which has since flourished under the patronage of the empress. The hospital contains 36 beds, and between 2000 and 3000 children are admitted as out-patients, some of whom are visited at their own homes. Of 15,836 children who have thus come under his notice, 1747, or about 11 per cent., were suffering from some disorder of the cerebral system, of whom about 10 per cent. died. The frequency and the importance of diseases of the brain and spinal cord in childhood have induced Dr. Mauthner to make them the subject of this volume; and he promises at some future time to investigate in a similar way the other diseases of early life.

"Diagrams," says the author, "are in geometry just what the histories of cases are in medicine. The former illustrate the proposition, and serve to reduce it to absolute certainty; the latter illustrate the laws which regulate nature even when suffering, and lead to as complete a measure of clear perception as is to be attained in an experimental science."

The whole book is a kind of practical commentary on this motto; for it contains the minute details of 123 cases, connected by general observations on the diseases of which they are instances. Such an arrangement unquestionably presents many advantages, but inseparable from it are several inconveniences which greatly detract from its usefulness. No clear description is given of any affection, but its peculiarities have to be learnt by the somewhat tedious process of reading several cases. The particulars of one case suggest remarks on one striking character of the disease, and, eight or ten pages farther on, another case suggests the addition of a new feature to the portrait. It thus happens that no adequate conception is formed of the subject as a whole, from its not being represented, except in parts. Another defect, traceable to the same cause, is, that the author's remarks are too often merely suggestive, and his descriptions so brief, that, though their truthfulness would at once be recognized by those who are already familiar with their subjects, they are frequently little more than allusions which would be wholly inadequate to teach the inexperienced. But, though these circumstances somewhat limit the utility of this work, it will yet fully repay an attentive perusal, since it contains very much practical information, gathered, not from the writings of others, but from personal observation at the bed-side of the sick.

The book commences with some remarks on the frequency of diseases of the cerebral system, on their diagnosis and treatment. The author then passes to the consideration of the special diseases of the brain, which he has arranged under the following heads: "1, Congestion, irritation of the brain (febris cephalica); 2, Apoplexy; 3, Inflammation of the brain. (encephalitis and meningitis); 4, Acute hydrocephalus; 5, Hypertrophy of the brain; 6, Atrophy of the brain; 7, Chronic hydrocephalus; 8, Tubercle of the brain; 9, Softening of the brain; 10, Cerebral convulsions." (p. 12.)

CEREBRAL CONGESTION. This, though not in strict propriety an independent disease, is yet so frequent an attendant on the different maladies of childhood, as to merit a separate examination of its causes and symptoms. Its frequency is so great, that Dr. Mauthner observed it in 186 out of 229 children who had died of various diseases. In a large proportion of these cases it occurred in all probability in the very article of death,

which tends to empty the arterial and gorge the venous vessels throughout the whole system. In the course of various diseases, however, and under various circumstances, the brain may become overloaded with blood, as the result of an exaggerated or an enfeebled activity in the cerebral vessels and the vascular system in general. On this difference of cause the author founds a distinction of cerebral congestion into the active and the passive, either of which varieties may be acute or chronic. He further attempts a distinction between that form of cerebral congestion in which the surface of the brain is the seat of the affection, and that in which the central parts of the organ are chiefly involved. He confesses, however, that this distinction is no longer practicable when a state of intense congestion of any part of the brain is present; and we have much doubt whether the differences he indicates at p. 14 do not depend on the degree of the affection and the suddenness of the seizure more than on the seat of the congestion.

Febris cephalica. Intermediate, between the acute form of active congestion and the chronic form, Dr. Mauthner places what he calls the febris cephalica, which is attended by fever, with pain in the head, disorder, or, more generally, constipation of the bowels, and a train of symptoms, such as are often supposed to be premonitory of an attack of acute hydrocephalus. Dr. Mauthner is of opinion that it sometimes occurs as an independent affection, when it tends to a critical termination by sweat and urine on the third or fifth day. We cannot quite subscribe to the correctness of this last observation, for we do not think that there is any form of cerebral congestion so distinctly separated from others by its symptoms and by its tendency to critical termination at a certain period as to need a distinct place in our nosologies.

It is only in the most active forms of cerebral congestion, and in children above six months old, that the author attempts general depletion, and he adds (at p. 17) a very useful caution against inferring anything as to the propriety of venesection from the excitable pulse, and the changeable hue and temperature of the surface in young children. In milder cases less active treatment may suffice, as the employment of cold applications to the head, the administration of purgatives, of small doses of calomel, and of antiphlogistic remedies, which it is of great importance to administer in a form as nearly as possible tasteless.

