A system of clinical medicine, dealing with the diagnosis, prognosis, and treatment of disease / 2nd edition.

  • Thomas Dixon Savill
Date:
1909
Catalogue details

Licence: In copyright

Credit: A system of clinical medicine, dealing with the diagnosis, prognosis, and treatment of disease / 2nd edition. Source: Wellcome Collection.

Provider: This material has been provided by Royal College of Physicians, London. The original may be consulted at Royal College of Physicians, London.

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    § 625 ] important landmark, and may be found by drawing a line from the root of the nose to the occipital protuberance. Then mark a point to f inch behind the middle of this line, and draw a second line from that point downwards and forwards at an angle of 67 degrees ; the second line will lie over the fissure. This is conveni- ently done in practice with soft metal joined at the required angle. The fissure of Sylvius is found by drawing a line from the external angular process of the frontal bone to the occipital protuberance. The fissure starts at a point 1J inch behind the external angular process. The horizontal ramus of the fissure lies beneath a line drawn from this point to the parietal eminence. Sir William Macewen attaches importance to the percussion of the skull as an aid to the diagnosis of intracranial tumours. § 625. Hydrocephalus is a distension of the ventricles of the brain with fluid. It occurs in two forms : (a) Congenital or infantile ; and (6) acquired or secondary hydrocephalus. (a) Typical cases of Congenital Hydrocephalus may be recognised by the shape of the head, which is enlarged and dome-shaped, projecting all round and beyond the bones of the face. The fontanelles are very wide, and Wormian bones may fill up the gaps between the cranial bones. The face in proportion to the size of the head seems to be extremely small. The orbital plates of the frontal bones are pushed downwards, so that there is exophthalmos, and the eyelids do not cover the sclerotics. The condition dates from birth. It may exist before birth sufficiently to obstruct labour, or it may be so slight as not to be noticed until the child is one or two years old. The circumference of the head of a child of four may reach as much as 25 or 30 inches. The general symptoms consist of bodily weak- ness and developmental delay, and backward mental condition, which shows itself in the slighter cases as a constant peevishness, and in the graver cases as idiocy. In some cases the intellect is quite normal. Spina bifida, talipes, ence- phalocele, and other developmental deformities may accompany hydrocephalus. The Causes of this form of hydrocephalus are not known. In slight cases the Diagnosis may have to be made from rickets, in which there are (1) a bossed and square shape of the head, (2) a flattened instead of a dome- shaped vertex, (3) evidences of rickets in the other bones of the body. Prognosis.—Most eases of congenital hydrocephalus die within the first five years of life. Moderate cases sometimes live until the twelfth year. Mild cases of hydrocephalus sometimes do not deteriorate further. The patient lives without other symptoms perhaps for the normal span of life. (b) The symptoms of Acquired Hydrocephalus are less decided. They come on insidiously at any age, and are associated with those of the causal con- dition. The head does not enlarge if the disease supervenes after closure of the fontanelles, but there are symptoms of cerebral compression (§§ 547 and 551), and sometimes gradual blindness, due to optic neuritis. Causes.—Acquired or secondaryhydrocephalus mostlydepends on some obstruc- tion of the veins of Galen, such as that produced by a tumour at the base of the brain, or in the third ventricle, or the iter. It may also result from intracranial inflammation, especially post-basic meningitis (§ 549). Pressure on the middle cerebral or straight sinus, into which the venae Galeni empty, has the same effect (§ 551). The Treatment of congenital hydrocephalus is not hopeful. Drugs are powerless to promote the absorption of the fluid. In the milder cases the treatment resolves itself broadly into a general strengthening or tonic treatment. In other cases “ lumbar puncture,” similar to that successfully used in tuberculous meningitis, has been employed with a measure of success in hydrocephalus. A smooth, fine aspirating needle is introduced between the third and fourth lumbar vertebrae, a little to one side of the middle line, to the depth of 2-5 centimetres in children and 5 centimetres in adults. One to one and a half ounces have been removed at a time (Quincke). It is especially worthy of trial if pressure symptoms are present. The treatment of acquired hydrocephalus is not much more promising, unless the cause is removable.