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AMERICAN ACADEMY OF PEDIATRICS

PROCEEDINGS

ACUTE SUBDURAL EFFUSIONS AND LATE SEQUELAEOF MENINGITIS

By Ralph V. Platou, M.D., Andrew Rinker, M.D., and Joseph Derrick, M.D.Department of Pediatrics, Tulane Medical School, and the Charity Hospital of Louisiana

Presented at the Annual Meeting of the American Academy of Pediatrics, October 20, 1958.ADDRESS: (R.V.P.) 1430 Tulane Avenue, New Orleans, Louisiana.

962

Ped #{237}a!ticsVOLUME 23 MAY 1959 NUMBER 5

T HAT subdural effusions commonly com-

plicate purulent meningitis, particularly

in infants, is now generally appreciated/9

but some confusion and concern remains

as to their prognostic significance and

management. Tile present study is an at-

tempt to evaluate final prognosis in relation

to these subdural collections in a consecu-

tive and unselected group of patients under

the age of 3 years, treated by reasonably

standard regimens, and followed for inter-

vals of 6 months on more thereafter. The

concern we now all share over the eventual

fate of sucil patients is cleanly related to

improved survival rates;1#{176}�2 more babies

now survive to have more complications.

PATHOGENESIS

The mechanisms by which subdural col-

lections 913 14 are not here our

immediate concern, but some of the van-

ous speculations will be briefly enumerated

only to emphasize that by several of them

-alone on in combination-additional dam-

age other than that producing the subdunal

collection might be expected in other parts

of the central nervous system. In other

words, the same factors whicil might be

responsible for producing subdunal effusions

could logically be invoked to explain a num-

ben of other complications and neurologic

sequelae whicil develop during or after

recovery from meningitis; by tile same

reasoning, the presence of subdunal collec-

tions might simply reflect accompany’ing

neunologic damage.

Briefly, these mechanisms include: em-

bolic phenomena; septic thromboses and

rupture of bridging veins; direct extension

or simple transudation through the arach-

noid on its villi (“leaks”); thromboses of

dural sinuses or their tributaries with retro-

grade extension to the subdurai space by

way of the pacchionian granulations; simul-

taneous blood-borne infections; sudden

changes in intracranial tension related

either to the meningitis alone or to early

diagnostic procedures; previous or concur-

rent subdunal bleeding incident to convul-

sions on other trauma; alterations in capil-

lary permeability or in clotting mechanisms

related to associated diseases or deficien-

cies; the effects of asphyxia; and perhaps

some collections resulting from local bleed-

PEDIATRICS, Ma�y 1959

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AMERICAN ACADEMY OF PEDIATRICS - PROCEEDINGS 963

ing incident to initially negative subdural

taps.

Regardless of which cause or combina-

tion of causes obtains in the individual case,

subdunal collections are most commonly en-

countered in the youngest patients during

the phase of rapid head growth, presumably

while cranial structures are most expanda-

ble. Also, they are apt to occur in those

patients who are recognized and treated for

meningitis at relatively late stages, in those

who exhibit the most conspicuous clinical

symptoms and signs of early high intra-

cranial pressure, or in those whose early re-

sponse to conventional therapy is unfavon-

able or atypical.

CLINICAL MATERIAL FOR ANALYSIS

Patients

The present analysis is concerned with 343patients, newly’ born to 36 months of age, being

consecutive admissions for acute purulent men-

ingitis over a 4-year period ending in 1955.

Fift�’-one (14.9%) of the patients died, and

14 of these had major underly’ing neurologic

defects for which the meningeal infection

might be legitimately considered only as a

terminal event. These 14 patients had such

preceding conditions as congenital hydrocepha-

lus, hvdrancephalv, meningomyelocele, en-

cephalocele, ponencephaly, communicating

dermal sinus, astroblastoma, ependymoma, in-

fantile coanctation and severe compounded

skull fractures. In each of the 14, death seemed

more logically related to the preceding condi-

tion than to the meningeal infection. Thus we

might claim a “corrected” total fatality rate of

10.8% for all 343 patients.Among the 292 survivors, there were 55 who

had early subdural effusions, 32 who had mildneurologic sequelae, and 25 who were left withsevere handicaps. In Tables I and II, the totalgroup is distributed by age, etiology and case-

fatality rates.

