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i(^QJ3QX3QJ3QX3Q/3QJ3QJ3Q®Q.GQJ3QfJ<
 
 
 
                 AN
         INAUGURAL ESSAY
                 ON
HYDROCEPHALUS INTERNUS.
             SUBMITTED TO
         THE EXAMINATION
                OF THE
REV. JOHN ANDREWS, D. D. PROVOST, (pro tem.)
                 THE
  TRUSTEES AND MEDICAL PROFESSORS
                OF THE
     UNIVERSITY OF PENNSYLVANIA,
       On the 21st day of April, 1806.
              FOR THE
    DEGREE OF DOCTOR OF MEDICINE, ;)■><.
         _ , _    _______   __ jff   .       '2
     By JACOB DAVID WACKER,/ °^l?y
            or SWABIA.  ------    '^XU'll
MEMBER OF THE PHILADELPHIA MEDICAL LYCEUM,
 AND HONORARY MEMBER OF THE PHILADELPHIA
          MEDICAL SOCIETY.

PRINTS* FOR THE AUTHOR, BY JOHN H. OSWALD
1806. 
 
               TO






    GEORGE FRENCH, M. D.





               OF






   FREDERICKSBURGH,  VIRGINIA.






     THIS ESSAY IS INSCRIBED,





               AS





A MARK OF ESTEEM AND GRATITUDE,





        BY HIS MUCH OBLIGED






      FRIEND AND PUPIL,






                   THE AUTHOR. 
 
                        AN

               INAUGURAL ESSAY

                        ON

HYDROCEPHALUS  INTERNUS.
     THERE are two diseases, both called Hydro-
cephalus; though they are very different  in their
symptoms and causes.

  Hydrocephalus, properly so called,  is a disease
which may with propriety be considered as a chro-
nic affection, perfectly analogous to other dropsies
of the human  body.  Rickets, or other kinds of
constitutional debility, are generally held to be its
predisposing cause ;  its progress is frequently so
slow, that patients have been known to labour un-
der it from the  period of birth to an advanced age;
the heads of children, so affected at birth, are pre-
ternaturally large, and continue to encrease for years
without any very distressing symptoms attending
it;  the patients  frequently enjoy tolerable  health,
and those who arrive to an advanced period of life,
have commonly sound intellects,  until a short time
before death, when they are  generally affected by
convulsions; after death the brain is found so ex-
ceedingly distended by water,  within the ventricles,
as to be reduced to an amazing degree of thinness; 
(   6  >
I have seen a case where the brain was  reduced to
the thickness of half an inch;  the  ventricles con-
tained at  least two quarts  of  water, though  the
child was no more than five months old;  it was also
affected with Spina Bifida, which it is said is fre-
quently the case.   This  disease is never, or but
rarely, cured.

  The other disease which has been very improper-
ly termed  Hydrocephalus, by  some writers, Dr.
Cullen has called simply by the name of apoplexia
hydrocephalica; but  Dr. Rush has. given it  the
name of phrenicula, in its  first, and chronic apo-
plexy, in its last stage.   This disease attacks per-
sons of all ages, but most generally children.

   The brain,  in children, is larger in proportion to
other parts of the body, than it is in adults; and of
course  a greater proportion of blood is sent to it,
than in the subsequent periods  of life.   The tex-
ture is also less consistent in infants than in adults.

   In  all febrile diseases there, is a preternatural de-
termination of blood to the brain; and  this occurs
in a more especial manner in children;—hence the
reason why they are so apt to be affected by convul-
sions in fevers.

   Dr. Quin, in his  excellent  treatise  on Hydro-
cephalus,   has  given  a history of  its  symptoms, 
(  7  )
 fnore correct ftian any of those that wrote before
 him.  I shall therefore take the liberty of introdu-
 cing it here as he has given it.

   " In general,  the patient is at first languid and
 " inactive, often  drowsy and peevish,  but at inter-
 " vals cheerful and apparently free from complaint:
 "the appetite is weak;  a nausea, and in many
 " cases a vomiting occurs once or twice in the day,
 " and the skin is observed to be  hot  and dry, to-
 " wards  the evening ; soon after these  symptoms
 " have appeared,  the patient is affected with a sharp
 " head-ache, chiefly in the forepart, or if not there,
 "generally  in the crown of the head;  it is some-
 " times however  confined to one side  of the head,
 " and in that case, when the posture  of the body
 " is erect, the head often inclines to the side affect-
 "ed; we frequently find, also,  that the head-ache
 " alternates with  the affection of the stomach;  the
 " vomiting being less troublesome, when the pain
 " is  most violent, and vice versa;  other parts of
 " the body  are likewise  subject  to temporary at-
 " tacks of pain, viz. the extremities and the bowels,
 <c but more constantly the back of the neck, and
 " between the scapulae.  In all such cases the head
" is more free from uneasiness.

