flushed and pale, with an aspect, wild at times, at others, expressive of great suffering. The skin is burning hot and dry. The digestive system also sympathizes. The tongue is red and dry; vomiting of bilious matter incessant, and the thirst urgent. The excretions from the bowels are scanty, and the urine high-coloured and diminished in quantity. If the disease be not arrested by treatment, the convulsions become more frequent and severe, with grinding of the teeth, strabismus, dilated pupil, and coma; where it is protracted, hemiplegia is sometimes present, and occasionally spasms of the muscles of the arms and legs; these latter, more particularly, when there has been an extension to the spine of the diseased action."

In the early stage of this disease it is not easily confounded with congestion of the brain. The acute pain, quick pulse, burning skin, the frowning, and grinding of the teeth, are the symptoms which will enable the practitioner to distinguish it from the former affection. We must be careful in not mistaking acute meningitis for the pneumonia of children, which is often ushered in by vomiting and convulsions. We ought also to recollect that symptoms of hydrocephalus sometimes are manifested in the last stages of pneumonia, the result of hyperæmia of the brain. The convulsions from teething, worms, &c., are less frequent, the attacks intermit, the pulse and respiration are but little accelerated. The patient does not exhibit that peculiar frown, and gives no indications of pain in the head. In acute meningitis, no marked remissions take place. Convulsions are sometimes the consequence of hæmorrhage into the arachnoid membrane. This is a rare disease. M. Legendre says, "Children attacked with meningeal apoplexy exhibit contractions of the fingers and toes, a symptom not observed in meningitis."

This affection is sometimes confounded with otitis. In the latter disease, the child gives evidence of acute local suffering, and generally "lies on the affected side, and presses it (the head) against the pillow, or keeps the hand to the ear." In the early stage, bleeding locally and generally, purgatives, with fœtid and turpentine enemata, are the principal remedies, modified according to the age of the patient. The gums should be effectually lanced. In severe cases, where the symptoms show no desire to remit, the patient should be placed under the influence of nauseating doses of the tartrate of antimony. With these remedies should be conjoined the warm bath, cold to the head, purgatives, calomel to salivation, fomentations, and sinapisms to the lower extremities.

Dr. Duke recommends also "the early shaving of the head, and application of counter-irritants to the scalp, more especially when we

have reason to suspect that the retrocession of a cutaneous affection may have had any share in inducing the disease. Tartar-emetic ointment, with croton oil, will generally be sufficient for this purpose. Before having recourse to this latter means, in cases where we do not suppose that the disappearance of an eruption has had anything to do in producing the meningitis, the application of cold should be long and perseveringly tried. A thin towel, frequently wetted and kept upon the head, seems as good a method of using this as we can select. Ice in bladders is also recommended; and a method of slow irrigation, by means of a thread, conducting cold water from a vessel placed over the child's head, is recommended by M. Rilliet. We have had the child's head held over the side of the bed, and cold water poured in a stream from the spout of a tea-kettle, for several minutes, with decided benefit.

In our attempt to introduce mercury into the system, we need not fear to combine it with small quantities of opium. The tendency to coma is not so great as to be increased by the latter to any alarming extent. Small doses of Dover's powder will be found very useful in allaying irritation, and procuring sleep.

Tubercular Meningitis, or Hydrocephalus Acutus.-This is a disease of every stage of early life. It is frequently preceded and accompanied by derangement of the digestive functions, and often dependent upon, or associated with, the irritation of dentition. There are no symptoms which unequivocally point out the occurrence of effusion into the ventricles, those cases which have proved fatal exhibiting the worst symptoms, severe convulsions, strabismus, coma, &c., often, upon dissection, furnishing the least quantity of watery effusion, and vice versa. This disease has almost always tubercular origin, and is frequently complicated with tubercular deposit elsewhere than in the brain. The liver is said to be the organ mostly at fault in this disease. Dr. Cheyne's* description of the incubation of the disease is so true to nature, that we offer no apology for copying it in extenso:—

"We find that before any characteristic signs appear, the patient, for some days, or even weeks, has complained of pains in his head or belly, while at the same time he has been slightly feverish, dull, vertiginous, sallow, without appetite, or perhaps with an increased or capricious one, and with a considerable disorder in all the functions of the abdominal viscera. In some instances a dragging of one of the legs has been observed, which has led to a fruitless examination of the hip-joint and spine. In others, a very painful crick in the neck has taken place, as the first symptom of disease. These complaints arise gradually, and the child's friends are not awakened to a sense of danger until, advancing a step farther, the commencement of a specific disease has more dis

* Of Dublin.

tinctly shown itself. The dulness and severe pains are now accompanied with vomiting, usually upon getting up in the morning, or after the child has begun to stir about; yet even this symptom is often disregarded until the second or third time of its recurrence, and the disease has made considerable progress before the illness of the patient is suspected to arise from a disordered condition of the brain. When the attention is more particularly excited by these symptoms, the head-ache, or pain in the forehead, will be observed returning at shorter intervals. The child often affectingly complains of his head; he sighs frequently, is dull, his head requires to be supported, he complains of weariness in his eyes, the pupils appear unusually contracted, and he has an aversion to light; but in the dark, he sometimes fancies he sees flashes of light. His tongue is white, and his belly generally costive. The stools at first are of the colour of clay, but as the disease advances, they become of a gelatinous consistence, of a dark-green colour, and they have a peculiar smell, not unlike the smell of the breath in the beginning of some of the exanthemata. The pulse becomes quick, and at peculiar times these symptoms are attended with febrile heat and irritability, and the child complains, not of head-ache only, but of pains in different parts of the body, which are sometimes exceedingly acute. At one time, he will complain of pains in his limbs, at another of pain in his breast, or in the nape of the neck, very often in his bowels; but before his friends can make any preparation to relieve him, the pain ceases, or is transferred to some other part; at another time, he will lie long on his mother's knee, restless and whining, from dull rheumatic pains. These disorders cannot last long without impairing the child's strength; accordingly, in ten days or a fortnight, the period usually occupied by the first stage of this attack, his appearance is altered, his manner becomes peevish, his hand tremulous, and his gait tottering.

