which may be accompanied by purulent exudation and by a corresponding
affection of the pia mater: 2d, hemorrhagic inflammation or hæmatoma
of the dura mater. Simple inflammation of the internal or lower
surface of the dura, without the coexistence of external
pachymeningitis is rarely found in the adult. The morbid appearances
differ but little from that of the external form, and the causes and
the diagnosis are also similar. In children, however, it is not
uncommon, according to Steffen.[2] The pus may discharge itself
spontaneously through the fontanels or the sutures, or caries of the
cranial bones may open a passage for its exit. It has also been
evacuated artificially when the symptoms have indicated its presence.
In other cases more or less extensive firm adhesions {707} between the
dura and pia mater have shown the previous existence of inflammation,
but it would be difficult to say in which membrane it began. In some
instances no symptoms are observed during life; in others the
coexistence of inflammation of the pia, effusion into the ventricles,
etc. prevent an exact diagnosis.
[Footnote 2: “Die Krankheiten des Gehirns in Kindesalter,” von Dr. A.
Steffen, in _Gerhardt's Handb._, 5 B., i. Abt., 2te Hälfte, p. 380.]
The TREATMENT does not differ from that of inflammation of the
external layer of the pia.
Hæmatoma of the Dura Mater.
SYNONYM.—Hemorrhagic pachymeningitis.
DEFINITION.—A chronic inflammation of the dura mater, resulting in the
formation upon its inner surface of successive layers of false
membrane, into and between which there is usually an effusion of
blood, the whole sometimes forming a large solid mass between the dura
and the cavity of the arachnoid.
ETIOLOGY.—Hemorrhagic pachymeningitis never occurs in healthy persons
except from traumatic causes. It is most frequently observed in
advanced life, and especially in the male sex. In a large number of
cases the blood is in an unhealthy condition, and hence the disease is
seen in alcoholism, in scurvy, in acute articular rheumatism, and in
the acute febrile affections, as typhoid fever, pleuro-pneumonia, and
pernicious anæmia, of which last, according to Huguenin,[3] it
complicates one-third of the cases. It is frequent among the chronic
insane. It is occasionally met with in young children, but with them
its causes are mostly unknown; according to Steffen,[4] they may
consist in alterations of the blood resulting from insufficient
nourishment or from the infectious diseases, and from abnormal
blood-pressure, as in whooping cough, asthma, etc., as well as from
blows on the head.
[Footnote 3: G. Huguenin, “Acute and Chronic Inflammations of the
Brain,” in _Ziemssen's Encylop._, Am. translation, New York, 1877,
vol. xii. p. 401 _et seq._]
[Footnote 4: _Op. cit._, p. 386.]
SYMPTOMS.—Many cases of hemorrhagic pachymeningitis complicating other
cerebral diseases can be distinguished by no special symptom from the
original malady. Thus, in cases of chronic insanity its existence may
not be suspected during the lifetime of the patient. Steffen quotes[5]
the case, reported by Moses, of a child seven months old who died of
catarrhal pneumonia, and who exhibited no symptom which could suggest
any disease of the brain or its membranes. The autopsy revealed a
pachymeningitic cyst extending over the anterior half of the right
hemisphere. When symptoms are present they vary in different cases
according to the acuteness of the inflammatory process, the amount and
situation of the effusion, and the participation of the pia mater and
brain in the disease. In the beginning they are usually indefinite,
headache being the most common and often the only complaint. This may
continue for weeks without any other indication of disease, but it is
frequently accompanied by tinnitus aurium, vertigo, muscular weakness,
and contraction of the pupils. Wakefulness and restlessness at night
and slight twitching of the facial muscles or of the limbs sometimes
occur. There may be no change in the condition of the patient for a
{708} considerable length of time (weeks or months), or he may improve
to some extent, owing to the absorption of the serous portion of the
effusion or to the tolerance of the foreign body acquired by the
brain. Sooner or later a fresh hemorrhage is followed by a recurrence,
and usually an aggravation, of all the symptoms. Sometimes the patient
becomes comatose, and dies speedily with apoplectic symptoms, but this
is not common at an early period. The extravasation of blood generally
takes place in small quantities at a time, without giving rise to
unconsciousness or paralysis. After a period of uncertain duration,
when the tumor has attained considerable dimensions a condition of
somnolence may take place, the patient sometimes sleeping twenty-four
hours or longer at a time. Distinct paralysis rarely occurs, though
hemiplegia is sometimes seen, and the paralysis has been observed on
the same side with the lesion. When symptoms of compression appear the
pupils become dilated. Toward the end of life the patient is usually
in a state of profound coma, the pulse is slow and irregular, and the
sphincters are relaxed.
