Tubercular meningitis almost invariably begins insidiously, and the symptoms have a regular progression. It is seldom ushered in by a con vulsive fit, and if such a seizure occur at the beginning, it is rarely repeated. Slighter signs of nervous disturbance may, however, be gener ally discovered by careful observation and inquiry. The child will be found to have lately changed in character. From an even-tempered placa- ble boy, he has become suddenly irritable and spiteful ; if naturally head strong and independent, he turns strangely timid and affectionate, 'and is moved to tears by a kind word. Often he grows curiously silent and un willing to play or even to speak. Again, he may be noticed to frown often and avoid the light. He flushes frequently, sighs deeply, and complains of headache and giddiness. All these small details assume great value if combined with feverishness, vomiting, and a look of care. Drowsiness is an early symptom, and when succeeding to the above is very suspicious. At the same time the breathing generally becomes unequal, with long pauses and deep sighs, and this, itself an important symptom, becomes of double value when associated with others pointing in the same direction. If now the pulse falls in frequency and is intermittent, without improve ment in other symptoms, the evidence it supplies may be considered con clusive.
The early period of tubercular meningitis may be mistaken for any of the other lesions or derangements which are accompanied by loss of flesh, vomiting, headache, and signs of nervous excitement.
The condition called spurious hydrocephalus, which sometimes occurs in exhausted infants as a result of anaemia of the brain, with sluggish cere bral circulation, and is sometimes a sign of thrombosis of the cranial sinuses, is usually readily distinguished by the history of severe vomiting or diarrhoea, the evident exhaustion of the child, the depressed fontanelle, and the normal or even subnormal temperature. This condition is seldom seen after the first year of life, and therefore is more likely to be mistaken for a general tuberculosis with secondary meningitis than for the primary form of the disease. Sometimes older children after an attack of serious acute disease may be left in a state of profound malnutrition, in which all food excites vomiting, and the stomach seems incapable of retaining or digesting even the simplest articles of diet. The child is restless and fret ful, and complains of headache. His skin ceases entirely to act, is dry and rough, and the hardened epithelial scales can be brushed off as a fine dust. His lips are dry and cracked, his bowels confined, and his urine scanty and high coloured. After a time the child becomes drowsy and sinks into a stupor in which he dies. In these cases the brain and the internal organs generally are bloodless and wasted. A distinction from meningitis may
usually be made by the low temperature, which even in the rectum is often no higher than 97°; the history of the case, the absence of retrac tion of the belly, and the course of the illness, which has not the regular progression peculiar to the tubercular disease.
An acute catarrhal condition of the stomach in a scrofulous child some times presents symptoms—feverishness, vomiting, headache, and constipa tion—which may be mistaken for the onset of tubercular meningitis, more especially as, when convalescence begins, the pulse often gets slow and intermittent. But in all derangements, as distinguished from grave dis eases, there is an important distinguishing mark, viz., that the patient does not look seriously ill. If he be not profoundly depressed by the severity of the symptoms, or harassed with pain, his face is placid and shows no signs of distress. Moreover, his breathing is regular, and his abdomen normal in appearance and not retracted. If, later, the pulse becomes slow and intermittent, the slackening coincides with an improvement in the symptoms and not with an unfavourable change in the condition of the patient.
Still, even a child suffering from tubercular meningitis has not always a haggard, careworn look. Some time aop I saw, with Dr. hiller, of Black heath, a little boy, four years old, who had been noticed to be getting thin and pale for six weeks. He was often found asleep on the floor in the middle of his play. He flushed up at times and was very fretful, crying without cause.
On November 18th he began to vomit, and the sickness continued all through the week. It occurred usually about an hour after food, and seemed generally to be induced by movement. The bowels were confined, but acted readily after aperients. The temperature at night was about 100°.
When I saw the child, on November 25th, he was lying in bed, with a slight flush on his cheeks. His pulse was at first 100, and regular ; after wards 80, and slightly intermittent ; respirations, 26, and somewhat irregu lar, for the child occasionally heaved a deep sigh, although his breathing was never quite arrested, Temperature (at 3 Rm.) 98.4° ; eyes bright ; no squint ; pupils normal, and acted perfectly ; no photophobia ; no cerebral flush ; consciousness perfect, and the boy answered questions readily. He said that his head sometimes ached at the back. Tongue furred, white ; motions, after aperients, of normal appearance and contained no mucus or worms. The belly was deeply hollowed, and the parietes were soft, doughy, and compressible ; the liver and spleen were of normal size, and the physical signs of his heart and lungs were healthy. There was no al bumen in his urine.