Two forms of tubercular meningitis, a primary and a secondary form, will be described.
In primary tubercular meningitis the prodromal period is often short, and its symptoms, on account of their indefinite character, may excite little attention. The child is thought not to look well, but he makes no com plaint for he suffers no pain. He generally becomes thinner and paler, and his appetite is capricious. The loss of flesh is, however, seldom con siderable, and may be only recognised by the use of the weighing scales, for no diminution in bulk may be visible to the eye. He is usually listless and unwilling to exert himself ; sits and lies about instead of joining in the sports of his companions, and if urged to take part in their games, ob jects that he is tired. He is often drowsy, and may be noticed to stop in the middle of some childish employment and fall asleep on the floor of the room. A change in character is frequently noticed ; and this is a symptom. so common that it should be always The change is usually indicated by an increase in his emotional sensibility. If reproved, he shows exaggerated distress ; his endearments exhibit an unaccustomed warmth ; he readily takes offence, and cries without apparent reason, or sits moody and silent in a corner of the room. A certain sluggishness of mind is also apparent. An ordinarily bright child becomes stupid over his lessons ; be seems drowsy and incapable of fixing his mind upon his task. There may be headache, and be may say that the room seems turn ing round. Sometimes there is confusion of sight. The bowels may be irregular and costive. The temperature during this period is often slightly elevated, and the child looks flushed at night and has hot dry hands. In one case which came under my own notice the evening tem perature for the five nights immediately preceding the outbreak was 100.4°, 98.4°, 98°, 99.6°, and 97.6°.
The special symptoms of the disease are usually divided into three stages ; and when the affection is a priniary one this arrangement is justi fied by clinical observation. There is a stage of invasion, in which the in definite symptoms of the prodromal period are suddenly broken in upon by the first indications of local mischief ; a stage of irritation, in which there is exalted nervous activity ; and, finally, a third stage, which is marked by diminution of nervous power and abolition of the functions of life.
The first symptoms of the stage of invasion are in the large majority of cases vomiting and headache, and the bowels which were before costive become obstinately constipated. The is often repeated and
distressing, and occurs without any reference to taking food. It is, in deed, characteristic of a cerebral that retching and vomiting occur in the intervals of the meals—towards the end of digestion when the stom ach is nearly empty., The heaving is often excited by the child up into a sitting position. The matters ejected consist of food and bilious or watery fluid. The headache is generally severe. It is referred to the front or top of the head, and seems to occur in paroxysms so that the patient screams out with pain. The cephalalgia is increased by movement or by a bright light, and is accompanied by dizziness so that the child staggers in his walk. The expression is distressed, and may be irritable or spiteful. The tongue may be clean, but is often thickly furred ; the thirst is often great, and appetite is completely lost. The child takes early to his bed, from which he never again rises. The abdomen is of nor mal fulness to the eye, bat its parietes have a peculiar, soft, doughy feel, which is very characteristic, and are easily compressible. Often there is marked loss of elasticity of the skin. The pulse is generally rapid and regular at this time, but may be slow, and sometimes a fall in the rapidity of the pulse is the earliest symptom noticed. Thus, in the child whose case has been referred to, a fall in the pulse from 100 to 74 occurred on the evening preceding the actual outbreak. The temperature is moder ately elevated (100° 101°). The breathing is generally irregular, and may be unequal and sighing from the first. is a symptom of great importance. The child takes several quick breaths in rapid succession. Then the respiratory movements cease, and during some seconds the chest is motionless. The patient then heaves a deep sigh and pauses again, or his breathing returns for a few minutes to the natural rhythm. Signs of great irritability of the nervous system are rare. at this early period of the illness, although in exceptional cases the disease may be ushered in by a convulsive seizure. Still, there are sufficient indications of nervous agita tion. The senses are excessively acute, the pupils are contracted, and light. is painful to the eyes ; the child is distressed by loud noises ; and hyper msthesia of the skin may be present so that a touch is painful. During this stage the urine is scanty and may contain excess of phosphates.