Treatment

During the period of this study, patientswere treated by a reasonably uniform plan.

Immediately’ after prompt collection of all

pertinent diagnostic specimens, and without

delay for establishing a definitive etiologic

agent, the patients were “flooded” with a

priming combination of agents designed to

combat effectively the commonest causes formeningitis in this age and at that time. Initialdoses were given parenterally and quickly, withproper attention to renal function and state of

hydration. The priming combination (“blitz”)

consisted of sulfadiazine 100 mg/kg, chlor-amphenicol 100 mg/kg and penicillin 600,000

units.Continuing therapy usually included these

three same agents for 8 days but with per-

missible variations in dosage and duration and

substitutions, according to the organism ne-

covered, its in-vitro sensitivity tests and the

clinical response. The continuing dosages were:

for sulfadiazine, from 100 to 200 mg/kg dailydivided into three or four parts and given at 6-

to 8-hour intervals; for chloramphenicol, a totaldosage of 50 to 100 mg/kg/day divided into

three or four equal parts and given at these sameintervals; and for penicillin, the original dosage

of 600,000 units was given every 2 to 6 hours.

TABLE I

DEATHS (NUMERATORS) AND TOTAL CASES (DENOMINATORS) ARRANGED ACCORDING

TO AGE AND CAUSE

Age (no)

Under 6

6-b2

Over 1�2

if.I.� � Pn.� �

4/40 �/13

3/34 1/8

3/44 0/10

Men.*

1/�

1/�

�/1�

“Other8”t

13/�6

�/5

‘3/7

Unknown**

81.50

�/33

6/5�

Totals

�8/l31

9/8�

14/130

Totals 1o/1�23 � 3/31 � 4/16 18/38 16/135 .51/343

* Ilemophulus influen.zae, Pneumocoecus, Meningococcus.

t See text for components.** Cultures negative; previously treated.


964 SUBDURAL EFFUSIONS

TABLE II

CASE FATALITY RATES, BY AGE AND CAUSE

Age (mo) 1-1.1. Pn. � Men. “Other” Unknown Totals

Under6

6-1�

Over1�

10.0

8.9

6.8

15.4

1�.5

0.0

-

-

16.6

50.0

40.0

43.0

16.0

6.1

11.5

�1.3

11.0

10.8

Totals 8.1 9.7 � 25.0 47.4 11.9 14.9*

* (“Corrected” : 10.8.)

Parenthetically, it speaks well for the diligence

and care furnished by the many house officersdirectly concerned with treatment of these pa-tients that toxicity referable to the initial dos-age of sulfadiazine was encountered in only 3

of the 343 patients treated. In all 3, eventual

outcome seemed entirely satisfactory following

diuresis and reduction of drug dosage. It

seemed to us that the calculated risk of occa-sionai undesirable side-effects of such therapy

was more than favorably offset by the urgent

need to obtain high levels in the tissues for each

of the therapeutic agents, promptly and effec-

tively.

RESULTS OF ANALYSIS

Subdural Collections

Although subdural collections were cx-

pected (particularly in young infants who

were admitted to the hospital late) for those

with conspicuous early symptoms of intra-

cranial hypertension or those whose re-

sponse to therapy was atypical or unfavora-

ble, more specific features which led to

diagnostic subdural punctures included:

convulsions, focal neurologic signs, per-

sistent fever, bulging fontanelie, rapidly in-

creasing head size, projectile vomiting and

opisthotonus. When any of these features

were present, alone or in varying combina-

tions, punctures were promptly done at the

lateral angles of the fontanelles (or in older

infants slightly beyond) through the coronal

sutures.

Among the survivors, early collections

were demonstrated in 55 patients, and

suspected by the same criteria but not

found in 33. For lack of any suspicious

symptoms or signs the subdural spaces in

the remaining 204 patients were not tapped.

