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AND OF A
CASE IN WHICH PARACENTESIS WAS PERFORMED,
AND ON' THE
STATISTICS OF  THIS OPERATION.




        I'UOM THE NEW YORK JOURNAL 01 MEDTCTXK.
        By GEORGE C. BLACKMAN, M.D.,
jffelloto of tlje 3&o»al iWetifcal antt <ffi)fvuvp,fcal Socfctij of HoiVBon.
WITH ILLUSTRATIONS.
sfi
%

*■'. -. „ *.
              NEW YORK:
HOLM A V. CRAY So CO., PRINTERS, CORNER OP CENTRE AND WHITE STREETS
MDCCTUV. 
 
AN  ACCOUNT
CHRONIC   HYDROCEPHALUS.
About the first of May, 1S50, a child of Mr. P., of Newburgh,
was  placed undpr our  care,  for the treatment of chronic
hydrocephalus.  This child was six months of age ; its body
and extremities were well formed, but the appearance of its
head is well represented in Fig. 1st.  The circumference of
the head was about thirty inches, and, when held between
the eye and the light, it was perfectly transparent.  The in-
teguments were highly vascular at various points; and at its
anterior and posterior portions there Mere bag-like protuber-
ances, appearing as if about to burst from the pressure of the
enormous quantity of fluid within.  The health of the child
was good, nutrition well performed, and, with the exception of
the threatened rupture of the cranial coverings, there were
no indications of^nmediate danger to life.   The head began
to enlarge very som\  after birth, and  continued to increase,
              1 
4              Blackman on Paracentesis in

without crying, was deaf, and  died without any convulsion
or apparent struggle.              a , ,-
  These  are all the  cases we  havejpaiafen able to find, corre-
sponding with our own, as to the almost complete disappear-
ance of the cerebral substance.  It certainly is remarkable,
that with such extensive disorganization the child should be
able to see, hear, taste, feel,  &c, and  yet this was true
not only in my own case but in that of Dr. Wetmore.   Trans-
parency  of the head, we believe, is not  a  common  feature
in  this disease, though it has been observed by Butcher
(Gazette  Mi'uliaile,  1843),  as well as in the patient which
came under our care.
  The sudden  and spontaneous  disappearance of the fluid
after diarrhoea, copious perspiration, cutaneous eruption, and
other salutary crises, has been  noticed by M. Nelaton (Elem.
de Path. Chirurg., vol. ii., p.  642).  Dr. J. W. Hubbell has
reported in the  New-York Journal of Medicine, May, 1S50, p.
396, an interesting case of hydrocephalus terminating spon-
taneously in recovery, after  the  appearance of an eruption
on  the side of the head, which  gradually  spread over the
whole scalp, and kept up a constant and free discharge for
the space of two months.   The head constantly diminished,
while the body increased in size.   In two months, the bones
of the cranium had approached  each  other, but not united.
In three months, the sutures  had united,  and the eruption
disappeared. The child was fat, and in every respect healthy.
—No medication was used at any time.  Frank mentions a
case which disappeared on the invasion of a scrofulous affec-
tion in another part  of the body ; and both he and Golis
have seen very favorable effects from the appearance of erup-
tions.  In our patient the fluid was transferred to the cellu-
lar tissue, covering the whole  body.
   We have alluded to the perfect manner in which nutrition
was performed; and instances  are on record in which patients
thus affected have reached upwards of thirty years of a^e.
Prof. Vrolik has represented, in his magnificent Tabulae Em-
bnjogennesin Hominis,  &c. (plate 38), the skull taken from  a 
Chronic Hydrocephalus.                 5
man, aet. 32, who died affected with internal hydrocephalus.
This man " a prima infan'tia hydrocephalo laboravit, et cum
eo ad satis provectam, quam dixi, aetatem pervenit, colum-
nam dorsalem habebat curvatam.  Inferioris corporis artus
vix superioris pondus sustentare valebant.   Ceteroquin erat
sanus et nequaquam mente imbecillus."  From the uniform
and equal  distention of the ventricles, this man's head ap-
peared like that of a giant.
   Rokitansky states (Path. Anatomy,  Syd.  Ed. vol. hi., p.
366) that, as a general rule, hydrocephalus is a symmetrical
disease ; and that its chief seat, in all its forms, is the lateral
ventricles.  When   it  is  found  in the arachnoid  cavity,
according  to MM. Rilliet and  Barthez (Traite  des Maladies
'de.s Enfants), it is always the result of a hemorrhage from
this serous membrane into its cavity ; for it is in this variety
that the fluid is generally found bloody.
   The  authors  of   the Compendium de Chirurgie Pratique,
&c, Tome Deuxicme, p. 537, remark that it is in these cases
we sometimes meet with transparency; but, when seated in
the ventricles, the latter, as in the cases related in connection
with  our own, and likewise by Ruppius, in Meissner's For-
schungen, vol. iii., p. 240, may together form one huge cavity ;
and the  cerebral mass  around  the  ventricles, especially
towards the top of  the head, may, as stated by Rokitansky,
and as observed in our own case,  be so attenuated as scarcely
to measure a line in thickness.
   The substance of the brain is  often compressed and atro-
phied, and occasionally  it is lacerated  at various points.
Sometimes it becomes  so expanded and  so  attenuated as to
be with  difficulty recognized.  In some cases, doubtless,
there is a  close alliance between .congenital hydrocephalus
and hemicephalus, there  being a decided  arrest of develop-
ment in the organum.  " I believe," says Rokitansky, " that
the really  essential  part  of congenital hydrocephalus—that
which arrests the development of the brain—is the affection
of the ependyma ; that, m proportion to the degree to which
the hydrocephalus has advanced, and according to the period 
g              Blackjian on Paracentesis in

of foetal life at which it commenced, it does, in various
manner, and to different extent, arrest the development of
the brain, and occasion monstrosity of it, and so far contains
the ground of its  alliance  with  hemicephalus, hydrence-
phalocele,  singleness of  the cerebrum  (cyclopia),  &c. (Op,
cit., p. 363.\
                            Fig. 2.
   The diagnosis of hydrocephalus, though generally, is not
 always, unattended with difficulties.  For example, in some
 cases the dimensions  of the head, as in the cases observed
 by Gall, Golis, Breschet, and Baron, are sometimes less than
 natural; and  then,  if the cranium be  of unusual size, the
 latter may be owing to an hypertrophy of the brain.  If par-
 acentesis  is ever justifiable  in  cases of  hydrocephalus, in
 hypertrophy of the brain, it can only be productive of mis-
 chievous results.* Fig. 2 represents the head of a child some

  * Dean Swift, to, use his own words,
             " Gave the little wealth he had
 .  , .  ...      To build a h°use for fools and mad," &c.
Ana in tow same  "house" in Dublin, about'a century since, several insane 
Chronic  Hydrocephalus.                 7
 •3 years of age, in  which case wre were  consulted as to the
 propriety of an operation.  From the history of the case, we
 learned that the head had commenced to grow rapidly shortly
 after birth, and that the child had never been able to sit or
 stand  erect.   Every portion of the cranium was of stony
 hardness, and with no  amount of pressure with  the  fingers
 could  we produce  the slightest indentation.  The patient
 was frequently affected with convulsions  and  other  symp-
toms of cerebral disturbance, though nutrition was perfect,
 and the child fat and hearty. He constantly remained in f:he
 horizontal position with his head  thrown back.  Believing
 the case to be  one of hypertrophy, not only of the brain, but
 of the bones of the cranium, we  declined any interference.
   In the Brit. For. Med. Chir. Review, April, 1S46, we find
 the following  attempt  by M. Mauthnier to establish the dif-
 ferential diagnosis of hypertrophy  of the brain  and chronic
 hydrocephalus:—

