Meningeal apoplexy and cerebral hemorrhage are so very rarely met with in children, that they will seldom cause us much trouble. Where any obscurity exists, we may remember in those cases the irregularity and sudden accession of symptoms, the absence of quick pulse and febrile excitement, with the early supervention of convulsions and delirium. M. Legendre attempts to found a diagnosis between cerebral hæmorrhage and simple meningitis, by noticing the presence of flexions of the thumb and great toe, or carpopedal convulsions, as they have been termed, in the former cases, and their absence in the latter. We are not able, from our own experience, to say what value attaches to this as a diagnostic mark, having never had an opportunity of examining a fatal case of cerebral hæmorrhage in an infant; but we have repeatedly seen such flexures present in cases which were considered to depend merely upon the irritation of dentition, and in which recoveries took place.

Hypertrophy of the brain, and phlebitis of the sinuses of the dura mater, are very rare occurrences also; the former disease is very slow in progress, and attended with visible enlargement of the head, from a yielding of the parietes, when it occurs in the very young child, or has made much progress; a very slight attention to, and study of the case, will reveal the true nature of the affection. We have not seen phlebitis of the sinuses, but it has been accurately described and diagnosed. When it occurs, the early symptoms are exceedingly acute, and followed soon by syncope, dilatation of the pupils, strabismus, grinding of the teeth, alternate relaxation and contraction of muscles, &c.

The diagnosis from convulsions, arising from worms and other remote causes of irritation, must be made by close attention to the history of the case, and examination of physical signs of disease elsewhere.

The convulsions which are caused by pneumonia in children, and those from spasmodic croup and spasm of the glottis, are generally accompanied by such a train of symptoms as will throw sufficient light upon their causes, and there is very little likelihood of a mistake being made as regards them.

In relation to the diagnosis of hydrocephalus and those disturbances of the brain so frequently associated with attacks of infantile remittent, Dr. V. Duke observes-"I would again warn those who may have charge of cases of remittent fever, to watch, closely and anxiously, every change; the less frequent the remissions, the greater danger would there seem to be of the invasion of hydrocephalus. Our diagnosis may be assisted by observing, in the former, those remissions occurring with regularity. The countenance, too, though expressive of suffering, is different from that in hydrocephalus; the lips are retracted

or drawn, so as to show the teeth or gums; the countenance is pale, or sallow and sunk. The child seems to dread motion, lies on the back, with the knees bent or drawn up, and is pained by pressure on the abdomen. Here, neither the brow is knit, nor the pupil of the eye affected.' (Maunsell and Evanson.) The heat of the skin is much greater in remittent fever; the pulse, also, is quicker, and the thirst more intense; vomiting, too, is more constant. The tongue is more loaded, and sometimes is red and pointed; the evacuations are very different in remittent fever, and procured with greater ease, diarrhoea, rather than constipation, being present. The lips are generally red, chapped, and fissured, and there is often stomatitis or general abdominal tenderness. Such are the principal points of difference between the two disorders; but candour obliges me to say, that the distinction seems easier made upon paper than by the bedside of the patient. I would take this opportunity of bearing testimony to the general accuracy of, and great value to be attached to, the observations of mothers; naturally acute, their powers of observation seem heightened by parental anxiety, and they have time and opportunities for making remarks that we cannot command. Put yourself, then, in full and free communication with the mother; tell her what you suspect or want to ascertain, and direct her attention to the matters you wish elucidated. This will serve you far more than a 'dignified reserve,' and cannot injure your patient, (provided a proper time is selected for the conversation,) as might be the case were he of more mature years, and likely to be excited by being told a good deal of the doctor's opinion."

We have frequently symptoms of hydrocephalus as the result of difficult dentition. In these cases, the gums should be carefully examined and effectually lanced, and the state of the secretions particularly attended to.

When this disease is fully formed, the prognosis is unfavourable. There is a general consonance in all the symptoms of amendment, when the disease yields to treatment. In acute cases rapidly running their course, the brain and its membranes, after death, present evidences of the effects of inflammation; in other forms of the disease, the tubercular deposit will be detected. When these depositions take place in the membranes of the brain, they occur as "minute, flattened, spherical bodies, of the size of a small pin's head, or smaller, and either of a yellowish colour and rather friable under pressure, or greyish, semitransparent, and resistant, almost exactly resembling the grey granulations which are sometimes seen in the lungs or pleuræ of phthisical subjects."

In the earlier stage, these deposits look like "small opaque spots, communicating no perceptible roughness to the membranes. This appear

ance is absorbed in the arachnoid, covering the cerebellum and base of the brain. The fine grey bodies are mostly seen about the front, or imbedded in the pia mater, in the neighbourhood of the optic nerves.

"The surface of the brain generally presents but trifling appearance of disease, though sometimes the convolutions are flattened and the sulci partially obliterated, by the pressure of fluid contained in the ventricles.

"The appearances observed when the case has been acute, and inflammation has been decidedly present, are somewhat different. The vessels of the membranes will be found full and turgid. There is generally considerable vascularity of the pia mater; slight thickening and dulness of colour, or opacity of the arachnoid membrane, are also observed, with a dryness of that membrane, and occasionally an effusion of serum between the membranes. Lymph is also found around the vessels, and between the sulci. These changes are most apparent in the base of the brain.