When a collection was suspected, bilateral

taps were routinely made, and in 24 of the

55 cases with subdural collections these

were present on both sides. The distribution

of these collections according to age of the

patients and cause of meningitis is dis-

played in Tables III and IV.

Interestingly, both fatality rates and fre-

quency of subdural collections were great-

est among patients who had meningitis due

to “mixed and other” causes. These included

mostly the very young infants with menin-

gitis due to a variety of organisms-coli-

form, staphylococci, streptococci, listenia,

mimeae, pseudomonas, and salmonellas-

with dual etiology in several cases and

difficulties in attaining bacteriologic control

for many.

Most patients for whom etiologic diag-

TABLE III

PROVEN SUBDURAL COLLEC’rIONS AMONG ALL SURVIVORS, DISTRIBUTED BY AGE AND CAUSE

Age (mo) H.I. Pn. Men. “Others” � Unknown Totals

Under6

6-1�

Over 1�

1.5/36

7/31

�/46

5/11

1/7

1/10

0/1

0/1

1/10

7/13

1/3

0/4

11/4�

3/31

1/46

38/103

1�/73

5/116

Totals �4/113 7/�8 1/1� 8/�0 15/119 55/’29�2


TABLE IV

l�EI( CENT OF PATIENTS hAVING PII0vEN SIBDURAL CoLI�Ec�rIoNs, BY AGE AND CAUSE

Age (nio) � /1.1. � Pa. Men. ‘Others” Unknown

1Ilder 6

6-1�

Over 1’2

Totals

41.7 45.4

�2.6 14.3

4.3 10.0

�21.�2 �25.0

10.0

8.3

Totals

53.8

33.3

0.0

40.0

�6 . ‘2

9.7

1’2.6

37 �0

16.4

4.3

18.8


nosis remained “unknown” on “questiona-

ble” had been treated by various persons

and means before they were admitted to

our hospital, and for only a few had previ-

ous therapy been guided by any prelimi-

nary examination of cenebrospinal fluid. In

a large number, penicillin on other antibac-

tenial agents had been given without suspi-

cion of meningitis on before development

of signs on symptoms of meningeal irnita-

tion. It is gratifying to note, perhaps as a

reflection of the very efficacy of even indis-

cniminate therapy, that both fatality rate

and the incidence of subdural collections

in this group compared so well with those

of patients with meningitis of specified

etiology.

The character, amount, timing, latenality

and clinical features accompanying the sub-

dural collections were critically examined

to establish the validity of criteria for cx-

pecting them or for relating their charac-

tenistics to the likelihood of additional neu-

roiogic sequelae. Though the general

criteria for recognition of these collections

seemed to be borne out, there were enough

exceptions so that we could not establish

statistically the validity of any one circum-

stance-on of several combinations. On the

average, tilose with proved subdural collec-

tions received therapy about 3 days later

tllan did those who had no evidence to

suggest sucil collections. The initial pres-

sures of the cerebrospinal fluid, measured

at lumbar level, were not signficantly dif-

fenent among those who did or did not

develop collections; the means and medians

for both groups were about 300 mm. One

might argue, but would have difficulty in

proving, that those without collections were

apt to be more robust, to struggle more,

and thus to destroy the validity of such

comparisons.

There were no apparent differences in the

frequency of subdural collections or other

complications related to race or sex of pa-

tients, etiology of tile meningitis, frequency

of positive blood cultures, and chanactenis-

tics encountered in the routine examina-

tions of the original cerebrospinal fluid Sc-

cured at lumbar taps. In only 8 of the 55

patients was an initial diagnostic subdural

tap negative and a later tap positive; in

other words, significant collections (1 ml or

more, obtained promptly) were encountered

at the first tap in 47 of the 55 patients who

had these demonstrated at any time.

The typical subdunal fluid was xantho-

chromic and cloudy, often slightly blood-

tinged; in only three instances was frank

pus encountered, and only five collections

were definitely or grossly bloody. From 10

of the 49 collections cultured, the same

organism was recovered as had been se-

cured from the initial specimen of cere-

brospinal fluid. The pressures within the

collections were not routinely measured,

but seemed usually increased. At the time

these patients were being treated, many

initial subdunal collections were completely

drained, not merely sampled; and the

amounts varied from as little as 1 ml to as

much as 54 ml from either side. A 5-month-

old patient had the largest collection in

our experience and it cleaned completely;

the infant has had no recognized neurologic

defects.