                                CHRONIC HYDROCEPHALUS.
                                1. The  forehead is the first
                              part to present an unnatural
                              prominence;  the altered  di-
                              rection of the  eyes,  and the
                              great  width of  the  sutures,
                              are  also characteristic.
                                2. Children lie on  the  bel-
                              ly, with the head  lower than
                              the  body, and buried  in the
                              pillow.
                                3. Countenance  etiolated,
                              with an expression of prema-
                              ture old age.
                                4. Functional  disturbance
                              begins early, and involves the
                              cerebrum from the  beginning.
                                5. Patient  ill   nourished,
                              subject to rickets and tabes.
HYPERTROPHY OF THE BRAIN.
   1. The  posterior  part of
the skull first presents an un-
natural prominence.
   2. Children lie horizontally,
or throw the head back.
   3. Face  puffy, eyes inex-
pressive or   staring,  mouth
half open.
   4. Functional disturbance
comes on  gradually, not be-
fore the period  of dentition
or weaning,  and consists at
first in affection of  the  res-
piratory apparatus.
   5. Patient  fat  and leuco-
phlegmatic.
patients were trephined, on the supposition that their insanity was produced by
the brain having become too large for the cranium! 
8               Blackman on Paracentesis in
   In both affections the skull is commonly enlarged, but to
 the touch the sensation produced by pressure is widely dif-
 ferent ; in the one giving the idea of a solid, unyielding case,
 in the  other of a wide separation  of the bones, which in
 many cases  are  but imperfectly  ossified.   True, even in
 hypertrophy, where the  progress  of the  disease has been
 very rapid, the  sutures of the skull, in hypertrophy,  may
 become loose and separate, particularly at  the upper part of
 the head, but these cases are rare.   Mr. Paget, in his Lectures*
 on Surgical Pathology, Am. Ed., p. 64, remarks that it is very
 rarely that the due thickness of the skull  is attained while
 its bones are engaged in the extension of their superficial area.
 " Hence, the weight of an hydrocephalic skull is not much, if
 at all, greater than that of the healthy one; a large parietal
 bone (No. 2 in the College Museum), measuring nine inches
 diagonally, weighs only four ounces, while the weight of an
 ordinary parietal bone is about three ounces."  The extent
 of the skull,  he  asserts, is in a measure made up in some of
 these cases by  the symmetrical  placing  of the  wormian
 bones, thus showing "how the formative process, though
 thus thrown into straits and difficulties, yet  conforms, both
 in growth  and  development, with the law of symmetry."
 This  condition of the wormian bones  existed  in  our  own
 patient."   Dr. Todd (Cyclop. Anat. and Physiology) observes
 that it  is uncertain what the precise  change  is which the
 brain undergoes  in hypertrophy, but it is  probable that in
 this perverted nutrition, a new material is deposited between
 or in the proper  anatomical  elements of the brain, and  that
 there is evidence of a similar condition of  the cranial walls,
 the bones of the  skull being  preternaturally thick.  The
 substanc*  of the brain  is universally firm, and cuts some-
 what like cartilage.
  To add to the difficulty  connected  with the  differential
diagnosis of chronic  hydrocephalus and hypertrophy of the
brain,  these  affections  are  found  sometimes  to coexist.
 Otto, indeed, asserted that hydrocephalus is occasionally
cured by the supervention of hypertrophy  of the brain, but 
Chronic Hydrocephalus.
9
 upon this  point  Rokitansky observes (op. cit., p. 359),—" I
 believe, further, that  the hydrocephalus  (the hydrocephalic
 process)  may  itself  sometimes give the first  impulse  to
 hypertrophy of the brain ; but that any compensation for
 or cure of hydrocephalus is effected by hypertrophy, appears
 to be altogether problematical.  Such an opinion is founded
 upon the fact, that in some  large skulls of hydrocephalic
 sljape, the brain exceeds the normal size and wreight.  But I
 believe that these are cases in which the hypertrophy, having
 taken place in childhood, has continued ever since; and that
 belief is confirmed by the resemblance, in shape, which sub-
 sists between the skull in hypertrophy and the hydrocephalic
 skull, as well as by the difficulty which the similarity in the
 symptoms  of hypertrophy and hydrocephalus imposes, upon
 our  determining positively what  disease of the brain did
 exist in  childhood.   So far as I am aware, the morbid in-
 crease in the volume of the brain in hydrocephalus, as well
• as its normal growth, takes place always in the neighborhood
 of the  enlarged ventricles;  it is  a peripheral deposition
 around them ;  and the skull  goes  on increasing in size to
 whatever extent its closure may be prevented by the hydro-
 cephalus."
    The skull of Sir Walter  Scott was found much  thinner
 than  natural  after death,  and  this was supposed to have
 been caused by cerebral hypertrophy, although the imme-
 diate cause of his death was  ramollissement of the corpus
 striatum, producing hemiplegia.
   Dr.  Forry, the original  editor of the Nexc-Yorh  Journal
 of Medicine,  died Nov.  24th,  1S44,  from hypertrophy and
 induration of the brain.  For  some  months before  his death
 he suffered from epilep.-y and other  severe cerebral disturb-
 ance.  The anterior and posterior portions of the skull, cor-
 responding, to the hypertrophied cerebral  substance, were
 evidently thinned.   Long-continued vascular excitement
 may  lead both  to hypertrophy  and effusion.   Dean  Swift,
 who  lived like a madman,  and expired  "a  driveller and a
 fool," is said to  have been temperate in early life, yet, by his 
10
Blackman on Paracentesis in
intemperance in after years, he produced the hypertrophy of
the brain and the effusion within the cranial cavity which,
even at the age of 78, caused his death.  Up to 1742, when
he was 75 years of age, he showed no  symptoms whatever
of mental disease, beyond the ordinary decay of nature, nor
did he have anything like epileptic attacks  or  general con-
vulsions  until some 36 hours  before his death, yet we are
informed  (Works  of Swiftr Dub., Faulkner,  1763, vol. ii.,
p. 261) that Mr. Whiteway, who examined the body, "found
much water in the brain."  The frontal region of the cranium
was thickened, flattened, unusually smooth and hard in some
places, whilst in others it was  thinned  and roughened.  At
some  points in the occipital fossae, the supraorbital plates,
&c, the  skull was so thin as to be  transparent.  (Vide Mr.
Wilde's  Report,  &c, Dub.  Journ.  Med.  Science, May and
August,  1847.)
  Hydrocephalus, therefore, is not a disease confined to any
particular age, as is proved by the case reported by Prof.  ,
Vrolik, and that of the Dean, just mentioned.  Besides these
cases, Dr. West refers to  another, in which the patient lived
to 29 years of age; Dr. Baillie to one of 56 years, whilst
Golis mentions three in which it came on in old age, two
of these patients having been upwards  of 70  years  old.  Of
course the changes produced  upon the  skull  by  chronic
hydrocephalus, and hypertrophy of the  brain,  must vary
according to the period of life at which these affections com-
mence.  In early  life, as in Fig. 2, the cranial bones partake
of the hypertrophied action of the brain, and becomes thick-
ened as it expands.  In adult life, the effect is  different, the
bones  becoming thinner from  the  pressure, as  seen in the
skulls of Sir Walter -Scott, Dean Swift, and Dr. Forry.  But.
we have neither time nor space to  dwell longer upon this
part of the subject, nor could we do  so with profit to the
reader; for,from among all the writers to which we have been
able to refer, we have not succeeded  in collecting the ele-
ments by which an absolute differential diagnosis in all these
cases can be  established. 
V
                   , Chronic Hydrocephalus.                11

