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CHAPTER 10
Landscapes Formed by Streams

GOALS
 Understand how streams use their kinetic energy to do the geologic work of erosion and
deposition.
 Learn what factors control stream erosional and depositional behavior.
 Become familiar with constructional (depositional) and destructional (erosional) fluvial
landforms.
 Understand how streams and fluvial landscapes change over time.
 Estimate potential damage from flooding.

BACKGROUND
Chapter 10 begins the study of the agents of erosion and the distinctive landforms and landscapes
they produce. It also sets the tone for the coverage of landscapes produced by glaciers (Chapter 11),
groundwater (Chapter 12), waves (Chapter 13), and how these agents work differently in arid regions
(Chapter 14). These five chapters focus on understanding the similarities and differences in the
processes by which these agents operate, rather than on simply memorizing landforms. A major
theme throughout these chapters is how each agent uses its kinetic (and/or chemical) energy to erode
and deposit Earth materials. Their different behaviors lead to distinctive landforms, which in turn
help us understand what agents produced particular landscapes.
A single laboratory session cannot possibly cover all fluvial processes and resulting
landforms. Therefore, Chapter 10 uses our inquiry-based approach to focus on a few basic
concepts that students deduce for themselves from carefully scaffolded exercises:
 Water flowing downhill gives streams kinetic energy with which they do geologic work.
 A decrease in a stream’s energy causes deposition.
 A stream’s gradient and elevation above its base level control whether a stream is using
its energy to cut downward or laterally; whether its valley is broad and flat or V-shaped
and steep; and whether it has a broad-straight course or meanders.
The pedagogy here is the same as that used in studying rocks in Chapters 4 to 7: “reading
the rocks” is replaced by “reading the landforms.” Students are still required to recognize
characteristic fluvial features, but in the context of what they tell us about the evolution of the area.

CHAPTERS 10 TO 14 IN THE CLASSROOM

All maps and figures in Chapters 10 to 14 are available at Norton’s Instructors’ Resource
website. This makes some exercises easier because elevations can be estimated much more
readily from an enlarged version—especially in rugged topography where contour lines are
spaced closely. It also permits an entire class to work on an exercise together, a practice that
engages students in conversation and, if you wish, debate.

10.1
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
 As with the study of minerals, rocks, and contour lines, students learn basic principles
through discovery rather than memorization. For example, building on two basic concepts—a
stream’s downhill flow gives it kinetic energy, and its base level controls how deeply it can
erode—students measure gradient and sinuosity (on paper, online, or onscreen) to deduce how a
stream’s gradient controls its erosional activities and sinuosity. By comparing these features for
different streams, they learn to understand how a stream is “working.” Building on the basic
principle that streams deposit sediment when they lose kinetic energy, students explore the
origins of alluvial fans, deltas, natural levees, and floodplains.
With practice that begins in this chapter, students should become progressively more
adept at visualizing slope changes and shapes of landforms. Constructing topographic profiles
will still be needed at this stage, reinforcing exercises from previous chapters.

SUGGESTIONS
Our treatment of streams is a template for how the other landscape-forming agents will be
presented in the following chapters and sets a norm against which the other agents will be
compared. Thus, the theme of how a geomorphic agent uses energy underlies Chapters 11 to 14
as well. Recognizing their similarities and differences promotes deeper understanding of how
each agent operates and why their landscapes are so distinctively different. Our students report
that the following study guide has been helpful in summarizing the course unit on
geomorphology—we hope it also helps your students.

10.2
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
 Many of the exercises in this chapter can be done digitally by using Google EarthTM,
Google MapsTM, or free GIS software such as NASA’s World Wind.
We have found National Geographic’s TOPO!4 digital library of topographic maps
extremely helpful because it provides instant access to classic geomorphological features
anywhere in the United States at any scale. Loaded onto a single classroom computer, it is
superb for demonstrations and group discussions because its functions include profiling,
determining elevations and latitude-longitude elevations, and measuring distances. In a computer
laboratory, it allows an entire class to do exercises digitally.
Use your unique campus setting to continue our practice of demonstrating the relevance
of the material in students’ lives. Is there a stream or river nearby that can bring the concepts
alive? Is there a history of flooding in the area? Are local rivers used for transportation or
generating energy?

10.3
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
ANSWERS TO EXERCISES
In Exercise 10.1, students compare two streams in a totally unguided fashion, describing the
differences they observe in whatever terms they wish—geologic terms if they’ve learned them,
everyday terms otherwise. Exercise 10.2 guides them to aspects of stream behavior that will be
explored in detail (and with appropriate nomenclature) in the rest of the chapter.

EXERCISE 10.1: Differences between Streams

Differences between the two streams include:
i. Apparent velocity of flow: rapid in Yellowstone, slow in Cuckmere.
ii. Turbulence: turbulent in Yellowstone, calm in Cuckmere.
iii. Straightness: Yellowstone much straighter than Cuckmere.
iv. Valley: Yellowstone—narrow, steep-walled, V-shaped valley. Cuckmere—broad flat valley
with walls not clearly defined.

EXERCISE 10.2: Getting Familiar with Properties of Streams

(a) This is not an easy question because the width of the Yellowstone River channel varies and
there aren’t scale bars for reference. Using the trees visible in both photos, the River
Cuckmere channel is perhaps a little wider than that of the Yellowstone.
(b) The River Cuckmere valley is much wider—indeed, both valley walls cannot be seen in the
photograph.
(c) Yellowstone River.
(d) The Yellowstone River channel completely fills the base of the narrow valley in which it is
flowing. The channel of the River Cuckmere is much narrower than its valley.
(e) The Yellowstone River has a straight channel, whereas that of the River Cuckmere is more
sinuous (meanders broadly).
(f) The Yellowstone River appears to be flowing faster, based on the turbulent white water in its
rapids.
(g) The River Cuckmere appears to be nearly horizontal, with little vertical change over the
course of the photograph. The Yellowstone river appears to drop a greater distance,
particularly in the area between the two sets of rapids.