  " The patient  dislikes  the light at this period;
" cries much, sleeps little,  and when he does sleep, 
(  8  )
" he grinds his teeth,  picks his nose, appears to be
" uneasy, and starts often, screaming as if he were
" terrified; the bowels are, in the majority of cases,
" very much  confined, though  it sometimes hap-
"pens that they are  in the  opposite  state;—the
" pulse at this early  stage, of the disorder, does
" not usually indicate any material derangement.

  " When the symptoms  above mentioned have
" continued for a few days, subject as they always
'■' are,  in this disease, to great fluctuation, the axis
" of one eye is generally found to be turned in, to-
'* wards the nose : the  pupil of this side  is rather
" more dilated than the other;  and when both eyes
" have their axes directed inwards, (which some-
** times happens) both pupils  are larger than they
" are observed to be in the eyes of healthy persons:
"the vomiting becomes more constant; and the
" head-ache more excruciating;  every symptom of
" fever then makes its appearance,  the pulse is fre-
" quent,  and the breathing quick; exacerbations of
*' the fever take place  towards the evenings, and
" the face is occasionally flushed;  usually one cheek
" is much more affected than the other; temporary
*' perspirations likewise occasionally  break forth,
" which are not followed by any  alleviation of dis-
" tress :  a discharge of blood from the nose, which
" sometimes appears,  about this period, is equally
" inefficacious. 
(  9   )
  " Delirium, and that of the most violent kind,
" particularly  if the patient has arrived at the age
" of puberty, now takes place, and with all the pre-
ceding symptoms of fever,  continues for a while
" to  encrease, until about fourteen  days,  often a
" much  shorter space of  time, shall have  elapsed
" since the appearance of the symptoms which were
" first mentioned in the above detail.

  " The disease then undergoes  that remarkable
" change which sometimes suddenly points out the
" commencement  of what has been called its se-
" cond stage;  the pulse becomes slow, but unequal,
" both as to its strength,  and the intervals between
" the pulsation ;  the pain  of the head,  or of what-
" ever part had previously been affected, seems to
"abate,  or at least the patient becomes apparently
" less sensible of  it; the interrupted slumbers  or
" perpetual restlessness which prevailed during the
"earlierperiods of the disorder are now succeeded
" by  an almost lethargic torpor,  the strabismus and
"dilatation of the pupil  increase;  the patient lies
" with one or both eyes  half closed, which when
" minutely examined,  are often found to be com-
" plctely insensible to light;'  the vomiting ceases;
" whatever food or medicine  is offered,  is usually
" swallowed with apparent voracity; the bowels at
** this period generally remain obstinately costive.
                         B 
(  10  )
  " If every effort made by art fails to excite  the
" sinking powers of life,  the symptoms of what
" has been called the second stage, are soon succeed-
" ed by others, which more certainly announce the
" approach  of death.   The pulse  again  becomes
" equal, but so weak and quick, that it is almost
" impossible  to count it; a difficulty of breathing
" nearly resembling the Stertor  Apoplecticus,  is
" often observed; sometimes the eyes are suffused
" with blood; the flushing of the face is more fre-
" quent than before, but of  a shorter duration, and
" followed  by a  deadly paleness;  red  spots,  or
" blotches, sometimes appear on the body and limbs;
" deglutition becomes difficult, and convulsions ge-
" nerally  close the scene.   In one  case I may  ob-
" serve, the jaws of a child of four years of age
" were so firmly locked for more than a day before
" death, tkat it was impossible to introduce either
" food or medicine into his mouth;  and in another
" case a hemiplegia, attended with  some remarka-
" ble circumstances, occurred during the two days
" previous to dissolution.

  " Having thus given as exact an account of apo-
" plexia hydrocephalica, as I could compile from the
*' writings of others, and from my own observations,
" I should think  myself guilty of imposition on my
" readers, if I did not caution them, that it must be
" considered  as  a general  outline.   The human 
'  11   "i
"brain seems to be so capricious, (if the expression
" may be allowed) in the signals it gives to the
" other parts of the system, of the injury it suffers
" throughout the  course of this disease, that al-
" though every symptom above mentioned does
" occasionally occur, (and indeed few cases of this
" disease are to be met with, which do not exhibit
" many of them ;)  yet it does not appear to me, that
" any one of them is constantly and inseparably con}}
" nected with it."

  Although I take this to be the most correct his-
tory that ever  has been  given of this disease, yet
there are many deviations from it, and it  is indeed,
as Doctor Quin has happily expressed it, of a " truly
"Protei-form nature."

