1 See W. Hughes Willshire's valuable paper, entitled “Historic Data on Scrofulous Meningitis,” in Brit. and For. Med.-Chir. Review, Oct., 1854.
In 1827, Guersant remarked that the inflammation of the meninges constituting acute hydrocephalus presented such peculiarities as led him to denominate it granular meningitis. He did not, however, connect the granular deposit with tubercle. This was left for Papavoine to effect, who in 1830 published two cases of tuberculous arachnitis, in one of which effusion into the ventricles, or hydrocephalus, existed. The meningeal granulations or tubercles were described with care, and their coincidence with tuberculous deposit elsewhere was remarked upon, as also the apparent occurrence of the former previous to the inflammatory action in the meninges, and in one case the existence of the tuberculous granules without the sequence of inflammation. The important pathological element of acute hydrocephalus thus clearly pointed out by Papavoine now became apparent to observers, and obtained almost universal assent. The attention of the profession in this country was first called to it by W. W. Gerhard of Philadelphia in 1833, in an admirable paper published in the American Journal of the Medical Sciences,2 containing the reports of thirty-two cases with autopsies. In every case but two tubercles were found in other organs besides the meninges. In one of these two, gangrenous cavities were found in the lungs without tubercles, though perfectly characterized miliary tubercles existed in the membranes; in the other case the lungs were not examined with care, Gerhard not being present at the autopsy.
2 Vols. xiii. and xiv., 1833-34.
Finally, the distinction between tubercular and simple meningitis was pointed out by Guersant in 1839, and clearly established by Barthez and Rilliet in 1843 in their systematic work on the diseases of children; and it was further elucidated by Rilliet in 1847.
ETIOLOGY.—The causes of tubercular meningitis are predisposing and exciting. Among the former are hereditary tendency to tuberculosis and to the so-called scrofulous diathesis; the previous existence of tubercle in any part of the body, especially in the lungs; and the presence of caseous degeneration in the bronchial, the mesenteric, and other glands, or in the parenchyma of various organs, as the lung, the testicle, the liver, the spleen, etc. The dependence of miliary tuberculosis of the pia upon previously-existing caseous or other inflammatory deposits in some part of the body is acknowledged by most modern pathologists. Seitz3 states that out of 130 cases, with autopsies, of adults, upon which his work is based, such deposits were found in 93.5 per cent. General constitutional weakness, either congenital or resulting from grave disease or from overwork, from insufficient or unwholesome food, and from bad hygienic surroundings, also favors the deposit of tubercle in the meninges. Sometimes two or more predisposing causes exist at once. Thus, a child born of tuberculous parents may be fed with artificial diet instead of being nursed, or may live in a house whose sanitary condition is bad. Hence the disease is common among the poor, although by no means rare in the higher classes of society. In some cases it is difficult or impossible to assign any predisposing cause. A single child out of a numerous family may be stricken with the disease, while the rest of the children, as well as the parents and other ascendants, are healthy. For instance, while writing this article I had under observation a little boy six years old whose parents are living and healthy, with no pulmonary disease in the family of either. The only other child, an older brother, is healthy. While apparently in perfect health the child was attacked with tubercular meningitis, and died in seventeen days with all the characteristic symptoms of the disease. At the autopsy there was found much injection of the cerebral pia everywhere, a large effusion of lymph at the base of the brain and extending down the medulla, abundance of miliary tubercles in the pia and accompanying the vessels in the lateral regions of the hemispheres, lateral ventricles distended with nearly clear fluid, ependyma smooth, choroid plexuses covered with granulations, convolutions of brain much flattened. Careful investigation, however, will usually enable us to detect some lurking primary cause, either in the family predisposition or in the history of the patient himself.
3 Die Meningitis Tuberculosa der Erwachsenen, von Dr. Johannes Seitz, Berlin, 1874, p. 317.
Season appears to have but little influence on the production of the disease. The largest number of cases is observed during winter and spring, owing doubtless to the influence of the temperature and weather, and to the exclusion from fresh air, in favoring the development of tubercle and the scrofulous diathesis. Males, both children and adults, are somewhat more frequently attacked than females.
In regard to the exciting causes it may be said that where a disposition to the deposit of tubercle exists, anything which tends to lower the vitality of the individual is likely to hasten the event. In infants with hereditary tendency to tubercle, an improper diet is especially liable to develop meningeal tubercle. In older children, besides unwholesome or insufficient food and unfavorable hygienic surroundings, the acute diseases common to that period of life, such as the eruptive fevers, intestinal disorders, whooping cough, etc., often act as immediate causes. Sometimes the development of the disease may be traced to over-stimulation of the nervous system by excessive study, often aided by imperfect ventilation or overheating of the school-room. Caries of the temporal bone from disease of the middle ear may act as an immediate cause of tubercular meningitis, although simple meningitis is of course a more frequent result of that condition. The disease has been known to follow injuries of the head from blows or falls. In a larger number of cases the exciting cause is not discoverable, especially when the meningeal affection is simply an extension of the disease from some other part of the body, as the lungs, the bronchial or mesenteric glands, etc. This is often the case, both in adults and in children, when tubercular meningitis complicates pulmonary consumption.
SYMPTOMS.—The disease is most frequently observed in children between the ages of two and seven years. It is much less common in adults, who are generally attacked between the ages of twenty and thirty years. In the majority of cases the invasion of the malady is preceded by a prodromic stage, usually occupying from a few days to several weeks, though sometimes extending over a considerably longer period. This stage probably represents the process of deposit of miliary tubercles in the pia mater before their presence has given rise to much structural change in the tissue. The characteristic symptoms of the prodromic stage consist chiefly in an alteration of the character and disposition of the patient, varying in extent in different cases. In general, it may be said that he becomes sad, taciturn, apathetic, irritable, indisposed to play, often sitting apart from his companions, gazing in a strange way into vacancy. There is diminution or loss of appetite and some emaciation. He is restless at night, is disturbed by nightmare, or grinds his teeth. The digestion is deranged. Usually there is constipation, but occasionally diarrhœa, or these conditions may alternate with each other. Squinting and twitching of the facial muscles are sometimes noticed. Headache may occur early in this stage, but it is usually observed later, and it then forms a prominent symptom. Vomiting is also frequent, usually not preceded by nausea, sometimes provoked by sudden movement, as in sitting up in bed, and is apt to occur when the stomach contains little or no food. These symptoms vary much in degree, and they are often so slight that they pass unnoticed by the parents or friends. Occasionally the patient, if a child, will manifest a strange perversity or an unusual disobedience, for which he is perhaps punished under the belief that his misconduct is intentional. In older children and in adults delirium, especially at night, sometimes followed by delusions which may be more or less permanent, is frequent at this stage. The above symptoms often remit from time to time, and during the interval the patient may seem to have recovered his health. The prodromic symptoms are rarely altogether wanting in children, although they may have escaped notice from lack of opportunity of observation on the part of the physician. On the other hand, as Steffen4 justly observes, the most characteristic symptoms may be present, and lead even an experienced observer to a confident diagnosis of tubercular meningitis during the early stage of a case of typhoid fever or of cerebral congestion without tuberculosis.
4 “Meningitis Tuberculosa,” by A. Steffen, in Gerhardt's Handb. der Kinderkrankheiten, 5 B., 1ste Abth., 2te Hälfte, p. 465.