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Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
EXERCISE 10.3: Why Some Streams Meander but Others Are
Straight
(a)
Bighorn River Unnamed tributary
Channel length (miles) 6.50 2.35
Straight-line length (miles) 3.98 2.24
Sinuosity (no units) 1.60 1.05
Highest elevation (feet) 3,870 4,150
(between 3,879 and 3,861) (between 4,159 and 4,141)

Lowest elevation (feet) 3,850 3,850

(3,859 to 3,841) (3,859 to 3,841)
Vertical drop (feet) 20 300
Gradient (feet per mile) 3.07 128
(b) It appears that the steeper the gradient, the straighter a stream will be; the gentler the
gradient, the more a stream will meander.
(c) Some data is provided in this exercise to aid its completion.
Casino Lakes area
Genesee River
Stream A–B Stream C–D
Broad, flat- Steep V-shaped
Valley shape V-shaped
bottomed valley with flat bottom
Gradient (ft/mi) 0.54* 393 936
Valley width (mi) 1.56 Channel essentially fills
Channel width (ft) 330 the valley floor
Valley width/channel width 25 ~1.0 ~1.0
Sinuosity 3.01 1.07 1.05
*No contour line crosses the Genesee River between points A and B, indicating a vertical drop less than 9 feet.

(d) The streams on these maps appear to confirm the hypothesis that high-gradient streams tend
to have straight courses, whereas low-gradient streams tend to meander more broadly.
(e) The straighter a stream, the lower the valley width/channel width ratio. The greater the
sinuosity, the greater the valley width/channel width ratio.
(f) The steeper the stream gradient, the more V-shaped its valley will be; the gentler the
gradient, the more likely it is that the valley will be broad and flat-bottomed.
(g) The River Cuckmere has a lower gradient than the Yellowstone River because, like the
Genesee River, it meanders broadly. The Yellowstone River is straight and, like the two
tributaries in the Casino Lakes area, has a steeper gradient.
(h) Using the same reasoning, the left-hand stream in Figure 10.3 has the steepest gradient, the
right-hand stream the gentlest gradient, and the stream in the middle a gradient intermediate
between those two.

10.5
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
EXERCISE 10.4: Interpreting Stream Behavior
(a) By inspection, the Meadow River (Figure 10.9b) has the lowest valley width/channel width
ratio and therefore probably has the steepest gradient of the three. The St. Francis River
(Figure 10.9a) has the largest valley width/channel width ratio and therefore probably has
the gentlest gradient of the three.
(b) With the highest gradient and straightest channel, the Meadow River (Figure 10.9b) is using
more of its kinetic energy in eroding vertically than the other two streams. The St. Francis
River is using most of its energy in lateral erosion. The Arkansas River (Figure 10.9c) is
intermediate between the others in both valley width/channel width ratio and proportion of its
energy used in eroding vertically.
(c) Two of the three maps provide this information. Numerous oxbows and meander scars
outlined by former natural levees in the St. Francis River (Figure 10.9a) identify former
positions of the channel. For the Arkansas River (Figure 10.9c), the arcuate shapes of the
valley walls indicate where the meandering channel had cut into the walls. The Meadow
River (Figure 10.9b) lacks these features and has probably not occupied other positions
within its valley previously.
(d)

Meander scars

Point bar

Channel

Meanders

Oxbow lakes

Valley wall

10.6
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
(e) The river is flowing slowest on the inside of the meander loop, fastest on the outside.

10.7
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
EXERCISE 10.5: Drainage Basins and Stream Divides
(a, b, c)

(d) The patterned area north of the Missouri River will potentially be affected—essentially
along Hilliers Creek downstream of where the tributary closest to the toxins enters the
drainage basin.

EXERCISE 10.6: Recognizing Drainage Patterns

(a) A dendritic drainage pattern. That suggests that materials underlying its drainage basin in
the central United States are approximately equally erodible—probably horizontal strata.
(b) The drainage pattern in Figure 10.12 is dendritic, indicating equally erodible materials.
The pattern in Figure 10.17 is a trellis pattern, indicating parallel ridges and valleys
underlain by resistant and less resistant rock types, respectively. It is likely that the rocks

10.8
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
 in the area shown by Figure 10.12 are horizontal but those in the area of Figure 10.17 are
either tilted or folded.

EXERCISE 10.7: Recognizing Stages of Landscape Erosion

In this exercise, you may want to coach students that terms can be used multiple times in a row and
that if three options are given as examples they may not all be used once. Some instructors may
want to provide suggested terms for approximate relief and estimated stream gradients rows.
(a)
Southeast Texas Colorado Plateau Appalachian Plateau
(Fig. 10.14) (Fig. 10.15) (Fig. 10.16)
Low in highlands,
Approximate relief:
Low moderate between Moderate
low, moderate, high
highlands and rivers
Number of streams: few; Many (one large,
Few Many
moderate; many many small)
Estimated amount of land
area that is valley slopes as a ≈ 15% ≈ 30% ≈ 95%
percentage
Estimated stream gradients Low High Intermediate
Stream divides—broadly
rounded, angular, can’t see Broadly rounded Broadly rounded Angular
divides
Stage of stream dissection
Stage 3 Stage 1 Stage 2
(Stage 1, 2, or 3)
(b) Figure 10.1a: narrow, steep-walled valley suggests high gradient = Stage 1.
Figure 10.6: almost entire area in slope plus numerous narrow V-shaped valleys = Stage 2.
Figure 10.9a: very gentle stream gradients plus low relief plus few master streams = Stage 3.

