ART. V.-A Statement of the Early Symptoms which lead to the Disease termed Water in the Brain; with Observations on the necessity of a watchful attention to them, and on the fatal consequences of their neglect in a Letter to Martin Wall, Esq. M.D. Clinical Professor at Oxford, &c. &c. By G. D. YEATS, M.D. of Trinity College, Oxford, &c. Callow, 1815. 8vo. pp. 114.

FEW

Ew diseases have a better claim to popular attention than the one which forms the subject of the present article; and Dr. Yeats's publication affords a favourable opportunity of pointing out what is of most consequence to be generally known. To parents it must be particularly interesting to be put upon their guard against the insidious approaches of a disease which, if allowed to establish itself, almost uniformly baffles the utmost efforts of medical skill; more especially as the victims of this disorder are usually found amongst children of the most lively and engaging dispositions, and such as early manifest superior intellectual endowments, which render them objects of peculiar interest to all their friends. It must also be useful thus to warn them of the dangerous tendency of certain apparently slight symptoms, which are too often allowed to pass unheeded, until the case becomes truly alarming; because these will almost always yield without difficulty to early and judicious treatment; but

serô medicina paratur,

Cum mala per longas convaluêre moras."

Our author very properly insists with much force upon the importance of attending to the first indications of disease; but when he says, "the necessity of such watchful attention is more indispensable in a curative point of view, on the subject of the present letter, inasmuch as, with all other diseases in which our art is at all available, a cure may be effected in almost any of the subsequent stages," he appears to have been blinded by long gazing on a favourite object; and, like many others, to have indulged the natural propensity of an author to give an undue and exclusive importance to that which he has made his particular study. Dr. Y. must very well know, that the maxim, "principiis obsta," is universally applicable; and that there is not one, in the long catalogue of human maladies, which will not ultimately become incurable by being neglected.

Formerly, when the history of diseases had not yet been

illustrated by anatomical investigation, that congeries of symptoms, now commonly known under the name of acute hydrocephalus, was confounded with some other diseases peculiar to childhood, between which and hydrocephalus it has been since endeavoured to draw a distinction; and it is not altogether improbable, that the progress of science may bring us back, with much more light however, to the point from which we have in the course of ages departed. When pathologists discovered in those who perished, after exhibiting such a train of symptoms as will be presently detailed, that the ventricles of the brain were distended with an aqueous fluid, they naturally enough attributed to this so prominent appearance of disease the whole of the preceding symptoms; and hence the name bestowed on this affection. But it was soon observed that the brain, in these cases, exhibited considerable marks of inflammation; and that there was one period of the complaint which corresponded with a state of vascular excitement; the first stage of suffering, therefore, was ascribed to this, and the subsequent one of stupor to the effusion of water, which was supposed to be the consequence of the previous action, and the cause of injurious pressure upon the brain. Again, some cases were noticed, in which all the distinguishing signs of hydrocephalus had been conspicuous, and yet no water was found in the brain, whilst all its vessels were unusually distended with blood. It then became a question, whether any of the symptoms are really dependent on effusion, seeing that deranged vascular action is alone sufficient to produce them all; and this conclusion receives additional support from a case related by Mr. Abernethy, and from another by Dr. Warren, in neither of which could any disease whatever be detected in the brain, though there was every reason to expect some: in these instances, disordered circulation had occasioned stupor, without being so excessive as to leave a trace of its existence. In the further prosecution of the inquiry, the abdominal viscera were often found very much diseased; and a more accurate observation of the progress of fatal cases demonstrated some notable disorder of the stomach, liver, or intestines, to be amongst the earliest signs of an indisposition terminating in confirmed hydrocephalus. Guided by observations of this kind, some practitioners have adverted to the doctrine of sympathies for an explanation of the origin of this complaint; and considering the powerful influence reciprocally exerted by the brain and the stomach, as well as the intimate sympathy existing between

the brain and all other parts of the body, they are persuaded that the affection of the head, at present under consideration, takes its rise, in a great majority of cases, from abdominal irritation. For the purpose of calling public attention more generally and forcibly to this view of the subject, Dr. Yeats has published his truly commendable letter; from which we gladly indulge ourselves in quoting a very satisfactory history of the disease.

"In the very first commencement of the symptoms, before any alarm is taken, and before any person can possibly imagine, but from experience, that they will often terminate in water in the brain, an occasional languor, as if arising from fatigue, with intervals of considerable activity, is observed; it is, therefore, attributed to this cause, from the disposition, too, which the child manifests of reclining on the sofa, chair, or lap of the mother; the usual degree of healthy appearance of the countenance diminishes, though not permanently, in a transient paleness and occasional collapse of the features; a dark-coloured line is observable under cach eye, with a dulness of that organ; the usual softness and pliability of the skin diminish, with a consequent harshness and increased heat of the surface; the appetite capricious; occasional thirst; state of the bowels more than commonly tardy; the tongue white, and rather disposed to be dry, if examined in the morning; the pulse at this period exhibits no particular morbid change, either in its frequency, strength, or regularity; the urine is at times higher coloured than it ought to be; and from observing that the child has not had an evacuation by the bowels as often as usual, recourse is had to some domestic purgative, and a stool is procured more than commonly consistent and firm, and not in the same quantity as formerly with the same dose of the medicine; no very striking alteration of colour is observable, unless attentively examined, when it will plainly appear that a diseased secretion has already begun to take place in those glands which pour their secretions into the intestinal canal: at times the evacuation will be throughout much lighter than it ought to be; at others, only partially so; and again, the whole will be more tinged with a darker colour of a greenish cast, and accompanied with some quantity of slimy matter, but more than the mere abrasion of the intestines by a purgative will produce. When any uneasiness in the head is complained of, it is not of pain either acute or dull, but of a disagreeable noise and confusion; the scalp at times feels sore on being rubbed or touched.

