The lungs are pale, resisting, and marbled by red spots sprinkled over their surface. These spots, formed by the engorged lobules, are hard and do not float in water; their exterior is red, livid, rather dense; it cuts smoothly and gives the appearance of carification; they are not numerous. Besides the small and thinly scattered nuclei of lobular pneumonia, there is a little congestion at the posterior and inferior part of the organ. But this is not all; there exists under the pleura and in the interior of the pulmonary tissue a considerable number of transparent granulations due to the presence of tubercular matter in its first stage of formation. Some may be described as consisting of a vesicle in the midst of which is an opaque tubercular granulation. It is these granulations which by their number give to the lung the density which has been described. The bronchial glands are very much enlarged and are completely degenerated into a very hard opaque yellow substance, analogous to crude tubercular matter; no gland has become softened. The heart is enormous, relatively to the age of this child; it is as large as that of a child of four years; it is twice the size of the first of the subjects. The hypertrophy is chiefly confined to the left ventricle, the cavity of which is equally enlarged. The organ is filled with very fluid clots, without fibrinous concretions. Abdomen. The mesenteric glands are very numerous, a little hypertrophied, but without having undergone degenerescence. White streaks are observed in the mesentery due to the presence of chyliferous vessels which lead to these glands; when they are cut, a milk-like liquid exudes. The liver is very large; beneath the peritoneum, but above the capsule, large numbers of miliary granulations are observed, which might be called tubercular, but of the nature of which we are ignorant. Similar granulations existed in the interior of the slightly enlarged spleen. They are innumerable. The other organs are healthy. It would be a matter of great difficulty to explain the development of the hydrocephalus we have just described. There was no trace of inflammation in the meninges nor in the encephalon; none of those accidental productions which could produce the irritation of the brain, none of those lesions which some pathologists regard as the causes of the effusion of serum into the ventricles and of their dilatation, could be discovered. Granulations of the meninges have almost always been met with in connection with hydrocephalus; thus MM. Rufz, Guersant, Becquerel, &c., have thought that these accidental products were the cause of this disease. There was nothing of the sort however in the foregoing case; the meninges were sound, and there were no tubercular granulations. The lungs, on the contrary, were filled with these productions. Essential acute hydrocephalus is characterized anatomically by the effusion of serum into the ventricles, into the arachnoidean cavity, or even into the thickness of the cerebral pulp itself. The meninges present no alteration except a slight serous infiltration. The effused liquid is never in very great abundance. Its quantity varies from 3ij to 3 v. The symptoms of this disease are very obscure: they all indicate a disease of the brain, but there is not one of them which specifies its particular nature. As may be observed in the case related, and which is, perhaps, an advantageous type to consult, the child had had, for some time, convulsions, nocturnal frights, wakings with ache the start, stiffness in the limbs; its character became changed, it groaned incessantly, uttered sharp cries, and then, at last, a convulsion put an end to these symptoms. These symptoms relate quite as much to the symptoms of encephalic tubercles, as to the symptoms of essential acute hydrocephalus. It would be impossible to establish a precise diagnosis of any value. Much better is it, like most physicians, to confess our inability to do so, than to seek to hide it by a minute discussion, which is rather detrimental than useful. Essential acute hydrocephalus is seldom a primary disease. Most of the cases which have been published are to be referred to cases of hydrocephalus, consecutive pneumonia, tubercles of the lungs, as in the patient whose case we have reported, nephritis, measles, scarlet fever, &c. M. Barrier has especially called the attention of his professional brethren to this latter variety, which he established on authentic observations, commented on with much talent and interest. 2ND. ON CHRONIC HYDROCEPHALUS. Chronic hydrocephalus cannot be considered in the same manner as acute hydrocephalus; it is impossible, for instance, to divide it into essential and symptomatic hydrocephalus. This disease constantly presents itself under the same form; it is under the absolute dependence of vices of organization, or of accidental lesions of the encephalon. It is, therefore, always symptomatic. The hydrocephalus sometimes develops itself several months or several years after birth, but it is usually congenital. Acquired hydrocephalus is very rare, and appears to result from a chronic inflammation of the meninges; from the presence of tubercles ;^ from acephalocysts in the brain, &c. In these cases the disease is never of a very long duration; it terminates rapidly by death, giving rise to the train of symptoms which will be pointed out further on. Congenital chronic hydrocephalus is the most common variety. It Must securmber 2t Clucks Divisione congruital & acquired) es resurses the Sutional & Exterical tie. commences in the mother's womb, and finishes its development after the birth of the child, if, indeed, it is not the cause of its death during labour. The seat of the effusion is very variable. It may be situated, 1st, between the dura mater and the bones of the cranium; 2nd, between the dura mater and the arachnoid; 3rd, in the cavity of the arachnoid, and at the exterior of the encephalon; 4th, in the ventricles of the encephalon; 5th, in the laminated and vascular tissue of the pia mater. These divisions are borrowed from M. Breschet. They will be found in the article Hydrocephalus (Dict. de Méd., nouv. édit.); the most satisfactory paper which has been published on this subject. CAUSES. The causes of congenital hydrocephalus are to be especially referred to vices of conformation, and to morbid alterations of the brain. Whether the arrest of the development of the different parts of the encephalon be the result of a disease, the nature of which we are ignorant, or of a vice of the nisus formativus, the hydropsy is not less the consequence of it, and it is impossible to penetrate the mystery which surrounds its appearance. Besides these important facts in the etiology of hydrocephalus, there are others to which attention has been called. Thus, the effects of the imagination of the mother, her moral impressions, her sorrows, &c., have been added