LECTURE X.

HYPERTROPHY OF THE BRAIN-usually associated with general disorder of nutritionsymptoms and course-seldom directly fatal-nature of change in brain-alterations in form of skull, and difference from chronic hydrocephalus-Treatment — Partial hypertrophy.

ATROPHY OF THE BRAIN- case illustrative of its defective development-Wasting of the brain in protracted illness-Temporary retrocession of mental powers in children after long illness-Case of partial atrophy.

THE anxiety of parents is sometimes needlessly excited in consequence of an infant's head being larger than common, and even though the child's health be good the relations are apprehensive lest it should be affected with water in the brain. Now you must not be too ready to take up this cry, which is one often raised by nurses and ignorant persons, or to suppose that every large head is therefore unnatural; for one child may have a bigger head than another, just as it may have a bigger hand or foot. But it may be that the child's head is not only larger than natural, but that well-marked symptoms of cerebral disturbance are present, and you may feel yourselves compelled to adopt the opinion that the case is one of incipient chronic hydrocephalus. The subsequent history of the patient may in many respects confirm your original diagnosis, so that great will be your surprise, on examining the body after death, at not finding a drop of serum in the ventricles, although, when you opened the skull, the cerebral convolutions had appeared flattened, as if the brain were greatly distended with fluid.

Individual cases of this kind had been mentioned by medical writers at different times, but Laennec was the first who drew attention to hypertrophy of the brain as a condition resembling chronic hydrocephalus in many of its symptoms, and liable to be mistaken for it. It has since then been frequently noticed, and I am not sure that an undue importance has not sometimes been * Journal de Médecine, Chirurgie, et Pharmacie, 1806, t. xi. p. 669.

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attached to it, as though it were of much more common occurrence than you will really find it to be in practice.

I have placed upon the table a cast taken from the head of a child who was affected with hypertrophy of the brain, and whose very remarkable case is related by Dr. Watson.* He came under the care of the late Dr. Sweatman when two years old, and his head, which had been gradually increasing from the age of six months, was then so large as by its weight to prevent the child from continuing long in the upright posture. The boy was active and lively, though thin. He had never any fit or convulsion, but occasionally seemed uneasy, and would then relieve himself by laying his head upon a chair. He had never squinted, nor was he subject to drowsiness or starting during his sleep, and his pupils contracted naturally. His appetite was good, and all the animal functions were well performed. The case was supposed to be one of chronic hydrocephalus; but no urgent symptoms being present active remedies were not employed. About six months afterwards the child died of inflammation of the chest, and Dr. Sweatman examined the head. It measured 12 inches from ear to ear over the vertex, 13 inches from the superciliary ridges to the occipital, and 21 inches in circumference. The anterior fontanelle, which was quite flat, measured 2 inches by 1 across its opposite angles; the posterior fontanelle was completely closed, as was the frontal The skull generally was increased in thickness; the morbid appearances in the membranes of the brain were quite trivial; the ventricles were empty, not dilated; the convolutions were perfectly distinct, and retained their proper rounded shape. The medullary matter, however, presented a very unusual vascularity.

suture.

It is not merely on account of the great size which the head attained that I have quoted this history, but because it affords an instance of the overgrowth of the brain unconnected with any general disorder of the processes of nutrition. Such an occurrence is very rare, for hypertrophy of the brain is usually only one manifestation of a deep-seated disorder of the nutritive process, and is. met with, in connection with rickets or scrofula, in the narrow lanes of a crowded city, or in the unhealthy valleys of mountainous districts, where goitre and cretinism are endemic.

The majority of cases of hypertrophy of the brain that have come under my notice in London have occurred in infants about six or eight months old. Their history had usually been, that

* Lectures, 4th ed. vol. i. p. 425.

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without any definite illness, the children had lost their appetite, and grown by degrees dull and apathetic, though restless and uneasy. Notwithstanding the general apathy, this restlessness is often very considerable, though it does not show itself in cries so much as in a state of general uneasiness, and in frequent startings from sleep. Short gleams of cheerfulness occur when the children are awake, but these are usually very transient. The head seems too heavy to be borne, and even when its size is not much greater than natural it hangs backwards, or to one side, as if the muscles were too weak to support it. If placed in its cot, a child who is thus affected bores with its occiput in the pillow, while its head is almost constantly in a state of profuse perspiration. Convulsions sometimes occur without any evident cause, but threatenings of their attack are much more frequent than their actual occurrence, the child awaking suddenly with a start and a peculiar cry, like that of spasmodic croup, the surface turning livid, and the respiration becoming difficult for a few moments, and the symptoms then subsiding of their own accord. Such attacks may issue in general convulsions, which may terminate fatally; but infants thus affected do not by any means invariably die of the cerebral disorder; but, being weakly, they are often cut off by the first malady which attacks them.

