DEP/DUA/1/13/11 (Normalised version)

Ann Ramsay

(1777)

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Ann Ramsay.

A patient of whom for some time past have seen nothing.

Probably from place of residence being at some distance.

Had she continued regularly in attending would have afforded rather opportunity of marking progress of disease, than of cure.

Respecting nature of affection to which this patient subjected no room for doubt.

From first view of head disproportion which bore to rest of body could not fail to strike even most inattentive observer

While at same time in this enlargement face unless in as far as constituted by bones of cranium had evidently no share.

That part of head however which in natural state occupied only by brain here augmented to very great degree.

Such an affection though not every day to be met with yet upon whole can hardly be reckoned an infrequent occurrence with infants.

In so much that at present two others subjected to same distemper under our care

Such enlargements universally found on dissection to arise not from any morbid increase of natural contents of cranium but from a dropsical affection.

And that case before us affords striking instance of Hydrocephalus can admit of no doubt

Under this general term however very different affections comprehended.

And perhaps no affection in which symptoms more varied from seat of water.

Practitioners in general divide affection into hydrocephalus externus & internus.

By last understanding those instances where water deposited within ventricles of brain.

By first all cases where the water exterior to brain itself.

If examine nosological¹ systems however will find that definition in all except that of Mr Sagar. apply only to externus

And definition of Sagar a very vague one

For no more than that Hydrocephalus a dropsy of the head.

All definitions into which enlargement of head enters, the mode followed by the other nosologists will by no means apply to hydrocephalus internus in sense in which we would adopt the term.

A disease so accurately described by Dr W. that few practitioners who have read his work with attention will be at loss to distinguish it although in earlier stages an affection of most insidious nature.

And till very lately we may perhaps say not understood.

This the rather mention as terms of Hydrocephalus internus & externus employed by Mr [J]. in sense different from that in which commonly understood

By Hydrocephalus internus he means those cases where water collected within cranium distends & opens sutures as in instance before us

By exterior he means those cases in which a mere anasarca affection occurs partially, to integumentary system of head.

From these different senses of same term difficulty may sometimes arise

Apprehend that would not only be means of avoiding confusion but would even farther serve some good purpose at least in prognosis if affection divided into three species.

Which indeed perhaps properly speaking to be considered rather as distinct genera than species.

At least if as in other parts of body genera constituted by cavity in which water effused.

These would distinguish by following terms

1 Hydrocephalus of ventricles – when the water situated within these cavities.

2. Hydrocephalus of cranium, when situated between brain & skull.

3. Hydrocephalus of integumentary system when situated totally exterior to skull.

That instance before us of second kind can admit of no doubt.

Which although less rapid in progress than first, Hydrocephalus viz of ventricles perhaps not less mortal.

Has even been disputed whether instances of recovery in any case.

To this opinion however cannot agree

For persuaded that have witnessed once instance of recovery from hydrocephalus of ventricles.

And if this the case will not be disputed that may occur with regard to Hydrocephalus of cranium.

Some however so much persuaded of fatal tendency even of last that advise no measures to be taken during course of it.

As imagining that if have any affect will be to hasten death of patient.

Must then look upon case before us from nature of affection to be of very dangerous tendency.

And but faint hopes to be entertained of cure in cases even much more favourable than present.

For here to be observed that disease not merely characterised by [enormous] increase of size of head.

Though has not given rise to all yet had produced several of symptoms arising from hydrocephalus of ventricles.

Such for example as Strabismus or peculiar squinting dilation of pupils, & loss of sight.

No doubt that in present instance as well as an hydrocephalus of ventricles these affects of compression on brain.

And to same cause also may refer several other appearances in case before us.

Particularly inability to use legs, & want of power of articulation although now near three years old.

To these we might I think add with respect to intellectual faculties as far at least as these can be judged of at so early a period of life, if not absolute idiotism at least a very considerable degree of it.

For of this we had I apprehend sufficient corroborating evidence in wild shrieks which she emitted

From all these particulars then taken together may consider this affection in instance before us, as in very advanced state.

And indeed has already subsisted for upwards of space of two years.

Must however remark that have [known] instances of longer duration & where head had even increased to greater size where same appearance not induced.

And have seen a child farther advanced in life, with much larger head who could not only articulate, but even extremely talkative.

Would appear then that in instance before us the progress of the affection as destroying powers of system had been great even for time.

And without cure or at least alleviation of complaint little prospect that would hold out much longer.

Besides what already mentioned however another circumstance to be taken into account in giving prognosis in all such cases as present.

That is cause to which affection may be referred.

And from this as far as goes would in present case draw rather favourable judgement as otherwise.

