Multimedia Tools and Applications for

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Alexis Joly
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Multimedia Systems and Applications

Alexis Joly · Stefanos Vrochidis

Kostas Karatzas · Ari Karppinen
Pierre Bonnet Editors

Multimedia Tools
and Applications
for Environmental
& Biodiversity
Informatics
Multimedia Systems and Applications

Series editor
Borko Furht, Florida Atlantic University, Boca Raton, USA
More information about this series at http://www.springer.com/series/6298
Alexis Joly • Stefanos Vrochidis • Kostas Karatzas
Ari Karppinen • Pierre Bonnet
Editors

Multimedia Tools and

Applications for
Environmental &
Biodiversity Informatics

123
Editors
Alexis Joly Stefanos Vrochidis
Inria ZENITH Team Centre for Research & Technology
Montpellier, France Hellas – Information Technologies
Institute
Kostas Karatzas Thessaloniki, Greece
Aristotle University of Thessaloniki
Thessaloniki, Greece Ari Karppinen
FMI/Atmospheric Composition
Pierre Bonnet Finnish Meteorological Institute
CIRAD, UMR AMAP Helsinki, Finland
Montpellier, France
AMAP, Univ Montpellier
CIRAD, CNRS, INRA, IRD
Montpellier, France

Multimedia Systems and Applications

ISBN 978-3-319-76444-3 ISBN 978-3-319-76445-0 (eBook)
https://doi.org/10.1007/978-3-319-76445-0

Library of Congress Control Number: 2018943131

© Springer International Publishing AG, part of Springer Nature 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, express or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by the registered company Springer International Publishing AG part
of Springer Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
The authors would like to dedicate this book
to the citizen scientists all around the world
who invest their time, capacity and
knowledge to develop research projects with
the scientific community. Several research
results presented in this book could not have
been reached without a large and massive
investment of citizens: this is why the authors
would like to thank, in the broad sense, the
citizen scientist community.
Preface

The recent and rapid advancements of digital technologies have resulted in a

great increase of multimedia data production worldwide. This is also the case for
multimedia data that characterize our environment and the earth biodiversity and
reflect their status, behavior, change as well as human interests and concerns. Such
data become more and more crucial for understanding environmental issues and
phenomena. Therefore, there is an increasing need for the development of advanced
methods, techniques and tools for collecting, managing, analysing, understanding
and modelling environmental and biodiversity data. This edited volume focuses
on the last and most impactful advancements of this field. It provides important
recommendations for the implementation of computational platforms dedicated
to environmental monitoring or citizen science observatories. It gives innovative
and detailed architectures and specifications for the development of real-time,
highly scalable, detection systems. Finally, it demonstrates the effectiveness of
computational intelligence approaches in the analysis and modelling of relevant
data.

Montpellier, France Alexis Joly

Montpellier, France Pierre Bonnet
Thessaloniki, Greece Stefanos Vrochidis
Thessaloniki, Greece Kostas Karatzas
Helsinki, Finland Ari Karppinen

vii
Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Alexis Joly, Pierre Bonnet, Stefanos Vrochidis, Kostas Karatzas,
and Ari Karppinen
2 Developing Mobile Applications for Environmental
and Biodiversity Citizen Science: Considerations
and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Soledad Luna, Margaret Gold, Alexandra Albert, Luigi Ceccaroni,
Bernat Claramunt, Olha Danylo, Muki Haklay, Renzo Kottmann,
Christopher Kyba, Jaume Piera, Antonella Radicchi, Sven Schade,
and Ulrike Sturm
3 A Toolbox for Understanding and Implementing a Citizens’
Observatory on Air Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Hai-Ying Liu, Mike Kobernus, Mirjam Fredriksen, Yaela Golumbic,
and Johanna Robinson
4 A Real-Time Streaming and Detection System for Bio-Acoustic
Ecological Studies After the Fukushima Accident . . . . . . . . . . . . . . . . . . . . . . 53
Hill Hiroki Kobayashi, Hiromi Kudo, Hervé Glotin, Vincent Roger,
Marion Poupard, Daisuké Shimotoku, Akio Fujiwara,
Kazuhiko Nakamura, Kaoru Saito, and Kaoru Sezaki
5 Towards Improved Air Quality Monitoring Using Publicly
Available Sky Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Eleftherios Spyromitros-Xioufis, Anastasia Moumtzidou,
Symeon Papadopoulos, Stefanos Vrochidis, Yiannis Kompatsiaris,
Aristeidis K. Georgoulias, Georgia Alexandri,
and Konstantinos Kourtidis

ix
x Contents

6 Traits: Structuring Species Information for Discoverability,

Navigation and Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Thomas Vattakaven, Prabhakar Rajagopal,
Balasubramanian Dhandapani, Pierre Grard,
and Thomas Le Bourgeois
7 Unsupervised Bioacoustic Segmentation by Hierarchical
Dirichlet Process Hidden Markov Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Vincent Roger, Marius Bartcus, Faicel Chamroukhi, and Hervé Glotin
8 Plant Identification: Experts vs. Machines in the Era
of Deep Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Pierre Bonnet, Hervé Goëau, Siang Thye Hang, Mario Lasseck,
Milan Šulc, Valéry Malécot, Philippe Jauzein, Jean-Claude Melet,
Christian You, and Alexis Joly
9 Automated Identification of Herbarium Specimens at Different
Taxonomic Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Jose Carranza-Rojas, Alexis Joly, Hervé Goëau, Erick Mata-Montero,
and Pierre Bonnet
10 A Deep Learning Approach to Species Distribution Modelling . . . . . . . 169
Christophe Botella, Alexis Joly, Pierre Bonnet, Pascal Monestiez,
and François Munoz

A Existing Data and Metadata Standards and Schemas Related

to Citizen Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

B Creative Commons (CC) and Open Data Commons (ODC)

Licenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

C List of Apps, Platforms and Their Functionalities in Citizen

Science Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

D Examples of Symbolic and Non-symbolic Rewards in Citizen

Science Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

E List of Apps for Sonic Environment and Noise Pollution

Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Contributors

Alexandra Albert University of Manchester, Manchester, UK

Georgia Alexandri Democritus University of Thrace, Xanthi, Greece
Marius Bartcus DYNI Team, DYNI, Aix Marseille Univ, Université de Toulon,
CNRS, LIS, Marseille, France
Pierre Bonnet CIRAD, UMR AMAP, Montpellier, France
AMAP, Univ Montpellier, CIRAD, CNRS, INRA, IRD, Montpellier, France
Thomas Le Bourgeois CIRAD, UMR AMAP, Montpellier, France
Christophe Botella INRIA Sophia-Antipolis - ZENITH team, LIRMM - UMR
5506 - CC 477, Montpellier, France
INRA, UMR AMAP, Montpellier, France
AMAP, Univ Montpellier, CIRAD, CNRS, INRA, IRD, Montpellier, France
BioSP, INRA, Site Agroparc, Avignon, France
Jose Carranza-Rojas School of Computing, Costa Rica Institute of Technology,
Cartago, Costa Rica
Luigi Ceccaroni 1000001 Labs, Barcelona, Spain
Faicel Chamroukhi LMNO UMR CNRS, Statistics and Data Science, University
of Caen, Caen, France
Bernat Claramunt CREAF, Edifici Ciéncies, Autonomous University of
Barcelona (UAB), Bellaterra, Catalonia
Ecology Unit (BABVE), Autonomous University of Barcelona (UAB), Bellaterra,
Catalonia
Olha Danylo International Institute for Applied Systems Analysis (IIASA),
Laxenburg, Austria

