In young children, especially in the new-born, meningeal hemorrhage may follow difficult and instrumental labor, either from injury to the skull or from delay in the establishment of respiration, as in breech presentation, though it sometimes occurs in cases in which the labor has been normal. In a case of breech presentation under my care in 1873 the child, a female weighing nine pounds, did not cry or breathe for some minutes after birth, although delivery had not been much delayed. Soon afterward it was noticed that it did not move the right arm, although it moved the hand and the fingers. In the course of twenty-four hours, during which time it cried much more than usual, it became comatose, and remained so until its death, three days after birth. The whole surface was livid, and the child had two or three short convulsions. At the autopsy a clot about the size of a grape was found in the pia mater on the upper surface of the cerebellum, in the immediate vicinity of the pons Varolii. The brain was so soft that the amount of injury received by the cerebellum could not be exactly ascertained, but it was probable that the clot extended into the fourth ventricle.
Thrombus of the sinuses of the dura mater, and less frequently of the cerebral arteries, is the origin, in a considerable number of cases, of meningeal hemorrhage in children, in consequence of pressure upon the delicate vessels of the membranes caused by the obstructed circulation. Bouchut12 reports an observation of hemorrhage produced in this way.
12 E. Bouchut, Clinique de l'Hôpital des Enfants maladies, Paris, 1884, p. 263. See, also, Steffen, op. cit., p. 352.
SYMPTOMS.—In some cases the attack is preceded by indications of congestion, such as headache, vertigo, staggering, confusion of ideas, noises in the ears, feeling of weight in the head, delirium, stupor. At the time of the attack the patient frequently complains of severe pain in the head, just as in cerebral hemorrhage, and then falls to the ground with complete loss of consciousness. Sometimes the symptoms come on gradually. Hemiplegia occurs in a notable proportion of cases. Convulsions may occur at any time after the attack. In Webber's case, already referred to, the first symptom was sharp pain in the head and neck; this was followed by very severe headache and pain on motion of the head. Intelligence gradually diminished; on the sixth day there was almost no consciousness, and the patient died in about eight days. She had occasional spasms, in which both eyes were turned toward the left in extreme conjugate deviation, and the left side of the face was distorted. The spasms were followed by suspension of respiration for nearly a minute, cyanosis, and paralysis of the left hand and leg. Both the nature of the lesion and its seat were correctly diagnosticated during the patient's lifetime.
As a rule, the condition of unconsciousness continues up to the time of death, but in some cases there are intermissions during which the patient responds to questions more or less promptly. Death takes place at a period varying between a few hours and several days. Durand-Fardel13 reports a case in which the patient lived a month from the first attack, with preservation of the intellect and of motion. An inmate of the Home for Aged Women in Boston, eighty-eight years old, previously in good health, complained of severe pain in the head one morning before rising. She took her breakfast in bed, and immediately afterward vomited copiously. From that moment she became insensible, and remained so until her death, seven days and three hours afterward. During this time there was no stertor. No decided paralysis could be discovered, but there was some rigidity of the left arm. At the autopsy an effusion of blood was found in the arachnoid cavity extending from below upward on each side to a level with the top of the ear. There was a large amount of blood at the base of the brain, and both lateral ventricles were distended with bloody serum. The vessels were generally in an atheromatous condition. There was no laceration of the brain. The source of the hemorrhage could not be ascertained. In such a case the condition of the patient in respect to power of movement often cannot be ascertained with certainty, in consequence of the abolition of consciousness. Complete muscular resolution is most common when the effusion is bilateral, but when the hemorrhage is limited to one side more or less paralysis of the opposite limbs may exist. Should the blood make its way into the spinal canal, it might give rise to special symptoms, but this is not probable in view of the large amount of the cerebral effusion under the circumstances, which would produce complete insensibility or speedily cause death by pressure on the medulla.
13 Op. cit., p. 202.
The temperature of the body immediately after a copious cerebral or meningeal hemorrhage falls below the normal point, and remains so for several hours, after which it rises, its degree varying according to circumstances. In fatal cases the elevation is extreme, and remains so until death. If the patient recover, it gradually returns to the normal standard.
