Symptoms.
—When the disease is limited to the vertex and follows several days after injury it usually begins with chills and malaise, with increasing temperature; after which the symptoms assume the pyemic type, distinguished from true pyemia by their comparatively early onset. The pulse becomes frequent, first full and then small; patients are disturbed, restless, or uncontrollable, and complain of headache, moan, grate the teeth, become delirious, with glistening eyes and congested face. After a while delirium subsides into stupor and restlessness into insensibility. The pupils contract and remain inactive to light. Paralyses and cramps are not infrequent. Traumatic basilar leptomeningitis occurs often with fracture of the base. Signs and symptoms are less distinctive here; paralyses occur more easily and are less distinctive, save those which involve the special cranial nerves. When ptosis occurs with dilatation of the pupils and glossopharyngeal paralysis we should be quick to suspect extension of the process along the brain. Cramp or stiffness of cervical muscles mean the same thing, and are signs of grave import which may be considered pathognomonic. Albuminuria is frequent, with marked increase of phosphates in the urine.
In the non-traumatic cases the symptoms of leptomeningitis are those of increasing brain pressure and temperature. The disease usually commences with headache followed by vertigo, hyperesthesia, restlessness, delirium, insomnia followed by somnolence, muscle spasm, paralyses, coma, and death. If the disease extends from the middle ear there is frequently facial paralysis before the meningeal symptoms appear.
The type of fever is one of gradual increase, though before death temperature often falls even below the normal. Pathognomonic fever should not be mistaken for the elevation of temperature which often accompanies absorption of intracranial hemorrhages. In these latter cases temperature may mount to 39° C., but if rising higher than this meningeal complications should be suspected.
Diagnosis.
—The diagnosis as between sinus phlebitis and leptomeningitis depends principally upon the existence of pyemic symptoms. When the latter are entirely wanting we may at least say that the predominating symptoms of sinus phlebitis are absent.
Prognosis.
—The prognosis is unsatisfactory. Many cases end in forty-eight hours; others may live for two weeks or more.
Treatment.
—Treatment seems almost futile, though one should endeavor by energetic purgation, venesection, etc., to do what he can. The only prospect or hope comes from the possibility of relieving the compression from effusion of purulent fluid, and of irrigating and draining what is now an enlarged abscess cavity. Since we do not hesitate to open and wash out other serous cavities when thus affected—e. g., peritoneum, pericardium, joints, pleura—we should no longer hesitate to open the dura and wash out the subdural space, even though this necessitate more than one trephine opening. The measure was suggested by S. W. Gross, in 1873, when he reported cases thus treated with success, and has since been practised by other surgeons, among them by Souchon, who has advised multiple puncture with the small drill and irrigation and disinfection through numerous small openings. Of 11 cases collected by Gross more than twenty-five years ago, 45 per cent. recovered.