104

DIET IN HYDROCEPHALUS-USE OF NARCOTICS.

combination with a third of a grain of the sulphate of quinine; and I can recommend this practice as yielding results, on the whole, more encouraging than any other with which I am acquainted.

I insisted much on the local employment of cold when speaking about the management of cases of cerebral congestion. It is likewise a very valuable agent in the treatment of hydrocephalus ; but its application requires to be judiciously regulated. You will generally find it of service after depletion, for you have abstracted blood on account of the febrile disturbance, and heat of head, and other indications of congestion of the brain, all of which cold will be a powerful auxiliary in subduing. So long as the signs of active congestion of the brain are present, cold will be of service; but it should not be employed independently of the symptoms which betoken the existence of that condition; nor can you hope to see any benefit result from cold applications to the head in the advanced stages of the disease. I need scarcely say that the application of cold with a shock, or the pouring cold water from a height upon the head, though a very valuable means of arousing the child from the state of coma into which it sinks in some cases of intense cerebral congestion, is wholly inapplicable in the coma of hydrocephalus. The functions of the brain are here not merely interrupted by the excess of blood in the organ, but they are abolished by the disorganisation of its tissue, or the compression of its substance by the effusion of fluid.

In the management of children attacked by hydrocephalus you must not forget that for the most part they are of feeble constitution, and that they will not bear too rigorous a diet. Just at first, indeed, while the febrile symptoms run high, and the bowels are unrelieved, or the sickness is urgent, the less the patient takes the better. Afterwards, however, it is desirable that he should be supplied with as much light and unstimulating nutriment as he will take; such, for instance, as arrow-root, or veal or beef tea, either of which will often remain on the stomach when most other articles of food or drink would be rejected.

In the treatment of many diseases you see physicians destroy the sense of pain by narcotics, and the question naturally suggests itself to you whether you may not sometimes venture, in the management of hydrocephalus, to mitigate by their means your patient's sufferings. The enquiry is one not very easy to reply to satisfactorily. I think, however, that there are two conditions in which you will be justified in trying the experiment of giving them. Sometimes the disease sets in with great excitement, and

USE OF BLISTERS-TARTAR-EMETIC OINTMENT.

105

a condition closely resembling mania in the adult, symptoms which may have been ushered in by convulsions. In such a case, although the heat of head and the flush of the face may have disappeared after free depletion and the copious action of purgative medicine, and though the pulse is feeble as well as frequent, yet the excitement may be scarcely if at all diminished. Here an opiate will sometimes give the relief which nothing else will procure; your patient will fall asleep, and wake tranquillised in the course of two or three hours. In other cases, which did not set in thus violently, restlessness, talkativeness, and a kind of halfdelirious consciousness of pain in the head, become very distressing as the disease advances, being always aggravated at night, so that the patient's condition seems one of constant suffering. But he is not able to bear any more active treatment, and, indeed, you have already emptied your quiver of such weapons. In these circumstances I have sometimes given a full dose of morphia, and have continued it every night for several nights together with manifest relief.

Another enquiry that you may put is, when are you to employ blisters? Certainly not at the beginning of the disease, when they would increase the general irritation, and do more harm than good. At a later period they may be of service, when the excitement is about to yield to that stupor which usually precedes the state of complete coma. They should then be applied to the nape of the neck or to the vertex; and I am disposed to think the latter the better place, since, when applied to the nape of the neck, they often become displaced by that boring movement of the head which the child in many instances keeps up unconsciously. It is well, too, to remember that the skin in hydrocephalus is very inapt to vesicate, so that a blister will require to be kept on for ten or twelve hours; contrary to what ought to be your usual practice with children. Cases enough are on record proving the utility of blisters thus applied, to render it your duty not to neglect this means.

I have made a few trials of a very energetic counter-irritant which has been strongly recommended by a German physician,* but my experience does not induce me to recommend its adoption. Dr. Hahn employs an ointment composed of one part of tartar-emetic and two parts of lard; of which a portion, the size of a hazel nut, is to be rubbed on the shaven scalp over a surface some two and a half inches in circumference, * De la Méningite Tuberculeuse, etc., par H. Hahn. 8vo. Paris, 1835.

106

TREATMENT IN THE LAST STAGE OF HYDROCEPHALUS.

every two hours, till an abundant pustular eruption is produced. The sores which follow this inunction are remarkably intractable, requiring sometimes many months for their cure; but Dr. Hahn asserts, and gives some cases in proof of the assertion, that even in an advanced stage of hydrocephalus, and after the supervention of coma, recovery has often taken place under the use of this remedy. Many of the cases that he relates, however, are clearly not instances of hydrocephalus at all, while the theory which he propounds of the existence of a sort of antagonism between tubercular meningitis and certain pustular eruptions of the skin, and on which he founds the assumption of a sort of specific virtue in the tartaremetic ointment, is a mere hypothesis, of the correctness of which, as a general law, we have no sort of evidence. In the cases in which I tried it, it produced most formidable ulcerations of the scalp it did what a very energetic counter-irritant might be expected to do, but nothing more, and it was difficult to convince bystanders that a large black-looking wound did not increase the suffering of patients whose disease it certainly failed to arrest.

