• In secondary tubercular meningitis the earlier symptoms of the special lesion are masked. by the more general phenomena indicative of the suffer ing of the whole system from the tubercular cachexia. This form of the disease is the shape the affection invariably takes in infants, and it is not uncommon iu older children. In. these cases nutrition is always greatly interfered with. The child is thin, weakly, and miserable-looking. He is more or less feverish, although, unless catarrhal pneumonia be present, the temperature rarely exceeds 101'; has no appetite ; often vomits ; and appears to be gradually wasting away. Suddenly he is seized with a fit of convulsions. This is followed by partial paralysis which involves some of the cerebral nerves, notably the occulo-motor ; dilated, sluggish, and often unequal pupils ; joints, and stupor. In this state he lin gers a few days ; the convulsions are repeated ; the pulse is small and rapid; the breathing is irregular ; the abdomen is retracted, and the child dies without any return of consciousness. After death the gray gTanulation is discovered widely distributed throughout the internal organs, and the lungs as well as the cerebral meninges are usually the seat of inflammation.
The convulsions are often very partial in these cases, and may consist merely of tonic spasms affecting one or more limbs, with squint or conju gated deviation of the eyes. Sometimes, also, there are slight clonic spasms or faint tremors, unilateral or limited to one limb. The outbreak of the head symptoms is often preceded by sighing or irregular breathing, flat tened abdominal parietes, and slight twitches in the limbs ; but the slow intermittent pulse, which is such a valuable sign in the diagnosis of the pri mary form, is usually absent. Often, before the actual onset nothing at all is noticed to give rise to suspicions of intracranial mischief, although our knowledge that in every case of acute general tuberculosis affecting a very young child such symptoms are likely to occur should lead us to watch for them very narrowly.
In infants the affection, when secondary, almost invariably assumes this form, and death usually follows within a few days of the occurrence of the head symptoms. In older children the course of the secondary form is somewhat longer, and, indeed, the symptoms in some cases may approach nearly to the type observed when the disease is primary. Still, there are in most cases many differences. Delirium alternating with stupor, without convulsions, squinting, or other form of paralysis, may be the only sign that the meninges are affected. Sometimes there is repeated vomiting, with some wandering of mind and intellectual sluggishness, so that the child seems not to understand questions addressed to him, and when told to put out his tongue makes no effort to obey. The disease may even
reach its termination without any more positive signs of intracranial lesion being noticed. Indeed, in these cases the variations in the symptoms are infinite ; but if the existence of general tuberculosis has been ascertained, we shall be at no loss to explain the meaning of any new symptoms which may arise from the head at this late period of the illness.
Many anomalous cases of secondary tubercular meningitis occur in children suffering from cerebral tubercle. This is a chronic clisease which. continues often for months, and is accompanied by more or less severe symptoms pointing to the brain. Fever is usually present, and sickness and headache, which are characteristic symptoms at the onset of the menin gitis, are also common in the brain tumour. Consequently the recurrence of these familiar phenomena is often attributed to the gTowth, and is sel dom interpreted as indicating a new phase of the illness. In such cases the early period of the meningitis passes unnoticed, and the complication is seldom recognised before the more violent symptoms which are charac teristic of its third stage are actually present..
Diagnosis. —It is not always easy at the beginning of an attack of tuber cular meningitis to speak positively as to the nature of the illness. The first symptoms are often mild and apparently trifling, and if, misappre their importance, we make light of what eventually proves to be a fatal the mistake is one which will be certainly remembered to our disadvantage.' Vomiting and constipation, especially if conjoined with headache, form a very suspicious combination, and if these occur in a deli cate child or succeed to a period, however short, of general failure of health, we should view them with serious apprehension. If our suspicions are well founded, symptoms soon appear to give them confirmation. The pulse becomes slow and intermittent, the breathing is irregular, the child gets stupid and drowsy, the pupils dilate and are sluggish, and there may be a slight squint. When this stage of the disease is reached, there is little room for hesitation. It is principally in cases where the illness varies from the normal type that the beginning of the disease gives rise to uncer tainty. be absent. Instead of constipation there may be looseness of the bowels. But still, if the child is feverish, complains of headache, and has a pinched, distressed expression—if with even trifling symptoms he looks really ill, we should never speak slightingly of his condition.