In this case which was seen on the seventh day of the disease, the gen eral mildness of the symptoms, especially the slightness of the headache and the complete clearness of mind of the child at so long a period after the beginning of his illness, seemed to tell against tubercular meningitis ; but the history of the case, the pulse, the sighing breathing, the deeply excavated abdomen, the absence of sufficient signs of digestive derange ment to account for his state, and the want of elevation in the temperature, which excluded a continued fever—all these symptoms taken together pointed very strongly in favour of the tubercular disease ; indeed in a few days the child became comatose, and he died shortly afterwards.
"Cerebral pneumonia" may be accompanied by symptoms which re semble tubercular meningitis; and as the physical signs of the chest may be normal on the first examination, it is often difficult at once to distin guish the real nature of the disease. There is often delirium and stupor ; vertigo may be a prominent symptom ; and the pulse, although rapid, is in termittent_ In such a case the history, the absence of prodromata, the per verted pulse-respiration ratio, the greater elevation of temperature, and the early occurrence of the head symptoms are not in favour of tubercular meningitis; but until signs of consolidation are discovered we cannot ven ture positively to exclude meningeal tubercle.
In special cerebral disease the course is usually very different from that of tubercular meningitis, as the illness almost invariably begins violent nervous symptoms. The phrenitic form of simple meningitis of the convexity approaches most nearly to tubercular basic meningitis in its at tendant phenomena ; but here the early symptoms are far more severe than in an ordinary case of the tubercular variety. The disease breaks out suddenly with violent headache, almost immediately followed by loud, often furious delirium ; the temperature is very high from the first ; stupor quickly supervenes, and the whole course of the disease is rapid.
In the secondary form of the tubercular disease the earliest sign of the occurrence of the cerebral complication is usually vomiting, and this symp tom should never be disregarded. Often, however, the intra-cranial in flammation may first reveal itself by a fit of convulsions or a squint. In a child who, after a period of wasting and general illness, has an attack of catarrhal pneumonia in which he is suddenly taken with a convulsive seiz ure, the presence of a secondary tubercular meningitis may be more than suspected.
A basic meningitis is sometimes seen in infants as a consequence of in herited syphilis. The symptoms are identical with those of the tubercular form ; but the nature of the illness may be sometimes inferred from the appearance of the child and the presence of other signs of the congenital malady.
Cases are sometimes seen in which a child dies with all the signs of a tubercular meningitis, although after death no appearance of intracranial inflammation or exudation can be discovered, nor can the closest examination detect any gray granulations either in the skull cavity or at any other part of the body. Such cases occur now and then in most children's hospitals. I
have seen one or two ; and as far as I know the form of tubercular men ingitis thus simulated is always the secondary form ; i.e., the cerebral symptoms do not arise suddenly in an apparently healthy child, but come on towards the close of a more or less prolonged febrile attack.
Prognosis.—Tubercular inflammation of the cerebral meninges is so mortal a disease that when the nature of the case is established beyond a. doubt, a fatal termination is inevitable. The disease is said to have been sometimes arrested before the second stage had been reached. In such a case it is reasonable to doubt the accuracy of the diagnosis. Probably many of the cases in which recovery from a basic meningitis has been recorded have been instances of the syphilitic form of the intracranial inflammation, which is much more amenable to treatment.
Treatment.—The disease is so fatal when once established that special precautions should be taken in every case where we have ascertained the existence of the tubercular diathesis to prevent the development of the cachexia, and ward off all influences tending to promote irritation and con gestion of the brain. For the general means to be adopted to strengthen the constitution and weaken the diathetic tendency the reader is referred to the chapter on tuberculosis. With regard to special measures, we should be careful to forbid the more exciting amusements and too boister ous games. The mind of the child should not be overtaxed with protracted study, and care should be taken that his intervals of relaxation are frequent and regular.
When the disease is actually established, we can have little hope that any treatment we can adopt will succeed in checking the course of the illness. The violent measures which it was at one time thought necessary to employ in cases of tubercular meningitis have been found to be not only useless but actually hurtful. Few judicious practitioners would now think of applying leeches, of blistering the skin, of running a seton into the neck, or of rubbing tartar emetic ointment into the shaven scalp. If the case be seen early, perfect quiet in a room carefully shaded from the light should be enforced ; ice-bags should be applied to the head, and the feet should be kept warm. The bowels must be relieved by a dose of calo mel and jalapine, or compound scammony powder, and in the hope that the disease may have a syphilitic origin, the perchloride of mercury, in doses of fifteen to thirty drops, can be given two or three times a day. The child should be supplied with liquid food in sufficient quantities ; and if he re fuse to swallow, he must be fed through an elastic catheter passed down the gullet. Stimulants must be given as seems necessary.