> V, -y>f*M .  - '
■3-r**". 
UNITED STATES OF AMERICA
*** *  .
FOUNDED  1836
WASHINGTON,  D.C.
B19574 
 
 
            ESSAYS
                  ON

THE  DISEASES OF  CHILDREN.
                 WITH

     CASES AND DISSECTIONS.
       VOLUME SECOND,

             CONTAINING

ESSAY HI.....ON HYDROCEPHALUS ACUTUS, OR
        DROPSY IN THE BRAIN.
     B Y JOHN CHE YNE, M. D.
Fellow of the Royal College of Surgeons of Edinburgh.



          PHILADELPHIA .-

    PUBLISHED BY ANTHONY FINLEY,
        AT HIS MEDICAL BOOKSTORE.
            Merritt, Printer.
              1814. 
 
AN  ESSAY
ON
HYDROCEPHALUS  ACUTUS,
OR
DROPSY IN THE  BRAIN.
        BY JOHN CJIEYNE, M. D.
Fellow of the Royal College of Surgeons of Edinburgh.
      PHILADELPHIA .-
PUBLISHED BY ANTHONY FIXLEY,
    AT BIS MEDICAL BOOKSTORE.
        Merritt, Printer.
          1814. 
 
                    TO

        MR. CHARLES BELL,

            SURGEON IN LONDON,

  FELLOW OF THE ROYAL COLLEGE OF SURGEONS
          OF EDINDURGH, &c. &c. &c.

              IN TESTIMONY

OF RESPECT FOR HIS HIGH PROFESSIONAL TALENTS ;

        OF ESTEEM FOR HIS CHARACTER;

                    AND

     OF GRATITUDE FOR MANY OBUGATIONS;

          THIS VOLUME IS INSCRIBED

                   BY HIS SINCERE FRIEND,

                         JOHN CHEYNE. 
 
PREFACE.
   I have now, in separate Essays, considered all
 the diseases peculiar to the stage  of life between
 weaning and puberty; with the exception of Cho-
 rea Sti. Viti.  That disease I have not ventured
 to discuss, because never in my own practice
 have I witnessed a fatal case of it, and from the
 first, I resolved not to enter upon the pathology
 of any disease, in which I could not compare the
 observations of others with my own.
   It is not my design, to propose this as a work
 for general use; but to call  the; attention of the
 profession,  whom  alone I  address, to a subject
 of great difficulty.   What I have  attempted,  has
 been with a full consciousness that our knowledge
 of this disease is  very imperfect; that it has not
 yet been  sufficiently investigated; that  many of
 the facts are not yet ascertained; and that it is the
 duty of a physician, no less than of a  sound phi-
 losopher,  to be cautious in the admission of hy-
potheses,  industrious and careful in the collection
of materials.
   As we  are thus only in the  stage of collection,
and not advanced  as yet to that  ci' theory, my
chief  hope  of being useful rests on the ca^< s
                       A 
6
which I have been enabled tc-lay before the pro-
fession ; and on the results, neither rash I hope
nor unimportant, which I have ventured to draw
from  them.   These cases are not recollections;
nor were they ever in danger ofbeing altered,  or
even coloured by any prevailing or favourite doc-
trine.  They were invariably drawn up in the bed-
chamber of the patient, and present a faithful ac-
count of every symptom and circumstance that
attended  the disease.  They may, perhaps, ap-
pear to others to authorize conclusions different
from what I have drawn: my reasoning may be
wrong, but  my facts may be implicitly relied on.
  These cases  were drawn up at first with no
view to publication;  but with the design only  of
establishing, for my own guidance in practice,
the symptoms that distinguish this disease from
the febrile attacks which it so frequently resem-
bles.   With this intention, I suffered no case  to
pass without the most minute consideration. And
in the progress of several years, my notes seem-
ed to me to suggest several circumstances inci-
dent to Hydrocephalus,  which were  worthy  of
being more distinctly marked than they had been
hitherto,  and in this view, not  undeserving  of
public attention.  But  perhaps the  best lesson
that I have learnt, certainly  that which I  would
most seriously impress on the profession, is the
strict attention with which the earliest symptoms
of the disease should be observed. 
ESSAY III.
                   ON

HYDROCEPHALUS ACUTUS.
    Hydrocephalus  Acutus,*  the  disease
which is the  object of the  following pages far-

  * With Burserius I denominate this disease Acute Hy-
drocephalus, and I recommend in preference a term by
which all v?gue theories of the disease are avoided, one
too which conveys  a practical distinction, which, it would
seem, is requirecl.  Nothing is to be neglected which can
assist us in attaining greater accuracy and simplicity in
distinguishing and treating this disease.  I have no hesi-
tation in saying that, in general, no cases are more loose-
ly reported than those of Hydrocephalus.  Cases are pro-
duced, as examples of this disease, which had lasted ma-
ny months.  Instances of successful treatment are given,
where the history of the symptoms leaves us altogether in
doubt as to the existence of the disease.   Instances which
(where a point of practice is to be  established) ought to
have no admission as evidence are brought forward.  For
example, it is merely said that the patient had most of
the symptoms of the inflammatory stage  of dropsy of the
brain.  Symptoms not pathognomonic are often trusted
to as indicating the nature of the disease, such as the size
of the head, &c.   Gaping of the sutures,  fluctuation, and
other symptoms of chrome Hydrocephalus, are mixed
with the essential.symptoms of acute  Hydrocephalus. 
b*
 ilier to  illustrate,  occurs chiefly  in childhood.
 It is attended with  pyrexia, and with symptoms

   It would appear almost unnecessary to distinguish this
 disease, the  apoplexia Hydrocephalica of Cullen, from
 the Hydrocephalus (g. lxxvi.) with the gaping sutures,
 as it is already clone by medical writers,  particularly by
 Dr. D. Monro, Quin,  Sec. but the  following quotation
 from the last manual of practice published by a respecta-
 ble physician in London in 1805, a book adopting the ar-
 rangement, and for the most part the definitions of Cullen,
 will enable me to apologize to the reader for the interrup-
 tion.  We find Cullen's definition of apoplexia Hydroce-
 phalica, viz. Apoplexia Hydrocephalica paulatim adoriens;
 " infantes et impuberes, primum lassitudine, febricula, et
 "  dolorc capitis, dein pulsu tardiore, pupillae dilatatione,
 i; et somnolentia afficiens," with the compiler's addition,
 ■"* Hiantibusplerumque cranii suturis;" and after deliver-
 ing the history and  cure, he observes, " The progress
 " of this disease is sometimes very gradual, and the head
 " enlarges progressively;  in  the acute state,  I have at-
 " tended several cases, in which  the sutures have been
 " perfectly closed, the bones of  the cranium perfectly
 " ossified, and the head not larger than natural, and, upon
 k' examination after death,  several ounces of a watery fluid
 '<■ have been found in the ventricles of the brain; there-
 !< fore it would appear,  that the character of the disease,
 i{ as given in the Nosologia of the III. Cullen, is not suited
" to all cases."  It is  unnecessary to comment on this.
 Cullen properly separates the two diseases; but the con-
fusion is revived by this endeavour to identify them.   I
have not a doubt that this gentleman will excuse the liber-
ty which I have taken,  and in a future edition of his work
 correct this error. 
                        9
 indicating a diseased  state of the sensorium.  It
 generally terminates in death, when, along with
 other morbid appearances, the  ventricles of the
 brain are found enlarged and full of lymph.
   Hydrocephalus was not known as a distinct dis-
 ease before the year 1768, when a full and accu-
 rate history was published by our celebrated coun-
 try man Dr. Why tt.   Since the publication of Dr.
 Whytt's treatise,  the disease  has engaged the
 attention of many  eminent physicians,  both in
 Britain and on the continent; yet the subject is
 so far from being exhausted, that  the disease is
 universally  admitted,  both in pathology and  in
 practice, to be still involved in great obscurity.
   Authors have acknowledged the extreme diffi-
 culty of drawing up a  distinct account of Hydro-
 cephalus.  They have been unable  to fix  what
 ought to be considered as the leading symptoms,
 and  have warned us to expect, in practice, great
 deviations from the histories which they have de-
 livered.  After  much experience and long con-
 sideration, although I  felt these  difficulties,  I
 began to entertain  hopes  that  they might  in a
 great measure be removed  by arranging, under
distinct classes,  the various forms which the dis-
ease assumes.   This I have attempted, and I am
convinced that the following classification is  n^t
                      a 2 
10
.•rtiiicial nor arbitrary,  but that it has a founda-
tion in the nature of the disease.*
   I. In that class of the disease which I am first
to describe, we find, that before any characteris-
tic signs of the disease appear, the child for some
days, or even weeks, has complained of pains in
his head or belly, while at the same time he has
been slightly  feverish, dull,  ill-complexioned,
without  appetite, or  perhaps with an  increased
appetite, and with considerable disorder in all the
functions of the abdominal viscera.  These com-
plaints arise gradually,  but are seldom  alarming;
and the child's friends are not awakened to a sense
of his danger, until, advancing a step farther, the
commencement of a peculiar disease has more dis-

   * In No. IX. of the Edinburgh Medical Journal, I find
a great coincidence in observation.  A Continental phy-
sician, whose work I have not  had the good  fortune to
procure, has divided  this disease into three species, in
many respects resembling those forms of  the disease
which I have described.   To avoid the charge of plagia-
rism, while the Journal was wet from the printing-office,
I carried my notes, which in this part were complete (the
Essay copied fairly for publication being then in the hands
of a friend  in England) to one  of the  ingenious editors,
and read to  him verbatim the history which is subjoined.
The candid reader, even without this explanation, when
he views my cases, the selection  from  many years prac-
tice, would, I think, admit that my observations are from
nn original  source. 
11
tinctly  shown itself.  The dullness and severe
pains in his head are now accompanied,  perhaps,
upon getting up  in  the  morning, or after he has
begun to stir about, with. vomiting.  Yet  even
this symptom is often disregarded until the se-
 cond or third day of its recurrence, and the dis-
 ease  has  made considerable progress before the
 illness  of the patient is suspected to arise from
 a disordered condition of the brain.
   When the attention is more particularly excit-
 ed by  these  symptoms, the  headach (chiefly in
 the forehead) will be found  to return at shorter
 intervals.   The child often affectingly complains
 of his  head.   He sighs frequently, is  dull, his
 head requires to be supported; he complains of
 weariness in his eyes; the pupils sometimes ap-
 pear unusually contracted, and he has an aversion
 to light.   His tongue is white, and his belly ge-
 nerally costive;  the stools are at first clayeypas
 the disease advances they become of a gelatinous
 consistence,  dark green, of a sickly smell, some-
 times as  dark as tar.  The pulse becomes quick,
 and at  particular times of the day these symptoms
 are attended  with febrile heat and irritability, and
 the child complains not only of headach, but of
 pains in  different parts of the body, sometimes
 astonishingly acute.  At one time  he  complains
 of pains in his limbs,  at another of pains  in his 
                      12
breast, or in the nape of the neck, very  often in
his bowels;  and before the anxiety of his friends
can make any preparations to relieve him, the
pain is gone, or fled to some other part; at ano-
ther  time he for a long time lies on his mother's
knee, restless  and whining, as  from dull rheu-
matic  pain.   These disorders cannot  continue
without impairing the child's strength; and ac-
cordingly in ten days or a fortnight, the period
usually occupied by the  first stage of this attack,
he is altered in appearance; in his manner he has
become peevish and undecided; his hand tremu-
lous; and his gait tottering.
   II. In the second form of  the attack the dis-
ease  runs a  more rapid  course.  This does not
occur  so frequently, yet it  is  well  entitled to
the attention of every one wishing to gain a clear
conception of Hydrocephalus.  After the  child
has  been drooping for a short time, which,  al-
though it sometimes escapes observation,  is ge-
nerally recollected,  there is a sudden change to a
fever, attended, even from the first,  with a great
degree of pyrexia,  with frequent,  but short, and
irregular remissions, flushing,  severe  headach,
tenderness  all  over the abdomen, and increased
sensibility, with sometimes brilliancy of the eyes.
It is said to be often difficult immediately to dis-
tinguish Hydrocephalus  from fever, and this is
the form  of the disease  in which there  is the 
IS
greatest resemblance between the two diseases;
but  we are led to  suspect some deeply-seated
evil, from  the frantic screams,  and complaints
of the  head  and  belly,  alternating with  stu-
por,  or   rather lowness;"* and  we are  struck
with  the  irritability  of the  stomach, in a de-
gree  beyond  what  we find in  fevers of this
country,  retching  and  vomiting  being  often
brought on by a change of posture, certainly by
every attempt to sit up in bed; and with the dis-
ordered  state of the bowels  which  attends this
irritability of the  stomach.   And when at any
time the child has a little respite from the violence
of these symptoms, we  find our suspicions con-
firmed by his look;  for,  in this disease, when the
features do not express pain or terror,  there  is not
unfrequently an expression, which it has, in com-
mon  with some  other  diseases  of the brain, of
dejection,  bordering upon insensibility, which is
quite insupportable to those who are interested in
his recovery.
   III. I have observed less frequently than the
first case, yet I think more so than  the  second,
what  I mean to describe as the third  form of the
disease.   It may be considered as an instance of

  * This lowness, however, differs  from what  occurs
only in the last stage, viz a state resembling the coma
vigil of fevers,  as when roused, or spoke  loudly to, in
general the answer to each question is ready and collected 
14
that conversion  of diseases,* which arises either
from the excess or combination of the symptoms
of the original complaint, operating upon a habit
favourable to the new disorder, or perhaps from
the state of  the  habit  produced  by the primary
giving rise to the consequential disease.   When
hydrocephalus arises  after an imperfect state of
health, as where there had  been a  scrophuious
action which has abated; or where,  from predis-
position  and  the anomalism of  the symptoms,
such action  is looked for; or where  the child has
had some epidemic disease formerly (perhaps ma-
ny months  before) from which he has not per-
fectly recovered, or  regained sound health;  the
attack is sometimes made with all the violence
which  I  have described as distinguishing the se-
cond form.   When, again, the attack  comes as
the sequel of an acute disease, as fever, hooping-
cough, perhaps dentition, or during some actu-
ally existing scrophuious disease, then the child
almost imperceptibly slips into  Hydrocephalus; f

  * See the ingenious paper on this subject by Dr. Fer-
riar, of Manchester.
  t< Perhaps  had I not been misled  in these  cases by
my security as to the nature of the previous disease, I
might more early have detected some Hydrocephalic ten-
dency.  I have reason to think, in one case of this varie-
ty, that the symptoms  were not unlike those described
in the first form of the attack;  but they were thought
symptomatic  of the original disease.  In some cases, even 
15
there are scarcely any of the acute symptoms; and
the palsies or convulsions are the first indications
of the new disorder.*
   The situation of the child is not yet absolute-
ly desperate;  for, after the appearance of most,
or even all of the symptoms enumerated in speak-
ing of the two first forms of the disease, the con-
stitution is  not always  subdued.    Instances  are
recorded,  in which, without the use of any active
medicine, the disease  has gradually  abated, in-
stead of running a fatal course, f

had I been on my guard, I think I scarcely could have
pointed out the precise time when the change from the
one disease to the other took place.
   *  Instances of Hydrocephalus  unattended  with  pain
are mentioned by authors, and have repeatedly occurred
in my practice.   Dr.  Quin takes notice of a case, where,
during the child's illness, no more symptom suggested
any suspicion of the real cause of the child's death ; but
when  the body was examined, a large  quantity of water
was found within the  ventricles of the brain.  See also
Case XX, App. to Dr. Quin's Treatise, which is of this
kind.   It is a case of conversion from a scrophuious dis-
ease of the mesentery.
   t Dr. Watson, 4th vol. London Medical Observations and
 Inquiries, relates  the case of a boy who recovered from
 the last stage of Hydrocephalus.  If we except a blister,
 the medicines used were of little activity.   And for four
or five daysafter the blister wasappiied, every symptom
increased.   We may conclude that Dr. Watson did not
 place  much to the account of the medicines which were 
16
    Of cases under the  first two classes now  de-
 scribed, I shall add examples of recovery: those
 which I have attended of the third class,  with but
 one exception, ended fatally,  and I presume re-
 coveries are  very rare.   I consider the first form
 of the disease as the  most  favourable ;  perhaps
 the second  might be equally favourable,  were it
 seen and detected early ;  but  I conceive  that, in
 cases of the  second class, the first two  or  three
 days are  decisive, and these are  generally lost.
 The second form of  the  disease is the most uni-
 form  in its progress;  in  the  examples which I
 have seen, not only the first, but all the stages, were
 distinctly  marked.   I would have  it understood,
 that the distinction which I have made is chiefly
 applicable to  the attack ; in the latter stages of the
 disease, there is little diversity in the symptoms.
   But,  in all the stages  of this disease,  we  see
 proofs  of irregular excitement; these indeed be-
 come more conspicuous as the disease advances,
 but are often observed, even in the  early part of
 the disease : at one time  the pulse is quick and
 prescribed,  for his deduction  from the case is, that " it
 " may sometimes happen, as in the present instance, that
 " nature, although but moderately assisted^ will enable  the
 " sir.k to struggle through diseases  beyond our  most
" sanguine expectations."
  Dr. Willan» Vid. Reports on the Diseases of London, fi.
269. tells us of a child who recovered, after being  aban-
doned to his fate." 
                        IV

throbbing; tiie  heat of  the  body is increased;
the  skin parched; there is a deep blush on the
face, or on one cheek ; and the breathing is sigh-
ing, laborious, and quick: at another time the
blood circulates  more equably ; the skin is of  a
natural warmth, or moist with perspiration; the
countenance  is pale; and the  breathing so soft
that it cannot  be heard.   The appetite and the
thirst vary ; sometimes exhibiting nearly a natu-
ral state of the stomach; at other times the  hea-
vy smelling  breath,*  which has  been supposed

   * Dr. Whylt has remarked a sickish and most offen-
sive smell of the breath, which he never had observed in
any  other distemper.   Another author has observed,
tl  Aer e pulmonibus  saepius  magisque quam in aliis
"  aegris faetidissimus est."  This smell is perceivable in
many disordered states of the stomach, which, perhaps,
are connected with a peculiar state of the skin.  It is the
same smell which is perceived in the  beginning of the
exanthemata.  I have observed a smell resembling it in
several dropsies, in  diabetes, both  in  a case which was
under my care in the surgical ward of the  Royal Infir-
mary, and in the case of Captain  M. who afterwards re-
covered while  under the care of Dr. Rollo.   It also has
some resemblance  to the  breath of a determined dram-
drinker, before he has commenced his potations for the
day.
   How does the breath become impregnated  with this
odour ? From the lungs, I suppose; not, I should think, from
the pharynx.   It certainly cannot arise immediately from
the stomach ; and yet, in  a case which was  lately under
my care, of great sickness  at stomach,  with acute pain
                        R 
18
peculiar to this disease, the total absence of ap-
petite, and constant  vomiting,* even  for  days,
show the stomach to be in the greatest  disorder.
The bowels are never regular.; they are general-
ly slow, requiring cathartic medicines; and now
and then a constant  and severe  bilious purging,
attends the vomiting.   The urine is sometimes
withheld for twenty-four or thirty-six hours ; yet
I have  had a  patient with  a  constant  desire  to
pass urine, which was voided  with excruciating
pain, and  always  followed by great increase  of
the pain of the head.   And not only  are the vital
and natural functions irregular; we find the  same
extremes  in the  animal functions :    To this in-
deed the diseases of the brain owe much of their
interesting character.   The senses and judgment

in the abdomen, furred tongue, and purging, every thing
rejected from the stomach had this smell in a most offen-
sive degree. This  odour  would seem to attend other
cases of debility, after violent excitement of the stomach.
A boy swallowed some soap-ley; his stomach was much
injured, and he escaped only with his life: on the third
day after the accident,  his breath was strongly  impreg-
nated with this disagreeable odour.
  * Dr. Fothergill  says that  the sickness and headach
alternate.  I have not, from my own observation, had
this  confirmed. But, as the remark is repeated  in Dr.
Quin's work, I cannot  doubt its accuracy.  I have ob-
served the head and belly complained of,  as if the pain
had suddenly struck both at the same instant; and, once or
twice, upon the pain suddenly leaving the belly, it was
complained of in the head. 
19
are often perfect and entire,  sometimes morbidly
acute ; in general,  the retina is painfully sensible
to light,  and the child is sometimes  unpleasantly
affected by slight sounds;  on the contrary,  some-
times, even in the early days of the disease, the
mind is subdued, and there is  the greatest dull-
ness  of apprehension.   Towards  the end  of the
disease, after delirium,  convulsions, and  insen-
sibility, I  have once or twice been surprised a
little before death to find a complete return of in-
tellect.
   Dr. Whytt, and after him other  authors, ob-
serving in Hydrocephalus the  remarkable varia-
tions which  often  take  place in the state  of the
pulse, have divided the disease into three stages,
of each of which the peculiar condition of the cir-
culation  is  made the leading  symptom.   And,
doubtless,  it generally- happens,  that after the
signs enumerated in describing the attack  of this
disease have continued for a  certain time, the
pulse changes,  becoming  first  unequal and ir-
regular,* and then slow, but doubled by the least
exertion; and with the  slow pulse there is gene-
   * There is often this peculiarity in the pulse.   It
beats, perhaps, ten or twelve strokes at the rate of 60, and
the next six or eight at the rate of 100.  The same kind of
pulse has been observed after poison had been swallow-
ed.  At a first visit, when  I had found the child asleep,
I have several times detected the disease by this state of
the pulse. 
20
rally a greater degree of dullness, and  more tor-
por ;  at first,  the pain in the head does not abate,
nay, I have known  it increase; but  when the
slow pulse has continued for some time, the pain
is less complained of.  And now we  observe a
very dilated pupil, and a want of consent between
the eyes, attended with imperfect, and not unfre-
quently double vision; the child is no longer able
to sit up, even for the shortest period;  there is
a dosing state,  interrupted by startings, and short
intervals of delirious pain,  and often by a trouble-
some cough; still,  however, there is  not much
incoherence;*  sometimes  the  stage, which has
been characterized by the slow pulse, advances
with  regularity, after the  child has been eight
or ten days ill,  and then (though it is impossible
with certainty to predict  a second change in the
pulse) perhaps in three  or four days more, it
becomes more rapid than ever;  and thus it marks
the commencement  of what is called the  third
stage,  and ushers in, some time before death, a
still more hopeless series of symptoms.
   Whatever  difficulties there may  be  in the ear-
ly,  there is no disease more easily distinguished
in the more advanced stages.   Indeed, how can
we mistake, when we see a child rolling his head
on the pillow, or perhaps sawing the air with one
  * In plerisque (uti supra diximus) nulla vel lenissima
tantum deliria adsunt.  Ludwig, Vid. Baldinger Sylloge,
vol. iii. p.  139. 
21
hand, while the opposite side is palsied ;  with *.
hectic on the cheek, his eye-lids half concealing
the pupil, and the eye deprived of its vivacity by
the  filmy covering of the cornea,  the complete
dilatation  of one or both of the pupils, and the
suffusion of the adnata;  drawing  a  long  sigh;
frequently  grinding  his  teeth;  quite incoherent,
or  in a  state  of complete insensibility ; with  a
burning fever on his skin, or sweat forced from
every pore; and all  these symptoms alternating
with, and at last finished by, apoplectic breathing,
and violent convulsions.
   But the student will be disappointed, if he  ex-
pects, as  Dr.  Whytt  * has taught,  that  these
stages will follow each other in a regular and mea-

  * Dr. Whytt first introduced this important disease
to the profession, and although so many eminent physi-
cians have directed their attention to it, little has been ad-
ded to the history which he has given. Yet I am inclined
to think that he was directed to this disease by two arti-
cles in the Edinburgh  Medical Essays.  The one, to
which I shall afterwards refer, is a very distinct and perfect
case of acute Hydrocephalus,  related by his predecessor
in the medical chair of the university of Edinburgh,  Dr.
St.  Clair; the other is by Mr. Paisley.  Mr. P. con-
cludes his account of a case, where the ventricles were
distended with  fluid, with these observations; u Since
" this case, I have seen several children who complained
" of a pain in one particular part of the  head, having
" great drowsiness and heaviness ol their eyelids, a pulse
" slower than natural, an  inclination to  vomit,'*  !kc. 
22
i/uicd progress.  A child has sometimes appear-
ed in  health on the very night in which he was
seized with the convulsions which in a few days
destroyed him.  I have observed the pulse  be-
come slow, without any other change in the dis-
ease,  for some days;  and although there is,  for
the most part, a period, sometimes at the very
beginning of the disease, during which the pulse
is slow, yet it often lasts for so short a time, that
unless the child is very  attentively observed, it
will escape  notice.   Every attentive observer
must have found  the  pulse slow and quick, and
and then again slow, constantly varying towards
the end of the disorder.*
  Although Dr. Whytt is  perhaps  too methodi-
cal in his  arrangement of the  history, and  has
adopted, as  the distinguishing symptom, one
which, though striking and important, does  not
uniformly or correctly indicate the changes in t
the disease, and which is common to many dis- *
eases of the brain, yet in most cases these chan-
ges are  so regular, that a di vision into  stages is
perhaps,  upon the whole, advantageous.   To ac-
complish this is not easy, consideringthe alterations
in the excitement, and the variety  in the course
of the symptoms in every different  constitution.
Still retaining the three stages,  I shall venture to
present them under some  change  of character.
  * Authors mention the disease  unattended with  the
slow pulse. 
23
 The 1st as the stage of increased sensibility; the
 2d the stage of decreased sensibility ; the 3d the
 paralytic or convulsed stage.
    In the  first stage, every  stimulus produces a
 sensation more  than proportioned to its common
 effects.   There is great aversion to light and to
 sounds; there is watching, sickness, pain, a quick
 pulse.  In the second stage, the child is not easily
 roused, his pupil  is dilated, his  pulse slow, he
 is lethargic, with often an obstinately costive bel-
 ly.*   In the third stage,  which  perhaps may be
 considered as a continuation  of the second,  there
 is squinting, rolling of the head,  raving,  stupor,
 convulsions, with a rapid thready pulse.
    It must be  allowed by every physician who
 has had frequent  opportunities of seeing this dis-
 ease, that its duration is uncertain when once the
 pulse has become slow, or rather when the  stage
 of torpor  has arrived.  I have known instances
* where, in the forenoon, the child,  although sub-
 dued, was perfectly collected in mind,  and the
 slow pulse of very short duration, and yet before

    *  I believe it is not known to what extent medicines,
 stimulating particular parts of the system, may be given
 after the first stage.  Beginning with a moderate dose, I
 have at last given three drachms of tincture of cantharides
 daily, without producing any strangurious affection, or
 indeed the slightest sensible effect.  It is well known, in-
 deed, that the  largest doses of cathartic medicines are
 'Sometimes unavailing. 
24
night the child was dead.  When the disease has
advanced to the last stage, it is not  to be expect-
ed that nature will long sustain the struggle,  and
accordingly, in  some  children,  it is  continued
only  for a few  hours; but  others,  particularly
those more advanced, sometimes linger for a long
time.  I have been painfully obliged to continue
my visits,  day after day, for a week or ten daysr
at every visit thinking  the  child had only a few
hours to live, and generally I have found that no
symptom except the hurried breathing, so fatal a
symptom at the end  of febrile complaints, can
with certainty  be said  to denote the speedy ap-
proach of death.
  From the date of  the first  symptom,  Dr.
Whytt supposes the disease to  extend  to four,
five,  or six  weeks.  Dr. Fothergill has found,
that it is almost  always ended in three weeks.*
  * Dr. Quin observes, that Fothergill perhaps formed
his opinion of this disease  from what is observable in pa-
tients of a more advanced  age, some of whom he saw af-
fected with  this disease.  This is entirely a misapprehen-
sion on the  part of Dr. Quin; for, at the end of Fothcrgill's
paper (Medical-Observations and Inquiries,  Vol. IV. p.
55) there is the following paragraph : " When this paper
was read to the  society, " Dr. Huck said,  he believed
♦* that the disease (Hydrocephalus, was not  confined to
« children,  or such as were under puberty, for lie ima-
« gined that he had seen it two or three times in adults,
** and gave  me the following case, where the dissection
« put it beyond a doubt,"  &c.  This is  a proof that Dr. 
25
Like every disease of the brain, the duration is
uncertain; in some cases in the second, and  also
in the third variety of the  attack, it appears to
run its course in  a  few days; and I have known
it in the first variety, from the great  length of the
first stage, last many weeks; but the result of my
observation, even in this  variety, has been in
favour of the more limited period of Dr. Fother-
gUl.
   In  children at the breast we do not so readily
distinguish the attack of Hydrocephalus;  we in-
deed  see somewhat of the expression; we observe
the child moaning, feverish, watchful, frowning;
the expression of pain not violent.  The disease
evidently not from any  disorder in  the breast or
bowels, for the respiratory organs are unaffected,
and there is not the flinging out of the limbs, and
extreme impatience,  which  children  evince in
cholic or  griping  pain.   The  Hydrocephalic
stools differ from those attending any of the bowel
complaints of children at the breast;  and in no
other infantine complaint have I been struck with
the knitting of the  eyebrows, unaccompanied by
crying.  The disease  certainly wants, in these
cases, much of the decided  character which it
Fothergill drew his account of the disease from children
alone.  And so far  from this being a more rapid disease,
if we may judge from cases on record, it is in adults
sometimes more tedious.  Consult on the subject Me-
moirs of Medical Society, Vol. VII. p. 173. 
                     26
assumes  in  childhood and youth;  but,  even in
infancy, I believe Hydrocephalus may in general
be early detected by the attentive observer.
  I have, on two different occasions, been called
to children not a year old in convulsions, both of
whom died in a few days of Hydrocephalus.   To
their mothers they had not appeared materially ill
before the fits seized them.  One of them, for
several nights,  had had frequent  spasms of the
glottis, very short, but threatening suffocation,
the child crowing,  and becoming purple, but
immediately recovering.  Both children had Hy-
drocephalic  stools.  It is always desirable to know
whence the convulsions arise, and perhaps the
following distinction will be found useful. When
convulsions arise from Hydrocephalus, generally
one side  is more affected than the other, one arm
or foot being with some regularity retracted and
flung out again,  while the other is palsied, or per-
haps spasmodically retracted; the eyes are suffus-
ed ;  there is often a circumscribed deep blush on
the cheek;  and the  breathing is slow and irre-
gular;  sometimes, however,  it is convulsive.
Whereas, in convulsions not radically depending
upon organic disease of the brain, both sides of
the body are equally affected;  the head is thrown
back, the shoulders elevated,  the eye  is ghastly,
the white of the eye bloodless, and the pupil often
dilated;  the eye not unlike its appearance  after 
27
death; and the whole countenance is flushed.   In
the interval between  the convulsions, we have
the best opportunity of discovering their origin.
   Hydrocephalus  is the disease of every  season
of the year.  Were I to trust to my  own cases, I
should say that it prevails most  in summer.   It
is also the disease  of  every stage of life, perhaps
with the exception of old age.   Hydrocephalus
is,  however,  more particularly  the  disease  of
childhood; and  in  the middle   years, between
weaning and puberty, I have met most frequent
examples of it.*   It  chiefly falls upon the chil-
dren  of families having a strumous taint;  at least
upon children  having those peculiarities of skin,
complexion, and features which indicate scrophu-
la ;f  and sometimes it attaches itself to particular
   * lam inclined to coincide with  the  observations of
Ludwig:" In infantibus vero sexus  nullum descrimen
" fuisse, sed malum maribus aeque ac  fceminis commune
" esse observationes Lipsiae factae probant.  Sed post de-
" cimum annum ingruens, pierumque puellas adflixit."
   t Dr. Perceval observes, that  of twenty-two cases of
which he kept  notes, eleven were certainly strumous
children, and four were  probably so. Med. Facts and
Obs. Vol. I. p. 129.  From my own observation, I should
think  this  proportion a very moderate  one.   When a
whole family is swept away by Hydrocephalus, I su ,pt ct
it is  intimately connected   with this strumous taint.
" Novi familiam cujus infantes circa-sextum " aeutis an-
" num omnes periere ex hoc morbo,  scrophula huic
" effusioni ansam praebente "  Vide Convulsio ab Hydro-
cephalo Sauvages, T. I. p. 553. 
28
families.   I have attended two families, in one of
which four children, in the other three,  died of
this disease;  and I  have  heard of an unfortunate
father who lost  eleven children of Hydrocepha-
lus.  In these families the disease does not how-
ever appear in a more inveterate  form.  It has
been observed, that where mania is a hereditary
disease, it is  more easy of cure.   I  am inclined
to think  that this is also the  case with Hydroce-
phalus when a family complaint; as I have seve-
ral times seen it brought to a  favourable issue in
families where previously it had  been fatal.
  I can affirm, from extensive and careful obser-
vation, that not only are children in whom scro-
phula is active very liable to Hydrocephalus,  but
conversely, that all the symptoms of Hydroce-
phalus are sometimes exchanged for a scrophnlous
disease.
  Upon dissection, we generally find within the
cranium,  the veins,  particularly  those  of the
membranes on the surface of  the brain and lining
of the ventricles,  gorged with dark  coloured
blood; sometimes considerable  adhesion between
and thickening of  the membranes,  and minute
and florid vessels upon the pia mater.   The ven-
tricles we find to contain from two to six ounces
of limpid serum; also fluid,  in  a small quantity,
under the tunica  arachnoides, both above and at
the base of the brain.  The substance of the brain
■is generally  soft and blanched, fimbriated,  and 
2y
particularly  soft  where it  forms the  ventricles.
The substance of the fornix is often  like a  soft
curoh  In the abdomen, I have found the intestines
inflamed and constricted from spasm, and the  sur-
face of the liver of a bright red colour, abounding
in minute vessels;  and sometimes extensively ad-
hering to the peritoneum.*  In several dissections,
I have found the surface  of the liver studded with
small white  tubercles, not larger than a grain of

