_Reynolds's System of Medicine_, Philada., 1879, vol. i. p. 832.]
PROGNOSIS.—Although there are on record undoubted instances of
recovery from tubercular meningitis, yet their number is so small that
practically the prognosis is fatal. It is safe to say that in almost
all the reported cases of recovery the diagnosis was erroneous.[13]
Even should the patient survive the attack, he is usually left with
paralyzed limbs and impaired mental faculties, and dies not long
afterward from a recurrence of the disease or from tuberculosis of the
lungs or other organs.
[Footnote 13: Hahn, “Recherches sur la Méningite tuberculeuse et sur
le Traitement de cette Maladie” (_Arch. gén. de méd._, 4^e Série,
vols. xx. and xxi.), claims to have cured 7 cases, but of 5 of them
there is no evidence that they were examples of tubercular meningitis
at all. The subject of the curability of tubercular meningitis is ably
treated by Cadet de Gassicourt (_Traité clinique des Maladies de
l'Enfance_, vol. iii., Paris, 1884, p. 553 _et seq._). His conclusion
is that most of the alleged cures are cases of meningitis of limited
extent, arising from the presence of tubercular tumors, syphilitic
gummata, cerebral scleroses, and neoplasms of various kinds.]
TREATMENT.—In view of the fatality of the disease, and of its frequent
occurrence in childhood, the prophylactic treatment is of great
importance. Every effort should be made to protect children whose
parents or other near relatives are tuberculous or scrofulous, and who
are themselves delicate, puny, or affected with any constitutional
disorder, from tubercular meningitis, by placing them in the best
possible hygienic conditions. Pure air, suitable clothing, wholesome
and sufficient food, and plenty of out-of-door exercise are
indispensable. Sedentary amusements and occupations should be
sparingly allowed. Especial pains should be taken to prevent fatigue
by much study, and school-hours should be of short duration. The
hygiene of the school-room is of paramount importance, and if its
ventilation, temperature, and light are not satisfactory, the child
should not be permitted to enter it. The bed-chamber should be well
ventilated night and day. A sponge-bath, cold or tepid according to
the season or to the effect on the patient, should be given daily,
followed by friction with a towel. The bowels must be kept regular by
appropriate diet if possible, or by simple laxatives, such as magnesia
or rhubarb. For delicate, pale children some preparation of iron will
be useful. The choice must be left to the practitioner, but one of the
best in such cases is the tartrate of iron and potassium, of which
from two to six grains, according to the age, may be given three times
daily after meals. Cod-liver oil is invaluable for scrofulous patients
or where there is a lack of nutrition. A teaspoonful, given after
meals, is a sufficient dose, and it is usually taken without
difficulty by children, or if there be much repugnance to it some one
of the various emulsions may be tried in proportionate dose. Along
with this, iodide of iron will in many cases be found useful or as a
substitute for the oil when the latter cannot {736} be borne. It is
best given in the form of the officinal syrup, in the dose of from
five to twenty drops. Change of air is useful in stimulating the
nutritive functions, and a visit to the seashore or mountains during
warm weather will often be followed by general improvement.
Since it is not possible to arrest the disease when once begun, the
efforts of the physician must be directed toward relieving the
sufferings of the patient as far as possible. In the early period the
restlessness at night and inability to sleep will call for sedatives,
such as the bromide of sodium or of potassium, in the dose of ten or
fifteen grains at bedtime or oftener. This should be well diluted with
water, sweetened if necessary. The addition of five to twenty drops of
the tincture of hyoscyamus increases the effect. Sometimes chloral
hydrate, either alone or combined with the bromide when the latter
fails, will procure quiet sleep. From five to ten grains may be given
at a dose, according to the age. Compresses wet with spirit and water
or an ice-cap may be applied to the head if there be much pain in that
region, or it may be necessary to give opium in some of its forms by
the mouth, such as the tincture or fluid extract, in doses of from one
to five drops. Constipation is best overcome by means of calomel in
three- to five-grain doses, to which may be added, when necessary, an
equal amount of jalap powder, or an enema of soapsuds may be
administered. Active purging should be avoided. Liquid nourishment,
such as milk, gruel of oatmeal, farina, or barley, beef-tea, broths,
etc., must be given in moderate quantities at intervals of a few hours
so long as the patient is able to swallow. Occasional sponging of the
whole surface with warm or cool water, and scrupulous attention to
cleanliness after defecation, especially when control of the
sphincters is lost, will add to his comfort. He should occupy a large
and well-ventilated chamber, from which all persons whose presence is
not necessary for his care and comfort should be excluded. He should
be protected from noise and from bright light, and should lie on a bed
of moderate width for convenience of tending.
