consist, in a great measure, in the use of warm or vapor baths, and friction with oil of almonds or narcotic liniments; dry friction of the skin, the application of bags filled with warm ashes, and gentle purgatives. Jadelot recommends, also, cold affusions, with camphor or valerian, internally, and frictions to the affected parts with ether or the tincture of digitalis. Guersent directs friction with a liniment containing laudanum, and if this is unsuccessful, opium internally. Diaphoretics, as infusions of borage, and the acetate of ammonia, have been recommended, as also the sesquicarbonate of iron, in large doses. If the patient is of a plethoric and vigorous habit, and the muscular contraction has occurred suddenly, we should not hesitate to resort to venesection. Contrivances to produce extension of the contracted parts have been tried, and have succeeded in some cases, when seconded by the employment of baths, emollients, &c. The section of the contracted muscles, has, also, been proposed, but the success attending this measure is not such as to recommend its general employment.

4. Acute Meningitis.

The whole of the inflammatory affections of the brain are, by many writers on diseases of children, included under the general term of hydrocephalus. This, however, is incorrect. The acute forms of meningeal inflammation occurring in children are not invariably productive of extensive serous effusion, and their phenomena differ in many important particulars from those by which that form of cerebral disease to which the term hydrocephalus is more strictly applicable, is ordinarily accompanied. Acute meningitis, it is true, is not of very frequent occurrence, as an original disease, during infancy and childhood; it is, nevertheless, a very frequent consequence of many of the affections peculiar to these periods of life.

When the disease occurs as a primary affection, it commences, almost invariably, with strongly marked symptoms of febrile excitement, preceded by a decided chill. The skin is dry, and generally increased in temperature; the pulse and respiration are accelerated, but often variable; the lips are dry and frequently cracked; and the child repeatedly picks or rubs his nose and mouth. There is usually increased thirst and loss of appetite. The tongue is coated with a whitish or yellow mucus, and is often red at its edges and apex. There is very generally copious and repeated vomitings of a bilious matter; occasionally, the attack commences with vomiting. The bowels are in some cases obstinately costive, while in others they are affected with diarrhoea, the discharges being composed of a sour, frothy mucus, of either a green, almost black, or pale color. The urine is usually spare in quantity and high-colored. The face is ordinarily red and turgid. There is an anxious, suffering expression of countenance, with contracted brows, and most commonly, intolerance of light and sound, contraction of the pupils and injection of the eyes.

The pain of the head, principally referred to the forehead and temples, though occasionally seated in the upper or back part of the head, is often accompanied by a violent throbbing, and a sense of constric

tion around the forehead. It increases in violence, at short intervals, and then excites the peculiar, sharp, wild scream, so characteristic of acute affections of the brain in children. During the exacerbations of pain, there is increased flushing of the face, as well as an increase of the peculiar suffering expression of countenance. In the intervals of these exacerbations, the child often rolls his head from side to side, and saws the air with his arms, moaning or complaining of his suffering, or he falls into a state of partial stupor, and grinds violently his teeth.

The countenance is generally flushed, but in some cases the flushing occurs only during the exacerbations of pain, the face in the intervals being decidedly pale. Vertigo is often present. The eyelids are generally firmly closed, and in some cases, the patient resists every attempt to open them. Slight twitchings of the muscles of the face are not unfrequent. The pulse is increased in frequency, and most generally full and hard; the respiration is accelerated, but often interrupted by long deep sighs.

If the disease is not arrested, the patient becomes more and more drowsy, and finally, completely comatose. In some cases, from the first day of the attack there occurs an alternation of stupor and violent agitation, or of coma and acute delirium. The delirium may not, however, occur until a later period. In the progress of the case, the increased heat of the surface disappears, and frequently a degree of chilliness supervenes; diminished temperature of the extremities is often a very early symptom. The external senses lose, by degrees, their abnormal acuteness, and finally become morbidly obtuse. The pupils are at first alternately contracted and dilated, but at length become permanently dilated, and insensible to the brightest light. The eyes are often affected with strabismus, or the eyeballs have a rolling tremulous motion, or are permanently turned upwards and outwards. The hearing becomes more and more dull, and finally there is a total insensibility to sound. The face becomes pale and cold, and the features shrunk; the eyes assume a dull and sunken appearance, and in the progress of the disease, perfect blindness most generally ensues. Convulsive twitchings of the muscles of the face and extremities are now more frequent and violent. Convulsions of the limbs, alternating with a state approaching to paralysis, or convulsive movements of certain sets of muscles, with imperfect paralysis of others, are not unfrequent; but in the progress of the case, when complete coma ensues, the whole of the voluntary muscles become completely relaxed. The pulse decreases in frequency, and becomes weak and soft, but at the same time, extremely variable; being at one moment increased in frequency, or in strength, and at the next remarkable for its slowness and feebleness. It frequently becomes greatly accelerated upon the slighest exertion, and again slow, as soon as the exertion ceases. Often, immediately preceding dissolution, the pulse suddenly acquires a remarkable increase of frequency, beating often with great regularity, from 120 to 160 strokes and upwards in a minute. The respiration also becomes quick and irregular, but at the moment of dissolution again slow, and often stertorous.

