such as occurs in mastoid or middle ear disease, in chronic nasal inflamma-
tions and syphilis of the cranial bones. It may also follow fractures of the
skull and erysipelas.
Symptoms. These are often obscure; there is usually headache, abnor-
mally high temperature, delirium, convulsions, and the symptoms of increased
intracranial pressure due to the inflammatory exudate. This is usually
purulent and is occasionally of sufiicient amount to cause paralyses; in severe
cases the infection may extend to the pia mater.
Treatment consists in the proper management of the causative factor and
the relief of the pressure by means of operation.
Synonyms. Pachymeningitis Haemorrhagica; Haematoma of the Dura
Definition. An inflammation of the inner surface of the dura characterized
712 DISEASES OF THE NERVOUS SYSTEM,
by the production of new tissue which is rich in blood-vessels, the walls of
which easily rupture with resulting haemorrhage.
jS)tiology. The disease is rare; it is seen more usually in males of middle
age or over but occurs occasionally in children. The chief cause seems to
be chronic alcoholism; it has also been observed in insanity, general paralysis,
after the acute infectious diseases, in tuberculosis and syphilis and associated
in mild form with chronic cardiac, pulmonary or renal conditions.
Pathology. The inflammation usually begins somewhere in the distribution
of the middle meningeal artery as a congestion and extends from this point;
layers of false membrane are formed which is thickly reticulated with dilated
and tortuous blood-vessels, the walls of which are frequently subject to rupture
with consequent haemorrhage varying from mere traces of blood to extrava-
sations of considerable size. The amount of blood seen on necropsy may be
greatly in excess of that of the new-formed tissue, or the opposite condition
may obtain; both the new tissue and the extravasated blood may degenerate;
in the former the blood-vessels are obliterated and the blood itself becomes de-
colorized and at times is partly absorbed. Suppuration is a rare complication.
Symptoms. In many cases these are obscured by the co-existent insanity
or mental abnormality. There may be headache, vomiting, muscular weak-
ness and signs of cerebral compression evidenced by convulsions, nystagmus,
stupor, coma, optic neuritis, partial paralyses. Seizures resembling apoplexy
may occur with the incidence of fresh hasmorrhagic extravasations.
The prognosis is unfavorable in the extreme.
Treatment consists in combating the symptoms as they arise, keeping the
patient quiet in a darkened room, elevating the head and the application of
the ice helmet.
Suppurative and pseudo-membranous inflammations of the internal surface
of the dura resulting from injury, from extensions of adjacent inflammatory
conditions and as complications of the infectious diseases are seen but their
symptoms are so obscure as to prevent their recognition during life.
Definition. An inflammation of the pia mater and the arachnoid mem-
brane characterized by an exudation between these two structures.
.Etiology. The disease is most often seen in young children and as a com-
plication of the acute infectious diseases, pneumonia, influenza, smallpox,
measles, scarlatina, enteric fever, and septic conditions. The exciting cause
is a pathogenic micro-organism of almost any variety which obtains entrance
to the skull by means of the blood current, as a result of diseases of the cranial
bones â€” for instance petrous necrosis following otitis â€” through the cribriform
plate or any other opening in the skull.
Pathology. The condition may be localized or diffuse and affects the
basilar portion of the brain more often than the convexity; it may spread to
the ventricles. The membranes are first swollen and hyperasmic, then cloudy
in appearance and finally become infiltrated with sero-piu:ulent or purulent
fluid. The process may spread to the dura mater or the cerebrum itself.
Symptoms. The prodromata of this condition are headache, general
malaise, dizziness, nausea and vomiting; after a few days signs of irritation
appear, such as a continuance of the headache and projectile vomiting, con-
vulsions, an irregular temperatiire, ioiÂ°-to3Â° F. (38.5Â°-39.5Â° C), photophobia,
unequal and contracted pupils, hypersesthesia of the skin, retraction of the
abdomen and stiffness of the neck; there may be low muttering delirium or
alternating delirium and stupor. The pulse is usually irregular and weak,
its rate may be slow (60-70); the respiration is accelerated and irregular; the
bowels are constipated; as the disease progresses the symptoms become more
marked, there may be general rigidity and optic neiuritis. As the stage of
paralysis sets in the pupils become dilated, there may be facial paralysis,
ptosis or strabismus, the abdomen becomes still more "boat-shaped," coma
is present, the intestine and bladder are incontinent; death supervenes within
a few days as a rule.