xi
xii Contributors

Balasubramanian Dhandapani French Institute of Pondicherry, UMIFRE 21

CNRS-MAEE, Pondicherry, India
Mirjam Fredriksen NILU – Norwegian Institute for Air Research, Kjeller,
Norway
Akio Fujiwara GSALS, The University of Tokyo, Tokyo, Japan
Aristeidis K. Georgoulias Democritus University of Thrace, Xanthi, Greece
Hervé Glotin DYNI Team, DYNI, Aix Marseille Univ, Université de Toulon,
CNRS, LIS, Marseille, France
Hervé Goëau CIRAD, UMR AMAP, Montpellier, France
AMAP, Univ Montpellier, CIRAD, CNRS, INRA, IRD, Montpellier, France
Margaret Gold National History Museum London, London, UK
Yaela Golumbic TECHNION – Israel Institute of Technology, Technion City,
Haifa, Israel
Pierre Grard CIRAD, Nairobi, Kenya
Muki Haklay Extreme Citizen Science (ExCiteS), University College London,
London, UK
Siang Thye Hang Toyohashi University of Technology, Toyohashi, Japan
Philippe Jauzein AgroParisTech UFR Ecologie Adaptations Interactions, Paris,
France
Alexis Joly Inria ZENITH Team, Montpellier, France
Kostas Karatzas Aristotle University of Thessaloniki, Thessaloniki, Greece
Ari Karppinen FMI/Atmospheric Composition, Finnish Meteorological Institute,
Helsinki, Finland
Hill Hiroki Kobayashi CSIS, The University of Tokyo, Tokyo, Japan
Mike Kobernus NILU – Norwegian Institute for Air Research, Kjeller, Norway
Yiannis Kompatsiaris Centre for Research and Technology Hellas – Information
Technologies Institute, Thessalonki, Greece
Renzo Kottmann Max Planck Institute for Marine Microbiology, Bremen,
Germany
Konstantinos Kourtidis Democritus University of Thrace, Xanthi, Greece
Hiromi Kudo CSIS, The University of Tokyo, Tokyo, Japan
Christopher Kyba GFZ German Research Centre for Geosciences, Potsdam,
Germany
Contributors xiii

Mario Lasseck Museum fuer Naturkunde Berlin, Leibniz Institute for Evolution
and Biodiversity Science, Berlin, Germany
Hai-Ying Liu NILU – Norwegian Institute for Air Research, Kjeller, Norway
Soledad Luna European Citizen Science Association (ECSA), Institute of Forest
Growth and Computer Science, Technische Universität Dresden, Dresden, Germany
Nazca Institute for Marine Research, Quito, Ecuador
Valéry Malécot IRHS, Agrocampus-Ouest, Rennes, France
INRA, Université d’Angers, Angers, France
Erick Mata-Montero School of Computing, Costa Rica Institute of Technology,
Cartago, Costa Rica
Jean-Claude Melet Independent Botanist
Pascal Monestiez BioSP, INRA, Site Agroparc, Avignon, France
Anastasia Moumtzidou Centre for Research and Technology Hellas – Information
Technologies Institute, Thessalonki, Greece
François Munoz Université Grenoble Alpes, Saint-Martin-d’Hères, France
Kazuhiko Nakamura CSIS, The University of Tokyo, Tokyo, Japan
Symeon Papadopoulos Centre for Research and Technology Hellas – Information
Technologies Institute, Thessalonki, Greece
Jaume Piera Institute of Marine Sciences (ICM-CSIC), Barcelona, Spain
Marion Poupard AMU, University of Toulon, UMR CNRS LIS, Marseille, France
Antonella Radicchi Technical University Berlin, Berlin, Germany
Prabhakar Rajagopal Strand Life Sciences, Bangalore, India
Johanna Robinson JSI – Jožef Stefan Institute, Ljubljana, Slovenia
Vincent Roger DYNI Team, LIS UMR CNRS 7020, AMU, University of Toulon,
Marseille, France
Kaoru Saito CSIS, GSFS, GSALS, The University of Tokyo, Tokyo, Japan
Sven Schade European Commission, Joint Research Centre (JRC), Unit B06-
Digital Economy, Ispra, Italy
Kaoru Sezaki CSIS, The University of Tokyo, Tokyo, Japan
Daisuké Shimotoku GSFS, The University of Tokyo, Tokyo, Japan
Eleftherios Spyromitros-Xioufis Centre for Research and Technology Hellas –
Information Technologies Institute, Thessalonki, Greece
xiv Contributors

Ulrike Sturm Museum für Naturkunde Berlin, Leibniz Institute for Evolution and
Biodiversity Science, Berlin, Germany
Milan Šulc Czech Technical University in Prague, Prague, Czech Republic
Thomas Vattakaven Strand Life Sciences, Bangalore, India
Stefanos Vrochidis Centre for Research & Technology Hellas – Information
Technologies Institute, Thessaloniki, Greece
Christian You Société Botanique Centre Ouest, Nercillac, France
Acronyms

CNN Convolutional Neural Network. 162

FCM Flat Classification Model. 158, 160, 162–164, 166, 167
H1K Herbaria1K. 156–158
HD-CNN Hierarchical Deep CNN. 155
I ImageNet. 157
MCM Multi-Task Classification Model. 160, 161, 163, 165–167
PRELU Parametric REctified Linear Unit. 160

xv
Chapter 1
Introduction

Alexis Joly, Pierre Bonnet, Stefanos Vrochidis, Kostas Karatzas,

and Ari Karppinen

Abstract The recent and rapid advancements of digital technologies, as well as the
progress of digital cameras and other various connected objects have resulted in a
great increase of multimedia data production worldwide. Such data becomes more
and more crucial for understanding environmental issues and phenomena, such as
the greenhouse effect, global warming and biodiversity loss. Therefore, there is an
increasing need for the development of advanced methods, techniques and tools for
collecting, managing, analyzing and understanding environmental and biodiversity
data. The goal of this introductory chapter is to give a global picture of that domain
and to overview the research works presented in this book.

