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permanent marks of morbid action, the condition of those afflicted with this distressing malady was nearly hopeless. This was the state of its pathology when Dr. Smyth wrote his essay, which, though published in 1814, he informs us was written more than twenty years ago, and at the instance of a nobleman whose request was to him a command. More than half of this long period (grande spatium mortalis ævi) the Doctor has withdrawn himself almost entirely from the habits and duties of professional life; and hence his essay presents us rather with a view of what the soundest opinions and the best practice of physicians in Hydrocephalus were at that period, than what they are now. For these we must, in many instances, have recourse to the pages of Dr. Cheyne and Dr. Yeats. Dr. Smyth's essay is written with great clearness; it gives proofs of much accurate observation, and many of its remarks are unusually scientific; but the pathological views which pervade it will not, of course, be found to afford a satisfactory explanation of some of the morbid appearances which more recent and extended observation has proved to exist in many cases; and the practice founded upon it is less vigorous than that at length followed. After some preliminary observations on the cause of dropsy in general, Dr. S. proceeds to show the cause of that of the brain, which he proposes shall hereafter be called Hydrencephalus, since this term conveys (to those acquainted with the Greek language) the precise signification of water in the brain, while the old term Hydrocephalus signifies nothing more than water in the head. The latter cause, he thinks, is only to be found unequivocally in debility; and hence, though in his opinion most frequently a primary disease, it occasionally occurs as a secondary affection in the state of weakness which succeeds the infantile remittent and scarlet fever. This view of the subject, it is now ascertained, does not afford a competent explanation of all the appearances which have been remarked even within the cranium. In some cases even death has taken place under all the symptoms of hydrencephalus, and yet no fluid has been found in the ventricles; and though Dr. S. takes it for granted, that, in such instances, the fluid has been effused, but afterwards re-absorbed, we do not find that the opinion is supported by adequate proof. A collection of serous fluid in the ventricles of the brain, is however one of the morbid appearances most constantly met with; but though it was one of the first which was observed, as being the most prominent, yet there are others; and some of these Dr. S. has himself noticed in his dissections, though his pre-conceived opinions have led
him, we apprehend, to undervalue their importance. When, however, we are seeking for data on which to establish important conclusions, or endeavouring to trace the connexion of symptoms which have been observed in the living body, with morbid appearances after death, every manifest deviation from the natural and healthy structure ought to be considered with profound attention. Without this we can never arrive at any certain and accurate knowledge. Now the brain has been ob served to exhibit marks of morbid changes, which could hardly be connected, in any way, with simple effusion as a consequence of debility. These appearances cannot be wholly referred to inflammatory action, according to our present views of that process; they are such as indicate that the organ has been in a state of over excitement and congestion, of which effusion is to be regarded as the consequence, not the cause. The following case, which we transcribe from Dr. Smyth's essay, affords an example not only of these appearances, but also of those strong indications of morbid action in the abdominal viscera, of which the affection of the brain is, in the opinion of Dr. Yeats and Dr. Cheyne, a very frequent consequence, the last link in the train of morbid action. It is one of the most instructive cases with which we meet, in the writings of those who treat on Hydrocephalus.
"Miss S. eleven years of age, formerly healthy, well formed and active, was some days previous to my seeing her, seized with vomiting and purging, the usual symptoms of cholera; accompanied with head-ach, for which she had taken an emetic, and some opening medicine; the purging ceased in three or four days, and on the 18th of March, when I first saw her, she had been three days without any motion. I found her in great agony, from pain in her bowels and head, the whole abdomen, but particularly the precordia so tense and swelled, that she could not bear the slightest pressure on the part, and at times she beat her forehead with her hand. Her pulse was irregular, and rather slower than natural in a person of that age. The heat of her skin and hands was temperate, and her countenance, though at times distracted with pain, was not flushed; her tongue was white and moist. Apprehending that the chief and most immediate danger was from peritoneal inflammation, which had either taken place, or might soon be expected, I ordered blood to be taken from the arm, the abdomen to be fomented, glysters thrown up, and an opening medicine to be given every four hours, until proper evacuations should be procured. The treatment so far succeeded, as to relieve the pain and tenderness in the abdomen; but she had no sleep, and next morning I still found her screaming as before, but chiefly from the violence of the headach, complaining that her head was splitting asunder. Upon examining her eyes, I found the pupils considerably dilated; which circumstance, with the violence and unremitting acuteness of the headach, lod me now to suspect some material injury to the brain, and that the headach was not altogether symptomatic or secondary.
