why physicians have differed so much in their accounts of the same
remedies, and why the same remedies have operated so differently in
the hands of the same physicians. It is because they have been given
without a reference to the different states of the system, which have
been described. Dr. Sydenham says, that he cured the first dropsical
patient he was called to, by frequent purges. He began to exult in
the discovery, as he thought, of a certain cure for dropsies, but his
triumph was of short duration. The same remedy failed in the next case
in which he prescribed it. The reason probably was, the dropsy in the
first case was of a tonic, but in the second of an atonic nature; for
the latter was an ascites from a quartan ague. It is agreeable, however,
to discover, from the theory of dropsies which has been laid down,
that all the different remedies for these diseases have been proper in
their nature, and improper only in the state of the system in which
they have been given. As the discovery of truth in religion reconciles
the principles of the most opposite sects, so the discovery of truth
in medicine reconciles the most opposite modes of practice. It would
be happy if the inquirers after truth in medicine should be taught, by
such discoveries, to treat each other with tenderness and respect, and
to wait with patience till accident, or time, shall combine into one
perfect and consistent system, all the contradictory facts and opinions,
about which physicians have been so long divided.
3. If a state of great morbid action in the arteries has been
demonstrated in dropsies, both from its symptoms and remedies, and if
these dropsies are evidently produced by previous debility, who will
deny the existence of a similar action in certain hæmorrhages, in
gout, palsy, apoplexy, and madness, notwithstanding they are all the
offspring of predisposing debility? And who will deny the efficacy of
bleeding, purges, and other debilitating medicines in certain states
of those diseases, that has seen the same medicines administered with
success in certain dropsies? To reject bleeding, purging, and the other
remedies for violent action in the system, in any of the above diseases,
because that action was preceded by general debility, will lead us to
reject them in the most acute inflammatory fevers, for these are as much
the offspring of previous debility as dropsies or palsy. The previous
debility of the former differs from that of the latter diseases, only in
being of a more acute, or, in other words, of a shorter duration.
4. From the symptoms of tonic dropsy which have been mentioned, it
follows, that the distinction of apoplexy into serous and sanguineous,
affords no rational indication for a difference in the mode of treating
that disease. If an effusion of serum in the thorax, bowels, or limbs,
produce a hard and full pulse, it is reasonable to suppose that the same
symptom will be produced by the effusion of serum in the brain. But the
dissections collected by Lieutaud[45] place this opinion beyond all
controversy. They prove that the symptoms of great and feeble morbid
action, as they appear in the pulse, follow alike the effusion of serum
and blood in the brain. This fact will admit of an important application
to the disease, which is to be the subject of the next inquiry.
[45] Historia Anatomica Medica, vol. II.
5. From the influence which has been described, of the different states
of action of the arterial system, upon the lymphatic vessels, in
dropsies, we are led to reject the indiscriminate use of bark, mercury,
and salt water, in the scrophula. When the action of the arteries is
weak, those remedies are proper; but when an opposite state of the
arterial system occurs, and, above all, when scrophulous tumours are
attended with inflammatory ulcers, stimulating medicines of all kinds
are hurtful. By alternating the above remedies with a milk and vegetable
diet, according to the tonic, or atonic states of the arterial system,
I have succeeded in the cure of a case of scrophula, attended by large
ulcers in the inguinal glands, which had for several years resisted the
constant use of the three stimulating remedies which have been mentioned.
6. Notwithstanding I have supposed dropsies to be connected with a
peculiar state of force in the blood-vessels, yet I have not ventured
to assert, that dropsies may not exist from an exclusive affection of
the exhaling and absorbing vessels. I conceive this to be as possible,
as for a fever to exist from an exclusive affection of the arteries, or
a hysteria from an exclusive affection of the nervous system. Nothing,
however, can be said upon this subject, until physiology and pathology
have taught us more of the structure and diseases of the lymphatic
vessels. Nor have I ventured further to assert, that there are not
medicines which may act specifically upon the lymphatics, independently
of the arteries. This I conceive to be as possible as for asaf[oe]tida
to act chiefly upon the nerves, or ipecacuanha and jalap upon the
alimentary canal, without affecting other parts of the system. Until
such medicines are discovered, it becomes us to avail ourselves of the
access to the lymphatics, which is furnished us through the medium of
the arteries, by means of most of the remedies which have been mentioned.