EXERCISE 10.8: Deducing the History of the Susquehanna River

(a) These two rivers seem to ignore a clear pattern of resistant and nonresistant rocks—cutting
across both valleys and ridges at nearly 90°. The smaller streams throughout the area define a
trellis pattern controlled by erodibility of the underlying rock: long streams in valleys (easily
eroded rock) and shorter streams from the ridges (resistant rock) into the valleys.
(b) The elongate valleys are underlain by rock that is easily eroded, forming lowlands.
(c) The two large rivers might have had enough energy to cut through the ridges, whereas the
smaller streams didn’t (reasonable hypothesis). Perhaps the rivers and smaller streams are of
different ages and the rivers flowed southward before the ridges formed (not entirely true but
a possible explanation based on observation).
(d) The classic explanation is that after folding produced the linear bands of resistant and less
resistant rock, erosion stripped off much of the overlying material and the area subsided, was
covered by water, and the linear bands were buried beneath horizontal sediment. The
Susquehanna and Juniata rivers started flowing southward in this sediment and established

10.9
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
 their drainage systems. With time, these rivers carved downward through the sediment and
encountered the linear bands of rock with different erodibilities. At that time, it was more
energy-efficient for the two rivers to cut through the ridges than to rearrange the entire
drainage system. The trellis pattern produced in the valley-and-ridge topography formed
when the overlying horizontal sediment was stripped off and the smaller streams were
constrained to flow in the more easily erodible rock.

EXERCISE 10.9: Origin of Incised Meanders

(a) The Green River meanders widely as it flows southward, but the meanders are cut deeply into the
surrounding plateau—unlike what would be expected normally as in Figures 10.9 or 10.14.
(b) Sinuosity is approximately 3.00.
(c) Based on the nearly identical sinuosity of the Genesee River in Exercise 10.3, the Green
River would be expected to be using most of its energy to cut laterally.
(d) At this time, there is little evidence that the Green River is eroding laterally. There is no evidence
of meander scars that would outline previous meander locations, and the valley walls are of
relatively constant width, unlike those of meandering streams seen in earlier maps.
(e) The near-vertical valley walls and very high relief between river channel and plateau argue
against significant lateral erosion and suggest that the river is cutting downward despite its
sinuosity.
(f) It is highly unlikely that the Green River will be able to cut off the Bowknot Bend meander
because of the enormous amount of solid rock that would have to be removed to do so—
unlike the St. Francis River in Figure 10.9a.
(g) The elevation of the Green River in this area is more than 4,000 feet above sea level and
therefore 4,000 feet above the river’s base level in the Gulf of Southern California. One
would normally expect a highly sinuous stream to be close to its base level so that it would
use its energy for mostly lateral erosion. That is not the case here.
(h) The Green River at one point had eroded much closer to its base level. At that time, it
developed the normal sinuous channel path. But the Colorado Plateau in which the river is
flowing subsequently experienced (and continues to experience) tectonic uplift, increasing
the gradient. Vertical erosion has kept pace with uplift so that the river continues to be high
above base level and is cutting downward. As a result, the early meandering path has been
maintained as the river cuts downward.

EXERCISE 10.10: Estimating Potential Flood Problems

(a) Figure 10.9a: The St. Francis and Mississippi rivers are only about 10 feet lower than the broad
floodplain. A 20-foot flood would inundate the entire floodplain with about 10 feet of water,
making the entire road network impassable—including Interstate 40 and U.S. Route 70.
Figure 10.9b: There would be very little effect on human infrastructure. The Meadow River
is flowing in a V-shaped valley in an area in which homes are more than 200 feet above normal
river levels. A 20-foot rise would be accommodated within the valley without affecting the local
roads. U.S. Route 19 crosses the river at the Ritchie Memorial Bridge, but it appears that bridge
is more than 20 feet above river level, so traffic would not be affected by a flood.

10.10
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
 Figure 10.9c: A 20-foot flood of the Arkansas River would inundate much of its
floodplain in the map area with about 5 to 10 feet of water. This would flood a few local
roads, much of Turkey and Beaver islands, and several active oil wells. There do not appear
to be any homes or businesses in the floodplain, and the surrounding uplands are well above
the reach of a 20-foot flood.
(b)
In most cases, the river is less than 20
feet below the floodplain, so the entire
gray-shaded area would be covered by
water from a 20-foot flood. The three
ellipses highlight rails and roads that
might be affected.

(c) No. Although the airport is built on the floodplain of the Genesee River, it is more than 30
feet higher than the river and should be safe, as would its access roads.
(d) The contour lines on the map make it possible to estimate the effects of floods of different
magnitudes. The satellite image gives more details of features in the floodplain that might be
affected by flooding. For example, it shows that much of the area adjacent to the airport is
farmland. It also shows structures northwest of the cloverleaf that would be damaged.
(e) The highway network in the floodplain would become impassable, and the airport would be
flooded. Both would be unusable for relief efforts.

10.11
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
EXERCISE 10.11: U.S.-Mexico Border Issue
(a) The presence of several oxbow lakes shows that the Rio Grande River has changed its course
several times in the past. The river has several tight meanders that will, eventually, be cut off
in the normal course of stream erosion.
(b) By treaty, the U.S.-Mexico border is in the center of the river. All land on the north side of the
river is in the United States (Texas), and land south of the river is in Mexico (Tamaulipas).
Shading on the map below shows areas where, if certain meanders are cut off, parts of
Tamaulipas could be added to Texas and parts of Texas could become part of Tamaulipas.

