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drowsy, and vomited often, and his skin became quite jaundiced. His abdomen at this time was large and hard, and he cried when pressure was made on the right hypochondrium: these symptoms still continued when he was brought to me. A leech now applied on the right side drew a good deal of blood, and the hæmorrhage was stopped with difficulty; the bowels, previously constipated, were acted on by small doses of calomel and castor oil, and in three days the child lost the yellow tinge of his skin, became cheerful, and seemed much better. He was now, however, on the 18th of July, suddenly seized with hurried respiration and great depression, soon followed by violent convulsions, during which he screamed aloud. At the same time it was observed that his left hand had begun to swell, and to put on a livid hue, and on the 20th, the right hand also became œdematous. His whole surface grew quite sallow, and, on the day before he died, the oedema of the left hand had much increased; the livor had become considerably deeper, and there were small spots of extravasated blood over each knuckle. The right elbow was slightly livid; the right hand much swollen, but of its natural colour; and a small black spot had appeared under the chin corresponding to the knot of the cap-string. The fits recurred very frequently, the child in the intervals lying quite still; the pupils were contracted, and the condition seemed to be one of extreme exhaustion rather than of coma. On the 20th, the power of deglutition was lost, and after several returns of less violent convulsions the child died at 9 A.M. on July 21st; about sixty hours after the occurrence of the first fit.

The sinuses of the brain were full of fluid blood; a black coagulum, three or four lines thick, covered the whole posterior part of both hemispheres, extending from the posterior third of the parietal bones, occupying the whole concha of the occipital bone, and reaching along the base of the skull to the foramen magnum. Α little blood was likewise effused about the anterior part of the base of the brain, though the quantity was very small in comparison with what was found at its posterior part. The substance of the brain was very pale, and all the organs of the body were anæmic, except the liver, which was gorged with fluid blood, while the heart was quite empty. The ductus arteriosus was closed, the foramen ovale admitted a probe with ease, the ductus venosus admitted one with difficulty.

Another instance has since then come under my notice, in which passive hæmorrhage took place into the arachnoid in a child exhausted by long-continued illness, the effects of which were

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aggravated by poverty and want. From the age of two to that of five months the child had been under my care in consequence of frequent attacks of hæmatemesis and purging of blood, and though his health afterwards improved, yet he never became strong, and his evacuations were almost always white, and deficient in bile. After he was weaned, the coarse food which his indigent parents gave him did not nourish him; he lost flesh and strength, and when almost three years old was puny and emaciated. Three days before his death an attack of diarrhoea came on, which induced great exhaustion; and while suffering from this affection, he suddenly grew comatose, cold, and almost pulseless, and his breathing became so slow that he inspired only four or five times in a minute. In this state he lay for twenty-four hours, and then died quietly. Nearly six ounces of dark coagulated blood were found in the sac of the arachnoid, over the right hemisphere of the brain; a little blood was likewise effused beneath the arachnoid, and there was a very small clot in the lower and front part of the right middle lobe of the brain, but no ruptured vessels could be perceived. Great anæmia of every organ, and a state of extreme attenuation of the walls of the heart, were the only other remarkable appearances.

Hæmorrhage into the substance of the brain, though extremely rare in infancy and childhood, does sometimes occur, and then gives rise to appearances similar to those with which we are familiar in the adult. Death, however, usually takes place too speedily in these cases for any of those changes to occur in the apoplectic effusion which are often observed in the adult, and which betoken the advance that nature has made in her efforts to repair the injury of the brain.

I have only twice met with distinct extravasation of blood into the substance of the brain in children. In the first case, that of a little girl 11 months old, the occurrence was evidently due to the impediment to the circulation through the brain produced by the formation of a thrombus in the longitudinal sinus, and consequent inflammation of the sinuses of the dura mater. In addition to other appearances, which I shall describe in a future lecture,* there was great venous congestion of the membranes covering the middle lobe of the left hemisphere of the brain, and the cerebral veins were distended with coagula, and their coats were thickened. At the anterior part of the lower surface of the left middle lobe of the brain there were four apoplectic effusions, in all of which

* See Lecture VIII.

F

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HÆMORRHAGE INTO THE SUBSTANCE OF THE BRAIN.

the blood still retained its natural colour, and each effusion was situated close to an obliterated and distended vein. The largest clot extended for an inch into the substance of the brain, and the others were of smaller dimensions. Head symptoms, as might be expected, had existed in this little child for a long time before her death. The occurrence of the effusion was probably synchronous with a sudden attack of extreme faintness that came on forty-eight hours before she died, and from which she never completely rallied.