  * There are some  circumstances, perhaps connected
with the frequency of the disease, peculiar to the condi-
tion of the brain in childhood.  These, I imagine, it would
be difficult to  explain.  It is  but a poor approach towards
an explanation to say, that where the deposition of  mat-
ter is great, as in the increase  of  parts, the absorbents
are unusually active.   I shall  therefore  content  myself
with the bare statement of the facts which have led me to
this conjecture.  When the body of an adult is wasted to
skin and bone, as after a marasmus, from whatever cause,
there appears  to have been no absorption within the skull;
in dissection,  we still  find the brain  entire.  Whereas,
in childhood,  when the  body is exhausted  by a tedious
disease, as from  scrophula,  I  believe we  shall seldom
fail to find more or less fluid in the ventricles.  Some-
times this effusion is  in great quantity.  I must avail my-'
self of this opportunity of explaining, that effusion is not
to be considered as proceeding from the disease of which
I am treating, unless when preceded by the  symptoms
which I have  described. Often it would seem to result
from a condition of the brain more allied  to  chronic  than
to acute  Hydrocephalus, the original symptoms of in-
creased vascular action in the brain being  exceedingly
obscure. 
                    30
mustard.  The glands of the mesentery are often
diseased, as is evinced by their enlargement,  and
the caseous depositions which we find in the sub-
stance of the glands.
  After the attempt which I have made to deliver
a full history, it might be thought unnecessary to
discuss  formally the diagnosis of the disease; to
describe minutely the combination of symptoms
which distinguish it from other diseases.  I shall
therefore satisfy myself  with little more than a
short notice of  the causes from which  similar
symptoms arise.
   1st. They arise from an immediate affection of
the sensorium, in consequence of some general
disease, as fever.
  2dly. From other organic diseases of the brain,
as tumour of  the  brain, or partial inflammation,
ending in suppuration.
  3dly. From the  brain morbidly sympathizing
with a distant part.
  It is  in general  easy, even in  the more early
periods  of the two diseases, to distinguish Hy-
drocephalus from fever.  We must particularly
attend to the train of the symptoms.  The gradual
commencement;  the  more irregular remissions;
the dyspeptic  symptoms; the nature of the ex-
cretions, in  particular the glairy, dark, and un-
natural  stools; the aversion to  light;  and  the
whole expression of the disease,  differing much
from that of fever.   The peculiar nature of the 
31
 pains attending Hydrocephalus; the acute pains
 of the body ; the peculiar pain of the head.  The
 pain, when fixed, is oftener dull than acute;  but
 so  overpowering, that  it does not admit of the
 head being raised from  the pillow.   It  is some-
 times a very acute pain.  It is not increased  by
 every throb of the artery, like the phlegmonic
 pain.  Generally, it is deep-seated, like the pain
 attending some of the visceral inflammations;  but
 it differs in this,  that it is not increased,  or ren-
 dered more frequent, by any  muscular exertion.
 At intervals, and these sometimes regular,   it
 darts through the  centre of the brain,  and  the
 child is roused with an  expression of helpless an-
 guish from the dosing  which  precedes this acute
 pain, and into which he instantly relapses when
 it is gone.
  Hydrocephalus resembles several of the  va-
 rieties of fever,  but none so much as  the acute
 infantile  remittent.  The two diseases  may  be
 distinguished, among other symptoms, by these
 which are peculiar to the latter.  1st, The regular
 and complete remission.  Dr. Butter (the author
 of an accurate description of the infantile remit-
 tent fever) refines too much when  he says that
 there are three remissions, one in the forenoon,
 one  in the afternoon, and one during the night.
 Unless in the advanced  stages,  and  in  the worst
form of this fever (when, perhaps, the  remission
is hardly to be observed) there is one remarkable 
32
remission generally in the morning,  sometimes
early in the forenoon; and the exacerbation com-
mences late in the forenoon, or in the afternoon,
and lasts till next morning, the nights being rest-
less and delirious.   2d, Foetid  and dark brown,
or mud-like stools.   I must however admit, that
1 have once or twice,  in remittent fever, found
what might have been called Hydrocephalic stools
—a glairy dark green discharge.  A young phy-
sician  cannot too much habituate himself to the
variety of expression which he will find  in  the
countenances of the sick.  In going into the ward
of an  hospital, or approaching the bedside in the
sick  chamber, he  ought first to try  to discover
the disease  in the face of the patient; he thus
acquires a faculty like  the tactus eruditus of the
surgeon, which is  very imperfectly derived from
books; which he cannot, it is true, easily com-
municate,  but  which, notwithstanding,  is  of
sterling value.  To this faculty, which gives both
method and simplicity to a clinical investigation,
the experienced physician owes his real and well-
deserved superiority.  Hydrocephalus and fever
are thus often known by a glance of the eye.
   I have twice attended cases of the fatal disease
of the brain and its membranes,  which arises in
scrophuious habits from a caries  of the temporal
bone.   There are first suppurations of the ear:
these sometimes happen at the interval of many
vears; for this is a disease not  confined to chil- 
33
  dren.   These  suppurations  are  not, in the first
  instance, attended with very great pain.  Indeed,
  while the discharge of matter from the ear is free,
  there is little other  inconvenience.  At last, how-
  ever, one of these attacks of suppuration is fol-
  lowed by extreme  pain, darting  from the  crown
  of the head to the ear or mastoid process, by dis-
  order in the stomach and bowels,  stupor and pal-
  sies.   As all organic diseases of the brain have a
  general resemblance,  this, at first  sight,  might
  be mistaken for a case of Hydrocephalus;  but in
  the examples which I have seen,  the disease was
  much  more tedious than Hydrocephalus.   This
  scrophuious disease may be known by attending
  to the  previous suppurations; to the pain striking
  through the head;  the fixed pain, sometimes in-
  flammation and swelling behind the ear; the stiff-
  ness of the jaw,  which is sometimes nearly lock-
  ed, and only opened with extreme pain ; the in-
  ability to turn the head,  and the great pain in the
  attempt;  and the swelling of the chain of lympha-
  tic glands of the neck.   This swelling, indeed, is
  occasioned by other diseases of the  brain;  but it
  never arises from Hydrocephalus, although we
  find it accompanying that disease.   In dissection,
  we find a considerable portion of the bone dis-
 eased,  the membrane  destroyed,  and the brain,
♦particularly the cerebellum, often extensively sup-
                       c2 
34
purated.*   I  confess that I have been somewhat
embarrassed in the diagnostic between Hydroce-
phalus and some of the organic diseases  of the
brain.   I had  some intention of attempting the
elucidation of this subject by a description of these
diseases;  but as most of the cases which  I  have
seen were also attended by Mr. Charles Bell, and
as they will appear to much more advantage in the
important work on  morbid anatomy,  which has
for years engaged his attention, I shall leave to
him the investigation, only  remarking, that where
there was suppuration, there were also paroxysms
of shivering, almost of a convulsive nature;  and
that all the other organic diseases of the brain in
children which have fallen  under my observation,
have had a  more  tedious course than Hydroce-
phalus.
  * Dexterum cerebelli lobum abscessu magnam partem
corruptum vidit eel. Janus Plancus Ariminensis in no-
bili puero, qui a suppresso puris ex aure ejusdem lateris
fluxu,  cui a primis usque annis obnoxius fuit, inciderat
in acerrimam cephalalgiam cum  febre continua acuta j
ex qua intra breve  temporis spatium  mortem opetiit.
Febris pluries intra diem exacerbatur et horrifica erat sic
ut hemitritaeo similis videbatur.  Accedebat  subinde
aphonia et trismus,  sed brevi  redibat loquendi potestas.
Tandem paralysinon oppositi, ut moris est, sed ejusdem
lateris correptus, sensibusque  orbatus fato cessit.   Vid.
Burserius  Institut.  Med. Pract. Vol. V. § xix.  Bell's
Principles  of Surgery, Vol. II. Part II.  Title Vomica
Hyfiocranii. 
35
  I have, lastly, to mention, that a train of symp-
toms, similar to  those  of Hydrocephalus,  often
arises  from  the brain,  morbidly  sympathizing
with those parts of the  system to which it is
associated by an immediate connection.   We
know, by the phenomena of other  diseases, that
these are the alimentary canal, the liver,  and the
urinary organs;* and I  have seen Hydrocephalic
symptoms,  arising from sympathy with a derang-
ed state of all these organs;  however, it is chiefly
from a  morbid  state of the  liver and alimentary
canal, that we find the Hydrocephalic symptoms
by association to  arise.
  I  am naturally led to attend to the sympathetic
connection between the  abdominal viscera and the
brain, not merely to establish the diagnostic,  but
to regulate  the practice,  as I am convinced  that
the disease of which I am  treating is often fairly
and incurably established by the sympathy which
the brain has with these  organs.   It may  be diifi-
  *  The Carus Ischuriosus Sauvages, Vol. I, p.  839,
must be admitted as a proof of the sympathy of the brain
with  the  urinary organs.  That  ischuria gives  rise  to
Hydrocephalic as well as apoplectic symptoms.  I  have
had  an opportunity of seeing; and in the 3d  vol. Med.
Facts and Obs. Art. /, it is related of a boy under cure
for ischuria renalis, » that his original disease  (ischuua)
" appeared to be completely relieved ; but in the course
« of a few days, he again became languid and heavy, and
 « I am sorry to add," says the writer, « that he died about
 « a month after with symptoms of Hydrocephalus." 
                      36
cult absolutely to prove this.   It is one of those
opinions,  of which there are many among physi-
cians, pressed upon the mind by repeated obser-
vation in the course of practice, and yet liable to
considerable objection.   But I shall state the con-
siderations which appear to me to render this con-
jecture extremely  probable, after  requesting  the
attention of the reader to the following case.
  The subject of this case was a  boy  two years
and  a half old,  a fat and lively child, with blue
eyes, delicate  and fair skin, and much neglected
in his diet.
  Friday, Aug. 29.—I found him flushed, with a
full and  thick pulse, breathing very laboriously
and  quickly (76 in the minute) the diaphragm,
violently heaving,  and the chest much  raised by
every inspiration.   He became pale,  and flushed.
again, as I  sat by his bedside.  He  is quite le-
thargic, and sleeps with his eyes only half closed.
In his sleep he starts and moans.  When taken
out  of bed,  he  vomited some light green bile.
He has a cough, not frequent,  and it  is unattend-
ed with any pain in the chest;  his breath is offen-
sive ; his belly costive; his stools are dark  and
foetid.
  He was seized with these symptoms two nights
ago.  Yesterday morning he was rather relieved.
He was again extremely ill all last night.
     R. P. Rad. Convolv. Jalap, gr. x.
       Submuriat. Hydrarg. gr. vi. n\,. f. Pulv. ii. 
37
One of these powders he is to have immediately,
and the other at bedtime.
  Aug. 30, 4th day.—Yesterday evening he was
exceedingly ill; the breathing more laborious than
ever I  saw it in a child.   In addition to the pow-
ders, which were ordered to  be repeated  every
four hours, he had a blister applied to the pit of
the stomach.  He had seven or eight stools,  not
foetid,  but dark and  slimy; in one of the  stools
was a large lumbricus.   His breathing continues
very laborious, p. 120.  He is flushed; still dos-
ing, and not roused by being lifted out of bed.
His  tongue is much loaded.   He picks his nose,
and grinds'his teeth.

    R. Aloes Soccot. in Pulv. trit. gr. xx.
       Submur. Hydrargyri, gr. xvi. %. f. Pulv. iv.

One to be taken every six hours.
  Evening.—Symptoms increasing; great heat
of body;  respiration  88;  nails purple.   The
aloetic  powders have been vomited; return  to the
powders formerly prescribed.
  5 th day.—His  breathing  continues very labo-
rious;  p. 140; his  countenance is livid; his eye
is heavy ; his tongue  white  and  dry.  The  vo-
miting has ceased during the  night;  he has had
several stools, exactly such as we find in Hydro-
cephalus ; mucus mixed with  very dark bile.
  6th day.—1  did not visit him before evening.
He has had no stool for 36 hours;  p.  140.  His 
38
 expression becomes more unfavourable.   As he
 lies awake, he frequently  grinds  his teeth.   The
 severe dyspnae admits of a very  imperfect circu-
 lation through  the lungs, and causes the leaden
 countenance and purple lips.  His belly is swell-
 ed.   Omittantur Pulv.
          R.  Tart. Antimonii, gr. ij.
             Aq. Dist. g vi. %.
 Of this solution give a table-spoonful every hour.
   1th day.—The nauseating solution was duly
 administered.  He  vomited  two or three times,
 and was, during the whole night, extremely sick.
 After a soap glyster  (injected this  morning) he
 had one large dark green and more foetid stool;
 and, since morning, he has had  two more, con-
 sisting of faeces, mixed  with mucus  and bile.
 Since these evacuations he has appeared relieved,
 in particular, less lethargic.
   9th day.—In the two last days he appeared to
 be  convalescent; however, he  had  gained  no
 strength.  He is wonderfully feeble to-day.   His
hands are swelled;  his tongue is dry; his skin
hot.  He had a restless night; often feebly tossing
about his hands in restless anxiety: this  restless-
ness continues.   He  has some  hiccup.   His
stools are again scanty.
   10th day.—He has been extremely restless and
uneasy all night; flinging out his arms; vomiting
every thing swallowed; starting from his sleep;
constantly  sighing.   To-day  the  restlessness, 
                      39
sighing,  moaning, and irregular  breathing, con-
tinue.  His eyes are inflamed,  and distil a gluti-
nous matter; the pupil is dilated, and the cornea
filmy.  The face  and palms are much flushed.
The tongue is dry and foul, and the lips chopped.
Belly costive ; pulse 140, small and jarring.
      R.  Pulv. Cinnam. Comp
         Submur. Hydrarg. Aq. xviij. n^. f. Pulv. vi.
   Sig.
One to be given every four hours.
   11th day.—No stools; another restless night;
p.  140 ; respiration  quick;  insensible ; dosing
and starting; he sighs constantly;  his  breath is
very sickly.
   12th day.—His friends think that he  has been
for these three days totally blind.  His pupil is
much dilated; his right cheek  deeply flushed.
He sighs constantly.  He has had no  stools; nor
has he passed any urine for the last eighteen hours.
His tongue is dry.   Cont. Submur. Hydrarg.
   13th day.—Since my last  visit he  has passed
much liquid faeces, quite black, intolerably foetid;
p. 140.   His eye  is again expressive,  the pupil
contracting.  He sees distinctly.  He has taken
some nourishment.
   15th day.—He  purged seven or  eight  times
during the night.   The stools are fcetid, and dark
green. The n outh is aphthous.  He is extremely
weak; but he now takes enough  of  nourish-
ment. 
                     40
  18th day.—I found this boy amusing himself,
still extremely languid,  but daily  convalescing.
His stools are quite natural.
  I  would observe in  this,  which is a case of
acute remittent  fever,  among  other  alarming
symptoms, lethargy, brought on solely by a dis-
ordered state  of  the abdominal  viscera. When
the cathartic  medicines failed to alter the nature
of the stools,  and indeed to procure any discharge,
by substituting the nauseating solution, the bile
was  poured out in sufficient quantity to  stimulate
the  bowels,  and the comatose state subsided.
The viscera again became  torpid,  alarming Hy-
drocephalic symptoms came on,  and,  had I been
ignorant of the  previous  history,  I  might have
thought the  child in the last stage of Hydroce-
phalus ; as it was, I had almost lost hope of his
recovery.  The dark stools, however, were thrown
off (whether  by  the calomel I  shall  not say);  a
proof that the functions of the viscera were re-
sumed; and  the child quickly regained his health.
I have  seen  many such  cases, some  of which I
could have added, but this one is sufficient for
my purpose.
   1. Cases* less  acute must have occurred to
   * Case communicated by a friend.—"  Christie  Mac
" Lean,  a girl  about nine years old, complained of head- 
41
 every physician in extensive practice, of children,
 especially in the lower ranks  of life,  relieved by
 a short  course  of  active  purgative medicines,
 from a situation in which much of the expression
 and many  of the symptoms  of  Hydrocephalus
 were combined—irregular  fever,  retching, head-
 ache, lethargy to a great extent;  symptoms evi-
 dently arising from a disordered state of the ab-
 dominal viscera.*

 " ache in the evening; her mother bathed her feet, and
 11 put her to bed.   She soon fell asleep, and no notice
 " was taken of her till next morning.  She was still
 " asleep, and her mother became alarmed when she found
 " she  could  not  awaken her.   I  saw her about noon
 " sleeping profoundly, respiring fully  and  slowly, with
 " now and  then a  heavy sigh or moan: the  pulse 100,
 " and intermitting.  When  the  eyelids were lifted up,
 " the eye appeared fixed, and the  pupil  large and im-
 " moveable.  The  flame  of a  candle  excited indeed a
 11 slow, feeble, and undulating contraction.  1 was inform-
 " cd that she  had  been extremely costive, and what her
 " mother called drooping, for  some days ;  and that, two
 " clays ago, she had taken a dose of senna without effect.
 " I  ordered a purgative injection  to  be given immedi-
 " ately, which evacuated  her bowels  twice.  She was
 '' soon after so far roused as  to swallow a bolus of jalap
 " and calomel.  It  also operated powerfully; and next
 " morning I was presented with two chamber  pots load-
 " ed  with the most extraordinary collection of feces I
 " ever saw.  But my patient was perfectly recovered,''
  *  Nay, it would appear that Hydrocephalic symptoms
arising from sympathy vith disordered digestive organs
                        D 
                      42
  2. In many  cases, previously to the appear-
ance of the Hydrocephalic  symptoms, the chy-
lopoetic viscera have been  disordered for many
weeks.   The appetite has been bad; the bowels
costive, the stools betraying disorder in the hepa-
tic system ; there has been all that want of alacri-
ty,  both of body and  mind,  so invariably  the
consequence of the derangement of the biliary se-
cretion :  and in several children, previous to the
existence of any morbid sensation, the first symp-
tom of ill health was the loss of the  healthy co-
lour of the skin.
  3. In  children predisposed to the disease,  I
have,  while removing, by  a course of purgative
medicines, a vitiated biliary secretion  and disor-
dered state of the bowels, removed also the  very
symptoms  which had  presented themselves in
other  children  of the same family, when  the at-
tacks  of a Hydrocephalus,  which actually proved
fatal,  were supposed to have been established.
  4.  In children where I  did not  know of  any
family predisposition, I have, by the same means,
in many instances, removed the symptoms which

and existing without any change of structure in the brain,
are  sometimes fatal. Mr.  Abernethy examined the bo-
dy of a child who had unequivocal symptoms of Hydro-
cephalus, in which the  brain was found perfectly healthy,
the  only diseased appearance being in the bowels.   Vid.
Surgical Observations, part, ii, p. 193. 
43
are always found  in the beginning of  Hydro-
cephalus.
   5. In some cases, I have found that  children
under Hydrocephalus, early in the disease, when
the region of the  liver  has been handled, have
complained much  more than they did when the
same pressure was  applied to any other part of the
abdomen.
   6. Upon dissection of Hydrocephalic children,
I have found in the liver the remains of great in-
flammatory action, and also proofs that undue ir-
ritation had existed in the alimentary canal.
   In  a former essay, I endeavoured  to enforce
the necessity  of observing more attentively the
connections of the liver,  in order fully to compre-
hend some of the  most important diseases of in-
fancy, and I am induced to recal the attention of
my readers to the derangement of this  important
organ.
   The increased arterial action on  the surface of
the liver, the remains of which I have  observed
in my dissections,  to every appearance, had been
of some standing,  and in two  or three instances,
from the extent of the adhesions, it evidently had
been of great intensity.
   While the disease is forming, there is general-
ly a defect in the  function of the liver.   It seems
to admit of only a  scanty and imperfect formation
of the bile, insufficient to stimulate the intestinal 
44
 canal, which becomes  torpid, and is  sometimes
 loaded with foetid clay-coloured excrement.  This
 state of the canal, in conjunction  with the disor-
 dered condition of the liver, is perhaps one cause
 of the dyspeptic symptoms which are almost in-
 variably present in the beginning of Hydrocepha-
 lus, although it is not to be denied that the vomit-
 ing in the more advanced stages of the disorder,
 is more  naturally explained  (according  to  Dr.
 Whytt)  by the stomach sympathizing with the
 diseased  state of the  brain.
  When Hydrocephalus is established, the stools,
 although  small  in quantity, contain  an unusual
 proportion of  bile.   Indeed  they appear to be
 solely a mixture of dark bile, and of the mucus
 of the intestines; but  the state  of  the  bowels
 shows that this bile is an imperfect secretion,  and
 insufficient to stimulate  the canal;  and this, I ap-
 prehend, is in a great measure the explanation of
 the  torpor of the intestines, not that in this stage
 of the disease they are slow from paralysis.
  In  some constitutions of greater  irritability,
there is a Continual vomiting and purging of bile.
Here the very irritable state of the stomach over-
comes the condition of the liver proper to the dis-
ease,  and by reflected sympathy, if I may use the
expression,  forces it  to pour out an increased se-
cretion. 
                         45
   Vertigo occasions a flux of bile  into  the sto-
 mach, and consequent sickness and  vomiting, as
 may be seen in sickness from swinging, or in sea-
 sickness,  and in cases of sickness from  vertigo,
 originating in organic diseases of the brain.  In-
 juries of the  brain have often been succeeded by
 abscesses of the  liver, &c.   On the other hand,
 there are  many instances of apoplexy succeeding
 to  jaundice;  and  ingenious   physicians  have
 thought that sudden death in gouty  persons,  has
 been occasioned by metastasis from  the  liver to
 the  brain ,* or, in other  words, by sympathy
 which  the brain  has  with a  torpid  state of the
  * Dr. Powel, in  the Gulstonian lecture for  1800, p.
 83, says, that,  in a short time, he had met two cases,
 where a jaundice of some continuance was followed by a
 decided apoplexy and death.  I  very lately visited a wo-
 man who was seized with palsy of the right side, loss of
 speech, &c.; and in two days after seizure she died apo-
 plectic.  She had been  ailing for seven or eight months •
 for the last  four she had anasarca of the lower extremi-
 ties, and  ascites ; and, from her habits of life, and in-
 deed from every consideration, I had long considered
her liver as the primary seat of the  disease.  This  wo-
man was  past the middle of life; Dr.  Powel's  patients
 were  both young.  Cases of apoplexy,  with jaundice
 and other diseases of the  liver, are  not  rare   Baglivi,
Dissert, iii, de Bilis Natura, p. 433, oper.  Morgagni,
 Epist. xxxvii.  Powel's Observations on the Bile ami its
 Diseases, 8cc. loc. cit.   Consult also the Sepulchretum,
lib. iii, sect, xviii, obs. 6, et seq.
                        D2 
46
liver,   hi the bodies of  apoplectic patients, the
liver is often found greatly diseased.   Thus, in
other diseases,  the reciprocal sympathy between
the liver and  brain is immediate.   It would be
quite unnecessary to  adduce many  examples of
the sympathy between the brain and the alimen-
tary canal;  they  must be in the recollection of
every  reader.*

   * One afternoon, not long ago, I received a hurried
message to come to a child who was said to have swal-
lowed poison.  I found a fine child,  about three years of
age, in great agony.  He had, about an hour after taking
a hearty dinner of broth,  &c. come in from play, thirsty,
and taken hold of a bottle, thinking to get  a draught of
table beer; the bottle, however, was  one in which was
kept, for cleansing dirty bottles, concentrated caustic
alkali,  which had been procured from the soap manufac-
tory.   Of this he took one mouthful: the servant, who
was in the cellar  when he  ran in,  declared he took no
more.   I found  his mouth  dreadfully burned; but the
greatest distress was in his stomach.  He was  sitting,
when  I entered the room,  with his hand pressed upon
his stomach,  pale and sunk.
   In the night after the accident he slept much ; but he
 frequently awoke  uneasy and thirsty, and  he vomited
several times.
   Next day he  salivated, without  ceasing,  a very ropy
 colourless fluid; his pulse  was  160; he had subsultus,
 flushed face, hissing inspiration ; and he was in a state
 approaching to perfect stupor.   He opened his eyes now
 and then ; but he was incapable of attending to what was
 passing.  When,  with  great difficulty,  shaking him. 
47
  I am not prepared to frame rules by which we
may decide when the  symptoms arise  from the
morbid sympathy between the  brain and a de-
ranged state of the liver or the intestines, or when
it originates from the disordered state of the brain,
unconnected  with any  distant  organ.   This in-
vestigation is important, but  not easily  prosecu-
ted; perhaps future obervation may  prove  that
we shall not be wrong to trace the disease to the
organ  which  first has  its  functions sensibly  im-
paired ;  in a great many  cases it has appeared to

and talking loud, he was somewhat roused, he appeared
oppressed with the greatest anxiety.
  On the  second day after the accident, his expression
was  improved ;  he looked up; he still had great fever;
his  breath was  extremely  sickly  and offensive;  his
mouth  appeared one aphthous sore.
  It was not before the fourth day after the accident that
a stool  was procured.  After this, for  several days, the
stools were pale, firm, and mixed with grumous blood.
The child was treated with diluents, copious bleeding,
particularly from the temples, blisters to the stomach, lax-
ative glysters, &c. His mouth was sore for three weeks;
bis health not fully restored for a Ion,? time.   Indeed this
accident laid the foundation of another disease, viz swel-
ling of the lymphatic glands of the neck.
  Some years ago I was sent for to a child who had, by
the same mistake, swallowed soap-ley.  But his stomach
being  empty,  he died  within twenty-four  hours apo-
plectic.  The  stomach was corrugated like a  piece of
burnt parchment. 
48
me that the series of diseased actions has com-
menced  with the  disordered state of the abdomi-
nal viscera.   To this, it is not a sufficient objec-
tion to say, that the symptoms denoting a morbid
state of the abdominal viscera,  are  apparently of
inferior importance to those which indicate a dis-
order of the  brain; for  it should be recollected,
that it is a law in morbid sympathy, that the dis-
eased  sympathy  apparently bears no proportion
to the diseased action.   Contenting myself with
having, in this imperfect sketch, connected the
appearances, upon dissection, with  the disorder-
ed function of the liver,  as we find it early in Hy-
drocephalus,  and  with attempting to give impor-
tance to these circumstances,  for the present, I
shall  relinquish the subject.   The  consideration
of  it,  however, has  made me  adopt a  practice
which is supported by  cases,  and,  I  am  happy
to  discover, by the  observations of experienced
physicians.*

  * The following paragraphs I shall make no apology
for transcribing  The last  I read with great satisfaction,
as it confirms what I had written,  and perfectly agrees
with the result  of my practice for  some years,  in the
intercourse of private practice, I have long been accus-
tomed to respect the author's observations, and to value
his friendship   It is needless to say that  he is a physici-
an of distinguished  candour and eminence.
  « This  much  is  known,  that Hydrocephalus often
« steals slowly  on the  devoted victim,  with symptoms 
                         49
   Non interest quid morbum faciat sed quid tol-
 lat.   Unfortunately this,  which was the favourite

