the brain against the upper walls of the cranium. From the greater or less quantity of the effusion results the flattening or the disappearance M of the cerebral convolutions, the easy or difficult distinction of the grey and white portions, and lastly the preservation of the central parts of the brain. It may easily be conceived that a considerable effusion, situated in the ventricles, can transform the organ into a kind of membranous sac in which it would be impossible to recognize the texture of the encephalic pulp.

The corpus callosum is sometimes pushed up close to the cranium ; the septum lucidum torn through; the corpora striata flattened; the optic thalami wasted; the nerves atrophied, softened, canaliculated, &c. In other children, according to the observations of MM. Baron and Breschet, the liquid occupies the arachnoidean cavity. The brain does not exist or only exists in a rudimentary state. It consists of a small, shapeless, soft, greyish mass, placed in front of the annular protuberance. This part, the cerebellum and the spinal cord, are preserved. The nerves are atrophied, and issue from the mass which replaces the encephalon. Thus, the seat of the hydropsy being the same, there is only atrophy of the brain. It is sometimes more marked in one hemisphere than in that of the opposite side; but with regard to this, it is impossible to state anything precisely.

The meninges rarely present any alteration. No important modifications are observed on the dura mater. Breschet, however, has observed the absence of the falx cerebri. The arachnoid is of a whitish colour and sometimes infiltrated with an opaque serum. The pia mater is very thin, so much so, that it is said to have disappeared; but an attentive examination will always demonstrate its existence.

[The pia mater (and the arachnoid also must be here included) in chronic hydrocephalus is morbidly changed to such a degree that it clothes the cerebral ventricles as a thick, firm, opaque, scarcely tearable membrane. It is undoubtedly this serous membrane which is the originally diseased structure, producing the extensive effusion of serum, and moreover gradually becoming hypertrophied to a high degree. The other abnormal appearances met with in the brain, its inordinate distention, the almost membranous thinness of the cerebral matter around the ventricular cavities, as also the abnormalities of ossification and of the form of the skull, are undoubtedly but consequences of the primitive disorder of the pia mater. Dr. Weber, Op. Cit., p. 49.-P.H.B.]

The quantity of effused serum is very variable. From the usual quantity of eight ounces and one pint it sometimes amounts to five and ten pints. Some authors, Aurivill, Buttner, Cruikshank, speak of cases in which they found as much as eighteen, twenty, and even twenty-seven pints of fluid. But similar examples are necessarily very

rare.

The chemical composition of the serum enclosed in the cranium has

been the subject of the researches of several very skilful chemists. The following are the results of the analysis of Barruel, published by Breschet. In 1000 parts he found

The analyses of Marcet, Bostock, Berzelius, and John agree very closely with the above.

lal, Lastly, to terminate this chapter, we may mention the vices of lus conformation which frequently accompany congenital hydrocephalus. Thus, hare lip, cleft palate, opening at the back of the cranium, hydrorachis, club feet or hands, the incomplete development of the lungs, of the heart, and of some other viscera are the most common malformations which are met with in these circumstances.

SYMPTOMS.

It is impossible to recognize chronic hydrocephalus as long as the child is enclosed in the mother's womb. We can at least only predict the existence of this discase when the woman has already given birth to one or several hydrocephalic children.

The increase of the volume of the head is the most important symptom of congenital chronic hydrocephalus; it is also the most easy to verify in the patients. If the head is not too much increased in size at the period of birth, the delivery terminates easily, and the disease, arrested for an instant, develops itself with renewed vigour. If, on the contrary, it possesses very considerable dimensions, it becomes an obstacle to parturition, and it is necessary to crush it with the cephalotribe.

Unfortunately, this external sign does not always exist. As has already been observed, there are cases in which the head preserves its normal dimensions, and even in some children it appears to be smaller than usual.

In these patients the head is pointed, flattened on the sides, and depressed at the frontal region; the sutures are ossified and the fontanelles closed previous to birth, which is rapidly followed by death.

The small number of those who escape, says M. Breschet, terminate their existence at the end of some weeks or of several months. They are deprived of the intellectual faculties, and their senses are obliterated. The do not see; their pupils are dilated and insensible to the action of light; their eyes are in a state of continual oscillation. They scarcely hear. Sensibility exists, but motion is difficult, the movements

of the limbs being nearly abolished. The functions are irregularly performed. The children eat with avidity, but they digest badly: their dejections are involuntary. Their respiration is well performed, ****~ ~ but is easily embarrassed. Their intelligence is abolished; they do not observe exterior objects; they have convulsions or coma when they are moved or when the head is shaken, and die at last in the midst of these symptoms.

In congenital hydrocephalus, with increase in the size of the head, Cost there is also deformity of this part. These modifications are never very considerable at the time of birth; they manifest themselves in the months which follow it.

The dimensions of the cranium gradually increase, by means of the separation of the sutures and by the projection outwards of the upper bu border of the frontal, occipital, and parietal bones. From this results an important modification of this part, which loses its proportions, and is no longer found in harmony with the face, the dimensions of which remain the same. It constitutes a true deformity, the remembrance of which can never be lost after having once met with it.

The senses develop themselves with difficulty, and are exposed to frequent aberrations.

