In several authenticated cases of subacute hydrocephalus, but in which the presence of a large serous effusion 'in the ventricles could not be proved, the patients have been cured by large doses of iodide of potassium.

One table spoonful of this solution is to be given to the children every hour.

[I have observed decided benefit result from the treatment by iodine. The external application of the compound iodine ointment should be combined with the internal administration of the iodide of potassium. Dr. Christie of Keith, and Dr. Woniger of Hamburgh, have published cases of successful employment of iodine in the treatment of acute hydrocephalus.-P.H.B.]

Several authors have recommended puncture of the cranium, so as to give issue to the cerebral fluid. This operation proposed by Hippocrates, Celsus, Monro, Lecat, Astley Cooper, and condemned by many celebrated surgeons, has been practised in this age amongst us by Dupuytren and Breschet. It has been constantly followed by unfavourable results. Death has been the consequence of it. This may be readily conceived, when the frequency and extent of the anatomical alterations of the brain of hydrocephalic patients are considered. It perhaps would be wiser to banish this operation from practice. Yet eminent medical men do not hesitate still to have recourse to it.

M. Schoepf Méreï has practised the puncture of the hydrocephalic cavity seven times, and that without any inconvenience in those cases in which the effusion took place, after symptoms of very short duration, in children whose cranial sutures were yet open, who were from three to six months old, and in whom, also, notwithstanding a large quantity of liquid, there were no symptoms of collapse or of cerebral softening. He repeated the operation once or several times in the same children, giving them, internally, iodide of potassium, or cod's liver oil, and externally, cold douches to the head, and keeping this part moderately tightened by a bandage. M. Schoepf Méreï states that he has thus saved two of his patients.

This operation consists in making a puncture, by means of a long and slender trocar, above the lateral part of the brain, corresponding to the lateral ventricle. The instrument is pushed forward until it has penetrated into the cavity of this ventricle. Sometimes one pound and a half of liquid passes through the canula.

As soon as the nervous symptoms and the convulsions make their appearance in children attacked with this disease, the therapeutical

agents of which we have spoken in the article devoted to convulsions should be administered.

[It would appear from the results of sixty-three cases operated on by different persons, eighteen, or two out of every seven, terminated favourably. No doubt this success has been overstated, and probably this unfavourable result is more due to the fact of the presence of the disease than to the operation itself, for children may suffer severe injuries to the brain, and yet survive.

Recovery of an infant after perforation of its cranium, is related by Dr. Lagre (Revue Medico-Chirurg.; tom. vi, p. 55). A feeble male infant, heaving some sighs, able was delivered by the Cæsarean section, after vain endeavours to deliver by the forceps, after craniotomy. There was a large wound in the cranium, situated to ' the right of the sagittal suture, and a few lines in front of the posterior fontanelle. Through this the brain was visible, looking like a sanguinolent pulp, a small portion escaping by the wound, as did other portions, after the suppurative process was set up. The child recovered; compresses, dipped in cold water, being alone applied to the part. He is now nine years old; a loss of substance, equal to a florin in size, is still observable in its cranium, notwithstanding that reparation of the loss of the cranial bones occurs in the young. The child's intellectual faculties are in their normal state. A circumstance worthy of note is, that at the solution of continuity in the bone, when the soft parts alone cover the brain, there sometimes takes place a depression, and then the brain is plainly seen raised up by the arterial pulsations at the bottom of their cup-like depression. When this appearance manifests itself, experience has shown that the child is not well. At other times, the soft parts remain on a level with the cranial bones, and the arterial pulsations are slightly, if at all, observable.

Prof. Mende mentions the fact that a child may suffer a considerable loss of cerebral substance, and yet be born alive; whereas, continued pressure on the surface of the brain causes coma, asphyxia, or death. Dr. Beatty of Dublin, and others, have related cases where the crochet and perforation had been used, and yet the child cried loudly after delivery; and a case has been observed, in which a child, delivered by these instruments, lived three weeks after delivery, troubled, however, as the mother observed, with nine-day fits.-P.H.B.]

CHAPTER XVIII.

ON THE APOPLEXY OF NEW-BORN INFANTS.

Amongst children at the breast there are several diseases which may be described under the name of cerebral apoplexy. Thus, the apoplectic state of infants, a sort of passive cerebral congestion which seizes them at the moment of birth, the hæmorrhage of the meninges or of the brain during suckling should be included under this denomination.

Still it is necessary to distinguish clearly these morbid states which have nothing in common, and which develop themselves in special circumstances and at different ages.

The apoplectic state of infants manifests itself even at the moment of birth, under the influence of a difficult parturition, or of an unnatural position of the foetus; this is what has been called the apparent death of infants. All that relates to this subject will be described in the chapter devoted to asphyxia.

Cerebral apoplexy and meningeal apoplexy develop themselves at a more advanced age, and under the influence of causes which are still unknown.

One is characterized by an active congestion of the encephalon, without internal hæmorrhage, and without effusion of blood into its envelopes.

The other only exists in the condition of cerebral hemorrhage, either ventricular or meningeal.

The apoplectic state of infants, and the hæmorrhage of the meninges or of the brain, must then be described separately.

THE APOPLECTIC STATE, OR CEREBRAL CONGESTION OF

NEW-BORN INFANTS.