   It is not  our purpose to discuss the various methods of
 treatment which have been adopted in chronic hydrocephalus,
 but shall confine our remarks to puncture of the cranium.
 The Rev. Mr. Stevens  has the credit of being the first to pro-
 pose trepanning the cranium for hydrocephalus, and this was
 in the case  of Dean Swift, who  died in  1743.   From Mr.
 Wilde's  report of the Dean's case, to which we have already
 alluded, we learn that up  to 1742, three  years  before the
 Dean's death, there were no symptoms of mental disease ; and
 it was not until some 36 hours before his death, that he suf-
 fered from epileptic attacks and general convulsions.  Con-
 quently  we may assume that it was in 1845 that the Rev.
 Mr. Stephens proposed this  operation.  Dionis, is his Cours
 oPOperations  de Chirurgie,  3d ed., 1736, has the following
 observations:
   "Toutes les especes d'hydrocephale demandent la main du
 chirurgien pour donner issue aux eaux qui font la maladie.
 Les anciens appliquoient deux cauteres potentiels, l'un sur
 le commencement de  la suture  sagittale, et 1'autre  sur  la
 pointe d,e la suture lambdoide ; les. escarres etant tombees,
 ils laissent sortir la lymphe par ces deux ouvertures, etc.  Je
 suis plutot pour les scarifications  aux parties cleclives de  la
 tete, par ou  les eaux,  dont elle  est abreuvee, peuvent sui-
 vre," etc.
   He  then  refers to  a case  of  congenital hydrocephalus,
 which he cured by this method of treatment.  In the Philo-
 sophical  Transactions, vol. xlvii., there is the report of a case
 in which Le Cat punctured the head for hydrocephalus.  The
 operation was performed on the %3d October, 1744.  A trocar
 with  a canula much shorter than  ordinary was  used.  On
 the upper part of the canula were two circles, each fastened
 to a different piece, so made as to screw on each other.   The
 circles were  somewhat concave on their  surfaces, so-as
reciprocally to correspond,  their circumferences  touching
while there remained a tolerable vacuity towards their cen-
tre.  A circular piece  of plaster, with a hole in its centre,
was fhen applied to the lower  circle, the screw of  which 
12
Blackman on Paracentesis in
■
passed through the hole of the plaster.  The object of this
arrangement was to prevent the trocar from penetrating too
deeply.  The trocar and.canula were thrust up to the circles
and plaster, which was made adherent to the  scalp, after
which the  trocar was  withdrawn, when 4  or 5 ounces  of
serosity, of a brownish white, " or the color of pale white
wine," and somewhat foul, was allowed to issue.  This was
on the 23d October.  On the 24th, he unstopped the canula,
and drew off the same quantity.  On the 25th, "the infant
was ill," for which reason he was not disturbed on that day.
On the 26th, he was better, and 5  ounces more were with-
drawn. Tuesday he was suffered  to rest.  Whenever the
fluid  was  withdrawn,  the head was  bound with  a strong
bandage.  The child died on the night of the 27th.   The
brain was thin, expanded, in contact with the  dura mater,
forming a kind of thin  sack filled with water.  Both lateral
ventricles were excessively dilated, and but slight traces  of
the pineal gland, choroid plexus, remained.'
  Dr. Remmet, of Plymouth, E., operated in 1778, and  SO
ounces of fluid were discharged at  five different  operations.
The child died on the seventeenth day.
  In  Van'Sivicten's Commentaries, vol. xii., p. 24S, we find that
Petit expressed his regret that all the patients who had been
subjected to this operation died.  He believed that if a large
quantity of water  should be drawn off, the patient must die
in four or  five hours after  the discharge; and even if less
should be, removed, they would  still die, though not  so
speedily, surviving, perhaps, the operation some forty hours,
but never longer than this period.
  The operation was condemned by Heister, Boerhaave, De
la Motte, Pare,  Portal, Richter,  Golis,  Breschet,  Boyer,
Dupuytren, Physick.   Among the  modern opponents of this
proceeding  we  have  found  none more  decided than  Dr.
Battersby.  In his very elaborate paper published in the
Edinburgh Medical and  Surgical Journal, July, 1850, he has
most thoroughly entered into the examination of the path-
ology of this  disease,  and he declares that  all the evidence 
Chronic Hydrocephalus.
13
thus far derived from morbid anatomy, as  well as from the
statistics collected upon the subject, goes to prove that punc-
ture in chronic hydrocephalus is a useless and unjustifiable
operation.  In abdominal dropsies, as well as in hydrocele of
the tunica vaginalis testis, he asserts, the simple withdrawal
of the fluid is seldom sufficient to effect a cure; and if, in cases
like these, he adds, where the containing parts naturally return
to their proper position after the fluid is evacuated, it would
be absurd to expect that dropsy of the brain, where the parts
cannot reassume their  normal position, should be cured by
paracentesis 'of the  head.   The  operation he regards as
attended with danger, the cases reported showing that punc-
ture is sometimes followed by an almost immediate aggrava-
tion of  the  cerebral symptoms, and  by  death.   Another
objection urged by him is that the fluid soon collects again,
and even if relief be  afforded by the first operation, it is less
marked in  the second, the quantity of fluid even increasing
with its repetition.   With this increase in  the dimensions of
the  head,  the body.becomes  emaciated;  and  death  takes
place from  exhaustion, coma, or convulsions.   The number
of cases in which the operation  has been performed  is
sufficient to settle the question  of its value  as  a  curative
agent; and, while the  statistics bear unfavorably upon it in
this light, there can be no question that, as  a  palliative
measure, the surgeon may not unfrequently be justified in
resorting to it.   Dr.  Charles West published in the London
Medical Gazette, April, 1842,  " An Inquiry into the Results
of Puncture of the Head, in cases of Chronic Hydrocephalus"
and so completely has he exhausted the subject up to that
time, that  we  are compelled to avail ourselves  of his labors.
His Table  comprises 56 cases, and  we have added such  as we
have been  able to find reported since the date  of  his publi-
cation, a period of twelve years. 
14
TABULAR  VIEW OF CASES OF INTERNAL  HYDROCEPHALUS IN
No.
Sex.
Acre.
2 F.
 Duration
of disease
b'tween
11 & 12
 years
 4 m.    began in
11  days 6th  weeek.
JI.
12 wks.
4 mths.
Symptoms before Puncture.
Size of the
  Head.
Came on in consequence of
  a fall; head enlarged  to
  a  third  beyond  natural
  size, and  parietal bones
  opened  so as  to allow
  fluctuation  to  be  felt
  These symptoms came on
  three months  after the
  fall.
B*egan with fits and enlarge-
  ment  of head.   Bowels
  torpid ; strabismus; child
  had an idiotic look.
  A third
   larger
than  natu-
   ral
Apparent-
    iy
 double.
  Number |    Quantity of
and date of Fluid in lbs. and
Punctures.      ounces.
One
 began a
 few days
after birtli
  head
large  at
  birth
8 M.
9	F.
10	F.
11	F.
12	F.
13	JI.
14	F.
15	M.
1C	jr.
14 m.
10 m.
20 m.
5 mths.
General health good,  but
  bowels irregular ; strabis-
  mus, rolling of the eyes.
Child healthy, cheerful, not
  emaciated.  The fluid was
  supposed to be external
  to the ventricles.
 Eighteen
Dec. 10. 17.
 25. 28.31.
 Jan.  5.  9.
 14. 19. 23.
 28. Feb.  4.
 8.  IS. 25.
 Jlar.  3.  6.
 10.
  excited
from  birtli
 began in
Mth month
congenital
Child very ill; pupils dila
  ted.  States that  inflam
  mation of  the  brain and
  its membranes  existed,
  but does  not mention  a
  single symptom.
Head had been  gradually
  enlarging for half a year.
Hiccough  and vomiting;
  eyes  heavy,  somewhat
  convulsed.
 23 inches
in  circum-
  ference.
18 1-2 inch-
 es in cir-
  cumfe-
   rence
lbvj. of water
 drained  away
   in 20 days.
■ oz. 1-8 + 5+4
+ 51-2 + 4 + 4
+ 7 + 71-2 + 7
+-2 6-S+-10  +
3 1-2 +0+0+5
+ 3 + 4 + 4=
76 1-4.
   Four    oz. 3 + 5 1-2+1
August 25.!+9 1-2=19.
 Sept.    4
 15. Oct.  5.
 Head of
enormous
 size from
   birth.
  Eleven   oz.  1 1-2 +2 + 2
Jan. S.  15. + 2 1-4+11-2 +
 23.Feb.lS.
 Jlar.   15.
 19. Ap. 19.
 27. Jfav5.
 17. Ju.' 23
   1-4  +11-2 +
 11-2+2 1-4 +
2 1-2 + 2=21 1-4
  Nine*
within 4
 months

  One
Ojss. by first punc-
ture, less by sub-
sequent ones.

     oz. 24.
One	oz.	2, but a large
	quantity,supposed	
	to	ie Oij. drained
	away.	
Two	oz.	12 + 12=24.
>eginning		
of Aug.		>
Sept. 3		
Five		oz. 55.
Three		oz. 26.
One		oz. 13.
One		oz. 9.
One		oz. 6.
Three		oz. 31 1-2.
Two		oz. 14.
One		oz. 9.
 
