Epileptic Attacks. One of the most serious features of the cere bral palsies of children is the marked tendency to the development of epileptic attacks. These appear in fully one-half of all cases. They are due to the brain-lesion, and usually are most marked in the paralytic limbs, but with a tendency to spread and become generalized. True Jacksonian fits are but rarely encountered. In some cases the initial eclamptic attack is at once followed at regular intervals of weeks or months by these seizures. In others they do not appear for a period of years and may be preceded by petit mal attacks. They are always to be expected, and when established constitute a serious menace to the health and mental state of the patient. The ordinary tendency of epilepsy to induce dementia is exaggerated in these already defective brains.

Diagnosis. The diagnosis of cerebral palsy when the condition is well marked should present no difficulty. In the slighter grades the epileptic attacks or the choreoid movements are frequently mistaken and the organic basis overlooked. The combination of head symptoms and mental enfeeblement with the motor difficulties in diplegic cases should be sufficiently striking. The hemiplegic distribution of paralysis can tell but one story. In cases presenting paraplegic features it may require a careful investigation to locate the trouble in the brain. The history here, as elsewhere, is a valuable guide. In addition the preserved electrical reactions, the comparatively normal trophic conditions, and the exaggerated reflexes should readily exclude a cord-lesion. The teratological defect which furnishes the cases of amaurotic family idiocy and the defective development of Little's disease must both be deciphered from the clinical data or the post-mortem findings.

Prognosis. The prospects in these diverse cases vary widely, but it may be positively stated that complete recovery never occurs and that a perfectly normal condition is never attained. In the cases of prenatal origin the prognosis must rest on the observed course of development during the first year of life. Improvement in motor control and the appearance of mental awakening are hopeful indications, but the majority of these cases are doomed to mental retardation or idiocy and more or less physical helplessness. The cases that conform to the type of Little's disease are exceptions. In these the prognosis for mental development is good and progressive motor improvement, up to a certain point, may be confidently expected. Amaurotic family idiocy, which is a congenital defect, is, at present, of absolutely fatal prognosis.

In the cases of birth palsy the intensity of the convulsions, their persistence, and the apparent extent of brain injury, in a very rough way, guide the prognosis as to life. If, after a few months, spasticity is still absent and some voluntary motion occurs in the paralyzed limbs, the prospects are much improved. The question of mental development can only be decided by watching the course of events. In the acquired cases the prognosis is much the same as in the apoplexies of adults as far as motility is concerned. The return of motion in the paralytic limb and the absence of contractures permit hope of a fair degree of motor restoration. Speech is usually restored, unless the frontal lobes have been injured and mentality impaired. The loss of sight and more especially of hearing is likely to prevent mental development and to in

duce idiocy. Whenever epileptoid attacks appear, they constitute a very serious feature and foreshadow dementia. They are somewhat more common in the late than in the congenital cases and in the hemiplegic than in the diplegic palsies.

Treatment. In the birth-palsy cases the nutrition of the child is the first problem, as suckling and swallowing are often impossible. The evidence of meningeal hemorrhage is usually so indefinite that trephining, which has been proposed, can rarely, if ever, be practised. The convulsions must be subdued by cold applications to the neck and head, and by sedatives, such as chloral, bromid, morphin, and by continued chloroformization, if necessary. The bowels should be thoroughly opened, preferably by means of calomel. The same measures are indicated as in older cases of acute hemiplegic convulsions and in convulsions generally.

In the later cases the management of the apoplectic and paralytic states is the same as for adults (see p. 208). From the first, the nutrition of the paralytic muscles and the tendency to contractures must be met by massage, passive movements, and faradism. As soon as contractures the massage and electricity must be used only on the weaker muscles-that is, as a rule, only on the extensors. The use of these measures to increase the strength of the overacting muscles may occasion decided harm. Unfavorable positions of the limbs must be obviated by mechanical measures, if necessary. Such means may do much to retard contracture, to hasten and increase voluntary control, and to favor growth in the paralytic members. Orthopedic appliances and tenotomies in neglected cases sometimes secure much permanent improvement. Transplantation of tendons has lately come into prominence, and in some instances can be resorted to with fair prospects of improvement.

Athetosis may be subdued to a considerable extent by fixation appliances or plaster-of-Paris splints. Hammond reported some cases temporarily much benefited by nerve-stretching, and Horsley has extinguished the athetosis by excising the corresponding brain-centers. In one such case the writer advised the removal of the cortical centers for a very unruly upper extremity, and the resulting palsy in the member was replaced finally by slight but useful voluntary control.