7. If it should appear hereafter, that we have lessened the mortality
of certain dropsies by the theory and practice which have been proposed,
yet many cases of dropsy must still occur in which they will afford
us no aid. The cases I allude to are dropsies from enclosing cysts,
from the ossification of certain arteries, from schirri of certain
viscera from large ruptures of exhaling or lymphatic vessels, from a
peculiar and corrosive acrimony of the fluids, and, lastly, from an
exhausted state of the whole system. The records of medicine furnish us
with instances of death from each of the above causes. But let us not
despair. It becomes a physician to believe, that there is no disease
necessarily incurable; and that there exist in the womb of time, certain
remedies for all those morbid affections, which elude the present limits
of the healing art.
AN INQUIRY
INTO THE
_CAUSES AND CURE_
OF THE
INTERNAL DROPSY OF THE BRAIN.
Having, for many years, been unsuccessful in all the cases, except two,
of internal dropsy of the brain, which came under my care, I began to
entertain doubts of the common theory of this disease, and to suspect
that the effusion of water should be considered only as the effect of a
primary disease in the brain.
I mentioned this opinion to my colleague, Dr. Wistar, in the month of
June, 1788, and delivered it the winter following in my lectures. The
year afterwards I was confirmed in it, by hearing that the same idea
had occurred to Dr. Quin. I have since read Dr. Quin's treatise on the
dropsy of the brain with great pleasure, and consider it as the first
dawn of light which has been shed upon it. In pursuing this subject,
therefore, I shall avail myself of Dr. Quin's discoveries, and endeavour
to arrange the facts and observations I have collected in such a manner,
as to form a connected theory from them, which I hope will lead to a new
and more successful mode of treating this disease.
I shall begin this inquiry by delivering a few general propositions.
1. The internal dropsy of the brain is a disease confined chiefly to
children.
2. In children the brain 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 in childhood, than in the subsequent periods of life. The
effects of this determination of blood to the brain appear in the mucous
discharge from the nose, and in the sores on the head and behind the
ears, which are so common in childhood.
3. In all febrile diseases, there is a preternatural determination of
blood to the brain. This occurs in a more especial manner in children:
hence the reason why they are so apt to be affected by convulsions in
the eruptive fever of the small-pox, in dentition, in the diseases from
worms, and in the first paroxysm of intermitting fevers.
4. In fevers of every kind, and in every stage of life, there is a
disposition to effusion in that part to which there is the greatest
determination. Thus, in inflammatory fever, effusions take place in the
lungs and in the joints. In the bilious fever they occur in the liver,
and in the gout in every part of the body. The matter effused is always
influenced by the structure of the part in which it takes place.
These propositions being premised, I should have proceeded to mention
the remote causes of this disease; but as this inquiry may possibly
fall into the hands of some gentlemen who may not have access to the
description of it as given by Dr. Whytt, Dr. Fothergill, and Dr. Quin, I
shall introduce a history of its symptoms taken from the last of those
authors. I prefer it to the histories by Dr. Whytt and Dr. Fothergill,
as it accords most with the ordinary phenomena of this disease in the
United States.
"In general, the patient is at first languid and inactive, often
drowsy and peevish, but at intervals 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 towards the evenings: soon after these symptoms have
appeared, the patient is affected with a sharp head-ach, chiefly in the
fore-part, or, if not there, generally in the crown of the head: it is
sometimes, 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 affected. We frequently find, also, that the head-ach alternates
with the affection of the stomach; the vomiting being less troublesome
when the pain is most violent, and _vice versâ_; other parts of the body
are likewise subject to temporary attacks of pain, viz. the extremities,
or the bowels, but more constantly the back of the neck, and between the
scapulæ; 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, 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 happens that they are in an opposite state: the
pulse in 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 towards the nose;
the pupil on this side is rather more dilated than the other; and when
both eyes have the axes directed inwards (which sometimes 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-ach
more excruciating; every symptom of fever then makes its appearance,
the pulse is frequent, and the breathing quick; exacerbations of the
fever take place towards the evening, and the face is occasionally
flushed; usually one cheek is much more affected than the other;
temporary perspirations likewise break forth, which are not followed by
any alleviation of distress; a discharge of blood from the nose, which
sometimes appears about this period, is equally inefficacious.
"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 preceding symptoms of fever, continues for a while to increase,
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 second
stage: the pulse becomes slow but unequal, both as to its strength,
and the intervals between the pulsations; the pain of the head, or of
whatever 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 earlier
periods of the disorder, are now succeeded by an almost lethargetic
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 completely 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.