WHICH PARACENTESIS WAS SUCCESSFULLY PERFORMED.
15
Subsequent Progress.
Authorities.
" Patient was saved."
Monroe on Hydrocepha-
         lus,
       p. 146,
quotes the  case  from
  /   Prof. Rcssi.
The fluid  removed was  clear first, but, on the
  8th and 9th punctures, Mas of a darker color
  and  thicker consistence, but  regained  its
  transparency at subsequent operations. The
  immediate effects of the puncture were never
  serious.  Slight febrile s-ymptoms, and occa-
  sional vomiting, and fretfulness, occurred  at
  different periods, but  fits only once, just be-
  fore the sixth operation.  The ossification  of
  the head proceeded so  that the situation  of
  the first puncture became ossified.
The fluid was serous, on  the second time was
  turbid and mixed with flakes of lymph. Slight
  fever after first, not after others.  Ossification
  advanced; head  diminished; child went  on
  well; obscure  fluctuation  remained three
  weeks alter last puncture.   Calomel was then
  given, so as to affect the mouth.
 After  each operation there was great faintness,
  pallor, and failing of the heart's action during
  several hours.  Great  restlessness followed
  for a night or two after each operation.
Ninety days after first punc-
 ture, day of last puncture
 Case then going on favor
 ably.
     Mr. Lizars,
Ed. Jlcdical and Surg.
       Journal,
       vol. xvii.
       p. 243.
Four months after last punc
 ture,  then stout, healthy,
 and very large  of her age.
 Head ossified, except ante-
 rior  fontanelle, and  four
 inches less  in  ^circumicr
 ence.
Seventeen months after last
 puncture, child was healthy
 and head measured 18 3-4
 inches in circumference.
Great improvement followed the first puncture
  the others left the child in a very satisfactory
  state.

Iodide of potassium ointment employed ;  calo-
  mel and mild aperients given.  " Though the
  little sufferer was for some time in a precari*
  ous state, he did recover, and is  now a very
  fine boy, never having had the slightest re-
  turn of the complaint."
One  convulsion  followed  the puncture, and
  afterwards other symptoms of meningeal irri-
  tation.
Died  of pneumonia  more
 than a year afterwards.
Continued weakly- during the day of puncture,
  but more lively than before,  and for  some
  time after the intensity  of all the former
  symptoms diminished.  A  month after it was
  found necessary to repeat the puncture.
     Mr. Russell,
Ed. Medical and Surg.
       Journal,
     vol. xxxviii.
        p.  43.
  Graefe, Graefe and
Walther's  Journal, Bd.
   .  xv. S. 348.
("Dr.  Fourcade, Lan-
| cette Francaise, vol.
) iv., No.  47,  p.  188,
 reports from recollec-
 tion, case operated on
. by Dr. Bed or.
     Jlr. Marsh.
  Medical Gazette.
      vol xvii.
        p. 985.
Two and a half years after-
 wards, health and intellect
 good.

Nearly eight  years after,
 head  then  too large, but
 not larger  than before the
 operation.  Health good.

Five  years  after, head  22
 inches round ;  ossification
 complete, except  posterior
 fontanelle,  and two open
 ings  in coronal   suture.
 Health  good, remarkably
 shrewd.
 Dr. Conquest, Lancet,
>JIarch 17, 1838 ; and
 Med.  Gaz..  vol. xxi.
        p. 967. 
/
1G
TABULAR VIEW OF CASES OF INTERNAL HYDROCEPHALUS IN
Sex.
Age.
 Dura-
tion of
disease.
Symptoms  before
    Puncture.
Size of the
  Head
[No.  of
 Punc-
 tures.
Quantity of
   Fluid.
Immedi'te Effect.
M.
M.
M.
9 m
3 m.
3 m
2 m
2j
Began at
3d month
Began in
7 th week
Sucked well, but was
emaciated.
Well  nourished,  but
fretful.
5 m
9 m.
20 d
8 M.
F.
9 m
4 m,
6 ir
 Con-
genital.
 Con-
genital.
Noticed
 at 5 th
month.
 Con-
genital.
Healthy  and strong
head  had  much  in
creased  in  size ; eyes
very prominent.
Well.
Indisposed  for three
weeks with crying and
screaming.  Pupils im
movable.
 Con-
genital.

 Con-
genital.
 Six or
  seven
weeks af-
ter birth.
Good, and continued
so,   notwithstanding
fruitless  employment
of medicines; head hot
appetite craving.
Child had a spina'bifi-
da, but health good.

General health good;
head had progressively
enlarged.
Always [unquiet, but
tolerable health to 5th
week ;  became gradu-
ally emaciated; bowels
irregular ;    constant
crying, no sleep.
  At 8th
  month
  larger
than head
of a man.
  Sutures
separated.
Very large.
 25 inches
 round at
6th  month.
  ery large,
fluctuating,
 23 inches
  round
above  lips
  of ears.
27 inches
 round.

24 inches
 round.
23 inches
 round.
One.
Three
One.
Five.
One.
Six.
lib.  Fluid con
tinued to  drain
  away after-
    wards.

5 4.5_|_5=15
10+12+14 +
12+ 32 = 80
9i + 9£+6 +
l + 2i + li =
291
4J+1+5+3
+ 34 + 3 + 35
+ 3.4 + 4 +
= 40.
Three.
Eight.
1,  but
wound
opened
twice a
day for
sev'ral
 days.
Bore   operation
well.
Sickness and vo-
miting after 2d ;
4th    puncture
made in the fon-
tanelle ; 4^ oz. of
blood   escaped,
and child seemed
likely to die.

  No striking
     effect.
10+16 + 15=
40

12+12+12 +
 + 12 + 3 + 9
+ 12 = 81.
116 in course of
8 days.
Very  slight ex-
cept  after 5th
puncture,   when
taintness was pro-
duced. 
WHICH PARACENTESIS WAS UNSUCCESSFULLY PERFORMED.          IT
Subsequent Progess.
Child sank.
Date of Death,
Well for two days, then taken
 ill: died on evening  of 4th
 day.
After third puncture, head re-
 duced to natural size ; after
 1st week, head swelled again.
 Exhaustion came on 3 weeks
 after 5th puncture ;  death
 in ten days.
More lively ; convulsions; and
 hemiphlegia  affecting right
 side, on third day after first
 puncture, ceasing in course
 of one  day.   Diarrhoea  for
 some  days.   Coma before
 second and third punctures ;
 relieved  by  the  operation.
 Seemed  bettter on day of
 sixtli puncture ; fits on fol-
 lowing day ;  tranquil death
 soon after.
Slight improvement followed
 each puncture.   Continued
 well,  except  erysipelas of
 face, till day of  last  punc-
 ture ; then, convulsions re-
 turning  frequently,  child
 wasting till death.
Health good for a few days ;
 considerable exhaustion after
 2d puncture.   On 5th punc
 ture, 6 weeks after 1st, situa-
 tion of original puncture ossi
 tied. Two convulsions before
 7th puncture, again after 8th
Seemed going on well, though
 fluid   re-collected;   head
 greatly diminished in size.
 sutures, which had  been  3
 inches across, came  into ap-
 position.   On  the  9th day,
 convulsions, coma, death.
Condition of the Brain after Death.
36 hours after
the puncture


84 hours after
 1st, 36 after
last  puncture.

Day after  the
   puncture.
Excessive dilatation of ventricles ;
 atrophy of pineal gland ; very little
 trace of choroid plexuses.

Fluid  between  cranium  and dura
 mater.
3 m'ths 9 days
 after  1st, 31
days after last
   puncture.
16 hours after
  puncture.
37 days after
1st, 1 day after
last puncture
Cavity of  brain  full of  enormous
 quantity  of  clear  water ; scarcely
 any brain  found, but only medulla
 oblongata, and a small quantity of
 brain behind the  orbits.
84 days after
 1st, 11 after
last puncture
30 days  after
1st puncture, 9
  after last
110 days after
1st, 8 after last
  puncture.
9th day from
the puncture.
Authorities.
Fabricius  Hilda-
nus, Observ. Chi-
rurg. cent.iii. obs
       17.
 Le Cat, Philo-
soph.   Trans, v
  xlvii. p. 257.

La Motte, Traite
 complet de Chi-
 rurgie, tome i.
    obs. 115.