Mexico to U.S. U.S. to Mexico

The satellite image shows that this natural “land swap” would have very different effects on
the two countries. The area within the easternmost meander loop that would be transferred from the
United States to Mexico is unpopulated, largely woodland. In contrast, the two areas that would be
transferred from Mexico to the United States are heavily populated parts of the city of Matamoros.

What Do You Think?

It is clear that many people will be affected if the Rio Grande cuts off these three meander loops.
Student solutions might include:
 Prevent the problem by stabilizing the meanders with concrete lining the walls of the
channel.
 Recognizing that the cutoffs will occur, stabilize the border at its current position. If the
cutoffs do occur, neither nation will lose land or citizens.

10.12
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
ANSWERS TO PRE-CLASS WORKSHEETS
1a; 2d; 3d; 4a; 5c; 6d; 7c; 8c; 9d; 10c; 11d; 12b; 13b; 14d; 15a.

10.13
Copyright 2016 W.W. Norton – For instructor and teaching assistant use only
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 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.

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.)

DIAGNOSIS.—The distinction between meningeal hemorrhage and

cerebral apoplexy is always difficult, and in the majority of cases
impossible. Sudden pain in the head, vomiting, and lowering of the
bodily temperature (the thermometer should be placed in the
rectum), followed by loss of consciousness, are strongly suggestive
of hemorrhage within the cranium, either cerebral or meningeal. If
these symptoms are followed by coma and resolution without
obvious paralysis, the diagnosis would be almost impossible
between intra- and extra-cerebral extravasation. If the loss of
consciousness be not complete, so that the presence or absence of
paralysis can be ascertained, we can sometimes distinguish the
situation of the hemorrhage. Right-sided hemiplegia, with paralysis
of the face or tongue, or with aphasia, is most probably owing to
hemorrhage or embolism somewhere in the left motor tract, and
hence within the brain. If the absence of paralysis can be certainly
ascertained, the probabilities are in favor of meningeal apoplexy.
Convulsions affecting the face or limbs of one side would point to
irritation of the cortical centres of those parts, and so far to
extravasation on the surface of the brain (on the opposite side), as in
Webber's case. Where the amount of hemorrhage is small it
furnishes no diagnostic indications. In the case of new-born children
the presumption is in favor of meningeal effusion.

PROGNOSIS.—If the effusion be considerable in amount, as indicated

by prolonged coma with resolution, the issue is almost inevitably
fatal, though life is occasionally prolonged for a surprising length of
time. Slight hemorrhages are doubtless recovered from, but there
are no means for their certain diagnosis.

TREATMENT.—The treatment, which is essentially the same as that for

cerebral congestion, has for its object the arrest of the hemorrhage,
and, if that can be effected, the absorption of the effused blood. In
view of the former, the patient's head should be elevated and kept
cool by the application of ice. Unless the bowels have previously
been freely moved, saline laxatives, followed by enemata if
necessary, must be given. The state of the bladder must be carefully
attended to. Liquid nourishment alone, in moderate quantities at
regular intervals, is permissible, with stimulants if there be signs of
exhaustion. For the absorption of the effusion mild counter-irritation
to the scalp and the administration of the iodide of potassium may be
employed.

Congestion of the Cerebral Pia Mater.

The pia mater consists of two layers, separated by a loose

connective tissue. The outer layer, being that which was formerly
called the visceral layer of the arachnoid, is stretched smoothly over
the convolutions of the brain without dipping into the sulci; the inner
layer is closely connected with the surface of the brain, whose
inequalities it follows. The two layers are more firmly united together
over the convolutions than between them; in the latter situation the
connection is loose, and the space which separates the surfaces is
called the meshes of the pia. The membrane extends into the
ventricles, investing the ependyma and the choroid plexuses, and
over the medulla oblongata and spinal cord. In the normal condition
it is loosely attached to the brain, from which it can be stripped off
without loss of substance. The meshes of the pia, together with the
ventricles, constitute a series of cavities connected with each other,
containing a variable amount of cerebro-spinal fluid, and they
communicate with the lymph-spaces surrounding the blood-vessels.
Pressure within the cranial cavity, from congestion of the vessels or
from the products of inflammation, is thus relieved in a measure by
displacement of the cerebro-spinal fluid, which is driven out through
the perivascular lymph-spaces.

Congestion or hyperæmia of the pia mater probably never occurs

independently of that of the external surface of the brain, on account
of the intimate vascular connection of the two. In the adult it can only
exist to a limited extent, on account of the unyielding nature of the
cranial walls and of the limited compensatory action of the cerebro-
spinal fluid. In young children the incomplete ossification of the skull
and the delicate structure of the vessels are more favorable to
congestion.

ETIOLOGY.—The causes of hyperæmia of the pia mater are in the

main the same as those of congestion of the dura.

SYMPTOMS.—Since congestion of the pia always coexists with that of

the corresponding part of the external portion of the brain, it is
impossible to separate the symptoms belonging to each. They are
therefore usually included under the head of Cerebral Congestion, to
which article the reader is referred.

PATHOLOGICAL ANATOMY.—Arterial hyperæmia of the pia is seldom

discovered after death, the elasticity of the vessels causing
transudation of the fluid part of the blood through their walls. Venous
congestion of the pia is more frequently noticed, usually in
connection with that of the dura, the sinuses with their accompanying
veins being distended with blood, and in cases of long standing often
containing thrombi. Simple hyperæmia of the pia being rarely or
never fatal of itself, these appearances are usually accompanied by
those of inflammation of the membrane or of the cortical layer of the
brain (effusion of lymph or pus), or by hemorrhage.