A. Joly ()
Inria ZENITH Team, Montpellier, France
e-mail: alexis.joly@inria.fr
P. Bonnet
CIRAD, UMR AMAP, Montpellier, France
AMAP, Univ Montpellier, CIRAD, CNRS, INRA, IRD, Montpellier, France
e-mail: pierre.bonnet@cirad.fr
S. Vrochidis
Centre for Research & Technology Hellas - Information Technologies Institute, Thessaloniki,
Greece
e-mail: stefanos@iti.gr
K. Karatzas
Aristotle University of Thessaloniki, Thessaloniki, Greece
e-mail: kkara@eng.auth.gr
A. Karppinen
FMI/Atmospheric Composition, Finnish Meteorological Institute, Helsinki, Finland
e-mail: ari.karppinen@fmi.fi

© Springer International Publishing AG, part of Springer Nature 2018 1

A. Joly et al. (eds.), Multimedia Tools and Applications for Environmental
& Biodiversity Informatics, Multimedia Systems and Applications,
https://doi.org/10.1007/978-3-319-76445-0_1
2 A. Joly et al.

1.1 From Field Studies to Multimedia Data Flows

During centuries, the study of earth biodiversity and environment mostly relied on
field studies conducted by highly skilled experts from museums and universities
who travelled the world to collect samples. Only recently did we see the emergence
of alternative observation practices. First of all, the success of social networks and
citizen sciences has fostered the emergence of large and structured communities
of observers (e.g. e-bird, zooniverse, iNaturalist, iSpot, Tela Botanica, Luftdaten,
Citizen Weather Observing Program, etc.). Citizens have become increasingly aware
of the importance of watching biodiversity and ecosystems in particular because
of their impact on human health and well-being (e.g. allergies, food safety, water
quality, landscape management, etc.). As a consequence, a very large number of
citizen science projects have been launched all over the world during the last decade.
To inventor them and facilitate experience sharing, dedicated portals have been
developed at the international and national level (such as SciStarter,1 EU BON,2
or NatureFrance3 ).
In parallel to the increased engagement of human observers, the development
of new acquisition devices also boosted the emergence of alternative observation
practices. Indeed, the quality, capacity and diversity of connected objects have pro-
gressed dramatically during the last decade. These new devices can produce, store
and transmit large volumes of data acquired automatically or semi-automatically.
Smart phones in particular allow to dramatically increase the number of people
in capacity to produce simple but very useful information for environmental and
biodiversity monitoring. Besides, fully autonomous audio-visual sensors start to be
installed all over the world such as underwater cameras [4], camera traps [6], fish-
eye cameras [5], bio-acoustic recorders [1] or hydrophones [2]). All these devices
produce huge data streams that are clearly under exploited today because of the lack
of efficient tools to process them. A last important source of data that has emerged
recently is the digitization of old materials such as natural history collections. This
digitization process has been largely accelerated these last years thanks to newly
developed equipment and consistent dedicated funding. For instance, biological
specimens have been massively digitized in recent years [3] resulting in millions
of digital records.
Based on the study of various initiatives that produce and exploit such multimedia
data flows for biodiversity and environment monitoring, we can draw some stable
patterns, as illustrated in Fig. 6.1. As a first necessary step, environmental records or
biodiversity observations have to be integrated in accessible databases. To facilitate
this step, common formats and international standards are being developed by the
scientific community. For instance, the Taxonomic Databases Working Group (also

1 https://scistarter.com/finder.
2 http://biodiversity.eubon.eu/web/citizen-science/view-all.
3 http://www.naturefrance.fr/sciences-participatives.
1 Introduction 3

Raw observation Others

data exploitable
data
Accessible Exploitable sources
integration observation data cleaning observation data
& &
structuring enrichment Modelling
&
analysis

New models
&
Simulation data
User communities
Evaluation & promotion
Educator
Land manager Implementation in
Decision maker Viewable
public platforms
Collection curator knowledge
citizen

Fig. 1.1 Biodiversity and environment monitoring dataflow

known as Biodiversity Information Standards), is in charge of the development

of standard formats for the exchange of biological/biodiversity data. As an other
example, the Unidata Program Center is a diverse community of education and
research institutions with the common goal of sharing geoscience data and the tools
to access and visualize that data. Once made accessible, raw observation data often
needs to be cleaned/or and enriched before being exploited. For instance, degraded,
inconsistent or duplicated data samples might need to be filtered out. Or some
measurements/properties might need to be extracted from raw audio-visual content
(e.g. categorical names, objects count, color attributes, visible surfaces, etc.). Once
made exploitable, observation data can be used for modelling and simulation. More
and more often, this is done by combining several observation data sources (e.g.
environmental data and species occurrences are combined for estimating species
distribution models in ecology). The resulting models and simulation data can
then be integrated in publicly available visualization tools. This allows different
communities of end users (experts and non experts) to appropriate the knowledge
produced and to act accordingly. Then, the conclusions drawn from that knowledge
might be used for the planning of new observation campaigns (Fig. 1.1).

1.2 Book Content Overview

Figure 1.2 presents an overview of the typical processing pipeline to be implemented

when setting up an end-to-end environmental monitoring system. As illustrated by
the Gantt chart below, the chapters of this book relate to one or several steps of this
pipeline and were sorted based on their location within this pipeline.
16 S. Luna et al.

Additionally, forking open code facilitates the interoperability with the original
database, and contributes to the growth of the two platforms by sharing improve-
ments to the underlying base code.

2.2.7 Data Management and Data Privacy

Data Management has become one of the central challenges to emerge with the
growth of citizen science projects [17, 18]. One important aspect of this is data
privacy. Although scientists are naturally inclined to capture as much data as
possible, including for the community of participants, it is better practice to capture
as little personal data as possible the only minimum needs of the project.
Additionally, participants have to be provided with the means to indicate how
their data may or not be used or shared, and it is generally considered best practice
for this to be provided as an opt-in, rather than an opt-out (see for example the
UK Information Commissioner’s Office Guidelines for Small Businesses collecting
information about their customers23 ). For example, if data points will be shown on
a publicly available map, it is critical that the participants understand and consent to
this, as observations taken and shared may reveal home locations or other personal
details, even if their user ID is anonymized.
Moreover, project managers are responsible for secure data transmission and
storage. Personal data have to be deleted as soon as possible if they are no longer
needed to meet the objectives of the project. In other cases, data can be obfuscated
using reliable methods that keep the data meaningful, but without disclosing details
about the participant [19, 20].
These aspects of data management in citizen science are starting to gain attention
in the literature. Bastin et al. [21] present the current state of the art regarding data
management practices, schemas and tools, along with best-practice examples, and a
range of open source technologies which can underpin robust and sustainable data
management for citizen science. Additionally, Williams et al. [22] discuss how to
sustain and maximize the impact of citizen science data.

2.2.8 Data Quality

One unique aspect of citizen science contributed data is data quality and the
connected question of reliability. Therefore, in addition to standard data validation
techniques, citizen science projects might also put additional effort in cross-
validation data by comparing collected data to other sources such as remote

23 ico.org.uk/media/for-organisations/documents/1584/pn_collecting_information_small_business_

checklist.pdf.
Another random document with
no related content on Scribd:
Ziegler of the ear department of the Hospital of the University of
Pennsylvania showed atrophy of this membrane.