  Dr. Remmet,
Edin. Med. Com-
ment, vol. vi. part
       4
Two pounds of clear  fluid  contained
 in  brain,  in  cysts, with  vascular
 coats:  cerebellum  around  fourth
 ventricle hard ; cura cerebri ulcera-
 rated.
Two pounds of sero-sanguineous fluid
 in  ventricles;  walls  of  ventricles
 very thin  ; brain  soft;  coagulum
 size of a hazel-nut in posterior cor-
 ner of left  lateral ventricle.
Dura mater thickened ; pia mater in-
 flamed ;   cerebral  substance  very
 thin, lined by false membrane ; no
 trace of  corpus  striatum, callosum,
 etc.;  bag of cerebrum divided into
 cells  by  membranous  bands, con-
 tained 35 ozs. of fluid ; cerebellum
 firm.
Fluid between dura and pia mater;
 the former thickened, but with no
 signs of acute inflammation ; brain
 nearly all absorbed, not larger than
 a hen's egg, soft, and parts  not dis-
 tinguishable.
Membranes gangrenous for several
 inches round puncture, contained
 pounds of turbid, foetid fluid ; whole
 upper  part  of brain disappeared;
 some at base, like pons varolii.
 Dr. A. Monroe,
Morbid Anatomy
of the Brain, vol.
    i. p.  11.

 Mr. R. Brown,
Med.  and  Phys.
Journal, vol. li. p.
      102.
Mr. Money, Med.
and Phys. Journ.,
 vol. lii.  p. 462.
Mr   Grey, Med.
and Phys. Journ.,
 vol. liv. p. 204.
Dr. Glover, Phil-
adelphia Journ. of
Med. and  Phys.
Sciences, vol. ii.
     p. 159.

 Dr. Whitmore,
American   Me,
 Recorder, July,
      1821.
2 
18         TABULAR VIEW OF CASES OF INTERNAL HYDROCEPHALUS IN
No,

Ti
Sex.
M.
Age
7 m.
12
13
14
15
16
M.
M.
11 w
5 m.
5 w.
17
F.
64m
16m
Duration
   of
 Disease.
 Began
about a
 month
 after
 birth.
Began in
3d month
Began in
6th week
Began at
2 months
Symptoms  before
    Puncture.
Began in
4th m'th
Fever;    screaming
squinting at 3d week ;
in ten days  enlarge
ment  ef  head,  which
increased; other symp
toms abated.
Sickly  from   birth ;
convulsions   at  two
months ;   emaciation ;
constant crying ; stra-
bismus.

Always fretful, throve
till  6th  week,  then
wasted ; head swelled.
No squinting.
Good for two months
but  head always  in-
clined to side ; then
swelling  of  head,  fits
of crying, cough, and
emaciation.  No vom-
iting or convulsions.
Size of the
   Head
21^ inches[
  round
214 inches
 [round
  Fluctua-
    tion
  in head
  distinct.
20/| inches
in  circum-
  ference.
18
19
F.
16 m
6 m.
3w.
Began at
 end of
3d month
Began at
4th m'th.
Well  nourished
eral   symptoms
slight.
gen-
very
 Supposed
  to con-
tain 2 to 3
  pints.
No. of
 Punc-
 tures
One
Began with   convul
sions; health then good
until  dentition began,
then lost motion of left
arm and leg ;  had fits
with  each  tooth,  and
occasional strabismus
Health  bad;  pupils
dilated ; insensible to
light; coma for several
months j    occasional
convulsions.
Began at Great strabismus.
5 th m'th.
26 inches
 round.
 18 inches
in circum-
  ference.
Five
Six
One
Five
One
One
Quantity of
   Fluid.
One
Four
1*4 + 31+7+
7 + 16 - 47^6-8
6 by first, after-
 wards + 36=
      42

      11
4 + 3+  4+4
+ 4=19
37
24,  and more
drained from
   wound.
Immedi'te Effect.
Vomiting   soon
after.
20
9 + 2+3 + 2^
=164
Uneasy  during
1st,  sensible  of
pain afterwards;
uneasy and occa-
sionally convuls-
ed after 5 th.
No   inconveni-
ence ;   sensible
improvement.

None; head much
collapsed; vomit-
ed same evening.
Brain protruded
through 1st punc-
ture (with a  lan-
cet), which  was
therefore repeat-
ed.
Considerable col-
lapse.
Cold, faint, lips
livid,  requiring
strong    stimu-
lants.
No suffering. 
WHICH PARACENTESIS WAS UNSUCCESSFULLY PERFORMED.
19
Subsequent Progress.
Date of Death.
First  night  restless;   next
 night better ; screaming 58
 hours after, followed by fits;
 and  death, in fit,  14  hours
 after.
Slight convulsions  on night
 after 1st puncture ; improve
 ment,  less  strabismus, in
 creased  ossification ; cried
 much after 4th convulsions,
 and death 3 days after 5th.
Relief after each puncture; a
 fortnight  after  last,  water
 ceased to accumulate.  No
 ossification of skull.
Went on  well till 3d day
 head being 24 inches smaller
 On 3d day great restlessness
 vomiting,  rigidity of  one
 arm, convulsions ;  death on
 4th day.
                            16 weeks after
                             1st, 5 weeks
                            after  last ope
                               ration

Pretty well, but  somewhat 9th day after
 excited 1st day ; head filled the  puncture.
 again between 3d and 6tb
 day ; on 7th, a gush of fluidl
 from situation of 1st puncture, followed by
 convulsions and involuntary dischage  of
 urine and faeces.
A little improved 1st  night, 4th day after
 pretty well till third day ; the puncture.
 then violent convulsions and
 death
72 hours' after
   puncture.
Condition of the Brain after Death.
51 days after
1st puncture,
 3 after last.
11 weeks after
1st puncture, 3
  after last.

87 hours after
the puncture
No trace of inflammation ; brain very
 soft; two transparent sacs in left ven-
 tricle, one in right communicatin
 with  third  and fourth ; they were
 smooth and tough, attached to brain
 at under, unconnected at upper sur-
 face ; nates and testes formed a tu
 mor,  containing one drachm of pus ;
 lower parts of brain healthy.

No sign of inflammation ; fluid in ven
 tricles;  brain  greatly  expanded
 cerebellum healthy.
Slight fever for a  few days,
 then seemed better.   In 10
 days  water began to accu-
 mulate   In  1 month and 3
 days symptoms  of nervous
 debility,  in  3 days more
 painless death
Vomiting on 2d and 3d day.
•fever on 4th, coma on  5th,
 convulsions on 6th.
5 weeks after
the puncture.
6 days after
 puncture.
Authorities.
 Mr. Hood, Ed.
Med. Surg. Jour.,
vol. xvii. p.  510,
   Oct. 1821.
Dr. Freckelton,
Ed. Med. Surg.
Jour., vol. xvii.
    p. 240.
No  sign of recent inflammation ;  24
 lbs. of fluid in sac of arachnoid ; atro-
 phy  of  cerebrum  which  was  not
 larger than a bean.
No  inflammation of brain or its mem
 branes; ventricles contained yellow-
 ish  white fluid, like  seropurulent
 fluid  and  water, with albuminous
        some softeningjof ventricles.
Brain bloodless; 2 pounds of fluid in
 ventricles;  great  thinning  of their
 walls,  of right especially, which
 formed a mere membranous bag, and
 was in parts of consistence of cream;
 parts at floor of left ventricle barely
 recognizable ; at floor of right undis-
 tinguishable ; cerebellum and  base
 of brain healthy.

No trace of  inflammation ; great ac-
 cumulation  of fluid in the ventricles.
One pound of fluid in cranium ; punc-
 ture had not penetrated the brain ;
 dura mater  adherent to skull; brain
 soft and  very  vascular; great dis-
 tention of  lateral  ventricles with
 fluid; no  inflammation  about  punc-
 ture.
 Mr. J. Sym, Ed.
Med. Surg. Jour.,
vol. xxiv.  p. 295.

