CHAPTER XIX. ON HÆMORRHAGE OF THE MENINGES, OR MENINGEAL The term meningeal apoplexy is applied to the effusion of blood which is formed on either surface of the membranes which envelop the brain. This disease is more common amongst children than in adults and the aged. It is especially observed amongst infants, and more rarely during the first years of life; this appears at least the result of the interesting researches of Dugés, of M. Cruveilhier, and of my colleague M. Legendre. CAUSES. It Meningeal apoplexy often follows birth and the state of apparent death. It often manifests itself without an appreciable cause. sometimes appears after a violent cerebral congestion, occasioned by Sen an attack of anger, by exposure to the sun, &c. It is met with as Coucal's Amongst children, infancy appears often in summer as in winter. to be a predisposition to its development. Thus nearly all the examples of this disease have been collected amongst children just born or from one to three years old. None of the patients cited by M. Legendre had exceeded this period of their existence. ANATOMICAL LESIONS. Meningeal hæmorrhage takes place almost invariably in the large cavity of the arachnoid; very seldom external to this serous membrane, whether on the side of the pia mater, or on the side of the dura Y JA mater, except in cases of fracture of the cranium. It is observed in the arachnoid which covers the ventricles; but its usual position is on the surface of the hemispheres. The hæmorrhage always covers the two hemispheres. There are few exceptions to this rule. The effused blood presents very different characters according to the period of the disease in which its condition is studied. At the commencement the blood is fluid, but towards the fourth or fifth day it coagulates, the serum gradually disappears, and there remain clots of greater or less thickness which contract adhesions with the parietal serous layer, and which ultimately undergo important transformations. These clots are quickly covered on both surfaces by a thin, smooth membrane of a new formation. The superior layer, contiguous to the dura mater, easily recognizable early in the disease, gradually becomes thinned, and contracts intimate adhesions with the serous membrane which lines this meningeal covering. The inferior layer soon assumes the characters of a serous membrane; on the edge of the clot it becomes lost in the parietal layer of arachnoid, so as to lead to the belief in the existence of extra-arachnoidean hæmorrhage. M. Baillarger has demonstrated, by anatomical research, the falsity of this supposition. He has shown that it was always possible to isolate the clot, and to exhibit the parietal serous layer situated above it. The clot, at first soft, becomes gradually firmer; it daily becomes diminished in size. The interior is formed of fibrine of a blackish colour, which by degrees loses its colouring matter, and becomes of a pale red. The serum, which it encloses, is slowly absorbed. It then gradually diminishes in size, and passes at length to the condition of a whitish fibrinous layer, which sometimes presents the characters of fibrous tissue. Wilsh In some Moreover, a real organization of the clots is found, which, after having lost a part of their volume, live at the expense of the tissues by means of vessels of a new formation developed in their interior. At the same time a considerable congestion of the pia mater and of the encephalon is also observed. The ventricles are slightly dilated, enclose a small quantity of serum, which is limpid or of a yellowish colour, but always transparent. In young children, the brain is not at all compressed by the effusion of blood. The bones of the cranium, not being united, separate and prevent the compression of the cerebral hemispheres. If the effusion was more frequently confined to a single hemisphere, the partial dilatation of the cranium might become an important sign in the diagnosis. It loses a great part of its value when it is known that the anatomical lesions usually exist on both sides of the brain. SYMPTOMS. The symptoms of meningeal hæmorrhage in children at the breast are very obscure, and may be entirely confounded with those of cur inflammation of the meninges or of the brain. These are the terms in which M. Legendre describes them: "After L-cuitu one or two vomitings, or even without precursory vomiting, the children were seized with fever and with some convulsive movements, ht the most usual seat being the globes of the eyes, which leave behind as a consequence a slight strabismus; the appetite was lost, and thirst considerable; the evacuations were natural, or readily inouine produced. Soon a permanent contraction of the feet and hands was observed, which was quickly followed by tonic or clonic convulsive attacks. During