 » resembling those of incipient marasmus.  Till  some
 '•*" better theory  is established, it is not unreasonable to
 " suppose, that the marasmus  of which I  have treated,
 " may,  on some occasions, give rise to Hydrocephalus,
 " by impairing  the  vigour  of the  constitution, and fa-
 " vouring serous effusion in the ventricles of the brain.
  u This conjecture merits the greater attention, on this
 " account, that the symptoms of Hydrocephalus resem-
 " ble  those of incipient, and even of confirmed maras-
 " mus, and  have been removed by  the diligent exhibi-
 " tion of purgative medicines-  The truth of this obser-
 " vation has been repeatedly confirmed in my private
 u practice, and it affords an additional reason for the ex-
 " ercise of watchful attention, to prevent the confirmed
 " state of marasmus, which may, in more instances than
 "■ we are aware of, have been the forerunner of Hydro-
" cephalus."  Observations on the utility and administration
 " of Purgative Medicines, by James Hamilton, M.  D.
  A very respectable physician, the  late Dr Haliday of
 Belfast,  relates, that " the  son of Mr-----— had the
 " most  evident symptoms of this disease:  vomiting in
 " the  beginning, perpetual  stupor  afterwards, with a
 " slow  pulse and respiration, pupils astonishingly dila-
 " ted, and a total loss of vision ; yet he emerged.   His
" head   was  blistered, and cataplasms  were laid to the
" feet, and he  was largely  purged with jalap and calomel.
" He is now perfectly well."   This communication will
be found in Macbride's Methodical  Introduction  to  the
 Theory  and  Practice  of Medicine.   Dr Macbride adds,
that " he himself once had the care of a boy with similar
" symptoms, who escaped, after violent purging,  by  means
"' of calomel and resin  of jalap." 
50
saying with the ancient empirics,  cannot be made
to apply to the disease in question.   In the con.
firmed stages, and often from the very first of this
disease, the  practice is  as unsuccessful  as the
causes and explanations are obscure and unsatis-
factory.  The observations which I have to make,
however little they  may advance the  cause in
which I am embarked, arise from a  feeling, that
it is only in an improved, or rather corrected ex-
planation of the symptoms,  that we are  to expect
the true practice to be properly established.
   I have accidentally mentioned Dr.  Whytt's
way of accounting for the retching in the  begin-
ning of Hydrocephalus.   There  is  a section of
his paper,  entitled, " an attempt to  account for
" some of the most remarkable symptoms attend-
" ing a dropsy in the brain," which I shall briefly
analyse.   The inclination  to  vomit is  explained
by the sympathy which the stomach has with the
disordered state of the brain : the  aversion to light
by the increased sensibility of the  retina: the slow
irregular pulse, in the second stage, by  the defec-
tive sensibility of the cardiac nerves,  in  conse-
quence of a  general want of nervous  energy.
The quick pulse,  in the third stage, is  said to
arise  from the violence  done to the medullary
fibres of the  brain, causing such an  irritation as
must  quicken the pulse: the dilatation of the pu-
pil, from  the insensibility of the retina ; the apo- 
51
plectic breathing, from  the compression  of the
brain.   This, he  supposes, prevents the uneasy
sensation  occasioned  by the  accumulation of
blood in the lungs from  being so soon  felt; so
that the inspiration  is not made  until there is a
sense of suffocation in the breast.
  I have  dissected  the brain  of a  woman who
died of apoplexy, in which there was no appear-
ance of disease.   Numerous references to similar
dissections, in the writings of physicians both of
the present and  of the last age, might be produ-
ced ; * and idiopathic  epilepsy sometimes termi-
nates fatally, without leaving any apparently dis-
eased change in the  brain.   That a state of dan-
ger,  prior  to any change in the structure  of the
organ, or  even  to increased  vascular action, as
discoverable  by dissection,  often exists in Hy-
drocephalus, as  well as in  other diseases  of the
brain, is highly probable ; nay, in one child who
died of Hydrocephalus  (foot-note. p.  45,) the
dissection  put it past a doubt.   The brain was
perfectly healthy in appearance, the disease being
in the bowels.   The symptoms, therefore, must
have arisen from a sympathetically  excited state

  * Morgagni, Kirkland, Burserius, Abernethy.  Some
of the papers written in aid of Mr. Crowfoot, in the con-
troversy  on apoplexy,  may be  consulted, in particular,
the ingenious  paper signed Pyrrho, London  Med. &
Phys. Journal, vol. vii. 
52
of the brain,  or from a change in the structure of
the brain, which the most skilful anatomist is un-
able to discover.
  Were there no other foundation, we might in-
fer from the headache, which has  been observed
before the regular formation  of the disease,  that
this  state of excitement,  in many cases, precedes
increased vascular action. This excitement takes
place before we find the pulse quickened and the
sensibility increased.  These, however, are soon
added, and,  doubtless,  arise from  the increased
vascular action in  the brain, and show that the
headache is no longer merely a sympathetic pain.
The  increased vascular action  explains most of
the symptoms of the first stage.
  The  most  striking  symptom of the  second
stage is  the affection of the  eyes—the squinting
and  double vision.  Of these  I would venture
the   following explanation.    There are  four
straight muscles of the  eye, sufficient for every
change in its  direction ;  these are under the com-
mand of the will.   To poise and preserve  the eye  •
in its situation, the oblique muscles pull  against
the recti; but these not being necessary to direct
the eye, are,  like other merely antagonising mus-
cles, not under the command of the will.  The
effect of loss of sensibility falls, in all parts of the *~
body, first on those muscles which are under the
direction of the will.  The recti lose their power 
53
 sooner than the obliqui;  so that the obliqui, ob-
 taining a preponderance over the recti, turn the
 eye from its proper axis, and occasion squinting;
 and as the rays of light no longer strike on cor-
 responding parts of the retina, we have also dou-
 ble vision.  These derangements in vision are
 not confined  to this disease; they are  found in
 all diseases where there is general debility of the
 muscles, from effusion in the brain, in  tubercles
 or suppuration in the brain.  This is even  ex-
 emplified in the end of fevers, where the squint-
 ing goes as the strength returns.
    In the last stage of Hydrocephalus,  the whole
 svstem is again excited, from " the injury sustain-
 " ed by trie substance of the brain."*
    The quick pulse before death arises  from the
 great effort made to keep the machine in motion.
 "The pulse  is rapid from the  struggle;" but,
 from  the loss of the  sensibility of  the substance
 of the brain, the vascular action does not arise to
 a great height; hence the  pulse, though  rapid,
i is small and thready.
    In  the dissection  of the brain  after Hydro-
 cephalus, the most  striking  appearance is the
 fluid contained in the ventricles; but, in reason-
 ing on the  immediate causes of the symptoms,
 the importance of this effusion appears to me to
 be  overrated.  What is only  an effect, a  mere
                    * Whytt.
                        £ 
54
symptom,  is assumed  as  the  cause of all  the
symptoms.
  It requires but  a very limited  knowledge of
pathology to render it obvious that this disease is
not a dropsy (as supposed by Dr. Fothergill) pro^
duced by a ruptured lymphatic: or by any ori-
ginal weakness or laxity of the brain, whereby the
small exhalent arteries will throw out the lymph
faster than the absorbent vessels can imbibe it; or
by a too thin and watery state of the blood; sup-
positions of Dr. Whytt.  Perhaps there does not
exist a dropsy of this kind—an idiopathic dropsy.
My  notion of dropsy is nearly conveyed in this
aphorism of the venerable Heberden: " Hydrops
" non tarn  ipse morbus  est quam  alicujus  morbi
" signum."  It is obvious, that, before the drop-
sical effusion takes place, the condition of the part,
as it exists in  health, must be altered; and this
antecedent  condition of the part is the  disease.
Accelerated circulation as certainly precedes the
effusion of lymph, unless arising from a strangu-
lation or rupture  of the lymphatic,  as it does the t
formation of purulent matter.   Indeed it would
be difficult to point out a disease which has not its
commencement in accelerated circulation.   The
science  must be in a very improved state  before
all the different modifications of increased vascu-
lar action be understood.   In  Hydrocephalus I
do not pretend to offer any explanation of its pecu- 
55
   liarities,  yet I am  inclined to think that the mor-
   bid  action in the brain is specific.  It certainly
   appears to me different from all  those actions to
   which it has been  assimilated.   This,  however,
   I may safely affirm, that,  in the.effusion into the
   ventricles  there is nothing at variance with  the
   uniform effects of disease, nothing different from
   the effusion into other cavities of the body, arising
   from a diseased condition of the contained visce-
   ra, or their investing membranes.
     Dr. Quin says,  that Hydrocephalus " owes its
   ''  origin to a  morbid accumulation of the blood
   "  in the vessels of the brain, sometimes proceed-
   "  ing to a degree of inflammation,  and generally
   "  (but not always) producing an extravasation of
   "  watery fluid before death."
     I do not mean to detract from the merit of this
   ingenious physician,   who rectified  the  error
   (which rested on the authority of  Whytt and Fo-
   thergill) that this disease was a dropsy of the brain;
   and who has done  much towards the present im-
•   proved treatment of the disease.   Still I am afraid
   I must ditter from  him, in limine.   I am not dis-
   posed to cavil where inaccuracy is merely in  the
   mode of expression; but in the present instance,
   the explanation appears to arise from a view of the
   subject not sufficienUy clear to serve as the  basis
  of reasoning and practice. 
56
   There must be an active before there is a passive
state.  There certainly is some change  prior to
the morbid accumulation of blood.  Inflammation
does not adequately express this altered state; yet
Dr.  Quin's view to me were less exceptionable
had it been thus announced.   That this disease
owes its origin to a degree of inflammation which
produces a morbid accumulation of blood,  and
generally an extravasation of watery fluid before
death.
   I would venture to submit the following as a
more consistent view of the pathology of Hydro-
cephalus.  That, in this  disease, there is pro-
duced a venous  congestion, in  addition to,  and
probably arising  from,  the  increased arterial
action: that the  effusion  of  serous fluid  arises
from this  venous  congestion:  that this effusion
has a tendency to counteract the baleful effects of
the increased  action, and  to retard the fatal ter-
mination of the disease; of course,  that the effu-
sion  into the  ventricles is not the cause of the
violent symptoms;*  and that the increased arte-
rial action, though perhaps varied, does not cease
   * " It appears to me even doubtful whether the symp-
" toms which generally show themselves in this disease
t* depend  upon the effused fluids."  Remarks on a case
of Apoplexia Hydrocephalica, by Dr. Garnet, Med. and
Physical Journal, vol. v.  This short paper appears to me
one of the most valuable which has been written on the
subject. 
57
when the congestion  and  effusion have  taken
place.
  Dr. Darwin imputes the fluid found in the ven-
tricles to a debility of the absorbents.   But  this
debility, as  I  conceive, will perpetuate  rather
than cause the effusion of serous fluids.  This is
little better than to return to the  exploded  opi-
nion of Dr. Whytt.
  Dropsy,  I suspect, never appears before the
balance which  in  perfect health exists  between
the venous and arterial systems is lost,  by the in-
ordinate action of the latter.   Serous effusion  is
one of a long list of evils arising from venous de-
bility.   After a certain time, by the laws of our
constitution, without any palpable disease, the
balance in the circulation is lost.  This, indeed,
is slowly developed;  but, after the prime of life,
every  year  takes  something from the  vigorous
action  of the veins, admitting more  and  more  of
congestion in this  system of vessels.  It is  this
venous plethora which is prematurely effected by
excess of stimulus. Compare with the arterial pre-
ponderance, the vermillion fullness of youth, the
livid and bloated  countenance of  the  habitual
drunkard;  here the tortuous  and  dilated veins
may show  us  how imperfectly their  absorbing
function is  performed; and their  weakness is  as
distinctly, although less  strikingly demonstrated.
in the  effusion into the ventricles, and upon the
                      **.2 
58
 surface of the brain, in those who have been long
 paralytic and infirm, as when it  is produced by a
 more rapid process, by the Hydrocephalic action;
 yet in neither case is the  effusion itself,  I  appre-
 hend,  productive of harm.   In age,  when, like
 every  other part, the  brain  is absorbed, it may
 act a very important part.*
   I imagine that the stage of  torpor commences
 with the  congestion in the system of the veins.
 In the  early part of the disease, when there is only
 arterial action,  we find irregularity  in the excite-
 ment;  but the prevailing  state is of increased ir-
   * To infarction in the veins of  the abdominal viscera
 much  has  been attributed by the German physicians.
 Kaempff, who published a dissertation in support of this
 hypothesis,  entitled,  De infarctu  vasorum  ventriculi,
 imagines, that from this source are derived not only ma-
 ny abdominal  diseases, as  hypochondriasis,  dyspepsia,
 maelena, hysteria, and many of the uterine diseases,  but
 also more distant affections, headaches,  apoplexies, epi-
 lepsy, asthma, in  short,  the  whole  circle  of disease.
 Much has been ingeniously written  on  this subject, as
 any one who will take the trouble of consulting the pa-
 pers of  Kaempff, Koch, Elvert, Faber,  Brothbeck, Tis-
 sot, &c. will find.   The doctrine of these physicians is
 obscured by the prevailing opinions of the period when
 their  dissertations  were  written;  yet their hypothesis,
•' of the  blood circulating in veins so weakened as to be
" unable to  push it  forward with sufficient vigour, being
l( a great cause of disease," is as respectable as some
which have more recently usurped its place in the medical
schools. 
59
ritability.   While only the one system of vessels-
is affected,  we may expect symptoms as in an ir-
ritative disease;  but,  in an  incompressible  vis-
cus, when, along  with increased  arterial  action,
there is also  venous congestion,  the  prevailing
state is that of inirritability; oppression must en-
sue in  all the vital functions;  there is irregularity
in the  breathing and in the pulse, which is  also
slow and labouring.
   I have  met  with a  case  of Hydrocephalus,
where the child died in  consequence of the  dis-
eased state of the brain; yet, after death, no effu-
sion was discovered in the ventricles.*   The dis-

  * Dr. Quin found  no fluid  in the dissection of some
bodies, when there existed every symptom of Hydroce-
phalus    Instances are given by authors, where the dis-
ease early terminated fatally before there  was effusion.
The following case I owe to an ingenious  and learned
friend.
  " The most acute case of Hydrocephalus I  ever attend-
" ed, was that of Captain W—'s child, a boy in his fifth
" year.  He died within eight days after the first sensible
" illness, and was confined to bed only four days.  The
" progress of the disease, although rapid,  was regular,
" the three stages of Dr. Whytt being  well marked. He
" died at length convulsed. The head  was opened. The
" ventricles contained not more than a table-spoonful  of
" watery fluid; but the brain was  so  turgid, that  when
" the bones were sawn fairly round, the section was thrust
" up half an inch by  the sudden and forcible protrusion
" of the cerebrum.  Not only the veins of the pia mater 
                      60
ease was strictly the acute Hydrocephalus; it was
indeed an extreme case of the disease, where the
excitability was suddenly exhausted by the vio-
lence of the attack.  When, as in this case, the
child dies early in the disease, with every symp-
tom of accelerated  arterial action, but before, the
subsequent congestion has existed for any length
of time, the dissection  will never afford  much
effusion.   When, on the  contrary,  the patient
long survives the slow pulse, and when, from the
continuance of  the disease, we  have reason to
think that the congestion has existed for a consi-
derable time, then we find a large  effusion.  In
such cases, I have discovered,  within the head,
little appearance of  increased arterial action, as
marked by the tissue of minute  and florid vessels.
This stage of the disease was over;  yet the effects
of inflammation abundantly appeared in the thick-
ening and greater adhesion of the membranes; in
the great congestion; and indeed, from the pain,
suffusion of the eye,  &c. we cannot doubt that it
exists to the last.
   The great pain,  pyrexia, convulsions, and suf-
fused eye, cannot be derived from a small quan-
tity of a mild fluid in the ventricles.  Do we not

" were loaded with blood in a very remarkable degree;
" the medullary substance of the brain was finely dotted
■*■« with numerous red points, and the cortical  substance
* streaked with pencils  o?red parallel lines." 
                        61
 find immense quantities of fluid, of exactly  the
 same nature, collected in the brain,  without any
 bad symptoms.   Persons have lived under chro-
 nic Hydrocephalus, after the  ventricles were dis-
 tended with twenty pounds of fluid.*  I have, in
 three instances 'of acute Hydrocephalus, after the
 child had been delirious, convulsed, and blind,
 seen  him recover the use of his understanding,
 and,  what was less to be expected,  of his sight.
 Now the effusion must  have begun long before
 this period,  and therefore cannot be held as the
 cause of the suspension  of the animal functions.
 It  is  the  morbid action of the blood-vessels
 wasting the brain, and unfitting it for its functions,
 which destroys the child; and I think  it no rash
 opinion,  that death  would  occur earlier in the
 disease,  did  not the fluid exude, and thus  con-
 tinue to the brain the necessary degree of support
 from within, which would have been lost by the
 wasting of the organ, f
  * For ample information of chronic Hydrocephalus,
 see in the 2d vol. of Sandifort,  a paper,  entitled, J.  H.
 Gaudslij Disacrtatio de Hydrocephalo.  The following
 is the character of this thesis justly given by the editor:
 Ex  praecipuis  scriptoribus, qui hoc  argumentum per-
 tractarunt  omnia quae  illud  illustrare possunt, sedulo
 collegit, et in  brevem lectu dignissimam, epitomen re-
degit.
  t  Some ingenious  remarks  on this subject will be
found in Bell's Anatomy  of the Human Body. vol. iii, p.
73, et seq. 
62
   It is curious to meet this opinion in the writ-
ings of the ingenious and acute opponent of Hal -
ler:  " That the whole symptoms of this disease
" proceed  from  different  degrees of the same
" cause, viz.  the  pressure or  distension of the
" parts of the brain, occasioned by the water con-
" tained in the ventricles."  It is from  the  cir-
culation being loaded, and not from the substance
of the brain being compressed, that the symptoms
of what is usually called compression arise.  Even
were the brain compressible, which the best phy-
siologists  deny, there  is a  striking proof that, in
this disease, it is not compressed.   The veins al-
ways appear remarkably turgid.   Had there been
pressure within the head, they would, upon  dis-
section, be found empty  and  flaccid.  I admit
that there is  tension ;  but  this appears necessary
to life: remove this tension  and asphyxia  will
follow.  Dr. Whytt might have  recollected ma-
ny instances of death following the rash removal
of this tension.  What is the result of tapping the
brain in chronic  Hydrocephalus?  This opera-
tion, which has often been performed  by igno-
rant  men,  is generally almost  immediately pro-
ductive of fatal consequences.
  Could we  suspend  the  diseased  action, after
the effusion even  of a considerable quantity of
fluid into the ventricles of the brain, provided the
structure of the brain were  not  injured,  I rather 
                       63

think we should find little irregularity or defect
in the functions of the body; for, upon dissec-
tion, quantities of effused fluid have  been found
in the ventricles, when no complaint of  pain in
the  head, or  symptom denoting an oppressed
brain, had existed  before death.   Maniacal pa-
tients,  in whose ventricles many ounces  of fluid
have been found, have died without evincing any
Hydrocephalic symptoms, or  symptoms of op-
pression.*   Fluid is to be found in the ventricles,
wherever the substance of the  brain has been ab-
sorbed  in consequence of increased action, from
whatever cause.   In dissecting patients who have
died of a scrophuious disease of the brain, of firm
tubercles called schirrus of the brain, ofsuppura-

  * Whether symptoms of oppression had or had not ex-
isted in maniacal cases, effusion is one of  the most unir
form appearances that is  met in dissection.  In six out
of thirteen, maniacal  dissections, described  by  Mor-
gagni, fluid was found in the ventricles.  See  Arnold
on Insanity, vol. i, p. 278. The physician  to St. Luke's,
Dr Simmons, says, that he has found effusion in a large
proportion of the maniacal cases which it had fallen to his
lot to examine.   Loud  Med Journal for 1785, p.  159.
Of twenty-six epileptic maniacs, there were thirteen in
whom both ventricles were quite  distended with fluid,
and five  others in  whom  these cavities were  full.  Of
twenty-four melancholic patients, there  were  ten in
whom both ventricles were found  astonishingly distend-
ed with water, and four in whom they were quite full.
Medical Aphorisms on Melancholy, Sec. by J. Ernest Gre-
ding.  See Appendix to Crichton on Insanity. 
64
 tion from a diseased bone,  of the consequences of
 trepan, I have found effusion to a great extent.
 There is scarcely an organic disease of the brain
 which is not accompanied by effusion.   The opi-
 nion that effusion into the ventricles of the brain is
 not  necessarily destructive, is also supported  by
 the appearances sometimes found m the dissection
 of apoplectic  patients.  Cavities of a large size,
 containing fluid, the  effect of a former attack,
 have been  found in the substance  of the brain,
 and the person has enjoyed good health  between
 the first and the fatal attack.   And we are not left
 without the aid of observation ; for cases are re-
 corded where Hydrocephalus has abated, after the
 appearance of those symptoms which may be con-
 sidered as indicating water already effused.*
   Dr. Cullen   has considered this disease as a
 variety of apoplexy.  I am inclined to doubt the
   * In explaining the nature of the cavities containing
 a serous fluid, which are sometimes found in the sub-
 stance of the brain, Dr. Baillie observes, " they would
 " appear to be the remains of the cavities formed by ex-
 " travasated blood in cases of apoplexy, when the patients
 " have not been  cut off immediately,  but  have  lived af-
 " terwards for some months or years.   The extravasated
 " blood would seem in such places, to be dissolved and
 " taken up by absorption;  but the injury is not repaired,
 " and  a cavity remains filled with serous fluids."  App.
 to chap. xxiv. Morbid Anatomy.  This would  show, if
the explanation  be just, that effusion is  the  remedy
which nature provides for absorption within the cranium 
65
 propriety of this collocation,  for there appears to
 be little affinity between the two diseases.   Age,
 indolence, and intemperance, lead to apoplexy;
 in their predisposing causes no two diseases can
 be more strongly contrasted.  I  believe Hydro-
 cephalus was never known to arise from any one
 of the many occasional causes of apoplexy men-
 tioned by Dr. Cullen; and as to  the proximate
 cause of Hydrocephalus, I have indeed given a
 very erroneous view,  if it be the same with the
 proximate cause,  according  to  Dr.  Cullen,  of
 apoplexy, viz.  " some compression of the   rigin
 " of the nerves.1'   The attack in apoplexy  is mo-
 mentary, in Hydrocephalus it is sometimes pro-
 tracted; and  when the  diseases are  established,
 there is as little resemblance in the  symptoms  as
 in the mode of attack.
   Although  I derive all the bad symptoms from
 the morbid state of the circulation in the brain, I
 am equally  far from thinking that this resembles
 that which tikes place in phrenitis.*   We  must
                  f
  * Of three children of one family who  died of Hydro-
 cephalus, the two last had the  disease in  a singular way.
 Of the case of the  last I have preserved a note.   In the
 beginning there  was sickness andcosliveness, no  pain  in
the head, great languor; after a purge, which occasion-
ed some tarry stools, the boy was for some time relieved.
He again became  languid, and dosed for several days.
Then convulsions  came on. There was no expression of
pain, nor direct appearance of increased circulation  in
                        F 
60
again apply  the same  test,   and compare  the
causes, symptoms,  and in  particular  the morbid

the head from the beginning, nor indeed till  within thirty-
six hours of death, when the convulsions came on.
  Phrenitis  is a  disease scarcely seen in  this country.
The only case of which,  in thirteen years of full practice,
I have seen, I shall oppose to this note, more forcibly to
show how distinct in character it is from Hydrocephalus.
The occasional cause of  this phrenitic attack was power-
ful; the predisposition had been established by a former
attack, arising from exposure to a tropical sun.
  In August 1801, I was sent for, late one evening, after
an oppressively warm  day, to visit a poor man who was
represented as in extreme danger.  I  was conducted to
a small garret, to which  I ascended by a trap-stair.  In
this small low-roofed room every air hole was shut; and
it was  filled with the  officious women who lived in the
neighbourhood.   The object  of their curiosity was a
young man, full and sanguine, who lay in the corner of
the floor,  under the sloping roof.  Until I got the hatch
in the roof thrown back,  and the room cleared, I was ac-
tually gasping for want of air   This young  man, who had
been a soldier, is now a tobacco-pipe maker.  He was
quite well in the morning, and spent the greater part of
the day at the oven where the pipes are baked.  In the
afternoon, he was seized with a most racking pain, which
darted through his head, with a weariness  in his hams,
and pain in all his bones  and joints.  The pain in his head,
in a short time, became intolerable,  and  he has been
howling from the  intensity  of it.  His countenance is
inflamed; his  eye full and bloodshot; his skin is burning
hot: his pulse quick and bounding; his  breathing diffi- 
67
changes produced by the two diseases.   Now, in
all these  points, the  view  which Dr. Rush has
taken appears erroneous.   Granting even that, in
the main, he were right in his opinion, it  is cer-
tainly  objectionable  both in  perspicuity  and in
simplicity.
   Dr. Rush observes, that the disease in its first
stage is the effect of causes which produce a less
degree of that inflammation  which  constitutes
phrenitis ; and that its second stage  is the effect
of a less degree of that effusion which produces
serous apoplexy in adults.    I have  taken the li-
berty, he adds,  of calling the former stage phre-

cult, from the tightness across  his breast.  He is very
irritable, but quite unable to command his attention.
  This is a man of temperate habits,  who had taken no
intoxicating liquors.  His wife knew no cause  for his ill-
ness, but the heat  of the day and of his work.   He was
wounded while campaigning in the Mysore ; and, during
his recovery from his wounds, he sustained a similar, al-
though less violent attack.  Upon being largely bled he
was relieved; but the attack prolonged his recovery from
his wounds.
  I had the bed  removed into the middle of  the room,
and bled him freely.  I introduced as much air  as possi-
ble into the room,  and left him almost naked.   I order-
ed him 10 gr. of jalap and of calomel.
  In the morning  he was much relieved; the relief fol-
lowed the bleeding; he became almost immediately tran-
quil.   The attack was much more severe than that which
he had sustained in India ; the relief more immediate. 
68
 nicula, from its being a diminutive species or state
 of phrenitis; for the second stage, I have pre-
 ferred the name  of chronic apoplexy.
   Are we  to  understand that the  same  causes,
 opera-ting less powerfully than they  do when they
 occasion phrenitis, will occasion Hydrocephalus ?
 This is not what is expressed ;  but I rather think
 it is intended.    If it is not, I  am at a loss to know
 what those causes really are which produce a less
 degree of  that  inflammation which  constitutes
 phrenitis.   The exciting causes of phrenitis, we
 all know,  are excess  in wine, external violence,
 insolation,  indulgence in the more violent  pas-
 sions, or  indeed excess in  any kind of mental
 exertion.   Now children are  not subjected to the
 influence of any of these causes,  if we except ex-
 ternal  violence.*   To  this, indeed, they   are

   * The causes which act directly on the brain, Dr.
 Rush  says,  are falls and bruises on the head, certain po-
 sitions of the body, and childish plays, which bring  on
 congestion or inflammation, and afterwards an effusion of
 water  in the brain.  The indirect causes  are,  1, inter-
 mitting, remitting, and  continual fevers ; 2, the rheuma-
tism ;  3, the pulmonary consumption;  4, eruptive fe-
vers ;  5, worms;  6, the cholic,  palsy, melancholy, dysen-
tery, dentition, insolation, scrophula.  In the four first
 heads, we may consider the disease as from conversion.
 In the fifth,  1 suppose the Hydrocephalic symptoms are
originally by consent.  In the last head, insolation might
be considered rather as a direct cause.  I cannot account 
69
 abundantly exposed; and  being stated by Dr.
 Rush, in another part of his paper,  as a direct or
 exciting  cause  of Hydrocephalus,  I  shall make
 some observations on this part of his doctrine.
   With extensive opportunities of seeing Hydro-
 cephalus, I have not met one instance of its hav-
 ing been directly, and  I believe only one where
 it was indirectly, occasioned by external violence.
 In three cases which I attended, the disease was
 said to have been  occasioned by accidents.   In
 two of them,  there was  an  interval of nearly two
 months of perfect health: in these, therefore, the
 accident,  as an  exciting cause, must go for no-
 thing.   In the third case, it is noted, that about
 ten weeks before the boy died, while at play, he
 had a severe fall upon his head.   The scar  of a
 wound on the upper and middle of his  forehead
 still continues, about an inch long.    Some  days
 after this fall, he began to complain of pain hi his
 head; but having a severe cold, the headache
 was supposed to  arise  from the  troublesome
 sough.   The child continued now and then com-
 plaining  of  his  head, and  coughing; declining,
 but almost insensibly,  until the eighth week  after
 the accident, when he could no longer go about;
 for  cholic, palsy, melancholy,  dysentery, dentition, be-
 coming indirect causes, in any  other way than by  their
inducing a state of general bad  health, which appeals to
be the most general predisposing cause of any.
                      j2 
                      70
and his friends became alarmed, &c.  This is the
only case in upwards of 100'which I have attend-
ed that can with  any probability be ascribed to
external violence; and I would observe,  even in
this, that due attention ought to be paid to an ob-
stinate catarrh, as more likely to impair the gene-
ral health of the  child,  and to predispose to Hy-
drocephalus, than even the accident.
  Sometimes,  in a  short time after an accident,
there has been observed,  as in this case,  a droop-
ing state, long before the brain is palpably affect-
ed.  I do not mean to affirm,  that injuries  of the
head never give rise to Hydrocephalus ; all I con-
tend for is, that  when they  do, it  is only  inter-
mediately, by inducing this asthenic state,  or by
calling into play  what, from a good and fortunate
management, had hitherto been latent; I mean a
scrophuious condition of the system,*  which I
have repeatedly  seen to follow a severe accident,
and which wonderfully favours the establishment
of Hydrocephalus.
  *  This Sauvages has noticed in more places than one,
 Vid. lorn, i, p. 576, Eclampsia ab Hydrocephalo.  " Ac-
" cidit  infantibus  trium, quatuor quinque  annorum,
:k maxime, illis qui scrophuloso viru sunt  infecti, quo-
■>' rum  mesenterium  glandulis duris est obsitum."  I
have already quoted what he has said under the head of
Convulsio ab Hydrocephalo, t. i, p. 553.  What Ludwig
has said is even stronger.  " Tamen habitum  scrophu-
'•* losum forte habere vim prsedisponendi, &c." 
                      71
  From the causes of Hydrocephalus, a subject
exceedingly obscure,  Dr. Rush proceeds to  the
morbid effects of the disease upon the brain.   He
affirms, that the two  diseases differ only  in  de-
gree :  that Hydrocephalus is only a diminutive
species of phrenitib; and in calling the former phre-
nicula, he is followed  by  later writers.   So far in-
deed has this view prevailed,  that the disease,
undergoing another change  of name,  has been
called  Hydrocephalus  Phreniticus; and this name
is adopted, even in the Edinburgh university.
  , Now it  ought to be recollected, that  Hydro-
cephalus  scarcely ever  affects the adult, and
phrenzy as seldom occurs in childhood.   They
are diseases of different  conditions of  the brain,
the nascent and adult state of the organ.   Phren-
zy  is  an endemic disease.   Hydrocephalus,  I
should suppose to be a  very general  disease, at
least it prevails in very different climates, both in
the new and the old world.  Hydrocephalus I have
oftener seen in children  with dark eyes and com-
plexion ; phrenitis is  the disease of the sanguine
and choleric.  All this should imply  something
 very different in the  essence of the two diseases.
 Hydrocephalus  often indeed appears in children
 who were previously healthy; yet, as I have al-
ready  remarked, it is in strumous constitutions,
such as are but little  susceptible of the phlegmo-
nic inflammation, that  we meet with most fre- 
72
quent instances of the disease : it often, too, suc-
ceeds imperfect recovery from fevers,  particular-
ly of the eruptive kind, and attends the debility
which follows many infantine diseases.  If it be
maintained, that the cachectic state which follows
an  injury  of  the  head,  arises  from the  com-
mencing affection  of the  brain,  this,  it must be
allowed, evinces a very chronic  disease, and one
differing widely  from phrenzy,  which is among
the most  sudden  to  which our frame is liable.
Lastly, it  ought to be  recollected, that,  in Hy-
drocephalus,  the centre of the  brain  is the part
chiefly  affected; at least, in most cases, we find
the effusion on the surface of the brain  bearing
no porportion to that in the ventricles, and the corti-
cal part of the  brain  sound,  while  the central
parts are broken and dissolved; whereas the ef-
fects of phrenitis  are  more superficial *  being