There is no specific treatment at present known which is likely to be
of any benefit in this disease, any more than in tuberculosis of other
organs than the brain. Common experience has shown that mercury, which
formerly had so high a reputation in the treatment of cerebral
diseases of early life, not only fails completely, but adds to the
sufferings of the patient when pushed to salivation. The iodide of
potassium is recommended by almost all writers, but, so far as I know,
there is no proof that it possesses any virtue in meningeal
tuberculosis. It has the high authority of Charles West,[14] however,
who thinks the remedy is more encouraging than any other, and who
mentions one instance in which recovery took place under its
employment. He recommends that two grains be given every four hours to
a child three years old, the bowels being kept free. Most authorities
recommend much higher doses, such as ten or fifteen grains, three or
four times daily.
[Footnote 14: _Op. cit._, p. 102.]
Counter-irritation to the head or back of the neck was formerly much
employed, but is now generally abandoned, as giving rise to much
discomfort without obvious beneficial effect. In the cases reported by
Hahn, already alluded to under the head of Prognosis, recovery is
attributed to the energetic application of tartar-emetic ointment to
the scalp, {737} producing extensive ulceration, which in one of them
lasted more than ten months before cicatrization took place. A careful
examination of the reports of these cases satisfies me that but two
out of the seven were really examples of tubercular meningitis. How
far the recovery in the successful cases is to be attributed to the
treatment is very doubtful. Small blisters applied to the vertex or
back of the neck are alluded to favorably by West, but he quotes no
observations in which they were followed by benefit.
Tubercular Meningitis in the Adult.
Tubercular meningitis may occur at any age, but after the period of
childhood it is most frequent between the ages of sixteen and thirty
years. About 75 per cent. of the patients are males, and 25 per cent.
females.[15] The disease does not differ essentially in its course and
symptoms from that in children. A family history of tuberculosis is
common, or the patient may be already suffering from phthisis,
scrofulous glands, cheesy deposits in various organs, caries of the
bone, syphilis, or other constitutional affections. According to
Seitz, in 93.5 per cent. out of 130 cases with autopsies chronic
inflammatory conditions or caseous deposits were found in various
organs of the body. Many cases are examples of acute tuberculosis in
which the brunt of the disease has fallen upon the brain rather than
the other organs.
[Footnote 15: Seitz, _op. cit._, p. 9.]
When cerebral symptoms supervene upon acute disease, such as typhoid
fever, pericarditis, acute rheumatism, pneumonia, the exanthemata,
etc., the diagnosis between tubercular and simple meningitis is
important, because the latter is not necessarily fatal, while the
former is almost never recovered from. If the patient were previously
healthy and presumably free from tubercular disease, the chances would
be in favor of the simple form. A rapid course of the disease would
also speak for acute meningitis, and recovery would almost certainly
preclude tubercular meningitis. In some cases the diagnosis is
difficult or impossible in the beginning.
In cases beginning without acute antecedents—in adults as in
children—there is no pathognomonic symptom, but the combination and
succession of the phenomena are usually sufficient for the diagnosis.