Dr. J. Alison, Ed.
Med. Surg. Jour.,
vol. xliii.  p. 359.
Mr. Callaway, as
reported by Op-
penheim,  Rust's
Mag., v. xxiv. p.
       77
 Dr. Roechling,
Hufeland's Jour.,
Aug. 1826, p. 114.
Dr. S. Hall, Med.
 Gaz., vol. vi. p.
      334.
Mr. Jlarsden.Lan-
cet, Feb. 12,1831.
     p. 648.
 Oppenheim,
Rust's Mag. v
 xxiv p. 89. 
20         TABULAR VIEW OF CASES  OF INTERNAL HYDROCEPHALUS IN
No.
Sex.
Age
■ 20
21
22
23
jr.
15w
9 m
2 m.
4 m.
24
25
3 m.
7 m
12 d.
Duration
   of
Disease
 Con-
genital.
Began at
1 month
Began at
1 month.
Began at
2d month
26 F.
10 d.
27
M:-]
8 m.
 Con-
genital.
Symptoms before
   Puncture.
Great emaciation.
Health tolerably good
—child intelligent.
Good, except frequent
convulsions.
Health good, but bow-
els costive; had spasms
when a week old, ceas-
ed after 3 weeks, when
head suddenly  enlarg-
ed.
Small-pox at 5th week;
enlargment  of  head
from 2d month ; at 5 th
month  blind;  oscilla-
tion  of eyes ; starting
and  screaming, after-
wards fits.
Good at birth ; at end
of ten  days head hot;
child fretful;  bowels
disordered.
Size of the
  Head.
30 in hes
in circum-
 ference.

23 inches
in circum-
 ference.
21 inches
in circum-
 ference.
No. of
Punc-
tures.
One
One
Two
Seven
Quantity of
   Fluid.
224 inches
 round at
3th month,
Began at
 end of
4th m'th.
Health quite  good up
to 10th week, even now
tolerably good; bowels
regular; well nourish-
ed ;  eyes  constantly
rolling.
 Head at
birth twice
  natu-
 ral size
224 inches
in circum
 ference.
Four
Ten
Two
Four
== 10
10
Immedi'te Effect.
28
14 + 2 + 6 +
11 4- 15 +-124
+ 14=63.
 14 + 17 + 14
+ 134=584.
4+5 + 6+7
 4. 12 + 16 +
 12 + 28 + 42
  + 20=153
10 + 8=18
20 + 23 + 22
  19=84
Improved    ap-
pearance.
None.
Slight   haemor-
rhage from a ves-
sel  at  3d  punc-
ture.
After three of the
punctures,  faint
and  pale,   and
once   vomited.
Nothingafter any
of the others.
After 1st punc-
ture  cold, faint,
as though about
to die; state after
2d not mention-
ed.
No  peculiar  ef-
fect. 
WHICH PARACENTESIS  WAS  UNSUCCESSFULLY PERFORMED.
21
Subsequent Progress.
Exhalat'n of sense of hearing,
 then improvement for 2 or 3
 days;  re-accumulation  of
 fluid in a fortnight, gradual
 sinking after 2d puncture
Convulsions   ceased  a  few
 hours after  1st  puncture;
 returned slightly before 3d
 and  5th.  Health good till
 day  before   last  puncture,
 then stupor; relieved for a
 time by puncture ; 2  days
 after, quiet death.
Convulsions on 5th day ; con-
 tinued enlargement of head
 after each  puncture ; occa-
 sional convulsions, followed
 at length by coma and death

Improvement  for  2  months
 and progressing ossification;
 then improvement ceased,
 and  head became  qui*e as
 large as ever.
Convulsions  came  on,  but
 ceased some weeks, till day
 before death, and child died
 in a fit.
After  1st puncture, seemed
 improved; water re-accumu-
 lated at end of a week; after
 2d, no improvement; at end
 of a fortnight after, head as
 large as  before.   Parents
 would not permit its repeti-
 tion.  Child  wasted;  died
 convulsed.
Occasional vomiting ;  slight
 convulsions;  head rapidly
 regained its size.   14 days
 after last puncture, moaning,
 crying, contractions of limbs,
 faintness,and difficult breath-
 ing came on.
Date of Death
In a few days
after the punc
     ture.

3 weeks after
 1st puncture,
 1 week after
     last.

115 days after
1st, 2 after last
  puncture.
 62 days after
 1st, 11 after
last operation
131 days after
 1st puncture,
 2 days after
     last.
  6 months 5
days after  1st.
 5 months 12
days after last
  operation.
7 weeks 3 days
 after 1st, 15
days after last
  operation.
Condition of the Brain after Death.
All the ventricles  formed but one
 large cavity,  covered by but very
 little brain.
Authorities.
Great vascularity of the membranes;
 softening of the brain;  accumulation
 of fluid in the ventricles.
Membranes pale,  bloodless ; septum
 lucidum  torn:   lateral  ventricles
 formed one large sac, lined by thick
 flakes of matter, like pus or mucus.
Fluid in ventricles:  great  thinning
 of the brain ; hole through  falx and
 tentorium;  cerebellum healthy.
Arachnoid  engorged;  fluid  in  all
 three  ventricles;  brain very  soft:
 lymph at is base.
Ruppius, in Meiss*
 ner's Forschun-
 gen, vol. iii. p.
      240.
Meissner,Die Kln-
 derkrankheiten,
  vol. ii. p. 187i

 Mr. F. Cooper,
Lancet, June '27,
  1835, p. 405.
Prof. L. A. Dugas,
 Amer. Journ. of
 Med. Sciences)
 vol. xx. p. 536.
 Dr. J. B. With-
ridge, Am. Jour.
of Med.  Sciences,
 vol. xx. p. 5381
Dr. J  R. Smytjh,
 Med. Gaz.  vol.
   xxv. p.: 83."
Fluid under dura mater; cerebrum so
 flattened  that parts were undistin-
 guishable.
Fluid within the membranes ;  left
 hemisphere almost totally destroyed,
 right  greatly  compressed;   optic
 nerves  diseased ; left olfactory des-
 troyed ; right nearly so ;  cerebellum
 healthy.
              |
 Mr. Armstrong,
Med. Gaz. v.xxvi.
     p. 226.
Dr. Kilgour, Ed.
Med. Surg. Jour.,
 vol. liii. p. 365. 
22      TABULAR VIEW OF CASES OF INTERNAL HYDROCEPHALUS IN
No	Sex. F.	Age 9m"	Duration of Disease.	Symptoms before Puncture.	Size of the head.	No. of Punc-tures.	Quantity of Fluid.	Immediate Effect.
~28			Began in	Healthy; in 15th week	214 inches	One	4, much drained	4 oz. of blood es-
			3d month	able to hold up its head, though very large ; cried occasion-ally ; continued well to 9th month, but head then too big to move.	in circum-ference.		away.	caped; 4 d'ys after, ou passing a probe, 4 oz. of water.
29	—	« 8 m	Began at 4th m'th	Screamed very often; slight convulsions ; oc-casional vomiting ; dis-tortion of eyes down-wards.	—	Two	4 + 3=7	Improved appear-ance followed im-mediately.
30		7m	Began at 2d month	Good health.	19 1-6 inchs in circum-ference.	Two	20 + 284=484	Pale, cried slight-ly after 1st; pale, did not cry after second.
31	F.	12 w	Began in	Fits of crying a fort-	I64 inches	Five	12 + 12+5 +	Crying ceased;
		Id	3d week.	night after birth con-tinued to recur, but without convulsions or strabismus.	in circum-ference.		8 + t>=53	child seemed more comfortable.
32	M.	—	—	—	__	Five	484	
33	M.	—	—	—	_	Four	45	
34	M.	—	—	—	_	Two	20	
35	M.	—	—	—	_	One	8	,
36	M.	—	—	—	_	Two	22	_,
37	M.	—	—	—	—	Two	17	_
38	F.	—	—	—	—	One	n	__
39	F.	—	—	—	_	Four	33	
40	M.	15 m	Began at 5th m'th.	Inward fits lio«n birth: emaciation at a fort-	26 inches in circum-	One	16	Cried much; slight fit immediately after.
				night; increase of head and fits at 5 mo.; gen-	ference.			
				eral health improved				
				until 14 months, then				
				fits more frequent, and				
				child wasted more;				
				but appetite very good.				
41		6 m		Comatose, moaning,	20 inches	Five	10 + 10 +10+ 10 + 10=50	Aroused in a
				pupils dilated, insensi-	round.			marked manner
				ble ; no strabismus.				after each opera-tion.
42	M.	17 m	15 m.	Blind; pupils natural	274 inches	One	20	No change.
				size, and sensitive	round, I84			
				to light; constant roll-	over vertex			
				ng of eyes; fluctua-	Tom ear to			
				ton of head; veins	ear.			
				distended.				
 
