Hydrocephalus

“ The bones of the cranium will sometimes be widely separated by it, and the head be made so large that it cannot possibly be born till made less. The causes which produce this disease before birth are unknown.
In cases of hydrocephalus the head does not descend into the straits, owing to its size, and is felt to be full and firm, during a pain, but soft and yielding during the intervals, especially at the fontanelles and sutures, which are also very large. The bones are usually very wide asunder, or even totally separated, as if floating in the fluid. ”

“ The average circumference of the adult head is 22 in., and in the normal child it is of course much less. In chronic hydrocephalus the head of an infant three months old has measured 29 in.; and in the case of the man Cardinal, who died in Guy’s Hospital, the head measured 33 in. In such cases the head cannot be supported by the neck, and the patient has to keep mostly in the recumbent posture. The expansibility of the skull prevents destructive pressure on the brain, yet this organ is materially affected by the presence of the fluid. ”

“ The symptoms of cerebral disturbance in chronic hydrocephalus are much less striking than one would expect, doubtless because the increase of pressure upon the brain is so gradual. Actual paralysis, especially of the limbs, is rare, but convulsions are not infrequent, as is the spasmodic constriction of the glottis known as laryngismus stridulus or spasmodic croup. A general state of uneasiness and restlessness is common. Vision is often impaired and sometimes wholly lost. Strabismus is frequently present, or there may be an involuntary rolling movement of the eyeballs. ”

“ The state of the encephalon in those patients in whom spurious hydrocephalus occurs is interesting. In protracted cases of the diarrhoea the brain wastes like the body and limbs. In the young infant, in whom the cranial bones are still ununited, the occipital and sometimes the frontal bones become depressed and overlapped by the parietal, the depression being of course proportionate to the diminution in size of the encephalon. ”

“ Spurious hydrocephalus either continues till death, or by stimulation the patient may emerge from it. When profound the usual result is death.
Although the summer complaint in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. Improvement is shown by better digestion, fewer stools and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. ”

“ Whereas in the hydrocephalus there is only a partial pressure of the brain; and probably in nervous fevers with stupor the pressure on the brain may affect only the nerves of the senses, which lie within the skull, and not those nerves of the medulla oblongata, which principally contribute to move the heart and arteries; whence in the lethargic or apoplectic stupor the pulse is slow as in sleep, whereas in nervous fever the pulse is very quick and feeble, and generally so in hydrocephalus. ”

“ Some of the forms of chronic hydrocephalus are difficult to distinguish from tumors, especially gliomata. In hydrocephalus, when not the result of, or not accompanied by, tubercular meningitis, the disease advances more slowly and with less irritative symptoms than in cases of tumor. Headache, vertigo, vomiting, and the other symptoms of meningeal irritation are not so frequently present, although the ophthalmoscopic appearances are often the same. ”

“ When progressive loss of flesh and strength has continued several weeks, and the patient is much exhausted, another complication is apt to occur, known as spurious hydrocephalus or the hydrocephaloid disease, the anatomical characters of which will be described in the proper place. ”

“ A large proportion of children born hydrocephalic live but a short time; a few survive one or more [p. 745] 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. ”

“ It is universally allowed among medical men that irritations in the stomach and bowels will, through the agency of particular nerves, produce sympathetic irritation [Pg 40] in the brain,—that peculiar action being thus elicited which terminates in the effusion of serum, constituting the disease named Hydrocephalus.—'The continued irritation of important or very sensible nerves is, perhaps,' says Mr. Burns, 'one of the most common causes' (of Hydrocephalus) ”

“ Von Ziemssen regards chronic hydrocephalus as not a rare consequence of epidemic meningitis, and as one not absolutely or immediately fatal. Its symptoms include severe paroxysmal pain in the head or neck or extremities, with vomiting, loss of consciousness, convulsions, and involuntary evacuation of excrements. Between the paroxysms, which sometimes occur periodically, the patient generally suffers from neuralgic pains, hyperæsthesia, and various motor and even mental disorders; but in other cases the intervals are free, or nearly so, from all morbid manifestations. ”

“ Hydrocephalus, tabes mesenterica, and other similar maladies, are natural agencies which cut off the children of races that are sinking below the decent minimum which nature has established as the condition of viability, before they reach the age of reproduction. They are really not so much diseases, as manifestations of congenital incapacity for life; the race would be ruined if art could ever learn always to preserve the individuals subject to them. ”

“ Another peculiarity may be found in the size of the brain, which is usually so much larger, in proportion in infants than in adults; and we are told by M. Jadelot, that in many children who had died with symptoms of hydrocephalus, dissection presented no other pathological condition than morbid hypertrophy of the brain. ”

“ In a family residing in this neighbourhood, where, out of fourteen children, eight have died; it appears that, of these eight deaths, three were cases of hydrocephalus, two of disease of the mesenteric glands, and two of phthisis pulmonalis. In other families we find the osseous fabric the seat of strumous disorganization, and one child will have a rickety affection, or a deformity of the chest, such as in after life may evoke some phthisical tendency, another a caries of the bones, and a third spinal distortion. ”

“ The results obtained by operation for internal hydrocephalus are not sufficiently encouraging to enable the surgeon to urge immediate operative treatment. [15] Still, it is perfectly clear that he cannot possibly carry out surgical treatment with benefit to the patient if the ventricular distension is allowed to progress to such a degree that marked cortical flattening and degeneration occurs. No fixed probationary period can be laid down as a guide, each case must be judged on its own merits. Special attention should be paid, however, to the disks and lower extremities. ”