The respiration is marked by irregularity and inequality. Long deep sighs are often succeeded, after a pause of some duration, by frequent, short; quick respirations; or there is a regular alternation of a number of slow, and a number of quick, gasping respirations. The tongue becomes of a dark brown color, and more loaded, dry, and parched; the lips and teeth are covered with dark-colored sordes, and the bowels are obstinately costive; but towards the fatal termination, there usually occur involuntary discharges of feces, as well as of urine. There frequently occurs more or less tympanitic tension of the abdomen. The patient continues for a long time able to swallow, and before the coma has become complete, will often take food with apparent greediness, if it be placed, by means of a spoon, upon the back part of the tongue.

As the period of dissolution approaches, the surface becomes icy cold; cold clammy perspirations break out, and the face assumes a sunken, ghastly aspect. The fatal event is frequently preceded by convulsions.

When the inflammation involves a considerable extent of the membranes over the superior surface of both hemispheres, the disease may suddenly terminate, at an early period, by the occurrence of violent, general convulsions, succeeded by deep coma and death.

When the meningitis is seated at the base of the brain, the disease often continues for a longer period. The patient exhibits greater and more constant drowsiness, verging, at an early period, into complete coma, while the latter stages are marked by more frequent convulsive movements, or tonic contractions of the muscles, alternating with partial paralysis, and succeeded finally by complete muscular relaxation. The regular course of the disease, commencing with symptoms of more or less excitement, succeeded, after a shorter or longer period, by those of depression, and finally of complete collapse, is not unfrequently interrupted, either by the rapid occurrence of violent febrile excitement, with convulsions, stupor, and partial paralysis, or by the occasional and often repeated alternation of a state of stupor with the phenomena of excitement.

The occurrence of acute meningitis in the course of a febrile disease is marked, according to the observations of Rilliet and Barthez, by excessive agitation, without appreciable pain of the head, and unattended with vomiting. If diarrhoea was present, it persists; the pulse, from being regular, becomes unequal, irregular and diminished in frequency; or it remains equal, frequent, and excessively small. The inspirations, if already accelerated, become slower. The face is pale, the countenance anxious. The agitation, without diminishing in intensity, continues until death, which early ensues. (Maladies des Enfans.)

The appearances presented upon dissection, in cases of death from acute meningitis, are, chiefly, injection of the arachnoid membrane and pia mater, with effusions of serum, lymph, or pus. The injection of the arachnoid is, in general, of very limited extent, occurring at a few points only: either at the upper surface or base of the brain, and occasionally within the ventricles. In place of this injection, the

membrane may present a slight degree of thickening and opacity, which gives to it an opalescent or milky appearance. When death occurs at the onset of the inflammation, it is often unusually dry.

The injection of the pia mater is in the form either of distinct vascular arborescences, or of a bright, uniform redness, diffused, or in circumscribed patches, according to the less or greater intensity of the inflammation. Effusion may exist in the cellular tissue, between the pia mater and arachnoid membrane, either of clear serum, albuminous serum, or of pus. When the serum contains much albumen, in place of gradually oozing out, when the arachnoid is punctured, it is detained in the meshes of the subarachnoid cellular membrane, which gives to it a gelatinous appearance.

