pearance. It is not that the bowels are loaded and torpid, but the secretions are become vitiated and irritating, and therefore a simple increase of the peristaltic motion of the intestinal canal is insufficient, and will conduce but little to the restoration of health. Nothing can be more unsafe, under such circumstances, than to trust, as is too often done, to the occasional exhibition of some common domestic purgative. Some temporary relief is indeed obtainable even from this practice; but if the morbid action, already commenced, is not arrested, serious mischief will commonly arise at no very remote period. The benefit does not in these cases depend on the number of evacuations produced by the medicine administered; but on the effect in restoring the healthy action of all the secretory glands connected with the intestinal canal and its appendages. Indeed it is of great importance that the villous membrane lining the intestinal canal should not be irritated or distressed by the violent action of the medicines given; and hence their judicious adaptation to the circumstances of the patient is of much practical consequence. In general, more active cathartics will be required, than the constitution can bear at other periods; and as the organs affected easily relapse, and are with great difficulty established in regular and healthy action, a more frequent exhibition of such cathartics will be necessary than in most other diseases of children. It will be proper too, not only that they should be judiciously combined, but that they should occasionally be varied, in order that their proper effects may be produced, and that the different organs, and even the different parts of the alimentary canal, may receive their appropriate excitement. In general, some of the more common preparations of mercury will be found indispensable: Dr. Y. however strongly expresses his conviction that mercury cannot alone be trusted to. It must be combined with other cathartics such as the compound extract of colocynth, or scammony, or jalap, &c. to render it an efficient remedy. Indeed the whole of Dr. Yeats's observations on this part of his subject, are so judicious, and stated with so much candour and good sense, that they will recommend themselves to the serious consideration of every professional reader. If, unfortunately, either from neglect, or from the constitutional tendencies of the individual, or from improper treatment, the morbid derange ment which we have described is not arrested, a more formidable and alarming train of symptoms will gradually be established, which will alone place the patient in a most hazardous situ ation, and require the most prompt interposition of medical aid for their removal. These symptoms are very fully and accu

rately detailed by Dr. Yeats, and the perfect fidelity of the description will be immediately recognized by those who have ever witnessed this stage of the disease. At this period all the symptoms which attend the former stage are greatly aggravated, and some additional ones make their appearance, which indicate great and serious constitutional excitement. Not only does the countenance assume a more permanently unhealthy look, but a degree of febrile action comes on, which is indicated by an occasional transient flush of the cheek, and a permanently harsh state of the skin. The head is more or less acutely painful, and strong light becomes painful. The pulse is sometimes quickened a good deal, and if examined attentively during the febrile accession will often be found irregular. Periods of drowsiness supervene, and the bowels become more obstinately constipated. The stools are not only unhealthy in appearance, but they have a peculiarly offensive and disagreeable smell. The stomach becomes disordered, and sickness, nausea, and vomiting frequently occur, either after taking food, or from slight causes of any kind. The condition of the abdomen, if carefully examined, will be found to afford pretty certain indications of considerable internal disease there.

"In a great proportion of the cases of acute hydrocephalus," Dr. Cheyne observes," which have fallen under my care, before any affec tion of the brain could be perceived, there were various symptoms of disorder either of the secerning part of the liver, or of the mucous surface of the stomach and intestines; and in many of these cases, the hypochondria, in the early part of the disease, were tumid, the liver was enlarged, sometimes it was the seat of pain, at other times great uneasiness was occasioned when moderate pressure was applied to it, through the integuments of the abdomen. In many of the dissections which have been made after hydrocephalus, the liver has been found with the stamp of inflammation; it has been found enlarged, tied to the peritondeum by preternatural adhesions, studded with tubercles, and otherwise deviating from the sound state; vivid remains of inflammation in the intestinal canal have also appeared, and sometimes those constrictions and volvuli which are the effect of irritation and spasin in the primæ viæ: lastly there has been observed considerable enlargement of many of the mesenteric glands." "Hydrocephalus often follows febrile eruptive diseases, of which I had a remarkable proof in 1808. The most fatal epidemic, for the time it lasted, which has visited Scotland in the memory of man, was the measles of 1807 and 1808. In April, May, and June, I attended five cases of hydrocephalus, all of which appeared within eight weeks after measles. The exanthemata, every physician knows, often leave the bowels in a very disordered state. In Scotland even the common people universally employ cathartics to carry away the dregs of the measles. Primary affections of the abdominal viscera, such as infantine remittent fever, are apt to wear the mask of hydrocephalus, nay, have frequently degenerated into that disease. And scrofula, which is gene rally attended with a disordered state of the bowels, often ends in hydroNO. X. Aug. Rev VOL. II.