Sequelae

Sequelae which may follow purulent

meningitis (whether on not there is an

effusion) are numerous, reasonably well-



TABLE V

SEVERITY OF SEQUELAE AMONG 29’2 SURVIVORS (AS

JUDGED 6 MoNTHS OR MORE ArFER

ACUTE MENINGITIS)

Symbol Status Number

0* Considered or known to be intaCt. ‘235

+ t

+ +

BehaVior problems, emotional

instability, poor gains in weight

and height.Localized defects, but functional.

21

11

+ + + Retarded development and con-

vulsions. 12

+ + + + Invalids; “decerebrste,” hydro-

cephalus, opisthotonus, etc. 13

* “Negative.”

t “Positive.”

known, and too variable for detailed de-

scniption here. For our present purposes, we

have considered that those we encoun-

tered could be divided into four groups,

as indicated in Table V. Neither the parents

nor the physicians who have examined the

235 individuals that are indicated as “in-

tact” have had concern as to any handicap

whatsoever, though data are incomplete

for some of these patients. Twenty-one of

the patients are said to have, or are known

to have had, behavior disturbances, emo-

tional instability, poor weight or height

gains, and questionable delays in develop-

mental schedules, which might be attributed

either to the meningitis or to other preced-

ing and environmental causes. In other

words, these mildest residua in 21 patients

are only questionably attributable to the

preceding meningitis-”post hoc, ergo prop-ter hoc.” A second group of 11 patients have

localized defects of relatively minor nature,

but are not seriously incapacitated. These

included palsies of the extra-ocular mus-

des, hearing defects, mild monoplegia,

hemiparesis, etc. For our present purposes

we have designated these first two groups,

including 33 patients in all, as “mild.” The

third and fourth groups, comprising 25

patients, have unmistakably severe subse-

quent neurologic handicaps; in group 3,

there are 12 patients who are definitely

retarded and have serious convulsive dis-

orders, while in group 4 there are 13 pa-

tients who present the pitiful picture of

chronic basilar meningitis with fixed

opisthotonus and hydrocephalus. In Table

VI, sequelae are arranged according to age

and by etiology of the purulent meningitis;

nearly a fifth of all survivors had residua of

concern, and slightly less than half of these

were severe and disabling.

Though there seems no doubt that seque-

lae are significantly more common among

those who had early subdunal collections,

specific significance as to frequency or

severity of sequelae could not be attached

to the time at which these occurred, their

amount, their character on their duration.

Both acute collections and later sequelac

were commonest in the youngest patients

and in those who were treated late-but in

the older patients, where the collections

were less frequent, they were ominous by

their more consistent association with later

handicaps. Among 10 patients with subdural

collections from which cultures were posi-

tive for the same organism that caused the

meningitis, only 3 escaped with no residua;

3 had severe sequelae, and 4 had mild

sequelac. Distribution of sequelae was al-

TABLE VI

TOTAL SEQUELAE AMONG ALL SURVIVORS, BY AGE AND CAUSE

Age (mo) ii.!. � Pn.

7/36 3/11

3/31 2/7

9/46 4/10

Men.

0/1

0/1

1/10

“Others” � Unknown �

5/13 9/4’2

2/3 5/31

1/4 6/46

Total

‘24/103

1’2/73

21/116

Per Cent

‘23.3

16.4

18.1

Under6

6-12

Overl’2

Totals 19/113 � 9/28 1/12 8/20 � ‘20/119 57/’29’2 19.’2


�‘UtsJ � CAUSES

PATIENTS l3�

�5tJ�R.VlVED 11Q (88%)

U)

zLii

�;2O

10

0

*Q�

0 #{128}� ia is 21

MONJ1�-4S

30

ANIERICAN ACADEMY OF PEDIATRICS - PROCEEDINGS 967

Fic. 1. Nulllher of deatlls, sequelac and recoveries in each 6-month period, by age

at which purulent meningitis due to “unknown” organisms occurred.

most identical when related to the time

or number of taps before the collections

cleaned.

