THE
MEDICAL EXAMINER,
AND
RECORD OF MEDICAL SCIENCE.
NEW SERIES.—NO. LXIII—M ARCH, 1850.
ORIGINAL COMMUNICATIONS.
Case of Tubercular Meningitis, occurring at St. Joseph’s Hospital.
Service of Dr. Stille.
Catharine S., aged aboutl2 years, entered the hospital Oct., 1849-
Catharine arrived in this country from Ireland, in Dec., 1848,
with her parents and several younger children. Very soon after-
wards both father and mother died from the effects, it is supposed,
of a long voyage and insufficient food. Catharine was their only
nurse, and watched them day and night with a devotion and intel-
ligence far beyond her years. She was completely exhausted by
her labors, and at her mother’s funeral, which she would not be
prevented from attending, could only succeed in following the
coffin by interrupted and persevering efforts. On returning home
she fainted repeatedly. She was then taken into the employment
of a benevolent lady, with whom she continued to live. She re-
mained feeble, however, and complained of weakness in her limbs,
and of a sense of tightness around her waist. Within the last
month or two, her eyes gave her pain whenever she applied them
to needlework, although no signs of inflammation were visible;
she suffered almost constantly from headache, and at times be-
trayed a degree of perverseness foreign to her natural disposition.
About a week before entering the hospital she was attacked by
spasmodic movements, with some wandering of the mind, and
stupor, which were regarded by her physician as symptoms of
hysteria, and treated accordingly. After her admission she lay
with closed eyes, her brow somewffiat corrugated, and her cheeks
flushed. With much difficulty she could be roused, so as to answer
questions by “ yes ” or “ no,” but immediately relapsed into stupor.
The natural temperature of the skin was preserved, and the pulse
was frequent and feeble. She refused nutritious food, but ate
greedily portions of an apple or orange placed in her mouth.
There was a partial paralysis of the whole of the left side of the
body. The coma was not uniformly of the same degree. Occa-
sionally it was interrupted by sharp and sudden cries, with grind-
ing of the teeth ; at night, by active delirium, and once or twice,
in the morning, by a state of comparative consciousness, in which
she spoke some sentences connectedly. The latter symptom fol-
lowed the application of a large blister to the nuchae. Calomel,
and other bulky purgatives, administered by the mouth, produced
vomiting; croton oil, which was freely prescribed, was retained,
but without evacuating the bowels. The blistered surface was
dressed with mercurial ointment.
Oct. 3d.—Face sunken ; left side partially paralyzed ; the right
eye slightly sensible to light, the left not at all. Pulse so feeble
that it cannot be counted; pulsations of the heart 160 in a minute,
and irregular; no intelligence; the eyes injected and filmy ; can
scarcely swallow; automatic movements of the hands, but chiefly
of the right hand; passes her water in the bed ; no stool.
This state continued until early on Oct. 4th, when she died
gradually, and by exhaustion.
Autopsy, 12 hours after death. Rigidity of the limbs and ema-
ciation moderate; skin sallow, but not jaundiced ; no ecchymoses
in the depending parts.
Head.—Scalp dry, with little fat; no blood followed its incision.
On removing the calvarium, a few drops only of dark blood flowed.
Vessels of dura mater distended. Surface of arachnoid dry, sticky,
and looking as if varnished. Its opposite surfaces were ad-
herent at four or five points on either side of the longitudinal
sinus, where there were somewhat firm and opaque fibrinous de-
posits. The vessels of the pia mater were uniformly injected; the
smaller of a dusky reddish hue, and the larger veins along the
anfractuosities swollen and of a leaden color. About two ounces
of limpid serum were at the base of the brain and in the opening of
the spinal canal. The vessels of the base wrnre injected like those
of the upper surface of the brain.
A semitransparent, thick and dense layer of fibrine covered the
chiasm of the optic nerves, extending along the fissure of Silvius,
and the angle between the cerebellum and the pons varolii and me-
dulla oblongata, on both sides. These adjacent parts were thus
firmly connected, and the middle could not be separated from the
anterior lobe by traction, without tearing the substance of the
former. In this fibrinous deposit were numerous granular bodies,
scarcely exceeding half a line in diameter, more opaque than the
substance around them, but neither hard nor readily isolated from
this substance. They were most abundant in the fissure of Silvius,
and along the edge of the medulla oblongata and pons varolii, but
also existed in the choroid plexus and the velum interpositum.
The lateral ventricles were distended with serum, and the cere-
bral substance between them was in some degree softened. The
internal face of the right optic thalamus was distinctly softened in
the space of half an inch square. The superior part of the hemi-
spheres retained their normal consistence, but the base was less
firm than natural. The two constituents of the cerebral mass con-
trasted strongly in color; the medullary portion was very white,
but presented upon section innumerable dark bloody points.
Thorax.—The cutis was remarkably thin, with a very slight
layer of subcutaneous fat. All of the superficial tissues, including
the muscles, were remarkably dry. The pleural cavities and the
pericardium contained no fluid. The lungs were of a perfectly
natural aspect upon their anterior face, and crepitated freely when
handled. The posterior surface of the lower lobe of the left lung
was mottled with black spots upon a ground the color of logwood.
The latter color was due to general hypostatic congestion, and
the former to local circumscribed effusions of blood, about the size
of an orange seed. The corresponding portion of the right lung
was more thoroughly congested, its natural toughness was some-
what impaired, and a fragment of it partially sunk in water.
From several points of a section of this part pus flowed upon pres-
sure. The bronchiae were dyed of a dark red color: the bronchial
glands were unchanged. No tubercles were detected in either lung.
Heart.—Its right cavities were distended with black blood, its
left empty. In all other respects the organ was normal.
.Abdomen.—The general color of the intestinal tube was a dusky
red. The peritoneum dry and dull. The liver extended com-
pletely to the left hypochondrium, and its right lobe was unusually
thick and had a pyramidal shape. Its lower surface presented a
fissure running nearly parallel with the edge, about an inch deep
at one point, and looking precisely like a cut made with a scalpel.
The peritoneum over it was quite natural. The general color of
the liver was very dark, and its surface mottled with lighter spots
in the general dark ground: a section presented a similar aspect.
The whole organ was gorged with black blood, and had less firm-
ness than natural. The gall bladder was filled with very dark bile
about the consistence of molasses.
The mesenteric glands were undeveloped, and the glands of
Peyer in the ileum could only be distinguished by a reflected light.
The lining membrane of this bowel was of a dusky red color. The
caput coli was found in the lower pelvis, whence the ascending colon
rose in front of and then to the left of the spine, till it reached
the pancreas, where it made an abrupt turn upon itself and de-
scended, in contact with the ascending portion, to the left iliac
region, whence it again rose to the neighborhood of the spleen,
and once more pursued the downward and usual course. The part
between the caput coli and the pancreas was distended with gas,
and hardened faeces could be felt within it. The following di-
visions were contracted, but contained a portion of faeces.
The uterus was scarcely thicker than a dollar, and its body
about an inch in length by f of an inch broad.
The other viscera were not examined.
The points of interest in this case are the coincidence of paraly-
sis of the left side and acute softening of the right optic thalamus;
the size and singular shape of the liver; and the malposition of the
colon, which may plausibly be attributed to the morbid develop-
ment of the liver. It is probable that the stricture around the
waist which the patient complained of may also be attributed to
the condition of the liver.