Eulenburg speaks of one case in which the external atrophy had

reached as far as the larynx, and in which the pronunciation of the
letter r was somewhat impeded. Beverly Robinson,17 reports a case
accompanied with slight paralysis of the adductors of the vocal
cords. The laryngeal paralysis in this case improved under
treatment, which led Robinson to believe that the relation between
the two affections might have been only one of coincidence.
17 Am. Journ. Med. Sci., October, 1878, p. 437.

Flascher18 has described a unique case of bilateral facial atrophy

occurring in a woman twenty-three years old. When an infant she fell
and injured her forehead, and soon afterward had an attack of
measles without eruption. Shortly afterward the atrophy appeared.
Tactile sensibility was diminished and the secretion of sweat absent.
The masseter, temporal, and facial muscles and bones were
atrophied. External strabismus of the left eye was present; the pupil
of this eye was dilated, irregular, and non-reactile; sight was
diminished, the optic disc atrophied. This case would appear to differ
somewhat from true facial hemiatrophy. It was probably a peripheral
nerve affection following measles.
18 Berliner klin. Wochenschr., 1880, No. 31.

Mitchell19 has reported a case of absence of adipose matter in the

upper half of the body. I had an opportunity of examining this patient,
who was exhibited at a meeting of the Philadelphia Neurological
Society, and noticed that both sides of the face presented a striking
similarity to the affected side in cases of unilateral atrophy. The
muscles were apparently not affected. Mitchell suggests the
possibility of separate centres capable of restraining deposits of
adipose tissue.
19 Am. Journ. Med. Sci., July, 1885.
DURATION AND TERMINATION.—The disease pursues a slow but
generally progressive course. In a few instances, after having
attained a certain development, it seems to have remained
stationary for many years. Nothing could better illustrate the slow
progress or stationary character of this affection than the study which
Virchow made in 1880 of a patient whose case had been described
by Romberg more than twenty years before. After comparing the
patient's present condition with that described in notes taken twenty-
one years before, Virchow was not able to convince himself that any
material alteration had occurred in the atrophic parts; in fact, he
regarded the disease as having long ago become stationary. Cases
reported by Tanturri, Baerwinkel, and others bear out the same view
as to the stationary character of the affection in some cases.

COMPLICATIONS.—In a case of Virchow's, in addition to the facial

atrophy the patient presented atrophy which, commencing in the
distribution of some of the dorsal cutaneous nerves of the scapular
region, affected the musculo-spiral nerve from its origin downward,
most markedly in the forearm and head. Mendel20 describes a case
of facial hemiatrophy occurring in a monomaniac, the diagnosis
being complicated by the somatic signs of degeneracy—congenital
facial and bodily asymmetry. The patient was twenty-eight years old,
and the disease could be traced back to the seventh year. In several
reported cases the disease has followed or has been associated with
epileptic seizures. Buzzard21 has published a case in which the
affection came on in a girl aged thirteen in the course of a second
attack of chorea. In another it followed typhoid fever. In a case
reported by Parry22 left hemiplegia with temporary disturbance of
intelligence preceded the disease by about two years. In another,
observed by Axman and Hueter, the patient, a man aged thirty-two,
had suffered from irregular contractures of the left masticator
muscle, which commenced in the seventh year. These spasms were
associated with an increased delicacy of sensation in the region of
the left trigeminus. Neuralgia is sometimes a complication. In a case
reported by Holland,23 the patient for several years suffered from
paroxysms of fronto-temporal neuralgia.
 20 Neurologisches Centralblatt, June 15, 1883, quoted in Journal of Nervous and
Mental Disease, 1883, x. p. 571.

21 Transactions of the Clinical Society of London, vol. v., 1872, p. 146.

22 Eulenburg.

23 American Practitioner, vol. xxxi. No. 182, Feb., 1885, p. 72.

PATHOLOGY.—Up to the present time, so far as I have been able to

learn, not a single autopsy in a case of typical progressive unilateral
facial atrophy has been made. Conclusions as to pathology can
therefore only be drawn from an analysis and study of symptoms
and from comparisons with other degenerative affections. Most
authorities hold that it is neurotic in origin. Lande, however, regarded
it as having its origin in the connective tissue, affecting the nutrition
of the other tissues by interfering with the circulation.

Different views have been held by those who have believed in its
neurotic origin. Moore regarded it as a form of progressive muscular
atrophy attacking the muscles supplied by the portio dura, but what
has already been shown with reference to the symptomatology is
sufficient to show that this is an erroneous hypothesis. The muscles
supplied by the facial nerve may diminish in volume, but they do not
undergo a true degeneration.

Brunner attributed the affection to continued irritation of the cervical

sympathetic by some continuing lesion. Irritation of such a lesion,
according to him, causes vascular spasms, diminishes blood-supply,
and thus leads to the gradual development of the atrophy. This view,
to say the least, has not been made out.

Virchow holds that the affection is peripheral, and not central. He

believes, however, that a primary process being once set up in the
nerve-trunks, owing to inflammations of the surrounding tissues it
may then extend upward to the spinal and basal ganglia. The
disease, according to this view, has some analogy to herpes zoster.
The manner in which nerve-districts are unequally attacked is similar
to what is observed in the various forms of lepra and in morphœa.
The doctrine of a tropho-neurosis is the one that is best upheld by
clinical facts. In the first place, various arguments can be adduced to
show that the disease is neurotic in origin. It is limited to one side of
the face and to special nerve-distributions. Affections of sensibility in
the domain of the trigeminal nerve are frequently present. In the
case given under Symptomatology, although anæsthesia was
absent, the patient complained of peculiar paræsthesia in the form of
stinging sensation. Either trophic centres or trophic fibres, which
have the same connection and course as the trigeminal, are affected
by a degenerative process. Whether nuclei, ganglia, or peripheral
fibres are primarily affected has not yet been satisfactorily
determined.

The case of Romberg, observed by Virchow twenty years after, was

considered by the latter to entirely overthrow the vaso-motor theory,
owing to the condition of the blood-vessels. While the surrounding
tissues from the skin inward were wasted and shrunken, the veins
and arteries of the parts appeared absolutely unchanged, the larger
even projecting above the surface of the skin. Under stimulation the
vessel dilated as in a normal individual, appearing to take no part in
the atrophy.

DIAGNOSIS.—The chief affections from which progressive unilateral

facial atrophy are to be diagnosticated are congenital asymmetry of
the face and head, facial paralysis, progressive muscular atrophy,
and hypertrophy of the opposite side of the face.

Congenital asymmetry of the face is observed in institutions for the

idiotic and feeble-minded. Such asymmetry, however, is usually
associated with corresponding defects of other parts of the body, as
of the head and limbs. In the nervous wards of the Philadelphia
Hospital is now, for instance, a patient the entire right half of whose
body is very decidedly wasted, the case being one of epileptic idiocy
with paralytic and choreic manifestations which point to atrophy of
the opposite half of the cerebrum. At the Pennsylvania Training-
School for Feeble-minded Children want of development of one-half
of the head is often observed, but in these and in other congenital
cases the special changes in nutrition, in the skin, in the color and
growth of the hair, and in sensation, are absent. In some cases of
congenital asymmetry of the head atrophy of the face or limbs, if
present, will be upon the opposite side of the body; and this is what
might be expected, as arrested development of the cranial vault will
probably correspond with arrested development of the cerebrum of
the same side and bodily defects of the opposite side.

