ORIGINAL LECTURES.

COMMENTARIES ON DISEASE IN CHILDREN.

By EUSTACE SMITH, M.D. Lond., Physician to H.M. the King of the Belgians, Physician to the East London Children's Hospital, Assistant-Physician to the Victoria-park Hospital for Diseases of the Chest.

LECTURE VI.-ACUTE TUBERCULOSIS (Continued)-TUBERCULAR MENINGITIS (ACUTE HYDROCEPHALUS).

(Continued from page 556, vol. 1.)

THE following case furnishes a very good example of an ordinary attack of acute hydrocephalus, and it is especially interesting from the fact that the patient was under observation for some time previous to the beginning of the first definite symptoms of the disease.

William G., aged four years, was admitted into the East London Children's Hospital, under the care of my colleague Dr. Bruce, on December 4. He had been a healthy boy until a month before admission. At that time he had an attack of measles, and on the disappearance of the eruption he did not thoroughly recover. The child seemed ailing; he coughed occasionally, and was a little feverish. He slept well, however, and had a good appetite; his bowels were regular, and he did not notably lose flesh.

On admission he was found to be suffering from pulmonary catarrh, and the percussion-note was thought to be a little high-pitched at the right apex, with some hollow quality of breathing there and at the left side, but nothing very definite was discovered. For a few days the evening temperature was 100°, but on December 10 it became natural, and remained so until the 17th, when the child was sent as convalescent into the country. On December 30, however, he was sent back to the hospital as not improving, and for the five following days he was noticed to be quiet and silent. He seemed unusually drowsy, and his appetite began to fail. The bowels were not confined, but acted two or three times in the day. During these five days his evening temperature was successively 100-4, 98-4, 98°, 99.6°, and 97.6°; and on this last evening (January 4) the pulse, which had been always over 100, was found to have fallen to 74 and to be irregular. On the next morning (January 5) he vomited, and his bowels became confined. The temperature in the morning was 99.4°; pulse 72, intermittent; respirations 36, irregular; temperature in evening, 101-6°. These invasion symptoms marked the first day of the established disease. The vomiting on this and the following day was very troublesome; he retched frequently, but with little effect. He was very drowsy, dozing and waking up from time to time with a scream. There was no squinting, and the pupils were equal.

January 6 (second day).-9 a.m.: Temperature 100-2"; pulse 62, very intermittent; respirations 18. 6 p.m.: Temperature 100°; pulse 78; respirations 26.

7th (third day).-Very stupid, but answers intelligently if roused. Occasionally gives a short angry cry, and then lies quiet. Conjunctivæ injected, and transient internal squint of both eyes. Pupils equal, and act naturally. Belly not much retracted. 9 a.m. Temperature 100.6°; pulse 80; respirations 22. 6 p.m.: Temperature 101.2°.

8th (fourth day).-Dulness increases, but he still can be made to answer intelligently. He passes his water, however, in the bed. Bowels acted to-day (first time for forty-eight hours) after a purgative followed by an injection, and a large ascaris lumbricoides came away with the stool. Face rather flushed, but tâche cérébral not well marked. 9 a.m. Temperature 101; pulse 84, still intermittent; respirations 28, still irregular and sighing. 6 p.m. : Temperature 102°; pulse 96; respirations 40.

9th (fifth day).-Lies with eyelids half closed, apparently asleep; contracts brows, and every few minutes gives a peculiar squeal; expression of face spiteful; cheeks flushed, but not much redness produced by irritation of the skin; nares acting, but not with each breath; squints slightly with left eye, and left pupil is larger than right. When called by name opens eyes, but does not appear to understand question. Respirations 16, with frequent pauses and occasional deep sighs; pulse 160, regular in force and rhythm. Decided rigidity of muscles at back of neck, but none of muscles of VOL. II. 1874. No. 1253.

limbs. Abdomen not particularly retracted, and walls flaccid. Percussion-note at right side of sternum over the second and third ribs rather toneless, and respiration high-pitched, but vocal resonance not increased. Elsewhere chest seems healthy. At 9 a.m., temperature 102.2°; pulse 116; respirations 28. At 7 p.m., temperature 102.4°; pulse 152; respirations 24.

