I am the more disposed to pronounce the cases which have been described to have been internal dropsy of the brain, from my having never been deceived in a single case in which I have examined the brains of patients whom I have suspected to have died of it.
I could add many other cases to those which have been related, but enough, I hope, have been mentioned to establish the safety and efficacy of the remedies that have been recommended.
I believe, with Dr. Quin, that this disease is much more frequent than is commonly supposed. I can recollect many cases of anomalous fever and head-ach in children, which have excited the most distressing apprehensions of an approaching internal dropsy of the brain, but which have yielded in a few days to bleeding, or to purges and blisters. I think it probable, that some, or perhaps most of these cases, might have terminated in an effusion of water in the brain, had they been left to themselves, or not been treated with the above remedies. I believe further, that it is often prevented by all those physicians who treat the first stage of febrile diseases in children with evacuations, just as the pulmonary consumption is prevented by bleeding, and low diet, in an inflammatory catarrh.
Where blood-letting has failed of curing this disease, I am disposed to ascribe it to its being used less copiously than the disease required. If its relation to pneumonicula be the same in its cure, that I have supposed it to be in its cause, then I am persuaded, that the same excess in blood-letting is indicated in it, above what is necessary in phrenitis, that has been practised in pneumonicula, above what is necessary in the cure of an acute inflammation of the lungs. The continuance, and, in some instances, the increase of the appetite in the internal dropsy of the brain, would seem to favour this opinion no less in this disease, than in the inflammatory state of pulmonary consumption. The extreme danger from the effusion of water into the ventricles of the brain, and the certainty of death from its confinement there, is a reason likewise why more blood should be drawn in this disease, than in diseases of the same force in other parts of the body, where the products of inflammation have a prompt, or certain outlet from the body. Where the internal dropsy is obviously the effect of a fall, or of any other cause which acts directly on the brain, there can be no doubt of the safety of very plentiful bleeding; all practical writers upon surgery concur in advising it. The late Dr. Pennington favoured me with an extract from Mr. Cline's manuscript lectures upon anatomy, delivered in London in the winter of 1792, which places the advantage of blood-letting, in that species of inflammation which follows a local injury of the brain, in a very strong point of light. “I know (says he) that several practitioners object to the use of evacuations as remedies for concussions of the brain, because of the weakness of the pulse; but in these cases the pulse is depressed. Besides, experience shows, that evacuations are frequently attended with very great advantages. I remember a remarkable case of a man in this [St. Thomas's] hospital, who was under the care of Mr. Baker. He lay in a comatose state for three weeks after an injury of the head. During that time he was bled twenty times, that is to say, he was bled once every day upon an average. He was bled twice a day plentifully, but towards the conclusion he was bled more sparingly, and only every other day; but at each bleeding, there were taken, upon an average, about sixteen ounces of blood. In consequence of this treatment, the man perfectly recovered his health and reason.”
Local bleeding by cups, leaches, scarifications, or arteriotomy, should be combined with venesection, or preferred to it, where the whole arterial system does not sympathize with the disease in the brain.
II. A second remedy to be used in the second stage of this disease is purges. I have constantly observed all the patients whose cases have been related, to be relieved by plentiful and repeated evacuations from the bowels. I was led to the use of frequent purges, by having long observed their good effects in palsies, and other cases of congestion in the brain, where blood-letting was unsafe, and where it had been used without benefit. In the Leipsic Commentaries[56], there is an account of a case of internal dropsy of the brain, which followed the measles, being cured by no other medicines than purges and diuretics. I can say nothing in favour of the latter remedy, in this disease, from my own experience. The foxglove has been used in this city by several respectable practitioners, but, I believe, in no instance with any advantage.
III. Blisters have been uniformly recommended by all practical writers upon this disease. I have applied them to the head, neck, and temples, and generally with obvious relief to the pain in the head. They should be omitted in no stage of the disease; for even in its inflammatory stage, the discharge they occasion from the vessels of the head, greatly overbalances their stimulating effects upon the whole system.
IV. Mercury was long considered as the only remedy, which gave the least chance of a recovery from a dropsy of the brain. Out of all the cases in which I gave it, before the year 1790, I succeeded in but two: one of them was a child of three years old, the other was a young woman of twenty-six years of age. I am the more convinced that the latter case was internal dropsy of the brain, from my patient having relapsed, and died between two or three years afterwards, of the same disease. Since I have adopted the depleting remedies which have been mentioned, I have declined giving mercury altogether, except when combined with some purging medicine, and I have given it in this form chiefly with a view of dislodging worms. My reasons for not giving it as a sialagogue are the uncertainty of its operation, its frequent inefficacy when it excites a salivation, and, above all, its disposition to produce gangrene in the tender jaws of children. Seven instances of its inducing death from that cause, in children between three and eight years of age, and with circumstances of uncommon distress, have occurred in Philadelphia since the year 1795.
V. Linen cloths, wetted with cold vinegar, or water, and applied to the forehead, contribute very much to relieve the pain in the head. In the case of Mr. Cypher's son[57], the solution of ice in the vinegar appeared to afford the most obvious relief of this distressing symptom.