In rare cases the symptoms may be relieved by spontaneous evacuation of the fluid. Mr. L. W. Sedgwick has recorded such a case. A little boy, two years of age, two of whose brothers had died of the disease, and who had always himself had a large bead, began to be listless and dull. He often complained of headache and wanted to lie down. He slept badly at night and often woke up with a scream. After a time his head was noticed to be growing larger ; the fontanelle became very wide ; the pupils were dilated and sluggish, and there was some insensibility to ex ternal impressions. The respirations, too, became slower and the breathing was oppressed. While in this state, the case appearing every day to be more hopeless, a sudden change was noticed for the better.. The patient be came brighter ; his drowsiness cleared off ; his pupils began again to re spond to light ; and he ceased to complain of his head. This improvement coincided with a copious flow of watery fluid from the nose ; and after a large quantity of fluid had thus escaped all the unfavourable symptoms disappeared. Twelve months afterwards they returned, and increased to a degree that seemed to render the child's recovery out of the question ; but again they were relieved in a precisely similar manner. A case of the same kind. is recorded by Mr. Barron in which a large quantity of watery fluid mixed with blood was discharged from the nose and mouth. In this instance the patient died, and on examination of the skull, a narrow pas sage was found conducting from the cranium to the nose through the eth moid bone.
Although the disease may become arrested, and in children who survive the accumulation of fluid always becomes stationary after a time, the usual termination is in death. Such children, with their weakly frames and feeble resisting power, fall easy victims to any intercurrent disease ; and, as a rule, succumb to an attack of bronchitis, pneumonia, or severe intestinal catarrh, even if they do not die from actual interference with cerebral function.
Diagnosis.—Mere enlargement of the head is no proof in itself of the existence of hydrocephalus unless other symptoms of fluid are present. In rickets the head is often large, and sometimes this increase in size is due to actual hypertrophy of the brain. In syphilis it may be also large from extreme thickening of the cranial bones. In both of these cases, however, a certain excess of fluid may be effused, although the quantity may be insufficient to produce any ill effects from pressure. Still, unless actual intra-cranial dropsy be present, we never see the peculiar globular shape of the skull which is met with in chronic hydrocephalus. The characteristic features of this condition have already been sufficiently de scribed.
In cases of acquired hydrocephalus, when the collection of fluid takes place after closure of the fontanelle, diagnosis is very difficult. The con dition is usually dependent upon a tumour of the brain compressing the veins of Galen. It may be suspected when symptoms of gradually increas
ing pressure upon the brain are noticed, and absence of the more special phenomena peculiar to the inflammatory forms of cerebral disease throws us back upon this as the most likely cause of the symptoms. The seat of the fluid effusion is often difficult to ascertain with any precision, but it must be remembered that internal or ventricular hydrocephalus is more common than the external variety. Mr. Prescott Hewitt states that the flattening of the orbital plates, which forces forwards the eyeballs, occurs only in the internal form. If, then, in any case the eyeballs are prominent, and we see the lower half of the pupil covered by the lower eyelid, while a rim of white is seen above the cornea, we may conclude that the dropsy is ventricular.
Prognosis.—So few children, comparatively, survive the second year that the prognosis in intracranial dropsy is always very serious. Congeni tal cases mostly die, and in no instance can we give a favourable opinion unless evidences of arrest of the disease have become unmistakable. Cer tainly in no case can we venture to hope for so favourable a termination as a spontaneous evacuation of the fluid. Even if the disease become ar rested, the patient remains in most cases with a large unsightly head and a more or less blunted intelligence. Convulsions, twitchings, retraction of the head, and other signs of cerebral irritation are unfavourable symptoms. So, also, are continued wasting and looseness of the bowels. If the patient is weak, any intercunent disease generally proves fatal.
Treatment.—Cases of chronic hydrocephalus are the despair of the physi cian. He can do little more than attend to the general health of the child, regulate his bowels, and exercise a judicious supervision over his dietary. As regards arresting the disease, or causing absorption of fluid already ac cumulated, treatment appears to be of slight value. I have thought that the persevering employment of- perchloride of mercury has been of service, for I have found arrest of the disease to occur in one or two instances while the drug was being given, but the same treatment has failed in so many other cases that the more favourable result was in all probability a mere coincidence. I have never seen special benefit derived from diuretics or tonics, blisters, strapping, or artificial evacuation of the fluid. I have several times punctured the fontanelle half an inch to one side of the median line, and after withdrawing a quantity of fluid have strapped up the head tightly with carefully applied strips of adhesive plaster. But although the patient appeared uninjured by the operation the fluid always quickly re-accumulated. If the skull is enlarging rapidly, I believe the strapping treatment to be decidedly injurious.