Eulenburg, Maragliano, and others refer to an acquired want of

symmetry of the face sometimes observed in cases of wry neck or
scoliosis with deviation of the spinal column. Eulenburg especially
speaks of the so-called habitual scoliosis, where a curve in the
dorsal region in one direction has a compensatory cervical curve, the
side of the face which corresponds to the dorsal curve being often
smaller than the other. This asymmetry is supposed to result from
compression of the vessels and nerve-roots in the concavity of the
cervical curve. Here, again, the absence of special nutritional
changes will assist in the diagnosis. A study of the spinal curvature
will also be of value. Indeed, only the most careless observation
would allow this mistake in diagnosis to be made.

Facial paralysis—Bell's palsy of the usual type—would not be likely,

except by a careless observer, to be confounded with the disease
under consideration. When the muscles in the facial distribution are
involved, it is only in a very slowly progressive deterioration, which
may be due to mechanical causes, as compression by the
contracting skin. Moore,24 as already stated, was wrong in speaking
of the morbid changes as entirely confined to the portio dura of the
left side. It is the fat, the connective tissue, and the skin which are
first and chiefly affected. In unilateral facial atrophy no true paralysis
of the facial muscles is present; consequently, the forehead can be
wrinkled, the eye closed, the mouth drawn up or down, or sideways,
etc.; in short, all the movements of the face are possible. The
opposite of this, it goes without saying, is present in general facial
paralysis. The drawing of the face to the side opposite the paralysis
in Bell's palsy is not here observed; the mouth is sometimes drawn
upward slightly on the atrophied side. In facial paralysis of any
severity reactions of degeneration are present. In unilateral facial
atrophy, as in progressive muscular atrophy, the muscles respond
both to faradism and galvanism. As minor aids in making the
diagnosis, the absence of loss of taste in one-half of the tip of the
tongue, and of deflection of the tongue and uvula, are in favor of
facial atrophy.
24 Dublin Journal of Medical Science, vol. xiv., August and Nov., 1852, p. 245.

It is possible that a case of progressive muscular atrophy might

begin in almost any muscle or group of muscles in the body. In
progressive muscular atrophy, however, the appearance of the skin
is different; it is not mottled; it is not thin, as can be demonstrated by
manipulation of it; it can be raised by the fingers; it is soft and flaccid.
In progressive muscular atrophy also first one muscle and then
another, just as likely as not at some distance from each other, are
attacked by the wasting process; in unilateral facial atrophy the
affection spreads uniformly and regularly over one-half of the face.
According to Duchenne of Boulogne, when progressive muscular
atrophy first appears in the face the orbicularis oris is the muscle
most likely to be attacked, causing the lips to appear enlarged and
pendent, and giving a stupid look to the patient. In unilateral facial
atrophy this appearance is not present. Progressive muscular
atrophy commonly begins at a later age than unilateral facial atrophy.

Hypertrophy of the opposite side of the face is suggested by

Eulenburg as a possible source of mistake; but a little study,
however, will suffice to exclude this affection.

The following points are given by Eulenburg with reference to vitiligo

and porrigo decalvans: “In vitiligo we find the same white
decoloration of the skin, the cicatricial feel, the turning gray and
falling out of the hair, but not the loss of volume, which is the special
characteristic of this disease. In porrigo decalvans inflammatory
symptoms and œdema of the skin come first; the disease first
appears in regular circular spots; the hairs fall out without previous
loss of color; and finally, the disease is contagious, and fungi can be
demonstrated (microsporon Audouini).”

PROGNOSIS.—The prognosis as to recovery is bad, but, as already

shown, the disease may long remain stationary.

TREATMENT.—No well-authenticated case of cure under any method

of treatment has yet been reported. Electricity, either in the form of
galvanism or faradism, has been resorted to in a majority of cases.
In most of these temporary benefit has been produced by the
employment of these agencies. Baerensprung reports two cases as
having been greatly benefited by faradism. In Moore's case it also
produced temporary improvement. Carefully administered massage
should be tried. With reference to friction or massage, however, it is
well, as advised by Eulenburg, to be cautious, as excoriations are
easily produced. Measures directed to building up the nervous
centres are indicated—such medicinal agents, for instance, as the
salts of silver, gold, zinc, and copper, arsenical preparations,
strychnia, and iron.

DISEASES OF THE MEMBRANES OF THE BRAIN

AND SPINAL CORD.

BY FRANCIS MINOT, M.D.

The membranes or envelopes of the brain and cord were formerly
reckoned as three in number: the dura mater, lying next to the inner
surface of the bones of the cranium and spinal column, forming an
internal periosteum; the pia mater, which is in immediate contact with
the brain and cord; and the arachnoid, which was described as a
distinct membrane loosely attached to the pia mater, but more firmly
united to the dura, and constituting a closed sac or serous cavity
called the cavity of the arachnoid. This view is now abandoned by
most anatomists, who regard the external arachnoid as simply a
pavement epithelium covering the internal surface of the dura, and
the visceral arachnoid as constituting the external layer of the pia.
The term cavity of the arachnoid has, however, been generally
retained for the sake of convenience; and it gives rise to no obscurity
if we remember that by it we simply mean the space between the
dura and the pia.

The diseases of the membranes which I shall consider are—

congestion and inflammation of the dura, including hæmatoma;
congestion and simple and tubercular inflammation of the pia; and
meningeal apoplexy.

The membranes of the brain and those of the cord may be

separately diseased, or both may be affected at the same time.
Simultaneous inflammation of the cerebral and spinal meninges is
apt to occur epidemically, and is supposed to be zymotic in its origin.
This is described in another article. (See EPIDEMIC CEREBRO-SPINAL
MENINGITIS, Vol. I. p. 795.)

Inflammation of the Dura Mater of the Brain.

SYNONYM.—Pachymeningitis. Either surface of the dura may be

inflamed separately, and in many cases the symptoms are
sufficiently definite to render it possible to diagnosticate the situation
of the disease in this respect during life, especially when taken in
connection with the causes. For this reason it is usual to speak of
external and internal pachymeningitis. A peculiar form of the latter is
accompanied by the effusion of blood upon the arachnoidal surface,
which sometimes forms a tumor called hæmatoma. Congestion is
also sometimes included in the diseases of the dura mater, but is
rarely alluded to by writers on pathology or clinical medicine.

Congestion of the Dura Mater.

