144 PARTIAL ATROPHY OF THE BRAIN. week, she got better, and was beginning to walk about again, when she awoke one morning with her face drawn to one side-a condition, however, which did not continue. When she attempted to walk, it was noticed that she halted very much on her left leg, and that it sometimes gave way under her, so that she fell down on that side, and then turned round upon her back. She had, besides, but little power with her left hand and arm, so that she could not grasp anything firmly, nor hold it steadily. The child's bowels were at that time constipated: I purged her freely, and sent her into the country, whence she returned in the beginning of August, much improved in every respect, though still limping a little with the left leg, and using her right arm in preference to the left. At the end of September I saw her again, she having then a bad impetiginous eruption on the scalp, which was treated with warm poultices and water dressing; when, on October 6th, she began to limp with her right leg, just as she had previously done with her left; though in other respects she continued pretty well. On October 17th, the affection of the right leg was a good deal less marked; but the child now became unwilling to walk, often turning giddy, and always catching hold of something by which to steady herself. When attempting to walk she often fell down into a sitting posture; and then would sit on the floor, laughing loudly. Fits of uncontrollable laughter often came on without any cause, and the face began to assume an idiotic expression. There was occasionally slight inward strabismus of both eyes, but the pulse was soft and undisturbed; the bowels were regular and the evacuations natural, and the child rested well at night, though her head was often rather hot. A week afterwards there was no new symptom, except that the child kept her neck quite stiff, as though she feared to move it. Her head grew hotter, and she began to have a frequent teasing cough, while her power of walking varied almost every day; she now, too, grew more restless at night. On the morning of the 27th, frequent convulsive twitches of the muscles of the face and extremities came on, and the left eye became permanently turned inwards. She had no sleep in the night; general convulsions came on at 8 A. M. on the 28th, and she died convulsed two hours afterwards. I found some deposit of tubercle in the bronchial glands, but none in the brain, where I had expected to discover it. The left hemisphere of the cerebellum, however, was, as you see both in this drawing and in the preparation itself, fully a third smaller than the right; thus presenting an additional instance in confir PARTIAL ATROPHY OF THE BRAIN. 145 mation of Schröder van der Kolk's statement as to the greater frequency of unilateral atrophy on the left side of the brain; it was of extremely firm consistence, quite leathery, and on making a section of it, its surface presented a rose tint. The halves of the pons and medulla oblongata were of equal size, as were the two hemispheres of the cerebrum. It was evident, too, that this condition was not congenital, since the two halves of the skull were of equal size, and the elevations and depressions in the interior of its base were precisely similar on both sides. There was a little fluid at the base of the brain, but none in the ventricles; a state of general congestion of the brain and its membranes being the only other remarkable appearances. The spinal cord could not be examined. There was no trace of any old effusion of blood in the substance of the cerebellum, though the symptoms that occurred in May, and the subsequent gradual improvement of the patient, are not easily explicable on any other supposition than that hæmorrhage had at that time taken place into the substance of the brain. The history of the case presents another difficulty, in the circumstance that the disease was seated on the same side as that to which the symptoms had been chiefly referred. Another problem which I cannot pretend to solve is, why the paralysis should in the first instance have affected the left side, while, on the occurrence of the relapse in October, the right leg was palsied. I must therefore content myself with the bare relation of this history. In his essay on Atrophy of the Brain, published in vol. xi. of the New Sydenham Society's publications, he states that in 17 out of 29 cases, the affection was situated on the left side of the brain. In his case, however, while the left hemisphere of the cerebrum was wasted, the right half of the cerebellum and the right half of the cord were atrophied. In his case the right side of the body was atrophied; in my case, no wasting of any part of the trunk or extremities was observed, the child's inability to regulate her movements being apparently the chief result of the affection of the cerebellum. S. van der Kolk, in his elaborate essay, regards the affection not as the result of congenital malformation, but as the probable consequence of inflammatory action, occurring sometimes before birth, at other times in early infancy; and the change of consistence of the brain substance observed in my case bears out the same opinion. LECTURE XI. HYDROCEPHALOID DISEASE-often succeeds to sympathetic disturbance of brain in course of various affections-supervening on diarrhoea, pneumonia, and cerebral congestion-diagnosis in each of these circumstances.- Prophylaxis, and treat ment. TUBERCLE OF THE BRAIN-its frequency in childhood-its anatomical characters. Symptoms-occasionally absent-generally very obscure-symptoms of premonitory stage, their great diversity-symptoms of acute stage also variousdiversities in these respects cannot be altogether explained by the morbid appearances.-Occasional recovery where symptoms of cerebral tubercle have long existed.