[Footnote 5: _Op. cit._, p. 394.]
The distinctive features of internal pachymeningitis, therefore, so
far as they are at present known, are those which would depend upon a
primary cerebral irritation, followed by those of compression of the
brain—persistent, often severe, headache, with contracted pupils, and
occasionally motor and sensory disturbances; afterward, coma, dilated
pupils, and involuntary discharges from the bowels and bladder.
The DURATION of the disease is exceedingly variable, extending from a
few days to more than a year. According to a table made from carefully
observed cases by Huguenin, 74 per cent. of patients die within thirty
days; 18 per cent. live from one to six months; 4 per cent. live from
six months to one year; and 4 per cent. live over one year.
PATHOLOGY.—A difference of opinion has existed among pathologists
concerning the true nature of hemorrhagic effusions of the inner
surface of the dura mater, especially as to whether the membrane in
which they are enclosed is formed by a deposit of fibrin from the
effused blood itself, or whether the disease consists essentially in
an inflammation of the dura, followed by a pseudo-membranous deposit
into which blood is afterward extravasated. The latter explanation,
offered by Virchow, has been generally accepted, but Huguenin, whose
opportunities for observing the disease were unusually good, believes
that the first stage of hæmatoma is not the formation of connective
tissue, but simply an extravasation of blood.
The disease begins with hyperæmia of the dura mater in the area of
distribution of the middle meningeal artery, followed by the formation
upon its inner surface of an extremely delicate membrane in small
patches of a yellowish color and studded with innumerable bloody
points. If the membrane be carefully raised, it is found to be
connected with the dura by very delicate blood-vessels, and to contain
an immense number of very wide and thin-walled vessels, much larger
than ordinary capillaries.[6] At a later stage we find the membranes
to be made up of several distinct layers, of which the innermost
exhibits the character of the primary deposit, being thin and
abundantly supplied with blood-vessels, while those of older formation
have become successively thicker and are {709} composed of tough,
lustrous fibres of connective tissue almost as dense as that of the
dura mater itself. The delicate structure of the false membranes and
of the vessels which they contain leads almost inevitably to the
effusion of blood, which increases in quantity with the thickness of
the whole growth, so that in an advanced stage it is not uncommon to
find large pools of blood, partly clotted and partly fluid,
constituting what is called hæmatoma of the dura mater. The small
bloody points are within the substance of the false membrane; the
extravasations are interstitial, the largest being always found
between the youngest membrane and the older layers. In some cases
serous transudations also occur between the false membranes. In still
rarer instances no blood or serum is found between or beneath the
layers. Occasionally small quantities of blood escape by leakage
through the delicate membrane into the cavity of the arachnoid.
[Footnote 6: See Rindfleisch's _Manual of Pathological Histology_, New
Sydenham Soc.'s translation, 1873, vol. ii. p. 302.]
The usual situation of internal pachymeningitis is the vault of the
cranium, near the median line, the upper or external layer of the
tumor being in relation with the dura mater, to which it is adherent,
and the lower or internal with the arachnoid and pia mater. If the
effusion be extensive, it spreads downward over the frontal and
occipital lobes of the brain, and laterally toward the fissure of
Sylvius. In the majority of cases the disease occupies both sides of
the median line symmetrically, but it may be limited to one side only.
According to Huguenin, 56 per cent. of the cases embrace the surfaces
of both hemispheres; 44 per cent., that of one only. Hæmatoma very
rarely occupies the base of the cranium. The thickness and consistency
of the deposit vary in different cases, depending upon the number of
successive exudations, and hence are most marked in cases of the
longest duration.