these convulsions, sensibility and consciousness were abolished, and the face, habitually injected, assumed a deeper tint. "In the interval of these attacks, drowsiness was present, which, though slight during the first days, augmented in proportion as the disease made progress; the fever continued during the whole course of the disease, and became stronger in proportion as the fatal term approached. Then the convulsions, separated at first by longer or shorter intervals, grew more and more frequent, and became almost continuous in the last moments." Death is often hastened by the appearance of intercurrent thoracic inflammations. If it were not for this complication, the disease might be cured, or pass into a chronic state. This is what has been observed in children attacked with arachnoidean hydrocephalus, who, several months before, had experienced all the symptoms of a meningeal hæmorrhage. If the child escapes the first attacks, and the disease terminates by the formation of a cyst filled with serum, the quantity of which increases every day, the symptoms of chronic hydrocephalus are observed. In conjunction with the nervous disorder, and the phenomena with which we are acquainted (See art. Hydrocephalus), the head assumes a peculiar form which is in relation with this variety of hydrocephalus. The deformity is not general. It takes place on one side or the other, according to the position of the cyst. By reflecting on the form of the head, and on the progress of the morbid phenomena, the nature of the disease may be determined. [The venous plexus surrounding the coverings of the spinal marrow is often congested, and in some cases suffers rupture, consequently permitting extravasations to ensue. These, as in the case of those within the cavity of the cranium, are not unfrequently causes of the child not breathing, although born with a pulsating heart. The spinal cord suffering pressure cannot impart its influence to the periphery at the moment of birth. The amount of extravasation varies considerably. In one instance Dr. Weber saw the dura mater of the cord, from the atlas to the sacrum, covered, both on its posterior and anterior surfaces, with a thick layer of semi-coagulated blood; but he has never seen extravasation between te the periosteum and the bones, as occurs in the cranium. The cellular tissue between the posterior surface of the dura mater and the inner face of the vertebra is often the seat of effusions and exudations; one of the most important, and almost without exception, fatal forms of which consist in the true croupous exudations of this locality formed during the course of previous meningitis spinalis. These are not to be confounded with an adipose layer, sometimes found on the dura mater of the spinal cord of well nourished children. The signification of the capillary injection of the dura mater itself is indicated by the accompaniments of such injection; on the one hand they demonstrate its congestive, on the other its inflammatory character. In the pia mater, injection of its vessels, with exudation into the sac of the arachnoid, are found. Frequently the arachnoid bursts, the fluid effused into its sac is discharged, and the spinal cord, throughout its whole length, swims as it were in water. Softening of the spinal marrow is not uncommon, but true sclerosis of it Dr. Weber has never seen. Cruveilhier records a case of hæmorrhage covering a considerable part of the convex surface of the brain and even occupying the spinal cord.-Anatomie Pathologique; liv. xv, pl. 1. Paralysis, which in the grown person is one of the most frequent results of the escape of blood from the cerebral vessels, is so rare in the child that it was observed by M. Legendre only in one out of nine cases (Researches Anatomo-Pathologiques sur quelques Maladies de l'Enfance. 8vo; Paris, 1846; p. 130) and by MM. Rilliet and Barthez (Traité des Maladies des Enfants; vol. ii) in one out of seventeen cases. This may doubtless be accounted for by the circumstance of the blood being almost always poured out into the cavity of the arachnoid, so that the pressure exerted by it on the brain is generally diffused over the surface of the organ, and is nowhere very considerable. West is of opinion that there seems reason for supposing that the hemorrhage is sometimes of a purely passive character, and dependent on an altered state of the blood. He relates two instances of this cachectic form of cerebral hæmorrhage. In the first, a boy of five weeks old, of healthy parents, and perfectly well for the first fortnight after birth; he then, without any evident cause, grew drowsy, frequently vomited, and became jaundiced. The abdomen was hard and large, and he cried when pressure was made on the right hypochondrium. A leech applied on the right side drew a good