The other instance of hæmorrhage into the substance of the brain occurred in a girl 11 years old, the child of healthy parents, and whose own health had been quite good until she was six years of age. At that time the extraction of a molar tooth was followed by necrosis of a large portion of the lower jaw, and by the formation of abscesses in the face and head, from which bone escaped. An abscess, attended with similar exfoliation of bone, formed likewise on the right foot, and it was three years before the child had recovered completely. Though much disfigured by the disease, her health ever after continued good until April 12, 1846. She was then suddenly and causelessly attacked by vomiting and pain in the head, for which no other treatment was adopted during ten days than the occasional administration of an aperient. During this time, however, a condition of stupor gradually stole over the child, for which, on April 21, a blister was applied to the back of her neck with great relief. On April 23 she had two attacks of convulsions, with an interval of four hours between each. She struggled much during their continuance, especially with the right side; when the convulsions subsided, partial palsy of the left side remained; the child complained much of her head, and sank from time to time into a state of stupor, from which, however, she could always be roused. Very free purgation on April 24, and the application of another blister to the back of the neck, were followed by some amendment. On the evening of the 25th another fit occurred, with symptoms similar to those that had been observed on the previous occasions; but it was not followed by any increase in the palsy of the left side, nor was the degree of stupor so considerable as on the former occasion. Mercurials, which had been employed from the commencement of the attack, had now produced a decided influence on the mouth, and the abundant action of the bowels was again succeeded by much improvement in the child's condition. The pulse, which had varied from 60 to 70, now continued about 70, and was natural in character, and the child im

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proved daily, though taking no other medicines than occasional aperients. The headache returned occasionally, though each time it was less severe than the time before; but on the evening of May 15th, this amendment was suddenly interrupted by an attack of violent pain in the abdomen, which was soon followed by convulsions and coma, and the child died convulsed in sixteen hours; on the 36th day from the first attack of pain in the head.

On making an examination of the head, blood was found to be effused into the subarachnoid tissue over a great part of the right hemisphere of the brain. The quantity of blood, however, was nowhere very considerable, but merely occupied the sulci between the convolutions. The brain presented no remarkable appearance, except that on a level with, and just exterior to the right lateral ventricle, there was a large clot of blood, rather larger than a hen's egg, but of more irregular shape, around which the brain was softened. This effusion was perfectly black throughout, the colouring particles of the blood being equally diffused through it, and no appearance betokened that hæmorrhage had previously taken place in this situation. The anterior cerebral artery ran for a considerable distance just outside the clot, but it could not be ascertained that it had given way at any point.

Cerebral hæmorrhage is one of the few affections of early life concerning the treatment of which but little can be said; for where the symptoms of a disease are so obscure, it would be idle laying down elaborate rules for its cure. The general principles, according to which you would manage a case of congestion of the brain, would still guide you if hæmorrhage had taken place. It cannot, however, be necessary for me to repeat to-day the observations on that point to which I yesterday directed your attention.

Before concluding, I must for a moment refer to a form of cerebral hemorrhage, which, though of no great importance, yet forms an exception to what has been stated as to the rarity of the accident in early life. In children who have been affected with tubercular disease of the brain, it is by no means unusual to observe very small effusions of blood in the midst of the softened cerebral matter that surrounds the deposit. This capillary apoplexy, produced by some of the minute vessels of the brain giving way, is, however, seldom extensive, and probably has but little share even in accelerating the fatal event.

When next we meet, we shall pass from this subject, which, it must be owned, has more of a pathological than of a practical interest, and shall enter on the study of the inflammatory affections of the brain in childhood.

LECTURE VI.

INFLAMMATORY AFFECTIONS OF THE BRAIN-frequent in childhood, but overlooked by early writers-first noticed about a century ago-described under the name of acute hydrocephalus, by Dr. Whytt.

ACUTE HYDROCEPHALUS-progress of knowledge with reference to it.-The name restricted in these lectures to scrofulous inflammation of the brain, which is much more frequent than its simple inflammation in childhood.

Morbid appearances in acute hydrocephalus-due either to inflammation or to tubercular deposit-alterations more apparent in the membranes at the base of the brain than in those of its convexity.-Reasons for considering granulations of the membranes as tubercular.-Increase of fluid in the ventricles almost invariable.-Central softening of the brain not a post-mortem alteration-frequently connected with changes in the lining of the ventricles.-Inferences to which these facts lead.

Symptoms of the three stages of the disease.

FEW of the diseases of childhood are more serious than those inflammatory affections of the brain on the examination of which we are now about to enter. They occasion 9.8 per cent. of all deaths under five years of age in this metropolis, while they are so especially the diseases of early life, that 81.1 per cent. of all cases of fatal inflammation of the brain occur in children under five years of age, 90.2 per cent. before the age of 10, and 92.4 per cent. before the age of 15.*

But though the frequency of these affections in the young is a matter of such popular notoriety that most of you were familiar with the fact long before you were engaged in your present profession, yet if you turn to the writings of any of the old physicians, you will find in them no mention of inflammation of the brain in childhood. At first this may surprise you, but a few moments' consideration will explain the seeming oversight. Convulsions, which form a prominent symptom in most cases of inflammation of the brain, occur, as I need not remind you, in the course of many

* Deduced from 5th and 8th Reports of Registrar-General for 1842-5.