Hemorrhagic pachymeningitis is occasionally met with in young
children, but much more rarely than in adults. The disease is usually
more acute than in older persons, but the anatomical appearances are
essentially the same.[7]
[Footnote 7: For an able description of the lesions of hemorrhagic
pachymeningitis in children see the third edition of Rilliet and
Barthez's _Maladies des Enfants_, by Barthez and Sanné, Paris, 1884,
vol. i. p. 152.]
PROGNOSIS.—The great majority of cases end fatally. A few instances of
recovery are reported in which the diagnosis seems justified by the
symptoms. Moreover, it is not very rare to find, on post-mortem
examination of those who have died of other diseases, evidence of the
former existence of hemorrhagic pachymeningitis. According to Steffen,
while the prognosis of simple pachymeningitis in children is
frequently good, owing to the favorable conditions for the exit of pus
through the open fontanels and sutures, in hemorrhagic pachymeningitis
recovery is rare.
DIAGNOSIS.—In a disease whose symptoms are so vague the diagnosis must
of necessity be difficult and often impossible. The chief elements for
the formation of the diagnosis are the slow and interrupted progress
of the affection, persistent headache, tendency to prolonged slumber,
and final coma; the absence of paralysis of the cranial nerves, of
vomiting, and of general convulsions; the age of the patient, the
coexistence of alcoholism, chronic insanity, or acute rheumatism, and
traumatism. The diseases for which hæmatoma would be most likely
mistaken are acute inflammation of the meninges, apoplexy from
cerebral hemorrhage, tumor in the substance of the brain, and
necrobiosis from thrombus or embolus. {710} The absence of symptoms
characteristic of these affections might lead to a probable diagnosis
by exclusion, but in many cases the existence of the disease cannot be
determined with certainty. In children it is most likely to be
confounded with tubercular meningitis, from which it may be
distinguished by the fact that it is most common under the age of two
years, the other being rare before that period, and that the
characteristic symptoms of tubercular meningitis (prodromic period,
vomiting, irregularity of pulse, etc.) are wanting. But the tubercular
disease in young infants may closely resemble hæmatoma, a profound
coma replacing all other symptoms. Here the existence of tuberculous
disease in the parents or other near relatives would point strongly to
tubercular meningitis, while the absence of such antecedents would
suggest hæmatoma.
TREATMENT.—If the disease be a complication of alcoholism, anæmia,
scurvy, rheumatism, etc., the treatment appropriate to those
affections should be employed, along with remedies addressed to the
local disease. For the early symptoms of irritation, perfect rest in
bed, cold to the head, bromide of potassium internally, sinapisms to
the back of the neck, together with simple and nutritious diet, are
the most efficient means. The bowels must be regulated, but purging is
not necessary. The abstraction of blood from the head by leeches to
the temples or behind the ears, or by cupping, is recommended by most
authorities, especially if there be much heat of the head. Mercury may
be tried, care being taken not to salivate the patient. It is obvious
that this treatment, in order to be of any avail, must be instituted
at the earliest stage of the disease. After the probable formation of
the hæmatoma an effort should be made to promote its absorption, which
sometimes actually takes place, as is proved by the autopsies of
patients who, having previously suffered from this affection, have
died from other causes. The iodide of potassium or the iodide of
sodium should be employed perseveringly for this purpose, in the dose
of from ten to thirty grains three times daily. The bromide should
also be continued if necessary. The acne which sometimes accompanies
the continued use of these remedies may be prevented or cured by the
use of three to five drops of the liquor potassæ arsenitis, given once
or twice daily after meals. Counter-irritation to the scalp by means
of stimulating liniments or croton oil, and small blisters to the
temples, are likely to do good. In alcoholic subjects the amount of
wine or spirit taken should be regulated by allowing enough to support
the strength, without too suddenly withdrawing the accustomed
stimulant. In the stage of coma the treatment must be purely
expectant. The state of the bladder must be regularly examined, and
the catheter employed when necessary. Liquid nourishment should be
carefully given as long as the patient is able to swallow.