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cephalus. In many instances, a combination of symptoms which might fairly be attributed to the formation of hydrocephalus, has yielded to the timely exhibition of cholagogues, which, while they improved the character of the fæcal discharge, reduced the volume of the liver, and restored the functions of the stomach. Such were some of the considerations which led me to conjecture that the affection of the brain, in hydrocephalus, is often secondary: that in most cases, it is owing to irritation in the abdominal viscera, and especially in the liver."

The clear and simple pathological view of this affection which is thus unfolded by Dr. Cheyne in his present essay, was first developed in a distinct form in the essay which he published on this disease, in 1808. Similar views had begun to suggest themselves to other practical observers. Dr. Curry, in his lectures delivered at Guy's Hospital; Dr. Hamilton, in his work on the Utility of Purgative Medicines; and Mr. Abernethy, in his various publications, have each had an important share in drawing the attention of medical practitioners to a practice founded on similar principles; and the experience of its utility is daily adding to the mass of evidence in its favour. The following is the judicious summary of the treatment recommended by Dr. Cheyne in this stage of the disease.

"The state of the hypochondria, the nature of the stools, and the other excretions, the appearance of the tongue, and the smell of the breath, ought to be examined with care. If the patient wince when the right hypochondrium is pressed, leaches ought to be applied to it, or the margin of the ribs may be cupped and scarified; if there be much pyrexia with head ache, blood must be drawn from a vein, or from the temporal artery. Then cathartics are to be given, to promote, or if necessary, to alter the secretions; generally calomel, with small doses of some common purge of an active kind, as rhubarb, jalap, or scammony: and if there be a sickly smell of the breath, and fulness and uneasiness at the pit of the stomach, an irritation of the mucous membrane of the intestines is denoted, which is sometimes relieved by mild antimonials, these consequently are to be added to the cathartics; squill may also be exhibited with the same view, more especially when the urine is deficient. If the stools be dark green and glairy, most probably the common cathartics will have little effect, indeed we cannot expect that they will change the nature or appearance of the secretion, which issues from an organ over which they have little control. Even calomel, the medicine from which most might be expected, is sometimes inert as a purgative, and has no influence over the system as a mercurial, and this seeins to arise from the want of suitable preparation. In the cases in which hydrocephalus seems most remarkably to have its source in a disorder of the abdominal viscera, and in which the cure is to be effected by exciting these organs to free secretion, we are generally unable, after the first day or two, to effect that purpose by direct means." p. 20.

In conformity with these clear and scientific views, Dr. Cheyne urges the great importance, and indeed necessity of attending in the first instance to the condition of the organs, the action of which has become disordered. It is to be considered as a law of pathology, that when an organ is excited beyond a

certain point by vascular congestion, it will be incapable of performing its secretory function, until that state be relieved; and the application of those stimuli which are known to increase its secretions when it is in a healthy state, will then only add to the irritation already existing, and increase the disease. «In hydrocephalus, the biliary secretion is generally languid as well as vitiated, and the presumption is strong, that this condition of the bile depends on the general vascular excitement of the liver." It is necessary therefore that this irritation should be allayed and soothed before the medicines, which have the power to restore and increase secretions, can be employed with advantage, or even with safety.

"The true practice is, in the first place to reduce arterial action by venesection, or by topical bleeding and blistering, and then to restore the secerning function of the viscera by means of calomel and other cathartics; nor can this irritation ever be regarded as completely subdued, until the secretions of the abdominal viscera shall have resumed their natural and healthy appearance."