10th (sixth day).-More comatose, and quieter; screams less frequently; lies with eyes half open and expression rather stupid than spiteful, but still is not completely insensible, for complains if disturbed. Face paler. Pupils nearly equal, and of moderate size; some internal squint of left eye. Bowels still confined; passes water in the bed. The nurse states that he has been rather convulsed, his limbs and eyes "working." Muscles generally flaccid, but still stiffness at back of neck, and some rigidity about right knee-joint. 9 a.m.: Temperature 102°; pulse 130, regular, but weaker; respirations 26, irregular both in depth and frequency. 7 p.m.: Temperature 102'; pulse 116; respirations 30.

11th (seventh day).-Quiet; has ceased screaming; seems less stupefied; has spoken distinctly, and takes drink without difficulty. Pupils act well with light; generally unequal. Belly rather distended; bowels very confined. 9 a.m. Temperature 103.2°; pulse 116, regular; respirations 30, sighing; 7 p.m.: Temperature 102-6°.

12th (eighth day).-Coma deeper; face flushed and perspiring. Ophthalmia of both eyes; pupils unequal. Irregular spasmodic movements of limbs, especially right arm and left leg. 9 a.m: Temperature 101.8°; pulse 112, regular; respirations 40, very irregular. 7 p.m. Temperature 103.

13th (ninth day).-Lying as if asleep; right cheek flushed. Pupils equal, large, contract with light. When eyelids are touched he opens both eyes and makes a moaning sound, but appears quite unconscious, although he is stated to have said "no" in answer to a question from his mother. Sighs frequently. Bowels relieved last night by injection. Same stiffness about knee-joints. Large bubbling rhonchus heard about chest. 9 a.m. Temperature 101.6°; pulse 116, irregular in force, regular in rhythm; respirations 40, excessively irregular. 7 p.m. Temperature 102-4°. In afternoon had a fit in which the right side of face alone was convulsed. Coma seems 14th (tenth day).-State much the same. deeper. Rigidity of extensor muscles of leg. Moans occasionally. Ulceration of left cornea. 9 a.m. Temperature 103.2°; pulse 128; respirations 44. 7 p.m.: Temperature 103.6°. 15th (eleventh day).-Sinking. Face covered with large drops of sweat. Abdomen more retracted than before. Respirations very irregular and laborious, 68; pulse excessively rapid and weak; temperature 9 a.m. 104-4°, 3 p.m. 105-8°, 6 p.m. 106. Patient died at 11 p.m.

On examination of the body the pia mater was found much injected at the base of the brain, and contained numerous small grey granulations; corpus callosum much softened. Lateral ventricles contained a large quantity of fluid, and the convolutions were flattened. The lungs contained patches of collapse and a few caseous nodules, but no grey granulations were found in them or in any of the other organs. bronchial glands were enlarged and cheesy.

The

The preceding description represents a typical case of acute hydrocephalus, in which the brain symptoms are the first local phenomena to occur in the general disease. It is then called primary tubercular meningitis to distinguish it from cases where the grey granulation is more generally diffused over the body, and where the symptoms arising from the cranial cavity occur subsequently to others proceeding from the chest or the abdomen. In this the secondary form of the disease, the symptoms of the earlier stages are usually masked by the more prominent symptoms emanating from the organs previously attacked. In such cases the first manifestation drawing attention to the brain may be a violent convulsive fit, a paralytic lesion, or other sign indicative of the third stage of the disease; and it is not uncommon for acute tuberculosis with severe chest symptoms to be brought to a sudden close by this complication.

John W., aged sixteen months, the illegitimate child of a consumptive mother, was said to have been healthy up to the age of six months, when he was attacked with sickness and diarrhoea, which lasted eight weeks. After this, however, he seemed to recover, and remained pretty well until the beginning of May, when he began to cough, and his breathing seemed oppressed. After some time these symptoms improved, and the child appeared, according to the mother's account, to be going on well, when, on June 9, he had a fit which lasted a