Often disease begins without any proper cause

In which case reason to dread that has origin in constitution.

Often a disease not supervening after birth but born with infants.

A circumstance still farther demonstrating that has origin in habit itself.

But in case before us the disease neither congenital nor without obvious cause

At least affection attributed to fever & convulsions with which was attacked about two years ago.

From that time head observed gradually to enlarge.

True indeed may be suspected that these consequences of this affection on first attack.

And no doubt that first stage of hydrocephalus of ventricles is marked by fever.

But as never observed a symptom of Hydrocephalus of cranium may conclude that was not so in present instance.

And as dropsical affections in general often a sequel of fever may infer then this took place in instance before us.

But allowing disease not to be origin but acquired & cause of affection obvious, whatever grounds might give for favourable prognosis in other instances can do little in present.

For after occurrence of symptoms indicating affection of all more material functions recovery would indeed be very extraordinary.

This however is I apprehend no sufficient reason why should not give trial to measures for cure.

For hold that even in most desperate cases patients, while will submit to treatment, not to be deserted.

In such desperate cases consider a practice as warranted even to make trial of doubtful remedies.

And even where does not choose to employ such perhaps no instance in which measures may not be taken which without chance of prejudice consequences have at least prospect of affording some relief.

On these principles then proceed to speak of cure in case before us.

Evident that as in other dropsical affections here two great objectives to be had in view.

1 The evacuation of water already collected within cavity of cranium.

2 The prevention of future accumulation.

Here as in other cases also all different modes of outlet may be referred to two kinds natural or artificial

Former unquestionably furnishes us with most safe latter with most affective mode of evacuation.

That is by means of these can at least draw off water whatever may be future event of the disease.

Must however be allowed that in this affection some of artificial modes of evacuation very doubtful.

Among these may mention what of all others the most certain.

That is puncture into cavity containing water.

Respecting propriety of this operation most oppose sentiments entertained by most eminent moderns.

Some represent as a mode of cure not only free from danger but never to be neglected

Others consider it as certain means of precipitating death of patient.

From my own experience on this subject can say nothing.

Have never either directed this operation to be performed or seen it tried under direction of any other.

Must however own that should not entertain from it any sanguine hopes of success.

At utmost can look for no farther benefit than from [taping] as ascites.

That is, to be considered merely as means of evacuating water not of preventing return.

And still a matter of doubt how far even in ascites [tapping] of any great advantage

One of most eminent practitioners in London [indeed] lately recommended even early [taping] in high terms.

But I am well assured that even he now much less fond of it than formerly.

While others, & these too of first eminence very strongly condemn it in every instance.

If however evacuation by an outlet of this nature except in ascites still more so in hydrocephalus of cranium.

For well known that in ascites even greatest inconvenience will arise if discharge not [comp] by due pressure.

Hence before bandages introduced was given as [constant] direction that in ascites whole water should not be drawn off at once but at different times.

And if ever attempted in hydrocephalus same injunction to be observed.

For here from state of matter forming cavity, viz bone pressure cannot have affect.

Or if intervals between sutures should admit of this yet cannot have influence in equable manner.

Notwithstanding all these objections however, where other remedies ineffective & where disease evident on increasing [hand] to be considered as giving only possible chance of recovery.

And though, as chance unquestionably a bad one never to be enforced yet ought I apprehend in such circumstances to be proposed

Perhaps few cases where evident concurrence of every circumstance requires it none manifestly present than in this before us.

But to the operation an unsurmountable objection in mothers dread at thought of it.

By this therefore here determined to try what might with safety be done by other artificial or natural outlets.

Have an artificial outlet not only to appearance less formidable, but in reality less dangerous in those excited by blister & continued in form of issue.

From these applied even to head itself less to be apprehended than in hydrocephalus of integumentary system & more to be expected than in hydrocephalus of ventricles.

Here however chose to give preference to application in neighbourhood of head.

Which while product of nearly same advantages, would seem less alarming.

Was intention to have supported discharge by use of antispasmodic ointment.

But although from blister itself very copious evacuation yet by issue ointment most discharge was not supported.

Probably from want of proper application.

Perhaps however a matter of doubt whether from this any real disadvantage

For if not an equal at least a very considerable discharge may be obtained by repeated blisters.

And to such repetition had here recourse.

What has been affect of it however have not since learned.

But besides blisters employed also a mixture which hoped would operate as a brisk purgative which directed as an evacuant of water by a natural outlet

But as of this shall have more opportunity of speaking in other cases shall say nothing of it here

And of future plans with this patient need make no observations as shall not probably see her again.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.