Basilar meningitis is characterized by paralyses of the cranial nerves, optic
neuritis and rigidity of the neck, while if the inflammation is confined to the
convexity, the delirium, convulsions and paralyses are more marked.
The diagnosis. The employment of lumbar puncture has proved a great
aid in the diagnosis of this condition. The character of the fluid withdrawn by
this means in inflammations due to other causes than tuberculosis, is purulent,
although pus in the latter case may sometimes be withdrawn. The only
pathological condition in which the fluid remains clear is tuberculosis; the
existence of disintegrated blood is evidence in favor of pachymeningitis or
trauma, while fresh blood appears as a result of the passage of the needle
through the tissues of the back. Cytological and bacteriological examination
of the fluid throws further light upon the cause of the process. The fluid
may be strained after centrifuging or cultures may be made. The finding of
the bacillus tuberculosis settles the diagnosis, but failure to isolate does not
disprove the possibility of this organism as the causative factor.
Other micro-organisms, such as the pneumococcus, staphylococcus, strep-
tococcus, etc., may be found. A differential estimation of the leucocytes con-
tained in the fluid is useful; the mononuclear lymphocytes are usually rela-
tively increased in tuberculous conditions while in inflammations due to other
causes there is likely to be a preponderance of the polymorphonuclear leuco-
cytes. Normal cerebrospinal fluid contains a small amount of sugar while
inflammatory exudates are free from this substance.
The prognosis. The disease lasts from a few days in very acute cases to
714 DISEASES OF THE NERVOUS SYSTEM.
several weeks in those of slower course. The prognosis is grave at best but
not necessarily fatal.
Treatment. Prophylaxis consists in the antiseptic treatment of cranial
injuries and early operation with proper after-treatment of otitic con-
ditions. Rest in a darkened room should be insisted upon and an ice
helmet applied. The bowels should be kept open by means of calomel.
For the pain the coal tar analgesics, acetanilide gr. v (0.33), acetphenetidine
gr. X (o.66)^r antipyrine salicylate (salipyrine) gr. x (0.66) may be given, but
in severe types opium may be necessary. The use of iodoform internally
and externally has been recommended; 6 to 10 grains (0.4-0.66) per day
may be given or an ointment of 20 percent, strength may be rubbed into the
shaven scalp; potassium iodide in doses of 10 grains (0.66) three times a day
should be given and hot applications â€” poultices or wet compresses â€” to the
upper spine, and leeches to the temples and neck are useful. The inunction
of mercurial ointment to the limit of tolerance in non-tuberculous cases has
The delirium and other symptoms of nervous hyperaesthesia may be con-
trolled by the bromides and chloral, and most excellent results have followed
the relief of the intracranial pressure by means of lumbar puncture; rarely a
single pxmcture with the withdrawal of from 8 to 10 drachms (30.0-37.50)
of the fluid will result in recovery. If necessary the procedure should be
repeated at daily or at longer intervals; the amount withdrawn at a single
puncture should not be larger than that above specified.
The diet should be of milk, other like fluids and broths.
Synonym. Acute Hydrocephalus.
Definition. An acute inflammation of the meninges due to infection by
the bacillus tuberculosis.
.Etiology. This disease occurs chiefly in children from two to ten years-
old; it is sometimes seen in young infants but rarely in adults. Its predis-
posing causes are the tuberculous diathesis, poor hygienic conditions of life
and the presence of tuberculous processes in other parts of the body. It
may follow an attack of any infectious disease, especially measles, and milk
from tuberculous cows may be an exciting cause.
Pathology. In cases of very acute course the brain is the seat of marked
congestion and there are miliary tubercles scattered over the pia mater of
both the base and the convexity. In other cases the tubercles are also found
at the base and the convexity, in the ventricles, the choroid plexus and often
in the spinal meninges; they are most abundant in the neighborhood of the
smaller blood-vessels, and larger tuberculous deposits in which bacilli are
CHRONIC HYDROCEPHALUS, 715
found, may occur as a result of the coalescence of a number of tubercles.