The apoplexy of infants is described, in connexion with asphyxia, by all writers on midwifery, under the name of apparent death, or the apoplectic or apoplectiform state. It will be described in the chapter devoted to asphyxia, and to which we may refer for fuller details.

The children have the skin, and particularly that of the face and head, quite cyanozed, of a livid red colour, interspersed with blue spots. The lips are violet, and pendant; the eyes closed; the beatings of the heart feeble; and respiration cannot establish itself.

If this condition is prolonged, death is the consequence. When it so happens that from the result of great and careful exertions, the respiration can be established, the livid colour of the skin is observed to disappear. It is replaced by a rose tint, at first manifested upon the lips and the face, before it becomes general. The heart beats with more force; its movements become regular and give more action to the respiratory forces; their life is saved if a relapse, caused by the cries of the child, does not renew the cerebral congestion, and again interrupt the action of the heart and of the lungs.

When the children die, the meninges are found very much congested, and the vessels of the pia mater enormously distended. Blood is sometimes effused in these membranes. The brain appears swollen, especially when the infiltration of blood into its parenchyma is great. If the organ is incised, the cut surfaces are covered by a multitude of small drops of blood, which soon unite together to form larger drops. 1 There are no lacerations of the tissue nor well-determined apoplectic spots.

All the soft parts of the head are gorged with blood. Of the viscera, the lungs are the only ones which present this alteration in a marked degree.

The apoplectic state, or the apoplectiform asphyxia of infants, is Causes observed in cases of difficult parturition, when the head of the foetus if the has remained a long time confined in the pelvis, and in a considerable state of flexion relatively to the rest of the body; in the cases of the twisting of the cord around the neck, at the moment of its compression by the head in the passage; and, lastly, in those cases Tikes where there is interruption to the placental circulation, which may happen in the labour when the placenta is attached to the neck of the uterus.

The apoplectic condition is very serious if it continues long. Life is soon extinguished. This happens when the cerebral compression, produced by the congestion of blood, occasions paralysis of the heart, "Akt and of the muscles of respiration.

The apoplectic condition of infants is allied to another form of asphyxia, which is observed at the moment of birth. These two conditions differ from each other in their exterior form, and are really only varieties of asphyxia. It appears to me convenient to describe them under the names of apoplectic asphyxia, and ordinary asphyxia.

In the ordinary asphyxia of infants, the child is pale, the lips are pendant and colourless, the skin dull, the limbs immoveable, the beatings of the heart nearly abolished, and there is no apparent respira-k tion; the weakness is extreme, the anæmia general, and life cannot manifest itself, since the blood, which is its source, has not the vivifying qualities necessary to communicate to the brain that excitation which provokes the firm beating of the heart and the first respiratory,

movement.

On the contrary, life is extinguished amongst apoplectic children, not by a diminution but by an increase of the excitation of the brain. It is compressed in its action by the violent sanguineous congestion of the brain, the efforts of which are paralyzed.

To remedy the apoplectic state of children it is necessary to place the infant in the conditions favourable to the manifestations of its existence, to remove the compression of the brain and the engorgement of the lungs. The umbilical cord is to be left without a ligature so as to permit the flow of a certain quantity of blood; and if it is wanting, this evacuation is to be favoured by putting the child into tepid water. If in spite of these precautions the blood flows with difficulty from the cord, if one or two spoonfuls cannot escape from it, it becomes necessary to apply a leech behind each ear.

In this disease the various external excitants which can be advan-(,)

10

[Part III. tageously applied against the torpor of the children are made use of. For instance, applications of warm linen, exposure to a clear fire, tepid and aromatic baths, are proper remedies to stimulate the skin. Dry and aromatic frictions, slapping the buttocks, frictions on the chest concur to the same end and may facilitate the establishment of the circulation of the respiration.

Those agents capable of exciting the respiratory nerves must be also employed. Sprinkling the face with vinegar and water or with brandy, the stimulation of the nasal mucous membrane with vinegar, ether, and ammonia, the application to the nostrils of a small quantity the of smoke from paper, all these means sometimes succeed in provoking efforts which lead to the infant making a respiratory movement.

The practice of pulmonary insufflation has also been recommended. This operation although very useful ought to be performed with some hesitation. There is no inconvenience in blowing into the mouth of infants, after having closed the nostrils by compressing them and alternately relaxing the thoracic walls.

festen It can also be done by taking the laryngeal tube and, with the view of sending a purer air into the lungs and practising the insufflation with a pair of bellows. Here, however, in remedying an already very serious disorder, another may be determined, which is emphysema of the lungs.

Galvanism, which has been proposed in these cases, has never been followed by very brilliant success. The wires should be placed on the muscles of respiration and especially on the diaphragm, which is the most powerful of all. They should then be placed in contact with the two poles of a moderately charged pile. This stimulus is sufficient in some children to establish respiration.

In the treatment of the apoplectic condition of infants an untiring perseverance must be adopted, and the long-continued employment of the means which have been pointed out as suitable. After numerous trials a favourable result is obtained which at first appeared hopeless. However, as this subject will be treated of more in detail in the paragraph devoted to the asphyxia of infants, I shall abstain from saying more at present.