WHICH PARACENTESIS WAS UNSUCCESSFULLY PERFORMED   .        23
Subsequent Progress.
Date of Death.
On day after the escape of the
 fluid, slight convulsions, eyes
 less distorted,  but child be-
 gan to  sink,  whined,  then
 threw its arms about.
On evening  of 4th day  after
 first   tapping,  child   grew
 dull;   respiration   hurried
 and death took place before
 midnight.
After  2d  puncture,  cerebral
 symptoms  came  on,  head
 being  smaller.   Head re-
 gained size in 10 days  after
 1st puncture.
Occasional  fits for  ten  days
 after  2d puncture ;  then fre-
 quent screaming,   and in-
 creasing  weekness, without
 fits, till 2 days before death,
 when theyreturned frequent-
 ly
6 th day after
 puncture.
Some congestion of membranes ; near
 puncture ; brain quite white,  very
 soft; ventricles immensely distend-
 ed ;  cerebral   substance   seemed
 macerated,  infiltrated with water;
 parts in ventricles undistinguishable;
 nerves at base soft; cerebellum large,
 soft; cavity in its centre ; no trace
 of arbor vitae.
4th day after
 1st, 3d after
2d puncture.
24 days after
1st, 24 after
2d puncture.
15 weeks after
1st puncture, 5
w'ks after last.
Daily fits for 4  days.,  with
 more sluggish condition than
 before.  In 7 days,  head as
 large as before the puncture,
 to the  repetition of which
 parents would not consent;
 refused food ;  diarrhoea  for
 7 days ; emaciation, increas
 ed weakness; death,
Strapped head with adhesive
 plaster, fluid rapidly regen-
 erated, no change  of symp-
 tom.
Fluid continued to flow  from
 wound ; on 4th day was more
 restless; spasmodic closure
 of hands ; head more tense
Condition of the Brain after Death.
Twenty-nine ounces of clear  fluid in
 ventricles, which were lined by  a
 brownish mucus ;  ceptum lucidum
 thickened ; small tubercle at decus-
 sation of optic nerves. J
17 days after
the puncture.
 5 weeks after
1st, soon after
last operation

 6th day after
  operation.
Authorities.
  Dr. Schaeffer,
Casper's Wocben-
 schrift, Aug. 19,
      1837.
 Dr. Watson  in
Tweedie's Lib. of
j [Med. p. 147.

   Malgaigne,
  l'Experience,
 Nov. 19, 1840.
Dr. Coldstream,
 Edin. Monthly
 Journ. of Med.
Sci. April, 1841.
Seventy-five  ounces of fluid in the
 ventricles, and infiltrated into brain,
 which was split up into layers form-
 ing  several  distinct  pouches;  the
 walH  of  these  pouches were  not
 formed by false membrane, but were
 all continuous with the corpus callo-
 sum, into which their fibres might
 be  traced;  cerebral   substance  at
 base had  a  jelly-like appearance ;
 optic nerves  much spread out;  fluid
 infiltrated between fibres of cerebel-
 lum.

Convolutions flattened; cerebralsub
 stance  half an inch thick; pint of
 clear fluid in ventricles ;  no signs of
 inflammation from  operation.
Hemispheres mere sacs, the parieties
 being an inch  thick; convolutions
 obliterated;  4  pints turbid serum in
 ventricles; cortical and  medullary
 matter  lost where  most  distension ;
 cerebellum, pons  varolii and mudulla
 oblongata natural.
  Dr. Conquest,
 Lancet, March
> 17, 1838;  and
 Med. Gaz.  vol.
   xxi. p. 967.
The writer.
  Dr. Parkman,
Am. Journ. Med.
 Sci., Oct. 1848.

   Dr. Pepper,
Quar. Sum.Trans.
of Col. Phys. and
  Surg., Phila.,
    vol. iii. 
24
TABULAR VIEW OF  CASES OF INTERNAL HYDROCEPHALUS IN
No.