There may be areas of softening due to the obliteration of the vessels by the
products of the inflammation. There may be deposits of fibrin, the arachnoid
fluid is usually increased and this may also be true of that in the ventricles,
which at times may become so abundant as to compress the cerebral substance.
Symptoms. Those of the prodromal period are headache, irritability,
dizziness, prostration, anorexia, projectile vomiting without nausea, and
constipation; rarely do paralyses of the facial muscles appear in the prodromal
stage. These symptoms may exist for several weeks before the appearance
of the true stage of irritation; this is characterized by an accentuation of the
symptoms already present, the tache cerebrale, inequalities of the pupils,
photophobia, convulsions, delirium, paralyses, etc., as already described in the
section on leptomeningitis. Succeeding this appears the comatose stage, with
the accompanying evidences of cerebral compression.
The diagnosis. Lumbar puncture is a great aid in diagnosis; tuberculous
exudates usually do not contain an excess of polymorphonuclear leucocytes,
sugar is likely to be present, while in other forms of meningitis its absence is
the rxfle, and the albumin content of the fluid is less reduced in the tuberculous
exudate than in those due to other infections. The presence of the tubercle
bacillus assures the diagnosis, but its absence does not by any means rule out
tuberculous infection as a causative factor.
The prognosis is distinctly bad, death usually supervening in three or foiu*
Treatment consists in the employment of the measures suggested under
the treatment of leptomeningitis (p. 714).
Definition. A condition characterized by gradual enlargement of the
head due to the accumulation of serous fluid in the ventricles of the brain.
.etiology. The disease occurs in a large majority of cases in early infancy,
often being congenital. Predisposing causes are poor bodily condition,
unhealthful surroundings, rhachitis and parental alcoholism, plumbism or
Pathology. The serous exudation which characterizes this disease is the
result of congenital or inflammatory obstruction of the aqueduct of Sylvius or
of the foramen of Magendie and the lateral foramina. As a consequence of
this the ventricular fluid is retained and, continually increasing, causes disten-
tion and pressure. The lateral ventricles, one or both, are the most frequent
seats of this distention which may be so extreme as to compress the cerebral
cortex to the thinness of half an inch or less. More rarely does the disten-
tion affect only the fourth ventricle.
7l6 DISEASES OF THE NERVOUS SYSTEM.
Symptoms. In congenital cases the size of the head may be so great as to
necessitate instrumental delivery or even craniotomy. When the disease
appears after birth the size of the head gradually increases, the frontal and
occipital regions bulge, the fontanelles and sutures bulge and spread and the
presence of fluid may be detected by palpation. The facies does not increase
in size correspondingly; as the condition becomes more marked, mental symp-
toms appear; the child is easily irritated; both mental and physical growth
are delayed^ In the severe cases the child may not learn to walk or talk, the
intracranial pressure results in optic atrophy or strabismus, there are vomiting
and convulsions; coma may supervene and death from asthenia or inter-
current disease results, although this event may not take place for several
years. In cases of less severity the progress of the condition ceases, the
cranial bones unite and become hard and firm and the mental and physical
processes become normal.
Chronic hydrocephalus occurring later in life is evidenced by vague symp-
toms of compression and is difi&cult of recognition.
Treatment is unsatisfactory; the symptoms should be met as they arise and,
upon the possibility of s^-philis being the causative factor, inunctions of mer-
cury and the internal administration of potassium iodide should be prescribed.
Surgical and other measures are of little value. Lumbar puncture will relieve
the pressure temporarily but the fluid returns.
Definition. Apoplexy is the term applied to the train of symptoms which
follows the rupture of an intracranial blood-vessel or that which results upon
embolism or thrombosis of these structures.
-Etiology. Cerebral haemorrhage is seen rather more frequently in males
than in females and is most common in individuals beyond middle life. This
is the case merely because arterial degeneration affects men more often and
occurs chiefly in those over 40. The kidneys are diseased in a large number
of cases and as predisposing causes syphilis, alcoholism and gout play an
important role. An arter}' weakened by injury or chronic inflammation may
at any time rupture as a result of increased blood pressure, which condition
may be due to emotional or sexual excitement, straining at stool, an undue
physical effort, alcoholic excess, over-eating, etc.