deal of blood, and the hæmorrhage was stopped with difficulty; the bowels, previously constipated, were acted on with small doses of calomel and castor oil, and in three days the child lost the yellow tinge of his skin, became cheerful, and appeared much better. On July 18th he was suddenly seized with hurried respiration and great depression, soon followed by violent convulsions, during which he screamed aloud. At the same time it was observed that his left hand had begun to swell and to put on a livid hue, and on the 20th the right hand also became cedematous. His whole surface grew quite sallow, and, on the day before he died, the œdema of the left hand had much increased, the colour had become considerably deeper, and there were small spots of extravasated blood over each knuckle. The right elbow was slightly livid, the right hand much swollen, but of its natural colour, and a small black spot had appeared under the skin, corresponding to the knot of the cap string. The fits recurred very frequently, the child in the intervals lying quite still; the pupils were contracted, and the condition seemed to be one of extreme exhaustion rather than of coma. On the 20th the power of deglutition was lost, and after several returns of less violent convulsions, the child died at nine a.m. on July 21st, about sixty hours after the occurrence of the first fit. The sinuses of the brain were full of fluid blood; a black coagulum, three or four lines thick, covered the whole posterior part of both hemispheres, extending from the posterior third of the parietal bones, occupying the whole concha of the occipital bone, and reaching along the base of the skull to the foramen magnum. A little blood was likewise effused about the anterior part of the base of the brain, though the quantity was very small in comparison with what was found at its posterior part. The substance of the brain was very pale, and all the organs of the body were anæmic, except the liver, which was gorged with fluid blood, while the heart was quite empty. The ductus arteriosus was closed, the foramen ovale admitted a probe with ease, the ductus venosus admitted one with difficulty. In the second instance the passive hæmorrhage took place into the arachnoid, in a child exhausted by long continued illness, all the effects of which were aggravated by poverty and want. From the age of two to that of five months the child had been subject to frequent attacks of hæmatemesis and purging of blood, and though his health afterwards improved, yet he never became strong, and his evacutions were almost always deficient in bile. After he was weaned he lost flesh and strength, in consequence of the coarse food given him, and at nearly three years old was puny and emaciated. Three days before his death an attack of diarrhoea came on, which induced great exhaustion, and while suffering from this affection he suddenly became comatose, cold and almost pulseless, and his breathing became so slow that he inspired only four or five times in a minute. In this state he lay twenty-four hours, and then died quietly. Nearly six ounces of dark coagulated blood were found in the sac of the arachnoid, over the right hemisphere of the brain; a little blood was likewise effused beneath the arachnoid, and there was a very small clot in the lower and front part of the right middle lobe of the brain, but no ruptured vessels could be perceived. Great anæmia of every organ, and a state of extreme attenuation of the walls of the heart, were the only other remarkable appearances.—Diseases of Infancy and Childhood; p. 42.—P.H.B.] PROGRESS-DURATION-TERMINATIONS. The invasion of the disease is sudden, and its duration is in relation with the quantity of blood effused. When the hæmorrhage is considerable, a speedy and fatal termination is the consequence. On the contrary, life is prolonged in the most favourable cases. The favourable termination of the disease is progressively effected to the entire disappearance of the clots, or to the formation of a cyst which may become the origin of an arachnoidean hydrocephalus. Meningeal hæmorrhage is not such a frequent disease that one can yet establish in a precise manner, by clinical observation, what its termination is to be. It is almost invariably fatal, or else it passes to the chronic state. There are, as yet, very few well authenticated examples of cure. All the patients, seven in number, which fell under the observation of M. Legendre, died, but many perished in consequence of acute diseases of the chest. Cure does not appear to me impossible, if the hæmorrhage is inconsiderable, and formed by a small portion of clot mixed with serum. DIAGNOSIS. This disease may be easily confounded, at its commencement, with another affection of the meninges-tubercular meningitis, for example. a |