The correctness of this observation is exemplified in other diseases besides that under consideration. It has been frequently observed by practitioners in warm climates, that in ordinary hepatitis, mercury would not act until the inflammatory action was in some measure subdued by copious venesection, and we have frequently had occasion to verify the remark here. When this is accomplished, it is remarkable how speedily this remedy will commonly produce its specific effect on the constitution.. The constitutional peculiarities of those threatened with hydrocephalus will however frequently forbid the free employment of venesection, at least in this country, and to any considerable extent; and Dr. Yeats observes that the force of the heart may be subdued by venesection, without subduing the action of the extreme vessels on which the effusion depends; an observation which the examination of the body after death often confirms. Hence local bleeding, blisters, sponging the head with cold water, or water and vinegar, or even the application of powdered ice inclosed in a bladder, will often be found very advantageous. Dr. Cheyne thinks highly of the powers of antimony, in arresting the action of the heart, and at the same time promoting the secretions of the stomach and liver, even when nausea is not produced; and hence he thinks it extremely useful in combination with calomel, in doses which do not excite vomiting, cathartics being interposed at proper intervals. The practice of giving antimonial powder in this disease, was introduced at Dublin empirically; but Dr. C. thinks its beneficial effect admits of satisfactory explanation on this principle, not only in

hydrocephalus, but in febrile diseases in which its efficacy has been long acknowledged. If by these means the health of the patient should be restored, it will still be necessary for some time to give some of the lighter vegetable tonics daily, to which should be added as much of some opening medicine as will ensure the regular daily evacuation of the bowels.

Unfortunately, however, it does not always happen that the most judicious treatment will, with certainty, bring about this most desirable event; and we have too often to lament that all the resources of the medical art are unequal to arrest the progress of that effusion, which we believe never takes place without proving fatal. Upon what this uncontrollable tendency of the constitution may depend, it is difficult to say; but it is probably to be referred to that peculiarity of habit, which is generally called strumous. The ultimate stage of the disease: is, however, one of the most deplorable suffering.

"The accession of this state," Dr. Yeats observes, "is marked with greatly increased violence, and with great suffering to the patient; the heat of the skin becomes more intense and harsh; febrile accessions more violent and distressing; the pains of the head more acute and more frequent in their return, and the loud screams of the child on this account are truly afflicting; the pupils of the eye show great dilatation, but still contract on the approach of light, though not healthily, but with a waving, languid, vibratory motion; a squinting takes place at times; double vision is complained of, and when the child is desired, though not seeing double at the time, to view an object, I have noticed that he sees the object not where it really is, but on one side of it, by pointing to the spot; a knitting of the eyebrows, with an expression of the countenance indicative of great distress; for a few minutes there will be a perfect quietism and silence, with a fixed steady stare of the eyes, and a very great dilatation of the pupils, when a sudden start will take place, with a loud screaming, and a quick tossing of the arms over the head; frequent moaning; deep sighing; sickness and vomiting; bowels most obstinately costive; the evacuations, when procured, are very scanty and ill formed, and extremely offensive; and when it happens that by any active means a good mass is brought away, it looks like any thing but fæces, being dark, yeasty, and gelatinous, smelling like a mixture of sour grains with putrid matter; the tongue foul, sometimes brown and dry; much thirst; no appetite; the urine irregularly secreted, both in colour and quantity; the pulse is very irregular, both in the tone of the vibration, and in the flow of the blood; sometimes slow, sometimes quick and intermitting, with a tensive feel, until at last it sinks into permanent sluggishness, ushering its ultimate and fatal celerity; a dewy moisture settles in drops upon the upper lip, and around the nose; a considerable wasting of the flesh takes place; the countenance pallid and sunk, with a hollowness of the temples; blueness of the lips, with their frequent retraction from an attempt but inability to cry, ending in a whining tone from weakness; the eyelids half open and motionless; the eyes filmy and fixed with a peculiar stare from the extreme dilatation of the pupils; the circulation is extremely