   * When  a blow on the head is fatal, not by injuring
the skull, exciting extravasation, or causing concussion,
but by directly inducing inflammation, this inflammation
would seem to be phrenitic, not merely by the rapidity
of its course, and the  violence of its symptoms,  but in
affecting the surface rather than the  centre of the brain.
I offer this  case in explanation.
   On the   15th May, a carter, about 30 years of age,
tall and  athletic, was knocked down by a stone striking
him on the  back part of the head.  The wound was tri-
fling ; it was situate at the lower and back part of the
parietal bone ;  but he lay senseless for some time after 
73
 sometimes apparently confined to the membranes
 on the  other side.   The assertion of  Dr.  Rush,
 receiving the  blow, and, on recovering, was much  af-
 fected with nausea; and, from the first,  he complained
 of severe pain in his head all about the wound.
   On  the 16th,  after  a  sleepless night, he was found
 complaining of pain and  nausea,  vomiting  whatever he
 drank, his tongue becoming foul.  He had  a cathartic,
 which operated briskly.
   17th.  The  symptoms were increasing,  the  pain in
 particular.  He complained of deafness in the ear of the
 Bide on which  he was struck, and  of a pain extending to
 the upper  part of the neck.  His tongue was foul; his
 face flushed; p. 72, and full   He was largely bled.
   18th.  Yesterday he  burst into expressions of wild re-
 venge against the man who  threw  the stone  at him.   In
 the night, or  rather  early  this  morning,   he became
 delirious.   He tore the fillet from his arm, and lost a
 great quantity  of blood in  his struggles.  He is to-day in
 a state  of the most restless uneasines, flinging about his
 arms, knitting  his brows, and contracting his eye-lids,
 quite incoherent.   The case now  appeared of the most
 hopeless kind;  but that nothing which medical skill could
 suggest might  be untried, Dr.  Monro, senior, was  call-
 ed into consultation.  We cut down to the bone,  rather
 to relieve the vessels of the scalp,  than with  the expec-
 tation of finding any injury.   The  bone was  sound.   He
 was again largely bled,  his pulse being 116; two hours
 after, it was not to be numbered.  He died in less than
 four hours after the consultation.
Dissection of the Head, obligingly made for me by Mr. Fyffc,
                      May 20.
  Upon laying back the skull-cap, it did not  appear that
the cranium had received any injury.  It was only upon 
74
that the second stage of Hydrocephalus is the ef-
fect of a less degree of that effusion which produ-
ces serous apoplexy,  is gratuitous ;  and the vio-
lation  of nosological propriety, in giving a dis-
tinct name, chronic  apoplexy, to  this stage, is
unnecessary; for it is not effusion which produ-
ces apoplexy; neither,  as I have already proved,
are the symptoms of the second stage of Hydro-
cephalus the effect of effusion ; nor is the effusion
less in degree in Hydrocephalus than in apoplexy.
   These  observations apply to the  disease in
whichever of the two first forms it makes  its ap-
proach.   If it be said, that,  in the second varie-

slitting up the  dura mater that the morbid  appearances
presented.  The falciform process was inflamed.  There
was no. uncommon turgescence of the veins; but marks
of inflammation were apparent all over the surface, both
above and  on  the  base of the brain  ; and  these were
most conspicuous between the convolutions of the brain.
Under the pia mater there was serous effusion, with, in
many places, a deposition of coagulable lymph.  The
coagulable  lymph was more generally  spread over the
surface of the cerebellum than  upon any other part of
the brain;  and  it surrounded  the vessels  as they dipt
into the substance of the brain.
   Upon  making an incision into the substance  of the
brain, the points of blood left on  the cut surface were of
a dark red colour.
   From  the right lateral  ventricle, there flowed about
half an ounce of serum, more than usually turbid.  There
was found a similar effusion in all the ventricles. 
                      75
ty there is much  of the violence of a  phrenitic,
attack, it may be urged in reply, that  although,
as asserted by a very respectable writer  (Ludwig)
the attack be modified by the constitution of the
child, " Quo robustiores sunt infantes,  eo violen-
" tior prima morbi accessio esse solet, et contra"
or by some less obvious cause,  yet there is a per-
fect identity of action, as may be proved by the
similarity in the suit of the symptoms  of the se-
cond and third stages, of the termination of the
disease, and of the change produced in the struc-
ture of the organ.
   Dr. Darwin has said,  that " Hydrocephalus
" internus, or dropsy of the brain,  is  fatal to
" many children, and some  adults.   When the
" disease is  less  in quantity,  it probably  pro-
" duces  a fever,  termed a  nervous  fever, and
" which is  sometimes called a worm fever, ac-
" cording to the opinion of Dr. Gilchrist, in the
" Scots Medical Essays."  There is here an ob-
scurity which it is hardly possible to dispel,  Per-
haps, mutatis mutandis,  I may recur to the form
of words  used by Dr. Rush, and  say,  that our
disease is the effect of causes,  which when less
powerful, produce nervous  fever.  To nervous
fever, we have Dr. Darwin's authority for say-
ing, that the typhus mitior is synonymous.   But
this is very  rarely called worm fever, and very
erroneously,  when so called.  Synonymous  to 
76
worm fever (an absurd designation  for any dis-
ease) are febris lenta infantum, febris lenta remit-
tens.  The typhus mitior,  it is generally admit-
ted, is produced by specific contagion, which, in
its  progress, it re-produces.   For this  disease,
Dr. Darwin, as remedies, advises wine,  opium,
&c.; nothing but stimulating medicines.  Now
we certainly are so little assisted by this analogy,
that we  may dismiss it without  any ceremony.*
   Nor do  I think  that the  disease is brought on
by causes  which  increase plethora within  the
head,f  as by the  suppression of  wonted dis-
  * If there were any merit in this opinion,  it rather
appears due to Dr. Macbride, who  has said, " that the dis-
" ease which Dr. Whytt has described so accurately, under
" the name of the internal dropsy of the  brain, appears
" to be a  nervous fever, and might rather  be termed the
" Hydrocephalic fever, as the appellation of dropsy gives
" an idea of a chronic disease.  It is peculiar to young
" subjects, and  is the most  deceitful of  all the febrile
" diseases, beginning for  the most part, like a  common
" fever, with slight anomalous symptoms," &c.   Metho-
dical Introduction to the Theory  and Practice of Medicine^
vol. ii, p. 49.
  t I shall subjoin a case of a disease very different from
Hydrocephalus,  brought  on  by violent exercise, in a
young man much disposed to what is called plethora in
the vessels of the head.
  J------S------, set.  23,  master of a  trading vessel,
a  tall and  active young man,  with a  sallow com-
plexion,  and languid, or rather dull  expression of coun-
tenance. 
77
charges, tumbling, or other childish plays, attend-
ed with stooping, or indeed by any obstruction to

  On Friday, 13th of September, he was at a merry-mak-
ing,  and danced all night, and came home on the morn-
ing of Saturday, apparently overcome with fatigue.   On
Sunday, he was languid and drowsy.   On Monday, upon
leaving his ship in the morning, he found himself giddy,
and in coming along the quay,  he was much ashamed to
find  himself staggering, as if intoxicated.  In the course
of the day, this  vertiginous  feeling increased, and he
was  very  dyspeptic.  On Tuesday,  with a  view of re-
lieving these uneasy feelings, he took an emetic,  which
produced  some vomiting, and occasioned considerable
flow  of blood from the nose,  and a greater degree of
sickness,  and the  sickness continued all day after.
  September  18th, Wednesday,   I found his p.  41,  per-
fectly regular, and of a  moderate  strength.   He has
slept well  during the night; and  he can  fancy himself
quite well while in bed ; but whenever he raises his head
from the pillow, the giddiness returns.  I made him rise
out of bed; he staggered  to  the window; and I  found
his pulse raised by the exertion to a natural quickness;
hut before he rose from the chair to return to bed, it had
sunk to 48. He was so overpowered with sickness, that
I was obliged  to support him in his way back to bed.
  It  is painful to him to fix his  eye upon any minute ob-
ject,  or indeed to  exert it in  any way ;  but his  vision is
not otherwise impaired.   His  manner is not natural.
He is generally  absent;  but sometimes, although not
without an apparent effort,  he is  for a short time ex-
tremely attentive to what  is said, but is not able to com-
mand his  attention for any length of time.  This I ob-
served, even when, by his own account, he was but lit-
                         C 
78
the return of blood from the  head.   These may
and do occasion venous congestion, and perhaps

tie affected with sickness or giddiness.   He has scarcely
any headache : his belly is costive.  In his habits of liv-
ing he is  temperate.   He says he  knows no  cause for
his illness.
  In the month of March last, his head was much hurt
by the fall of a carpenter's addice from a great height,
which divided the scalp for three inches in length.  The
wound healed easily;  and he says he  was in his usual
health in the latter end of last week.   All his life, till
within these eighteen months,  he  has been, in the warm
season,  subject  to profuse bleedings from  the nose,
which kept him much paler than  he is at present.   His
landlady says, that, for these two months he never came
into her house that he did not appear drowsy, often lying
down to sleep in  the day-time, and sometimes he would
fall asleep with his head resting on his arm.  I directed
3 xij of blood to be taken.

             R. P. Rad. Conv. Jalap.
                Submuriat. Hydr.  aa. gr. x.  i\.
  Sit pulvis q. primum sumend.
  September  19th.  The  purge  operated  freely.   He
slept well; but awoke  this morning with the same feel-
ings, and with some pain in his belly ; p.  48.  I had lb.
I. of blood taken from his arm; the blood in neither case
sizy. The pulse was not .affected by the bleeding.  He
complains of thirst.  Repeat the purge.
  September  20th.  He has had  several stools.  Since
the last bleeding, the  sickness and  giddiness have not
been nearly so distressing. He sat up all the  afternoon, and
passed a better night; p. 68 ;  tongue white; urine high- 
79
serous extravasation; but congestion, when not
produced by arterial action,  is attended with very

coloured.  He has still some giddiness, and is unable to
walk without  staggering ; but he  finds himself much
better,  and is able to look steadily at an object.  Repeat
the powder.
  September 21st.  There has been no return of the sick-
ness.   He  is still giddy.  He  slept several hours last
night,  but  was much disturbed by frightful dreams.
His belly is lax ; urine scanty and high coloured; p. 48;
gums and tongue affected by the mercury.  I directed
another free  bleeding, which  in no way  affected the
pulse.
  September 22d.   The blood  is sizy.  The night he
passed  restlessly; but  fie  is much better  to  day; the
sickness and giddiness arc abating ; p. 48.
  R. Sod. Phosph. 3 x. c juris bovini lb. i.  sumendas.
  September 23d.   In the afternoon, yesterday, he was
(breed to go to bed,  by the vertiginous feeling somewhat
modified.  After  an  attempt to read,  suddenly every
thing in the room seemed to spin  round with  great ra-
pidity.  This continued for nearly an hour; however, he
passed  the night well, and to-day he feels comfortably.
He has no remains of the vertigo or sickness ; and his
pulse is nearly natural.
  January  1806.  I met this young man, apparently in
excellent health.   He had no return of his complaint after
the 22d of September.                           '
  In a  vertiginous  complaint  of many years standing,
supposed to have  been brought on by wearing the neck-
cloth too tight to hide scrophuious cicatrices, the symp-
tsms were,  vertigo in stooping, a sense of fainting when 
80
different symptoms; and were this plethoric state
of the vessels fatal, the brain  would be found in
a very different state.   Hydrocephalus, as I have
already said,  appears to me to consist of a dis-
eased action of a peculiar kind.   What this is we
can as little explain as we can  the nature of  the
scrophuious or  syphilitic  action.   Our object
therefore here, as in these actions, is  to register
and arrange every essential fact, and never to re-
lax in our inquiry,  until,  by this induction,  we
shall arrive at a successful practice.
  Before entering upon the consideration of the
plan  of treatment,  I  beg leave to recapitulate
some  circumstances characteristic of Hydroce-
phalus.  They all  appear to%present themselves
upon taking an attentive view of the disease.
   1st,  Hydrocephalus often arises after a manifest
disorder of the digestive organs has existed for a
considerable time.
  2dly, Hydrocephalic symptoms of short stand-
ing often disappear while  we are  correcting  the
disordered state of these organs.
the head was suddenly thrown back, strabismus, paralytic
debility of the whole frame, diminution of mental energy.
  In these  cases,  I  am  inclined to think,  that, in the
first instance, there is no  arterial  action; mere plethora
from  venous obstruction, and perhaps some degree of
extravasation.  I do  not, however, pretend to say, that
this obstruction may not be the cause of arterial action.
I think the affirmative highly probable. 
                      81
  Are we not encouraged by every analogy  to
state as a thing probable in  the highest degree,
that, in these cases,  the Hydrocephalic action
arises from the brain sympathizing with the dis-
ordered condition  of the liver  and  alimentary
canal?
  3dly, In its first stage, Hydrocephalus is evi-
dently attended with a considerably increased ar-
terial action.
  4thly, In as far as we  know of these, the Hy-
drocephalic action differs essentially from the apo-
plectic and phrenitic actions.
  5thly, If, independently of arterial action, such
a state as plethora, in a particular system of ves-
sels, can with propriety be said to exist, the Hy-
drocephalic action  differs widely from such ple-
thoric state.
  6thly, Several diseases appear convertible into
Hydrocephalus.
  7thly, But, in  as far  as we know,  scrophula
alone, with Hydrocephalus,  is liable  to mutual
conversion.
  When gout leaves the joints, and the patient
dies, from an attack of  pain in  the stomach,  or
from an apoplectic attack ; or during an attack of
acute rheumatism, when the pain  leaves the ex-
tremities, and the patient dies,  after exhibiting
unequivocal  symptoms  of a pneumonic attack,
occurrences daily tobt met with, it is never doubt.-
                      c2 
82
ed that these transitions  are symptomatic of the
original disease.  When from an  attack of scro-
phula,  there is a change to Hydrocephalus,  it
would almost  appear, that the symptoms of the
latter were a continuation of the former disease.
This is the most obvious view of the change; it
is what first occurred to me.   But, although I
would by no means be understood to speak with
confidence,  there is a difficulty in  the way of this
conclusion,  which inclines me to consider  these
changes as instances, not of metastasis or transla-
tion, but  of conversion.  There is  another dis-
eased state of the brain evidently produced by the
agency of scrophula; I mean the tubercular; and
therefore, if a morbid action be uniform when it
seizes the same structure, and this I believe  is
admitted, Hydrocephalus  cannot  well be consi-
dered as an effect of scrophula.   It would appear,
that we are not warranted in admitting more than
a great affinity between the two actions;  that, by
the one, a  great tendency to the other is  esta-
blished.
   Tlje following propositions are rather to be con-
sidered as anticipations of what will appear in the
sequel.
   1st, This  disease so seldom, without the  in-
terposition of art, terminates in a healthy condition
of the brain, that it may be assumed, as strong-
ly the  tendency of the  Hydrocephalic  action, 
83
to terminate only  with the destruction of the
organ.
  2dly, We are at present  ignorant of any way
of subduing Hydrocephalus without the substi-
tution of another constitutional irritation.
  Perhaps those  cases,  in the  appendix,  in
which  little effect was apparently  produced  by
the mercurial medicines, and where the digitalis
seemed to produce  so much,  may be  urged
against this proposition.   I shall  be happy  to
find it  invalidated.   But the question must  be
determined  by man}* trials, not  by one or two
cases,  where  mercurial medicines were  freely
employed, and which sometimes in other diseases
are beneficial, even in the absence of those effects
which usually denote their presence in the system.
   3dly, After the new irritation  is substituted,
there is a much  greater  chance that a healthy
condition of the  brain will  ensue,  than that Hy-
drocephalus will return.
   4thly, But it ought not to be overlooked, that
there arc instances of the return of Hydrocepha-
lus,  after it had been apparently subdued.
   5thly, Increased secretion of urine, and unu-
sual diaphoresis (especially  from  the head)  fre-
quently the former, have occurred when this dis-
ease has terminated favourably.*
  * Are these occurrences to be considered critical, or
ought they to influence the curative plan I   The appear- 
84
   In  the progress of  Hydrocephalus, we  liave
reason to think that the state  of the brain varies
much.  During the existence of the precursory
state,  although  there  be excitement,  probably
there  is no increased vascular  action in the brain.
In the beginning of the first stage, the effects of the
increased action upon the sensorium are perhaps

ance of the urine varies so much in different patients, that,
in the  history of the disease,  I have taken no notice of it.
When the urine, after giving mercury, flows very freely,
I consider it a very favourable prognostic.   The follow-
ing communication from a friend, shows a termination of
the disease unusual, but I believe not singular.  " I have
" frequently observed, in the last moments of Hydroce-
" phalus, and when the patients were evidently moribund^
" a profuse sweating about the neck, or back part of the
« head.  My father used to mention the case of Mr W.
" S----'s  child, where a very profuse evacuation of this
« kind had the appearance of being critical.  This child
" was  attended by my  father and an eminent physician
" from Edinburgh.  The disease was  considered by
" both as Hydrocephalus, and treated accordingly,  till
« the child was thought past all hope.  The physicians
« visits were discontinued.   A profuse sweat broke out
" on the head  and neck, and flowed so  copiously, that
« the pillows  had to be shifted, one after another, as I
u have heard my father say, and as I have since been told
" by the father and mother, to whom I addressed myself
11 for farther information.   From that moment, the child,
■u who had for days  lain in an  insensible and hope-
« less  state, is  said sensibly to have recovered,  and yet
« lives.  Seven years have elapsed since his recovery." 
                      85
not great: even  when the disease  is  so far ad-
vanced that the  patient is febriculose, averse to
light, sick, disturbed in his  sleep, and in great
danger, perhaps  we should see  but little marks
of arterial  action.   In  cases where,   from the
symptoms, there was no  doubt of  the existence
of Hydrocephalus, no diseased appearances have
been found in the brain.  We however know,
from dissection,  that before the  patient has con-
tinued for many  days  in this alarming state, there
are sufficient proofs of arterial action.   When the
pulse is becoming irregularly slow, the effusion
is  probably beginning; and  as the slowness of
the pulse  is going off, when the torpor is great,
we should discover all the remains  of arterial ac-
tion, adhesions of the membranes,  great conges-
tion, effusion, and even obvious change of struc-
ture.   We shall find all these, when then the pa-
ralytic  or epileptic symptoms have  been present,
with the addition of effusion,  proportioned to the
duration of these symptoms.
   One class  of medicines, or one  regimen, can
scarcely be expected to suit all these states of the
brain;  on the contrary, I  believe every different
stage, certainly every  different  form of the  dis-
ease, requires a considerable  difference of treat-
ment.
   I have made the general history unusually full,
as the early detection of the disease is one great 
86
object of this essay;  and on the second or third
day from the attack,  it often appears with so dis-
tinct a character,  that all the danger is laid before
the diligent inquirer;  and it is now that he must
employ the most active  measures; there is  no
time for regulating his practice  by the result of
doubtful remedies.   For this disease, which un-
fortunately he too often meets with, the physician
must ever be  on the  watch.  He ought never to
hear a child complain of headache,  without pro-
curing the history previous to this complaint, and
comparing  it  with every ambiguous symptom.
He scarcely should trust the symptoms to his me-
mory.  In a page of a small note book, I have the
scheme  of Hydrocephalus, which will  be found
below;*  and while prosecuting my inquiries into
  * Constitutional Tendency.   Hydrocephalus a
disease in  the family, scrophuious  constitution.
  Previous  Diseases.   Fevers, disorders in the  ali-
mentary canal, scrophula active
  Precursory  Symptoms.   Irregular  appetite, dys-
pepsia, foulness of the bowels, disturbed sleep.
  1st. On Stage  of increased Sensibility.  Ex-
pression.  Contracted pupils, reserved and timid manner,
aversion to light. Sighing.  Febrile Symptoms.  State of
the pulse, watching, starting from sleep, headache, sym-
pathetic pains, vomiting.  State of the Belly.   Nature of
the stools, pain in the bowels, tenderness of the belly.
Smell of the breath.
  2d. Or Stage of Torpor.   Irregular  Fulse. Slow,
how altered by  exertion.  Respiration.  Irregular, sigh- 
87
the nature of the disease,  I have frequently  had
recourse to it;  and unless the symptoms are very
forcibly  impressed on the  mind, something of
this kind is necessary.
   The chance of cure is nearly in proportion to
the duration of the symptoms: if early discover-
ed, although a very dangerous, it ought not to be
held an  incurable  disease.   After what has just
been written,  I  need hardly add, that I act upon
a principle different from that laid down by some
authors, and several  physicians, with whom I
have conversed.  While there is a doubt remain-
ing,  that is,  until  the disease  is in  a hopeless
form, they proceed as if the symptoms arose from
worms,  or some cause of irritation, unconnected
with the state of the brain.   To hope  for the best
is the part of the patient's friends, not of his phy-
sician.   It is to take from the already  too unequal
chance  which he  has of recovery.   My practice
has been, when my fears are  once awakened, to
ing.  Expression.   Subdued  manner, enlarged pupil,
slight strabismus, dosing.  State  of the  Intellect.  Ten-
dency to delirium, pain indistinctly complained of. Urine,
stools.  Changes in the excitement
   3d-  Or Paralytic  Stage.   Expression.   Vacant,
suffused eye.  Quick and thready pulse    State of the In-
tellect.  Insensibility, raving, coma, occasional recovery
of intellect.  Palsies and Convulsions  State of the pupil,
horrid squinting,  sawing  witn  the hand,  opposite side
palsied.   Hurried respiration, manner of death. 
88
lose not an hour in prescribing the remedies from
which I  should expect  benefit,  were the disease
in the most unquestionable shape; and whatever
good  may have arisen from this principle,  I will
venture to affirm, that it never was productive of
barm.
  I now proceed to the indications of cure.  These
appear to me to be—
  I. To remove from  the constitution every ir.
ritation which  either may have given rise to, or
may have assisted,  by morbid  sympathy, in pro-
longing the diseased action in the brain.
   II. To subdue the Hydrocephalic action;  1st,
by diminishing the increased activity of the circu-
lation within the head; 2dly, by  substituting a
new action.
   III. To alleviate pain and sickness if very ur-
gent.
   IV. To accept every  assistance offered  by
 counter irritations,
   V. To  support and renew the strength;  to sup-
 port  it more particularly under any critical dis-
 charge.
   It is with great diffidence that I attempt to ex-
 plain what appears to me to  be the method of
 curing this disease.  The cases which are added
 to this essay, would show, that the disease yields
 to different methods of treatment.   They clearly 
89
point out the necessity of unwearied attention on
the part of the physician.
   By the following detail it will appear, that some
of the remedies recommended are quite opposite
in their tendency to others.   Some of them, viz.
the evacuants and digitalis, reduce  the vascular
action; others,  the  mercurials and blisters, in-
crease the action of the  arterial  system."*   The

   * Dr. Rush observes, with  great  discernment, that
this disease is produced nearly in the same manner as
pulmonary  consumption, by debilitating causes,  which
act primarily on the whole system.  I quote the following
paragraph from Dr. Garnet's remarks on Hydrocephalus,
already referred to.  I think the view just* and the prac-
tical deduction worthy of all attention.
  " In strong subjects, especially those who have attain-
» ed the age of puberty, general bleeding may be  used ;
11 but I should rather prefer local bleeding,  because even-
k' lually a great degree of debility comes on ;  and  it seems
« probable,  that the  accumulation in the vessels of the
■' head may be most  effectually relieved by evacuations
" made as near the part as possible.   I  am convinced that
" there often exists,  not only in this disease, but in some
" others of the inflammatory  kind, a  local inflammation
" without  much sthenic diathesis ; and  when the vessels
" have taken on an inflammatory action in any part, genc-
" ral bleeding may be employed to such an extent as to
M weaken the system very   much, without considerably
" abating the  increased action, while local  bleedings,
" especially after one general evacuation, often produce
l< a speedy solution of the inflammation."
                          H 
90
seeming inconsistence  will be  reconciled,  by
keeping in view the general indications of cure,
and that this is one of those diseases too little con-
templated by theoretic writers, where the state of
the organ affected appears to be at variance with
the  state of  the  system;  where  the  increased
action of the vessels of the part often follows ge«
neral debility; in a  word, where, to avert im-
pending destruction,  we  must employ measures
contraindicated by the existing diathesis; mea-
sures which, it is obvious,  must be strictly li-
mited by the danger,   I may also add, in apolo-
gy for practice which may seem too experimen-
tal, that I know no disease  which is so much in-
fluenced by the age,  constitution,  and tempera-
ment of the patient.
   Our  attention, in the first instance, must be
directed to the state of the alimentary canal.
   In  perhaps   every instance, upon the first ap-
pearance of symptoms of Hydrocephalus, it will
be safe to use some strongly cathartic medicine;
and it will be proper to repeat this as circumstances
require.   But, should we  ascertain that the ali-
mentary canal is torpid,  and imperfectly perform-
ing its functions, admitting an  accumulation of
faeculent matter,  or that  the secretions  flowing
into it are vitiated or diminished in quantity, which
we discover by the peculiarity in the  appearance,
or the pungent fee tor of the stools, we must, by 
                      91
steadily pursuing the  purgative  plan,  endeavour
to effect a change; for,  while this is produced in
the appearance of the stools,  by the stimulating
quality of our medicines, we are effecting a most
important change in the hepatic system, alimen-
tary canal, and all the parts, including every organ
essential to life,  which is connected with them.
  The purgative plan  may  be pursued without
inducing debility; on the contrary, with evident
accession of strength,  as long as there  is foulness
of the bowels;* either while the stools are foetid
and clay-coloured, or  while they are  dark and
slimy.   Occasionally, purgatives may  be  given
in the more advanced stages; in the state of the
bowels  peculiar to this disease,  known by the
oily-looking, or glazed dark green stools.   This
cannot be accompanied with any  sanguine ex-
pectations of effecting a cure; for these Hydro-
cephalic  stools appear to me to arise from the
liver,  acted upon by an excited state of the brain;
nay, these medicines may somewhat  retard the
establishment of the mercurial irritation; but they
will stimulate  the torpid canal, perhaps prevent
reaction upon the brain; obviate any  accumula-
tion in the great intestines;  contribute to keep
away  the purging and the dyspeptic  symptoms,
to  which the disease  is so liable;  and certainly
  • The note which this letter refers to will be found at
the end of the appendix. 
                     92
assist in moderating the convulsions, which ge-
nerally conclude the disease.
  When the disease is somewhat advanced, the
most active  purges will  sometimes be found un-
availing.   This arises from the torpor,  and per-
haps in part from  the   inverted motion of the
alimentary canal.   As combined with nausea, I
have found it difficult, sometimes impossible, to
remedy this condition of the bowels; sometimes,
however, when the strength of the patient is such
as to render the practice safe, it will  be  removed
by a general bleeding.
  In most constitutions, the first doses of almost
every preparation of mercury,  more especially of
calomel,  stimulate the  bowels.   If  this be the
case,  it is obviously the most suitable medicine.
In many, however, more particularly  after the
first dose, mercurial medicines have not this ef-
fect, and  in some  they appear  to render the
bowels torpid.   Wrhen  they have no purgative
effect, we must give, in  addition, some other me-
dicine, as scammony, gamboge, jalap, or aloes.
  Even should we observe little disorder in the
alimentary canal, biliary  secretion, &c. and should
the strength of our  patient be unimpaired, and
his constitution originally sound, we  shall find no
ill consequences  arising from the exhibition  of
purgative medicines, perhaps every  second  or
third day;  and,  from every analogy, we may in- 
93
fer, that these will abate the pain and increased
action in the head.
  Purges  have generally been  given in this dis-
ease ; but, when called early, what I recommend
is, the exhibition of the largest dose, which can
with safety be prescribed, of some powerfully ca-
thartic medicine, two, three, or four times a day,
and this continued for several days, or until na-
tural  stools are procured.   The advantage  of
keeping the intestinal canal  under the continued
influence  of a stimulus, I  have, in various in-
stances, found to be so great, that I am induced
to repeat  the  declaration of my  belief, that the
happiest result may be expected from this mea-
sure.
  When symptoms of Hydrocephalus arise after
the constitution has been exhausted  by a former
disease, I need not say how discouraging the case
is;  yet  it appears as if the cure ought, in this
instance, to be attempted  chiefly by purgative
medicines, assisted by blisters.
  These observations apply to the disease, from
whatever cause it may seem to have arisen; not
so the following.   The family constitution; the
constitution,  age,  and strength of the child; the
immediate and remote causes of  the attack, and
the symptoms present must be taken into account.
By these considerations,  at  least  as far as blood-
letting is concerned,  will be regulated the remain-
                     v2 
                        94

ing part of the  plan.   I conceive,  that  the phy-
sician, who,  like Dr. Rush, recommends  unli-
mited blood-letting,  and  he  who,  considering
Hydrocephalus as a dropsy, or disease purely  of
debility,  prescribes bleeding, are  equally  mis-
taken in their practice.
   In most cases,  local .bleeding by leeches,  or
cupping, or  general  blood-letting,  according  to
the state of the pulse, and strength of the patient,
must be  had recourse to.  This evacuation not
only brings down the pulse, and relieves the pain,
but is .of signal service when we are determined
on a mercurial course :* nothing so immediately

   * In Macgregor's Med. Sketches of the Expedition to
Egypt from India, p. 178, I find a confirmation of this
opinion, as to the  assistance derived from bleeding, when
we would secure the speedy effect of mercury. He
writes while he is treating of hepatitis.  " Sometimes  in
" Egypt, and in many instances in India, I have observ-
" ed that I could  not  affect the gums with mercury,  or
••" with acid, till venesection was performed.   After this
" operation, I have often succeeded;  and induced a flow
!' of saliva, in cases which had long resisted a liberal use
'' of mercury and  nitric acid."  I conceive that we must,
in a great measure, subdue the violence of the Hydroce-
phalic inflammation before the constitution will submit
*.o the influence of mercury.  I believe  that this princi-
ple is of general application, and ought not to be over-
looked when mercury  is to be given,  particularly in dis-
eases of high action.   The system, in robust young men,
must  be  brought down by confinement and  a reduced 
95
renders the constitution susceptible of the powers
of mercury.  With this view, when I could not
otherwise affect the mouth, I have, successfully
prescribed blood-letting.  However, I  am  con-
vinced that blood-letting, unless in very robust
constitutions, or in the second variety of the at-
tack,  is not to be repeated without great danger;
it must increase the debility which is induced by
the disease, and which sometimes  is such as  to
remove all hopes of a cure, even  when, by the
renovation of the animal functions, we  discover
that the Hydrocephalic action is suspended.
   I have applied leeches and blisters to the region
of the liver, to prepare the  way  for,  and co-
operate with,  the purgative  medicines (which
are generally of the cholagogue  class) in restor-
ing this viscus to a  sound performance of  its
functions; and I have imagined that benefit was
derived from these applications.
   The use of bleeding after the stage of increased
sensibility may  seem questionable.   Those  who
consider the disease at its acme before the begin-
ning of the stage of torpor,  may think  bleeding
improper,  when it is to be considered in its de-
clination.  As I hold that there is increased action
diet, when we would bring on salivation, for the cure of
venereal complaints.  This shows, that even the vigorous
state of the vessels of health is unfavourable to the mer-
curial influence. 
96
during the whole  progress of the disease, I do not
hesitate, with a stout child,  to recommend local
bleeding, if it is otherwise indicated at any period
before the appearance of the convulsions.*
   When the  existence  of the disease becomes
probable, there ought to  be no other delay than.
that occasioned by our endeavours to subdue the
disorder in the bowels,  in commencing the mer-
curial course, which, it must be  allowed,  has
cured Hydrocephalus, even  when far  advanced.
I have witnessed the efficacy of mercury, in se-
veral cases  of which I  have no voucher.   This -
medicine has, in many instances, in the practice
of Percival, Dobson, and others,  cured the dis-
ease.  Two of the cases subjoined show the vir-
tues of mercury in a strong light:  and it should
give us more  confidence in  this remedy, that I
have several times  observed, when the mercurial
stimulus was fully established, that the symptoms
were  interrupted,  and the  termination of the dis-
ease,  although fatal, unlike what we find in cases
where mercury has not been used.f   The  con-
  * Is this a disease favourable to  the trial of the cold
effusion ?
  t Zoonomia, Class  I, 2,  3,  12.  « A  solution of hy-
" drargyrus muriatus, corrosive sublimate of mercury
" three grains, dissolved in an ounce of rectified spirit of
" wine, is said to produce instantaneous  and violent sa-
" livation, as described Class II, 1,  5, 1.  Could a small
« quantity of this violent stimulus be used, according to 
97
vulsions  were  suspended; the senses,  both ex-
ternal and internal, restored;  the disease  appeared