The writer defines "passive congestion" as "that form of morbid accumulation of blood in the brain which takes place without violent symptoms of reaction and irritation." (p. 27.) In new-born children who breathe but imperfectly, and whose blood circulates languidly through the brain, this condition is physiological. If, however, there should be much delay in the establishment of respiration, a condition ensues of sopor, heaviness of the head, and want of power over the extremities; the heart beats irregularly, and convulsive twitchings occur. The state of passive congestion kept up by this imperfect respiration gives rise, in the course of time, to serous effusion, and this effusion may become very considerable without inducing reaction in the vascular or nervous systems. By slow degrees the cerebral substance becomes softened, partly by imbibition of the effused serum, partly by the serum being forced out into the parenchyma of the brain, and death ensues from direct paralysis of the nervous

centre. This is the condition described by Billard as non-inflammatory softening of the brain.

In older children passive congestion of the brain is a frequent result of various diseases, both acute and chronic, which give rise to much exhaustion of the nervous power. It is likewise by no means unusual in children who have been exposed to unfavorable hygienic conditions, or who are ill fed. It is also readily induced by the over energetic treatment of active congestion, and the abstraction of too large a quantity of blood. The symptoms which attend it are very different from those of active congestion :

They commonly consist in a pale and cool, or hot, though moist skin, eyes sunken in the head, and half closed, drowsiness without sleep, weariness, heaviness of the head, stupor, diminished sensibility, impaired digestion; and hence vomiting and purging of food, for the most part indigested, small and frequent pulse, and swelling of the veins of the head. To these must be added sopor and convulsions in the severer degrees of the affection." (p. 31.)

The treatment of this state consists in the use of warm mustard baths, and in the employment of mild diaphoretics and aperients. Alteratives, and even emetics, which latter are quite contraindicated in active congestion, are sometimes of great service, nor is the use of narcotics absolutely excluded. After mentioning a few other points that deserve attention in the management of this condition, and relating several illustrative cases, the author passes (at p. 40) to the next subject of his treatise.

APOPLEXY. He notices the rarity of circumscribed effusions of blood into the brain in infancy, although the symptoms of apoplexy are by no means uncommon. A state of general plethora even is not always essential to the production of apoplectic symptoms, but they may occur from general weakness and consequent diminution of the propulsive power which should impel the blood through the brain. Interrupted circulation, indeed, however produced, may produce apoplexy in early life-a fact, of which the peculiarities in the structure of the infantile brain and skull afford a satisfactory explanation.

"The impulse of the heart is powerfully felt in the cerebral vessels, while neither the external counter-pressure, nor the tension of the surrounding parenchyma is such as to assist its reflux. In proportion to the rapidity with which the atmospheric pressure propels the blood inwards, will be its accumulation in the long, fine, and numerous cerebral vessels, which have no firmer support than the soft tissue of the brain. So soon therefore as by any acceleration of the blood's motion the carotids bring a relatively larger amount of blood to the brain than the jugulars can carry off, danger of apoplexy arises." (p. 41.)

Cephalhæmatoma. Those very peculiarities, however, which tend to favour the accumulation of blood in the brain, either by increased afflux, or by diminished or interrupted efflux, are associated with another which serves the part of a safety-valve, and provides an outlet for its excess. This consists in the very free communications of the cerebral vessels with those of the cranium and the scalp. Hence, in early childhood, effusions of blood beneath the scalp are frequently met with, constituting the apoplexia tegumentaris of Billard, and cephalhæmatoma is regarded by the author, in common with Rilliet and Barthez, as the result of causes that tend to produce sudden and violent stasis of the blood in the brain, and as another instance of the utility of this safety-valve arrangement.

In older children, in whom these communications have, with the progress of ossification, become less numerous, death from apoplexy without any extravasation of blood is not very unusual. Such an instance is case 15, in which a healthy boy, aged 5 years, after overloading his stomach with indigestible food, was suddenly seized with convulsions, became livid and comatose, and died in thirty-eight hours. The brain was gorged with blood, but no vessel was lacerated, and no exudation of blood had taken place. The converse of this holds good also, and hemorrhage may occur without giving rise to any symptom of apoplexy, of which case 20 is a striking example.

Passive apoplexy. Some of the cases most difficult of explanation, are those of what Dr. Mauthner terms passive apoplexy, in which apoplectic symptoms occur in children who are neither plethoric nor possessed of vigour of constitution. He adopts much the same explanation of their occurrence as has been suggested by Hachmann with regard to the same condition which he has described under the name of apoplexia venosa.