Headache, depression or irritability of temper, delirium, half-closed
eyes, ptosis of one lid, squinting, inequality and sluggishness of the
pupils, moderate fever, sunken belly, vomiting, constipation, slow and
irregular pulse, sopor gradually deepening to coma, with occasional
convulsions or paralysis of the limbs, followed in the course of two
or three weeks by death, especially if occurring in a patient who has
already presented signs of tuberculosis in other organs, point almost
unmistakably to tubercular meningitis. Some of the symptoms may not be
strongly pronounced, one or two may be absent, but the general picture
will suggest no other disease. According to Seitz, tubercle of the
choroid is rare in tubercular meningitis of the adult. It is usually
associated with tuberculosis of other organs, the pia being free. The
subjoined cases are illustrations of the disease in adolescence and
adult life:
Case I.—A lad sixteen years old, always somewhat delicate, with a
{738} cough and morning expectoration of some months' standing,
exerted himself immoderately in gymnastic exercise on the afternoon of
Sept. 24, 1875. That night he was awakened by cough and hæmoptysis.
Signs of consolidation were found at the apices of both lungs. In
three months there were swelling, induration, and suppuration of one
testicle. Some months later, pain in the right arm, stiffness of the
shoulder-joint, and an abscess communicating with the joint, from
which small spicula of bone were discharged. He was about, and even
attended school, for more than a year from the time of the attack of
hæmoptysis. About Jan. 1, 1877, he began to complain of severe pain in
the forehead, with nausea (but no vomiting) and constipation. Jan.
27th he took to his bed, complaining chiefly of pain in the forehead
and eyes. Feb. 1st he was drowsy, irritable, and delirious. Feb. 3d
incontinence of urine and constant delirium. Up to this time the pulse
had not been above 76 in the minute, and on this day it was 64. The
next day, Feb. 4th, he was wholly unconscious; pulse 96, pupils
dilated. Feb. 5th, left hand in constant motion; pulse 112. From this
time the pulse steadily increased in frequency. Feb. 6th he swallowed
food, notwithstanding his stupor. Feb. 7th he answered questions;
there was oscillation of the eyeballs, and epistaxis from constant
picking of the nose. He died Feb. 9th, the pulse being 144 and the
respirations 60 in the minute for several hours previous. The
temperature never rose above 101.7° F. There was never any vomiting.
The duration of the case was thirteen days, in addition to the
prodromic period of twenty-seven days.—Autopsy by R. H. Fitz: The pia
of the base of the brain from the medulla to the optic thalamus
contained a large number of gray miliary tubercles, old and recent,
and the same condition was found in the surfaces of the fissure of
Sylvius. Ventricles distended with fluid, ependyma thick and
translucent. A moderate-sized cavity in the apex of the left lung,
with cheesy contents. Both lungs contained an abundance of hard, gray,
miliary tubercles. Left kidney contained a wedge-shaped, cheesy mass
of the size of a walnut, with numerous tubercles. Left testicle
contained a cheesy mass of the size of a walnut; both epididymes were
cheesy. The mucous membrane of the bladder contained tubercles near
the neck. The vesiculæ seminales contained softened cheesy masses with
openings into the urethra. There was a fistulous opening into the
right shoulder-joint.
Case II.—Emeline K. L——, 32 years old, single, nurse, had become much
exhausted by taking care of a difficult case, and entered
Massachusetts General Hospital March 6, 1883, complaining since four
days of a little cough, slight expectoration, and chilliness, but no
rigor. She seemed hysterical. There was complaint of severe pain in
the head, chest, and abdomen. A slight systolic murmur was found at
the apex of the heart, and a few moist râles at the base of the chest
on both sides behind. The urine was normal. Temperature, 103° F. Three
weeks after entrance she began to be delirious, especially at night.
April 13th, five weeks and three days after entrance, she was
semi-conscious, but would put out her tongue and open her eyes when
requested to do so; the abdomen was distended, the pupils were dilated
and unequal; there was twitching of the muscles of the right side of
the face. Careful examination only disclosed occasional fine râle at
the base of right chest. {739} She died April 16th, having been
completely unconscious for twenty-four hours. There was no vomiting
throughout the case. The temperature was very irregular, ranging
between 100° and 103° F., and once as high as 104° F.; it was usually
one or two degrees higher at night than in the morning. Pulse,
generally from 100 to 110; it rose steadily during the last few days
to 160 at the time of death.—Autopsy: Pia mater of brain œdematous,
slightly opaque; its lower surface, especially at the base of the
brain, showed numerous minute gray tubercles; enlarged cheesy glands
at the base of the neck; small, opaque, gray tubercles scattered
rather sparsely throughout both lungs. There was also miliary
tuberculosis of the liver, spleen, and kidneys.