TREATMENT.—In a case of suspected congestion of the pia the

treatment would be the same as that of cerebral congestion.
 Inflammation of the Cerebral Pia Mater.

SYNONYMS.—Meningitis, Leptomeningitis, Acute non-tubercular

hydrocephalus.

Meningitis (by which is generally understood inflammation of the pia)

appears under an acute, a chronic, and an epidemic form. The latter,
being a zymotic disease, is described in a separate article, to which
the reader is referred.

ETIOLOGY.—Meningitis occurs both as a primitive disease and as

secondary to other affections. The former is rare, the latter is more
frequent. The causes of idiopathic meningitis are for the most part
unknown. Exposure to the sun's rays and excessive indulgence in
alcoholic liquors are thought to excite it in some instances. It has
been known to follow blows and falls on the head which have
produced no injury to the skull. It is rather more commonly observed
in early manhood than at other periods of life. Secondary meningitis
may follow injury or disease of the cranial bones or of the dura, and
of the brain. A frequent cause is extension of disease of the ear to
the membranes and substance of the brain. The reader is referred to
the article on MEDICAL OTOLOGY for information concerning the
symptoms of that formidable complication. Certain diseases are
known to be occasionally complicated with meningitis—acute
articular rheumatism; erysipelas of the scalp and of the face; Bright's
disease, especially the chronic interstitial form; peritonitis; ulcerative
endocarditis; pyæmia; the eruptive fevers; the puerperal state; and
syphilis. Meningitis following or complicating acute rheumatism is
generally supposed to be not uncommon, but the number of cases in
which the existence of inflammation of the meninges has been
proved by autopsy is small. Fuller,15 along with three cases in which
dissection showed suppurative inflammation of the pia, cites several
others in which no cerebral disease was found after death, although
the symptoms gave every indication of it. True meningitis is rare in
chronic Bright's disease, the symptoms resembling it being caused,
in the majority of cases, by uræmia. Meningitis complicating
pneumonia is also rare, although cerebral symptoms are common
enough in that disease, especially in young children with
inflammation of the upper lobes. C. Neuwerk16 reports seventeen
cases of purulent meningitis complicating acute pneumonia. It was
more frequent in men, especially in alcoholic subjects, than in
women. The meningitis was generally total. The lungs were in a
state of gray or yellow hepatization.
15 H. W. Fuller, M.D., On Rheumatism, Rheumatic Gout, and Sciatica, 3d ed.,
Philada., 1864, p. 271. See also E. Leudet, Clinique médicale de l'Hôtel Dieu de
Rouen, Paris, 1874, p. 133.

16 Deutsches Archiv für klin. Med., xxix., 1881, p. 1; and Schmidt's Jahrbücher, Band
cxcviii., 1883, Nov. 5.

SYMPTOMS.—The symptoms of acute leptomeningitis vary much in

the course of the disease. This is readily explained by the complex
character of the functions of the parts involved in the inflammation. It
may be assumed that the cortical layer of the brain is implicated in
every case unless of the most transient and limited kind; the
substance of the brain, cerebellum, and medulla are subjected to
pressure from the afflux of blood, from the effused lymph and pus,
and from the accumulation of serum in the ventricles; the cranial
nerves are exposed to pressure from the deposit of lymph, which
may give rise to irritation or to suspension of function or both; parts
at a distance from the seat of lesion may be functionally disordered
by reflex action through communicating filaments. Finally, the
general system suffers from the effects of the high fever upon the
blood and the nutrition.

It is customary to speak of a stage of excitement followed by one of

depression as characteristic of the course of the disease; but
although active symptoms generally prevail in the early period, to be
succeeded later by coma and paralysis, this disposition is by no
means uniform. Sometimes sopor and paralysis constitute almost
the only symptoms throughout the disease—this is especially noticed
in infants—or active delirium and convulsions may persist until the
fatal termination. More frequently the two conditions alternate
several times with each other. A prodromic period of short duration, a
few hours or a day or two, is sometimes observed in primitive
meningitis, the patients complaining of headache, vertigo, vomiting,
restlessness, or lassitude. Infants are irritable or drowsy, with heat of
the head, quick pulse, and occasional vomiting. In secondary
meningitis this period is usually masked by the symptoms of the
primitive disease. In the majority of cases the beginning of acute
meningitis is abrupt. Rigor is sometimes the first symptom observed,
and in children is usually represented by a convulsion. More
commonly, however, the disease is ushered in by severe headache,
which is often referred to the forehead. The head is hot, the face is
flushed, the eyes are brilliant, the pupils are contracted, the pulse is
quick and hard, the temperature high (104° F. or upward). The
patient is wakeful, restless, and irritable, sensitive to light and to
sound. The skin is hyperæsthetic, especially that of the legs. There
may be wandering or even active delirium. Vomiting is not
unfrequent. There is thirst, but no desire for food. The urine is scanty
and high-colored, the bowels constipated. These symptoms
gradually increase in intensity, especially the pain in the head and
the delirium, and in many cases they are followed by convulsions, at
first in the form of twitchings of the facial muscles or of the limbs,
grinding the teeth, etc., which give place to tonic contractions of the
limbs or of the trunk, often confined at first to one or both members
of the same side, but afterward becoming general; the flexors of the
forearms and of the legs are most usually affected. The upper dorsal
muscles may become contracted, so that the head is drawn
backward, and more rarely trismus occurs.