When the disease has continued for a longer period, more or less effusion will be observed upon the upper surface of the membrane; most commonly of a limpid, serous fluid, but occasionally flocculent and turbid, from an admixture of lymph or pus. In some cases the arachnoid upon the surface of the hemispheres, or at the base of the brain, is covered with a pseudo-membranous layer, of a greenish white color. This is often of considerable thickness. When pus is effused, it may be either liquid or concrete. When the effusion of lymph or pus is in considerable quantity, it often separates the convolutions, and penetrates to their utmost depths. This occurs most commonly at the vertex and the base of the brain, and about the junction of the optic nerves, where there exists a considerable amount of loose cellular tissue. There are very often adhesions between the pia mater and surface of the brain, preventing the former from being detached without lacerating the cortical substance, which is not unfrequently reddened, and occasionally softened to a greater or less extent.

As we have already remarked, simple acute meningitis, whether of the periphery of the brain alone, or combined with inflammation of the base, or of the ventricles, is, under any of its usual forms, an unfrequent disease of childhood. The meningeal inflammation occurring at this period being usually of the granular or tuberculous character. Still more rarely, however, do we observe the inflammation confined exclusively to the lining membrane of the ventricles. Rilliet records one such case as having fallen under his notice, and which terminated in ventricular effusion, loss of intelligence, confirmed idiocy and death. Another case has been subsequently described by Dr. Willshire (London Lancet, 1853), which that gentleman believed he was authorized to consider one of simple acute ventricular meningitis, the ordinary characters of the acute form of simple hemispheric meningitis, as well as of those of the tubercular form being absent; and the comparatively slight evidence present of any lesion at the base of the brain, and the very prominent and distinct signs of the ventricular changes observable.

Among the predisposing causes of acute meningitis the most important is the age of childhood. The disease occurring far more often before than after puberty. Guersent places the most common age for its occurrence between the fifth and fifteenth years. So far as we have been enabled to form a conclusion from the data within our reach, it

would appear to occur more frequently in Philadelphia between the seventh month and seventh year. The condition of the brain at this age, and the facility with which irritations may be excited in it from various causes, render it peculiarly liable to inflammation of various grades. This predisposition is increased by a plethoric habit, hereditary irritability of the nervous system, and by precocity of intellectual development, subjecting the brain to premature excitement.

The exciting causes are external injuries of the head from blows, concussions, falls, &c., violent and long-continued paroxysms of crying, difficult dentition, the sudden suppression of chronic cutaneous erup. tions, especially those which occur about the head and face, and the imprudent drying up of a long-continued discharge from ulcerations behind the ears. In the majority of cases, however, acute meningitis in children occurs in the course, or towards the conclusion of other diseases, as the various forms of irritation and inflammation of the alimentary canal, pneumonia, scarlatina, rubeola, and pertussis. Deepseated inflammations of the ear very generally terminate, in children, in acute meningitis. We have occasionally seen the disease, also, produced in children by insolation.

Acute meningitis is, under all circumstances, a serious affection; but it is so especially when it occurs in the course of, or subsequent to, other diseases; when the patient is already exhausted, and active treatment, to the extent which is necessary for the cure of every form of acute inflammation of the brain, is inadmissible. In many cases, also, the course of the disease is so extremely rapid as scarcely to allow time for the employment of the appropriate remedies, even when it is detected in its earliest stage. Nevertheless, in robust children, whose vital powers are unimpaired by pre-existing disease, or exposure to depressing hygienic influences, a vigorous treatment, commenced early, will very often quickly arrest the progress of the inflammation and preserve the life of the patient.

The favorable indications are, an early abatement of the peculiar symptoms of the disease; a reduction of the morbid acuteness of the external senses; the disappearance of the febrile excitement; the return of natural, quiet sleep; the recurrence of the normal secretions; the tongue becoming moist and clean, the skin soft and cool, the bowels open, and the evacuations natural; the urine more copious and lighter colored; the pulse more soft, slow, and equable, and the respiration less frequent and more regular; together with an abatement of the heat, pain, and tension of the head, and a return of the ordinary expression of the patient's countenance.

There are few diseases that occur during childhood, in which it is more important to watch the slightest premonitory symptoms, than those which affect the brain. Their onset may, in many instances, be prevented, while their cure, after they have become fully established, is doubtful, if perchance possible. This is particularly true of acute meningitis. A careful attention to the early symptoms indicative of irritation and hyperæmia of the brain, will often enable us to guard the patient against an attack that were it to occur, would in all probability prove promptly fatal.