Vomiting is a frequent symptom at the beginning of the attack, just as in intracerebral hemorrhage, owing probably to compression of the pneumogastric by the effusion at the base of the brain. In Webber's case the vomiting was evidently the cause of the hemorrhage, and not its consequence, since it had been a frequent symptom for several days before the attack, and was probably due to the presence of a calculus in the pelvis of the right kidney, which was found at the autopsy, and there was no blood at the base of the brain.
PATHOLOGICAL ANATOMY.—The chief points of interest in the morbid anatomy relate to the seat and source of the effusion, the amount and condition of the blood, the state of the vessels and that of the brain, including the ventricles. In respect to the seat, the hemorrhage may occupy the space between the cranial bones and the dura mater; it may be found on the lower surface of the latter, in the arachnoid cavity, or in the meshes of the pia mater, the so-called subarachnoid space. Blood found upon the outer surface of the dura, between that membrane and the bones, is almost always the result of traumatic causes, such as blows or other injuries, with or without fracture, or of caries of the skull. If below the dura, but between that and the so-called parietal layer of the arachnoid, the lesion comes under the title of pachymeningitis interna, already described as an inflammatory disease of the dura with hemorrhagic effusion. The arachnoid cavity and meshes of the pia are by far the most common situations in which the blood is found in meningeal hemorrhage. The origin of the effusion is either the rupture of a capillary aneurism of one of the arterioles of the membrane or of one of the vessels themselves in consequence of atheromatous or other degenerations of its walls. On account of the minute size of the vessels it is seldom possible to discover the exact point at which the rupture took place. In rare instances the source of the hemorrhage is within the brain, the blood being forced through the cerebral tissue, either into the meshes of the pia or upon the surface of that membrane. The amount of hemorrhage varies according to conditions which are mostly unknown, but is probably dependent upon the size of the ruptured vessel and the conditions under which the accident occurs, such as muscular effort, cardiac action, etc. In some cases it is so small as to give rise to no definite symptoms, as is evident from post-mortem examinations of those who have died from other causes. In these cases there may be either a single effusion or several. The amount is largest when the arachnoid cavity is the seat of the extravasation. The blood, which may be either liquid or more or less coagulated, according to the time which has elapsed since the hemorrhage, is usually found upon the convexity of the hemispheres, most frequently on one side only, and oftenest on the left. But if the rupture have taken place at the base, it often ascends on each side, as in a case mentioned above. Where a large vessel has given way, its contents may cover a great part of the surface of the brain. The coagulum is found in a thin layer, which at the end of a few days is covered with a transparent envelope, evidently composed of a deposit or separation of fibrin. Should the patient survive long enough, this membrane may become organized, receiving vessels from the adjacent pia, and in turn become the seat of new hemorrhages, exactly as in the hæmatoma of internal pachymeningitis. In cases in which absorption of most of the fluid part of the effusion takes place, the membrane remains more or less dense and vascular, and usually contains a small quantity of recently-effused blood within its meshes. Small cysts, containing transparent or reddish-brown serum, are also occasionally observed enclosed between the layers of the membrane. In very young children, whose fontanels are not yet ossified, these cysts sometimes attain to a large size, containing several pints of fluid, which is more or less limpid from absorption of the coloring matter of the blood, constituting the so-called dropsy of the arachnoid.14 The convolutions of the brain are more or less flattened according to the amount of the effusion, and the cortical substance is correspondingly anæmic from pressure. The blood may make its way, if extravasated in large quantities, into the ventricles, over the medulla, into the spinal arachnoid cavity, or even into the central canal of the spinal cord. The arteries of the brain, especially at the base, are frequently in a state of atheromatous degeneration, and thrombi often occupy the sinuses of the dura mater.
14 Charles West, M.D., Lectures on the Diseases of Childhood and Infancy, 6th ed., London, 1874, p. 62. These large cysts are much more frequently (perhaps solely) found in cases of hemorrhagic pachymeningitis. (See Barthez and Sanné, op. cit., vol. i. p. 157.)