When idiocy is present it is open to educational methods only. The epilepsy that so frequently complicates these cases can be controlled to some extent by bromids or combinations of various sedatives with bromids. When the attacks are of a distinctly Jacksonian character, the question of operation will come forward. Every case must be considered by itself. As in many instances the condition is one of cerebral sclerosis, no operation can do good. If there be a cystic state, exploration and evacuation may be productive of much relief. In some cases the mere effect of the operation has been temporarily beneficial; in others it has acted by relieving pressure. Removal of cortical centers in Jacksonian fits of this class is very likely to merely displace the initial symptoms and to add to the traumatic conditions already present. Linear craniotomy when the brain is diseased can only be condemned. If it have any place it is in the cases that present closed fontanels at birth with microcephalic heads, the possible result of early synostosis.

CHAPTER XI.

TUMORS OF THE BRAIN.

THE encephalon is frequently invaded by various new growths common to other parts of the body, and by a number of neoplasms that are practically found only within the skull. In addition, new formations arising from the meninges and cranial walls, while not strictly brain-tumors, present symptoms that are identical with lesions of the cortex, and are localized in the same way. The term "brain-tumor” is here taken broadly to cover new formations within the skull.

Etiology. The causation of brain-tumors is an obscure subject. Many of them arise by metastasis from distant morbid fields, as is usually, if not always, the case in tubercular growths, carcinomata, and parasitic cysts and masses. Some arise by intracranial extension from the orbit, pharynx, and cranial bones. Heredity, aside from tubercular cases, plays a very insignificant if not an entirely negative rôle. Traumatism has probably been too frequently assigned as the inciting cause of brain-tumor, but it undoubtedly is competent in some instances. Thus, continuous symptoms have arisen within a few days of a head injury, and a tumor has subsequently been found at the traumatic site or in the brain beneath. There can be no doubt that even slight head injuries may localize tubercular and syphilitic activity and lead to corresponding tumor growth. Sarcoma and glioma are the neoplasms that seem to be most frequently attributed to trauma, but at the same time they are among the most common of brain-tumors.

The

No age is exempt from tumor growth within the cranium. The great majority of cases occur in childhood and active adult life. activity of tuberculosis in childhood, and the prevalence of syphilis in young adults, as well as liability to traumatic influences, may in part account for this. Males are somewhat more subject to cerebral tumor than females.

Pathological Anatomy.-Of all brain-tumors tubercle furnishes the largest proportion. The implantation of the tubercular process within the brain sometimes gives rise to the formation of large, solitary, isolated, often encysted cascous masses that may be single, but are multiple in about one-half of the cases. Tubercular tumors favor the base and the course of the large cerebral and cerebellar vessels, which recalls the usual propagation of tubercular meningitis. No part of the brain, however, is exempt. They do not destructively invade the braintissue, but displace it and act as foreign bodies, causing pressure atrophy. About them may often be found an area of tubercular infiltration and inflammatory activity, especially if they are seated so as to involve the meninges. Three-fourths of the cases occur before the age

of twenty. The tumors vary in size from a pea to a hen's egg, or even a larger size, and in number from one to a score.

Sarcomatous growths are next in frequency. Usually they present the distinctive and important character of being more or less encapsulated and sharply separated from the brain-tissue, from which they can, therefore, if accessible, be easily enucleated. As a rule, they are outgrowths of the cranial dura or periosteum, but the majority of them are situated in the basilar region, involving the brain-axis. In comparatively rare instances they infiltrate the brain-tissue, or, arising at the vertex, spread out broadly. They are of rapid growth, and in a given case furnish pronounced, persistent, and uniform symptoms. They present the variations of cellular elements that mark sarcomata elsewhere. As a rule, they are single.

Glioma is peculiar to nervous structures. It arises from the neuroglia and finds its most usual seat in the brain, though it may occur in

Fig. 93. Sarcoma of right temporosphenoidal lobe. A, Basilar surface; B, transverse section (Dr. W. A. Jones).

the spinal cord or retina. It presents a reddish, vascular color and a soft consistency quite like that of the brain-substance. Glioma is eminently an infiltrating and a destructive growth. Its outlines are difficult to determine. Owing to its strangulating effect, the center of a glioma is frequently filled with softened detritus and fatty-degeneration products, which may become fluid and the growth thereby cystic. Many alleged local "brain-hypertrophies" have been gliomatous infiltration in fact, and the microscopic examination of "cyst-walls" has alone discovered the true nature of the lesion in other instances. The favorite location of glioma is the white substance near the cortex, and it may infiltrate large areas, even the greater part of a hemisphere. Ordinarily it is single.

In consistency they are soft, often highly vascular, and may in some cases be easily mistaken for angiomata. Hemorrhages not infrequently occur in them. In other cases a great amount of interstitial fluid gives them a myxoid character.

Carcinomata, practically speaking, are found in the brain only as metastatic growths arising from primary cancer in the body organs, breast, etc., or through direct invasion by extension from orbital or other

Fig. 95.-Gliomata of right temporosphenoidal lobe and left parietal lobe.

cranial and facial carcinomatous growths. They are also practically confined to the second half of life. Uncontrolled by the soft tissue of the encephalon, carcinomata rapidly invade the brain, forming illdefined, nodular, rarely encapsulated, very vascular, and practically in