The above is generally accepted as representing the ordinary course of an attack of meningeal haemorrhage in the young child ; but if it induces us to look for elevation of temperature as an essential part of the illness it is certainly misleading. Statements with regard to temperature, made in days before the thermometer came into use as an aid to clinical in vestigation, should be accepted with caution. Moreover, in each of the two illustrations appended by the author to his description of the disease, a double catarrhal pneumonia was found to occupy the lungs ; and this complication would amply explain any elevation of temperature which might have been noticed during life. In cases of intracranial haemorrhage unaccompanied by an inflammatory condition of other organs the temper ature, as is shown by a case narrated later, is not raised above the normal level.
The chief difficulty in assigning to this form of haemorrhage its dis tinctive symptoms arises from the fact that it is rare to find a case in which the haemorrhage was not secondary to, or complicated by, some other malady. Even in instances where no morbid condition of other organs is to be discovered it is an open question whether the convulsions which are invariably present in such cases give rise to the haemorrhage or the haemorrhage to the convulsions. It is worthy of remark that paralysis is seldom a consequence of meningeal hemorrhage. The symptoms, indeed, are very much those of meningitis affecting the convexity of the brain, with the important exception that in cases of haemorrhage there is no pyrexia. They also differ from them in the fact that there are no signs of headache, and that at first the stupor is not profound. Infants with ex travasation of blood into the meninges, according to the testimony of all published cases, take the bottle well for a time. This is no doubt owing to thirst rather than to any appetite for food. Still, the fact remains that while in arachnoid hemorrhage the child takes food with avidity, in simple meningitis of the convexity of the brain he makes little attempt to suck, and generally refuses the bottle altogether.
Haemorrhage into the meninges or on to the surface of the brain is not confined to infants. A little girl, abed eight years, was a patient in the Victoria Park Chest Hospital, for heart disease and dropsy. The heart was enlarged in all directions ; prmsystolic and systolic murmurs were heard at the apex ; there was much oedema of the lower extremities, and the urine contained one-third of albumen. The child was kept in bed and made considerable progress for about a fortnight, when some thrombosis was noticed in the basilic and internal saphena veins of the left side. About a week afterwards she cried out one morning after breakfast with pain in her head, and shortly afterwards became convulsed. Twitchings were noticed in the muscles of the lower part of the face on the left side, involving the lips, the angle of the mouth, and the left side of the neck.
The face was turned to the left. There were also convulsive movements of the left arm, more particularly of the forearm, wrist, and hand. There were no movements of the leg on that side. The girl died in the course of the evening after a series of these convulsive movements. The temper ature was normal throughout.
On opening the superior longitudinal sinus, after death, the channel was found to contain a decolourised adherent clot which reached from nearly the anterior extremity to the posterior third. Opening into the sinus was a vein which ran from the right cerebral hemisphere. This was also filled with a clot, but less decolourised than the first, and the surface of the brain in its neighbourhood was the seat of a circumscribed haemor rhage. The clot was bounded posteriorly by the fissure of Rolando, and extended anteriorly over the posterior part of the superior frontal convo lution on the right side. These correspond very nearly to the areas de scribed by Ferrier, as connected with the movements of the lips, tongue, and mouth ; also that for the movements of the arm and leg. There were no convulsive movements of the left leg, but this was the seat of so much oedema that the child's own voluntary power over it had been very smalL This case, for the notes.of which I am indebted to Dr. Lawrence Hum phry, the resident physician, bears a very close resemblance to Valleix' case before referred to, although occurring in a much older child. It will be remarked that the temperature during the convulsive seizures was not elevated.
When the extravasation of blood takes place into the substance of the brain the first symptom is usually an attack of convulsions. Afterwards the phenomena may resemble those peculiar to an apoplectic seizure in the adult. It is probable that this form of lnemorrhage is less uncommon than might be inferred from examinations in the dead-house ; for if the amount of blood effused be moderate, the child may recover with a more or less extensive paralysis. In primary I believe this is not unfrequently the case. In hospital practice we not unfrequently see chil dren who, as a consequence of a fall or some injury to the head, are seized with headache and convulsions, and are then found to be paralysed in one hall of the body. The leg often recovers after a few weeks, but the arm may remain more or less permanently disabled with contraction of the fin gers. This was the case with a little girl, six years of age, who was lately a patient in the East London Children's Hospital. In addition the child was aphasic, and could not be persuaded to speak during her stay in the hospital. Otherwise her general health seemed fairly good, and she did not complain of headache. The case unfortunately could not be followed out, as after a few weeks the child was removed by her friends ; but I have little hesitation in ascribing her symptoms to a small clot in the brain.