Since mental overexertion and excitement are frequently mentioned as factors in the etiology of tuberculous meningitis, perhaps it is not superfluous to emphasize that restless and excitable or precocious and emotional children have not, in our experience, exhibited any increased predisposition.
Sex has no influence—which could not be accounted for by statis tical errors—though it is maintained that boys are more frequently attacked than girls.
Age is undoubtedly an etiologic factor. According to Huguenin the greatest predisposition exists from the second to the beginning of the seventh year; there are fewer cases from the sixth to the tenth year and the frequency diminishes rapidly from the tenth to the fifteenth year.
More elaborate statistics than these do not help us, since they depend too much on extraneous circumstances; however the question how early tuberculous meningitis may attack a child is of interest in view of the still obscure requirements for and modes of infection.
Congenital tuberculous meningitis and meningitis during the first week of life have never been reported. It has been observed by StefTen, Henoch and ourselves in children who died at the age of three months. Hohlfeld and Finkelstein repeatedly saw cases in early infancy. Dr. Hubert Reich (the district physician of Millilheim) in ISTS reported a very remarkable series of cases in early infancy. He saw ten infants of healthy- families die of tuberculous meningitis within fourteen months. The cases occurred in the practice of a midwife w-ho had severe phthisis, and who was accustomed to inspire air from mouth to mouth in cases of asphyxia and to frequently kiss upon the mouth all the children at whose birth she assisted. One child died at the age of tw-o and a half months, seven between three and four months, one at nine and one at six months. As all of these infections (except perhaps the two last) probably occurred directly after birth, from bacilli in the oral secretion of the midwife, the observation that meningitis terminates fatally at the earliest two and II half, in the majority of cases three to four months after infection, is certainly of great importance. The disease
lasted from one to three weeks in all the cases, but, so far as could be ascertained, was preceded by bronchitis, emaciation, anorexia, etc.
Symptoms.—The symptomatology and course of tuberculous meningitis are so varied that it is impossible to advance a valid type of all or even of the majority of cases. Mention has already been made of the easily comprehensible influence which disseminated tuberculosis, the general condition of nutrition, secondary diseases, and, finally, exciting trauma, may exert.
Hence if we endeavor to arrange a scheme of the disease, we must for the present omit all cases appearing at the end of severe general tuberculosis or cachexia of other origin and all fulminating cases subse quent to severe injury.
Robert Whytt who first described tuberculous meningitis, distin guished definite stages in the course of the disease.
As subsequently modified and accepted by Most authors Huguenin has formulated them as follows: I. Stage of Cerebral Irritation.-1-leadaehe, vomiting, constipation, retraction of the abdomen, incipient cephalic pulse, excitation and delirium, convulsions in children.
II. Stage of Pressure.—Pupillary symptoms, soporose and comatose conditions, cephalic pulse, constipation, retracted abdomen, cervical rigidity, facial paralyses (generally referred to the base of the brain), lesions of the facialis, hypoglossus, oculomotor and abducens nerves, bend phlegia, contractures, convulsions; frequent change in general health.
111. Stage of Paralynis.—Conia, immobility, diminution of all spasmodic sympton)s in general, increase of paralyses. disappearance of cervical rigidity and retraction of the abdomen, irregularity of pulse and rapid increase in pulse rate, agonal rise or fall of temperature, death.
Owing to the impossibility of sharply dividing these stages, we shall follow the precedent of Huguenin and others and reject them as a basis.
On children hitherto healthy or not yet very sick) begins, in the majority of cases, with certain prodrotnal yniptonis, which in themselves are not pathognomonic of meningitis, but if several occur together, should arouse suspicion.