Cerebral Meningeal Hemorrhage.
SYNONYM.—Meningeal apoplexy of the brain. Hemorrhage of or upon the
membranes of the brain is closely connected with intracerebral
hemorrhage. Both arise from similar causes, and the former may result
directly from the latter. It is for convenience of arrangement that
the two subjects are treated separately in this work.
{711} ETIOLOGY.—The causes of meningeal apoplexy are predisposing and
immediate. The most important predisposing cause consists in disease
of the cerebral vessels, especially the arteries, which favors the
formation of so-called miliary aneurisms, as demonstrated by Charcot
and Bouchard in the case of cerebral apoplexy. Disease of the vessels
in its turn arises from various conditions, among which alcoholism in
adults holds a prominent place from its tendency to favor a fatty
degeneration of the vascular walls. In subjects of purpura or
hæmophilia (the so-called bleeders), in whom, from an inherent
weakness of the capillary vessels or a deficiency of the fibrin of the
blood, or both combined, there is a tendency to extravasation of the
blood in various parts, hemorrhage into the arachnoid cavity may
occur.[8] A new-born child under my observation had bleeding at the
navel and ecchymoses in various parts of the body. Suddenly it became
comatose, and it died with signs of cerebral compression. There was no
autopsy, but it seems probable that hemorrhage into the cavity of the
arachnoid had taken place. A sister of the patient had also had
spontaneous hemorrhage from the navel and from other parts shortly
after birth, but recovered. Chronic general arthritis and gout also
probably predispose to the affection, as well as old age, which is
accompanied by atrophy of all the tissues. The disease is most
frequently met with in the two extremes of life; according to
Durand-Fardel,[9] in adults the largest number of cases occurs between
the ages of seventy and eighty years.
[Footnote 8: A case of this kind is cited in the article “Pathologie
des Méninges” in _Nouv. Dict. de Méd. et de Chirurg. pratiques_,
Paris, 1876, vol. xxii. p. 101.]
[Footnote 9: _Traité clinique et pratique des Maladies des
Vieillards_, par M. Durand-Fardel, Paris, 1854, p. 283.]
The exciting causes comprise injuries to the head, both with and
without fracture; strong muscular effort, as in lifting, straining at
stool or in labor; powerful action of the heart in cases of
hypertrophy. An interesting case is reported[10] by S. G. Webber of
Boston, in which the effusion was evidently caused by vomiting; a clot
of blood covered the greater part of the posterior two-thirds of the
right hemisphere. Sometimes meningeal hemorrhage may arise from the
bursting of an intracerebral apoplexy into the arachnoid cavity, as in
a remarkable case occurring in the practice of Morris Longstreth of
Philadelphia, of bilateral effusion.[11] Outside the dura,
corresponding with the left middle cerebral lobe, was a considerable
amount of blood connected with a fracture of the skull, and on the
right side a large quantity of blood in the cavity of the arachnoid,
originating in the middle lobe, which was torn up. The patient had
fallen in the street; he was stupid, there was no paralysis, active
delirium came on, followed by coma and death in twenty-four hours.
Here was cerebral apoplexy bursting into the cavity of the arachnoid
on the right side, and causing the fall, which was the occasion of the
fracture and hemorrhage on the left side.
[Footnote 10: _Boston Med. and Surg. Journal_, Jan. 17, 1884.]
[Footnote 11: _Ibid._, Dec. 28, 1882.]
In young children, especially in the new-born, meningeal hemorrhage
may follow difficult and instrumental labor, either from injury to the
skull or from delay in the establishment of respiration, as in breech
presentation, though it sometimes occurs in cases in which the labor
has been normal. In a case of breech presentation under my care in
1873 {712} the child, a female weighing nine pounds, did not cry or
breathe for some minutes after birth, although delivery had not been
much delayed. Soon afterward it was noticed that it did not move the
right arm, although it moved the hand and the fingers. In the course
of twenty-four hours, during which time it cried much more than usual,
it became comatose, and remained so until its death, three days after
birth. The whole surface was livid, and the child had two or three
short convulsions. At the autopsy a clot about the size of a grape was
found in the pia mater on the upper surface of the cerebellum, in the
immediate vicinity of the pons Varolii. The brain was so soft that the
amount of injury received by the cerebellum could not be exactly
ascertained, but it was probable that the clot extended into the
fourth ventricle.
