slowness of the pulse. In the majority of cases that have fallen under our notice, the patients have been inclined to fat; with which every part of their bodies was often excessively loaded. Mauthner has remarked a frequent coincidence of enlargement of the thymus gland, the left side of the heart, and the liver. Death, in the majority of cases of hypertrophy of the brain has occurred suddenly, during a convulsive attack; it has, however, been repeatedly preceded by an attack of genuine apoplexy, with effusion of blood in the substance of the brain; and in some cases, by all the symptoms of acute hydrocephalus.

The disease is divided by Andral into two stages; 1st. The chronic; marked by few symptoms, or simply by slight obtuseness of intellect, more or less headache, either permanent or intermittent, vertigo, apathy, drowsiness, and convulsions at intervals. All of these symp toms may occur in the same individual, simultaneously or successively, or only one or more of them. 2d. The acute stage; marked by sudden attacks of violent convulsions, idiocy, epileptic paroxysms, deep coma, or symptoms of acute hydrocephalus.

The duration of life in children affected with hypertrophy of the brain is extremely variable. Many arrive at puberty with but little suffering or inconvenience, while others die at an early age from the accidental occurrence of hyperæmia of the brain, convulsions, or cerebral inflammation, or from symptoms resembling acute hydrocephalus. In some instances death occurs suddenly, without being preceded by any particular symptoms of disease; and occasionally it takes place from diseases unattended throughout with any indication of cerebral affection.

The prognosis, according to Dr. Lees, is not necessarily unfavorable; as the affection is rather an error of development than an actual disease, there is a natural tendency in the brain to return to the nor mal state. The chief danger results from the very great suscepti bility of the hypertrophied brain to disease, especially upon the occurrence of the affections incident to dentition, of pertussis, or of either of the febrile exanthemata.

The appearance of the brain upon dissection is that of simple enlargement, with flattening of the convolutions, diminished amount of blood in the vessels, little or no serum in the ventricles, or beneath the membranes, and morbid paleness of the cortical substance. The brain is in many cases increased in density, resembling boiled albumen, blanc-mange, or cream cheese. Sometimes, according to Sims, the hypertrophy is confined to one lobe of the brain, or to the corpora striata or thalami. Whether these partial hypertrophies are marked by any peculiarity of phenomena, we are unable to say. In all cases the hypertrophy is chiefly confined to the cerebrum, the cerebellum being seldom much, if at all affected. In some instances, the brain, or rather the vessels of the pia mater, are injected with blood; in others, a slight amount of reddish serum is found at the base of the brain; in others, again, a clot of blood, with rupture of the fibres of the medullary portion, will be detected; whilst in a few, we have more or less extensive softening of the substance of the organ; but in all these

cases, death will have been generally preceded by symptoms of cerebral disease, in addition to those which properly belong to simple hypertrophy.

Professer Rokitansky states, as the result of many microscopic exa-' minations, that the augmentation in the bulk of the brain is not the result of a development of new nervous fibrils, nor of the enlargement of those already existing, but that it is due to an increase of the intermediate granular matter.

The principal affection with which hypertrophy of the brain is apt to be confounded, is chronic hydrocephalus, to which its phenomena bear a strong resemblance, and for which it has unquestionably been repeatedly mistaken; as was the case in the examples of cerebral hypertrophy referred to by Hufeland, Jadelot, Laennec, and Scoutettin. In the first case related by Dr. Sims, the mother of the child informed him that they had wished to tap the head at one of the hospitals. Dr. Hennis Green saw a child who had been condemned to death by a medical man, as having water on the brain, but who was laboring under simple hypertrophy, that did not interfere with its health.

It has been suggested by Dr. Lees, that the peculiar projection of the parietal protuberances on which Munchmeyer particularly insists, may prove a valuable guide in aiding us to discriminate cerebral hypertrophy from chronic hydrocephalus. The sensation of firmness communicated to the finger on pressing with it over the fontanelles, in cases of hypertrophy, contrasted with the fluctuating feel, in cases of chronic hydrocephalus, has also been proposed by Dr. Green as a diagnostic sign; this, it is evident, cannot apply, excepting in very young subjects, or in extreme cases.