"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
succeeded 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 frequent
than before, but of shorter duration, and followed by a deadly paleness;
red spots, or blotches, sometimes appear on the body and limbs;
deglutition becomes difficult, and convulsions generally close the
scene. In one case, I may observe, the jaws of a child of four years of
age were so firmly locked for more than a day before death, that it was
impossible to introduce either food or medicine into his mouth; and, in
another case, a hemiplegia, attended with some remarkable circumstances,
occurred during the two days preceding dissolution.
"Having thus given as exact a history of _apoplexia 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 merely as a general
outline: the human brain seems to be so extremely capricious (if the
expression may be allowed) in the signals it gives to other parts of the
system, of the injury it suffers throughout the course of this disease,
that although every symptom above-mentioned does occasionally occur, and
indeed few cases of the 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 connected with it."
To this history I shall add a few facts, which are the result of
observations made by myself, or communicated to me by my medical
brethren. These facts will serve to show that there are many deviations
from the history of the disease which has been given, and that it is
indeed, as Dr. Quin has happily expressed it, of "a truly proteiform"
nature.
I have not found the dilated and insensible pupil, the puking, the
delirium, or the strabismus, to attend universally in this disease.
I saw one case in which the appetite was unimpaired from the first to
the last stage of the disease.
I have met with one case in which the disease was attended by blindness,
and another by double vision.
I have 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 hiccory fire, produced great pain and startings which
threatened convulsions.
I have seen three cases in which the disease terminated in hemiplegia.
In two of them it proved fatal in a few days; in the third it continued
for nearly eighteen months.
I have met with one case in which no preternatural slowness or
intermission was ever perceived in the pulse.
I have seen the disease in children of nearly all ages. I once saw it
in a child of six weeks old. It was preceded by the cholera infantum.
The sudden deaths which we sometimes observe in infancy, I believe, are
often produced by this disease. Dr. Stoll is of the same opinion. He
calls it, when it appears in this form, "apoplexia infantalis[46]."
[46] Prælectiones, vol. I. p. 254.
In the month of March, 1771, I 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 it of a pain in her head
or limbs, nor of a sick stomach. The disease in this case was introduced
suddenly by a pain in the breast, a fever, and the usual symptoms of a
catarrh.
Dr. Wistar informed me, that he had likewise met with a case of internal
dropsy of the brain, in which there was a total absence of pain in the
head.
Dr. Carson informed me, that he had attended a child in this disease
that discovered, for some days before it died, the symptom of
hydrophobia.
Dr. Currie obtained, by dissection, seven ounces of water from the
brain of a child which died of this disease; in whom, he assured me, no
dilatation of the pupil, strabismus, sickness, or loss of appetite had
attended, and but very little head-ach.
The causes which induce this disease, act either _directly_ on the
brain, or _indirectly_ upon it, through the medium of the whole system.
The causes which act _directly_ on the brain are falls or bruises upon
the head, certain positions of the body, and childish plays which bring
on congestion or inflammation, and afterwards an effusion of water in
the brain. I have known it brought on in a child by falling into a
cellar upon its feet.
The _indirect_ causes of this disease 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
producing an internal dropsy of the brain.
1. _Intermitting_, _remitting_, and _continual_ fevers. Of the effects
of these fevers in inducing this disease, many cases are recorded by
Lieutaud[47].
[47] Historia Anatomica-Medica, vol. II.
My former pupil, Dr. Woodhouse, has furnished me with a dissection,
in which the disease was evidently the effect of the remitting fever.
That state of continual fever which has been distinguished by the name
of typhus, is often the remote cause of this disease. The languor and
weakness in all the muscles of voluntary motion, the head-ach, the
inclination to rest and sleep, and the disposition to be disturbed, or
terrified by dreams, which are said to be the precursors of water in
the brain, I believe are frequently symptoms of a typhus fever which
terminates in an inflammation, or effusion of water in the brain. The
history which is given of the typhus state of fever in children by Dr.
Butter[48], seems to favour this opinion.
[48] Treatise on the Infantile Remitting Fever.
2. The _rheumatism_. Of this I have known two instances. Dr. Lettsom has
recorded a case from the same cause[49]. The pains in the limbs, which
are supposed to be the effect, I suspect are frequently the cause of the
disease.
[49] Medical Memoirs, vol. I. p. 174.