Pathology. The morbid anatomy of cerebral haemorrhage before actual
rupture takes place is that of arteriosclerosis (p. 593); there are roughening
of the intima, fatty degeneration of the muscular coat and fibrous changes
in the externa. Miliary aneurysms are found upon the smaller arteries as a
resiilt of the degeneration of the artery wall; atheromatous changes affect the
larger arteries. The vessel which most frequently ruptures is the lenticular
striate branch of the middle cerebral artery, consequently cerebral haemorrhage
is most usually seen in or near the caudate and lenticular nuclei. The branches
of the anterior cerebral artery rupture less often and those of the posterior
cerebral, rarely. The reason for the election of the middle cerebral is that
this vessel seems more prone to degenerative changes than the others and that
it is in more direct communication with the heart ; consequently it receives the
blood under greater pressure than do the other vessels mentioned. Large
haemorrhages and those under high pressiire may burst through into the ventri-
cles and reaching the fourth ventricle, result in death from pressure upon the
centers there situated. The fourth ventricle is especially likely to be affected
in cerebellar haemorrhage. After extravasation the blood first coagulates;
the clot then softens and absorption begins; in about a week a wall of fibrin
is formed about the clot which becomes encysted within its fibrinous wall,
contraction of the cyst wall finally taking place.
Symptoms. Prodromal symptoms such as a feeling of fulness in the head,
dizziness, numbness and tingling of an extremity, ringing in the ears, irregular
heart action, etc., may occur; the usual onset of a "stroke"' is evidenced by
sudden loss of consciousness; if standing, the patient falls; more rarely is an
attack ushered in by convulsions and a seizure may take place without coma.
After the typical onset the patient is seen in an absolutely comatose state,
his, face is flushed, cyanotic or pale, the pulse is of high tension and usually
slow, the respiration is slow and stertorous; it may be irregular and expiration
is accompanied by an inflation of one cheek. The pupils may be contracted,
dilated or unequal but they usually do not respond to light. At the time of
the attack the temperature falls to a subnormal level â€” later it rises. *
Examination usually reveals a paralysis, most frequently a hemiplegia with
lack of sensation, the arm and leg if raised fall limply, rarely are they rigid;
the reflexes are lost or very greatly diminished; the tongue protrudes toward
the paralyzed side. After the return of consciousness when the right side is
affected there is inability to speak (aphasia â€” see p. 722). The bladder and
rectum may be incontinent or there may be retention of urine; examination
of the latter often shows the presence of albumin.
In the rapidly fatal cases there may be no return to consciousness, the
pulse becomes more rapid, the respiration may change to the Cheyne-Stokes
type, the temperature rises to io3Â°-io4Â° F. (39.5Â°-4o.Â°C.) and death supervenes;
just before death the temperature may fall. In fatal cases of slower course
the coma partially disappears, giving way to stupor or delirium, the tempera-
ture remains only slightly elevated, being higher upon the affected side; h}^o-
static pneumonia may develop, to be followed by death after a few weeks.
The cases which go on to the chronic stage gradually regain sensibility.
7l8 DISEASES OF THE NERVOUS SYSTEM.
the aphasia partially or wholly disappears and the paralysis slowly improves
to the extent that the affected limbs can be slightly moved and sensation is
partly regained; the mind may be permanently impaired.
The patient has now become a hemiplegic; the facial muscles are least
distin"bed, those of the arm most, those of the voice and of the chest are very
little affected; the knee and ankle jerks are exaggerated. Contractiires with
resulting deformity are developed; these involve the extensors of the foot
more than the flexors, while the opposite is the case in those of the upper limb.
There is n^ atrophy of the muscles and while their electrical reaction is dis-
turbed, the so-called reaction of degeneration does not result. Various motor
disorders may develop; tremors, choreic, athetoid, and ataxic movements, etc.
Complete anaesthesia is seldom seen but parsesthesiae are frequently observed.
Trophic and vasomotor disorders such as swelling of the extremities, sweating
and skin eruptions may occur. The nutrition usually continues good but
in patients who are confined to the bed, bed-sores are very prone to develop.
Progressive emaciation is rare.
The diagnosis of cerebral haemorrhage is often most difficult. A consider-
able number of conditions must be differentiated from it; among these are
Alcoholic coma. In this state the insensibility is less complete, the patient
may be aroused by the inhalation of ammonia or by pressure upon the supra-
orbital nerves; the pulse is rapid, the temperature is not subnormal, one cheek
is not inflated and drawn in with respiration, there are no signs of paralysis,
the pupils are equal and reactive and the odor of the breath is characteristic.