A diminution in the rapidity of the pulse, which may fall to the normal
rate, or even below that, notwithstanding the persistence of the high
temperature, indicates the beginning of the stage of depression. This
change is sometimes sudden, though more often gradual in its
approach. The activity of the delirium subsides, giving place to a
somnolence which may seem to the inexperienced observer a
favorable indication, but which soon deepens into coma. The face
becomes pale, the features are sunken. Only an occasional grimace
or a movement of the hand to the head shows that the patient is to
some extent conscious of suffering. This condition may alternate with
the previous one from time to time, the comatose state being
interrupted by noisy delirium and tonic or clonic convulsions, or even
a partial return of consciousness, giving rise to fallacious hopes on
the part of the friends, and sometimes deceiving the physician
himself into a belief that a favorable issue is at hand. Before long,
however, the symptoms of brain-compression become permanent.
The rigidity of the limbs gives place to complete resolution. The
patient lies absolutely unconscious, with dilated pupils. The pulse
becomes again rapid in consequence of compression of the medulla,
and thread-like and irregular; for the same reason the respirations
increase to 40, 50, or 60 in the minute. The sphincters are relaxed,
and the patient dies without any recurrence of the active symptoms.
In rare cases recovery takes place, although almost never after the
symptoms of compression have continued without interruption for
any considerable length of time. Moreover, it is seldom that recovery
takes place in the adult without leaving some traces of permanent
damage, such as general debility, paralysis of one or more limbs,
deafness, mental weakness, epilepsy, etc. Many cases of general
paralysis of the insane and other forms of so-called mental disease
are the result of meningitis.

DURATION.—In the adult usually the disease lasts about a week or ten
days; exceptionally, it may last two or three weeks.

COURSE.—In young children the course of meningitis differs

somewhat from that which is observed in adults, though the
symptoms are essentially the same. It is more sudden in its onset
and shorter in its duration. The prodromal stage may be brief or
hardly noticeable; but in older children restlessness, sensitiveness to
light and sound, wakefulness, slight twitchings of the features or of
the limbs, a half-open condition of the eyelids during sleep,
occasional vomiting, etc., are more commonly noticed. Convulsions
are more common than in the adult, and sometimes constitute the
chief symptom. They may be confined to a single extremity, but in
general they shift from one limb to another. The muscles of the
eyeball are usually implicated, causing strabismus. Retraction of the
head is rarely absent, especially in young infants. These convulsions
are almost always tonic, but occasionally they alternate with clonic
ones. Distension and increased pulsation of the anterior fontanel is
always observed in infants a few months old affected with this
disease. When meningitis is secondary to some other disease, the
first symptom noticed in children is apt to be vomiting, with delirium.
According to Steffen, pneumonia is the disease most frequently
complicated with meningitis in children. As in tubercular meningitis,
the most prominent symptom may be mere sopor, sometimes with
intervals of intelligence. Simple meningitis in children is generally a
rapid disease, proving fatal in most cases within a week, and
sometimes even in a few hours. Exceptionally, it may last much
longer. A case occurring in a girl six years old, the duration of which
was fifty-five days, is reported by J. Bokai, Jr.;17 the diagnosis was
substantiated by autopsy. Another case, which recovered after seven
weeks, is mentioned by Henoch.18
17 Jahrb. f. Kinderkrankheiten, N. F., xviii. 1, p. 105; and Schmidt's Jahrb., 1882, No.
6, p. 269.

18 Eduard Henoch, Vorlesungen über Kinderkrankheiten, Berlin, 1881, p. 277.

PATHOLOGICAL ANATOMY.—The lesions, which are rarely general, may

occupy a greater or less extent of the membrane. They are usually
disposed symmetrically with regard to the two hemispheres, or
occupy corresponding regions of the base. The vessels are in the
beginning of the disease distended, the finest ramifications being
injected, giving a red color to the membrane, which varies in different
places from crimson to light pink. The perivascular spaces of the
larger vessels are filled with a grayish or yellowish fluid composed of
extravasated liquor sanguinis and white blood-corpuscles. The
meshes between the two layers of the pia are soon infiltrated with
pus, and the thickened membrane can be stripped off from the
surface of the brain, which is, however, adherent to it in places and is
torn in the process. Sometimes a thin layer of pus, which can be
scraped off with the knife, is found upon the surface of the pia. The
extent of the lesion varies much in different cases. It may be
confined to a limited region of the hemispheres, or it may spread to
the fissure of Sylvius, where two surfaces become adherent.
Sometimes the concrete pus and fibrin are deposited in thick masses
upon the base of the brain, often completely surrounding the cranial
nerves, and even the medulla. The inflammation may extend to the
lateral ventricles, which become filled with a turbid fluid containing
pus-cells, and sometimes wholly purulent. The choroid plexuses are
often covered with flecks of pus. When the distension of the
ventricles is very great, the gyri of the brain are more or less
flattened by compression against the cranium, and the outer layer of
the cerebral substance is bloodless and œdematous. The cerebral
sinuses are distended with blood, and frequently contain thrombi due
to an early stage of the inflammatory process, besides recent
coagula.

