The lungs were engorged, but not to the same extent as in the first case; the anterior portions were light in colour, and crepitant.

case.

The heart presented an appearance similar to that observed in the first The right cavities engorged with dark treacle-like blood, and as in the first case, in the right ventricle it was enveloped in a capsule of fibrine which extended into the pulmonary artery. The vena cava were likewise engorged with dark blood; left cavities empty, and the left ventricle diminished in capacity and thickened in its walls.

In the abdomen the appearances were similar to those in the first case. The stomach presented a similar condition. The mucous lining of the œsophagus projected into the stomach, and presented the appearance of a wetted bladder or piece of parchment, and around the cardiac orifice the mucous membrane of the stomach exhibited the mammilated condition mentioned in the first case. In the duodenum Brunner's glands were enlarged, and in the jejunum and ileum the glands, both solitary and agminate, were distended and prominent, as previously detailed, and one of Peyer's patches near the cecum had discharged its contents, all its glandules being ruptured and collapsed, while all of those in its neighbourhood were full to distention with a light coloured fluid like gumwater. In the large intestines some vascularity was apparent.

The liver, spleen, and kidneys were in a normal state. He took one of the semilunar ganglia with the great splanchnic nerve connected with it, in order to test a theory which had been advanced in connexion with this disease. According to some paresis of the vaso-motor nerve system would explain most of the symptoms in cholera, and it had been suggested that perhaps congestion, or other abnormal condition of the semilunar ganglia might be found. Nothing of the kind, however, was to be seen in this instance; it will be observed that the ganglia and appended nerve are, to all appearance, in a perfectly healthy condition. (Morbid specimens exhibited).

The third case was that of a boy, aged four, who also died on the 24th September. In most particulars the details resembled those given of the preceding cases. The condition of the brain was similar, as was also the state of the intestines, which were quite full of a light grey viscid fluid, of the colour and consistence of boiled starch; examined under the microscope this was found to consist of columnal epithelium, and its debris with crystals of triple phosphate. The present case presented the best example of the enlargement, and likewise of one of Peyer's patches of the solitary glands in the stage of elimination. The large intestine was injected, as in the first and second case. He had also obtained from the body of a woman who was admitted in a state of collapse, and with complete aphonia, and who died two hours after admission, the larynx and tongue, with a view to determine whether the loss of voice was explained by some physical change in the organ of

voice. He had previously formed the opinion that the loss of voice was due to debility, or inability on the part of the patient to propel the expired air with the requisite force, but on examination he found that the true vocal chords were thickened, their sharp edges rounded off, and the ventricle of the larynx diminished in capacity, by thickening of the mucous membrane; there was, however, no abnormal vascularity of the larynx.

The first point on which he wished to make an observation was the condition of the glandules of the intestines. There was nothing new in the appearance presented by these. Dr. Parkes noticed it in his work on cholera, but he made a statement which appeared to him (Dr. Hayden) not to be justified, viz., that the enlargement of the glands was the result of the diarrhea. He could not agree in this opinion. He was not aware that enlargement of the glands had been the consequence, although frequently it has been the cause of diarrhea in other diseases, and when they found that in the neighbourhood of these glands there was no appearance of vascularity they could not admit Dr. Parkes' view, which would involve the existence of a considerable amount of irritation and vascularity. The mesenteric glands were enlarged in all these cases. They were secreting glands, as were also Brunner's glands, and yet these were quite as much enlarged as the excreting glands, properly so called.

With regard to the alleged lesion of the vaso-motor nerve system, whilst he would not be understood to deny the possible existence of some inappreciable alteration or functional derangement of that system, he did not think it was good philosophy to attribute to a lesion not proven to exist, a set of symptoms that may be explained by organic changes constantly found. If, in addition they assumed, as he thought they were warranted in doing by all the evidence before them, the existence in the blood of a specific morbid poison, they would have in that, taken in connexion with the lesions he had exhibited, a satisfactory explanation, as it seemed to him, of most, if not all, of the symptoms of Asiatic cholera. December 8, 1866.

TRANSACTIONS OF THE MEDICAL SOCIETY OF THE COLLEGE OF PHYSICIANS.

DR. STOKES, President.

Farther Observations on Hydrocephalus, and its Treatment, particularly by the Use of Issues. By HENRY KENNEDY, A.B., M.B.; one of the Physicians of the Cork-street Hospital, and attached to Sir P. Dun's.

Amongst the diseases of childhood, hydrocephalus occupies a prominent place; and I presume I address few who have not met it, and who will VOL. XLIII., No. 85, N. s.

not acknowledge its great fatality. Some twenty years ago it seemed to me the most fatal disease seen in early life, and must probably be still so considered. Yet, as years have rolled on, I have gradually come to modify my opinions materially; as I now know that a fair share of cases may be saved, even when the disease has passed into the second stage; that is, when dilatation of the pupils has taken place, and there is every reason to suppose that effusion is present. It is quite true that there are a number of cases of recovery on record, even from this stage of the disease. But the most of them all are isolated cases, and many of them published as what might be called curiosities, being recoveries under very hopeless circumstances. Now, I wish to state here that, with our present knowledge, we may look with confidence to a certain per centage of recoveries, aud what is of still more moment, that these recoveries are directly due to treatment, of which I hope to give sufficient proof before these remarks are concluded.