Except as the first stage of inflammation, congestion of the dura can

hardly exist unless in connection with the same condition of the pia
or of the brain. Its causes are either local, such as thrombosis of the
sinuses, syphilitic or other growths in the membranes; or remote, the
principal being obstructions to the general circulation, including
valvular disease of the heart, emphysema and other affections of the
lungs, renal disease, compression of the superior cava or jugulars by
aneurism and other tumors, delayed or suppressed menstruation,
etc. The symptoms cannot be distinguished from those of congestion
of the pia or of the brain—namely, headache, a sensation of
throbbing, pressure, or weight in the head, somnolence, etc. The
absence of fever would serve to distinguish the affection from an
inflammatory condition of the membranes or brain.

Inflammation of the External Surface of the Dura.

SYNONYM.—External pachymeningitis.

ETIOLOGY.—The most frequent causes of external pachymeningitis

are injuries to the cranial bones from violence, caries and necrosis of
the same, and concussion from blows on the head. Next in order of
frequency, if not even more common, comes the propagation of
inflammation from disease of the inner ear and of the mastoid cells.
It is only of late years that this important subject has been brought
prominently forward and the danger of ear diseases in this respect
fully pointed out. The channels of communication, as indicated by
Von Tröltsch1 in his valuable article on diseases of the ear, are along
the arteries and veins which pass from the skin of the meatus and
the mucous periosteal lining of the middle ear to the contiguous
bone, while the capillaries of the petrous bone are in direct
connection with the dura mater, so that the vessels of the latter are in
communication with the soft parts of the external and middle ear.
The vessels of the ear and the membranes of the brain are also
directly connected through the diploëtic veins of the temporal bone,
which discharge into the sinuses of the dura, as well as through the
venæ emissariæ, which, arising from the sinuses, pass through the
bone and discharge their contents into the external veins of the
head. Von Tröltsch also points out that the extension of an
inflammatory process may occur along the sheath of the facial nerve,
the canal of which (canalis Fallopii) is a branch of the internal
auditory canal and is lined by the dura mater. The latter is separated
from the mucosa of the tympanum only by a thin, transparent, and
often defective plate of bone. Inflammation may also be transmitted
from the scalp by means of the vessels which pass through the
bones of the skull. In this way erysipelas and other diseases of the
integument sometimes give rise to external pachymeningitis.
1 “Die Krankheiten des Gehörorganes,” von Anton von Tröltsch, in Gerhardt's Handb.
der Kinderkrankheiten, Tübingen, 1879, 5 B., ii. Abt., p. 150; also English translation
of the same, by J. O. Green, M.D., New York, 1882, p. 107.

SYMPTOMS.—There are no known symptoms which are characteristic

of inflammation of the external surface of the dura. In cases of death
from other diseases an autopsy may show traces of previous
inflammation, such as thickening of the membrane and its firm
adhesion to the cranial bones, which were not manifested during life
by other symptoms than those which accompany meningeal disease
in general; and in some instances none at all were known to have
occurred. At a variable time after the receipt of an injury to the head
the patient may complain of headache, followed by a chill, with high
fever, vomiting, vertigo, delirium, unconsciousness, convulsions, etc.,
arising from compression by the products of inflammation. The same
phenomena may follow the transmission of inflammation to the dura
from caries or other disease of the bones, or from otitis medea
purulenta. These symptoms usually continue without interruption,
though there is sometimes more or less complete remission of the
pain, and the patient may recover his consciousness for a time, thus
giving rise to fallacious hopes. In a large proportion of cases the
disease extends to the inner surface of the membrane and to the pia,
without any noticeable change in his condition other than coma. In
chronic external pachymeningitis the principal symptom is pain in the
head, which may persist for weeks or months without other
manifestations except drowsiness. Sometimes, on the contrary, there
is obstinate vigilance. Mental symptoms, such as loss of memory,
hallucinations, dementia, or mania, are sometimes noticed, ending,
as in the acute form, in coma.

PATHOLOGICAL ANATOMY.—In chronic cases often nothing is found but

thickening of the membrane, which generally becomes firmly united
to the inner surface of the cranium. Indeed, these appearances are
not unfrequently observed, to a limited extent, when there has been
no history of disease to account for them. In other chronic cases the
connective tissue of the membrane is found to be in part ossified,
and the osteophytes of the cranium sometimes found in pregnant
women and in patients with rheumatic cachexia are supposed to be
due to a chronic inflammatory process of the dura. The first changes
observed in acute external pachymeningitis are increased
vascularization, shown by red lines corresponding to the blood-
vessels, with punctiform extravasations, swelling, and softening of
the tissue. Later, there is thickening of the membrane from new
formation of connective tissue, and exudation of lymph, and
sometimes of pus, which latter may accumulate between the dura
and the cranial bones, or in traumatic cases may escape through
openings in the skull. The dura and the pia become united in most
cases of acute inflammation. The lateral sinuses frequently contain
thrombi, which, when ante-mortem, are firm in structure, reddish-
brown in color, often closely adherent to the walls of the vessel, and
may extend to other veins, sometimes reaching as far as the
jugulars. When purulent inflammation of a sinus occurs, its walls are
thickened, softened, and discolored, and the inner surface is
roughened. The thrombus becomes more or less purulent or
sanious, disintegrates, and the infecting particles are carried into the
circulation, giving rise to embolism and disseminated abscesses of
the lungs, kidneys, liver, or spleen. Other lesions, such as injury or
caries of the cranial bones and purulent inflammation of the middle
ear and of the mastoid cells, are frequently found in conjunction with
pachymeningitis, to which they have given rise. When the disease of
the dura extends to the pia, the adjacent portion of the brain is often
found implicated in the inflammation. In traumatic cases the dura
may be detached from the bone and lacerated to a greater or less
extent.

DIAGNOSIS.—The existence of external pachymeningitis may be

suspected from cerebral symptoms following traumatic injury of the
skull, erysipelas, or suppurative otitis medea, but apart from the
etiology it would not be possible to distinguish it from internal
inflammation of the membrane, or even from leptomeningitis.

PROGNOSIS.—In cases of suspected external pachymeningitis the

prognosis will depend upon the evidence of effusion of pus or blood
between the dura and the skull, and the possibility of their removal. A
large proportion of cases are fatal, especially those arising from
caries of the cranial bones and from the propagation of disease from
the middle ear, the mastoid process, or the external surface of the
skull, the inflammation extending through the membrane to the
arachnoid surface of the dura, and also to the pia mater. This would
be shown by a high temperature, rapid pulse, pain, and delirium,
followed by coma and perhaps convulsions. The frequency with
which external pachymeningitis occurs in connection with diseases
of the ear should put the physician on his guard in cases of otorrhœa
or pain in the ear, that he may warn the patient or his friends of the
possibility of danger, and may employ an appropriate treatment.
TREATMENT.—In all cases of injury to the skull or of severe
concussion the possibility of subsequent external meningitis should
be borne in mind. The patient should be confined to the bed and be
carefully secluded from excitement. Cold applications should be
made to the head, the diet should be simple and somewhat
restricted, and the bowels kept free without active purging. If there
be evidence or suspicion of the presence of pus or of blood between
the dura and the skull, means should be taken to evacuate the
effusion. In case of inflammatory symptoms leeches should be
applied behind the ears, and a stimulating liniment or croton oil
rubbed on the scalp. There is no specific treatment. Pain and
sleeplessness must be relieved by opiates and sedatives, and the
strength must be sustained by nourishing diet and stimulants.