DIAGNOSIS.—The diagnosis of acute meningitis is often difficult, and

sometimes impossible, especially in the early stages, when the line
between congestion and inflammation cannot be drawn, and in
complicated cases. The typical symptoms are sudden and acute
pain in the head, with sensitiveness to light and sound, contracted
pupils, rapid pulse, and vomiting, followed by delirium, convulsions,
and coma. If these symptoms were observed in an individual
previously in good health, they would be strongly suggestive of the
disease, and yet many of them are often present in the beginning of
pneumonia, erysipelas, typhoid, typhus, and other eruptive fevers,
uræmia, and poisoning from narcotic substances. Hence it is
important to eliminate these sources of error before coming to a
conclusion, and a neglect of this precaution is a not infrequent
source of error in the diagnosis. A careful examination of the urine
will generally enable us to exclude uræmia. The presence or
absence of the eruptive fevers can usually be determined by the
attendant circumstances, and yet cases of scarlatina, typhoid fever,
variola, etc., beginning with active cerebral symptoms, are
sometimes hastily pronounced to be meningitis by inexperienced
observers. In poisoning by narcotics the history will often aid us in
the diagnosis; moreover, except in the case of opium, the pupils are
dilated instead of being contracted. In traumatic cases, with fracture
of the cranial bones, it is always difficult, and often impossible, to
distinguish between the symptoms of meningitis and those due to
other lesions. In concussion without fracture we must be guided in
our diagnosis by the same rules as in idiopathic cases. The
distinction between extreme congestion of the pia mater and
meningitis must be based chiefly upon the duration of the symptoms.
The former is usually brief in its course; the latter lasts one or two
weeks, and in cases which recover is often followed by after-effects
which are more or less permanent in their duration, such as paralysis
or rigidity of the limbs, mental defects, etc. Rapid recovery from the
acute symptoms would be strongly suspicious of congestion, and
doubtless in many such cases the treatment has been credited with
a success to which it was not entitled. The diagnosis from tubercular
meningitis will be reserved for the article on that disease.

PROGNOSIS.—Acute meningitis is fatal in the majority of cases,

though recovery is possible. A gradual diminution of the severity of
the symptoms, especially in respect to temperature, pulse, pain in
the head, and other cerebral phenomena, would afford
encouragement, but we must not trust too much to the brief
appearances of amendment so often observed.

TREATMENT.—The indications for treatment are threefold: 1st, to

prevent or arrest the inflammation; 2d, to modify its violence and
shorten its duration when arrest is no longer possible; and 3d, to
place the patient in the best condition to withstand the violence of the
disease and to recover from its effects. It is only by prompt action
that we can hope to attain the first object, that of preventing the
passage of hyperæmia into inflammation. The patient should be
placed in a cool and well-ventilated apartment of good size, from
which a bright light is excluded. His head, moderately raised, should
be kept cool by means of pounded ice enclosed in a rubber bag or a
bladder. One or more leeches, according to his age, should be
applied behind the ears, or blood may be drawn from the temples or
back of the neck by means of cupping. The bleeding should be
encouraged by poultices if necessary, but with young children the
abstraction of blood should be done with caution. An active purge
should be given, such as ten grains each of calomel and jalap,
followed by castor oil or infusion of senna; for children, from three to
six grains, according to age, followed by oil, would be sufficient. The
medicine should be repeated in a few hours if there be no effect.
Counter-irritation by means of blisters is recommended by most
authorities as a valuable aid in the first stage of the disease. Unless
the application be very extensive, it is not likely to be of any avail,
and extensive blistering would hardly fail to greatly reduce the
strength of the patient, and also is likely to irritate the kidneys. There
are no medicines which can be relied upon to arrest the
inflammatory process. Nevertheless, the tincture of aconite-root, in
the dose of from one to three drops, according to the age of the
patient, every two hours, might be given early, with the view of
fulfilling the second indication by its sedative property. The bromide
of potassium or of sodium, combined with small doses of chloral
hydrate or of sulphate of morphia, will also calm the excitement and
pain, and diminish convulsions. The success which sometimes
follows the employment of ergot in the epidemic cerebro-spinal
meningitis warrants its trial. Bartholow recommends the wet sheet
two or three times a day if the temperature is high. Steffen advises
four grains of sulphate of quinine with one grain of salicylate of soda,
from two to four times daily, for young children, and in double these
doses for older ones. The alimentation of the patient should be
carefully attended to during this stage. Nourishing liquid food, such
as milk, gruel, broth, eggs, with stimulants if indicated, should be
given at proper intervals, care being taken not to overload the
stomach, as is frequently done. When the patient can no longer
swallow the food must be given by the rectum. During the stage of
compression it is useless, in the present state of our knowledge, to
expect any benefit from the further administration of drugs, and the
treatment then consists mainly in giving small quantities of food at
regular intervals, and in such external applications as the bodily
temperature may require. The bladder must be relieved by the
catheter when necessary. Simple enemata are generally sufficient to
prevent constipation.
 Chronic Cerebral Meningitis.

Chronic inflammation of the pia mater rarely follows the acute form,
but is generally secondary to other conditions, such as inflammation
and tumors of the dura, tumors and abscess of the brain, disease of
the vessels of the brain, suppurative otitis, and to constitutional
diseases, especially alcoholism, syphilis, and pulmonary
tuberculosis. It is one of the most common lesions found after death
from general paralysis of the insane. As a distinct affection,
unconnected with constitutional disease, it is extremely rare, though
less so, according to Flint,19 than the acute form. He cites a case in
which the symptoms were intermittent. The patient, fifteen years old,
died after a month's illness. The autopsy showed cerebral
hyperæmia, lymph at the base of the brain, and distension of the
ventricles with transparent fluid. There were no tubercles. In most
cases in which the results of chronic meningitis are found after death
the cortical substance of the brain is involved in the disease; hence
the difficulty in defining its symptoms, which are usually extremely
vague, and not always distinctive of cerebral disease. The principal
are pain in the head, vertigo, vomiting, impairment of the memory,
mental apathy, drowsiness, and muscular weakness. The anatomical
changes are thickening and opacity of the membrane by the deposit
of lymph upon its surface and into the connective tissue, adhesions
to the dura and to the cortical substances of the brain, together with
hyperæmia of the latter. These appearances are usually distributed
in irregular patches of greater or less extent.
19 Austin Flint, M.D., Principles and Practice of Medicine, 5th ed., Philada., 1881, p.
701.