“ Injuries to the mother during pregnancy have been unquestionably the cause of certain malformations, especially of congenital hydrocephalus. The embryo itself and its membranes may become the subject of inflammations, atrophies, hypertrophies, and the like ”

“ Eight diseases at the head are described, but in such terms that we fail to recognize the distinguishing features of each. Besides these, a little way further on the author describes several other diseases of the head, including hydrocephalus, the symptoms of which are given with great precision, namely, acute pain about the bregma and temples, alternate rigor and fever, impairment of the sight, double vision, vertigo, etc. He recommends errhines, purgatives, and even trepanning of the skull. Even of this disease several varieties are described in very striking terms ”

“ Operative treatment is seldom to be recommended in a young child unless it is otherwise viable and the swelling is increasing rapidly and threatening to burst, and there is reason to believe that the paralysis is due to pressure. The immediate results of operation are usually satisfactory, but in a large proportion of cases the child subsequently develops hydrocephalus, from which it ultimately succumbs. The hope of improvement in the motor symptoms after operation depends on the site of the spina bifida; above the twelfth thoracic vertebra there is no prospect of improvement ”

“ The parietes seem to be a continuation, or protrusion, of the membranes of the spinal chord, thickened and somewhat altered in structure, and usually in close contact with and adherent to the integuments. By pressure the size of the tumour is diminished; but, if firm or long continued, unpleasant effects are apt to result. There is often debility of the lower limbs, and the disease is not unfrequently coexistent with hydrocephalus. Children with this affection seldom live more than a few years. ”

“ Hydrocephalus, hī-dro-sef′a-lus, n. an accumulation of serous fluid within the cranial cavity, either in the sub-dural space or the ventricles: water in the head: dropsy of the brain.—adjs. Hydrocephal′ic, Hydroceph′aloid, Hydroceph′alous. [Gr. hydōr, water, kephalē, the head.]
Hydrochloric, hī-dro-klō′rik, adj. compounded of hydrogen and chlorine.—n. ”

“ Hypostasis likewise should not be regarded as a pathologic condition. Normally the membranes are moist; in increased intracranial pressure (tumors, hydrocephalus, hemorrhages) they are dry and dull. Inflammation is shown by a loss of transparency of the membrane and by the presence of exudate in the subarachnoideal space. Old thickenings are white and opaque. The amount of fluid in the subarachnoideal space may be so great as to cause the arachnoid to bulge out over the sulci. ”

“ The commencement of spurious hydrocephalus is announced by gradually increasing drowsiness, perhaps preceded by a period of unusual fretfulness. Vomiting and rolling the head are occasional early symptoms of this complication. As the drowsiness increases the pupils become less sensitive to light than in their normal state, and are usually contracted. When the drowsiness becomes profound and constant, the pupils remain contracted as in sound sleep or in opium narcotism. ”

“ Physical examination was very difficult through lack of coöperation and a screaming and kicking resistance upon every attempt. There was a suggestion of hydrocephalus in the protrusion of the forehead. The pupils reacted readily to light and accommodation. The knee-jerks were active, but there was otherwise no disorder of reflexes. The patient had great difficulty in getting up from the floor, and for the most part insisted upon lying in ventral decubitus on the floor, crying when attempt was made to raise her. ”

“ Basal Meningitis secondary to Temporo-sphenoidal Abscess.
From these few anatomical facts it is manifest (1) that a subarachnoid purulent effusion has every opportunity of spreading widely over the surface of the brain, and (2) that inflammation and its results in the immediate neighbourhood of the roof of the fourth [278] ventricle will tend to impede the normal flow of cerebro-spinal fluid through the foramina in that region, thus inducing a degree of internal hydrocephalus directly proportionate to the degree of obstruction. ”

“ The motion of the body, too, has a direct tendency to induce vertigo; and when the liability of the infant brain to congestion and its consequences is considered, when the frequency of hydrocephalus in infants is borne in mind, an exercise which impels blood to the brain will not be regarded as wholly insignificant. There is one more objection which seems not to have attracted attention. The hold taken of the child in the act of hoisting him is by the hand grasping the chest. The fingers and thumb, placed on each side of the breast-bone, compress the ribs ”

“ Golis, from observing the marked connexion "between the turgescent state of the brain from chylopoietic disturbance, and its serous inflammation, has concluded, that it essentially pertains to it;" consequently, that "whenever it occurs, it is a part of it;" that it should be considered as forming the first stage of the disease, and that in all instances, it precedes the excitement. He has, for the same reason, constituted all the symptoms of the chylopoietic disease into the first stage of hydrocephalus. ”

“ It is very remarkable, that since the discovery and description of the hydrocephalus internus, we hear and read much less than formerly of worm-fevers. I suspect that disease of the brain has laid the foundation for the principal part of the cases of worm-fevers which are upon record in books of medicine. I grant that worms sometimes increase the danger from fevers, and often confound the diagnosis and prognosis of them, by a number of new and anomalous symptoms. ”

“ The pathological anatomy of this disease is that of chronic hydrocephalus. Renault records cases in which the subarachnoid and arachnoid fluids were under the normal while the fluid in the ventricles was increased to a marked extent. ”

“ In certain cases of hydrocephalus the open and dangerous spaces in the skull are filled up with new bones, which interlock by perfect serrated sutures. (24/8. These cases are given by Blumenbach in his 'Essay on Generation' pages 52, 54.) But most physiologists, especially on the Continent, have now given up the belief in plastic lymph or blastema, and Virchow (24/9. 'Cellular Pathology' translation by Dr. Chance 1860 pages 27, 441.) maintains that every structure, new or old, is formed by the proliferation of pre-existing cells. ”