Pertinent Relationships

In Figures 1-4, results are portrayed by

age for each of the four major etiologic

groups; tile number of infections due to

meningococci was too small for sucil analy-

sis. In the etiologic groups, we have con-

sidered only those patients for whom the

eventual fate as to sequelae has been estab-

lished, and for whom subdunal collections

were cleanly demonstrated (“positive”) or

not suspected (“negative”). Thus, from the

point of view of prognosis, the figures

shown could be considered as at least con-

servative estimates as to frequency on

severity of sequelae. Suspected, but un-

proved collections, and any uncertain fol-

low-ups are excluded from the numerical

comparisons.

Among those 135 patients wilo had

meningitis due to unknown causes (Fig. 1),

most having been treated before admission,

88% survived. In this figure both deaths

and rcsidua among survivors arc distributed

by age. Half of 12 babies with proven early’

subdunal collections were left with severe

neurologic handicaps, while among 66 pa-

tients for whom no collection was suspected

there were only 2 such, and in one of these

the handicap migilt well have been sus-

pected before the meningitis occurred. In

all, there are 20 nesidua among 119 sun-

vivors.

Among the 123 patients with meningitis

due to Hemophilus influenzae, 93% survived

and about 16% of the survivors are known

to have residua of some degree (Fig. 2). In

this group serious disabilities were also

clearly more common among those who had

proven early subdunal collections (3 of 19)

than they were among the patients for

wilom such were not suspected (2 of 54).

As expected, poorest results as to sun-

viva! were obtained with the group of 38

patients who had the mixed on “other” in-

fections previously discussed (Fig. 3). Here

we were dealing with the youngest infants,

ITJ lxita.ct

___ Mild. sec�ie1ae� Severe sequ.elae

___Died


�-4. 1NFLUEMZAE

PATIENTS 123

SURVIVED I I 3 (93%)

c�J lrita.ct� �tiid Se.Qu�1a�ci� Severe s�cRLL�lO.a

- D�d

36

MIXED � �‘OT1.4EQS”’

PATlEI�.iT5 38

5LLR.V%VED �O (53#{176}%)

10

E=1�ill�

Ir�:act

M�1d se�la.�

9ever�z S�ualc�

36


40

2

�20I.-

10

00 6 12 IS a4 30

M0NT�S

Fic. 2. Number of deaths, sequelae and recoveries in each 6-month period, by age

at which purulent meningitis due to Hemophilus infiuenzae occurred.

almost half having serious underlying con-

genital defects involving the central nenv-

ous system. Even in this small group,

though numerically far from impressive,

the frequency of serious sequelac was

sliglltly greaten among the survivors who

had early proven subdural collections (two

of five compared to two of seven).

Survival rates among the 31 with pneu-

mococcal meningitis were better than we

would have expected, though nearly a third

of the survivors are considered to have

residual handicaps of some degree. Here

too (Fig. 4) severe sequelae appeared to be

cleanly related to the presence of early sub-

dunal collections, being obvious in three of

seven with effusions, and in none of 20 with-

out such.

0

Fic. 3. Number of deaths, sequelae and recoveries in each 6-month period, by age at which

purulent meningitis due to “mixed” and/or “other” organisms occurred.


PJ�.JEUM0COCCAL

H2

10-

00

1

15

Fic. 4. Number of deaths, sequeiae and recoveries in each 6-month period, by age at which

purulent meningitis due to pneumococcus occurred.

3E�


* (P<.0005.)