The DIAGNOSIS of chronic meningitis is often obscure or impossible.

Long-continued pain in the head, accompanied by vertigo,
impairment of memory, drowsiness, mental apathy, etc., without
paralysis, would be suggestive of it, especially if there were
occasional intermissions of the symptoms. The probability would be
greatly increased if the patient had a syphilitic or alcoholic history.
The diagnosis should exclude tumor of the brain, chronic
pachymeningitis, and chronic hydrocephalus, but as these diseases
are often complicated with chronic meningitis, the distinction might
be very difficult. As already stated, chronic meningitis is almost a
constant lesion in general paralysis, as well as in other forms of
chronic insanity, but there are no special symptoms by which its
presence can be ascertained during life.

TREATMENT.—Our aim should be to relieve pain, diminish congestion,

and favor absorption. Counter-irritation to the head and nucha by
means of small blisters or croton oil should be employed with
moderation. Bromide of potassium, or, if necessary, small doses of
morphia, may be given if the pain be severe. Should there be
symptoms of cerebral congestion, such as acute delirium, flushing,
and heat of head, an ice-bag should be applied to the head and
leeches behind the ears, or blood may be drawn from the temples or
nucha by cupping. As an absorbent the iodide of potassium is much
recommended, but it is not likely to be effectual, except in syphilitic
cases. The bowels should be kept free, but without active purging.
The general health of the patient should be promoted by suitable diet
and regimen, by relief from excitement and fatigue, or by change of
scene and of climate. For the treatment of chronic meningitis
complicating syphilis, alcoholism, and tuberculosis, the reader is
referred to the articles treating of those diseases.

TUBERCULAR MENINGITIS.

BY FRANCIS MINOT, M.D.

DEFINITION.—Inflammation of the pia mater of the brain, with effusion
of lymph and pus, caused by the deposit of miliary tubercles upon its
surface or into its substance.

SYNONYMS.—Scrofulous meningitis, Granular meningitis, Basilar

meningitis, Acute hydrocephalus, Dropsy of the brain.

HISTORY.1—It is only within a comparatively recent time that

tubercular meningitis has been distinguished from other cerebral
diseases. Up to the eighteenth century the term hydrocephalus was
employed not only for the dropsical diseases of the head, including
internal and external hydrocephalus, but also for meningeal
inflammations, both simple and tubercular, and for congestion of the
brain and of the membranes; the accumulation of water in the
ventricles or between the membranes being looked upon as the
disease, and not as one of its consequences. The term was even
applied to external tumors, as cephalæmatoma and caput
succedaneum. We owe the first accurate account of the
symptomatology of acute hydrocephalus, or ventricular dropsy, to
Robert Whytt of Edinburgh, whose remarkable monograph, entitled
Observations on the Dropsy of the Brain, first published in 1768,
after his death, was founded upon the study of 20 cases with 10
autopsies. No addition of importance has been made by later
observers to his graphic description of the disease or to his rules for
its diagnosis. Whytt, however, had no clear notion of its pathogeny,
and it was not till 1815 that Gölis pointed out that acute ventricular
dropsy was a secondary condition depending upon previous
inflammation of the membranes or vessels of the brain.
1 See W. Hughes Willshire's valuable paper, entitled “Historic Data on Scrofulous
Meningitis,” in Brit. and For. Med.-Chir. Review, Oct., 1854.
In 1827, Guersant remarked that the inflammation of the meninges
constituting acute hydrocephalus presented such peculiarities as led
him to denominate it granular meningitis. He did not, however,
connect the granular deposit with tubercle. This was left for
Papavoine to effect, who in 1830 published two cases of tuberculous
arachnitis, in one of which effusion into the ventricles, or
hydrocephalus, existed. The meningeal granulations or tubercles
were described with care, and their coincidence with tuberculous
deposit elsewhere was remarked upon, as also the apparent
occurrence of the former previous to the inflammatory action in the
meninges, and in one case the existence of the tuberculous granules
without the sequence of inflammation. The important pathological
element of acute hydrocephalus thus clearly pointed out by
Papavoine now became apparent to observers, and obtained almost
universal assent. The attention of the profession in this country was
first called to it by W. W. Gerhard of Philadelphia in 1833, in an
admirable paper published in the American Journal of the Medical
Sciences,2 containing the reports of thirty-two cases with autopsies.
In every case but two tubercles were found in other organs besides
the meninges. In one of these two, gangrenous cavities were found
in the lungs without tubercles, though perfectly characterized miliary
tubercles existed in the membranes; in the other case the lungs were
not examined with care, Gerhard not being present at the autopsy.
2 Vols. xiii. and xiv., 1833-34.

Finally, the distinction between tubercular and simple meningitis was

pointed out by Guersant in 1839, and clearly established by Barthez
and Rilliet in 1843 in their systematic work on the diseases of
children; and it was further elucidated by Rilliet in 1847.

ETIOLOGY.—The causes of tubercular meningitis are predisposing

and exciting. Among the former are hereditary tendency to
tuberculosis and to the so-called scrofulous diathesis; the previous
existence of tubercle in any part of the body, especially in the lungs;
and the presence of caseous degeneration in the bronchial, the
mesenteric, and other glands, or in the parenchyma of various