, we have yet preferred, following the example of our French confrères, to substitute for the old, and in reality incorrect term, the one at the head of this article, which is scientifically correct and represents a more accurate and truer pathology. We discard the term "acute hydrocephalus" because to retain it is to perpetuate inaccuracy of expression, a practice always to be deprecated in the science of medicine, and, moreover, while the condition it indicates is generally, but not always present, it is at most only one of many other conditions, is sccondary in importance,

and only symptomatic of that which is the very essence of the disease.

Formerly the term, "acute hydrocephalus," was applied to a disease which was known to be inflammatory, and to be attended with serous effusion; at first that was all, and hence its title. But more recent observation has, in our opinion, conclusively proved that both these conditions are results not causes, and that the deposit of tubercle upon the meninges or in the substance of the brain precedes all other symptoms, and is that by which the disease is to be recognized and ought therefore to be called. It should be noted however that tubercle may be deposited freely over the cerebral meninges without occasioning any inflammatory action.

Symptoms.-The symptoms of tubercular meningitis present great variety and uncertainty; but for convenience they may be arbitrarily considered as exhibiting three stages. The first or premonitory stage comes on slowly with indications of declining health, and loss of flesh, colour, and appetite. Perhaps a troublesome cough alone attracts attention; until there appear signs of cerebral congestion, together with general fever, the latter presenting exacerbations and remissions at irregular periods. The skin is then found to be harsh and hot; the appetite is capricious-sometimes bad, sometimes voracious; there is considerable thirst; the tongue is furred; the breath is offensive; there is often nausea and vomiting; and the bowels are disordered-generally constipated, the evacuations being unhealthy and deficient in bile. If the child is old enough to run alone, it soon gets fatigued; has frequent attacks of giddiness, but very seldom any headache; and sometimes in walking it seems to drag one leg. Although drowsy, he is restless; sleeps badly, moans, or grinds his teeth, screams, and awakes suddenly in alarm, without any apparent cause.

After the foregoing symptoms have become thoroughly established, the disease, if unchecked, passes into the second stage; when its nature becomes very apparent, and its cure almost, if not quite, hopeless. The child wishes to remain quiet in bed; its countenance is expressive of anxiety and suffering; its eyes are closed, and eyebrows knit; it is annoyed by light and suffers much from the slightest noise. The face becomes flushed alternately with pallor, a central red spot being observed on each cheek which is succeeded by a peculiar slaty or ashy appearance. If old enough to reply to questions, it complains of distressing headache, weariness, and sleepiness; crying out frequently, "Oh! my head, Oh! my head. head." This