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.
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.
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.
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 reported10 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.
10 Boston Med. and Surg. Journal, Jan. 17, 1884.
11 Ibid., Dec. 28, 1882.