On the 20th her countenance continued to be rather pale, the heat of the body temperate, the pulse irregular, and unless when she was agitated by the violence of the pain, rather slow. On the 21st, the enlargement of the pupils, and insensibility of the eyes to light, increased; and ane of the eyes appeared blood-shot, and the strabismus, or squinting, was now shocking to behold. On the 22nd, the headach continued with almost unremitting violence, she never slept, was said to be light-headed in the night; but I found her always perfectly sensible during the day, and her senses and speech remained until within five minutes of her death, which happened on the 23d. About twelve hours before her death, her pulse became quick, and her mouth rather parched, with a rattling in her throat; when asked where her pain was, she put her hand on her forehead, then on the precordia. During the few days that I attended her, she was freely and repeatedly purged, by means of scammony and calomel, with some of the neutral salts. Her bowels were constantly fomented, and glysters thrown up; besides which, she took small doses of calomel with camphor in powder, washing them down with a saline mixture and vitriolic æther; blisters were applied to her head, and behind her ears; and on the 22d, (the day before her death) I gave her the compound powder of ipecac with calomel, which sweated her; and at first she seemed relieved, but the relief was of short duration; she made water freely, and passed some hard waxy fæces.Dissection was performed the day after her death, by the surgeon who attended her. Upon removing the integuments of the head and cranium, a slight adhesion was found between the dura and pia mater, immediately under the vertex. The veins of the brain seemed to be unusually turgid with black blood, though the dissector did not think that there was in this any unusual preternatural appearance. There was a small quantity of fluid between the pia mater and convolutions of the brain; upon cutting through the two hemispheres, to get at the lateral ventricles, blood oozed out from the cut surface of the medullary part, which seemed dotted with a great many red points. Upon removing the cut. portions of the hemispheres, the ventricles were seen distended with Auid, the fluctuation of which was very perceptible, and upon cutting into them, they were found to contain a pure pellucid lymph, nearly two ounces of which we were able to collect in a tea-cup; and making allowance for what was spilt and found mixt with blood at the bottom of the skull, the whole quantity could not be estimated at less than three ounces. Water was found upon the sella turcica, and the cellular membrane surrounding the optic nerves had an onasaurous appearance. Upon opening the abdomen, the colon presented itself greatly enlarged and distended, and upon examination, was found to be in this state from the caput coli, for the whole of the ascending and transverse portions of this bowel. On the left side, immediately under the curvature, it suddenly contracted, and to a degree I never saw before, being much smaller than any of the small intestines: and continued so all the way into the pelvis. In several places it appeared to have been inflamed, and upon laying it open, the villous coat was found extremely red, and covered with inspis sated mucus. The small intestines seemed to have been greatly inflamed, and the ileum, at one part, was of a colour approaching to gangrene. The appendix vermiformis was five inches in length, and adhered to the posterior part of the colon. The stomach was out of its natural situation, drawn upwards to the left side, small and contracted, especially towards its lower and great end, and upou gently pulling it,
it burst near the cardia: upon laying open the stomach, an ulcer or abscess was found to have been in the part where it burst; the coats of the stomach, at this place, were all (the peritoneal excepted) entirely destroyed, nothing remaining but a greenish mucus. Upon opening the thorax, the lower portion of the left lobe of the lungs, with the pleura lining the false ribs of that side, had the appearance of being highly inflamed; and upon cutting into the substance of the lungs, purulent matter exuded in different places. Some small tubercles were likewise found in the posterior part. The pericardium and heart were not examined. The liver, spleen and kidnies were apparently sound." P. 92.
