The intelligence of hydrocephalic patients varies greatly in different cases. Sometimes it appears to be unaffected, and mental development continues in normal progression. As a rule, however, the child is back ward. He is slow to take notice, apathetic, and dull at an age when other infants can be easily amused. The time for walking arrives, but be makes no effort to "feel his feet," and if held upon the ground allows his limbs to double up helplessly underneath his body. When at last be learns to walk his gait is tottering and uncertain. This backwardness in locomo tion appears to be partially due in many cases to want of intelligence, but the general muscular weakness and the weight of the head contribute, no doubt, greatly to the deficiency.
It is very difficult to ascertain the degree of keenness of the senses in infants. Hydrocephalic babies are often thought to be deaf, but this is probably due in many cases to want of attention. The sight is often im paired, and—as in many other cerebral' diseases of infants—the child may not take notice of faces and objects because he sees them indistinctly. Dr. Clifford Allbutt believes ischtemia papillm to be the earliest change, but states that soon the disks and retinas become wholly disorganised and the optic nerve is atrophied from pressure. The ophthalmoscope shows the disks atrophied, their outlines blurred or lost, the vessels distorted or closed, and the retina maculated with patches and streaks of a brownish or whitish colour from old hcemorrhages, exudations, and fatty degener ations. Nystagmus is a common symptom in these cases, and there is often a convergent squint: Neryous symptoms are seldom absent. The patient may be distressed by attacks of laryngisinus stridulus, and Dr. West has observed spasmodic dyspneea. Convulsions are not rare, and sometimes recur at short intervals. So also partial paralyses, contractions, and automatic movements may be features of the disease. There may be also diminished sensibility of the skin, and occasionally the opposite condition—hypereesthesia—has been noticed. These children appear to suffer from frequent cephalalgia. The pressing of the head into the pillow and the frequent rolling of the head from side to side as the infant lies in his cot are almost invariably symp toms of uneasiness within the skull, and these are seldom absent in hydro cephalic cases. Sometimes the head is retracted.
As an example of an ordinary case of chronic hydrocephalus I may in stance a little girl, aged two years and a half, who was admitted under my care into the East London Children's Hospital. The child was of small
size except her head, and weighed eighteen pounds six ounces. The head had been noticed to be big from the age of three months, and had been constantly growing larger. The patient had been subject to convul sions ever since birth. She could not stand or support her head. The skull at the level of the bosses of the temporal bones measured twenty-two inches in circumference. The fontanelles were very large and tense, and the sutures were widely open. There was slight retraction of the head, with some rigidity of the muscles at the back of the neck. The wrists and elbows of both upper extremities were kept constantly flexed, and the thumbs were inverted. There were no actual convulsions, but the child often twitched all over. She was very dull and stupid, but could be made to look round by calling to her. She was not blind ; but there was nys tagmus, and squint was often noticed. Her temperature was normal.
The duration of the disease varies. Many patients die during the first year of life, and comparatively few survive to the second. Still death does not always take place so early. Sometimes a sudden arrest occurs in the disease. The head then ceases to enlarge, ossification goes on slowly, and general nutrition improves. In these cases it is often long before bony union is completed in the skull. In the case of Cardinal, recorded by Dr. Bright, who lived with an enormous skull to the age of thirty years, ossification was not completed until two years before the patient died.
In acquired hydrocephalus the symptoms are much the same as those described in the congenital form, so long as the effusion Occurs before consolidation of the skull is completed. If, however, it takes place after the fontanelle is closed, the symptoms are obscure, for there are no exter nal signs of distention. The child generally becomes dull and heavy. There is headache, vertigo, and often an apparent difficulty in supporting the head, so that the patient lies about and seems to dislike movement. If made to walk, he totters and steps cautiously. Twitching or convulsive movements may come on, the pul2ils get sluggish and dilated, and the pulse slow. Then the stupor deepgns into coma and the child dies.