"When we come to cut into the substance of the brain itself, we may find it very little altered from the natural appearance. The ventricles usually contain serum, varying from two to six ounces in quantity. The cerebral substance around the ventricles is often much softened, and breaks down very readily. Dr. West describes it as having the appearance of having been 'soaked in serum.' The quantity of fluid found in the ventricles is very variable; sometimes we find least where most had been expected, and vice versa; occasionally, the quantity is so large that there would seem to have been a considerable absorption of cerebral substance. In one case, where there had been considerable pain in the left side and back of the head, I found the choroid plexus occupying the inferior cornu of the lateral ventricle of that side, enlarged, and much more vascular than the corresponding one of the other side. The cerebral substance in this case, also, appeared, when cut into, dotted with bloody points, and this, too, chiefly at the left side.

"The organs in which tubercles are most frequently found, at the same time, are the lungs, bronchial glands, the spleen, liver, mesenteric glands, and intestines. Tubercular ulceration of the intestines,' Dr. West says, may give rise to diarrhoea; hence, constipation may not be an invariable symptom of hydrocephalus.'

"A morbid condition of the liver and intestinal mucous membrane has also been observed by Dr. Cheyne. He found the intestines inflamed and constricted, as from spasms, and the surface of the liver of a bright red colour, abounding in minute vessels, and sometimes. extensively adhering to the peritoneum.' In many dissections, also, he found the surface of the liver studded with small white tubercles, not

larger than grains of mustard. In every examination I have had an opportunity of making or assisting at, more or less distinct evidence was seen of the above pathological changes in the abdomen."

With regard to the treatment of this cerebral disease, Dr. Duke cautions us against "a too expectant plan, or that of treating symptoms as merely functional, or arising from some cause unconnected with the state of the brain itself, until, perhaps, fatal mischief has been done, and hydrocephalus declares itself in its most unquestionable shape."

Early attention should be paid to the state of the abdomen and alimentary canal. Dr. Duke commences his treatment by giving an emetic. He vouches for the safety and great success of this treatment. He prefers tartar emetic in the early stages, unless contra-indicated by the presence of debility. It is said to have a sedative and tranquillizing effect, and acts beneficially in lowering and equalizing the circulation, and unloading the vessels of the brain. He recommends the sparing use of purgatives. We must avoid keeping the digestive apparatus in a continual state of irritation by the exhibition of drastic or other cathartics. The head should be kept cool, and sponged with cold water. Bleeding, both local and general, must be resorted to when the symptoms are such as to indicate active disease going on in the head, and where the pulse, general temperament of the child, and other symptoms, justify us in believing the affection to be inflammatory in its nature. Great relief is sometimes obtained by the application of leeches to the Schneiderian membrane, and also to the region of the liver. Dr. Duke recommends the cautious administration of mercury combined with opium. He places this in the foremost position amongst our means of cure. He considers the fears entertained by many of the use of opium in cerebral affections exaggerated. He says it is a most valuable assistant. Dr. Duke generally recommends calomel and opium, hydrarg. c. mag. with pulv. ipecac. comp. and pulv. antimonialis. He observes-"I must speak in the highest terms of hydrargyrum cum creta or magnesia with ipecacuanha, as an alterative, not only in this, but in many other diseases of children. It seems to possess peculiar powers in restoring the healthy secretions of the mucous membrane of portions of the alimentary canal, and generally acts gently, also, upon the skin."

The early application of blisters to the nape of the neck is spoken highly of. The discharge from the blistered surface should be kept up by means of mercurial ointment with savine. We must, however, watch the effect of blisters, for frequently the irritation is so great, particularly in young children, that the cerebral disturbance is aggravated by their application. The legs and feet should have warm moist flannels applied to them. Dr. Duke does not speak favourably of iodine. He

saw a case connected with the scrofulous diathesis recover under the administration of iodine combined with mercury. The form used was the iodide of potash in solution with corrosive sublimate, made into small pills with crumbs of bread. The biniodide of mercury is spoken highly of. Support should be given to the child during this course of treatment by means of broths, jellies, arrow-root, light puddings, &c.

"Stimulants may occasionally be required, but must, of course, be given with great caution. Camphor mixture, with aromatic spirit of ammonia, will often allay vomiting, and rouse the system; even when coma has set in, such stimulants have acted most beneficially; and I have seen very good effects produced by a dose of croton oil. I once sat by the bed of a child, who, to all appearance, was sinking under the effects of hydrocephalus. There had been a gradual loss of vision, and stertor and difficult breathing seemed to indicate the supervention of coma. A blister to the nape, which vesicated well, and a dose of croton oil, which acted freely, were the means which seemed to arrest the morbid action. The boy ultimately recovered.

"When the urine is scanty, which is very often the case, some authors recommend the use of squill and digitalis. I have not any personal acquaintance with their effects in those cases, having found other means sufficient; but I would say, that digitalis is not an easily managed medicine with children."

On the prophylactic treatment we cannot do better than quote the words of our author:

"The state of the stomach and bowels should be particularly attended to. Children are prone to over-eat, and parents to give them too much. Many of their maladies arise from this cause, as I could quote case upon case to prove. Children should not have meat nearly so often as the generality of those in the upper and middle ranks are given it. The frequency should, in some respects, depend upon the opportunities they have for exercise, and being in the open air. Two, or even three days' abstinence in the week from solid meat would do much to preserve health, and prevent the necessity for those frequent powders so much in use. If this be thought 'diète absolue,' let them have broth on one of the abstaining days. When weather and other circumstances permit, children should spend many hours daily in the open air; even when the weather is cold, they will often enjoy being out of doors, if sufficiently clothed; and here I must enter a protest against the modern fashion of only half clothing children. I would rather my child wanted a meal, than see it subjected to that daily starvation from cold, to which those poor little fashionables, who trudge along with measured step, are exposed, as to their lower limbs especially.