On March 19th the boy vomited a great deal, and complained of head ache. On the morning of March 20th he seemed very sleepy, but made no complaint. At 11.30 A.M. the resident physician was summoned to his bed side, as the boy was said to have had a fit. The patient had vomited, and appeared to be very drowsy, but he answered questions. The pupils were equal and rather contracted ' • the conjunctivae were sensitive, and there was no squint or other sign of paralysis. Shortly afterwards he had several quasi-fits in which he became flushed.. His eyes rolled from side to side, and the conjunctivae were not sensitive. He passed water in the bed. The pupils were equal. Temperature, 97.6° ; pulse, 84, and regular. After this the coma became more and more profound, and the boy died at 4 P.M.
On examination of the body the veins over both hemispheres were much congested, especially on the right side. The pia mater over the whole surface was suffused. The left hemisphere was larger than the right, and the convolutions were flattened. At the base of the brain all the loose tissue of the arachnoid was filled with dark clotted blood, which had spread along the Sylvian fissure on to both surfaces of the cerebellum and downwards along the cord. Both lateral ventricles were completely filled with a large clot, as also were the third and fourth ventricles. From the the blood seemed to have spread by the transverse fissure to the outer portion of the brain, and not through the " iter." The source of the haemorrhage was a small aneurism, of the size of a small pea, seated on the Sylvian artery about one inch from its beginning. The coats of the aneurism were very atheromatous and brittle. The rupture was extensive along the top of the aneurism, and the blood had burst into the top of the anterior horn of the left lateral ventricle. Elsewhere the coats of the ves sels showed no sign of disease. The mitral valve was much beaded, and the pericardium was universally adherent.
Judging from the variety of symptoms found as a result of cerebral haemorrhage in the child we can only conclude that there are none which can be considered characteristic of this lesion. Symptoms of irritation of the brain coming on suddenly, and followed after a few hours by symptoms of compression, are not peculiar to haemorrhagic effusion within the skull ; and yet, as a rule, we find nothing more distinctive than these. Still, the very fact of profound depression following rapidly upon symptoms of violent irritation in a non-pyretic patient may give rise to suspicions of cerebral haemorrhage, especially in children over four or five years of age.
Diagnosis.—On account of the indefinite character of the symptoms, hemorrhage into the brain or meninges in childhood is very difficult to detect. The difficulty is increased by the lesion being so often a second ary one, occurring in infants and young children who are already suffering from other complaints. It must be confessed that in such cases intra cranial hmmorrhage is very likely to be overlooked. Even when the haemor rhage is primary it is difficult to lay down rules for the detection of the lesion.
If a young child, whose water has been examined and found to be healthy, be seized with repeated convulsions, in the intervals of which, al though drowsy and stupid, his temperature is normal, and he swallows liquid food with appetite, we may hesitate between congestion of the brain with effusion of fluid and intra-cranial heemorrhage. If, now, we notice that after the stupor has become marked the convulsions continue, and especially if any contractions and rigidity, more than merely temporary, are noticed in the hands and feet, the temperature remaining low, we are justified in suspecting a•haemorrhage.
When hemiplegia follows an attack of convulsions, the paralysis is not necessarily a symptom of haemorrhage, for the same phenomena (convul sions and paralysis) are occasionally seen in cases of tumour of the brain. In the latter disease, however, we can usually obtain a history of severe and paroxysmal headache ; there is often paralysis of ocular muscles, indi cating implication of cerebral nerves ; and an examination of the eye will generally detect the presence of optic neuritis. Contractions and rigidity of the fingers and toes, wrists or ankles, may occur in either case. If, after recovery of consciousness the hemiplegia persist, but the child re main free from headache, if the retina are normal and the general health seem fairly good, a cerebral growth may be excluded.
A diagnosis between hemorrhage into the meninges and that into the substance of the brain is probably impossible from the symptoms alone, although if paralysis occur this symptom is not in favour of meningeal extravasation. The age, however, is here of importance. Under the third year haemorrhage rarely takes place into the cerebral tissue. In nine cases of intracranial hmorrhage occurring in infants aged three years and under, observed by M. Legendre, in no case was the haemorrhage other than meningeal. After that age haemorrhage more commonly takes place into the brain-substance, as it does in the adult.