In all cases every part and organ of the body should he very carefully exam ined so as to exclude complicating eon ditions and establish the diagnosis. The initial treatment is of the greatest im portance, for after the effusion has oc curred there is less hope of doing good.
When the patient is a sthenic subject and the arterial tension high, leeches or wet cups to the mastoid regions may be employed. After these measures the ' spinal ice-bag should be used in the cases with high temperature; and they should be avoided in those with low-tempera ture range, as collapse has been induced in such patients in my own experience. The bromides and chloral will usually be demanded to mitigate the tendency toward convulsions, while they both tend to lessen cerebral hyperemia. Chloral may be used as a rectal injection in cases where the stomach is non-retentive. In some cases the warm bath is desirable and helps to calm the muscular system.
The diet should be carefully regulated and stimulants should not be given un less demanded by the condition of the pulse. In the later stages signs of col lapse should be watched for, and that condition anticipated, when possible, by the prompt administration of a rapidly acting stimulant, such as ammonia. Should the patient recover from the acute stage of the disease, diuretics, in cluding the acetate and iodide of potas sium, should be employed, with tonics, massage, and electricity, in order to in crease the nourishment and activity of the muscles. Although the percentage of recoveries is exceedingly small, it is large enough to warrant the utmost zeal in the treatment of these distressing cases.
II. Chronic Hydrocephalus.
Definition. — Chronic hydrocephalus means a progressive accumulation of serum within the ventricles of the brain, or in rare cases external to the brain and between its membranes, or between them and the skull itself; or in all of these situations. It is characterized by en largement of the head, an almost pathog nomonic facies, and by a progresive tendency toward death; often from grad ual failure of the vital powers, or from intercurrent disease, or more rarely from rupture of the head.
Varieties.—The term internal hydro cephalus is used to denote the cases in which the effusion is ventricular, while external hydrocephalus is used to denote the cases in which the effusion is external to the brain. The former class of cases is by far the most numerous, and is meant when the word hydrocephalus is used alone. The disease may also be primary or secondary. Many of the cases are congenital, but in the majority of instances it is first noticed some weeks after birth.
symptoms of chronic internal hydrocephalus and the external variety of the same disease are similar and differ only in degree. External
hydrocephalus is extremely rare, and is secondary, in the vast majority of the cases reported, to meningeal hwinor rhage and to pachymcningitis. It is also found in cerebral atrophy, probably as a compensating lesion, and also has been found in cases of congenital cerebral malformations. The amount of fluid found is very small in comparison with that found in internal hydrocephalus, but some cases have been reported in which the head was decidedly enlarged and the sutures separated.
Internal hydrocephalus, which is the ordinary variety met with in practice, presents as its chief symptom an en largement of the head. In some cases this enlargement is very great, as in a case reported by Steiner, which exhib ited a cranium 32 inches in circum ference at the eighth month. The normal circumference of the head at one year is given by Holt as from 18 to 19 inches. The increase in size of the head is usually in all directions, and the su tures in marked cases arc widely sepa rated, while the cranial bones are ex panded and thinned out until sometimes they have a parchment-like sensation to the touch. The fontanelles are very large and bulging; the veins of the scalp are engorged; fluctuation of the head is quite common, and it may also be trans lucent to light. The scalp is stretched and thin and exhibits very little hair.
On the other hand, internal hydro cephalus may exist with no perceptible enlargement of the head and with per fect, and even premature, ossification of the cranial bones. Primary cases of in ternal hydrocephalus are most often con genital, but in most cases the condition is only recognized after some weeks sub sequent to birth; but in other cases the condition develops rapidly in utero, and puncture of the head may be necessary to effect delivery. In the largest class of cases nothing is noticed until several weeks have elapsed after birth, when the abnormal size of the cranium attracts attention. The child is also noticed to have difficulty to support or move the head, or is incapable of supporting it at all. Soon drowsiness and apathy are apparent in the infant, and it sinks into a condition of hebetude with all the senses less acute than normal. There is apt, at this time, to be either undue flac cidity or stiffness of the extremities. The latter condition is more common and the thumbs are adducted with the fingers tightly closed. The pupils are usually contracted, but at times irregular or dilated. There is marked general ema ciation. Convulsions may occur and be repeated, and slow rolling of the eyeballs laterally or more or less strabismus may be features of the case.