PATIEkJTS �I

5uc�.vlvEo aS(90.3%

20i II

L_J

� �ild SequzLa.�

Sevzre 5caqu�Iac

- 1�i�d

Ill Tables VII and VIII#{176} known sequelae

are related to subdural collections which

were demonstrated (“positive”), to those

\vllich were suspected but could not be

proved (“negative”), and to a tllird group in

which there were no evidences of subdural

collections for which diagnostic ptinctures

��‘ere indicated ( “negative”). Among these

three groups tile differences in incidence of

sequelae are large; there is sufficient cvi-

‘I’ABLE VII

TOTAL KNOWN SEQLELAE AMONG TImER GuoUl’s;

ThosE WITH PROVEN EARLY SUBDUIIAL COLLEC-

TIONS (+). ‘I’IIOSE FOR \\IIOM CoI�LEc-rIoNS

WERE SUSPECTED BUT NOT FOUND (-), AND

THOSE AMONG WHOM No COLLECTION

WAS SUSPECTED

Taps

Sequelae

---

les No

Total Per Cent

+-

Notdone

‘21 ‘23

1’2 ‘21

‘24 1’2’2

44

33

146

477*

36.4

16.4*

Totals 57 166 223 25.6

* (P<.0005.)

0 Data were adequate for final satisfactory evalu-

ation in only 223 of 292 survivors; 69 were reported

or coflsi(lered to l)C normal, but are not included in

these tables.

dence that the frequency of both tile total

and severe residual effects differ significantly

among the three groups (p < .0005). Ob-

viously, tile observed gradations suggest

that the features indicative of subduna! ef-

fusions simply reflect underlying brain dam-

age or are causally related.

Finally, distribution of effusions and se-

quelac were considered among tile survivors

of three age-groups (Table IX). Among

those under 6 montils of age at the time

meningitis occurred, 37% had “positive” sub-

dural taps, and 63% had no collection sus-

pected or demonstrated. In this group of

103 babies, 23% had sequelae, 14% falling

among those witil subdural collections and

9% in those without. In this age group, then,

TABLE \‘III

As IN TABLE HI, BUT CONsIDERING ONLY

SEVERE (+++. ++++) SEQUELAE

Taps

Sequelae

�--

Yes No

Total Per Cent

+-

0

14 30

5 28

6 140

44

33

146

31.8*

15.2

4.l�

Totals 25 198 223 11.2



TABLE IX

PER CENT ACUTE SUBDURAL EFFUSIONS AND

LATER RESIDUA, BY AGE

Age (mo)

Under 6 7-12 Over 1�

With effusions

Residua, %36 . 9

31 . 6

16 . 4

33 .3

4.3

100

Without effusions�

Residua, %63 . 1

18.4

83 . 6

13.1

95.7

14.4

* (Not found, or tap not indicated.)

about a third of those with subdural collcc-

tions, and roughly a sixth of those without

such, had later sequelac of varying degrees.

Among 73 infants who survived punulent

meningitis during the second 6 months of

life, 12 (about 16%) had definite subdural

collections. Here again, about a third of

those with early subdural collections, and

about a seventh of those without such, had

later handicaps attributable to their menin-

gitis.

Among 116 survivors between 12 and 36

months of age, only about 4% had “positive”

subdunal collections and all of these were

left with sequclac; while only one-seventh

of those for whom no collection was sus-

pected or proved had similar damage.

DISCUSSION

These studies leave little doubt that sub-

dural collections in acute and purulent

meningitis have ominous prognostic signifi-

cance. It is difficult to believe that associ-

ated sequelac are due to the diagnostic

maneuvers necessary to demonstrate these

collections or to their commonly accepted

treatment by repeated taps according to

pressure symptoms until “dry.”

We have the impression that the best cx-

planation for the observed correlation is

that the subdural collections simply reflect

the occurrence of variously localized on dif-

fuse neurologic and vascular involvement in

acute bacterial meningitides.

Whether or not the over-all prognosis

could be improved with more aggressive

surgical attack on these collections at an

earlier date remains a controversial qucs-

915 5� fan, it has been our practice to

interfere surgically for removal of subdunal

membranes only when collections persist

despite repeated taps or when they have at

the initial tap or later the characteristics

typical of subdunal hematoma. In only one

of the present cases under discussion was

there evidence to suggest that a traumatic

subdunal hematonia had antedated the oc-

currence of meningitis. In only two others

was the initial subdural fluid grossly bloody;

in these three the residual effects were

severe despite concerted medical and neuno-

surgical measures.