*■**"■ the age of the child, with probable good effect ? Could
'<■ the trephine be  used with safety or advantage when the
" affected side can be distinguished ?" Turning to Class
" II, 1, 5, 1, we find it  stated, « that Mr.  Wright, an el-
" derly surgeon in Derby, thirty years ago assured the
« author, that he  had frequently given half a  drachm of
« corrosive sublimate as an emetic, without  any incon-
" venience to the patient."
  All this appears to me very inconsiderate; and it is the
more  reprehensible,  as  proceeding  from a physician
whose writings, from the extent of his observation, are of
good authority.   The  suggestions about  the trephine is
innocent, as  no surgeon  in  his senses would in such a
case listen to the  proposal: even the mentioning of such
a thing betrays an ignorance  of this part of pathology ve-
ry unworthy of the author.   But the recommendation of
corrosive sublimate is  really reprehensible, and ought to
subject the author to the severest censure.  An unguard-
ed person, when  he reads that half a drachm of this drug
 had been given by an  experienced and  respectable sur-
 geon, might be induced to prescribe it in a fatal dose.
   Although this  is  no excuse, I cannot help thinking
that there has been some mistake or misapprehension in
 Mr. Wright or Dr. Darwin.  The muriate of quicksilver,
 in a much smaller dose than half a drachm, is a certain poi-
 son. In very divided doses it is prescribed in untractable ve-
 nereal cases; but it is  an unmanageable medicine. I have
 known gr. ± bring on  alarming vomitings; and in small
 doses it  sometimes affects  the bowels  with great vio-
lence. I  leave  the reader  to judge whether this be a
medicine for an  infant labouring under  Hydrocephalus. 
98
 to be checked;  but the debility was such, that the
 vital functions  languished;  and the constitution
 had sustained so great a shock, that every effort
 to invigorate them was unavailing.
   The digitalis purpurea has repeatedly been re-
 commended for the cure of Hydrocephalus.  The
 use of  it might have been suggested by the ana-
 logy between  this complaint and phthisis pulmo-
 nalis.   I have not used this  mefficine long, and
 some of the cases have been nearly hopeless when
 I  took  the charge; therefore the observations
 upon it which I have to make will be few.  Yet
 I cannot be altogether silent,  as I have observed
 it  to produce a great, and in two cases,  I con-
 ceive, a salutary influence. Of these cases, which
 are added, I shall, however,  leave tho reader to
 form his own  opinion.
   Digitalis is  a  medicine of  great power, but it
 operates so differently  on different constitutions,
 that it must also be held a medicine of great un-
 certainty, requiring in all cases to be very nicely
 managed.  I have found an adult, from the con-
 stant tendency to deliquium,  pain in the temples,
 and depressing pain at the pit of the stomach, un-
able to bear 30 drops a day of the same prepara-
 tion (the saturated tincture) of which I was giv-
 I may add, that, when given in  moderate doses, it will
often disappoint  our expectation,  as it often fails in rais-
ing salivation. 
99
ing daily to a child, four years old, 120  drops:
we cannot, before trial, say what quantity of this
medicine  a patient  can bear.   The effects  of it
have little analogy with those of some other active
medicines.  An  under-dose of opium will pro-
duce, in an inferior degree, a similar  effect  to
that which is  produced by an over-dose.   Ten
drops of laudanum  will, in most constitutions,
induce languor; 50 drops, profound sleep.  But
of tincture of digitalis, although 50 drops would,
in most constitutions,  occasion vertigo, sickness,
great  prostration, in  some, for  aught I know,
death; yet ten drops, in the same persons, would
not produce  the slightest  effect:  therefore  an
under-dose of this medicine goes  for nothing.  If
we do not use efficient doses of digitalis, we are
undoubtedly trifling.   Again,  digitalis  does not
act with that uniformity which we observe in the
operation  of other  medicines: before trial,  we
cannot say what part of the system will be affect-
ed.   Another remark may be  worthy of notice:
we  cannot, by gradually augmenting the dose,
give, without danger,  what, in the first instance,
would be an over-dose, as  we  can of opium: for
instance, beginning with 40 drops of laudanum,
we  may bring the dose up to 400, in  short,  to
what, were not the  constitution gradually inured
to it, would be a fatal  dose.  But when we  give
as much of the tincture of digitalis as will affect 
100
"die heart, brain, or stomach, we must stop short;
we cannot, without  danger,  pass  this; indeed,
we cannot always continue it;  and if  we  rashly
push this medicine,  we may destroy our patient.
The system is often brought  under the influence
of the fox-glove, by  continuing the dose,  which
at first appeared to  produce  no  effect: yet this
does not avail our patient; for the disease is so
acute,  that he must speedily be placed under the
operation of a sufficient dose.   Lastly,  the  effects
of digitalis are more permanent than  of many
other active medicines derived from the vegetable
kingdom.   I have lound a pulse still  influenced
by digitalis after two or three  days.*
   The method which I have for some time fol-
lowed  in using digitalis is the  most obvious:  it
accords with the view which  I  have given of its
powers,  and does not appear  ill adapted  to the
attainment of a safe and  quick effect.  I begin
with a moderate dose, eight or ten drops  of the
saturated tincture; and to every succeeding dose,
which  is generally given at an  interval  of six
  * What I have said of the dangers attending the admi-
nistration of this medicine, I draw from the observations
of others, and from my experience of its effects in the
adult constitution, and in other diseases. There appears
to me  something, either in  the nature of the system
while under the influence of Hydrocephalus, or of the
infantile constitution, independent of disease, which re-
sists the powers of the digitalis. 
                      101
hours, I add two or three drops;  so that, in a day
or two, generally some part of the system is  af-
fected.   I proceed with great caution, ascertain-
ing, while augmenting it, the effect of the medi-
cine after each increased dose.
   There is a consideration peculiar to this disease,
which forbids the indiscriminate  use of this me-
dicine.   The effect of digitalis  resembles very
much the change produced on  the approach of
the stage of torpor; and thus, when there is every
necessity for pushing the medicine to a full dose,
we are induced to suspend  it altogether, from a
fear lest it be acting too powerfully.   Digitalis
renders the pulse slow and irregular, and induces
great  languor.    But  with the slow irregular
pulse of digitalis there is smallness and sharp-
ness ; with  that of Hydrocephalus  there is  soft-
ness and inequality, more of fullness.   The  lan-
guor from digitalis is attended with vertigo, some-
times momentary blindness; that from Hydroce-
phalus has more of coma.
   In the cure of Hydrocephalus digitalis appears
a medicine of great promise; and when it comes
to be more generally used, and the manner of ad-
ministering  it better understood,  it seems highly
probable that our hopes will be realized.
  In other diseases we find that digitalis has been
successfully combined with mercury; and as the
mercurial irritation is  more speedily established
                       i 
102
when bleeding is used, we might expect that any
other measure reducing the action of the  arterial
system would have the same effect.   We should
therefore expect similar assistance from digitalis;
but my observation, too  limited, I admit, rather
leads to an opposite conclusion.   In two or three
instances, where calomel and the tincture of digi-
talis were conjoined, it was found a very difficult
thing to affect the mouth.
  Digitalis exhausts the nervous* energy ; it oc-
casions vertigo and sickness; it retards the pulse;
it diminishes irritability, and quickens absorption.
From some of these qualities, which it  possesses
in an eminent degree, it appears admirably suit-
ed to meet the socond general indication of cure,
and  with consequences by no means so ruinous
to the constitution,  particularly of a delicate ohild,
as blood-letting.   I do not think it can be made
to supersede blood-letting; but  I  hope  it  will
obviate the necessity of repeating what  the weak-
ness of the  patient so  much opposes.  These
hints, however, and what  has been written on
this subject by others, are by no means  sufficient.
The reader,  by careful  trials, must satisfy him-
self; and  let him be assured, that this is a disease
in which  clinical experiments, prudently made,
are  not only allowable,  but highly  to be com-
mended. 
103
  Blisters are to be employed with the view of
producing irritation in the neighbourhood of the
diseased organ.  With  this view, large blisters
round  the head,  to the forehead, occiput,  and
sides  of the head,  should be applied in succes-
sion, and the surfaces dressed with strong mer-
curial ointment.   In the course of one illness I
have ordered nine or ten blisters to be applied.
  Of the utility of blisters in many diseases, phy-
sicians differ more than  might be expected con-
cerning  a  point which  is to be decided,  not by
reasoning,  but by experience.   Until of late, I
imagined the efficacy of blisters in this disease to
be rather questionable,  and in  many cases I de-
clined prescribing them: but  lately,  in  several
cases,  I have  witnessed a remarkable mitigation
of the symptoms after the application of a blister.
When the local irritation has been such as to call
the general circulation  into sympathetic action,
bleeding in general is necessary, after which,  I
believe the sooner blisters are applied the  better.
Bleeding,  independently of its  importance in re-
ducing the strength of the circulation, so as  to
deprive it of the power of supporting the diseased
action, is of great relative value; for it makes the
system more sensible to every impression, it pre-
pares the way for other agents,  and in particular
for this important counter irritation.   Still I am 
104
 of opinion that singly blisters will not cure the
^disease; but among the remedies for this disease
 they are entitled to rank high.
   To allay the pain of Hydrocephalus, when not
 attended with stupor, opium has  been  recom-
 mended.  With this  design I have  never pre-
 scribed it.  Joined with some aromatic, it some-
 times completely succeeds in correcting the bilious
 vomiting and purging.   For  this, however,  we
 have  a more  certain remedy  in  blood-letting.
 Cold  applications  to the forehead and  temples
 have been strongly recommended for moderating
 the pain in  Hydrocephalus.   A  blister  to the
 nape of the neck is a sovereign remedy  for the
 intense headache  which  sometimes accompanies
 the attack of the synochus biliosa.   I should
 think it  in  the  beginning of Hydrocephalus a
 very promising application.
    Much has been written on the best method of
 restoring the system to strength after the  declina-
 tion of disease.  Besides recommending a mode-,
 rately  nourishing diet, I have, on this  subject,
 little to offer.  Wrhen a  great cause of irritation
 is removed,  if there be any  strength  left,  the
 system never fails to act  with vigour.
    It is of importance to support the  strength of
 the child.  This is to be done by  soups, animal
 jellies, and even wine.   In this disease there are 
105
 times when the child will  eat even  voraciously ;
 these are to be taken advantage of.  Can any things
 be more evident than that every opportunity of sup-1
 porting the child's strength is to be  embraced,
 when it  is considered that  the debility attending
 the disease sometimes is fatal; the child dying
 from this,  and not from the paralytic state of the
 brain?  Should there  be  any discharge which
 may be considered as critical,  of course this indi-
 cation will merit the more attention.
   Of the method of preventing  Hydrocephalus,
 what I have to say is  short, but I hope not un-
 important.  The mother must be taught to attend
 to and understand every irregularity in the state
 of her child's  bowels.   It  is  not merely costive-
 ness which is  to indicate the  propriety of a pur-
 gative course: costiveness is not to be neglected;
 but constitutional costiveness  may perhaps  exist
 without danger.   Attention must be paid to every
 deviation (not absolutely temporary) from a natu
 ral appearance of the intestinal evacuation.
  Attention to the state of the  bowels  will be
 much easier both to the parent and child than the
 management of a seton or issue, and I apprehend
 much more availing,  although I by no mean-
forbid these   applications.   Were I to  explain
further what I think necessary to  be attended  to
when Hydrocephalus  is a  family  complaint,  I
                      i2 
                     106
should be led into too wide a field; nothing less
than the application to  my subject of every part
of the Hygieine;  and the cases which are added
have necessarily made  this paper much  longer
than I originally intended. 
107
           NUMBER  L


               CASES
                 OF

HYDROCEPHALUS ACUTUS.
                  CASE I.

  J. M.   12th May, 1804.—The subject of this
case, a  fair and  delicate  girl, of a scrophuious
family, after gradually losing her appetite, com-
plained, about ten days ago, of pain in her belly;
two days after this complaint she became fretful
and dull; then she was often flushed, particularly
in her sleep;  she  also complained of acute pain in
her head.
  For these three days she has  complained very
©ften of pain in her head,  and of pains in her belly
and legs.  She is not to be amused, never lifting
her head from her mother's breast.  During  last
night  she has frequently  started from her sleep,
screaming with  pain  in  her head.  She  yawns
and sighs  often,  and, when free from pain,  she
would fain lie unnoticed.   Her  pulse is  quick,
her tongue white,  and her breath heavy.  She 
108
has slight spasms in the eyelids, and subsultus in
the wrist.   Her belly is costive.  Her complaints
so much resemble those of her brother, who died
some years ago of Hydrocephalus, as to reduce
her mother to despondency.
   16th May.—By strong mercurial  purges, her
bowels were emptied of a great quantity of dark
green slimy fasculence.   The stools are now na-
tural, and she appears nearly well.


                  CASE II.
   R. S. four years of age;  a boy of a florid
complexion, and very dark eyes.
   15th May  1805.—About ten days ago  this
child became languid drowsy, and he frequently
fell asleep in his chair.   On the morning of the
12th he vomited  his  breakfast, the drowsiness
continuing, or rather  increasing; between the
12th and 13th he retched all night, and complain-
ed of pain  in his head.   The retching continued
during the  13th:  what victuals he took  he im-
mediately vomited.
   On the 13th he had a better night; but he of-
ten sighed.
   On  the 14th he sighed heavily: the sickness
was  constant.
   Before the  retching  comes  on he  generally
changes colour, from pale to a deep purple. 
109
  He is just now lying asleep:  he breathes soft-
ly ;  his pulse is 60,, and very irregular.  When
I had him roused, he was much inclined to dose
again; he was quite distinct.   He  continues to
sigh.
  Give one of these powders  immediately, and
one every eight hours.
        R. P. Rad. Jal. gr. xij.
          Submur. Hydr. gr. vi. %.  f. Pulv. ij.
  16th May.—In the  night he had two large
foetid stools,  green and gelatinous.  His stomach
is still unsettled;  p.  90 ; tongue  cleaner; sigh-
ing  somewhat abated.   Continue  the  powders.
  17th.—His  bowels are loose, the stools fre-
quent and more natural, without any admixture
of glairy matter.  The vomiting has ceased. His
look  is by  much  less dull; p.  100, and quite
regular.  His  skin is  cool;  his tongue  clean.
Continue the powders.
   18th.—His bowels are  loose;  his  stools are
natural.   No vomiting nor sighing.  His  appe-
tite  is  tolerably good.  No mercurial foetor in
his breath.   Omit the medicines.
   These cases I present as a  specimen of many
 of the  same nature,  which, during the last six
 or  seven years, have occurred to me;  and I am
persuaded, that the complaints would have been
relieved by any equally active purgative medicine
 with that prescribed.   I  neglected to mention, 
110
that three of the last patient's (R. S.) brothers or
sisters died of Hydrocephalus.  I am inclined to
think, that in those children who have a family
right  to this disease, it is to be detected more by
the nature of the stools, and comatose tendency,
than by the inflammatory symptoms.
   I have many notes of the cases  of children,
who,  several days successively,  have come home
from  play or school, pale, with pain in the head,
which, one said, was like the thumping of a ham-
mer  within the head, another,  like a knife run-
ning through the head, &c.  They  were observ-
ed sick,  drowsy in the day-time, sometimes fe-
verish, and vaguely complaining.   It  would be
unnecessary to record these cases.   I allude to
them partly,  because  sometimes  they ended in
Hydrocephalus, but more especially to say,  that
by far the  greater number  were  cured by con-
tinued purging with jalap and calomel.


                 CASE  III.
   D. R. aged 8, with dark eyes and complexion,
and coarse skin ; a fine intelligent boy.
   12th May  1805.—His  complaints  are  of six
days standing, during  which time he  has  been
extremely dull, and has  frequently  complained
of severe pain in his  head ; he has slept more than
usual; his belly has been costive.   Two or three 
Ill
evenings ago he retched frequently.   Some years
since  his  brother  died of Hydrocephalus.  His
p. is  56,  and very irregular.  He has not much
heat of skin.  His tongue  is  white.  Since I
came  into the chamber he has sighed often, and
has complained  indistinctly;  when roused,  he
says that he has pain in his head.   I ordered him
to have one of these powders every  four hours,
in a little treacle.
       R. Submur.  Hydrarg. gr. xxiv.
          Pulv. arom. 3 i.  rq,. f. Pulv. xij.
   13th.—He has  had  two free, dark, and slimy
stools;  p.  70, and irregular.  He  sighs much;
but he says that his head  is less pained.
   14th.—P.  104;  irregular.   Tongue  clean ;
still sighing.  He is more  lively.   His urine is
limpid  and copious.  His  stools are free, and
nearly natural.
   15th.—This boy complains more  of his head,
has a very alarming look, and sighs constantly.
He has  slight convulsive twitches.   His tongue
is clean.   His  skin is of a  natural warmth; his
belly natural.   He wakes from his sleep sudden-
ly, complaining of lancinating pain  through his
head.   He takes  the  calomel regularly.  Apply
six leeches to the head.
    16th.—Five large leeches were applied to the
temples.   The  blood  oozed from  some  of the
orifices  all night.  His  breath has  a mercurial 
112
fetor*   He says that he feels better.  His eye is
evidently  clearer.   P.  92,  and  regular.   He
sighs less.   His  urine  is  high-coloured and
scanty.
   17th.—P.  100 ;  tongue clean; considerable
salivation  and fcetor of breath.  The gums are
slightly ulcerated.  The  pain in the head and
sighing have ceased.
   21st.—He has no  Hydrocephalic symptoms;
his gums  are recovering ; and he is again going
out.
   25th May.—I was again requested to visit this
boy, which for several days I had left off.  Yes-
terday, in the afternoon,  he had an attack of vo-
miting, which has scarcely ceased since.  I found
him not vomiting;  but there was still a frequent
inversion  of  the oesophagus,  as in ruminating.
Since yesterday morning,  with little intermission,
he has complained of severe pain in the back part
of his head; and he has had a purging for these
two days.  To-day he has been observed again
to  sigh.  His  pulse  is 76, and irregular.  His
tongue is  clean.
   26th.—During the night he had several doses
of a purgative medicine.   The vomiting has aba-
ted, and the  purging is  less  troublesome ;  but
he has sighed very frequently, and is exceeding-
ly  dull.   I  observed him faintly  moaning, and
expressing much  uneasiness  in his  head.  His 
113
pulse is  remarkably irregular;  at  one time  so
slow, for two or  three beats, as to be felt inter-
mitting.  He  must return to the powders; and
again have six leeches applied.
  27th.—The  application of  the  leeches was
again followed by  a  great discharge of blood.
His tongue is white;  p. 96,  full, irregularly in-
termitting.   He is extremely  dull.  He feels the
light painful  to his  eyes.   The pupil contracts
readily.  For  some hours during  the night  he
had double vision.  He is still sighing, and com-
plaining of the pain in his head.  He had some
retching after  breakfast.   Since morning he has
had five dark-green  glairy stools, not incorporat-
ing with the fluid in the vessel.  He slept not ill
during the night;  but several times  he started up
incoherently; and, upon recovering himself,  he
complained of headache.   Sometimes, when his
attention  appears  attracted  by what  is passing in
the chamber, suddenly  the pain strikes through
the head, and forces him to cry wildly.
  28th.—Six  large leeches were again applied
last night;  and he takes  the calomel  regularly.
His pulse is 120 ; not quite so full; much more
regular.  His skin is cool.  His mouth, particu-
larly the gums, much affected with  the mercury.
Stools free, more natural, but still  rather green;
urine limpid.   He  slept  calmly,   and  did not
start.   He awoke vomiting ;  and since morning,
                      K 
114
he  has often retched.   He continues  very  dull.
He has several times  cried with  the  pain.  He
has less sighing.   He  had, by candle light, the
double vision.
  29th.—Yesterday, from half past two until he
went  to sleep, the retching was incessant.  The
retching returned at five o'clock this morning,
and has  continued very  troublesome.  He has
also been troubled with hiccup.  Since the retch-
ing came on this  morning, he has not  once com-
plained of headache.   He mentioned the double
vision; but he has  neither squinted nor sighed
to-day.  He has had  no  stools since last visit.
There is great salivation.   Leave off the calomel.
This  boy's brother, who died of Hydrocephalus,
in his last illness,  had the same incessant retching
for five da}'s :  in  most respects, his illness much
resembled that of my patient.
  30th.—He  is  lying in  a state of constant sa-
livation.   The inside of his cheeks and gums are
extensively ulcerated.  He has no complaint but
of his mouth.  He has ceased to sigh, and has
neither double  vision  nor squinting;  but he is
still dull; p. 108 ; retching suspended.
  8th July.—His gums are still spongy.   The
salivation has ceased.  His appetite is returned.
He  no longer complains of his head. 
115
  In less than a  month this boy was  again  at
school, and  he has had no return of his  com-
plaint.   In  this case, the return  of the disease,
after being apparentiy removed, deserves atten-
tion.  The case is more imperfect than otherwise
it would have been, had I paid more attention to
the secretion  of the urine,  in  particular to  the
quantity secreted.
   In the spring of 1807, he was  for  six  weeks
ill of jaundice.


                  CASE IV.
   D. M. aged 4; a fine looking boy, fair, with
blue eyes.
   25th December.—This boy is sitting with  his
head leaning on a pillow, asleep, his face flushed,
his eye-brows contracted, breathing  softly, now
and then sighing.   His p. is 132, and  his skin
warm.
   I find him expressing great aversion  to light,
 peevish, displeased when he finds himself observ-
 ed, unwilling to be roused, yet perfectly distinct.
 He frequently complains of severe  pain  in  his
 head,  pointing, as the  seat of it,  to the left tem-
 ple ;  and he complains of pain in his belly,  and
 sometimes in his limbs.  In  the night  he has
 little  sleep;  what he  obtains is  disturbed  and 
116
short; and he  awakes  starting  and incoherent.
During the day he is reserved and silent, unless
when in pain.  His tongue is furred in the mid-
dle, and his breath is sickly.  He has no appetite,
but considerable thirst.  His bowels, from  the
use of laxative medicines,  are open.  Yesterday
he  vomited once or twice.
  He has been confined several weeks  with  ca-
tarrhal complaints;  in  addition to  which,  for
•    e twelve  days,  he has had febrile symptoms,
with headache.  On the 19th, he appeared reliev-
ed ; on the 23d his complaints returned; and, ever
since, he has been in a situation much as I have
described, the headache, indeed, daily increasing.
  Two nights ago  leeches  were applied to  his
temples.
  He is  to  have 2 gr. of calomel  three times a-
day, and the leeches again applied.
  26th.—Four leeches were again applied to  the
temple,  and the discharge of blood was consider-
able.  The dullness increases.  He starts in  his
sleep, and never awakes without being agitated,
and complaining of his head.  He has great thirst;
the right cheek is much flushed; he sighs con-
stantly ; p. 132.  I have ordered eight drops of
the saturated tincture  of fox-glove to be given
with each dose of calomel.
  27th.—I found him amusing himself blowing
soap-bubbles; cooler; hisp. still 132. His tongue 
117
 is moister; he has not sighed so constantly; and
 he complains less of his head.   Again  apply the
 leeches.
   28th.—The bleeding was free.   He slept toler-
 ably well.  He has complained of his bowels. He
 is sighing more, and his look is more anxious.
 He always awakes troubled.  He has had many
 stools, in appearance  more  natural. His urine,
 which has hitherto been scanty, has in  the night,
 exceeded two pounds ; p. 140; tongue cleaner.
   29th.—He had a very restless night; towards
 morning, complaining much of his head.   His
 pulse, tongue, and the heat of his skin  as yester-
 day.  He is still sighing, and again flushed.  He
 has a short troublesome cough.   His  breath  is
 untainted.  I have desired his mother  to rub  in
 strong mercurial ointment thrice a  day, twenty
 minutes each time, and to repeat the leeching.
   30th.—This morning he complained  much  of
 his head; through the night, which was passed
 quietly,  he often sighed; since morning he has
 been  very  dull;  p.  108;  stools  natural; urine
 scanty.   He has ten  drops of the  tincture, and
 two grains calomel, four times daily.
   31st.—He  has not  once, to-day, complained
either of his head or bowels, nor has he sighed j
he had one low fit, lasting about half an hour;, but,
since, he has been playing with his brothers.  The
light is less offensive to him; his look is more
                     i2 
                     118
cheerful.  There is no mercurial  foeter  in his
breath, which is pure; the  night was  passed
calmly, without starting.  There is no fullness in
the pulse;  it is unequal, but regular.   It differs
from the pulse which is found  in the change from
the first to the second stage of Hydrocephalus, in
which the  beat  is  full, soft,  generally irregular
and unequal.
   1st January.—Although he awoke several times
complaining of his belly, yet, on the whole, he
slept tolerably well.  He has sighed two or  three
times to-day; he  looks more  anxious;  p. 96,
and regular; stools green.  Apply the leeches,
and increase the tincture to twelve drops.
   2d.—His look is less favourable.  His pupils
are much dilated.  His tongue  white; p.  104.
These two days he has again  complained of his
head; to-day often, and of his belly.  His  urine
is copious; his stools are slimy and green.
   3d.—He is again dull, and complaining much
of his head, and sighing; his p. is 100, irregular
and unequal; his stools get darker; his urine is
scanty.   Increase  the tincture to fifteen drops.
Continue the calomel.
   Eight o'clock Evening.—He  has  twice  taken
the medicine in the increased  dose; p.  92,  regu-
lar, compressible, rather jarring.   Since noon,
he has sighed often, and complained much of his
head.  For some  days, he has taken very little 
119
nourishment.   His tongue is loaded; his stools
are dark;  his head is hanging on his breast;  he
is certainly duller; his hand is cool; is breath  is
still untainted.
   4th.—His pulse is fuller, and more  irregular,
92;  he is duller; his pupil dilated;  tongue load-
ed ;  the heat of his skin is not great.   He has vo-
mited every thing which he has taken  since last
night.  The stools are  dark green,  and very
foetid.  The calomel and fox-glove have been vo-
mitted.   I have again recommended a large blis-
ter,  and eighteen drops  of  the tincture; and I
have allowed him to leave off the calomel.   He
has  been  regularly rubbed.
   5th.—His tongue is loaded; his breath untaint-
 ed;  his stools-are dark and scanty;  his urine na-
 tural, and  more abundant; the vomiting  has
 ceased.   In the night he started and sighed, and
 complained  of his head, probably of the blister;
 he is pale; but his eye is more expressive; p. 96,
 and irregular. I ordered him to take immediately
 two ounces of the  infusion of  senna, with a
 drachm of the tincture  of jalap, and twenty-one
 drops of the  tincture of fox-glove, at the usual
 time.
   6th.—In three hours  after taking the purging
 draught, he had two free and natural stools; with-
 in the last twelve hours,  he  has voided nearly two
 pounds of urine; since the forenoon of yesterday, 
120
 he has not sighed;  he slept from one o'clock  to
 eight without once awaking; when  he awoke,
 he called for bread.  He looks relieved;  p. 92,
 with one intermission;  tongue moist, not loaded.
 His nose, which for the most part has been dry, is
 now running;  and he has had a slight degree of
 salivation.   His  head,  as usual, is dressed with
 the  mercurial  ointment.   He  has twenty-four
 drops of the tincture.
   7th.—He had, from the purging draught, which
 he again took in the evening, three free stools; his
 urine is copious.  The night was undisturbed;
 no complaint;  no sighing; tongue clean; p. 84,
 sharp, and  irregular.   His eye is expressive; no
 salivation.
   8th.—Urine three pounds;  two stools, has no
 complaint  of his head, p. 100, sharp, now and
 then intermitting; there is some  return of the
 sighing; and he has been once or  twice  sick to-
 day.
   9th.—He slept softly;  but, during the night,
 he  was frequently disturbed  with sickness; he
 sighed  this morning;  he is  pale; he did not
 sicken after his last dose, twenty-five drops of
the tincture; but he vomited the  one taken in the
night; p. 92, and irregular;  in  every respect a
pulse which might be called Hydrocephalic, un-
less in the  sharpness or jar of the beat;  tongue
Clean.  Instead of the calomel, I ordered a mer- 
                      121
 curial pill (Hydrarg.) with every dose of the tinc-
 ture.
   10th.—With the exception of some muttering,
 he passed the night well, not complaining of his
 head, but much of his belly, and sighing.  Stools
 free;  rather  light  or clayey.   He  is  sick, and
 duller, with the same pulse as yesterday.  Apply
 a blister to his head.
   11th.—The  blister appeared during the night
 to distress him; and he sighed  often, as he  does
 still.  He  looks dull.   He has again lost his ap-
 petite.   He has no thirst.  His tongue is moist,
 with a gray fur.  He is again slightly salivating.
 I doubt if this be from the mercury, which  does
 not appear to affect the gums; perhaps from some
 nausea.   The urine is  more scanty; stools foetid
 and clay coloured.   He complains of pain in his
 right arm; p. 120, regular.  Give the pill, and
 thirty drops of the tincture, every sixth hour.
  12th.—His bowels  are rather slow, now and
 then pained.  His pupil is more contracted.  He
 has no complaint of pain in his head.  His tongue
 is white and moist; gums  not  affected; urine
 rather scanty.  He is  languid and pale;  and,
during the night, he was much  disturbed  with
sickness; and he  has  six or seven times com-
 plained, for a minute at a time, that he could not
 see; pulse irregular and indistinct; as small  as
 in the wrist of  an infant;  not more than 52; no 
                     122
sighing.   Omit the tincture.   Give a little wine
and soup.
  Evening.—The pulse confirmed again, jarring,
exceedingly irregular.   He has had two natural
stools; frequent returns of the sickness.   Conti-
nue the pills and ointment.  Omit the wine.
  13th.—He slept well.  His belly is  regular.
His  urine again is more  copious; his tongue
moist and clean;  pupil contracted;  eye lively.
He had only one attack of dimness of sight since
the fox-glove was  left off; p.  80, still irregular;
no pain in the head, or sighing.
   16th.—He  has no  complaints, nor  sighing.
His  tongue is  clean;  his appetite good; urine
free, with  much sediment;  belly natural.  He
never frets nor cries, without shortly after com-
plaining of pain in  his head; but  he complains at
no other time,
  At the  time of sending this case to the press,
the boy is in perfect health, which he recovered
in a few weeks after the date of the last report.
I believe that  several of the symptoms after the
7th were to be attributed to the tincture; but I
was not quite  sure of the disease being checked;
and, while  it  was going on,  I apprehended no
danger from the fox-glove.  The dimness of sight 
123
explained the patient's situation.   After every
increased dose of the medicine, the state of the
child was particularly examined.  The mercury
was continued for eight or ten days longer;  but
it produced no obvious effect.
                 CASE  V.