to the number of the causes of this disease without anything justifying the value of this influence. More importance must be attached to the diseases of the mother during gestation, and to a weakness, natural in consequence of age or of previous disease. These causes may concur to the development of hydrocephalus. There are some women who have a fatal predisposition to give birth to monsters of this sort. J. Frank relates the case of a woman who had seven pregnancies, all terminated by the birth of a hydrocephalic child. Goelis speaks of another person who was confined six times, and each time the child was dead, and laboured under this disease. The compression of the abdomen by belts, or by a too tightly laced corset, in persons who wish to hide their pregnancy, can, it is said, produce this disease; and this statement is supported by the fact that hydrocephalic children are more frequently born to single than to married women. The influence of the moral impressions which overwhelm women in this sad situation, must be also added to the influence of the compression of the abdomen. Amongst the other causes which have been regarded as likely to concur to the development of hydrocephalus, must be cited the habit of drunkenness in the father; blows upon the abdomen of the mother, and falls during pregnancy; the twisting of the umbilical cord around .. the neck of the child; compression of the head by forceps, or by the manoeuvres during a protracted labour; and, lastly, after birth, the chan immoderate shakings of the cradle, and the compression of the head by too tightly fitting caps. As to the influence of scrofula, of intestinal worms, of diseases of the alimentary canal, of spirituous excitants given to children, &c., it is useless to stop to consider them. These influences do not appear to us to have the slightest relation with the development of hydrocephalus. The causes of acquired hydrocephalus are nearly always relatedn to chronic affections of the brain, or of its envelopes. In this respect meningeal hæmorrhage occupies the first rank; it often becomes the origin of arachnoidean hydrocephalus. The blood becomes enclosed in a cyst, the clots disappear, and a quantity of serum, which every day becomes more considerable, supplies its place. The acquired hydrocephalus is also the consequence of chronic meningitis, tubercles of the brain, or of other tumours developed in this organ, &c., &c. ANATOMICAL LESIONS. The anatomical alterations of hydrocephalus are developed in the cranium and in the brain. The volume of the head is usually increased in consequence of the separation and enlargement of the bones of the cranium, which become flattened and considerably extended, superficially in order to cover in the spaces which result from the separation of the sutures. The cranium thus acquires enormous dimensions, varying from sixteen inches in young children to thirty-six inches in children of from ten to twelve years of age. J. Frank reports having seen in the museum of Cruikshank, the head of a hydrocephalic patient sixteen months old, which was fifty-two inches in circumference. I The increase in the volume of the head is one of the most common anatomical characters of hydrocephalus; occasionally this symptom offers some exceptions. In many cases the cranium is not too much developed, it is proportionate to the age of the subject. Goelis and Gall have witnessed similar facts; Baron and Breschet report several examples of this. They have seen the cranium filled with serosity, the encephalon imperfectly developed, without the head being of larger size than usual, in children attacked with congenital hydrocephalus Versi the existence of which they had not suspected. The enlargement of the head is confined to the vault of the cranium. The base preserves the ordinary dimensions. The same is the case with the bones of the face. The relative proportions of these parts are disturbed; the harmony of the face is destroyed, and thence results a strange physiognomy characteristic of the disease which we are now considering. Case. A young boy four years old died of hydrocephalus at the Hospital for Children: His head was 18 inches from one auditory meatus to the other. 26 inches in circumference. He preserved the use of his senses up to a very advanced period of his existence. It was only a few days before his death that he lost his hearing, sight, &c. The fluid was contained in the lateral ventricles which were dilated at the expense of the hemispheres, the substance of which had disappeared. Each hemisphere was converted into a pouch, the walls of which were one sixth of an inch in thickness and appeared composed of grey and white cerebral matter. The convolutions were flattened but visible. The membranes were healthy, and eighty-three ounces of liquid were enclosed in the dilated ventricles. In the cavity of the ventricles the septum medium was seen; it was from five to six inches in height, for the two ventricles were separated. The corpus striatum, the optic thalamus, the choroid plexus, were still visible on the right side; on the left all these parts with the exception of the corpus striatum. The fornix had nearly disappeared. There was no alteration in what remained of the cerebral substance. The bones of the head sometimes preserve their natural thickness (Aurivill, Malacarne, Hartell); most frequently they are thinned, and become as weak as a sheet of paper. They are transparent, flexible, yield easily to pressure as if they had been deprived of their saline ingredients and were reduced to their organic elements (Breschet). Their texture is quite peculiar; their porosity is very great and they offer round each point of ossification a radiated disposition very readily recognized. Their angles are rounded off; their borders, less separated, are united by membranes in the midst of which are often found osseous plates, the rudiments of wormian bones, destined to become developed and to fill up the sutures if the disease is to terminate in a favourable manner. The development of the cranium is very often irregular. Sometimes the distention is especially manifested on the vault of the cranium, sometimes on the contrary it is confined to the anterior or posterior part, or even to the sides of the head. If the diameters of this cavity are measured, sometimes four to six inches difference is observed between the fronto-mastoid diameter of one side and the same diameter taken on the opposide side. The multiplicity of the alterations of the encephalon or of its envelopes is such that the pure and simple exposition of them must be traced without the consideration of their comparative frequency. The facts known up to the present time are not sufficiently numerous to justify this proceeding. In some cases the liquid is found enclosed in the ventricles, and distends these to such an extent as to thin their walls and to compress |