Internal Pachymeningitis.

Internal pachymeningitis is of two kinds: 1st, simple inflammation,

which may be accompanied by purulent exudation and by a
corresponding affection of the pia mater: 2d, hemorrhagic
inflammation or hæmatoma of the dura mater. Simple inflammation
of the internal or lower surface of the dura, without the coexistence
of external pachymeningitis is rarely found in the adult. The morbid
appearances differ but little from that of the external form, and the
causes and the diagnosis are also similar. In children, however, it is
not uncommon, according to Steffen.2 The pus may discharge itself
spontaneously through the fontanels or the sutures, or caries of the
cranial bones may open a passage for its exit. It has also been
evacuated artificially when the symptoms have indicated its
presence. In other cases more or less extensive firm adhesions
between the dura and pia mater have shown the previous existence
of inflammation, but it would be difficult to say in which membrane it
began. In some instances no symptoms are observed during life; in
others the coexistence of inflammation of the pia, effusion into the
ventricles, etc. prevent an exact diagnosis.
 2 “Die Krankheiten des Gehirns in Kindesalter,” von Dr. A. Steffen, in Gerhardt's
Handb., 5 B., i. Abt., 2te Hälfte, p. 380.

The TREATMENT does not differ from that of inflammation of the

external layer of the pia.

Hæmatoma of the Dura Mater.

SYNONYM.—Hemorrhagic pachymeningitis.

DEFINITION.—A chronic inflammation of the dura mater, resulting in

the formation upon its inner surface of successive layers of false
membrane, into and between which there is usually an effusion of
blood, the whole sometimes forming a large solid mass between the
dura and the cavity of the arachnoid.

ETIOLOGY.—Hemorrhagic pachymeningitis never occurs in healthy

persons except from traumatic causes. It is most frequently observed
in advanced life, and especially in the male sex. In a large number of
cases the blood is in an unhealthy condition, and hence the disease
is seen in alcoholism, in scurvy, in acute articular rheumatism, and in
the acute febrile affections, as typhoid fever, pleuro-pneumonia, and
pernicious anæmia, of which last, according to Huguenin,3 it
complicates one-third of the cases. It is frequent among the chronic
insane. It is occasionally met with in young children, but with them its
causes are mostly unknown; according to Steffen,4 they may consist
in alterations of the blood resulting from insufficient nourishment or
from the infectious diseases, and from abnormal blood-pressure, as
in whooping cough, asthma, etc., as well as from blows on the head.
3 G. Huguenin, “Acute and Chronic Inflammations of the Brain,” in Ziemssen's
Encylop., Am. translation, New York, 1877, vol. xii. p. 401 et seq.

4 Op. cit., p. 386.

SYMPTOMS.—Many cases of hemorrhagic pachymeningitis
complicating other cerebral diseases can be distinguished by no
special symptom from the original malady. Thus, in cases of chronic
insanity its existence may not be suspected during the lifetime of the
patient. Steffen quotes5 the case, reported by Moses, of a child
seven months old who died of catarrhal pneumonia, and who
exhibited no symptom which could suggest any disease of the brain
or its membranes. The autopsy revealed a pachymeningitic cyst
extending over the anterior half of the right hemisphere. When
symptoms are present they vary in different cases according to the
acuteness of the inflammatory process, the amount and situation of
the effusion, and the participation of the pia mater and brain in the
disease. In the beginning they are usually indefinite, headache being
the most common and often the only complaint. This may continue
for weeks without any other indication of disease, but it is frequently
accompanied by tinnitus aurium, vertigo, muscular weakness, and
contraction of the pupils. Wakefulness and restlessness at night and
slight twitching of the facial muscles or of the limbs sometimes occur.
There may be no change in the condition of the patient for a
considerable length of time (weeks or months), or he may improve to
some extent, owing to the absorption of the serous portion of the
effusion or to the tolerance of the foreign body acquired by the brain.
Sooner or later a fresh hemorrhage is followed by a recurrence, and
usually an aggravation, of all the symptoms. Sometimes the patient
becomes comatose, and dies speedily with apoplectic symptoms,
but this is not common at an early period. The extravasation of blood
generally takes place in small quantities at a time, without giving rise
to unconsciousness or paralysis. After a period of uncertain duration,
when the tumor has attained considerable dimensions a condition of
somnolence may take place, the patient sometimes sleeping twenty-
four hours or longer at a time. Distinct paralysis rarely occurs, though
hemiplegia is sometimes seen, and the paralysis has been observed
on the same side with the lesion. When symptoms of compression
appear the pupils become dilated. Toward the end of life the patient
is usually in a state of profound coma, the pulse is slow and irregular,
and the sphincters are relaxed.
 5 Op. cit., p. 394.

The distinctive features of internal pachymeningitis, therefore, so far

as they are at present known, are those which would depend upon a
primary cerebral irritation, followed by those of compression of the
brain—persistent, often severe, headache, with contracted pupils,
and occasionally motor and sensory disturbances; afterward, coma,
dilated pupils, and involuntary discharges from the bowels and
bladder.

The DURATION of the disease is exceedingly variable, extending from

a few days to more than a year. According to a table made from
carefully observed cases by Huguenin, 74 per cent. of patients die
within thirty days; 18 per cent. live from one to six months; 4 per
cent. live from six months to one year; and 4 per cent. live over one
year.

PATHOLOGY.—A difference of opinion has existed among pathologists

concerning the true nature of hemorrhagic effusions of the inner
surface of the dura mater, especially as to whether the membrane in
which they are enclosed is formed by a deposit of fibrin from the
effused blood itself, or whether the disease consists essentially in an
inflammation of the dura, followed by a pseudo-membranous deposit
into which blood is afterward extravasated. The latter explanation,
offered by Virchow, has been generally accepted, but Huguenin,
whose opportunities for observing the disease were unusually good,
believes that the first stage of hæmatoma is not the formation of
connective tissue, but simply an extravasation of blood.

The disease begins with hyperæmia of the dura mater in the area of
distribution of the middle meningeal artery, followed by the formation
upon its inner surface of an extremely delicate membrane in small
patches of a yellowish color and studded with innumerable bloody
points. If the membrane be carefully raised, it is found to be
connected with the dura by very delicate blood-vessels, and to
contain an immense number of very wide and thin-walled vessels,
much larger than ordinary capillaries.6 At a later stage we find the
membranes to be made up of several distinct layers, of which the
innermost exhibits the character of the primary deposit, being thin
and abundantly supplied with blood-vessels, while those of older
formation have become successively thicker and are composed of
tough, lustrous fibres of connective tissue almost as dense as that of
the dura mater itself. The delicate structure of the false membranes
and of the vessels which they contain leads almost inevitably to the
effusion of blood, which increases in quantity with the thickness of
the whole growth, so that in an advanced stage it is not uncommon
to find large pools of blood, partly clotted and partly fluid, constituting
what is called hæmatoma of the dura mater. The small bloody points
are within the substance of the false membrane; the extravasations
are interstitial, the largest being always found between the youngest
membrane and the older layers. In some cases serous transudations
also occur between the false membranes. In still rarer instances no
blood or serum is found between or beneath the layers. Occasionally
small quantities of blood escape by leakage through the delicate
membrane into the cavity of the arachnoid.
6 See Rindfleisch's Manual of Pathological Histology, New Sydenham Soc.'s
translation, 1873, vol. ii. p. 302.