  A. S. aged three  years and six months, with
fair complexion, of a delicate  constitution, and
habitually loose in his bowels.  About six weeks
ago he had a severe attack of a bowel complaint,
to which he is subject;  and, along with this, he
had fever.   Of late, he has had slight catarrhal
symptoms.
  Last night, about eleven,  he became very rest-
less and feverish; was observed frequently start-
ing; and  had some delirium.  To-day, he  has
had rigors, followed by  flushing.  His eyes are
heavy.  He has some cough.   His pulse is 120;
breathing 32; tongue rather white, colour high;
the lips and inside of the nostrils of a bright Ver-
million.  Brows contracted.  He still  starts in
his sleep.   His belly is costive; his urine scanty.
I prescribed for him, to be taken immediately,
        R. P Conv. Jalap, gr.  vi.
           Submur. Hydrarg. gr. iv. nt,. 
124
 And a table-spoonful of this mixture every three
 hours.
      R. Infus. Cass. Senn. §iij.
         Carbon. Pot.gr. x.
         Tinct. Conv. Jalap $iy
         Syr. Simpl. 3vi. "%•

   16th.—During the night, he had five or six
 stools, of a deep yellow colour,  apparently con-
 taining  much bile.  He was feverish and thirsty
 in the night, but not delirious.   He  cannot sup-
 port his  head.   His look  is anxious; p. 140.
 His  tongue cleaner.  His breath is sickly smell-
 ing.  He  is  still starting.  I have  ordered  six
 leeches to the head, and the laxative mixture to
 be continued.
   17th.—Yesterday, in the afternoon, he  sighed
 often;  in the evening, he had some remission of
 the fever; during the night,  he  was restless and
 feverish.  His stools are brown  or muddy, less,
 natural.  His pulse is 132.   There is a deep hectic
 on the cheek.   The  bleeding from  the leeches
 was  considerable.  Repeat the powder,  and still
 give the  mixture.,
  18th.—He had'a restless, but not so feverish a
night.   He often complained of his head and bel-
ly.   When the  belly  is pressed, the hepatic re-
gion chiefly is complained of.  His eye is cloud-
ed;  his brow knit;  p. 128; his  bowels are free. 
125
  Omit the mixture,  and give, every eighth hour,
  two grains of calomel, and apply the leeches.
    19th.—Since  last visit,  he has had no remis-
  sion of fever.  He  passed  a restless  night, was
  thirsty, and had some difficulty of breathing, and
  cough.  He has  had two natural stools.   His ex-
  pression becomes unpromising.  His eyes  are
  dull;  brows knit.  Now and then he  is heard
  deeply sighing.   He is without any complaint of
  pain.   There is still considerable tenderness of the
  abdomen.   Hisp. is 132;  tongue clean.  Along
  with every powder, he is to have a  dose of satu-
  rated tincture of fox-glove.   Ten drops are to be
  taken with  the first powder, and every succeed-
  ing dose is to  contain a drop more than the last.
    20th.—He has had no remission of  fever.   He
  spent a miserable  night;  insensible;  tossing;
  feverish; very thirsty.   To-day, he  complains
  much of his head; p. 120, regular.  One stool
  like mud.
    2lst.—He has had  another restless night; in-
  sensible; flushed; no  remission of  fever.   He
  has had no  stool.  His urine,  hitherto scanty, is
  rather more copious.  His  pulse is 112,  regular.
- He has still a troublesome cough.  He frequently
  sighs.  He is  pale,  dull.  His eyelids are heavy,
  and his pupils  dilated.  His tongue is loaded.
  His breath  is extremely heavy.  Continue the
  powders and tincture, and again apply the leeches.
                        L 
                     126
  22d.—The discharge of blood with the leeches
was less copious.  In the afternoon of yesterday,
he sighed incessantly.   His cough was trouble-
some ;  yet, last night,  he slept four hours with-
out  interruption;  towards  morning,  he often
moaned.   His pulse is 120, not full.   There is
considerable mucous discharge from  the iiostrit.
His eye is dull;  the pupil dilated;  he sleeps now
with his eyes open.  His stools are dark green,
and muddy.  His urine  scanty.   He has taken,
since the beginning of his  illness, scarcely  any
nourishment.  Continue the medicines.  As yet,
he takes  only fourteen drops of the tincture.
  23d.—He  had a restless  night.  He vomited
his breakfast; the milk which he had taken curd-
led.  He at present is  asleep, breathing calmly;
his eyes are open.   His face expresses discontent.
He has frequent spasms of his eyes.   He has not
sighed to-day above three or four times.   His
breath  continues sickly.   His  pulse  84.   One
dark stooL   Urine scanty; not  3ij. in twenty-
four hours.   He takes twenty drops of the tinc-
ture.
   24th.—By the constant cough, he was prevent-
ed from passing a good night.   He has passed
three unnatural stools; urine  giij.  His pulse is
100, and regular, rather small; skin cool; tongue
clean; the pupil is more contracted: his expres-
sion is less unfavourable; yet he cannot support 
127
his head.   Yesterday afternoon, he again sighed,
without ceasing.  Twenty-two drops of the tinc-
ture were given with the calomel.
   25th.—All yesterday, after I saw him, he slept
so that there was no  rousing him.  His breathing
was  irregular;   sighing:  he  was grinding his
teeth.  In  the night, he complained of his head.
His  cough is less  troublesome;  he has had no
stool for thirty-six  hours, and passed scarcely
any urine :  his  skin is dry; p. 100.  There is no
mercurial fee tor in his breath.   Give him imme-
diately ten grains of  powder of jalap.   .Continue
the tincture and powders.
   26th.—He had a  calm night: he has  passed
two free stools,  dark green:  he has" had no  sigh-
ing;  p. 100: he sleeps constantly.
   Evening.—His  pulse  exceedingly irregular,
and does not exceed 60:  he is profoundly coma-
tose ; not in the least roused by being rudely lift-
ed from his bed: he sighs;  his eyes are spasmo-
dically affected; stools deep green.  Since morn-
ing,  he has once or twice opened his  eyes, and
then he complained  more than ever of his head.
Apply a  large  blister to the  forehead, and six
leeches to the temples.
  27th.—The  comatose state  in the night, seve-
ral times, was  interrupted by severe  shoots of
pain  in the head, and by an urgent thirst;  he at
one time sighed incessantly.   The bleeding con- 
128
 tinued for the  greater  part of the night.  The
 blistered part was dressed with Ung. Hydr. Fort.
 There is considerable subsultus in his hands and
 legs; and his eyes and  eyelids are agitated with
 constant spasms.   When his  eyelids were forci-
 r-ly  kept open, the pupil  appeared much con-
 tracted :  his nose is dry.  The coma prevailed
 until morning.   Continue the medicines.
   28th.—He has had ho drowsiness since yester-
 day  forenoon :  his night has been most uneasy;
 sleepless ;  with great thirst; vomiting and loose-
 ness ; the  stools  muddy, green, and  foetid: his
 eyes continue spasmodically affected.   There has
 been no sighing.  About seven  this morning,  he
 sneezed incessantly for more  than five minutes ;
 since which, he has again  complained more  of
 his head :  his pulse is 100,  and regular : he con-
 tinues to take his medicines, 24 grs. of the tinc-
 ture every six hours.
   29th.—He had an easy night.  About six this
 morning, the sneezing fit returned, lasting about
ten minutes; after  which,  came  on great thirst
and vomiting, the spasmodic affection of his lips
and mouth, and the headache.  He is pale:  he
has acquired a squint: he  is again sighing: his
stools are dark green; urine scanty.  Apply two
blisters, four inches in  diameter, to the temples.
   30th.—He had a bad night.   The  sighing
is constant.  The squinting and sickness  conti- 
129
nue.  Urine greatly increased, lbij.  since yester-
day afternoon.   Stools  plentiful  and natural;  p.
120, small.  Apply mercurial dressings to  the
blistered parts ;  and, as the skin has been uni-
formly hard and dry,  try  the tepid bath.   The
calomel is still given with the utmost punctuality,
and twenty-five  drops of the tincture four times a
day.  No mercurial fceter.
   1st May.—The  fomentation was followed by
some moisture of the skin: his eyes were a good
deal affected during the night:  he  has no head-
ache; no sighing;  squint very perceptible;  seve-
ral loose dark stools;  urine more scanty ; nose
running.   Dose of the  tincture,  30 drops.  Re-
peat the bath.
   2d.—He had a  sneezing fit in the  morning;
p. irregular, and jarring, 72.  The pupil of the
left eye (that which is  turned from the axis)  is
much dilated.  He sighs, is fretful,  and pale.
Stools copious, and clay-coloured;  urine plenti-
ful.  Dose, thirty-three  drops   of  the tincture.
The bath being unwillingly submitted to, is omit-
ted.  Apply a blister to the vertex.
   3d.—He had a  restless night, probably from
the blister.  The squint less perceptible ; p. 100,
and regular.  Stools large, apparently containing
little bile.  Urine  free.  Apply  mercurial dress-
ings to the blisters.  After taking thirty-three drops
 of the tincture, he generally complains of sickness
                       l2 
130
     4th.—He  slept well.    His  appetite is  con-
  siderable ; and he is able to stand alone.   After
  the morning dose of the tincture, he had a severe
  attack of  vomiting.   His jirine is lbij.  daily;
  stools  as  in  jaundice, colourless;  pulse  sharp.
  The  only Hydrocephalic  symptoms which re-
  main, are occasional sighing,  and slight strabis-
  mus.  He amuses himself with some other chil-
  dren.  Omit the  tincture.


     This boy, for  some days,  was making rapid
  strides to  health; however, his bowels, perhaps
  from mismanagement, became much disordered:
  they  were,  for many days, apparently' without
  bile.  He had also dysury  to a great extent.  He
  again  complained of his  head and belly.  The
  sighing,  squinting, and  starting, returned; and
  his pulse became irregular, sometimes not  more
  than  60.   His condition often varied.   About
  the middle of May, his  complaints  took an inter-
  mittent form,  the fever regularly  coming  on in
  the forenoon.  About this time, he had a  large
  sty  on each eyelid, near  the inner canthus.  I
  tried bark with little benefit;  then I prescribed,
  as if all the  symptoms arose from the disordered
-  bowels,  laxatives, testaceous  powders, opiates.
  The  medicines  appeared to  have little  effect.
  But,  as his stools became more natural,  his health  , 
                     131
again appeared  to improve.   This  was in  the
first or second week of June.
  On the 2d July, I called for the boy as I was
about  to draw out his case for publication.   I
found him in good health, rather pale, which his
mother attributes to the relaxed state of his bow-
els.  He  takes his victuals perhaps too  heartily.
He has not altogether lost the  squint.   I  have
learnt,  from the  best authority, that this boy's
only brother died of Hydrocephalus.


                 CASE  VI.*
  30th June 1806.—I was  desirecito visit For-
rest Fair,  a boy  between seven and eight
years of age, who had occasionally been  my pa-
tient for psorophthalmia.   He is of a scrophuious
family, of a slender form,  and  tall for his age.
He has been ill for two days, complaining, as he
does now, of constant severe headache, and pain
of the belly ;  moaning in his sleep,  picking his
nose, and grinding his teeth.   He vomited, this
morning,  a quantity  of  watery green-coloured
fluid, which has deposited,  at the bottom of the
vessel, a slimy viscid  sediment.  The  face  is
  •This descriptive case, and one which will appear in
the  sequel, I owe to my friend Dr.  Kellie of Leith.  I
am also indebted to Dr. K.  for some other valuable com-
munications on Hydrocephalus. 
132
much flushed;  the eye dull and heavy, the adna-
tabeing suffused, and slightly inflamed; skin hot;
belly tumid;  bowels costive ;  pulse  130.
      R. Pulv. Convolv. Jalap, gr. xij.
        Submuriat. Hydrarg. gr. ij. nt-
        Samat mox, et repetatur vespere si opus sit.
   1st  July.—Is  much  disposed  to  slumber,
moaning much,  and keeping his hand on  the
forehead.   He is easily roused, and then he com-
plains violently of his head.   When taken from
bed, and  brought to the light,  he grew faint,
and vomited.   Has passed three large stools, of
a  deep green-coloured,  consistent,  tremulous,
gelatinous substance, having a very peculiar smell
of what is called faint or  heavy,  but not at all fe-
culent.  The face highly flushed i the  eye  suf-
fused ;  tongue clean and  florid; skin  hot; p.
120.   He is also very thirsty ; his drink has been
milk  and water,  or toast and water; which he
has repeatedly thrown up again.
   Four ounces of blood were taken from the foot.
Two grains  of calomel to  be given  every three
hours.
   2d.—The calomel powders have been regular-
ly given.   He has passed five stools,  of the same
appearance as those described  yesterday.  The
stomach retains  drink  better;  he vomits only
when taken out of bed, or raised to the erect pos-
ture.   Seems less torpid than yesterday.   WheTi 
                     133
asked  how  he is,  the invariable  answer is, My
head!  My head!  p.  120;  skin  still hot;  face
flushed and eye suffused.
  Eight ounces of blood  were taken from the
arm.   The calomel to be continued.
  3d.—He  seemed  greatly relieved yesterday,
for  some  time after the bleeding;  complained
less  of his head; and said it  was better.   The
face, at my  evening visit, was less flushed, and
the skin not so hot; the pulse  was 112.   He has
since,  however,  passed  a  most  restless night;
screaming at times with great  violence, and cry-
ing to his mother to hold  his head.  Towards
morning, he became  quieter.  He is now in a
listless torpid state; but not asleep.   He answers
questions  slowly and unwillingly.  When asked
how he feels  his  head,  he says, better.  But,
when otherwise disturbed, as when I was feeling
his belly with my hand, he cries  out plaintively,
Oh my head!   He has not vomited since yester-
day morning.  Two tremulous gelatinous stools,
not quite  so green;  skin not  so hot; face less
flushed; the adnata of the eye less suffused, but
the pupil is large and dilated,  though sensible to
the impression of a stronger light; p.  100.
  Sumat. Sulphat. Sodae 3ij.  ex  Infus. Sennae  fiv.
  Evening Report.—Vomited the laxative soon
after it was  taken.   No stool.  He is still  more
romatose ;  p.  120. 
134
           Injiciatur Enema Purgans.
           Applicetur Vesicatorium Capiti.
   4th.—A quiet night.  He is now moaning hea-
vily, and tossing his head from side to side.   He
is easily  roused;  answers always  that his head
is very ill.   Pupil large.  Blister well risen.   In-
jection brought off one stool of no better appear-
ance than the former; p. 120.
    Sumat. Submuriatis Hydr. gr. ij. 3a q.q. hora.
   5th.—A restless uneasy  night, crying out the
pain of his head, and tossing with his hands.   He
is now more torpid than he was yesterday.   Bel-
ly tumid and hard;  three stools green and slimy;
p.  100,  and  intermittent.
          Vesicator: Abdomini
          Cont. Submuriat Hydrarg.
   6th.—Has passed a quieter night.   He is still
lethargic.   When roused, he says his head is
better.   Four stools  of the  same  unnatural ap-
pearance;  p. 112.
          Omitt. Submur.  Hydrargyri.
          Sumat. Infus.  Sennae § iv.
   7th.—Two  green  gelatinous  stools;  com-
 plains more  of his head.   Other symptoms as
 yesterday ; pulse intermitting.   Vesicator capiti.
   8th and 9th.—The symptoms continue much
 the same;  at  times he has been  restless and 
135
screaming, at others, he appears torpid and co-
matose.
  10th.—He  is more insensible.  The eyelids
remain half opened;  the pupils are still more di-
lated, and the left eye is turned away from the
nose.  He drinks a great  deal, and swallows
with avidity.   He takes beef tea, and milk with
water.   Three slimy stools; p. 120, regular.
  Two drachms of common mercurial ointment
to be rubbed in on the thighs and  belly night
and  morning.  To  be supported with  beef tea
or chicken broth.   All other  remedies to be
omitted.
   17th.—From  the  10th to this day, the symp-
toms have varied but little.   The lethargic  state
occasionally interrupted by irritable and restless
fits.   The pulse has varied from  100 to  120.
He has passed daily  one or two  green gelatinous
stools ;  and has made a considerable  quantity of
urine.   Every day  5 ss.  of mercurial  ointment
has  been  consumed in friction.  This day he is
sensibly better.   The eyes are more fully open-
ed ;  and he answers  questions with less difficulty.
His  fingers are constantly in his mouth,  of which
he complains.   The gums are evidently affected
by the mercury;  there  is  slight  foetor of the
breath, and the flow of saliva is increased.   He
cried for a breakfast of porridge, and ate several
spoonfuls; p. 100.   No stool  since yesterday. 
136
 The belly is less tumid, and feels soft and easy.
 Omitt. Ung. Hydr.
   18th.—A restless night.  Complains much of
 his mouth; he is constantly pulling the two mo-
 lares of the right side with his fingers.   They ap-
 pear a  little loose, and probably are giving him
 pain.  He is quite  sensible, and sees  distinctly; v
 says his head is still painful. \ No stools; p. 112.
   19th.—Slept  better.   Salivation  continues.
 Complains much of pain in the two right molares,
 the gum round which appears swelled anoVspon-
 gy.  He is very fretful; skin hot; p. 120.   No
 stool.
     *   Sumat. Infus. Sennae § iv.
   20th.—Symptoms  as yesterday.   One  gela-
 tinous stool.
        Sumat. mane et  vespere Calomel,  gr. ij.
   21st.—Three slimy watery stools, with very
 little fseculent smell.   Omitt.  Calomel.
   22d.—Salivation  continues, with  pain  and
 swelling of the right jaw;  in other respects bet-
 ter.   Takes porridge  and milk  for  breakfast;
 broath and potatoes for dinner; small beer  for
 drink: p. 112.  No stool  since yesterday.
   24th.—Continues to convalesce ; he  request-
ed to have  his clothes  this morning, and is now
lying in bed dressed, amusing himself with. toys.
No stool since the 21st.  His mouth is still sore. 
137
The molares loose; the tongue white and fur-
red; p. 100.
    Sumat. Infus. Sennae § ii. cum Tinct. Jalap. 5 i.
  25th.—Four  faeculent  lumpy stools,  of na-
tural colour, and odour; appears greatly  reliev-
ed ; is sitting dressed in  his mother's arms; p.
112.   Salivation  continues ; and he complains
much of the loosened molares.
  28th.—Convalescent. No stools since the 24th.
         Rep. Haust. Infus. Sennae.
  29th.—Three faeculent  stools.  Matter is  dis-
charged between the gum and the loose  bicus-
pides of the right side.  Saliva still flows abun-
dantly.
  1st August.—Convalescent;  functions  natu-
ral.   The two bicupides,  which have given him
so much distress,  came away incased in their al-
veolar process,  which  has been separated from
the jaw.
  5th.—Recovered.
M 
158
NUMBER II
               CASES

                 OF

HYDROCEPHALUS ACUTUS.
                 CASE I.

  6th • July.—D.  C. aged eight, was observed
to have become unusually dull more than a fort-
night ago.  He continued so for about a week;
and this would have been unnoticed,  had he not
several times come  from school complaining of
headache.  One day, about eight days since, he
returned  from play complaining heavily  of his
head.  His complaints after this attracted more
attention, and he was taken from school.   He
would willingly have passed the  whole day in
bed, but his  friends were constantly urging him
to bestir himself.  He had no spirit; and when
he was  not allowed to lie, he would sit down,
and in a  few seconds fall asleep on his-chair.  In
the night, though,  upon the whole, he slept a
great deal, yet he  was  feverish, and  he often
awoke alarmed or screaming wildly of his head. 
                      139
          »
 When he was sitting,  sighing, and yawning,
 and making  some faint and indistinct complaint,
 if he were asked what ailed  him, it was his head,
 or a pain darting through his head.   He has vo-
 mited  frequently, particularly in the morning up-
 on leaving his  bed.   He has,  since the  begin-
 ning of his  illness, been without appetite,  and
 his bowels have been slow.
   I made my first visit to-day,  and find that he
 is considerably emaciated,  and his complexion
 has  become  more  sallow.   As he  sits on his
 chair,  his head seems heavy, it appears ready to
 fall to  a side,  and, as if he had difficulty in sup-
 porting it.  He can hardly keep his eyelids open.
 There is great dejection in  his look,  and his eye
 is languid, and there is somewhat too  much of
 vascularity in the tunica  albuginea.  His  breath
 is sickly.  His pulse  about  100,  but so irregu-
 lar, that it beats five times in five seconds ;  and
 in the next five seconds, it beats ten.  It is raised
 twenty strokes in the minute by walking  across
 the room.  His respiration  is only fifteen in the
 minute.   His urine is high coloured.    Stools
 dark and foetid.
   7th.—Last  night four leeches were applied to
his temples,  and several  laxative  powders  (P.
Jal. gr. vi. Cal. gr. iij.)  were  given.   He  has
had two large evacuations from his bowels, glai-
ry, and of a  dark  green colour.  The leeches 
140
were  large,  and the  bleeding  continued four or
five hours from all the orifices.  His urine depo-
sits a considerable sediment;  his tongue is clean.
There is no change in his expression; he sits,
with heavy eyelids, sighing, and often yawning,
and much subdued;  p.  72, quite irregular.  His
friends say,  that  he  has complained less of his
head.  Continue the  calomel, without the jalap.
   8th.—About noon he was attacked with retch-
ing and vomiting of every thing which  he had
swallowed.  This continued till evening was far
advanced: it appeared to be  checked by a few
drops of laudanum.  After this he had a very
restless  night,  complaining much  of his head.
Since yesterday, he has had three  or four of the
same kind of stools.  There is little change in
his look; he is,  however, making some effort to
amuse himself;  p.  still  irregular,  about 100.
Breath sickly.
   Evening.—He has just had four large leeches
to his temple, having in the afternoon complain-
ed much of his head; p. 60, and quite  regular.
   9th.—A  large blister  was applied to his head
after the  bleeding stopt.   He  has moaned of his
head all night.   He has slept  but little : he start-
ed much.   His  look is  even more oppressed,
and is very  anxious ; the pain is all in the fore-
head ; his eyes are very averse to light.  He has
a slight  cough.   His tongue is whiter.  He is 
                      141
now confined to bed;  pulse when lifted and pla-
ced in a  chair, 80;  the  beat  very irregular;  in
bed, about  54.  Respiration  15.  Stools dark
and foetid.
  10th.—All night he has complained much  of
pain in his belly ; when examined, there appears
most tenderness under the margin of the ribs  of
the right side.   He is becoming weaker; his vi-
sion, hearing,  and judgment, are  perfect; still
his chief  complaint is  of his head; at whatever
time I enter the room he is moaning in the same
hopeless manner.   His pulse begins to quicken;
it is in bed 100, when lifted 13d.  Breath mer-
curial.  His head was dressed with the strongest
mercurial ointment.
  11th.—He had,  from the frequent paroxysms
of pain, a restless  night; he is  sleeping softly ;
he is troubled  with tenesmus ;  his stools form  a
dark bottle-green,  glairy mass; his gums are tu-
mid.  I had him taken out of bed,  but was glad
to replace him, as he retched violently,  and com-
plained of his  head;  he is less ready in his an-
swers : his  pulse is again down to 74:  the skin
of his neck and breast is like an ice plant covered
with small pellucid pustules.
  12th.—He  has  had  one ounce of the  Ung.
Hvd.  Fort, rubbed in within these three or four
days; and, for the  last six days, at the rate  of
12 gr. of calomel daily.  His mouth is much af-
                     m2 
                   < 142
fected  with the  mercury, so that he complains
more of his mouth than of his head ; and he has
refused to take even liquid nourishment,  of which
he had taken.plenty  hitherto.   His belly is  cos-
tive.   Omit the calomel, and give  12 gr. of
powder of jalap.
   13th.—He had three stools.  This night was
a very  uneasy one.   He called for food, but was
unable to sit up to take it; p. 120, and weak.
When roused, his vision and understanding are
perfect.
   14th.—At seven this morning he became  con-
vulsed.  The .convulsions have  continued  ever
since.
   15th.—He is quite blind and insensible.   The
convulsions continue.
   17th.—I  did not  see him yesterday;  but,
upon calling this morning, I found him without
convulsions; his pupils  contracting, and he was
able to distinguish objects.   He was taking food.
Pulse  120,  His stools  are more natural.  His
tongue is swelled from the mercury.
   19th.—He died in the evening of the 18th.
When I called,  a few hours before his death, he
was extremely weak; his breathing quick. He ap-
peared sinking,  as I should have  expected at the
end of a  fever; but  he had  then no convulsion;
and though said to have been convulsed some 
143
hours after,  I believe it was merely the dying
struggle.


  Dissection.—In the membranes  on the surface
of the brain and lining the  ventricles, there  was
rather more than usual of the venous congestion.
There were about four ounces of fluid in the ven-
tricles.
  Upon opening the abdomen, there escaped an
unusual quantity  of foetid air, which had been
confined within the peritoneum.  The omentum
was wasted to a  thin membrane.   The  great in-
testines were filled with flatulence; and the small
intestines, in many places,  appeared  solid, from
spasmodic contraction;  and,  at  two  different
points, they were involved.  The veins of the con-
cave arch of the  stomach were  unusually turgid.
  The whole of  the convex  surface of the liver
was connected, by strong adhesions, to the peri-
toneum.  This surface,  and the peritoneum op-
posed to it, were both highly inflamed, abound-
ing in minute and florid vessels.


                  CASE II.  •
  M. B. aged seven.
  Sunday,  15th  September.—This   girl  was
brought to me about seven weeks ago.   She then 
144
 complained of pains in her belly ; her bowels were
 foul; and she had passed ascarides; but she ap-
 peared to recover upon getting some doses of ja-
 lap and calomel. ,
   About eight days ago, she began  to complain
 a second time.   She had never regained a perfect
 state of health.  She now complained of her belly
 and head.  On  Wednesday last, her complaints
 were confined to her head; and she nas had scarce
 any intermission of pain, which is chiefly in the
 crown of her head, since Wednesday.  Shehasoften
 been sick, generally vomiting what she has drank.
 Her appetite is  gone.   Her  sleep is  not sound;
 she often starts up alarmed ;  it is  also disturbed
 by  the severe  shooting  pain  in  the  head.
 She is often observed drawing a long inspiration.
 Before Thursday last, she had a remission of her
 complaints at noon, with an exacerbation in the
evening.  But now a certain  degree of fever is
always present.
   Her p. is 104;  her tongue is white, or rather
gray ; her skin warm.  Upon examining her bel-
ly, she shows no uneasiness, unless in the right
side.   She  was lying dull, and was not disturbed
by the examination, until I  passed  my hand to
the right side, where there was so  much ten-
derness,  that she writhed and fretted under very
slight pressure, so that I was obliged to desist.
She is dull, and averse to light, and has constant 
145
ly a look of uneasiness ;  when the eye is expos-
ed to light, the pupil is contracted.  When lifted,
she is impatient until replaced in bed.
   17th.—Leeches were applied, on the 15th and
16th, to the temples;  and she has had several doses
of jalap and  calomel, which she is to continue
every six or eight hours. JThere are still some
ascarides in her stools.  Her nights are passed as I
have already described. She sleeps for a short time,
and then she starts up alarmed, or complaining of
her head.   During the  day, she lies  quiet for a
quarter or half an hour, anxious to escape every
notice or attention; and then she is suddenly dis-
turbed by a violent  pain in the upper part of her
head, or  in her breast,  and  cries  affectingly.
She complains little, for these  two days,  of her
belly;  to-day, she  has complained  of it  only
once, and she bears it  to  be  examined.  Her
urine is not high-coloured, but deposits a large
sediment.  The  sickness continues,  and retch-
ing.  Her pulse is 84; to-day  it is both irregu-
lar and unequal.  Her breath is dyspeptic.  She
often  sighs.   Upon  taking her  from  bed to the
window,  she complained of her  head,  and show-
ed much aversion to the light.
   18th.—Pulse 64 ;  less irregular; softer.   The
sighing  is  more  frequent.  The vomiting  con-
tinues.  Her  tongue is  white.   She complains
less of her head,  breast, or belly.  Her sleep is 
146
rather less disturbed.   Her  urine  scanty.   She
has had no stools since yesterday.   She lies quiet,
but is alive  to what is  going forward ; for when-
ever we talked of lifting her  out of bed,  she ex-
pressed great alarm.  Upon lifting her,  her pulse
rose above  100.   Her vision is perfect, and she
has no squinting.
   19th.—Stools green, and oily-looking.  There
is rather less of the sighing and vomiting.   Her
breath  is  very heavy ;  pulse  64; respiration 18;
pulse raised by  the  least exertion; respiration
not  quickened by motion.   Countenance very
anxious;  still averse to light.  Her intellect is
unimpaired.  She is reduced in flesh.   Her gums
are tumid from the  mercury.   During the night,
she again  complained as much as ever of her head,
chiefly of the forehead, and was restless and start-
ed.   She is  to have a large blister to the scalp.
   20th.—She* had  a  very restless night; com-
plaining, not of the blister,  but of pain shooting
through her head.  She has not vomited during
the  night;  but occasionally complained of her
side and belly.   Her  urine is scanty and limpid.
Stools dark  green, oily-looking, and  of a heavy
smell.
   She is sensible and quiet;  her vision is* unim-
paired ;  p. 70;  breathing 24; tongue clean.  In
extreme fear of being lifted out of bed. 
147
  21st.—Pulse  about 100; no  stools or urine
past for the last twenty-four hours;  and the vo-
miting of every thing  taken has returned.   She
was very feverish and hot in the earlier part of the
night  Since morning,  she has become some-
thing  lethargic;  every now and then complain-
ing, but more indistinctly,  of her head.  When
raised, her pupil  was  seen much dilated;  but
there was no squinting.
  22d.—In the evening of the 21st, she  was
somewhat  delirious; but, as the night advanced,
she felt  quiet, complaining faintly of her head;
during the last forty-eight hours, she has passed
her urine  but once, and only one  stool.  The
vomiting has ceased.   The sighing continues.
She complains so much of the uneasiness in her
mouth, as to induce me to order the  mercurial
medicines to be suspended.  Pulse about  100,
and rather small.  She breathes calmly (24.)  She
was sensible; but, upon lifting  her,  she became
insensible; her eyes  were fixed,  and her  face
without expression; immediately I  observed her
pupil to dilate;  her limbs were gently stretched;
her arm* after being thrown out awkwardly from
her body,  was cataleptically fixed for some time;
her pulse fell to 72. . I left her insensible and al-
most motionless.
  23d.—This  morning she is  lying quiet, and
breathing easily,  without spasm or  convulsion; 
148
but blind, and  quite insensible.  Her eyes are
fixed; the pupils much dilated, and half covered
with the eyelid; p. 100, and weaker; it intermits,
or rather some of the pulsations are  so feeble as
not to be felt.   She sighs heavily.  During the
night, she was  much agitated with convulsions,
of which the attack I witnessed yesterday was the
beginning.
  24th.—She lies in appearance much as yester-
day ; the  eyes are  more suffused; the vascular
action  so great, as  to  occasion the  secretion
of puriform matter, which  distils from the angles
of the eyelids.   She was sick, and vomited dur-
ing the night, and was  again much convulsed.
She called for drink in the  morning: but it does
not appear that she  either hears or sees ; p. 100;
breathing soft; belly costive.