3. The _pulmonary consumption_. Of the connection of this disease with
an internal dropsy of the brain, Dr. Percival has furnished us with the
following communication[50]: "Mr. C----'s daughter, aged nine years,
after labouring under the phthisis pulmonalis four months, was affected
with unusual pains in her head. These rapidly increased, so as to
occasion frequent screamings. The cough, which had before been extremely
violent, and was attended with stitches in the breast, now abated, and
in a few days ceased almost entirely. The pupils of the eyes became
dilated, a strabismus ensued, and in about a week death put an end to
her agonies. Whether this affection of the head arose from the effusion
of water or of blood, is uncertain, but its influence on the state of
the lungs is worthy of notice." Dr. Quin likewise mentions a case from
Dr. Cullen's private practice, in which an internal dropsy of the brain
followed a pulmonary consumption. Lieutaud mentions three cases of the
same kind[51], and two, in which it succeeded a catarrh[52].
[50] Essays, Medical, Philosophical, and Experimental, vol. II. p. 339,
340.
[51] Historia Anatomica-Medica, vol. II. lib. tertius. obs. 380, 394,
1121.
[52] Obs. 383, 431.
4. _Eruptive fevers._ Dr. Odier informs us[53], that he had seen four
cases in which it had followed the small-pox, measles, and scarlatina.
Dr. Lettsom mentions a case in which it followed the small-pox[54],
and I have seen one in which it was obviously the effects of debility
induced upon the system by the measles.
[53] Medical Journal.
[54] Medical Memoirs, vol. I. p. 171.
5. _Worms._ Notwithstanding the discharge of worms gives no relief in
this disease, yet there is good reason to believe, that it has, in some
instances, been produced by them. The morbid action continues in the
brain, as in other cases of disease, after the cause which induced it,
has ceased to act upon the body.
6. From the dissections of Lieutaud, Quin, and others, it appears
further, that the internal dropsy of the brain has been observed
to succeed each of the following diseases, viz. the colic, palsy,
melancholy, dysentery, dentition, insolation, and scrophula, also the
sudden healing of old sores. I have 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 facts which have been enumerated, and from dissections to be
mentioned hereafter, it appears, that the disease in its first stage is
the effect of causes which produce a less degree of that morbid action
in the brain which constitutes phrenitis, and that its second stage is
the effect of a less degree of that effusion, which produces serous
apoplexy in adults. The former partakes of the nature of the chronic
inflammation of Dr. Cullen, and of the asthenic inflammation of Dr.
Brown. I have taken the liberty to call it _phrenicula_, from its being
a diminutive species or state of phrenitis. It bears the same relation
to phrenitis, when it arises from indirect causes, which pneumonicula
does to pneumony; and it is produced nearly in the same manner as the
pulmonary consumption, by debilitating causes which act primarily on
the whole system. The peculiar size and texture of the brain seem to
invite the inflammation and effusions which follow debility, to that
organ in childhood, just as the peculiar structure and situation of
the lungs invite the same morbid phænomena to them, after the body has
acquired its growth, in youth and middle life. In the latter stage which
has been mentioned, the internal dropsy of the brain partakes of some
of the properties of apoplexy. It differs from it in being the effect
of a _slow_, instead of a _sudden_ effusion of water or blood, and in
being the effect of causes which are of an acute instead of a chronic
nature. In persons advanced beyond middle life, who are affected by
this disease, it approaches to the nature of the common apoplexy, by a
speedy termination in life or death. Dr. Cullen has called it simply by
the name of "apoplexia hydrocephalica." I have preferred for its last
stage the term of _chronic apoplexy_, for I believe with Dr. Quin, that
it has no connection with a hydropic diathesis of the whole system. I am
forced to adopt this opinion, from my having rarely seen it accompanied
by dropsical effusions in other parts of the body, nor a general dropsy
accompanied by an internal dropsy of the brain. No more occurs in this
disease than takes place when hydrothorax follows an inflammation of
the lungs, or when serous effusions follow an inflammation of the
joints. I do not suppose that both inflammation and effusion always
attend in this disease; on the contrary, dissections have shown some
cases of inflammation, with little or no effusion, and some of effusion
without inflammation. Perhaps this variety may have been produced by the
different stages of the disease in which death and the inspection of
the brain took place. Neither do I suppose, that the two stages which
have been mentioned, always succeed each other in the common order of
inflammation and effusion. In every case where the full tense, slow and
intermitting pulse occurs, I believe there is inflammation; and as this
state of the pulse occurs in most cases in the beginning of the disease,
I suppose the inflammation, in most cases, to precede the effusion of
water. I have met with only one case in which the slow and tense pulse
was absent; and out of six dissections of patients whom I have lost by
this disease, the brains of four of them exhibited marks of inflammation.