When I last spoke on this subject before the Obstetrical Society, I entered, at some length, into several points connected with the disease, such as the prognosis, diagnosis, and above all, the natural history of the affection, on a knowledge of which latter so much of the character of the physician depends. Into these I shall not enter again, and more particularly, as they have already appeared in print. There is one of them, however, to which I must again advert, I mean in reference to the two forms of the disease which are to be seen in practice. In the one-and this, probably, the more common form—the disease comes on in the progress of gastric or infantile remittent fever; or supervenes on an attack of some one of the exanthemata or hooping cough; or as a disease sui generis. In the second, the disease supervenes on regular typhus; by which I mean a fever attended with spots. Now, when hydrocephalus comes on in the course of the former, it is, in my experience, a much more fatal affection than in the latter. Some gentlemen I know have thought that the disease arising in connexion with typhus fever was not the genuine hydrocephalus. For myself I must say I cannot distinguish between them; but, as the point is one of considerable moment, it may be well to bring before the meeting a sketch of a few cases, and in this way the members can judge for themselves.

CASE I.-In July, 1855, a boy of ten years of age was admitted into Sir P. Dun's Hospital. He laboured under typhus fever, and had a copious rash over his body. He was sent in by Dr. Mecredy. The patient was quite stupid, and very hard to rouse in any way. There was a marked frown on his forehead, and any complaint made was of his head. Both pupils were dilated; the pulse was rapid, the discharges from the bowels blackish, and every now and then he had the cry which so often marks affection of the brain. This case got well, but his recovery was

of the very slowest, and the dilatation of the pupils was the last sign to give way.

CASE II.-A boy of ten years of age was admitted to hospital labouring under typhus fever, and well spotted. He had also oozing of blood from lips and gums, and was said to be eleven days ill. Two days later, that is, when about thirteen days ill, signs of the brain getting engaged appeared. Severe pain in the head came on, attended by marked screaming, and the pulse, which had been rapid, fell suddenly to 60. The pupils, too, became dilated, though not in a marked degree. It is enough to state that this case also recovered; but that recovery was, as in the last case, very slow, and the pupils remained still dilated, at a time when the patient was otherwise well.

CASE III.-Fitzgerald, a child of seven years of age, was admitted, labouring under fever, of as severe a character as is ever seen in childhood. The tongue was dry as a board, and the lips covered with sordes. There was also tympany, but there were no spots. I could not learn how long he was ill. In a day or two later symptoms of brain affection made their apppearance. The pupils became dilated, one more than the other; sighing also was very marked, and grinding of the teeth, and of such an intensity as made it most painful to hear. Then squinting came on, and finally convulsions, and death.

CASE IV.-Cunningham, a girl of thirteen, admitted labouring under heavy petechial fever. Whilst in this state she got a very severe attack of diarrhea, the discharge being of a light yellow colour, and attended with tympany, and marked pain on pressing the ilio-cecal region. Her lips were covered with sordes, the eyes deeply injected, and her nights very bad. In fact, the case was a good example of typhus and enterric fever conjoined. As the abdominal symptoms subsided the patient began to complain of her head. She got pain in it which she referred to the forehead, and this was attended by a very marked frown, with constant and deep sighing. The next day I found her with her head drawn back, and complaining still more of pain in it; and she was reported to have screamed out frequently during the night. The pulse was now become unequal, the pupils had a tendency to dilate, and the eyelids drooped. The treatment-of which more again—succeeded in removing all these grave symptoms, and the patient made a good recovery.

CASE V.-Burn, a boy of ten years of age, admitted to hospital labouring under fever, of what would be called the gastric type. His tongue was very red at the tip and edges; elsewhere thickly coated with a white fur. The eyes were deeply injected, the cheeks of a very

high colour, and he made great complaint of his head. When about ten days ill, a rash, of an unusually distinct character, appeared on his arms and legs, and, subsequently, on the body. This course of the rash, I may observe in passing, is by no means uncommon, and more particularly in childhood. The spots in this instance were large, welldefined, and of the bright colour so constantly seen in the young. Though the fever declined, and the spots disappeared, the head became worse and worse, and there was every prospect of the case proving fatal; as I had seen in too many instances before. Treatment, however, did ultimately prove successful, and the boy made a good recovery.

CASE VI.-A boy, of eleven years of age-one of four brothers, all in hospital at same time-presented very heavy spotted fever. As it declined, his brain became seriously engaged; so much so that his life was in imminent danger for many days. By treatment which would at present be thought very active, the patient gradually emerged from this state, and he made a good, though a remarkably slow recovery.

Did time permit, I could give a number of other cases where an affection of the brain-as I believe, of the nature of hydrocephalus—— exhibited itself; either when typhus, as shown by the presence of spots, was present, or just as the symptoms were on the decline; or the patient might even be pronounced convalescent. And here I may remark that hydrocephalus does not exhibit that uniformity of symptoms which books would lead one to expect; or at least exceptions are so frequent that we should be prepared for them. Thus I have seen cases, and they were proved by dissection to have been the disease, where there was no vomiting at all, or only at the very commencement of the illness; and, again, I have seen cases where the pulse did not go through the stages which writers have laid down as diagnostic of the affection; and so of other symptoms, as, for instance, the pupils, which may be seen contracted from first to last. The cases given this evening bear out these remarks, and show, as I believe, some of the varieties the disease exhibits; whilst the rate of mortality, which it must have been observed was very low, proves what I stated at first, that the affection of the brain, seen either in conjunction with typhus, or just as it is declining, is not so fatal as when hydrocephalus occurs under other circumstances. It is not my intention this evening, nor would it be suited to the meeting I have now the honour of addressing, to enter into any farther points connected with either the diagnosis or prognosis of the disease. But to some remarks on the treatment I would ask attention; and, indeed, it was for this special purpose I now appear here.

It is more than a century since the periodicals of the day began to contain scattered cases of hydrocephalus in which recovery occurred under very hopeless circumstances; the change being due to the