"It is a well known fact," says the author, "established by Magendie's ingenious experiments, that a very slight deviation from the normal properties of the blood suffices to impede its free circulation through the minuter capillaries. No alteration of the blood seems to arrest its passage through the finer vessels to so great a degree as that which depends on a deficiency of oxygen, and a predominance of alkaline constituents. While the circulation is thus retarded imbibition of the blood by the coats of the vessels goes on, the fluid becomes infiltrated into the neighbouring tissues, whence stasis of the circulation, oedema, and even inflammatory action may result. These results of deficient oxygenation of the blood take place most rapidly, when the mucous membrane of the intestinal canal has become diseased, (under the influence of conditions unfavorable to health, especially if with these there be associated a warm, damp, and foggy state of the atmosphere,) and excretes a large quantity of matter abounding in oxygen, the waste of which, owing to the progressive weakening of the respiratory function, becomes every minute more and more imperfectly supplied." (pp. 62-3.)

INFLAMMATION OF THE BRAIN. Dr. Mauthner endeavours to distinguish between inflammation of the brain or its membranes, and acute hydrocephalus; since he thinks, and with justice, that the collection of serum in the ventricles is neither the only indication of inflammation of the brain, nor indeed an invariable attendant on inflammatory processes. He states that he met with fluid in the ventricles in 172 out of 229 post-mortem examinations of children who had died of various affections, and that in 123 instances the fluid present was in considerable quantities.

"Encephalitis," says he, "is an independent, inflammatory process, either completely idiopathic, or occurring as a secondary result of some of the dyscrasiæ; hydrocephalus acutus, on the other hand, is the local manifestation in the brain of various morbid processes: as typhus, scrofula, impetigo, softening of the brain, scurvy, etc. A stage of inflammatory reaction may occur as one among the group of symptoms that attend this affection, but this does not, as in the case of encephalitis, constitute the disease itself, since hydrocephalus may occur, as what is called the waterstroke, without any previous stage of inflammation. Acute hydrocephalus, therefore, is always a secondary affection, while encephalitis often occurs as a primary disease, although it may likewise be excited by the existence of some other disease in the system. Acute hydrocephalus never occurs as the consequence of external influences alone." (pp. 76-7.)

There is great similarity between the two affections, so great indeed

as to make the attempt to distinguish between them appear at first sight a refinement of little use. There is, it must be allowed, no single symptom that can be mentioned as pathognomonic of either, but the different order in which the symptoms occur constitute, as the writer has well pointed out, the grounds of diagnosis. The stupor and unconsciousness which often exist at the commencement of encephalitis, usually occur towards the end of hydrocephalus. The former runs a rapid course, the latter advances slowly, passing through several stages, often presenting distinct intermissions. Rapid and causeless emaciation mark the commencement of hydrocephalus, and death is often unattended by convulsions; emaciation occurs later in inflammation of the brain, and convulsions are never absent. Another point of difference is found in the age of the subjects who are attacked by the two diseases; hydrocephalus seldom occurring before the end of the first year, and being most frequent from the age of 2 to 7, while inflammation of the brain may come on at any period.

Hydrocephalus. In these remarks Dr. Mauthner has, we think, seized very accurately the distinguishing marks which characterize two forms of disease frequent in early life. The one, acute in its course, tending rapidly to a fatal result if left to itself, but amenable to medical treatment; the other, a secondary affection, slow in its advance, often insidious in its progress, but uninfluenced by remedies. The former of these affections is manifestly inflammatory in its nature, of the essence of the other we know but little, but are wont to characterize the assemblage of symptoms which betoken its existence by the name of hydrocephalus acutus. What then is this formidable disease, and wherein does it consist? Dr. Mauthner's definition we confess does not satisfy us, we almost think it does not satisfy himself.

"The name of acute hydrocephalus," says Dr. Mauthner, "is to be applied to every morbid collection of serum in the ventricles, which supervenes in the course of other general diseases, is occasioned (bedingt) by them, and runs an acute course." (p. 107.)

We cannot but regard this definition as an advance in the wrong direction, and as tending to involve in hopeless confusion a subject already sufficiently obscure. We know that the symptoms of what is called acute hydrocephalus by no means invariably depend on the effusion of serum into the lateral ventricles, while most extensive collections of fluid are found after death where during life no symptoms have betrayed their existence. Thus in three fourths of all phthisical patients whom M. Louis examined after death, he found extensive effusion into the ventricles. Dr. Mauthner, himself, allows (at p. 291), that the symptoms of tubercular meningitis are, in the greater number of instances, only a repetition of those which constitute acute hydrocephalus, yet in this form of disease, serous effusion is not invariable in its occurrence, and when present is certainly by no means the most important of the post-mortem appearances. Had the author submitted his numerous observations to a rigid analysis, he would, we are sure, have given us something much clearer and more definite as the results of his labours.

Hypertrophy of the brain. We are glad to pass from the vagueness which characterizes this part of his subject to another form of disease to which the author has devoted much attention, and has treated of rather