"In the second variety, which is less frequent, the disease runs a more rapid course. After the child has been in a drooping state for a short time, which, although it sometimes may escape observation, is generally recollected, there is a sudden change to a fever, attended, even from the first, with a great degree of pyrexia, with frequent, but short and irregular remissions, flushing, severe head-ache, tenderness all over the abdomen, and increased sensibility, with, sometimes, brilliancy of the eyes. It is said to be often difficult immediately to distinguish hydrocephalus from fever, and this is the form in which there is the greatest resemblance between the two diseases; but we are led to suspect some deeply-seated evil, from his frantic screams and complaints of his head and belly, alternating with stupor, or rather lowness, and unwillingness to be roused; and we are struck with the great irritability of the stomach, which exists in a degree beyond what we generally find it in the fevers of this

country, retching and vomiting being brought on by a change of posture, and certainly by every attempt to sit up in bed; and the disordered state of the bowels which attends this irritability of the stomach is also remarkable; and when at any time the child has a little respite from the violence of these symptoms, we find our suspicions confirmed by his look, for when the features do not express pain or terror, there is not unfrequently a vacancy of look, the eyes being set with an expression of dejection which is peculiar to certain diseases of the brain."

He again says,-" When hydrocephalus arises during an indifferent state of health, as for example, after there had existed a scrofulous disease which has subsided, or where, from predisposition and from the anomalism of symptoms, some such disease might have been expected; or where the child has had some epidemic disease, as measles or scarlatina, from which he has not perfectly recovered, or regained sound health; the attack is sometimes made with all the violence which I have described as distinguishing the second form. When, again, the attack comes on

as the sequel of an acute disease, as, for instance, remittent fever, hooping-cough, dentition, the child almost imperceptibly slips into hydrocephalus. There are scarcely any of the symptoms of the early stages, and paralysis and convulsions are sometimes the first indications of the new disorder."

This affection is often, perhaps almost always, associated with a strumous diathesis. Whatever causes tend to bring into activity latent Hence, we frequently find this Unwholesome and insufficient

scrofula, will induce hydrocephalus.

disease among the children of the poor. food, filthy and ill-ventilated houses, inattention to the state of the digestive apparatus, are the too frequent causes of hydrocephalus in humble life. Under better circumstances, the disease is often developed as the result of over-taxing the brain and intellect, stuffing the poor child with rich and improper food, and subjecting it to irregularities of diet,. bad air, late hours, excitement of mind, &c. This disease is often the sequelae of the exanthemata, measles, scarlatina, and it frequently developes itself during attacks of remittent fever. All debilitating causes and sources of general irritation may produce this formidable affection. It is important to detect the earliest symptoms of hydrocephalic disease. Dr. Duke considers, seriatim, the derangements of the nervous, circulatory, respiratory, and digestive systems.

In cases where we have reason to believe that hydrocephalus has commenced its formidable train of symptoms, Dr. Duke says we shall detect, in the first instance, as an affection of the nervous system, restlessness and irritability about the child's manner, altered temper, an uneasy, whining, and distressed look,-anxiety of countenance, heavy eyes,-pupils contracted, aversion to light and noise,—an expression of

sudden alarm,—taking no pleasure in his former amusements. He has pain in different parts of the body,-particularly of the head, causing the little patient to scream out loud. The pain in the head is sometimes absent, and is occasionally only noticed at night, when the child will suddenly awake in a fright, and give a scream, complaining of pain in the head.

The Circulating System.-In this disease, we have early evidence of increased vascular action. The pulse and carotids give evidence of this. The former is sometimes wiry and harsh.

The Respiratory System is also in rotation affected. There is a great tendency to sigh, and the patient is sometimes troubled with a short, dry and hacking cough.

The Digestive Functions are often seriously at fault. The patient may, at an early period of the attack, have great irritability of stomach; vomiting is often one of the first and most important indications of cerebral disease in early life, the stomach so readily sympathising with the state of the brain. These symptoms ought always to excite our prompt attention. The secretions become depraved, the tongue foul, the bowels irregular in their action, the liver torpid, and occasionally there is a tympanitic state of the abdominal region; the appetite is capricious-sometimes entirely gone.

It is a matter of great importance to form a correct diagnosis in this complaint, for there are affections of the brain and nervous system which simulate true hydrocephalus,—we mean inflammatory hydrocephalus,—but which require for their treatment a plan essentially different from that which ought to be adopted for the cure of the more active affections of the brain. In forming our diagnosis, we must be guided by the history of the case and the consideration of the entire symptoms.

Simple acute meningitis may, in general, be early known and distinguished from the tubercular form, by closely investigating the cause and history of the disease; by observing the appearance and general health of the child we have to deal with; by noticing the violence of the attack and rapid increase of bad symptoms-viz., very acute headache, delirium, coma; by the incessant vomiting, thirst, and higher fever present, almost from the first. Constipation does not form so prominent a feature of the acute attack; the aggravation of the disorder is very quickly progressive, while in the tubercular form the course is comparatively slow, irregular, and often much prolonged.

Acute meningitis has been known to prove fatal in twenty-four hours. When it follows upon any special cause, such as eruptive fever, scarlatina, for instance, that previous occurrence will form a great aid in our diagnosis.