The usual situation of internal pachymeningitis is the vault of the

cranium, near the median line, the upper or external layer of the
tumor being in relation with the dura mater, to which it is adherent,
and the lower or internal with the arachnoid and pia mater. If the
effusion be extensive, it spreads downward over the frontal and
occipital lobes of the brain, and laterally toward the fissure of Sylvius.
In the majority of cases the disease occupies both sides of the
median line symmetrically, but it may be limited to one side only.
According to Huguenin, 56 per cent. of the cases embrace the
surfaces of both hemispheres; 44 per cent., that of one only.
Hæmatoma very rarely occupies the base of the cranium. The
thickness and consistency of the deposit vary in different cases,
depending upon the number of successive exudations, and hence
are most marked in cases of the longest duration.
Hemorrhagic pachymeningitis is occasionally met with in young
children, but much more rarely than in adults. The disease is usually
more acute than in older persons, but the anatomical appearances
are essentially the same.7
7 For an able description of the lesions of hemorrhagic pachymeningitis in children
see the third edition of Rilliet and Barthez's Maladies des Enfants, by Barthez and
Sanné, Paris, 1884, vol. i. p. 152.

PROGNOSIS.—The great majority of cases end fatally. A few instances

of recovery are reported in which the diagnosis seems justified by
the symptoms. Moreover, it is not very rare to find, on post-mortem
examination of those who have died of other diseases, evidence of
the former existence of hemorrhagic pachymeningitis. According to
Steffen, while the prognosis of simple pachymeningitis in children is
frequently good, owing to the favorable conditions for the exit of pus
through the open fontanels and sutures, in hemorrhagic
pachymeningitis recovery is rare.

DIAGNOSIS.—In a disease whose symptoms are so vague the

diagnosis must of necessity be difficult and often impossible. The
chief elements for the formation of the diagnosis are the slow and
interrupted progress of the affection, persistent headache, tendency
to prolonged slumber, and final coma; the absence of paralysis of the
cranial nerves, of vomiting, and of general convulsions; the age of
the patient, the coexistence of alcoholism, chronic insanity, or acute
rheumatism, and traumatism. The diseases for which hæmatoma
would be most likely mistaken are acute inflammation of the
meninges, apoplexy from cerebral hemorrhage, tumor in the
substance of the brain, and necrobiosis from thrombus or embolus.
The absence of symptoms characteristic of these affections might
lead to a probable diagnosis by exclusion, but in many cases the
existence of the disease cannot be determined with certainty. In
children it is most likely to be confounded with tubercular meningitis,
from which it may be distinguished by the fact that it is most common
under the age of two years, the other being rare before that period,
and that the characteristic symptoms of tubercular meningitis
(prodromic period, vomiting, irregularity of pulse, etc.) are wanting.
But the tubercular disease in young infants may closely resemble
hæmatoma, a profound coma replacing all other symptoms. Here the
existence of tuberculous disease in the parents or other near
relatives would point strongly to tubercular meningitis, while the
absence of such antecedents would suggest hæmatoma.

TREATMENT.—If the disease be a complication of alcoholism, anæmia,

scurvy, rheumatism, etc., the treatment appropriate to those
affections should be employed, along with remedies addressed to
the local disease. For the early symptoms of irritation, perfect rest in
bed, cold to the head, bromide of potassium internally, sinapisms to
the back of the neck, together with simple and nutritious diet, are the
most efficient means. The bowels must be regulated, but purging is
not necessary. The abstraction of blood from the head by leeches to
the temples or behind the ears, or by cupping, is recommended by
most authorities, especially if there be much heat of the head.
Mercury may be tried, care being taken not to salivate the patient. It
is obvious that this treatment, in order to be of any avail, must be
instituted at the earliest stage of the disease. After the probable
formation of the hæmatoma an effort should be made to promote its
absorption, which sometimes actually takes place, as is proved by
the autopsies of patients who, having previously suffered from this
affection, have died from other causes. The iodide of potassium or
the iodide of sodium should be employed perseveringly for this
purpose, in the dose of from ten to thirty grains three times daily. The
bromide should also be continued if necessary. The acne which
sometimes accompanies the continued use of these remedies may
be prevented or cured by the use of three to five drops of the liquor
potassæ arsenitis, given once or twice daily after meals. Counter-
irritation to the scalp by means of stimulating liniments or croton oil,
and small blisters to the temples, are likely to do good. In alcoholic
subjects the amount of wine or spirit taken should be regulated by
allowing enough to support the strength, without too suddenly
withdrawing the accustomed stimulant. In the stage of coma the
treatment must be purely expectant. The state of the bladder must
be regularly examined, and the catheter employed when necessary.
Liquid nourishment should be carefully given as long as the patient is
able to swallow.

Cerebral Meningeal Hemorrhage.

SYNONYM.—Meningeal apoplexy of the brain. Hemorrhage of or upon

the membranes of the brain is closely connected with intracerebral
hemorrhage. Both arise from similar causes, and the former may
result directly from the latter. It is for convenience of arrangement
that the two subjects are treated separately in this work.

ETIOLOGY.—The causes of meningeal apoplexy are predisposing and

immediate. The most important predisposing cause consists in
disease of the cerebral vessels, especially the arteries, which favors
the formation of so-called miliary aneurisms, as demonstrated by
Charcot and Bouchard in the case of cerebral apoplexy. Disease of
the vessels in its turn arises from various conditions, among which
alcoholism in adults holds a prominent place from its tendency to
favor a fatty degeneration of the vascular walls. In subjects of
purpura or hæmophilia (the so-called bleeders), in whom, from an
inherent weakness of the capillary vessels or a deficiency of the
fibrin of the blood, or both combined, there is a tendency to
extravasation of the blood in various parts, hemorrhage into the
arachnoid cavity may occur.8 A new-born child under my observation
had bleeding at the navel and ecchymoses in various parts of the
body. Suddenly it became comatose, and it died with signs of
cerebral compression. There was no autopsy, but it seems probable
that hemorrhage into the cavity of the arachnoid had taken place. A
sister of the patient had also had spontaneous hemorrhage from the
navel and from other parts shortly after birth, but recovered. Chronic
general arthritis and gout also probably predispose to the affection,
as well as old age, which is accompanied by atrophy of all the
tissues. The disease is most frequently met with in the two extremes
of life; according to Durand-Fardel,9 in adults the largest number of
cases occurs between the ages of seventy and eighty years.