  Doctor Rush has not  found the dilated and in-
sensible pupil,  the puking,  the delirium, or the
strabismus  to  attend  universally in  this disease.
He saw one case in which the appetite was unimg
paired from the first to the last stage of the disease;
he has met with one case in which the disease was
attended by  blindness, and another by double visior;
he has observed an uncommon acuteness in hearing
to attend two cases of this disease:  in one of them
the noise of the  sparks  which  were discharged from
a hickory fire,  produced  great pain  and  startings,
which threatened convulsions. 
(  12  )
  He has seen three cases in which the disease ter-
minated in hemiplegia, in two of them  it proved
fatal in a few  days; in the third,  it continued for
nearly  eighteen months.

  He has met  with  one case in which no preterna-
tural slownesss or intermission was ever perceived
in the pulse.

  He obtained a gill of water from the ventricles of
the brain of a negro girl of nine years of age, who
died of this disease,  who complained in  no stage of
itxof a pain in her head or limbs nor of sick stomach.
The disease, in this case, was introduced suddenly,
by a pain in the breast, and the usual symptoms of
a catarrh.

  Doctor  Wistar has met with a case in which
there was a total absence of pain in the head.

   Doctor  Carson attended a  child in this disease,
that discovered,  for  some days before it died, the
symptoms of hydrophobia.

   Doctor  Currie obtained seven  ounces of water
from the brain of a child, which died of this disease;
in whom no dilatation of the pupil, strabismus, sick-
ness, or loss of appetite had attended; and but very
 little head ache. 
(  13   )
  I have seen a case of this disease, in a boy of three
years of age, who had a constant desire to put his
fingers into  the orbit of the eye.  In this case the
disease succeeded an intermitting fever.

  Causes....These act either directly, or indirectly,
through the medium of the whole system.

  The causes which act directly on the brain, arc
falls or bruises on the head.  Doctor Rush men-
tions two cases  of this disease : one  of them was
produced by a fall upon the head, and the other by a
wound on the forehead, with a brick-bat*. Certain
positions of the  body,  and childish plays,  which
bring on congestion and inflammation ; afterwards
effusion  of water in the  brain.  The doctor has
known it brought on, in a child, by falling into a
cellar, upon its feet.

   The indirect causes are more numerous and more
frequent, though less suspected, than those which
have been  mentioned.   The following diseases of
the whole  system appear to  act indirectly,  in pro-
ducing chronic apoplexy.

  1st.   Intermitting,  remitting,  and   continual
fevers.  I have already mentioned that I have seen
a case of this disease produced by an intermitting
* Inquiries andobfervations, vol. 2d,page %\\ and 212. 
(  14   )
 fever.   Doctor Woodhouse saw a case  which was
 evidently the effects of a remitting fever ;<| Doctor
 Rush supposes that state of continual fever which
 has been  distinguished by the name of Typhus, is
 often the remote cause of this disease.

  2d.  Rheumatism.  Doctor Rush has seen two
 cases,  which succeeded rheumatism ; and if there
 be such a thing as misplaced gout, this might with
 great propriety be called misplaced rheumatism.

  3d.  Pulmonary consumption. Doctor Percival*
has furnished us with the history of a case, which I
 :.hall introduce here :  " Mr. C----'s daughter, aged
'•' nine  years, after labouring under phthisis pulmo-
" nalis four months, was affected with unusual pains
 " in her head.   These rapidly increased, so as  to
 " occasion frequent screaming.   The cough which
 " had  before been extremely violent, and was at-
" tended with stitches in the breast, now abated,
" and in  a few days ceased almost entirely.  The
" pupils  of the eyes dilated,  a  strabismus ensued,
" and  in about  a week, death put an end  to  her
" asronies.   Whether this  affection  of the  head
 " arose from an effusion of water or of blood, is un-
 " certain ;  but its influence on the state of the lungs

 * Medical, Philofophical, and experimental Effays,  vol. id, page
    339—340- 
(  15   )
" is worthy of notice."  Several other writers have
related similar cases.

  4th.  Eruptive fevers.  Doctor Odier* informs
us, that he had seen four cases in which it had fol-
lowed the small pox.  Doctor Rush has seen a case
in which it.was obviously the effects of debility in-
duced upon the system, by the measles.

  5th.  Worms.   If they are the  cause of this
disease, it is by first producing a febrile disease upon
the whole system, which has been already mention-
ed to be one of the causes which produce this dis-
ease.

  6th.  From observations and dissections of seve-
ral respectable physicians, who have paid particular
attention to this disease, it appears to have succeed-
ed all the  following diseases, viz. the cholic, palsy,
melancholy,  dysentery, dentition, and insolation ;
also the sudden healing of old sores.  Doctor Rush
has seen two cases of it from the last cause, and one,
in which it was produced by the action of the vernal
sun alone, upon the  system.