Opium poisoning. The onset of the coma is gradual, the pupils are con-
tracted and equal, the temperature is normal, the respiration slow, there is
no paralysis, the patient may be partially aroused and the examination of
the stomach contents is characteristic unless the drug has been taken hypo-
dermatically; in this case the needle puncture may be found. There is no
TJrczmic coma. Here we may have a history of antecedent convulsion,
there may be oedema and the waxy skin of the large white kidney, the pupils
are equal and the urine contains albumin and casts; the pulse is usually weak
and irregular and the respiration rapid. The evidences of pregnancy are a
strong point in favor of luraemia.
Epilepsy. The coma is preceded by the characteristic cry, there is a history
of previous attacks, there is frothing at the mouth; the tongue may be bitten,
the pupils are equal and dilated and there is no paralysis.
Cerebral embolism. This is more likely to occiu: in young individuals,
there often is evidence of valvular heart lesion ; the coma is slighter in character
and shorter in duration, the paralysis usually appears first and is followed
by the convulsion and the loss of consciousness. Seizures after child birth
CEREBRAL ELEMORRHAGE, 719
are more likely to be due to embolism. There is little disturbance of tempera-
ture, and the tense pulse and stertorous breathing are absent.
Cerebral thrombosis. Here we may have a history of light attacks from
which recovery is quick; the patient is usually aged and presents the signs of
atheroma; conviilsions, stertor and abnormal temperature are wanting. The
pupils are usually undistiirbed.
Treatment. The patient should be immediately placed in a horizontal
position, but with the head elevated. An ice bag should be applied to the
head and hot water bags to the feet. The lower limbs may be wrapped in
towels saturated with hot mustard water â€” a tablespoonful (15.0) of mustard
to 2 quarts (litres) of water. If the pvilse is of markedly high tension about
8 ounces (250.0) of blood should be drawn from one of the median basilic
veins. The bowels should be moved by an enema of warm water and a purge
administered; those preferable are croton oil, i or 2 drops (0.065-0.13)
mixed with a little olive oil and placed at the back of the tongue or elaterium,
gr. ^ to gr. \ (0.008-0.016) on account of their ease of administration and
rapid action. In moderate degrees of vascular tension, even after venesection,
aconite or veratrum viride â€” the tinctiures in doses of i drop (0.065) every
30 minutes â€” should be given until the tension becomes lower. Compression
or ligation of the carotid artery has been advocated with a view to lessening
the hemorrhage. The bladder should be watched and the urine drawn if
Following the treatment of the seizure, measures should be taken to preserve
the nutrition of the patient; rectal feeding may become necessary. Bed-sores
should be prevented by attention to the cleanliness of the bed, and of the patient's
skin. The buttocks and heels should be rubbed with alcohol and powdered
daily and the sheets should be kept as smooth as possible. The patient
should be frequently turned upon his sides both to guard against bed-sores and
against hypostatic pneumonia, additional points in the prophylaxis of which
are frequent thorough cleansing of the mouth with an antiseptic solution
and care lest particles of food be breathed into the lungs.
The treatment of the chronic stage consists in the internal administration
of sodium or potassium iodide, together with general tonics such as iron,
strychnine and quinine and attention to the action of the bowels and kidneys.
Arterial tension when it occurs should be relieved by means of glyceryl nitrate
gr. TiT~To (0.0006-0.0012) every four to six hours. Several weeks after the
attack the use of the faradic current upon the affected muscles should be begun
and continued at daily intervals, later static electricity is also beneficial.
Massage and exercises adapted to the patient's abilities are important and
warm baths are useful. The physical means above mentioned are effectual
both in the prevention of contractures and in the maintenance of musctilar
nutrition. The administration of small doses of strychnine â€” gr. y-j-jy to
720 DISEASES OF THE NERVOUS SYSTEM.
Y^ (0.0005-0.0006), of physostigmine salicylate gr. -rD"-o-to -^j^ (0.0006-0.001)
and of the bromides is said to be attended with good results when con-
tractures are present.
The mode of life should be regular and quiet, a temperate climate is pref-
erable and the diet should be simple.