In the dropsy of the head in adults which is the result of mechanical pressure or of cachexia the appearances are widely different. The effusion may occupy the cavity of the arachnoid, and even the space between the dura and the skull, as well as the ventricles. The amount of fluid is much less than in the chronic hydrocephalus of children. The ventricular walls present no signs of inflammatory changes.
DIAGNOSIS.—Chronic hydrocephalus is usually recognized without difficulty. The chief points of diagnostic importance are the progressive enlargement of the head, the separation of the cranial bones, with their peculiar change of position, as already described, and the evident signs of arrested intellectual development. If the head be but little enlarged, the case might be mistaken for that of chronic hypertrophy of the brain, but this is a very rare disease, and is not accompanied with defective mental development.
PROGNOSIS.—The elements of prognosis include the size of the head at birth, its rate of enlargement, the general condition of the child, both physically and intellectually, his hereditary antecedents, and the hygienic influences to which he may be subjected. A large proportion of children born hydrocephalic live but a short time; a few survive one or more years. The number of those who reach adult life is extremely small. The favorable indications are a tardy appearance of the dropsy and its slow progress, without marked evidence of defective mental and bodily development.
TREATMENT.—The treatment of chronic hydrocephalus is general and local, the first being the most important, although in many cases it is difficult to enforce it, from lack of intelligence and of means on the part of those in charge of the patient. Proper ventilation, good drainage, and cleanliness are essential. The child should be bathed daily, and should be protected against changes in temperature by suitable clothing. If his strength allow, he should be taken into the open air daily in fine weather. A wet-nurse should be provided for infants whose mothers are unable to suckle them. Older patients should take milk, cream, animal broths, farinaceous substances, etc., with wine or brandy. Tonics, especially cod-liver oil, hypophosphite of lime, and some preparation of iron or of the iodide of iron, are important, the choice being determined by the effect apparently produced. The internal and external employment of mercurial preparations, once in vogue, is now almost entirely abandoned by the best authorities. The evacuation of the fluid by puncture, followed by compression of the head by bandaging, has been occasionally resorted to, and in a few instances with success, but the cases in which it is indicated are rare. Thomas Young Thompson6 reports a case in which puncture was followed by recovery. The child, fourteen days old, fell, apparently without ill effects, but three weeks afterward a protuberance appeared on the crown of the head which continued to enlarge, and the signs of chronic hydrocephalus were unmistakable. In three months the circumference over the parietal eminences measured 20 inches, and a year afterward 24½ inches. In spite of energetic internal and external treatment the enlargement continued to progress, until the head was punctured, and about three hundred grammes of a clear, transparent fluid, free from albumen, were evacuated. Five weeks later a second puncture was made, and sixty grammes of a milky fluid withdrawn. The child recovered, and two years later was in good health, the head not being disproportioned to the rest of the body. West considers the cases in which the effusion is apparently external—that is, confined to the arachnoid cavity, rather than ventricular, and in which there are no indications of active cerebral disease—to be the most favorable for the operation. The proper situation for the puncture is the coronal suture, about an inch or an inch and a half from the anterior fontanel. A few ounces of fluid only should be withdrawn at a time, and compression should be carefully applied both during the escape of the fluid and afterward.
6 Med.-Chir. Transactions, vol. xlvii., 1864.
CONGESTION, INFLAMMATION, AND HEMORRHAGE OF THE MEMBRANES OF THE SPINAL CORD.
BY FRANCIS MINOT, M.D.