Dr. Mauthner (Krankheiten des Gehirns, Vienna, 1844) lays down. the following diagnosis between hypertrophy of the brain and chronic hydrocephalus: In hypertrophy, it is the posterior part of the skull which is observed first to become unnaturally prominent, the projection of the forehead occurring subsequently, while in chronic hydrocephalus the projection of the forehead is one of the first results of the disease. The latter affection is usually associated with a general emaciated condition; the former with a leucophlegmatic habit, and with increased deposits of fat. The constitutional symptoms of the two affections likewise differ; convulsions, sopor, and restlessness attend the early stages of chronic hydrocephalus, while spasmodic affections of the respiratory muscles are among the earliest indications of hypertrophy of the brain, but seldom occur until an advanced stage of hydrocephalus.

Hypertrophy of the brain has been most frequently observed in children of a lymphatic temperament, or in those affected with rickets. It may be present at birth, or be developed at any period subsequently, up to puberty. Its most usual exciting causes have not been very clearly made out. There is no doubt, however, that it may, as remarked by Sims, be more or less quickly induced by any cause capable of exciting the brain itself, or that is calculated to increase the nutrition of the body generally. Frequent contusions of the head have been enumerated by Dance as an occasional exciting cause. By

Laennec, Papavoine, and Rilliet and Barthez, the causes of colica pictonum have been supposed to have a very great influence on the development of the disease. Laennec states, that he has never seen a case of fatal saturnine epilepsy, in which there did not exist an evident cerebral hypertrophy. Extensive disease of the heart and lungs, by impeding the return of blood from, or obstructing its circulation through the brain, has been suggested by Sims as a probable cause of hypertrophy of the organ. We confess, we are at a loss to understand in what manner a state of venous congestion is likely to increase the nutrition of an organ. It is much more reasonable to suppose, with Mauthner, that the hypertrophy is the result of the repeated occurrence of the cerebral hyperæmia, from any cause that shall attract to the vessels of the brain an abnormal amount of blood. It must be recollected, however, that hypertrophy of the brain does not invariably result in cases in which hyperemia has repeatedly occurred at short intervals, and that it is frequently met with, where no hyperæmia has been observed.

In the cases that have fallen under our notice, we have sought in vain for any cause for the excessive development of the brain, beyond a congenital tendency to excessive nutrition of the organ.

In regard to the treatment, whether preventive, or that proper during the height of the disease, with the view of reducing the excessive size of the brain, we have very little to say. Our own expe rience affords us no positive results, and we find nothing satisfactory in the published observations of others.

When, in an infant, a tendency to excessive development of the brain is observed, it will be prudent carefully to avoid the slightest cause of increased excitement and determination to that organ. Every precaution should be taken to prevent, as much as possible, frequent or prolonged paroxysms of crying. The bowels should be kept freely open, and the body immersed daily in a tepid bath, followed immedi ately by brisk friction of the whole surface. Sponging the scalp frequently with cold water, appears to be a judicious means of keeping down any undue activity in the organic functions of the brain. The head should be invariably kept uncovered within doors, and but lightly clothed when the child is taken abroad. A luxurious growth of hair should be kept down by frequent cutting.

The appetite of these children is generally craving; it should, there fore be kept under a cautious restraint; and, after the child is weaned, his diet should consist solely of a moderate quantity of farinaceous food, with milk. Daily exercise in the open air, to an extent propor tioned to the patient's age and strength, should be insisted upon. When teething commences, the evolution of the teeth should be daily and cautiously watched; the slightest indication of undue swelling, or inflammation of the gums, should be met by free scarifications, repeated whenever the swelling or inflammation of the gums recurs.

When the child is more advanced in age, a serious question will arise as to its education. This should not be commenced too soon. To tax a brain in a state of hypertrophy, and predisposed, from the slightest cause, to hyperæmia and undue excitement, with even the

smallest amount of mental labor, would certainly be a very dangerous experiment: hence, when the hypertrophy is advancing with considerable rapidity, every degree of mental application should be positively prohibited; and those means employed, particularly bodily exercise, as have a tendency to direct nutrition to the muscular system, and thus, if possible, suspend its activity in the brain.

The slightest indication of undue excitement or hyperemia of the cerebral vessels, should be a signal for the application of leeches to the head, cold lotions to the scalp, the exhibition of brisk purgatives, and the application of counter-irritants to the extremities, as warm sinapised pediluvia, or sinapisms, &c.

We believe that our chief efforts should.be directed to prevent the increase of the undue cerebral development. After it has attained a certain height, we are unaware of any means capable of reducing it, without endangering the life or health of the patient.

