MENINGITIS, Cerebral (Tuberculous).
Prophylaxis.—There cannot be a doubt that primary cases of tuberculous meningitis often arise in children fed upon the milk of infected cows, but this source of infection is more likely to operate at a later date through infection from the mesenteric glands. The fine meshwork of these glands in very young children filter out the bacilli and protect the blood-stream for an indefinite period, till some softening or breaking-down of the gland tissue causes a secondary infection which may suddenly manifeseitself in the meninges or in an attack of acute general tuberculosis. Hence the importance of sterilisation of the milk supply of children brought up mainly upon this food as detailed under Mesenteric Gland Disease.
The disease occasionally shows itself after partial surgical measures for the relief of lupus, bone and gland disease: such operations should be condemned unless complete removal of the tuberculous foci can be carried out. When once the cerebra] symptoms have shown themselves, the treatment must be entirely symptomatic and palliative. Vaccine therapy is powerless owing to the rapidity of the progress of the disease, and if the meningitis is but a local manifestation of a general invasion this form of therapy only precipitates the final issue. Rest in a thickly carpeted and darkened room free from all noise and vibration is essential. The hair over the scalp should be shaved or clipped close with scissors, and the ice cap, Leiter's coil or iced cloths kept continuously applied. Headache may be further relieved by leeching the temples or mastoid region and by a sinapism to the nucha, but blistering this region or the scalp should not be practised, as this interferes seriously with the comfort of the patient as lie usually lies upon his hack. Antipyrine combined with Bromides in large doses may be pressed in the presence of severe restlessness, intense cephalalgia and photophobia, and Chloral Hydrate may be given to induce sleep, opiates being contra-indicated. A full dose of Calomel for the clearing out of the alimentary canal is a usual routine.
Only liquid nourishment as small amounts of diluted or peptonised milk should be administered at brief intervals, soups and animal foods Icing clearly contra-indicated. Fever must be controlled by assiduous
cold or tepid sponging, each portion of the body being submitted to the treatment seriatim. The movement of the body entailed by immersion in the cold or tepid bath, except in the case of young children, should be avoided.
Lumbar puncture can be at the best but palliative; nevertheless as a means of reducing cerebral pressure and agonising headache it may be resorted to when the suffering is extreme. When lumbar puncture has been followed by recovery, probably the attack was one of simple basic meningitis.
Mercury has been universally discountenanced in the treatment of an obviously tuberculous meningitis, though unquestionably it possesses the power of diminishing the cerebral tension during the later stages of the diseases by causing the absorption of serous or inflammatory fluid within the ventricles or in the arachnoid space. The writer does not hesitate to advocate inunction in every case where there is a reasonable doubt about the diagnosis, and it cannot be denied that in practice such cases are numerous. The rubbing in of weak mercurial ointment causes no discomfort, and cannot possibly do harm in a disease which is practically always fatal. He has insisted upon inunction even when the diagnosis seemed to be fairly certain and the case appeared to he hopeless, and has seen recovery follow; the diagnosis in such cases was almost certainly in error. But where as in the great majority of all examples of accepted tuberculous meningitis the fatal issue of the disease was not averted, the suffering was alleviated and never increased by mercurialisation.
Iodides in large doses appear not only to relieve headache, as they sometimes palliate other forms of pain, but they assist the action of mercury, and may be employed in conjunction with inunction in slowly progressive types of the disease.
Tapping of the ventricles alone or accompanied by drainage, trephining and other operative procedures appear to only hasten the fatal issue, often without affording any temporary relief.