During this state, upon examination, a puffiness will be felt, and also a fulness observable over the centre of the stomach, extending towards the navel; uneasiness is complained of there from pressure, but, like all the other symptoms at this time, they are not permanent; and the only symptom which observes any permanency, is the torpid state of the bowels, although the degree of it varies in diffe

rent patients; the costiveness is, nevertheless, always more or less present; the sleep is frequently disturbed by restlessness, indicated by repeated movements about the bed. The child is said to be only not well, and this is supposed to arise from some improper food that has been taken. It is evident we cannot, a priori, positively determine what exact state of disease this deviation from general health will ultimately produce; but full well I know, that this irregular excitement, this vacillating state, in the way above described, very frequently leads to the next chain of more manifest morbid actions, which terminate in water in the brain. We should be, under such circumstances, most carefully watchful." (p. 31-35.)

The puffiness and fulness above noticed in the region of the stomach, are ascribed to distension of the duodenum, which portion of the alimentary canal, our author thinks, has been too little regarded in the accounts given of disorders of the chylopoietic viscera. The manner in which an unhealthy state of this organ may be productive of uneasiness, and may induce disease in the neighbouring organs, is explained at some length; and as far as pathology is concerned, we are ready to allow the justice of all that is advanced on this topic, but practically we cannot think it of any importance whether the fault be in the stomach or duodenum. In the early and moderate state of disease, which has been now described, the administration of proper remedies will easily avert all further mischief; and fortunate it is, indeed, if it has so happened that this previous state has been attended to; if not, the chain of diseased actions is lengthened by firmer links more difficult to be broken, but still to be destroyed by discriminating and steady means, though with more time, trouble, and anxious solicitude, before it fixes completely in the brain."

"If unfortunately this should be the case, the symptoms assume a more formidable and commanding shape: the occasional languor wears more the appearance of permanent lassitude; the returns of activity diminish; the child wishes to be almost constantly in a recumbent posture; the unhealthy look of the countenance becomes more permanent, and more observable in every respect; the darkness under the eyes is of a deeper colour; the excitement from feverish action becomes more regular and more apparent, with the consequent harshness of the skin; occasional flushes pass across the cheeks, sometimes more fixed in one cheek; transient pains are felt in the head, more or less acute, and more or less frequent; and at times, when the child will be apparently enjoying itself with comfortable feelings, its attention will be suddenly arrested by this pain, crying out, Oh, my head achs! Some will complain of the head feeling sore to the touch externally. The pulse now becomes at

times much quickened, not particularly irregular; but if carefully examined, and it must be done with some attention, when the child is under the febrile accession, an irregularity will be readily discovered, once, twice, and sometimes more, in the minute. Periods of drowsiness supervene; the bowels are more obstinately torpid, and when stools are procured, they are of a very disagreeable smell, and of a very morbid appearance-sometimes a glutinous mass, intermixed with dark lumps of fæces, at others there is a mixture of a deep green, with matters similar to a yeasty fermentation: their colour and appearance will vary much in the same person at different times. Sickness, nausea, and vomiting, are frequently troublesome, either when the little patient raises his head from the pillow, to which drowsiness and lassitude had consigned it, or after taking food, or both. In some, the puffiness and fulness about the region of the stomach, are not now so perceptible, one part of the morbid actions having yielded to others of a more violent nature: this symptom, though common, does not invariably attend; its being observed, too, depends upon what portion of the digestive organs are most under morbid actions at the time of examination. All the symptoms bear evident marks of irregular excitement: a giddiness, with an unpleasant cloudiness in the sight, is complained of, and, although the eyes exhibit nothing morbid upon examination, a strong light is disagreeable and painful; the urine varies much in colour and quantity, depending entirely on the circumstance of the febrile accessions; the appetite becomes deficient; the thirst troublesome; the tongue white, and inclining to be dry. The complaint, in this stage of its progress, is still manageable; in some easily so, from the circumstances of the previous habits of the child, as already stated; but it must be recollected, that every hour is now most precious, and any moments lost are scarcely to be recovered; for, in proportion as the symptoms form more a disease of the head, so is it the more dangerous, and consequently with the greater difficulty removed." (p. 53-56.)

If the proper measures are neglected in this stage of the complaint, or if unfortunately they should be unavailing, it advances to a degree of activity and violence, which most frequently proves irremediable.

"The accession of this state is marked with greatly increased violence, and with great suffering to the patient: the heat of the skin becomes more intense and harsh; febrile accessions more violent and distressing; the pains of the head more acute, and more frequent in their return, and the loud screams of the child on this account are truly afflicting; the pupils of the eyes shew great dilatation, but still contract on the approach of light, though not healthily, by a waving, languid, vibratory motion; a squinting takes place at times; double vision is complained of; and when the child is desired (though not seeing double at the time) to view an object, I have noticed that he sees the object, not where it really is, but on