  From the symptoms,  and causes of this disease,
which are  so similiar to those of inflammation of
* Medical Journal. 
                   (   16  )
the brain, produced by  injuries from external vio-
lence, of which the late Mr. Pott has given a correct
history, in his excellent treatise on Surgery, where
he says,  " the symptoms' attending an inflamed,
" sloughy state of the membranes,  in consequence
" of external violence, are pain in the head, restless-
" ness,  want of sleep, frequent and hafd pulse, hot
" and dry skin, flushed countenance, inflamed eyes,
" nausea, vomiting, rigor,  convulsions, and deliri-
" ura ;  and these come  on so gradually as not to be
" observed,  until some  days have passed after the
" accident shall have happened :  all the complaints
" produced by extravasation, are such as arise from
" pressure, viz. stupidity, loss of sense, and volun-
" tary motion, laborious and obstructed pulse, and
" respiration; and these usually appear immediately
" or very soon after the accident."   It appears that
this disease is of a truly inflammatory nature ;  it
only differs from- phrenitis,  in its being the effect
of causes which produce a less degree  of morbid
action in the brain, and that its second stage is the
effect of a less degree of that effusion, which produ-
ces serous apoplexy in adults.    It bears the same
relation to phrenitis  when it arises from  indirect
causes, which r neumonicula does to pneumony," and
is pi educed in the same manner as the pulmonary
consr.niption, by debilitating causes, w hich act pri-
marily  on the whole  system.  In the latter  stage,
the  disease partakes  of some of the properties  of 
(  17  )
apoplexy.  It differs from it in its being a slow, in-
stead of a sudden effusion of water or blood;  &, in its
being the effects of a chronic, instead of an acute na-
ture.  In persons advanced beyond middle life, who
are affected by this disease, it approaches to the na-
ture of common apoplexy, by a speedy termination
in life or  death.  This I believe is owing to their hav-
ing less tenacity for life than children,  who,  it is a
well known fact, will  sustain injuries on the head,
which would produce instantaneous death in adults.

  Dissections also show that this disease  is of an
inflammatory nature.  Out  of  six  cases,  Doctor
Rush has found four, which exhibited marks  of in-
flamation.

   Mr. Davis discovered signs of inflammation after
death, from this  disease,  to be universal.   In
eighteen or twenty dissections he  found  the  pia
mater always distended with blood.*

   Much more  might be said in proof of its being of
an inflammatory nature ; but time and circumstances
will not permit me to dwell much longer, I shall
therefore proceed to mention the remedies,  which
have been used of late with the happiest effects, and
these are:
       * Medical Journal,  vol. 8.
                        C 
(  18   )
   1.  Blood-letting, general and local.   This re-
medy has been used by Doctor Rush with the great-
est advantage.  Many respectable  physicians have
followed his example with equal success.  Local
bleeding, by means of cups, leeches, scarification,
and arteriotomy,  promise more success, than vene-
section,  and ought always  to  be  preferred to  it,
especially where the whole system does not sympa-
thise with the disease in the brain.  Doctor Wistar,
in his lectures, mentioned a case of a man,  who was
affected  with  a  periodical head-ache,  who  was
always relieved by the application of two or three
cups to the temples, and  crown of the head, when
venesection had not the  least effect,  though large
quantities of blood were taken.

   2. Cathartics. These have been found very be-
neficial,  especially in what has been called the  se-
cond stage of the disease;  though it  ought not  to
be omitted in the first.  The confined stale  of  the
bowels indicate  their use.  Calomel  seems to be
best adapted for the  purpose;—irom four  to  ten
grains, or  even more,  ought  to  be given every
three or four hours, till plentiful and repeated eva-
cuations  take place,

   3. Blisters, have been recommended by all prac-
tical writers upon this disease.  They are most ef-
fectual when applied to the head, neck, or temples, 
(   19  )
 They ought to be perpetual.  I have seen the dis-
 tressing symptoms increase, as soon as they ceased
 to discharge.

   4. Cold applications to the forehead, have been
 found  beneficial  in relieving that pain in the head
 which is generally one of the most distressing
 symptoms in this disease.

   5. Mercury, was long considered  as the only
 remedy, which gave the least chance of a recovery
 from a dropsy of the brain.  But  experience has
 shewn that this is not the case,  (except when given
 as a purgative.) Dr. Monroe gave it to twenty two
 patients who were affected by this disease, but not
 one of them recovered.  Out of all the  cases (which
 I  suppose were  numerous) in which  Dr.  Rush
 gave mercury, as  a  sialagogue, before the year
 1790,  he succeeded but in two ; and  since he has
 adopted the  depleting  remedies, which have been
 mentioned,  he has declined to give  it altogether,
 except as a  cathartic;  for which  purpose, as  has
 been already  mentioned, it  is one of the  best ar-
 ticles.

  6. Diuretics,   have  been  recommended and
used, but if the theory which has been taught by
Dr Rush, and which I believe to be a correct one,
is true, they promise nothing.
FINIS. 
 
Med. Wist.
    WZ.
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