Thrombus of the sinuses of the dura mater, and less frequently of the
cerebral arteries, is the origin, in a considerable number of cases,
of meningeal hemorrhage in children, in consequence of pressure upon
the delicate vessels of the membranes caused by the obstructed
circulation. Bouchut[12] reports an observation of hemorrhage produced
in this way.
[Footnote 12: E. Bouchut, _Clinique de l'Hôpital des Enfants
maladies_, Paris, 1884, p. 263. See, also, Steffen, _op. cit._, p.
352.]
SYMPTOMS.—In some cases the attack is preceded by indications of
congestion, such as headache, vertigo, staggering, confusion of ideas,
noises in the ears, feeling of weight in the head, delirium, stupor.
At the time of the attack the patient frequently complains of severe
pain in the head, just as in cerebral hemorrhage, and then falls to
the ground with complete loss of consciousness. Sometimes the symptoms
come on gradually. Hemiplegia occurs in a notable proportion of cases.
Convulsions may occur at any time after the attack. In Webber's case,
already referred to, the first symptom was sharp pain in the head and
neck; this was followed by very severe headache and pain on motion of
the head. Intelligence gradually diminished; on the sixth day there
was almost no consciousness, and the patient died in about eight days.
She had occasional spasms, in which both eyes were turned toward the
left in extreme conjugate deviation, and the left side of the face was
distorted. The spasms were followed by suspension of respiration for
nearly a minute, cyanosis, and paralysis of the left hand and leg.
Both the nature of the lesion and its seat were correctly
diagnosticated during the patient's lifetime.
As a rule, the condition of unconsciousness continues up to the time
of death, but in some cases there are intermissions during which the
patient responds to questions more or less promptly. Death takes place
at a period varying between a few hours and several days.
Durand-Fardel[13] reports a case in which the patient lived a month
from the first attack, with preservation of the intellect and of
motion. An inmate of the Home for Aged Women in Boston, eighty-eight
years old, previously in good health, complained of severe pain in the
head one morning before rising. She took her breakfast in bed, and
immediately afterward vomited copiously. From that moment she became
insensible, and remained so until her death, seven days and three
hours afterward. During this time there was no stertor. No decided
paralysis could be discovered, but there was some rigidity of the left
arm. At the autopsy an effusion of {713} blood was found in the
arachnoid cavity extending from below upward on each side to a level
with the top of the ear. There was a large amount of blood at the base
of the brain, and both lateral ventricles were distended with bloody
serum. The vessels were generally in an atheromatous condition. There
was no laceration of the brain. The source of the hemorrhage could not
be ascertained. In such a case the condition of the patient in respect
to power of movement often cannot be ascertained with certainty, in
consequence of the abolition of consciousness. Complete muscular
resolution is most common when the effusion is bilateral, but when the
hemorrhage is limited to one side more or less paralysis of the
opposite limbs may exist. Should the blood make its way into the
spinal canal, it might give rise to special symptoms, but this is not
probable in view of the large amount of the cerebral effusion under
the circumstances, which would produce complete insensibility or
speedily cause death by pressure on the medulla.
[Footnote 13: _Op. cit._, p. 202.]
The temperature of the body immediately after a copious cerebral or
meningeal hemorrhage falls below the normal point, and remains so for
several hours, after which it rises, its degree varying according to
circumstances. In fatal cases the elevation is extreme, and remains so
until death. If the patient recover, it gradually returns to the
normal standard.
Vomiting is a frequent symptom at the beginning of the attack, just as
in intracerebral hemorrhage, owing probably to compression of the
pneumogastric by the effusion at the base of the brain. In Webber's
case the vomiting was evidently the cause of the hemorrhage, and not
its consequence, since it had been a frequent symptom for several days
before the attack, and was probably due to the presence of a calculus
in the pelvis of the right kidney, which was found at the autopsy, and
there was no blood at the base of the brain.