If life be prolonged, it becomes more and more evident that the process of nutrition is imperfectly performed: the child loses flesh and looks out of health, and enlargement of the wrists and ankles shows the connection between this disease and rickets-a connection which becomes more evident in the second and third years of the child's life. When the child survives infancy, or when, as occasionally happens, the symptoms of hypertrophy of the brain do not come on until dentition has been in a great measure accomplished, convulsions are of very rare occurrence. Complaints of headache, however, are frequent and severe; and, though drowsy in the day-time, the child generally rests ill at night, and often awakes crying and alarmed. Besides these symptoms, too, the child has occasional attacks of feverishness, with great increase of the headache, and giddiness, which last for a few hours or a day, and then subside of their own accord, while it grows by degrees more and more dull and listless, and its mental powers become obviously impaired.

It happens, in some cases, that as the child grows older, these symptoms become less and less severe; the health improves, the rickety deformity of the limbs gradually disappears, and the infant

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who had excited so much solicitude becomes at length a healthy child. There is a termination in complete idiocy, which I have never seen in this country, but some years ago I observed some instances of it in the Hospital for Cretins, which then existed near Interlachen; and I believe that the association of cretinism and idiocy with hypertrophy of the brain is by no means of unusual occurrence. Death is not often the direct result of the affection of the brain, but generally takes place owing to the supervention of some other disease. The affections, however, which prove most fatal are those which favour cerebral congestion-such as hoopingcough, or the eruptive fevers, especially scarlatina.

You must not infer that hypertrophy of the brain has existed in every instance in which the organ may appear to be large, and its convolutions somewhat flattened, although the ventricles are free from fluid. The weight and apparent size of the brain are much influenced by the quantity of blood contained within it, and it may appear too large for the skull simply because the vessels are overfull.* In true hypertrophy, on the contrary, the brain is generally pale and anæmic, unless death should chance to have taken place as the result of an attack of cerebral congestion. Neither, indeed, is the process one of mere increased growth, but the nutrition of the organ is modified in character as well as increased in activity. The grey matter of the brain is but little involved in it, and, with the exception of its colour being somewhat paler than natural, it shows scarcely any alteration. The white matter, on the contrary, is both paler and firmer than in a state of health; and Professor Rokitansky † states, as the result of many microscopical examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the enlargement of those already existing, but by an increase in the intermediate granular matter, most probably due to an albuminoid infiltration of that structure. These changes, too, do not affect indifferently all parts of the brain, but are confined to the hemispheres, and do not implicate either the base of the organ or the cerebellum.

Chronic hydrocephalus is the only affection with which hypertrophy of the brain is liable to be confounded: the diagnosis between the two affections is often by no means easy, though it is

See Mauthner's elaborate tables of the weight of the brain in various circumstances, lib. cit. sect. v.

Lib cit. 3rd ed., Vienna, 1856, vol. ii. p. 430.

See Jenner's valuable Lectures on Rickets, Lect. iii., in Med. Times, April 28, 1860,

p. 415.

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of much importance with reference both to our prognosis and our treatment, for we should have more hope of the recovery of a child whose brain is merely hypertrophied, than of one whose brain is distended with fluid, while the means by which we should endeavour to effect a cure would differ widely in the two cases. The history of the patient would afford some help towards determining this question; for the symptoms of chronic hydrocephalus generally come on earlier, and soon grow much more serious, than those of hypertrophy of the brain, and the cerebral disturbance is throughout much more marked in cases of the former than in those of the latter kind. The form and size of the head, too, present peculiarities by which you may often be enabled to distinguish between the two conditions. Both diseases are attended by enlargement of the head, and in both the ossification of the skull is very tardy, but the head does not attain so large a size in hypertrophy of the brain as in chronic hydrocephalus, neither are the fontanelles and sutures so widely open. The skull, likewise, presents some peculiarities in form, which are so remarkable as to have attracted the attention of several observers. The head not merely shows no tendency to assume the rounded form characteristic of chronic hydrocephalus, but its enlargement is first apparent at the occiput, and the bulging of the hind head continues throughout especially striking. The forehead may, in the course of time, become prominent and overhanging, but the eye remains deep sunk in its socket, for no change takes place in the direction of the orbitar plates such as is produced by the pressure of fluid within the brain, and which gives to the eye that unnatural prominence, and that peculiar downward direction, which are so striking in cases of chronic hydrocephalus. In hydrocephalus the anterior fontanelle is tense and prominent, owing to the pressure of the fluid within, but when the brain is hypertrophied there is no prominence, but an actual depression in this situation. I have more than once observed this condition in a very remarkable degree, the depression not being limited to the anterior fontanelle, but being observable at all the sutures; and you may notice something of the kind in this cast.

When hypertrophy of the brain occurs in the adult, the symptoms that arise are in great measure due to the compression which the organ undergoes from its bony case being too small to contain it. These symptoms are of course obscure, while, even if the nature of the affection could be recognised, its cure must be hopeless. In the infant, however, and the child whose head is incompletely ossified,