{740}
CHRONIC HYDROCEPHALUS.
BY FRANCIS MINOT, M.D.
SYNONYMS.—Dropsy of the brain, Dropsy of the head.
DEFINITION.—A gradual accumulation of serous fluid in the brain,
occupying either the ventricles or the cavity of the arachnoid, or
both, occurring chiefly in infants or very young children.
The term hydrocephalus, which was applied by the older writers to
accumulations of serous fluid both within and also without the
cranium, termed distinctively internal and external hydrocephalus, is
now restricted to dropsical effusions either between the meninges or
within the ventricular cavities. These may be acute or chronic, and
they arise from the same conditions which are followed by the effusion
of serum in other parts of the body; that is to say, from an
alteration in the serous membrane lining a cavity, from an obstruction
in the capillary circulation with increased tension in the larger
vessels, from an altered condition of the blood, etc.
Chronic hydrocephalus is almost entirely confined to young children,
and is probably due to an arrested development of the brain, as shown
by its being usually congenital, by the dwarfed intellectual condition
of the patient, and by its frequent association with spina bifida. The
pathogeny of the disease is, however, still obscure. Whether the
abnormal accumulation of serous fluid is to be ascribed to a chronic
alteration of the ventricular walls or of the choroid plexuses, allied
to inflammation, such as occurs in the pleura, for example, causing an
increased secretion, or to a closure of the communication between the
ventricles and the spinal cavity, as suggested by the late John
Hilton, resulting in dropsy by retention, or to some other cause, is
not yet determined. Hilton says:[1] “In almost every case of internal
hydrocephalus which I have examined after death I found that this
cerebro-spinal opening [between the fourth ventricle and the spinal
canal] was so completely closed that no cerebro-spinal fluid could
escape from the interior of the brain; and, as the fluid was being
constantly secreted, it necessarily accumulated there, and the
occlusion formed, to my mind, the essential pathological element of
internal hydrocephalus.” Sieveking, commenting upon Hilton's theory,
says:[2] “While giving these facts due weight, it must be pointed out
that we are yet far from understanding either how the fluid is poured
into the cerebral cavities or how it is removed, and that we do not
positively know that the spinal canal has any better means of getting
rid of an excess of {741} fluid than the cerebral cavities have.” An
arrest of the growth of the brain is supposed by some pathologists to
account for ventricular as well as arachnoidal dropsy by the creation
of a vacuum in the cavity of the cranium, which is filled by exudation
of the more fluid portion of the blood from the vessels or of lymph
from the lymphatics.
[Footnote 1: John Hilton, _Lectures on Rest and Pain, etc._, 2d ed.,
New York, 1879, p. 22.]
[Footnote 2: Jones and Sieveking's _Pathological Anatomy_, 2d ed.,
London, 1875, p. 248.]
ETIOLOGY.—That chronic hydrocephalus in young children is in a large
proportion of cases an hereditary disease is shown by the fact that it
is frequently congenital, that more than one child in a family is
occasionally affected by it, and that while one child is hydrocephalic
others may be idiotic. A scrofulous taint in the family history is
noticeable in many cases, the evil effect of which is frequently
enhanced by unfavorable sanitary conditions of life, especially by
residence in dark, damp, ill-ventilated, and badly-drained apartments
and by insufficient or unwholesome food. Hence the disease is more
frequently met with among the poor than in the well-to-do classes of
society. There is a difference of opinion as to whether it ever arises
in consequence of external violence, such as a blow on the head, or of
some strong impression, like fright or grief, acting on the mother of
the child during pregnancy. The probability is that such causes would
not be efficient except in cases where a predisposition to
hydrocephalus had already existed. West[3] mentions the case of a
healthy child five months old who fell out of the arms of her nurse,
and was taken with a fit the same day. She apparently recovered, but
when a year old had frequent returns of convulsions. At the age of
fifteen months the head began to enlarge, and it continued to increase
in size until she was three years old, when she was attacked by
measles, and died in a few days with convulsions and coma. The
symptoms, both bodily and mental, were typical of hydrocephalus, and
the diagnosis was fully confirmed by the autopsy.