When the growth of the cranium ceases, that of the brain continuing, morbid phenomena resulting from compression of the brain occur, which result may certainly be, to a certain extent, abated, the comfort of the patient increased, and life prolonged, by a proper hygienic course of treatment-but all hopes of effecting a cure must be abandoned.

2. Cerebral Hyperemia and Hemorrhage.

Apoplexy.-Paralysis.

Apoplexy and paralysis are of much more frequent occurrence during infancy and childhood than is generally supposed. We have met with these affections at every age, from one or two days subsequent to birth, up to the period of puberty. Lasserre has very satisfactorily proved the not unfrequent occurrence of apoplexy in infants immediately after birth. A very considerable proportion of the deaths annually reported as from convulsions, disease of the brain, and acute hydrocephalus in young children, we have reason to believe, are, in fact,. fatal cases of apoplexy.

When apoplexy occurs in infancy, the attack is generally sudden; but, in many instances, it may be preceded for some days by a deranged condition of the bowels; or it may occur after an attack of convulsions, or in the course of some other disease. The symptoms are, invariably, more or less complete stupor, with a tumid and livid appearance of the face, contraction and insensibility of the pupils,. laborious or stertorous respiration, and occasionally convulsions or a spastic rigidity of the neck and lower extremities. On recovering from the state of stupor, the child may exhibit no lesion of motion or sensation, or it may be that one entire half of the body, or the upper or lower extremity of one or the other side, may be in a state of complete or partial paralysis. This, however, is but rarely observed. Legendre met with it in one only out of nine cases, and Rilliet and

1 During the 38 years preceding 1845, there occurred in Philadelphia, in children under ten years of age, 69 deaths from apoplexy; namely, in those under one year of age, 27; between 1 and 2, 16; between 2 and 5, 14; and between 5 and 10, 12.

Barthez, in one out of seventeen cases. This results from the infrequency with which effusion takes place into the substance of the brain, the apoplexy of young children being generally meningeal, and with out rupture or other lesion of the cerebral tissue.

In other cases, the cerebral hemorrhage is attended by scarcely any other symptoms than frequent, intense, or long-continued convulsive paroxysms; thus Dr. Schleifer, in the Foundling Hospital of Prague, has detected, after death, preceded by convulsions in young infants, a hemorrhage on the dura mater, rarely between the membranes, and never into the substance of the brain.

In very young infants, if proper remedies are promptly resorted to, the brain may, in general, be very speedily relieved of its state of hyperæmia, and the patients restored to perfect health. If the disease be allowed to continue too long, or should it recur repeatedly at short intervals, and the child survive the immediate effects of the attack, serous effusion is very liable to occur in the brain, or some organic change in the structure of the organ, resulting ultimately in death, or in an impairment or destruction of the intellectual faculties, or in a permanent lesion of motion or sensibility of some part of the body. În children somewhat more advanced in age, apoplectic and paralytic attacks are generally of a much more unmanageable and destructive character, often proving immediately fatal, in consequence of extravasation of blood at the base or upon the surface of the brain, and occasionally within its texture.

The appearances met with upon dissection in fatal cases, are usually -turgescence of the vessels and sinuses of the brain, with sanguineous oozing from its medullary substance in the form of a number of small bloody points upon the surface of incisions made in it, and, occasionally, serous effusion beneath the arachnoid, at the base of the skull, in the ventricles, or in the theca of the spinal cord. The hyperæmia is occasionally found to affect the vessels and substance of the spinal marrow, equally with those of the brain. In children, even when paralysis has occurred, whether preceded or not by symptoms of apoplexy, hemorrhage of the brain from rupture of the vessels, or disrupture of the texture of the organ, serous effusion is met with much more rarely than in the adult. In the generality of cases, the only appreciable lesion is extensive hyperemia of the vessels of the brain and spinal column and of the meninges and roots of the spinal nerves. (Cazanvielh, Kennedy.) We have, however, in children over two years of age, repeatedly detected hemorrhage within the substance of the brain after attacks of apoplexy, and, in many cases, have observed persistent paralysis from the rupture of the texture of the brain, caused by cerebral hemorrhage.

Effusion of blood either at the base of the brain, upon the surface of its hemispheres or into the ventricles, and along the whole course of the spinal cord, is occasionally observed. (Abercrombie, Serres, Legen dre, Schleifer.)

When the hyperæmia, and effusion of serum or blood, is principally confined to the spine, constituting what has been denominated spinal