~43
44
Sex.
Age

«"y
3 m
45
46
F.
4 m
47
48
49
50
12 y
9 w
9 m
Duration
   of
Disease.
3 m.
 Con-
genital.
 Con-
genital.
 Con-
genital.
7w.
8 m.
Symptoms before
   Puncture.
Head hotter than natu-
ral; nursed well; wake
fulness at night; aver-
sion to light; axes of
vision formed an angle
of 90 ° from pressure
of fluid.
Head diaphanous; e]
rolling ; pupils dilated;
slight strabismus ; no
convulsions.
Obstruct'd labor; punc-
tured head.
Drowsiness ;  in other
respects well.
Vomiting and drowsi-
ness.
Size of
Head.
No. of
Punc-
tures.
27 inches
 round,
15 over
 vertex.
294 inches
round,  194
ov'r vertex.
19| inches
in circum-
 ference.
8 between
March  and
   Aug.
24 inches
in circum-
 ference.
One
Two
Two
One
Quantity of
  Fluid.
32
8 + 14=22
4 + 64=104
a One
Nine
One
32
 4 to 40 each"
time =143
89 ozs.
9 ozs.
Immed'e Effect.
Fulse free; ap-
peared better. 
WHICH PARACENTESIS WAS UNSUCCESSFULLY PERFORMED.          25
Subsequent Progress.
Began to sink in a few hours.
Applied compress and adhe-
 sive plaster; fluid continued
 to flow; bandage; urine more
 free ; 12 days after operation
 child better, and  continued
 to improve for about 6 weeks
 when fluid again began to
 collect; in two months  2nd
 operation, after  which it
 failed gradually.
Went on favorably for several
 days; died comatose.
Applied bandages ;  2d  day
 better ; 3d day fever, head
 hot, convulsive movements:
 4th day much#better, no stra-
 bismus, movement  of limbs
 and head  free, no fever, ap
 petite  good,  size  of  head
 diminished; 8th day improv-
 ing  markedly ;  took  cold,
 died on 9th day of a bron
 chitis.
Wound healed readily  ; child
 thrived for 23 days ; had con
 yulsions from re-accumula
 tion of water.
Symptoms improved after 1st
 6 operations ;  water rapidly
 re-collected each  time in
 large quantities.
Date of Death.
36 hours after
operation.
53  days after
first puncture ;
 20 after last.
9 days after
 operation.
Condition of the Brain after Death,
No injury to any part.
Strong  marks  of inflammation  of
 meninges ; brain a mere pulpy sac ;
 with scarcely a trace remaining of
 parts usually found in cerebral dis
 sections ; cerebellum unaltered.
Authorities.
23 days after
operation.
4 months after
first operation
9 m'ths 1 w'k
after 1st opera-
tion.
6 days after
 operation.
Fontanelles sunk;  head  224  inches
 round, 154 over vertex ;  no signs of
 inflammation ;  cerebrum spread  out
 like a sac, being \ of an inch  thick.
 but  of natural consistence ; no con-
 volutions ; corpus callosum or sep-
 tum  lucidum found ; base of brain
 normal.
No signs of inflammation ;  one quart
 of water in cranium.
Mr. Taylor, Lon.
Med. Gaz. 1850,
 Dr. C. A. Lee,
N. Y. Med.  and
Phys. Jour.,  vol.
      vi.
Mr. Chater.Prov.
 Med. and Surg.
 Journ.,  1845.
Air. Totlow, Lan-
cet, p. 100, 1839.
No  marks of  inflammation  about
 wound.
Lat. ventricles formed one  cavity ;
 absence of fornix, septum lucidum
 corpus callosum and choroid plexus;
 corpora striata and optic thalami flat-
 tened ; cerebellum soft;  nerves all
 perfect.
Convolutions on upper  surface oblit-
 erated ; brain formed a large bag :
 central white  parts absent, as well
 as  corpus callosum, fornix, septum
 lucidum, fifth ventricle, and choroid
 plexus; optic  thalami and  corpora
 striata  flattened,  and  of  unnatural
 appearance; medulla oblongata, cere-
bellum, pons varolii, and crura cere-
bri, healthy and hard.
Dr. Rose, Am.
 Med. Record,
   vol. 13.
  Dr.  Smyth,
Miscel. Contribu.
  to Path, and
 Therap., 1844.
Battersby.
 Battersby, Ed.
Med.  and Surg.
 Journ., vol. ii.
     1850. 
26        TABULAR VIEW OF CASES OF INTERNAL HYDROCEPHALUS IN  !»  > >
No.	Sex. M. M.	Age 8 m 14m	Duration of Disease.	Symptoms before Puncture.	Size of the Head. ■	No. and Date of Punctures.	Quantity of Fluid in lbs and. ou ices.
51 52 53			6 in. 6 m.	Fretful ana leveiisu ; diarrhoea and costive-ness alternately ; final-ly squinting and con-vulsions. Tendency to coma; tremul'us eyelids; slow pulse; stertorous breathing; strabismus: Blindness; partial par-alyses; face contorted; extremities placid.	23 inches round, 14 vertical.	One 1, April 6. Three	5 viij of a reddish fl'id. 3jxvi limpid. 12+8 +
  In relation to the first 16 cases in  this table which are
reported as successful, (and the same remarks are applicable
to the three cases which we have added,) Dr. West  very
properly observes that  chronic hydrocephalus  is a disease
usually slow in its  progress, and intermittent in its advan-
ces, occasionally pausing for months, or even years,  and then
increasing without any evident cause ;  consequently, before
any case be admitted  as cured, it  must be shown that  a
considerable time has elapsed since  the operation,  and that
during this  period the  health of the patient has been per-
fectly good.  The cases which he has  collected he regards
as affording but little encouragement to resort to it, as might
be expected from the appearance frequently presented  after
death,  as in many cases there exists  serious organic disease
or malformation of  the brain itself, " though no  symptom
during life had  betrayed the  existence of a condition which
mechanical interference could only aggravate."
   Dr. Watson,  on the   other hand, employs very  different
language in reference to this operation.  In his  Lectures, p.
284, Am. Ed., he remarks:  " He  must have  been a bold
physician who first  proposed to  decant  the water from the
brain, by means of a perforation, made with a trocar, through
the membrane  of the  fontanelle, through the membranes of
the brain, and through even the expanded cerebral substance
itself.   But the success of the project has amply vindicated 
WHICH PARACENTESIS WAS SUCCESSFULLY PERFORMED.          27
Subsequent Progress.	Date of Report.	Authorities.
Blood oozed from nostrils for 24 hours ; bandage ; gave aperients and nourishing diet; former symptoms gradually disap-peared. Left wound open, and about 4 pints fluid gradually drained off, with gradual con-traction of head and closure of open spaces. Paralysis disappeared jcountenancenatural; head diminished; sightreturned; strabismus ceased ; regained her natural playfulness.	Seven years. Four months. Several months after operation died of typhoid fever.	Dr. Edward, Monthly Journ. Med. and Scien., 1846. Mr. Kitsell, Prov. Med and Surg. Journ., 1849. Dr. Howard, Trans. Med. Journ., 1852.
this happy audacity.    Though denounced as useless and
cruel by some high continental authorities, by Golis and
Richter  especially, it furnishes  one of the  best of the few
chances of safety to the patient.   Of course, I mean ultimate
safety, for the  operation itself is attended with the present
risk-of accelerating the patient's death. We have to consider
that, by performing  the  operation, we incur the danger of
abbreviating the existence of a  being whose life without it
could scarcely be long continued, or capable of enjoyment,
but then  we  afford some  chance of a perfect  cure.  A
speedy  death,  or  an uncertain  life of mental  and  bodily
imbecility,  or  complete  restoration—these are the  three
events to be looked at. Had I to decide the painful question
in reference to  one  of my  own children,  I  would  accept
the alternative  of  probable speedy  death  on the one  hand,
or possible complete recovery on the other."
   Malgaigne, after examining a great number of facts bear-
ing upon this question, comes to the conclusion:  1st, that
the operation may be tried when the patient is from three
to four months old,  and the disease appears to be stationary;
2d, after this  period, when the disease  is  evidently in-
creasing and threatens the life of the patient.   (Bull  de
Thcrapcutiquc, 1840.)
   Dr. Copland  observes,   " While,  therefore, I so far agree 
28
Blackman on Paracentesis in
 with  those  who  argue for  the  operation, as  to  advise
 it to be  tried after the  measures  I  have  detailed  above
 have failed, yet I  would  not recommend its performance
 early in the disease: 1st,  because medical treatment has
 then sometimes  effected a cure, especially  when the head
 has  not been  very greatly enlarged ;  and  2dly,  because,
 when the fluid is  in the ventricles,  as it generally is in
 cases commencing  after birth, a greater depth of  brain must
 be penetrated to reach it at an early than at a later period."
 (Dictionary of Practical  Medicine, vol. i., Am. Ed., p.  779.)
   Dr. Charles A. Lee has advised a resort to puncture of the
 ventricles, even when to effect this object it is necessary to
 pass the instrument to a great depth.  A puncture  of the
 ventricles in cases like our own is not a matter of difficulty,
 as the  distended ventricles formed  together one vast cav-
 ity.
   Dr. Joy, in the Cyclopedia of Practical  Medicine, vol. ii.,
 Lon. Ed., p.  478, thus expresses his opinion on the subject :
 " There are a few cases on record where it  has appeared to
 effect a cure, and several where it has palliated the symp-
 toms.   In cautious hands, and where only  a moderate  quan-
tity of water is drawn off at  a time, it has rarely been attend-
 ed with any  danger.  In cases where all other kinds of treat-
 ment have been tried  without benefit, this is, perhaps, not
 altogether to be rejected."
   Rilliet  and Barthez, Barrier  and Legendre sanction the
 operation only in cases of hydrocephalus  arising from san-
 guineous effusion into the  arachnoid  cavity, a form of the
 disease  by all authorities admitted  to  be rare.   In cases of
 acquired chronic hydrocephalus, resulting from a  cerebral
 tumor,  or a profound alteration of the brain, they  would not
 recommend it.
   Mr. Fergusson regards the operation as worthy of trial, and
 relates several instances in which it has been performed by
 himself and his friends.  He states that, although his own
 experience does not enable him to be very  sanguine of great
 success from this proceeding, yet that which has been ob- 
Chronic Hydrocephalus.                29
tained by others is, in his opinion, a sufficient sanction for a
continuance of the practice in all "favorable-looking cases."
(Practical Surgery, 3d Lon. Ed., p. 556.)
  DiefFenbach is strongly opposed to the operation, having,
during the  earlier part  of his professional career, had three
unsuccessful  cases.    Although success may in  some  few
cases have  followed it, yet on the whole he is disposed  to
consider them as fortunate escapes, like those  which have
been recorded in which a sailor  recovered after a ship's an-
chor had passed through  his  abdomen, or  the shaft of a
cabriolet had pierced the thorax of a coachman, &c,  &c,
upon which cures a surgeon has  no right to calculate.  (Oper-
ative Chirurgie,  Zweiter Band, Leipzig.   1848, p. 9.)
  Dr. Battersby states that he is acquainted with ten case®
in which the operation has been unsuccessfully tried in Dub-
lin, and there can be  no doubt that a large mtmber of fatal
cases remain, and will ever remain unknown.  We have been
informed by Prof.  Stevens Parker, Dr.  Watson, and  others
in this city, of  several cases in which the operation has not
averted a fatal termination.   Still, we feel persuaded that, in
cases similar to our own,  and for the end proposed in this
case, a surgeon would be justified in resorting to it.
  Having thus noticed the sentiments of some of the most
prominent  authorities as to  the propriety  of  resorting  to
puncture in chronic hydrocephalus, we would remark, in con-
nection with the cases collected by ourselves and appended
to the table  of Dr. West, that they do not materially affect
the conclusions to which  this  distinguished physician had
arrived.  In our own case, the operation was not performed
with the expectation of effecting a cure.  The very idea of
the thing would have been perfectly absurd.
  One word as to the proper instrument to be employed  in
this operation.   Dr. Watson states, op.  cit., p. 236, that  he
once requested a surgeon to perform it  upon a child, and, to
their horror, when the trocar was withdrawn from the canula,
"instead of clear serosity, a  fine stream of purple blood
spouted forth.   We naturally thought  it was all over with 
>
5?