SECT. III.—ON HYDROCEPHALUS.
The hydrocephalic affection is so named from the peculiarity of the fluid, it being of a watery consistence. It occurs in infants, owing to their heads being improperly squeezed by midwives during parturition, or from some other obscure cause; or from the rupture of a vessel or vessels, and the extravasated blood being converted into an inert fluid; or from rarefaction, the matter exuding and lodging between the skin and the pericranium. For the fluid is formed either between the pericranium and the skin, or between the pericranium and the bone, or between the bone and the meninx. In those cases, therefore, in which the fluid is formed between the skin and the pericranium, there is a soft tumour, all of one colour, and without pain, accompanied with an elevated swelling, having only a thin substance intervening between it and the fingers, readily yielding and again resuming its form. When it is seated between the pericranium and the bone, all the other appearances are the same, but the swelling is harder, yields more slowly, seems to be felt through thicker substances, and is more painful. When the fluid is seated between the meninx and the bone, there will still be a swelling, but not of so yielding a nature, nor so easily felt, only it yields to the application of strong pressure; for the bones of infants, being recently formed, are of a more yielding nature; and this is more especially the case when, owing to enlargement of the sutures, the fluid escapes outwards. This is readily ascertained from the circumstance, that by pressure of the fluid it retreats to the deep-seated parts. In such cases the pain is greater, the whole head is distended, the forehead projects outwards, the eyes are fixed and shed tears frequently. In these cases we reprobate any surgical interference, although some remove a piece of the bone by trepanning, as will be described in the section on fractures of the bones of the head. But if the fluid be formed between the skin and the pericranium, and the swelling be small, we may make one transverse incision through the middle. But if the fluid is seated between the pericranium and the bone, and the tumour is large, we make two incisions intersecting one another in the middle; or if it is still larger we may make three imitating the form of the Greek letter Η. After the operation, having evacuated the fluid and applied suitable compresses, we bind it up, and soak it with wine and oil until the third day; after which, having loosed the bandages, we may cure it by the application of pledgets; or, if the bone is long of incarnating we may scrape it lightly.
Commentary. See Hippocrates (de Morbis, ii, 15); Celsus (iv, 2); Aëtius (vi, 1); Galeni (ut aiunt) Isagoge; Antyllus (apud Nicetam); Avicenna (iii, 1; iv, 2); Avenzoar (I, 9, 17); Albucasis (Chirurg. ii, 1); Haly Abbas (Pract. ix, 16); Rhases (Contin. xxvii; and ad Mansor. ii, 25.)
Hippocrates gives an interesting account of water in the brain, the symptoms of which, as described by him, are pain in the opening of the head and temples, rigor, fever, double vision, impatience of sounds, vomiting of phlegm, &c. He recommends emetics, caputpurgia, and afterwards purgatives. He also makes mention of hellebore and sternutatories, and even directs us to perforate the skull, or, in other words, to trephine it.
Celsus describes only the hydrocephalus externus. He recommends us to use stimulant applications to the head, such as sinapisms, and if this treatment does not succeed, he directs us to use the scalpel. The case, otherwise, is to be treated like dropsy, with sudorifics, exercise, friction, and diuretics.
Our author’s description is mostly abridged from Aëtius, who gives an extract from Leonidas. Even when the fluid is collected within the skull he directs us to let it out, provided it is in such quantity as to occasion a separation of the suture.
The account of the disease, given by Antyllus, in the Collection of Nicetas is nearly the same as our author’s. He speaks favorably of the operation only in cases in which the water is collected externally to the bone.
In the ‘Isagoge,’ generally ascribed to Galen, it is directed, when the water is collected below the skin on the pericranium, to evacuate it by making two or three straight incisions; and when immediately below the bone, to perforate it; but the case in which the fluid is seated between the membrane and the brain is pronounced to be utterly incurable.
Rhases borrows his account mostly from Antyllus and our author. Upon his own authority, however, he recommends bandages with compresses. He also approves of applying the actual cautery over the sutures. He further recommends friction and burning the temporal veins.
Avicenna borrows freely from Aëtius and our author, and supplies no new views of practice. When water is collected in the anterior ventricles of the brain, Avenzoar, although in general no advocate for the actual cautery, directs us to apply it over the sutures.
Albucasis says that he had only known hydrocephalus internus in infancy, and in every case it had proved fatal. However, he describes the operation of evacuating the collection in much the same terms as the Greeks. He warns the operator to avoid wounding an artery, lest the evacuation of blood should occasion immediate death. Alsaharavius mentions the frequent occurrence of the disease in sheep. Haly’s treatment is the same as our author’s.
The hydrocephalus externus is now scarcely mentioned, and the existence of such a case has been even questioned. Van Swieten allows the reality of it, but says that it is of rare occurrence. (Comment. 1217.) We are disposed to think that the cases described by our author must have been collections of lymph, or pus occasioned by external injuries forming between the integuments and the bone. Modern pathologists admit the reality of collections of serum and pus between the bone and the dura mater. We may further mention that the earlier modern authorities approve of the cautery in the present case. See Guido de Cauliaco (ii, 2, 10.)
The late Baron Larrey was a decided advocate for the application of moxa in this complaint. Henricus Regius directs us to evacuate the water slowly by making a small incision and introducing a silver canula. (Animad. Medic. 13.) Though recent experience does not give much encouragement to the operation, it sometimes happens that it is attended with success.
Fabricius gives the same account of these cases as the ancients. (Œuv. Chir. ii. 22.)