9 G. Huguenin, op. cit., p. 499.
10 Op. cit., p. 449.
Olaf M—— (male), æt. 8 years, born in Denmark, entered Massachusetts General Hospital Sept. 13, 1881. Maternal grandmother died of consumption; paternal grandfather lived to the age of ninety-five years. One brother had some disease of hip. Patient was the child of poor parents and lived in an unhealthy suburb of Boston. During the two preceding winters he had a bad cough. He was apparently well till four weeks before his entrance, when he complained of bellyache, and became listless, but he was out of doors ten days before he came to the hospital. It was noticed that he was sensitive to sound. No vomiting, no diarrhœa, no epistaxis, no cry; some cough. He had been somnolent, and was observed to swing his arm over his head while asleep. June 14, when first seen by me, he was lying on his back, unconscious, eyes half closed, pupils dilated, jaw firmly closed, much emaciated, belly retracted, left leg occasionally flexed and extended. No priapism. The optic discs were reddened. June 15, there is some intelligence, he answers questions; keeps one hand on the genitals. June 16, pupils contracted, does not swallow. June 18, left eye divergent, conjunctiva injected, whole surface livid, cries out occasionally. Died at midnight.
FIG. 30.
Autopsy.—General lividity of surface, much emaciation. Much fine arborescent injection on outer surface of dura mater. Numerous Pacchionian bodies. Yellow matter beneath arachnoid along course of vessels on each side of anterior lobes. Abundant fine granulations along course of vessels on each anterior lobe, on upper margins of median fissure, along fissure of Sylvius, and on choroid plexuses. Very little lymph at base of brain. Six or eight ounces of serum from lateral ventricles, and abundant fine transparent granules over ependyma of both. Numerous opaque granulations in pia mater of medulla oblongata. Surface of right pleura universally adherent. Mucous membrane of bronchia much injected; a considerable amount of pus flowed from each primary bronchus. No tubercles in lungs nor in peritoneum. No ulcerations in intestines. No other lesions.
The choroid plexuses are generally involved in the inflammatory process, and are sometimes covered with yellow purulent exudations. As in the above case, large numbers of tubercles may be found in them, notwithstanding the opinion of Huguenin that their number is always small.
The substance of the brain in the vicinity of the tubercular deposit is generally found in a more or less œdematous condition, owing to the obstruction of the circulation resulting from compression of the vessels by the tubercles and effused lymph. Softening, sometimes even to diffluence, not unfrequently occurs in the neighborhood of the deposit, probably from ischæmia (necrobiosis). If there be any considerable amount of exudation in the ventricles, the convolutions are flattened by compression against the cranial bones.
The above-described lesions are not confined to the brain, but may extend to the cerebellum, the pons, the medulla, and the spinal cord. If examinations of the latter were more frequent in autopsies of this disease, we should doubtless find, as has been done in some instances, that the membranes often show the characteristic alterations of tubercular meningitis, and even the presence of granulations in the cord itself. The lesions may extend throughout the cord, and are especially noticed in the dorsal region and in the vicinity of the cauda equina. Their presence explains some of the symptoms evidently due to spinal origin, such as retraction of the head with rigidity of the neck and of the trunk, contractions of the limbs, tetanic spasms, priapism, paralysis of the bladder and rectum, etc., which are common in simple spinal meningitis.