Because most of these collections arc

recognized after reasonably adequate con-

trol of the infection, and because we be-

lieve that most of them are due to inflam-

matory vascular changes in the very expand-

able immature meninges, adrenal steroids

may be justified or even indicated in their

treatment for an effect in ameliorating the

inflammation that is perhaps responsible

both for the subdural collection and some

of the associated ncurologic damage.

J udged from results observed in the present

series, effects of such a trial would have to

be remarkably consistent on comparable in

a considerable number of patients before

any final conclusion could be reached or a

firm recommendation made.

Certainly, with the improved survival

rates now obtaining for most types of puru-

lent meningitis, further studies arc urgently

indicated to elucidate the specific mecha-

nisms for production of these collections,

how best to treat them, and how to prevent

more of the many handicaps among sur-

vivors.

CONCLUSIONS

In a group of 343 consecutive patients

under 36 months of age with acute punulent

meningitis, survival rates were encouraging

but neurologic scquclae were disturbingly

frequent. Fifty-five infants had subdural



collections during the acute phase of their

disease. An attempt was made to evaluate

the prognostic significance of these.

It appears clear that the frequency and

severity of neunologic sequclac are related

to the presence of early subdunal collec-

tions, but these could not be specifically

correlated as to volume, character, on time

at which they occurred. Subdunal collec-

tions are most frequent in the youngest pa-

tients, for whom early recognition of menin-

gitis may be difficult or delayed.

It is assumed, but not proved, that factors

similar to those responsible for production

of the subdunal collections also caused

many of the evidences of brain damage that

appeared concomitantly or developed later.

Acknowledgment

We are indebted to Dr. Lila Elvebach

and Miss Ethel Eaton for advice and help

with the statistics involved in this study, to

Drs. W. A. Williams, Jr. and Crawford W.

Long for help with analyses of hospital rec-

ords, to Mrs. Scott Wilson for securing many

of the follow-up observations, and to Miss Vera

Morel for preparation of the figures.

REFERENCES

1. McKay, R. J., Jr., Ingraham, F. D., andMatson, D. D. : Subdural fluid compli-

eating bacterial meningitis. J.A.M.A.,152:387, 1950.

2. Smith, M. H. D., Dormant, R. E., andPrather, G. W. : Subdural effusions corn-

plicating bacterial meningitis. PEDI-

ATBICS, 7:34, 1951.

3. Guthkelch, A. N. : Subdural effusions in

infancy-24 cases. Brit. M. J., 1:233,1953.

4. Epstein, J. A., and Goldzier, S. E., II:Bilateral encapsulated subdural effusioncomplicating bacterial meningitis in in-fancy. Report of a case with review ofliterature. Arch. Neurol. & Psvchiat., 69:242, 1953.

5. Stevens, H., and Williams, J. M. : Sub-dural effusions in infancy. M. Ann.District of Columbia, 22:169, 1953.

6. Jones, H. E. : Subdural effusions in puns-

lent meningitis. Lancet, 1:891, 1954.7. Matthews, E. C. : Subdural effusions com-

plicating bacterial meningitis-a pedi-atnic review. Ohio M. J., 50: 1154, 1954.

8. Smith, M. H. D. : Acute bacterial menin-gitis; review. PEDIATRICS, 17:258, 1956.

9. Smith, M. H. D. : Subdunal lesions in child-

hood, with special references to in-fectious processes. Advances Pediat., 8:165, 1956.

10. Smith, E. S. : Puruient meningitis in infants

and children; a review of 409 cases. J.Pediat., 45:425, 1954.

11. Koch, R., and Carson, M. J.: Managementof Hemophilus influenzae (B) meningitis;analysis of 128 cases. J. Pediat., 46: 18,1955.

12. Ross, S. : Treatment of pyogenic meningitisin infants and children. Clin. Proc.Child. Hosp., 1 1 :49, 1955.

13. Weed, L. H., Wagafonth, P., Ayer, J. B.,and Felton, L. D. : A Study of Expcri-mental Meningitis. New York, Rockefel-Icr Institute for Med. Res., Monograph

No. 12, 1920.14. Spitz, E., Pollak, A., and Angris, A. : Sub-

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Springfield, Thomas, 1954, pp. 383-385.


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