The morbid appearances which were met with in this inte resting case, afford a singularly impressive illustration of the soundness of those pathological views which Dr. Yeats and Dr. Cheyne regard as supported by the most satisfactory evidence. The disease commenced in the abdomen, and the head was affected secondarily. It is clear, that no treatment directed solely to the relief of the head, after it became so severely affected, could have availed, since the chief source of the irritation would have remained undiminished. This case places in a strong point of view, the intimate dependance of that condition of the brain which leads to effusion, on morbid derangement in the abdominal viscera; and shows how much we have gained by learning to regard these morbid actions as links in the same chain, and associated by the established and permanent laws of the animal œconomy. It affords, too, a very apposite proof of the soundness of the remark which Dr. Y. makes in one of the early pages of his essay, that "if we proceed upon the principle that this is a disease of the head only, we shall be exposed to constant disappointment in our practical expectations, and to unavailing regret for the commission of errors." It must be confessed, however, that the advantages which are held out by this mode of viewing the subject, are chiefly prophylactic; and that when the effusion has taken place, it brings no additional means of cure into action. It is only by arresting the progress of the disease before it has reached its fatal stage, that it holds out any prospect of advantage; and hence arises the supreme importance of attending to the earliest indications of its approach. It is in reference to this highly important consideration, that the value of Dr. Yeats's essay must be estimated; and according to this standard its excellence is great. He has evidently watched the progress of the disease, from its earliest symptoms, with the attention of a vigilant and enlightened observer; and we doubt not that his work will have a salutary effect not only among medical practitioners, but, what is more wanted, among those who have to watch over the health and welfare of children, as subjects of domestic management.
In the very first commencement of the symptoms, Dr. Yeats remarks, before any alarm is taken, and before any person can possibly imagine but from experience, that they will often terminate in water in the brain, an occasional languor, as if arising from fatigue, with intervals of considerable activity, is observed; it is therefore attributed to this cause, from the disposition too, which the child manifests of reclining on the sofa, chair, or lap of the mother; the usual degree of healthy appearance of the countenance diminishes, though not permanently, in à transient paleness and occasional collapse of the features; a dark coloured line is observable under each eye, with a dulness of that organ; the usual softness and pliability of the skin diminish, with the consequent harshness and increased heat on the surface; the appetite capricious; occasional thirst: state of the bowels more than commonly tardy; the tongue white, and rather disposed to be dry if examined in the morning; the pulse at this period exhibits no particular morbid change, either in its frequency, strength, or regularity; the urine is at times higher coloured than it ought to be, and from observing that the child has not had an evacuation by the bowels as often as usual, recourse is had to some domestic purgative, and a stool is procured more than commonly consistent and firm, and not in the same quantity as formerly with the same dose of medicine; no very striking alteration of colour is observable, unless attentively examined, when it will plainly appear that a diseased secretion has already commenced in those glands which pour their secretions into the intestinal canal; at times the evacuation will be throughout much lighter than it ought to be; at others only partially so, and again the whole will be more tinged with a darker colour of a greenish cast, and accompanied with some quantity of slimy matter, but more than the mere abrasion of the intestines by a purgation will produce. When any uneasiness in the head is complained of, it is not of pain either acute or dull, but of a disagreeable noise and confusion; the scalp at times feels sore on being rubbed or touched. During this state, upon examination, a puffiness will be felt, and also a fulness observable over the centre of the stomach, extending towards the navel; uneasiness is complained of there from pressure, but like all the other symptoms at this time they are not permanent; and the only symptom which observes any permanency, is the torpid state of the bowels, although the degree of it varies in different patients; the costiveness is, nevertheless, always more or less present; the sleep is frequently disturbed by restlessness, indicated by repeated movements about the bed. The child is said to be only not well, and this is supposed to arise from some improper food that has been taken. It is evident we cannot, a priori, positively determine what exact state of disease this deviation from general health will ultimately produce; but full well I know, that this irregular excitement, this vacillating state, in the way above described, very frequently leads to the next chain of more manifest morbid actions, which terminate in water in the brain." p. 31.
In this early stage of the complaint, it may in general be removed, by the employment of remedies directed to the condition of the alimentary canal. Dr. Yeats judiciously remarks that they must not be merely purgative, they must be such as will change the state of the secretions which are poured into the intestinal canal, and restore them to the natural and healthy ap