  In this  state she lingered three days.   On the
27th, her  breathing became  accelerated.   She
died on  the 28th.   During  the last thirty-six
hours, the convulsions had much abated.
                 CASE III.
  W.  L****'s  daughter,  aged seven; a  well
grown girl,  with dark eyes, and sandy hair. 
149
  About three  years ago this girl had the scarlet
fever severely; after which, she was dropsical for
some  time;  her belly,  ever since,  has  been
larger than usual; and  she has not had the same
perfect health she had before.
  Six weeks ago, she  had  an irregular  fever-
ish  complaint,   of which the  most  striking
symptom  was a great  degree  of foulness of the
bowels.   During this attack, however, she never
once complained of her head.  She  recovered
while using a laxative medicine.  But she has not
Ix'cn so active or cheerful since;  and her colour
lias been unusually sallow;  however she amused
herself as usual;  had returned to school and play ;
and had no particular complaint.   I attended her
in these two illnesses.
  Saturday,  2d August.—On Wednesday even-
ing (30th) while  amusing herself beside her mo-
ther, she complained  of pain  in  her  head;  but
this complaint was transient,  and seemed acci-
dental.  On Thursday  (31st) morning, she was
quite well; but,  towards evening,  she occasion-
ally complained of her head ; and her mother ob-
served, that  the  palms  of her hands were warm :
upon this, thinking she had worms, she gave her
a  dose of the artemisia santonica.  On Friday
(1st August) she was observed drooping and fe-
verish ; and she  again complained of  headache:
her  mother was induced to give  her an emetic.
                      N 
150
To-day,  I was called in in passing.  I was much
hurried, and had scarcely time to note these cir-
cumstances.   I found her dull, hot, her tongue
white and moist, her pulse  quick; she was com-
plaining of her head.   I ordered Submur. Hydr.
P. Convolv. Jalap. P. Cort. Laur. Cassias, a. a.
gr. iv.
  Sunday, 3d August.—-In the evening of yes-
terday she  was tranquil,  and free of fever; dur-
ing the night, she slept tolerably well; but talked
much in her  sleep; and once  or twice awoke
starting; and several times started in  her sleep.
Upon holding a candle to  her eyes,  she turned
from  it,  and complained  of headache.   This
morning, she has seemed to dose much; but, while
dosing,  she has several  times  indistinctly com-
plained  of her head.   She  has been repeatedly
sick,  and once she has vomited some ropy co-
lourless  fluid.  She  lies opposite  to  a window,
but always with her face averted from the light.
Her  look is timid and thoughtful.  The pain is
chiefly in her forehead; but she has once or twice
complained of her  ear.  At times, and often  the
interval  is long, she is free from pain.   Her breath
is heavy, which often  it is  observed to be when
her stomach is disordered;  her pulse is<-quick;
her belly full; but soft, and not tender.  She has
a short,  not  frequent  cough.   She had several
stools from the purge,  dark green, but not glaz- 
151
ed.   Repeat the powder; and  give, every four
hours,  Submur. Hydr.  gr. iss.  P. Cort. Lauri
Cassias, gr. v.  Apply  six leeches to the fore-
head.  Let the head be shaved.
  4th.—Four leeches  were applied,  and, after
they dropt  off, the  blood flowed freely for man}
hours.   She has had two dark green glairy stools.
Her tongue is white,  furred, rather moist;  her
breath  is  not so sickly; her pulse 116, and,  I
think,  irregular.  There is slight subsultus in the
wrist.   In the night, she has been feverish, rest-
less, dosing;  in her mind  wandering,  and com-
plaining of her head; she has also complained of
pain in her belly; yet she has sometimes been for
a long time without any complaint.  Twice  this
morning,  when lifted from her bed, she vomited.
Her look is dull, and, from the contraction of the
eyebrows,  somewhat frowning;  the  pupils  are
much  contracted.   When replaced in bed,  she
naturally turned from the window, and buried her
face in the pillow, to avoid the light.
   5th.—Pulse 120.  Her tongue is furred,  and
less moist.   She had two  stools of the  same na-
ture as those  she passed yesterday; her urine  is
natural, the secretion scanty.   She has consider-
able appetite ; no thirst.  She was cool this morn-
ing, but not  all day yesterday.   All night long
she was restless, complaining much of her head,
tossing her head about, and very feverish; sigh- 
                      152
 ing;  vomiting; complaining much of the  light;
 and complaining of pain in her bowels.
   6th.—She has had no remission of fever since
 yesterday; the night was again passed uneasily;
 she was hot;  she tossed about her arms; she was
 sick,  vomiting  every thing she took, and often
 complaining of her forehead.  She is still very
 dull,  and the expression of  her countenance con-
 tinues unfavourable.   Her face is bedewed with
 moisture;  her pupils are contracted.   When lift-
 ed, her  head  is always leaned on  her mother's
 shoulders.   The sickly smell of her breath still
 prevails.  She has had two scanty stools.   Her
 p. is 96, and  regular; respiration  24,  irregular;
 sometimes sighing;  her tongue  is white, less
 furred.   Give % ss. of the following mixture
 every hour, till stools are procured.

          R. Tinct. Convolv. Jalap, f i-
            Aq. Dist. Laur. Cass, g v. v^.

   7th.—Although the night passed more calmly,
 yet she  complained  much of every noise.   She
 was sometimes  cool, sometimes  profusely  per-
 spiring.  She  has had no stool, and little urine;
 her tongue is loaded ; her p. 100.   Since morn-
ing, she has had more  torpor and flushing; she
lies with her hand pressed to her head.   All day
she has vomited immediately after swallowing any
liquid, and upon the least motion. 
153
  Eight ounces of blood were taken from the ex-
ternal jugular.
  Evening.—Her pulse is nowise  changed by
the bleeding.   She  has complained  less  of her
head, and the sickness has left her;  but she be-
comes rather incoherent.
  8th.  Evening.—Last  night, upon getting  a
glyster, she had a stool nearly natural, containing
apparently little bile; although now and then com-
plaining of her head, she had a quiet night, and
she was less flushed this morning; but the torpor
rather  increases; p.  104, firm.   The pupil  is
more dilated; her tongue is loaded, and her breath
still offensive.  She became more flushed as the
day advanced.   The faeces to-day are green and
glairy.  She  has already  taken  5  i. of calomel.
This forenoon she was again bled.  Omit the ca-
thartic mixture.
   9th.—During the night she  was  complainine;
much; restless,  incoherent,  and rolling her head
on the pillow.   At present she sleeps calmly;  p.
96.  When roused, her countenance has less ex-
pression of any kind;  more of stupid dejection;
her pupils are very dilatable.  Use the mercurial
friction.
   10th.—She has had a  dreadful night, almos;
constantly indistinctly moaning, rolling in the led,
raving, at one time  she  rose and  attempted  to
strike her father.   She is at pre  mt shifting from
                      n2 
154
side to side;  insensible;  not blind, yet with very
dilated pupils, and a vacancy of expression some-
what similar to whatblindness gives. She is some-
times flushed.  Her skin is warm;  her pulse 124;
her breath sickly.   She has had no stools, and has
passed very little urine.   She has had some return
of the vomiting.   Gums not tumid.
   llth.—All night she has been restless  and
complained of her head and belly; and, by her
mother's account, she has twice had some slight
convulsive attack; her pupils  are  dilated, the
right much more than the left.   She sees distinct-
ly ', and  at present is sensible,  but dull.   Her
 countenance is flushed;  pulse 104.  She breathes
 with great regularity.  In the night she had three
 stools.
   12th.—During  the night she  has  often been
 convulsed;  her pupils are much  and equally di-
 lated ; there is a flush on her left cheek;  her face
 is dull  and  inexpressive,  sometimes frowning.
 She is restless;  generally  insensible;  breathing
 irregularly; moaning;  p. 140.   While sitting
 beside her, she took a fit.  Her face, from a state
 of vacancy,  for a  second or two, became,  as it
 were, thoughtful; then it  was  much disturbed
 with  spasms, in  particular, about the left eye,
 which,  from strong  and  repeated  convulsions,
 appeared to  wink with great quickness.   The
 right eye was wide open, and staring;  the mouth 
155
pursed up; the left arm was gradually extended,
the fingers hooked in;  the  limbs stretched out;
the head thrown back;  then the eyes became fix-
ed, or moved  quickly  and tremulously,  which
motion  was  not discovered,  unless they were
narrowly inspected; then there was quick breathe
ing and sighing;  and lastly, she appeared to be
in a soft sleep.  Her pulse, which was 140 before
the fit, during it fell to 96.   After these attacks,
she lies quietly for nearly half an hour:  they  are
preceded by great restlessness and anxiety.
   13th.—Pulse 140; lying flushed.   Sometimes
she is deadly  pale.   She  has slight subsultus;
her gums are blistered; her breath is no longer
sickly, but not mercurial.  During the  night she
had four attacks similar to  that described yester-
day.   The vomiting has returned.
   14th.—Pulse 140.   She has not been convuls-
ed during the night.  She has convulsive twitches
of the lips and eyelids.  She has voided no urine,
nor has she had a stool since yesterday.
   15th.—Low, pale;  she is picking  the bed-
clothes and moaning, squinting, and quite blind;
the pupils dilated and inirritable, as  in death;
the eyes slightly suffused,  and slowly rolling from
side  to side.   Her  lips are sordid; her tongue
black and dry.   She is slightly convulsed, some-
times shuddering.  She shows no signs of sen-
sibility, further than sometimes raising her hand 
                      156
when the flies light on her face.   She has had no
stool, and scarce any urine for two days.
   16th.—She is  blind  and  insensible;  p.  144.
There has been some flow  of urine.   She had a
small stool,  which was  colourless.  Her respira-
tion is quicker.
   17th.—Her breath is -again sickly.   She has
had no evacuation.   She has  lain quiet since last
night.   Her eyelids are closed;  her countenance
without expression, pale ; her jaw sunk.
   In the evening she became again agitated  with
convulsions; she had frequent  hiccuping;  her
respiration  was still more hurried; and before
midnight she was dead.
   The  dissection was  not permitted, although
earnestly urged.
                 CASE  IV.*

  J. M. aged seven years eight months.
  The parents of this child are healthy, and ap-
parently free from  any constitutional  predisposi-
tion.  Of their other  children, two died of Hy-
drocephalus ;  the  one  under  the  usual acute
form, the other sunk under the chronic form of the

  *  This Case, and Case VI,  p. 131, are from the same
respectable quarter. 
                      157
 disease,  the head being much enlarged.  A third
 child of the family has lost one half the jaw-bone
 from scrophuious  necrosis; and the bones of one
 of the thumbs are  now exfoliating, from the same
 disease.   The  boy, the subject of the present
 case, has been  hitherto very  healthy, and was,
 in every respect, as fine a child as I ever saw.
   When called  to see him on the 6th July, 1807,
 he complained much of his head, which he seem-
 ed quite  unable to hold up.   Though dressed, he
 was lying on two chairs, and was seized with
 inclination to vomit, when made  to rise.   The
 pain, which he describes as very severe, is in the
 forehead and temples;  the eyes have a languid,
 heavy,  suffused appearance, and his eyebrows
 are kept strongly knit.   He picks his nose.   The
 tongue is white and furred, skin hot, pulse 120,
 belly costive, urine turbid, depositing a chalky-
 coloured sediment.
   For three days past,  his mother has observed
 him  looking  ill, refusing his food, declining his
 usual exercises,  and expressing a desire to go to
 bed  earlier than  usual.   Yesterday he  complain-
 ed of his head, for the  first time.   He has  had a
dose of senna, which operated twice the day be-
fore  yesterday;  and last night his  mother gave
him  an emetic of ipecacuanha.
  Sumat.  quam primum Submuriat. Hydrarg. gr. ij, et
eras  mane, Pulv. Jalap, gr. xv. cum Submur. Hydrarg. 
158
  7th.—Four highly feculent stools, of natural
colour and consistence, with a prodigious number
of ascarides.   He  appears, however, no way re-
lieved.  When raised from his bed, he vomited,
and complained grievously of his head.
  Sumat. statim Submuriat.  Hydr. gr.  ij. et repetatur
vespere.
  8th.—Complains more of his  head.   He lies
constantly on the  left side,  with the head very
low, and dislikes much to be disturbed,  has vo-
mited twice this morning, no stool, face flushed,
eyes suffused.   He dislikes  the light, and com-
plains of the slightest noise.  Skin very hot; p.
120,  not hard.
      Six leeches to be applied to the temples.
      Two grains of calomel every third hour.
  9th.—The leeches bled well.   He seemed for
a while somewhat relieved, and said his head was
better,  but  towards  evening he became worse,
screaming dreadfully, and crying to his mother
to hold his head.   In this restless manner he
passed  the  night, and slept none till  towards
morning.   He is now quieter, and says his head
is easier.  Two stools,  with ascarides.  Has not
vomited since  yesterday; p. 112.   The leeches
to be again applied.
      R. Pulv. Jalap. Comp. 3 i.
        Calomelanos, gr. vi. n^
         & divide in doses iv.
         Sumat. 1m. 3tia. quaque hor*. 
159
  10th.—Exacerbation of pain  and fever, with
return of restlessness last night.   Js again easier
this morning; but complains much of his head,
and now also of his arms.  The pupils appear
larger,  but by no  means fully dilated.   He  in-
clines still  to  lie on the left side, i. e. from  the
light.   Four large offensive stools, brown-colour-
ed, and not very watery; no ascarides.   Drinks
much,  but  refuses food  of every  kind.  Face
flushed.  Skin hot;  p. 100.  Repet^. Pulveres
Purg. ut heri.
  Evening Report.—He is much  worse  since
seven  o'clock.  , He screams constantly, oh my
head!  my-head! At eight  o'clock, he  is quite
delirious and  unmanageable, talks incoherently,
and tosses  his head about from side to side.   Pu-
pil more dilated; pulse 80; face extremely flush-
ed.  No stool.  To bleed him in the neck or arm
was impracticable, on  account of the frantic and
restless delirium.  With some difficulty, I open-
ed a vein  in the foot, and obtained about  four
ounces  of blood.   He  soon afterwards became
 quieter.  Two leeches were then applied to his
forehead.
    Omittantur Pulv. Purg.
    Sumat  Submuriatis Hydrarg. gr.ij. 2da, q.q. hora.
   11th.—The screaming and delirium continued
 till near four this morning, when he fell asleep,
and remained quiet till seven.   Says his head is 
160
 easier, but he complains grievously of his arms,
 which he has desired his mother to rub, and bind
 up with ribbons;  for he seems  now quite sensi-
 ble.   The  face  less  flushed, pupil  very large,
 but perfectly irritable on approaching the candle,
 he sees distinctly,  knows every  body, and every
 thing; pulse 80, and intermits three or four times
 in a minute.  Has eaten largely of jelly and bread,
 which  he asked for breakfast.   No stool yet.
 Contr. calomeles,  u. a.
   Evening Report.—Has  been very quiet since
 morning, till about eight this evening, when the
 exacerbation returned.   He  now screams, and
 calls out, oh my head! oh my  arms!  hold my
 head,  rub my arms! The  calomel  has been re-
 gularly  given.   One  spare stool; p.  100; in-
 termittent.   Calomel  to  be continued.   Two
 drachms of mercurial ointment  to be rubbed on
 the thighs, the head  shaved,  and a large blister
 applied.
   12th.—A very restless night.   He complained
 constantly of his head'and arms, and tossed about,
 but did not appear  otherwise delirious.  From
 three to seven he slept pretty softly.  He is now,
 at nine, lying on his back devouring, with sur-
prising voracity, a second  slice of bread with
currant jelly, and  asking for more.  All his ac-
tions, indeed, are precipitate and passionate.  He
complains of head  and arms; pulse 112, quite 
161
regular; the  beats being  full and firm,  rather
hard,  tongue clean, pupils dilated, face flushed,
no stool,  little urine passed.
      Sumat. statim pulv. Jalap. 5 i.
      Calomel  gr. ii.

   Six leeches ordered to the temples.  The mer-
curial friction to be continued.
   Evening Report.—The leeches have bled pro-
fusely.  He has been quieter and easier.   Three
copious,  highly offensive, brown-coloured, fecu-
lent stools.  No ascarides observed in them. He
has taken a great deal of beef tea and jelly with
bread.  At  this time,  nine of the evening, he  is
in a slumbering state, complaining at. times only,
or when asked how  he is,  of his head and arms.
He shuts  his eyes, and complains so much on the
approach  of the candle, that I cannot ascertain the
state  of the  pupils.  The face is rather pale, the
skin less  hot, p.  120,  smaller and softer.   Ano-
ther blister to be  applied to the head.   The calo-
mel to  be continued every  two  hours, and the
mercurial friction to be repeated.
   13th.—Slept quietly till  this morning; has
been since more restless, turning from  side  to
side, and complaining of the head and arms.  At
other times  he remains quiet, corrugates his lips,
opens his mouth, and then grinds the. teeth forci-
bly,  and  in  a manner most painfully audible.
                        o 
                     162
Has had one slice of bread with jelly, which he
ate quickly, but with less voracity than  he did
yesterday.  In general, he takes willingly what-
ever is offered  him, and  he answers questions
pretty distinctly.  He says he is better, and com-
plains less of the head than  of  the  arms.  In a
moderate light,  the pupils appear  much  dilated.
He sees, however,  distinctly, and names several
objects which have been presented.  Blister has
risen, and discharged well.   One  stool,  brown,
foetid,  and offensive.   Urined  once,  in small
quantity, yet pale and watery.  Tongue  slightly
white, pulse  130, regular.   The  blistered  part
to be dressed with Ung. Hydrarg.   The  calomel
and mercurial frictions to be  continued.
   Evening  Report.—During  the  day,   he has
been quiet, sensible, and collected;  at times only
moaning, and  sighing profoundly.   He  has re-
peatedly asked for various kinds of food, for beef-
stakes,  and dried fish:  He has  had beef-tea and
bread, and a few prunes.  In this way, he conti-
nued till about seven in the evening, when, after
repeated fits  of screaming and restlessness, he
was attacked with strong general convulsions, of
the spastic or tetanic kind.   One  of these fits, I
have just witnessed.  The neck,  the arms,  and
fingers, were chiefly affected; and the convulsions
seemed confined to the extensor muscles.   The
fit over, he appears quite insensible, he grinds 
163
the teeth with dreadful  force,  and,  between
whiles,  mutters indistinctly, like one in the low
delirium of typhus.  Pulse 140.
   At Midnight.—Low muttering delirium.  Eye-
lids half raised.  Pupils completely dilated.  He
turns himself occasionally  from one  side to the
other with a  kind of precipitate leap.   Only one
convulsion since that I witnessed at nine o'clock.
Nothing can be got within his mouth, the teeth
are kept so forcibly together.   Pulse 160.
   14th.—Several  convulsions  since  last report;
and,  in general, he has been  in the same low,
insensible state, muttering, moaning, and grind-
ing his  teeth with a most horrible stridor.  About
three this morning, he passed,  in bed, a large,
offensive, feculent, watery stool.   Has swallow-
ed, at intervals, a  small  quantity of  wine and
water.  At seven  this morning,  he appears less
insensible than he was last  night.   He grinds his
teeth as before, he  moans  heavily, and cries out
at times,  " Oh my arms!"  He  stretches them
frequently out; he picks his teeth, and tugs his
shirt  sleeve.   He swallowed easily a  spoonful of
jelly  which I gave him,  and  then cried out for
drink.  He  refused the  wine and water  which
was offered;  he refused also beef-tea.  He cried
out'again for water—" Water, water, I want cold
water!"  Of some cold gruel, he now drank very
greedily. 
164
   At ten o'clock A. M.—A most violent gene-
 ral convulsion, which continued with little miti-
 gation for twenty minutes.  Pulse, during the fit,
 100; before  and after the fit,  140.   Continue
 the mercurial frictions, and let him have wine, to
 the extent of four glasses,  with  water.
   Evening  Report.—Several convulsions from
 eleven till two o'clock, from which time he has
 been quiet and insensible.   At nine this evening,
 he still slumbers softly.   Has taken about three
 glasses of wine.  No stool nor  urine passed this
 morning.  Pulse 100.
   15th.—Has passed the night in the same slum-
 bering state, occasionally moving his arms,  and
 sighing deeply.  Towards morning, he turned
 himself, and passed  his urine in bed.  He looked
 up,  and drank some wine and water freely.   He
 knew his mother, and spoke to her.
   At  nine  this  morning.—He is awake;  the
 eye  is  clear;  the pupil  is much dilated;  and,
 though he rolls his eyes much, and seems to di-
 rect and fix them with difficulty, he sees and  dis-
 tinguishes objects distinctly, several of  which he
named.  When asked to  show  his tongue, he
pushed it out very readily : it is  very black, foul,
and  swelled, but moist.   He takes the  wine and
water willingly, but  has some difficulty in shal-
lowing.  The countenance is pale; the features
sharp :. the alee narium drawn close; p. 100, soft 
                     165
and equal.  Has taken,  since  yesterday, about
six ounces of port wine.
   The wine to be continued.   To have calf-feet
jelly,  arfd beef-tea, ad libitum.   The head, which
is still sore, to be dressed with Ung. Hydrargyr.
   Evening Report.—Has continued in the same
quiet state, though more awake.  Has taken four
glasses  of wine,  and  two glasses  of jelly.   He
answers  distinctly;  says his   head is bad,  and
arms  easier.   He picks  much at  his eyes  and
nose, but has not ground his teeth.  The pupil
is nearly natural.  He has urined three times very
plentifully.  No stool.   Pulse 130.  Continue.
   16th.—A tolerably quiet night; sleeping ge-
nerally ;  and at intervals moaning, sighing,  and
picking the bed clothes, eyes, and nose.   Has
passed urine twice.  No stool.  Has taken, dur-
ing the night, three glasses of wine, ana one of
calf-feet  jelly.   He answers distinctly; says he is
better, but complains of his head.  He swallows
more easily,  and  more  naturally.  Tongue  less
swelled.    Gums  look a little red and full; no
mercurial fcetor, however, nor salivation.  Pulse
 140.  Skin  hot.   Belly swelled and hard.  To
have four grains of calomel; to be repeated, if
no stool has been procured, at six  in the evening.
Urine, <fcc. as before.
   Evening Report.—Became uneasy, and  evi-
ifently worse, about five o'clock.  He moaned
                      o2 
                     166
heavily;  ground  his teeth most dreadfully ;  and
was soon afterwards seized with a general convul-
sion.   At ten this evening,  he is still  convulsed
over the  whole body.   As  before, the spasm
seems confined to the extensor muscles ; the legs
and arms are forcibly stretched out;  and the neck
and  trunk are  quite  rigid.   There  is very little
interval between the convulsions.
   17th.—The convulsions continued with very
short intermissions.  He died this morning at
seven  o'clock.

   No dissection. 
167
            NUMBER III.


                  CASES
                    OF

    HYDROCEPHALUS ACUTUS.


                 CASE I.

  J. M. whose case was given (Case I, No.  I)
again became my patient in December 1806. In-
deed, as  she never had regained her health after
her illness in May 1804, I had very often,  in the
meantime, been consulted about her complaints.
She had frequently scrophuious ophthalmia; the
lymphatic glands in her neck were swelled; there
was a protrusion of the tenth dorsal vertebra;
the instep was much enlarged, from  a swelling
of the bones of the foot.  She has been frequent-
ly  troubled with a disordered state of the abdo-
minal viscera; at these times, her abdomen was
 observed tumid, the  stools dark  and foetid,  her
 breath heavy, and she was  not  without fever.
 When these symptoms were relieved, by'aloetic
 purges,  she  generally had tolerable health  for
 some weeks or months.  When  the protrusion 
                        168
   of the spine was first observed, her bowels were,
   and for some time had been, in a  very disorder-
   ed  state;  and it appeared to me, and to others,
   that as her stools became more natural, the effect
   of the aloetic pill, the protrusion in the spine was
   less conspicuous.
    In the latter end of November,  when I called
   to inquire for this girl,  whom I had not seen for
   some months, I found that she  had had several
  fits of sickness, and had been for some days cos-
  tive.  I considered this as a return of the com-'
  plaint from which she had so often suffered, and
• ordered her pills, with aloes and gamboge.
    I visited her on the 1st December,  and found
  that  she  was still  costive, and that, in  addition
  to her other  complaints, she  had  occasionally,
  for two days, complained of pain in her head and
  belly; but that she  was often cheerful.   I found
  an unwillingness in  her friends  to give her medi-
  cine.  I urged the necessity of having the state
  of her bowels corrected.
    4th December.—She has had only one dose of
  the pills.   She is screaming with pain in her head
  and  belly.   She is drowsy, fretful,  and feverish.
       R. Tinct. Jal % i.
         Syr. Simp. ^ ss.
         Aq Font. 3  iij.  it^.
         Sumat. Coch. 3a q.q. hora. 
169
   6th.—She has  taken all the mixture, which
produced only one scanty stool.  She is extreme-
ly dull.   Whenever she leans her head upon her
mother's knee,  she  instantly falls  asleep, and
awakes confused.   The pain, which is chiefly in
her forehead, is more intense and constant.
      R. P. Jal. gr. xx.
         Submur. Hydrarg.
         Sacch.  a.a. gr.  xij. n^.
         f. Pulv. iv.

   7th.—She has taken three of the powders, but
has had only one small  stool.   I found her asleep;
pale ; altered in  appearance;  her eyes slowly rol-
ling under her eyelids;  the headache most excru-
ciating  during  the whole  night; her  pulse 60.
Upon awaking, she sighed heavily ;  was for some
time indistinct; her pupils much dilated.   She
had  considerable  strabismus.   Her  tongue  is
loaded.   As it was impossible to get her to swal-
low medicine, I advised laxative glvsters, two of
which were given, and were followed by the dis-
charge of a quantity of dark faeces, of a colour be-
tween red and brown, mixed with black and ropy
slime.
   8th.—She lies sleeping  calmly; in  her sleep,
now and then sighing.  Her pulse is under 60.
The heat of her skin is moderate.  She has a
fixed squint; her  mother thinks her blind.  No
more stools have been passed. 
                     170
  9th.—Her left side is motionless;  her right is
convulsed.  For some days she has refused all
Bourishment.  During the last twenty-four hours,
she has lain as I find her; comatose;  grinding
her teeth; breathing for the most part softly, but
sometimes stertorously; generally flushed; her
eye inflamed; and quite insensible.  Her stools,
of which she  has had several  during the night,
are  firm and clayey ;  pulse 100, full; her breath
is very sickly ; her mouth is drawn to a side;
her tongue is white and dry.  The slight convul-
sions,  with  which she is often seized,  generally
disappear after a long-drawn sigh.
  10th.—Pulse 140 ; sleeping calmly.   During
the night she had three violent fits of convulsion.
Her stools are dark,  but not Hydrocephalic.
  11th.—Pulse about  200.   Her respiration is
becoming quick ; it is about  40.   She is pale.
Her eyes are fixed.   Her mother says, for a con-
siderable time during the night, that she recover-
ed  her sight,  and was also sensible.  Her urine
and stools are scanty.
  12th.—She died on the evening of the 11th.
  Permission, with great reluctance, being given
to open the abdomen, these were the appearances
which were observed.
  There was nothing unusual in the first view
which presented of the intestinal canal;  but, up-
on a more narrow examination, I discovered,  in 
171
the small  intestines, evident traces of increased
vascular action ; in several places,  the blood ves-
sels had that florid and injected appearance which
is only found after inflammation.  In  children,
where there had  existed any  irritation in the
bowels, upon dissection, we seldom fail to find
construction and intussusception of the small in-
testines ;  accordingly, about  a foot of the ilium
was found thus involved; at this part, however,
 I could discover no remains of inflammation.  •
   The gall-bladder  was  much distended with
 dark-green bile.
   The surface  of the liver was quite irregular,
 from  a multitude of tubercles of various  sizes.
 When the substance of the liver was cut into,
 we  found the  structure universally  tubercular;
 and, except on  the convex surface,  it was unu-
 sually colourless.  The appearance of increased
 vascularity on  this surface  was striking; and it
 adhered, by numerous bands of unequal strength,
  some of them as firm as the broad ligament,  to
  the peritoneal coat of the diaphragm,  which also
  had been much inflamed.
    Many of the mesenteric glands were enlarged.
  Some of those which appeared unusually firm I
  cut into, and found containing a quantity of case-
  ous matter.   There was nothing unusual in the
  appearance of the spleen, pancreas, kidneys, or
  great intestines. 
172
  We were not allowed to make a dissection of
the brain.
                  CASE II.

  June 1801.—C. D. aged fourteen, of a high-
ly scrophuious family, complained from the be-
ginning of spring of rheumatic pains and want of
apatite; and  her constitution was so much sha-
ken, as to lead her friends to think that she was
in a decline.  Towards the end of May,  the pains
chiefly complained of were in her  head. In the
beginning of June, the pain was seldom absent.
Her bowels  about this time were much disturb-
ed ;  she had severe and constant purging, and, at
the same time, she was sick  and  vomited  bile;
her pulse denoted much fever; the slightest quan-
tity  of calomel, even half a grain, increased the
bowel  complaint.   Purgatives, opiates,  and cre-
taceous medicines,  were  alike  unavailing; the
sickness, diarrhoea, and fever continued; at last,
she complained  less of her  head;  but  this was
from her having become lethargic.   She showed
considerable displeasure when roused; and she
invariably turned from the light; her pupils ceas-
ed to dilate; she  had every symptom of Hydro-
cephalus, except  the  slow pulse ;  but  that this 
173
was her disease, was not suspected sooner than
about ten days before her death.
                 CASE  III.

  June 1805.—R. A.  aged six.
  This boy, since the beginning of last summer,
never has enjoyed good health.   In July 1804,
he had hooping-cough; this he surmounted;  but
the utmost delicacy of constitution remained ; he
was long without appetite.   After  the cold win-
ter weather  sefin, he was attacked all over the
body with circumscribed tumors, about the  size
and shape of a nutmeg, apparently formed in the
cellular  membrane,  which  slowly suppurated/
leaving  scrophuious sores.   When these tumors
first appeared, he was so dyspeptic, low, and weak,
as to be confined to bed. As the spring advanced,
he appeared to recover strength. I called occasion-
ally to see the progress of the scrophuious disease.
One day,  upon remarking that he had something
peculiar in  his look,  his  mother  said, she  was
afraid he was losing his sight.  I examined him,
and found that  the  pupils did not contract; one
side was paralytic.  He complained of no pain in
his head; but in ten  days he was dead, during
which time most of the symptoms of Hydroce-
phalus were manifested.
                       p 
174
                  CASE  IV.