[Footnote 3: _Op. cit._, p. 127.]
The causes of chronic hydrocephalus in older subjects and in adults
are, in addition to the above mentioned, chiefly mechanical. Any
lesion which hinders the exit of venous blood from the cranium may be
followed by dropsy of the arachnoid cavity or ventricles. The
principal ones are tumors of the brain or its membranes, the effusion
of lymph in the neighborhood of veins, thrombosis of the cerebral
sinuses, compression of numerous small vessels by tubercular
granulations, obstructions outside the cranium, including tumors of
the neck, aneurisms, obstructive disease of the heart, emphysema and
cirrhosis of the lungs, besides diseases giving rise to general
dropsy, as the different forms of nephritis, marasmus, the various
cachexiæ, etc.
SYMPTOMS.—When the disease is already somewhat advanced before birth,
the head is often abnormally large, the cranial bones are separated,
the fontanels are distended and fluctuating, and it occasionally
happens that delivery of the distended head can only be effected after
the fluid has been evacuated by puncture. Even when there is no
abnormal increase in the size of the head, indications of cerebral
disturbance are sometimes apparent from birth, such as strabismus or
convulsions recurring with more or less frequency, along with signs of
failure of the general health. In the course of some weeks, or, it may
be, months, the attention of the parents is attracted to the
prominence of the child's forehead, strongly contrasting with the
comparatively diminutive size of {742} the face. Soon an enlargement
of the fontanels is perceived, the sutures between the cranial bones
become broader, and the head assumes a globular shape from the
pressure of the contained fluid. The separation of the bones at the
vertex of the skull causes the os frontis to protrude forward, the
parietals backward and outward, and the occipital backward and
downward. The orbital plates of the frontal bone yield to the pressure
of the fluid behind them, and from a horizontal position tend to
assume a vertical one, protruding the eyeballs, which have a peculiar
downward direction. The sclerotica is visible above the iris, and the
latter is partially covered by the lower eyelid. The enlargement of
the head is progressive, though not uniformly so, there being pauses
of weeks or months during which it is arrested. If it be considerable,
the cranial bones are usually thinned, so that the skull becomes
translucent when opposite a bright light. When there is a wide
separation of the bones there is an unusual development of ossa
triquetra in the sutures.
In cases in which the ossification of the cranium is considerably
advanced before the beginning of the disease, the enlargement of the
head is apt to be correspondingly less. If all the sutures are
consolidated, there may be no increase in size, and this is especially
true of the mechanical dropsy of adult life. The dropsical effusion,
which is then moderate in amount, finds room through compression of
the brain-substance, and part of it escapes into the spinal canal.
The size of the hydrocephalic head varies considerably. Where there
has been an early arrest of the disease it may be but slightly above
the normal. On the other hand, the dimensions are sometimes enormous.
In the Warren Museum of Harvard University is a cranium which measures
27½ inches in its greatest circumference, and 20½ inches from one
auditory foramen to the other over the top of the head. Its internal
capacity is 257 cubic inches. The patient, who died at the age of
three years, was never able to sit up and support the head, or even to
turn it from the left side, on which she continually lay; she never
spoke, and seemed to have no intelligence. The skull of the celebrated
James Cardinal measured 32¼ inches in its largest circumference.[4]
Even more remarkable instances are on record. The dimensions of the
fontanels, particularly the anterior, usually correspond with those of
the skull in general. During any strong muscular effort on the part of
the patient the membrane covering them is seen to be bulged out by
pressure from the fluid beneath. The enlargement is not always
uniform; it may be in part or wholly confined to one side, owing to
consolidation of the sutures of the opposite side, or because only one
of the lateral ventricles is affected. The scalp is traversed by
numerous distended veins. The hair is very scanty. The head has a
soft, fluctuating feel, and the walls sometimes seem to crackle
beneath the fingers, like parchment.
[Footnote 4: _Reports of Medical Cases, etc._, by Richard Bright,
M.D., London, 1831, vol. i. p. 431.]