The eyes oscillate incessantly, the pupils are very much dilated and d slightly contracted; the impression of light is often painful; the sight is feeble, and is gradually lost.

The sense of smell is often abolished, and when it exists it is often perverted. Thus, children arrived at an age when they can give an account of their sensations, complain of disagreeable odours which do not strike those who surround them.

Hearing, very delicate in the first months of existence, becomes gradually more obscure and entirely disappears.

The intelligence is with difficulty developed; yet all those acts which relate to the instinct of individual conservation appear to be properly exercised. The child, still quite young, becomes habituated to his nurse and recognizes her. He tastes, and is sufficiently knowing to push away those articles of food which displease it on account of their bad quality.

Moreover, these modifications are in relation with the duration and intensity of the disease. The intelligence is sometimes abolished among children, who since then have no memory, and have not been able to learn to speak. Amongst others the speech is slow and nasal; they forget their words, and dwell over them a long time before pronouncing them. The voluntary movements are with difficulty developed; the limbs tremble and are usually not strong enough to sustain the body and to maintain it in equilibrium. The sitting position is possible at the commencement of the symptoms, but it soon becomes the cause of

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serious nervous phenomena. The pressure of the liquid on the nerves at the base of the brain is the cause of it. It determines pains in the head, vertigo, nausea, or convulsions. The children must then on the back or on the sides, and the head reclined on a

loomes be placed impossible

cushion.

In those hydrocephalic patients who can walk about, the gait tulis uncertain and unsteady; they keep their feet close together, and seek on the ground a spot suitable to insure the conditions of the equilibrium of their body.

The animal functions are subject to the same disturbances as the functions of organic life, according to the degree of the anatomical C/ alterations of the hydrocephalic patient. Digestion is usually well. performed, but there are occasional vomitings, and nearly always constipation. At the end of the disease, the alvine dejections are involuntary; the respiration is never greatly disturbed, it is especially irregular and accompanied by a violent dyspnoea on the approach of a fatal termination.

The regularity of the beatings of the heart indicates that there is no obstacle in the movements of this organ. The pulse is normal; in some cases, in the midst of the nervous symptoms which the children present, it becomes small, sharp, sometimes intermittent, and remains thus in the last moments of existence.

Hydrocephalic patients have frequently nervous symptoms which result from compression of the brain by the effused fluid. Cephalalgia, vertigo, vomiting, of which some subjects complain, ought to be referred to this cause. It is the same with the convulsions which are observed 4 in this disease, in consequence of a fit of anger or of spite. This symptom can also be produced at will by the agitation or by the slight compression of the head of the children. It is then followed by a more or less decided coma.

PROGRESS-TERMINATION.

Congenital chronic hydrocephalus generally leads to the death of the children shortly after their birth. Some resist, and vegetate for several years. J. Frank recounts, from various authors, many examples of hydrocephalic patients who have lived to the age of eighteen, twenty-five, thirty, forty-five, and even fifty-four, in this sad condition.

This prolongation of life depends solely on the nature of the alterations of the brain, and on the quantity of effused serum. There are some patients in whom the formation of the liquid is sufficiently slow so as not to constrain the liberty of motion, but which gradually becomes weakened. In others it is very rapid, and occasions sensorial and muscular disturbances, such as vertigo, convulsions, somnolence, coma, and paralysis of the limbs, precursory phenomena of death.

Confirmed hydrocephalus is beyond the resources of art; yet cases of cure are reported. In these cases the quantity of effused liquid was not very considerable, and there was probably no serious organic lesion of the brain, like those of which we have spoken.

[The following abstract, from the Report of the Registrar General, shows the deaths from hydrocephalus in 1845-9, and the deaths in each respective quarter of the year:

Total of the

And of 825 males and 639 females who died from this disease in 1849, 735 males and 572 females were under five years of age.-P.H.B.]

TREATMENT.

Chronic hydrocephalus ought to be treated by means of remedies capable of preventing the formation of a fresh quantity of liquid, and of assisting the absorption of that which is already effused.

In order to bring about this double result, digitalis under all its forms, oxymel of squills, nitrate of potash, and all the diuretics; the purgatives, and especially calomel, so as to produce three or four stools a day; mercurial frictions to the neck, and especially to the head, &c., have been successively made use of.

Topical astringents to the head, such as bandages wetted with vinegar of squills, aromatic wine (Van Swieten), or the essential oils, either ethereal or camphorated; plasters of soap and camphor are very useful in this disease, if only to procure comfort to the patient.

In those cases in which the phenomena of congestion, or of a determination of blood towards the head, are observed, leeches should be applied or cupping glasses to the back of the neck. To prevent the return of these symptoms, a blister may be put to the same region, or a seton, both of which should be strongly excited by an epispastic ointment.

If it is wished to act directly on the head, often repeated large flying blisters should be applied; and in some circumstances, cauteries. The first of these means is always preferable to the second.

Compression of the cranium has often been made use of. It should be made gently at first, and very methodically, by means of a leather cap, or rather with straps of diachylon plaster. This means is of no efficacy without it is employed for a long time. It may be attended with great danger if it is not cautiously applied. Its use is often followed by a considerable diminution in the dimensions of the head, and one can thus hope to impede the progress of the disease.