Need I say that you must not think of treating a case of hydrocephalus throughout just in the same way as you did at its commencement? There is, if the disease do not run a very rapid course, a stage of weakness and exhaustion, often associated with a half-comatose condition, though sometimes attended with a considerable degree of suffering, which frequently precedes the signs of approaching death. The bowels are now sometimes relaxed, though oftener they continue constipated, because the nervous energy which kept up the peristaltic movements of the intestines is worn out. The powers of organic as well as those of animal life are palsied. This is the time for the administration of quinine, for the employment of nutritious broths and jellies, and even of wine.

You may perhaps be disposed to ask me what I think of this remedy or the other, which has at different times been boasted of, as having done good when other means had failed. Now you must not infer from my silence that I do not believe that other medicines besides those which I have spoken of have been of service; but to attempt to canvass the respective merits of each would, I fear, be a tedious task, and one from which you would derive but little profit.

Besides, let me remind you of what Sydenham says: *** In eo præcipuè stat Medicina Practica, ut genuinas Indicationes expiscari valeamus, non ut remedia excogitemus quibus illis satisfieri possit; quod qui minus observabant, Empericos armis instruxere, quibus Medicorum opera imitari queant.'

LECTURE VIII.

SIMPLE INFLAMMATION OF THE BRAIN-its differences from hydrocephalus-occasional extreme rapidity of its course- cases in illustration-morbid appearances-frequent connection with meningitis of the cord-extreme rarity as an idiopathic affection-treatment.

INFLAMMATION OF THE BRAIN SUCCEEDING TO DISEASE OF THE EAR-digression concerning otitis-its symptoms-distinctions between it and inflammation of the brain — treatment-chronic otorrhea, with disease of the temporal bone-case.

PHLEBITIS OF THE SINUSES OF THE DURA MATER-circumstances in which it occursit sometimes succeeds to large collections of pus in distant organs-case in illustration.

WE have been engaged at our last two meetings with the study of one form of inflammation of the brain in the young subject. We found hydrocephalus to be an affection almost exclusively confined to children whose previous health had been indifferent, who had shown some indications of phthisis, or in whose family phthisical disease existed. We observed its development to be gradual, its progress often tardy and attended with irregular remissions, but its issue almost always fatal. The alterations of structure discovered after death were seen to be slight at the convexity of the brain, but very obvious at its base, where, in addition to the effects of inflammation, the membranes often present a peculiar granular appearance. The fluid contained in the ventricles of the brain is almost always transparent, and tubercle is discovered in some, often in many, of the viscera.

But we sometimes meet with cases in which inflammation of the brain has given rise to changes that contrast remarkably with those which true hydrocephalus produces. We find the cerebral membranes intensely injected, the effusion of lymph or pus abundant, especially about the convex surface of the brain, where it sometimes forms a layer concealing the convolutions from view. Moreover, the fluid that occupies the cavity of the arachnoid, as well as that within the ventricles, is turbid and mixed with lymph, while the membranes present no trace of that granular appearance so remarkable in true hydrocephalus, and the various organs of the body are free from tubercle.

108

SIMPLE INFLAMMATION OF THE BRAIN.

If we enquire as to the symptoms by which this disease was attended during the lifetime of the patient, we shall most likely find that they present fresh reasons for distinguishing between it and hydrocephalus. We shall learn that the attack came on in a previously healthy child, that it was either ushered in by convulsions, or that they soon occurred, that they returned often, and probably that they continued with but little intermission until death took place. We shall be told, moreover, that the disease set in with violent vomiting and intense febrile excitement; and that having commenced thus severely, it advanced rapidly, and without remission, to its fatal termination, which may have arrived in the course of a few hours, and is seldom delayed beyond the first week. Some cases of this simple encephalitis are recorded by Gölis, under the name of Water-stroke: I will select one of them, as affording a good specimen of the most acute form of the disease.*

A little girl, 14 months old, who was healthy and strong and fat, was suddenly seized at 5 o'clock in the morning, after a restless night, with violent fever and frightful general convulsions. Medical assistance was at once obtained, and in less than thirty minutes from the commencement of the attack four leeches were applied behind the ears, which drew three ounces of blood: calomel and other remedies were administered internally, and mustard poultices were applied to the soles of the feet. These measures soon alleviated the symptoms, but the relief lasted for but a very short time; the fever returned as intensely as before, convulsions came on again, attended with opisthotonos, and the child became comatose. Hemiplegia succeeded; the pupils became extremely contracted; complete loss of vision, and spasmodic twitchings of the muscles of the face, soon followed, and, thirteen hours after the first convulsive seizure, in spite of most appropriate and energetic treatment, the little child died.

The vessels of the scalp were loaded with blood, and the skull was so intensely congested as to appear of a deep blue colour. The sinuses were full of coagulated blood mixed with lymph, and all the vessels of the brain and its membranes were enlarged and turgid with blood.

'A large quantity of coagulated lymph covered the convolutions of the brain and the corpus callosum like a false membrane, and furnished a delicate lining to the lateral ventricles, whose walls were softened and in part broken down. The ventricles contained

Praktische Abhandlungen, etc. vol. i. Case 2.