--Treatment. HYDATIDS AND CANCER of the brain. CLOSELY connected with the state of atrophy of the brain, which we examined in the last lecture, is that condition which is induced if the organ be somewhat suddenly deprived of its usual supply of blood. Even in the adult a profuse loss of blood is followed, as you well know, by extremely severe headache, and by various other cerebral symptoms. In the child, whose brain needs for the due performance of its functions a proportionably larger quantity of blood, the symptoms that follow its excessive loss are of a corresponding gravity. Often, indeed, they present a striking similarity to those which betoken inflammation of the brain; a fact implied in the name of the hydrocephaloid disease, by which Dr. Marshall Hall, who was among the first to call the notice of the profession to this affection, has proposed that it should be designated. 'This affection,' says he, in his admirable essay on the subject,' 'may be divided into two stages: the first, that of irritability; the second, that of torpor. In the former there appears to be a feeble attempt at reaction; in the latter, the powers appear to be more prostrate. These two stages resemble in many of their symptoms the first and second stages of hydrocephalus respectively. * Republished in his work 'On the Diseases and Derangements of the Nervous System,' 8vo. chap. v. sect. iii., London 1841. It can scarcely be necessary to refer to Dr. Gooch's Paper On Symptoms in Children erroneously attributed to Congestion of the Brain,' for another most graphic account of this disorder. HYDROCEPHALOID DISEASE. 147 In the first stage the infant becomes irritable, restless, and feverish; the face flushed, the surface hot, and the pulse frequent; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing and moaning during sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered. 'If, through an erroneous notion as to the nature of this affection, nourishment and cordials be not given, or if the diarrhoea continue, either spontaneously, or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold; the eyelids are half closed; the eyes are unfixed, and unattracted by any object placed before them, the pupils unmoved on the approach of light; the breathing, from being quick, becomes irregular, and effected by sighs; the voice becomes husky; and there is sometimes a husky teasing cough; and eventually, if the strength of the little patient continue to decline, there is a crepitus or rattling in the breathing. The evacuations are usually green; the feet are apt to be cold.' In early infancy symptoms of this kind sometimes succeed to premature weaning, especially if that be followed by an unsuitable diet; but afterwards they are generally induced by some definite attack of illness, either exhausting in itself, or for the cure of which active measures had been necessary. It is important too to bear in mind that they are not equally apt to come on in the course of all diseases, but that those in the early stages of which considerable cerebral irritation has existed, are much more likely to assume the characters of this spurious hydrocephalus when the bodily powers are exhausted. There is no disorder in which the two conditions of considerable sympathetic disturbance of the brain, coupled with rapid exhaustion of the vital powers, are so completely fulfilled, as in infantile diarrhoea, and in no other affection do we meet with such frequent or such well-marked instances of the supervention of the hydrocephaloid disease. Some time since a previously healthy boy, aged 18 months, was brought to me suffering from vomiting and diarrhoea, which had existed for three days. After treatment had been continued for two days the purging ceased, but the child seemed to have a distaste for all nourishment, and refused both milk and arrow-root, and the mother made but few attempts to overcome this repugnance; so 148 SYMPTOMS OF HYDROCEPHALOID DISEASE. that for twenty-four hours the child took hardly anything except water and barley-water, and those in small quantities. On the afternoon of the sixth day the child became faint, and seemed so feeble during the night that the mother became much alarmed, and came again to me on the morning of the seventh day. The child's face was then sunken and very anxious; it lay, as if dozing, with half-closed eyes; breathing hurriedly; suddenly waking up from time to time in a state of alarm and restlessness, and then in a few moments subsiding into its former condition. The skin was dry but cool; the extremities were almost cold; the lips were dry and parched, and some sordes had collected about the teeth; the tongue was dry, red, and glazed, and coated in the centre and towards the root with yellowish fur. The pulse was extremely feeble. There was very great thirst. The bowels had not acted for twelve hours. I ordered the child a table-spoonful of equal parts of milk and barley-water every half-hour, with the addition of fifteen drops of brandy every hour, and directed that some strong veal broth should be prepared and given every two hours. At the same time, a draught containing ten grains of aromatic confection, half a drachm of the compound tincture of bark, and six drops of sal-volatile, was given every three hours, and a grain of Dover's powder was directed to be taken at bed-time. Within six hours after the commencement of this treatment the child began to improve; it slept tolerably well in the night, and the next day was lying tranquilly in bed, looking about and smiling cheerfully; the extremities were warmer, and the skin had lost its harshness; the tongue was no longer dry, and the pulse had increased in power. The stimulants were gradually withdrawn ; no further bad symptom came on, and the child was soon convalescent. It is of great importance rightly to interpret the meaning of the symptoms which attend the first stage of this affection, and to discriminate between the cerebral disturbance of approaching exhaustion, and that which implies the existence of real mischief in the brain. A little girl was seized with diarrhoea on August 8th, which at first was severe, but soon yielded to treatment, and she was again convalescent; when, on the 15th, vomiting and purging returned with great violence, and were attended with much febrile disturbance. On the following day she was still worse in all respects, but was not brought to me again until the 17th. She then looked |