Diagnosis.—The diagnosis is usually an easy one. Chronic hydrocephalus must be distinguished from rickets and hypertrophy of the brain. No error is liable to occur in the very marked cases, but when the effusion is of moderate amount the diagnosis may demand care ful examination. From hypertrophy of the brain hydrocephalus is separated by its more rapid development, the greater enlargement of the head, the fluctuation which is often present, the universal character of the expansion of the cra nium, which is more marked at the vertex in hypertrophy of the brain, and by the almost pathognomonic facies of hydrocephalus, including the oblique direction of the eyes, with failure of the upper lid to completely cover the eyeball. To the touch hydrocephalus is softer and more compressible than hypertrophy.
Diagnosis of idiopathic internal hydro cephalus in the adult: great stress laid upon the variation in the intensity of the symptoms from day to day. These remissions and intermissions in the chronic cases ninst be largely relied upon to distinguish them from cases of brain tumor. Martin Prince (Jour. Nerv. and Mental Dis., Aug., .97).
From rickets chronic hydrocephalus is distinguished by the rounded head, which in rickets is square or angular and often marked by nodules; also by palpa tion and the other signs of the hydro cephalic head above noted. In rickets, also, there will usually be other evi dences of the disease in other parts of the body.
Cases of chronic external hydroceph alus may present more difficulties in diagnosis, but they are of very rare oc currence, and careful examination will usually separate them from the cases under consideration.
treatment of chronic hydrocephalus by internal remedies only rarely results in any benefit. Probably the best diuretic and alterative in these cases is the iodide of potassium, which should be given a trial in cases where it is not especially contra-indicated.
In all cases of hydrocephalus congeni tal syphilis should be looked for, and, if found, antisyphilitic treatment should be adopted energetically and as early as possible. Heller (Deutsche med. Woch., June 30, '92).
Case of child, 7 months old, suffering from chronic hydrocephalus. The head was enlarged, the fontanelles were wide open and bulging, and the veins of the face and scalp were dilated. The child was treated with potassium iodide inter nally (2 or 3 grains daily), and in five. months all signs of chronic hydroceph alus had disappeared. J. Heller (Deut. med. Woch., No. 5, '9S).
Surgically, compression of the skull by adhesive plaster applied in strips has been tried, and cases of marked improve ment have been reported as resulting from this treatment. The treatment
much in vogue is a combination of press ure with adhesive strips covering in the entire vault and sides of the cranium, combined with occasional aspiration of moderate amounts of fluid, followed by the reapplication of the adhesive plaster_ The effects of the pressure must be care fully watched and the strips loosened or removed should dangerous symptoms appear. If syphilis is suspected mer curial inunctions to the head should be practiced.
Other modes of treatment are: inci sion with drainage, puncture by the trocar, blisters, and lumbar puncture. When any operative interference is con sidered, the preference of the writer is for repeated aspiration with strapping of the head.
Puncture of the skull favored in the treatment of hydrocephalus. The ad vantages are: 1. Cessation of convul sions. 2. Quieting of the restless, scream ing patient. 3. Good influence on bodily development. 4. Improvement or saving of the physical functions. 5. Restoration of sight when lost. The disadvantages are: 1. Formation of an lnematoma ; very rare, and usually avoidable. 2. In fectious meningitis; avoidable by asep sis. 3. Meningitis through pressure; gangrene; occurs also without puncture, and is avoidable by drawing off small quantities at a time. 4. Collapse; never occurs in dangerous degree under favor able conditions. Wyss (Corres. f. Schwei zer Aerzte, Apr. 15, 93).
Quinche's statements in regard to the comparative ease and safety of puncture and drainage of the spinal canal in hy drocephalus confirmed. In eases of high pressure a small fountain of cerebro spinal fluid flows from the eannula. The quantities of fluid drawn off vary be tween 1 and 3 ounces. The pulse is at first arbythmie, but soon becomes steady again. It should be performed only under chloroform narcosis. Operated in twenty-two cases forty-one times with out harm. Von Ziemssen (Centralb. f. d. Gesammte Therap., July, '931.
Of six cases, all tapped more than once, four improved and two almost recovered. The operation, if performed aseptically and the fluid drawn off slowly with the head well depressed. is not attended with the danger usually ascribed to it; im provement usually follows the operation; and if done sufficiently early there is some prospect of the child becoming a useful member of society. Hem (Brit. Med. Jour., Nov. 11, '93).