   Hydrocephali interni, et acuti, ut illud a lento
 et  chronico  distinguam, historiam  etsi brevem,
 et  non absolutissimam, qualem accepi  ex  ore
 ejus, qui curationi praefuit,  cum sectione  cada-
 veris heic referre non  erit inutile.   Puella qua-
 driennis,  caput habens  magna?  molis, tempera-
 mento sanguineo, et bono  corporis habitu praedi-
 ta, antehac tussi rheumaticspluries ob?ioxia, coe-
 pit de dolore capitis subinde  conq'ueri.  Quadam
 die repente subriguit et post frigus et horrorem,
 incaluit non exigua febri prehensa.   Ducta ei al-
 vus est eccoprotico antiphlogistico,  sed febri ad-
 huc prosequente, missus postea etiam e vena san-
 guis.  Febris interdiu inequaliter incedens saepius
 invalescebat et vicissim se remittebat,  nunquam
 ad apyrexiam perveniens.   Post missam  sangui-
 nem melius  habuit, ita ut non  modo paullatim
 febris evanescere videretur verum  a lecto etiam
 surgeret,  cibumque et appeteret,  et paullo largio*
 rem per aliquot-dies assumeret.   At dolor capitis
nunquam earn penitus reliquit,  nee pulsus ad na-
turalem omnino motum rediit,  inaequaliter enim,
et celerius micabat.  Tandem quatuor ante mor-
tem diebus febris iterum accessit, auctusque  est 
175
capitis dolor sic ut primum deliraret, deinde mo-
tibus convulsivis faciei et demum  artuum  sub-
inde corriperetur.   Postremo resoluta ex  uno
corporis latere,  stertens, et sensibus orbata vigin-
ti quatuor amplius  horas transegit,  nequidquam
juvantibus epispasticis, antiphlogisticis et revel-
Ientibus quibuscunque medicamentis misere  vi-
tam cum morte commutavit, die  nimirum deci-
ma septima, ex qua morbus  incipere visus est;
quarta vero ex  qua febris, et capitis dolor recru-
duit.   Sectioni anatomicae ejus cadaver opportu-
no ab obitu tempore traditur.   En quae parentum
defunctae amicissimus Kavina, strenuus militum
praetorianorum chirurgus primarius, in ea inve-
nit, mihique scripto  retulit: aperto cranio dura
mater tensa et colore subcaeruleo, uti esse in pue-
ris ob  cerebri molem, et vasorum subter posito-
rum  transparentem nigredinem solet, apparuit.
Ejus  vasa sanguinea, item  que piae matris, et
cerebri ipsius turgida  admodum et sanguine ple-
na, et prae ceteris sinus omnes venosi qui pneter
modum eo tumebant.   Retractis meningibus  ex-
terior sinistri anterioris cerebri lobi facies  obtege-
batur concreto tenui quodam humore translucido
et flavo qui gelatinam aemulabatur.   Ventrieuhs
magnae vis aquas inerat qua  turgebant.   Haec in
capite.   Thorax deinde reseratus est.  /// ante-
riore pulmonis dextri parte  ?nox occurrit  tuber-
vulum, ex quo secto et expresso aliquid humoris 
176
 lymphatici prope ad drachmas duas prodit.  Su-
 pra eandem pulmonem  concreverat mucosus hu-
 mor quidam flavescens  gelatinosus.   In sinistro
pulmone duo  reperta  tubercula fuere  qua pus
fxtidum expressa fendebant.  Extrinsecus ejus-
 dem  faciem foedabat macula violacea nigricans.
 Vasa pulmonica  vix quidquam  sanguinis  con-
 tinebant.   Auricula vero dextra  polypo magno
 occupabatur, et eo  maxime intumuerat.  Abdo-
 men non fuit dissectum, Burserius, Inst. Med..
 Pract. vol. v,  § 52.
   Dr. St. Clair, Edinburgh Medical Essays and
 Observations,  vol. ii, art.  18,  gives an excellent
 case of Hydrocephalus converted from scrophula:
 the attack is also of the acute form.  This boy
 had  had hectic,  from  pulmonary  complaints,
 from which he appeared to have recovered.  Sud-
 denly, fever with delirium came on;  then  starl-
 ings, shrieking,  increase of  fever; epileptic fits;
 a return of intellect; " the pulse slower than that
 " of a man in health;" violent convulsions and
 death.   He died on the  8th  day.   In  the dissec-
 tion, was found, near the beginning of the jeju-
 num, a small quantity of  the  feculent matter
 which  is almost peculiar to this disease.   In the
breast, nothing was faulty but the lungs, which 
177
adhered firmly on all  sides  to the pleura, and
were full  of tubercles, and suppurated  impost-
humes of different sizes; so that whenever they
were cut,  either thin pus ran out, or a thick sub-
stance  of  the consistence  of new  cheese, was
found  within  the  membranes of the tubercles.
The blood vessels of the brain  were all  greatly
distended with blood;  and in the ventricles about
six ounces of water were found.
   Dr.  Percival relates, " that a girl, aged nine
" years,  after labouring  under symptoms  of
" phthisis pulmonalis four months, was affected
" with unusual pains in her head, which increas-
" ed rapidly, to such a degree as to occasion fre-
" quent screamings.  The cough that had before
" been  extremely  violent,  and attended with
" stitches in her breast, now abated,  and in a few
 " days ceased almost entirely.   The  pupils of the
 " eve  became dilated;  a strabismus ensued ; and,
 " in about a week,  death  put a period to herago-
 " nies."   In the paragraph preceding that which I
 have  quoted, Dr.  Percival  says,  *«  Practical
 " writers h .ve related many cases  of  dropsical
 " metastasis.  I  have seen  an affection  of the
 " brain  which  appeared to  be Hydrocephalic
 " and probably originated in  inflammation, sud-
 " denly and completely relieved, by the attack of
  " an  acute pain  in the side, which terminated in
  < a fatal abscess and h} drothorax."
                       r2 
178
  It is surely unnecessary farther to pursue this
illustration of the connection between Hydroce-
phalus and scrophula.


                  CASE V.

   On the 4th of July, while visiting the garrison
hospital under my care in Leith fort, a  soldier's
child was  brought  to  me, a  girl of  eighteen
months,  not much fallen away in flesh,  but pale,
or rather of a sickly yellow complexion, such as
children  with a relaxed state of the bowels ac-
quire.  She had been weaned nearly two months;
and her bowels, since the weaning, and indeed
for some weeks before, had been loose.   The
lymphatic system appeared deranged.  With the
looseness, her belly was full, her limbs  soft, and
somewhat  cedematous.   However, I  expected
 that a gentle mercurial  course would restore her
 to health.   On  the 9th, her father requested me
 to go to his room to see her, as  she appeared to
 him  much   worse.  I  found her lying, at first
 sight, I  thought,  asleep, sawing .with  her  right
 hand; and  her  left, I  understood, she had lost
 the power of using.   Upon investigating the case,
 I discovered,  by the  most unequivocal  signs,
 what I might have concluded from this appear-
 ance, that she had fallen into Hydrocephalus, 
179
                 CASE VI.

  A. S. two years and a half old, a  fair child,  of
a temperament which formerly would have been
called pituitary or phlegmatic.
  9th  December.—About eight  o'clock  last
night, this boy was seized with  a convulsion fit.
When I saw him, which was about ten minutes
after seizure, he was recovering from the fit.   He
had  past, during  the  fit, a loose  clayey stool,
mixed  with   dark   slimy streaks,  exceedingly
foetid.   A glyster of gruel with salt was imme-
diately injected; then he  was put  into the tepid
bath; and he  had regularly given him, every two
hours during the night, a potion, containing car-
bonate of magnesia and powder of jalap.   About
four in  the morning he had  another fit.  I was
sent for; but before I arrived, the violence of the
convulsion was again over.  However, his  body
 was still retracted;  his limbs, particularly of the
 left  side (which was the side  most convulsed)
 were extended ; his pupils were dilated, his coun-
 tenance was  pale.   This morning, from ten to
 twelve,  he was never altogether free of convulsion
 —often violently convulsed.   I have not seen him
 during  the violence of the convulsion ; but it is
described as  sometimes a perfect •*-j»oTm(.  In
the interval between the fits he is quite distinct. 
180
  To night he is pale, he has frequent convulsive
twitches.   His pulse  is  extremely  quick and
hard, his skin is warm.  Having had about two
drachms of magnesia, and one drachm of jalap, his
belly has  been very  loose; the  stools are dark
and viscid, with a very pungent fcetor.
  About the 2d of December, this boy's  gums
and tongue were observed affected with those cir-
cular painful ulcers,  attended with  salivation,
which vulgarly are supposed to indicate difficult
dentition ;  he was feverish,  and lost his appetite.
On the  5th and 6th, he appeared to  be in a state
of convalescence.   On the 6th, he was running
about the house in good spirits, and  his mouth
was much easier.   On the  morning of  the 8th,
he often complained of pain in his belly; he was
dull in the afternoon,  he lay with his head on his
mother's breast.  He never has complained either
of sickness or of headache.  Some of the ulcera-
tions, more superficial than they  originally were,
are still to be seen  in his gums.
   10th.—This boy had another  fit last night at
midnight.   He is  now insensible.  His pulse is
extremely hurried, and  vibrating.   His  pupils
are wonderfully contracted.  His skin  is hot, his
tongue  loaded.   The  subsultus  still  continues.
His stools are large, green, and slimy.  His head
has been shaved, and rags dipt in cold water and
vinegar frequently applied. 
                     181
  11th.—Four leeches were applied to  his tem-
ples, and a blister to the scalp.  His pulse is by
no means so  quick (about  130.)   The  adnata is
suffused, not deeply; "{he iris appears pale.  His
pupils are less contracted.  One cheek is flushed.
He   is  frowning,  sighing, restless, insensible.
The twitches, particularly of the left side, conti-
nue ; he passes frequent dark stools ;  his urine all
along has been scanty.
  12th.—Yesterday he  began to take digitalis
and calomel.   The cornea is covered with a viscid
secretion,  which conceals, in the  right eye, the
shape of the pupil.  The pupils are but moderate-
ly dilated,  and contract, upon  the  approach of a
candle  to the eye;  yet he  appears  quite blind;
his pulse is about 200 ;  his respiration quick (50)
not laborious; he sometimes sighs;  his breath is
very sickly; he has convulsive twitches  about the
eye,  and his left hand and fingers are irregularly,
sometimes  spasmodically,  moved:  his  mother
says that he was at one time to-day quite sensible
to her  attentions; he has had  three green and
slimy stools.
  13th.—He died last night about midnight. 
182
                 CASE VII.

  11th October.—Two children and their mother
had fever, with morning remissions.  One of the
children, about the  seventh or eighth day of the
fever, had symptoms  of oppressed  brain, appa-
rently from Hydrocephalus having taken place of
the fever.   She was  briskly purged,  blistered,
and she took digitalis in large doses, and calomel.
In four days, from the change in her disease, she
had no symptoms either of fever or Hydrocepha-
lus.   She was indeed very  weak.  About the
time (30th September) that the fever left the mo-
ther of these  children, a  third girl, about  four
years of age,  sickened.  The fever which this
last child had was ardent, with a morning remis-
sion,  not very complete ; she never complained
of her head, nor was she sick.  On  the 9th day
of October, the fever  appeared to have left  her;
and immediately a severe vomiting  arid purging
of bile ensued.  She  became exceedingly dull,
and has scarce spoke since.   The purging con-
tinuing, on the 10th an opiate was administered,
after which the purging ceased ; the dullness and
insensibility increased, and she was,  in the night
of the 10th? quite insensible, and  rolled inces-
santly from side to side.  The heat  of her  skin
returned. 
183
  She is still  extremely  restless;  her pulse Is
nearly 200.  Her pupil  is  dilated,  yet contracts
upon the approach of  a  strong light.  Although
she is insensible to every  thing which  passes
in the chamber, yet she is able to express  her
displeasure upon being lifted out of  bed.  She
sighs frequently.  I  attended her sister dur-
ing her illness;  my first visit to this girl was made
to-day.   I was as careful  as I could be  in pro-
curing the foregoing account of her  disease.
   12th.—The night was passed miserably;  the
girl was not so much  convulsed  as  in a state of
constant  restlessness,  tossing  about the bed,
grinding her teeth.   Her eyes were often fixed;
her pulse is  180,  or 190, and  small.   She is
blind ;  her breathing is irregular, her breath sick-
ly.   Such restlessness I never witnessed.
   13th.—She has had no stool for these two days.
 Her night was quieter.   She still is restless,  and
apparently insensible.    She is  deeply  flushed.
 She sighs much.  There appears in her agitation
 great impatience.
    14th.—She  died this  evening,  before I had
 made  my visit; but I  understand that  her left
 side was in  constant  motion during  the  greater
 part of the day.
   Dissection,   15th October.—There occurred
 unusual difficulty in separating the skull-cap from
 the dura mater.   This arose from an  indissoluble 
184
adhesion, at the upper part of the lambdoidal su-
ture,  of a part of the membrane to the bone.  The
adhesion  was circular,  and  about  an inch in
diameter.  It was evidently the effect of inflam-
mation, but whether of a recent date, is, I think,
very doubtful.  The dura mater  did not at any
other  part exhibit any great mark  of disease.
  The longitudinal  sinus was but scantily filled
with blood.  On lifting the dura mater, there ap-
peared on the brain the  most incontestible re-
mains of arterial  action.  All  over the surface,
the red blood vessels were very abundant;  and,
in the spaces  between them, there were suffusions
of vermillion-coloured  extravasation,  in  pretty
extensive masses.  Under the tunica arachnoidea,
there  was a considerable quantity  of serous effu-
sion extending over all the surface of the brain,
but lodged chiefly in the interstices between the
convolutions.   The  veins were not empty,  but
by no means turgid.  The substance of the brain
was of a  natural degree of firmness; and,  on di-
viding it, numerous red spots of blood studded
the cut surfaces.
  The ventricles were  found but  little dilated.
They contained a certain quantity of serous effu-
sion.   The hole of communication between the
ventricles was somewhat enlarged, allowing the
free transmission of  the fluid.  The fluid in the
ventricles did not exceed an ounce.  The plexus 
185
choroides was coloured deeply with arterial blood;
and the velum interpositum was beset with little
red blood vessels in great numbers, and similar
to the appearance which presented when the dura
mater was removed from the surface of the brain.
  The substance of the fornix was perfectly firm.
All around the base of the brain, the surface ex-
hibited the  same marks of inflammation which
were described  on  the upper part of the brain.
Yet there, was no such appearance on the surface
of the cerebellum  ; on the contrary, there was
not to be discerned a single red blood vessel.
  The dissection of the head was  conceded by
the friends so unwillingly, that I did not propose
to open the abdomen, without  which, however,
no dissection of Hydrocephalus is to be consider-
ed as complete.
                CASE  VIII.

  September 1806.—A few  days ago,  a girl
about seven years  of age, who had been labour-
ing under  a continued fever, with morning re-
missions, with  which three  children in the same
lane were affected,  appeared  to me to have got a
crisis.   She became cold on the  15th day of her
fever;  her  tongue c\ean.   I  called  on  the 18"th 
186
day, and  then I  discovered  a sad change;  her
pulse was about  80, and was raised  to great
quickness by lifting her up upon  the pillow, or
turning her.   The pupils were dilated;  the  iris
paralytic.   She was  totally blind, and quite in-
sensible.   She was breathing irregularly;  fre-
quently sighing.   She  had  every symptom of
Hydrocephalus, with the exception of the stools^
which  were foetid, and of a dark  reddish brown.
In this state she lay three days,  and died, after
being much convulsed.
   I could adduce many other instances of remit-
tent fever terminating in Hydrocephalus.
   Dr. J. Hunter records an instance, in an adult,
of the remittent fever of the West  Indies termi-
nating in effusion of the ventricles.   I  shall  con-
tent myself  with referring to the work of this in-
telligent writer.   Observations on the Diseases of
the Army, p. 81.   If I mistake  not,  in typhus,
the dilatation of the pupils is mentioned by some
authors  as a fatal symptom ;  and  well  it may, if,
as I imagine, it arises from a conversion of a very
hopeless nature.  In the case of an adult, whom
I attended this spring, in fever, with great disor-
der of the sensorium, the pulse,  a few days be-
fore death, came  down  below 80,  was soft  and 
187
irregular.   Perhaps the pulse, as in this instance,
eoming down, may be mistaken for a crisis.   It
has occurred to me since, that I might have been
mistaken when I thought that the girl (Case VIII.)
had got the crisis.   Dr. Willan desires us to dis-
tinguish between acute Hydrocephalus and  the
symptomatic Hydrocephalus,  which  takes place,
with very similar symptoms,  after the  crisis of
malignant  fevers.   Reports on  the  diseases of
London, p. 270.
   It may be considered as the tendency of other
diseases, in which the bowels are torpid, to lead
to  Hydrocephalus.  Dr.  Willan  observes, that,
in two cases  of chorea Sil Viti, which he exa-
mined after death, from two  to  four  ounces of
clear lymph were found in  the ventricles of the
 brain.  Reports on the Diseases of London, p.
 245.


    A  sufficient  number of cases  have been  pre-
 sented to show the conversion of other diseases
 into Hydrocephalus. 
188
NUMBER IV.
DISSECTIONS,
                     I.

  Dissection  of a boy of six years  of  age,
who died of Hydrocephalus.   The disease lasted
exactly twenty-one days.  There was rather more
of pain in the head than usual;  in other respects,
it was a case presenting a fair example of the dis-
ease.  The boy, before the attack, had been ap-
parently in good health.
  The intestinal canal appeared rather paler than
usual; the liver darker.  There was no  fluid in
the  cavity of the abdomen;  indeed the peritoneum
was not even lubricated.
  After  minutely  examining  the  abdominal
viscera,  we  proceeded to  the  dissection of the
head.
  In lifting back  the  dura  mater, it was found
to adhere to the  tunica arachnoidea in several 
                      189
places.   The veins of the pia mater were full of
blood, but not turgid.
  On cutting off part of the brain,  we found it
firm and tough,  in  the cut  surface there were
numerous  spots  of  dark, apparently  venous,
blood.
  On cutting into the left lateral ventricle, a co-
lourless fluid flowed out, and the ventricle  appear-
ed to be considerably dilated.   The veins on the
walls of the ventricle were filled with blood.  The
plexus  choroides  had  no  redness in its  colour.
The vena Galeni was full of blood.  The edges
of the fornix were fringed, the  substance of it
was peculiarly soft.
  The other ventricles were in a condition similar
to the lateral ventricle; the ventricles contained
in all about three ounces of fluid.
                      II.
  Dissection of a fair-complexioned boy, eight
years of age,  apparently of a scrophuious habit,
who died of Hydrocephalus on the 6th May.  Six
or seven weeks before his death, he became un-
usually  reserved, then thin and pale ; yet he took
his victuals soniew hut too greedily.   About three
weeks alter, he began to decline in his health;. he
was seized with a severe bowel complaint, which*
                     *2 
190
continued eight or nine days; when it stopt, he
left off taking nourishment almost entirely ;  what
he took he vomited.  About this time (viz. a-
bout ten days before he died) there was observed
great quickness and brilliancy of the eyes, and he
complained  almost incessantly of headache; for
several days after the vomiting left him, he had
frequent fits of retching.   Since the.purging left
him, he has been scarcely  out of bed.  In the
latter part of his illness, he dosed much, and al-
ways awoke delirious; he  sighed, started, was
convulsed, complained constantly and impatient-
ly of his head, frequently also of acute pain  in his
belly, and had great tenderness of the abdomen.
The pupil was dilated; and the consent between
the eyes was lost.   He died after violent convul-
sions.  The symptoms which, strictly, are attri-
butable to a diseased state of the brain, were of a
very short duration—under a fortnight.  I saw
him only five days before  his death, when the
case appeared to me hopeless.
   Upon laying back the integuments of the ab-
domen, the intestines appeared generally distend-
ed by flatus.  The transverse arch of the colon
was greatly contorted, and remarkably distended
above the rest of the intestines.  In diameter, it
might measure 2* inches.   In the whole course of
the small  intestines, were frequent, but not high-
coloured, marks of inflammation ; and, in several 
                     191
places,  circular contraction of the coats.  The
colon was free of any marks of inflammation.
  The surface of the liver  was  studded with
white  tubercles,  of  the size  of  millet seeds.
There were no other  morbid appearances in  the
abdomen.
  On removing the skull-cap and the dura mater,
there was observed nothing very remarkable on
the surface of the brain.  The veins on the pia
mater were filled,  but not distended.
  The substance of the brain was firmer than
natural.   On cutting a pretty thick layer off the
superior part of the brain, the lateral ventricle ap-
peared to  be much distended.   A fluid, by tap-
ping with  the fingefX could be distinctly felt;  it
pushed up the roof of the ventricle.  On making
a small opening with  the point of the knife, water
spouted to some  distance.  The foramen com-
mune, under  the  fornix,  was much enlarged,
 and the ventricle of the other side was found col-
 lapsed.  The  substance of the fornix was very
 soft, being  nearly of the  consistence of thick
 cream.  The plexus choroides was quite colour-
 less ;  there  were upon  it several  little papulous
 eminences.
   All the ventricles contained  water, and had
 been much distended by  it.   The veins on the
 walls of the ventricles were full, but not turgid. 
                      192
   The appearance of the vessels on the base was
 similar to that on the surface of the brain.
   The quantity of fluid collected from the brain
 during the dissection was five ounces.


   The quantity of fluid was,  considering the du-
 ration of the disease,  remarkable.   I can explain
 this only by the violence of the symptoms which
 were  present at the beginning of die Hydrocepha-
 lic attack.

                     III.

   15th May.—Dissection of a boy twelve years
 of age.  This boy died, after being for  two days
 dreadfully  convulsed.   I saw him for the first
 time on the day previous to  that on  which he
 died.    I  found him drenched in sweat, large
 drops standing  upon  his face  and forehead;  his
 pupils dilated;  his eyes rolling slowly ;  his pulse
 quick  and  thready; asleep;  his breathing low.
 I attempted to rouse him, but could not.   I  un-
derstood that he was quite insensible.   He was a
boy of a  very  scrophuious constitution, subject
to scrophuious  ophthalmia, and swelling  of the
glands. During last winter,  he did not enjoy a
day of health.   I recollect that he was brought to
me about six weeks ago.   He then complained 
                      193
 of a constant pain in the back  part of his neck.
 At that time  I  examined  him particularly, and
 discovered a commencing rising of the spine.   I
 understand that he complained of his head about
 a fortnight ago.   He was then much in bed.  On
 the  8th, he had an attack  of sickness; constant
 vomiting; nothing remained  on his stomach.
 On the 9th, and succeeding nights, he had se-
 vere diarrhoea.  The  vomiting and purging was
 incessant till the 12th.  On the night of the 12th
 he became delirious;  and,  with very  short inter-
 vals, he continued so to the last.
   When the skull-cap and dura mater were raised
 from the upper part of the brain, there appeared
 to be some effusion on the surface, and lodged in
 the angles between the convolutions of the cere-
 brum.   On  puncturing  the membrane  under
 which  it lay, the effusion was found to be serous;
 on the pia mater,  towards  the  back part  of the
 head, were marks of inflammation.
   On cutting away part of the brain,  the surface
 presenting was moist.   The substance was  of a
 moderate degree of firmness.
   On puncturing the  lateral ventricle of one side,
 a quantity of watery fluid flowed out (about three
 ounces.)  The ventricle was enlarged; the veins
on its sides were conspicuous.   The plexus cho-
roides  had upon  it vesicles filled with serum.
When  the fornix  was raised, there appeared, in 
194
the middle of the velum  interpositum, a vesicle
of the  size  of a  large  pea,  containing  serous
fluid.  The substance of the fornix was  quite
soft.  The hole between the ventricles was  en-
larged ;  and both ventricles were  emptied by the
puncture into the  one which was  first opened.
They appeared to  have been equally distended.
   The third  ventricle was enlarged,  and contain-
ed fluid.  In examining the base  of the brain,
the tunica arachnoides, round the infundibulum,
was distended with fluid of a light green or yellow
colour.   On puncturing  it, a good deal of serous
fluid escaped.  Besides the fluid, there  was  on
the pia mater, at this place, a considerable deposi-
tion, apparently of coagulable lymph.  It lay in
distinct clots.
   The  fourth ventricle was enlarged, and con-
tained fluid.    The  quantity  of fluid collected
during the dissection was five ounces.
   We next proceeded to examine  the contents
of the abdomen, and found the intestines general-
ly,  and  very  much distended with flatus; at  one
or two  places there  were  contractions  of their
coats, and marks  of increased  vascular  action.
The  glands  of the  mesentery  were enlarged.
The gall bladder was completely distended.
   The last vertebra of the back, and first of the
loins, were found projecting. 
195
                     IV.

  Dissection of a boy nearly three years of age,
who died of Hydrocephalus.  First he  was  ob-
served sallow and dull;  the dullness lasted for six
weeks, during which time his appetite was much
impaired; but he made no complaint.   He took
to bed eighteen days before he died.   On the
morning of the 5th day  after he was confined to
bed, he became sick, and vomited; in the after-
noon he had  a severe fit;  he had many in the
latter part  of his  illness.   During the last four
days of his life, he was  insensible and blind.
   On raising the skull-cap,  there appeared to be
on  the dura  muter an increased number of little
red blood vessels.  The longitudinal  sinus  and
veins on the  pia  mater were  filled with blood.
There was a considerable quantity  of  serous ef-
fusion over the whole surface  of the brain,  and
marks of increased action in the  small  arteries,
with here and there spots of extravasated blood.
Towards the back  part and  right side of the
brain,  there  was a  considerable secretion of co-
agulable lymph.
   The substance  of the brain was firm.   The
left lateral ventricle was distended, and on open-
ing it, a limpid and colourless fluid, to the quan- 
196
 tity of three or four Ounces,  escaped.   The ven-
 tricle was considerably enlarged.   The right la-
 teral ventricle corresponded in appearance with
 the left.   The foramen, under  the fore part  of
 the fornix,  was  much  enlarged,  allowing the
 water which had been in the right ventricle  at
 once to escape, by the opening made in the left.
 The plexus choroides was free of blood and co-
 lourless.   The substance and continuations  of
 the fornix were very white and soft.   The third
 and fourth ventricles were enlarged, and had con-
 tained a proportion of fluid.
   On the cerebellum under the tentorium, there
 was a deposition of coagulated lymph, but not of
 great extent.   On the base of the brain was effu-
 sion of serous  fluid, and at particular parts, of a
 thicker opaque lymph, similar  to  what was ob-
 served on the upper part.
   In the abdomen, the morbid appearances were
 white spots, not larger than a mustard  seed, like
 minute tubercles all over the surface of the  liver;
 in  distribution like  a regular and distinct erup-
 tion : enlargement of many of the glands of the
 mesentery.  They  were  white and hard; and
 when cut into, were found  to contain a cheesy
 substance, of a  pure yellow colour, as  if mixed
with purulent matter. 
197
  On the following  case and dissection,  I shall
not venture to give a decided opinion.   I  am
inclined to think  it a specimen of a different dis-
ease, rather than  a variety  of  Hydrocephalus
Acutus.   I am persuaded that it  is not a rare
disease.   Although  this is  the  only  dissection
which  I have made,  I think that it is the second,
if not the third case of the kind which I have seen.
It appears of importance, to  attend to  every  cir-
cumstance which can obscure the  diagnosis of
Hydrocephalus.  I  have pointed out two acci-
dents which appear  to me to embarrass the phy-
sician.   1st, He makes a favourable prognosis in
some infantine disease, e. g. in  remittent fever,
and in a day  or  two he finds his patient  Hydro-
cephalic by conversion, he is led  to the rash con-
clusion,  " that Hydrocephalus is only to  be  dis-
" covered by dissection."*   2dly, By  another
unlooked-for  turn, this conclusion is confirmed.
An unfavourable prognostic  is made in the case
of  Hydrocephalic symptoms arising from sym-
pathy  with disordered  bowels,   and the child
upon the administration of active purgative  me-
dicines,   unexpectedly recovers.    The  disease,

  •• These are the words of an eminent physician in Lon-
  lon.
                        R 
198
of which I am about to give an instance, may be
another cause of confusion,  as  in its symptoms
and  its effects,  it  closely resembles Hydroce-
phalus  Acutus.  Hence  it is entitled to  every
attention.
                      V.

  J. P.'s  child, eight months old, with  blue
eyes; a fair and thriving child.
  On the 10th April, this boy, in the forenoon,
was quite well, cheerful,  and happy.  In the af-
ternoon,  he was fretful.   All night he was ex-
tremely fretful.
  On the 11th, he was dull, oppressed, fretful,
and feverish.   In the afternoon, he started and
screamed wildly, rather than in pain.   His bowels
were disordered;  and, upon taking a cathartic
medicine, he passed  some  green, foetid, and ill
concocted stools.
  On the evening of the 12th, he was lively and
cool.   In  the  afternoon, the  fever, fretfulness,
and starting, returned.  He had  a   very  restless
night.
  13th.—I first saw him.   His complexion is
pale; brow contracted; he  is extremely  warm.;
his  pulse  180; tongue rather loaded.  He starts
and sighs often; his legs are in constant motion, 
199
not violent;  his hands are  frequently drawn in
and extended, and his fingers are spasmodically
moved; at times  his  eyes  are much affected—
fixed, with enlarged pupils; he is said  to have
had a convulsion fit shortly before  I called.  Be-
fore I left him the effects of it seemed to have
disappeared.   He was again  quick and observing.
   14th.—This child  passed  a  very disturbed
night.   His left hand is in constant motion;  it is
hard to say whether it is spasmodic or voluntary,
it is the regular motion which we observe in Hy-
drocephalus.   He  has slight  spasms about  the
mouth and eyes.  His  brow is contracted; pupil
rather dilated, not readily contracting.   His re-
spiration  is quickened (70;) pulse about 160.
He has great febrile heat.  His tongue is cleaner;
complexion pale; bowels loose; his stools are of
a  bright  yellow colour, as  if containing much
bile, with green streaks, and a very sour smell.
   15th.—In the course of last night he had three
severe epileptic  fits.   He often sighed.   He is
much  worse this  morning; his  pulse is about
200.   His eyes are spasmodically affected;  the
pupil much  contracted.  There  is  subsultus;
moaning.   He is pale.   His belly  loose.
   16th.—As  the day  advanced,  yesterday,  the
convulsions became less violent.  The nervous
twitchings remaining.   He died at three  o'clock
this morning. 
                     200
   Dissection of the head of this child, performed
the day after death.
   On  raising the dura  mater, we were  struck
with the appearance of the parts presenting.   On
a superficial view, there  appeared to  be,  on the
brain,  a quantity of a green coagulum like jelly,
in a layer of considerable thickness, in which the
veins of the pia mater lay imbedded; these seem-
ed to be coated with a white opaque deposite.
   What at first appeared like jelly, upon exami-
nation  proved to be serous exudation between the
tunica  arachnoides and pia mater; it  was in far
greater quantity on the  upper part of the brain
than elsewhere, and seemed pretty equally distri-
buted on each hemisphere.   It might be compar-
ed to a large flat vesication, the margin of which
arose from the horizontal line which divides the
upper  and middle third  of the circumference of
the brain.   Although beyond this part,  the ap-
pearance of vesication did not extend, yet the
veins on the pia mater, all around the external
part of the brain, were  nearly coated with  what
appeared to be coagulable lymph  (at some places
flakes of it  lay distinct;)  from this the pia mater
appeared as if converted  into a thick membrane,
in fact  it was thickened,  as appeared on examin-
ing that part of it where the exudation on the sur-
face did not exist; and here we found little red 
201
vessels and  streaks of blood, such as appear on
an inflamed  membrane.
  The sinuses in the dura,  and the veins in the
pia mater, were filled with blood.
  The substance of the brain was very soft.  On
cutting it, fluid exuded  so as to bedew the new
surface.
   There was but little fluid in the ventricles, not
exceeding half an ounce.   The plexus choroides
was nearly colourless, as if bleached.
   The substance of the fornix,  as  well as the
other parts of the brain,  was very soft.
   There  was  little or no  fluid  in  the  third or
 fourth ventricle.
   The quantity of fluid  collected exceeded three
 ounces and a half, of which three ounces was
 collected from the  surface of the brain.
THE END. 
 
ANTHONY  FINLEY,
             PHILADELPHIA,

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