A system of practical medicine. By American authors. Vol. 5

by Unknown

For convenience of description it is customary to divide the disease proper, after the prodromal period, into three stages—viz. of irritation, compression, and collapse. In some cases it is not difficult to observe these divisions, but it must be borne in mind that in others the symptoms do not follow any regular sequence, so that no division is possible. In infants profound slumber may be the only morbid manifestation throughout the entire disease. Steffen records such a case, and I have seen two similar ones.

First Stage: The interval between the prodromic period and the first stage is usually so gradual that no distinction between the two can be detected. In other cases the disease is ushered in suddenly by some striking symptom, such as an attack of general convulsions, with dilated pupils and loss of consciousness. This is not often repeated, though partial twitchings of the limbs or of the muscles of the face may follow at intervals. In young children a comatose condition, with unequal pupils, is apt to take the place of these symptoms. The principal phenomena of the first stage are headache, sensitiveness to light and sound, vomiting, and fever. The latter varies much in intensity from time to time, but is not usually high, the temperature seldom rising above 103° F., and usually, but not always, higher at night than in the morning; but there is no characteristic curve. The pulse varies in rate, but is usually slow and irregular or intermittent. The respiration is irregular, with frequent sighing. The tongue is dryish and covered with a thin white coat. The bowels are costive. Delirium is frequent at night, and the sleep is disturbed, the patient tossing about and muttering or crying out. The eyes are half open during sleep. These symptoms become more marked from day to day. The pain in the head is more frequent and severe; the patient presses the hands to the forehead or rests the head against some support if sitting up. During sleep he occasionally utters a loud, sharp cry, without waking. There is increasing apathy, and some intolerance of light, shown by an inclination to turn toward the wall of the room or to lie with the face buried in the pillow. The appetite is lost, the constipation becomes more obstinate, the slowness and irregularity of the pulse persist. With the rapid emaciation the belly sinks in, so that the spinal column can be easily felt. Soon the child falls into a state of almost continual somnolence, from which, however, he can be awakened in full consciousness, and will answer correctly, generally relapsing again immediately into slumber. His restlessness diminishes or ceases altogether, and he lies continuously on the back with the head boring into the pillow. He becomes more passive under the physician's examination, in strong contrast to his previous irritability. At the end of a week or more from the beginning of this stage symptoms of irritation of some of the cerebral nerves begin to show themselves, in consequence of pressure from the increasing exudation at the base of the brain and into the ventricles. Strabismus (usually convergent), twitching of the facial muscles and grimaces, grinding of the teeth, or chewing movements of the mouth are noticed. The somnolence deepens into sopor, from which it becomes more and more difficult to arouse the patient, who gradually becomes completely insensible.

Notwithstanding the alarming and often hopeless condition which this assemblage of symptoms indicates, intervals of temporary amendment not unfrequently take place. The child may awake from his lethargy, recognize those about him, converse rationally, take his food with relish, and exhibit such symptoms of general improvement that the parents and friends are led to indulge in fallacious hopes, and sometimes the physician himself ventures to doubt the accuracy of his diagnosis. Such hopes are of short duration; the unfavorable symptoms always return after a brief interval. The duration of the first stage may be reckoned at about one week.

Second Stage: This period is not separated from the preceding one by any distinct change in symptoms. The patient lies in a state of complete insensibility, from which he can no longer be aroused by any appeal. The face is pale or of an earthen tint, the eyes are half closed. If the anterior fontanel be still open, the integument covering it is distended by the pressure beneath. Often one knee is flexed, the opposite leg extended; one hand applied to the genitals, the other to the head. Sometimes one leg or arm is alternately flexed and extended. The head is apt to be retracted and bores into the pillow. The pupils are dilated, though often unequal and insensible to light: the sclerotica are injected; a gummy exudation from the Meibomian glands forms on the edges of the lids. The patient sighs deeply from time to time, and occasionally utters a loud, piercing cry. Paralysis, and sometimes rigidity of one or more of the extremities, are often observed, and occasionally there is an attack of general convulsions. The pulse continues to be slow and irregular, the emaciation progresses rapidly, and the abdomen is deeply excavated. The discharges from the bladder and rectum are involuntary. The average duration of the second stage is one week.

Third Stage: No special symptoms mark the passage of the second stage into the third, which is characterized by coma, with complete resolution of the limbs. The constipation frequently gives place to moderate diarrhœa. The distended fontanel subsides, and often sinks below the margin of the cranial bones. A striking feature of this stage is a great increase in the rate of the pulse, the heart being released from the inhibitory influence of the par vagum in consequence of the complete paralysis of the latter from pressure. The pulse varies in rapidity from 120 to 160 or more in the minute. For the same reason the respiration also increases in frequency, though not to the same degree. The eyelids are widely open; the pupils are dilated and generally motionless, even when exposed to a bright light. The eyes are rolled upward, so that only the lower half of the iris is visible; the sclerotica is injected from exposure to the air and dust. Convulsions may occur from time to time. Death terminates the painful scene, usually in from twenty-four to forty-eight hours, but sometimes the child lives on for days, unconscious, of course, of suffering, though the afflicted parents and friends can with difficulty be brought to believe it.

Certain points in the symptomatology of tubercular meningitis demand especial consideration.

I have already observed that the division of the disease into definite stages is purely arbitrary, and is employed here merely for convenience of description; in fact, few cases pursue the typical course. A period of active symptoms and another of depression can often be observed, but these frequently alternate. Stupor and paralysis may characterize the early stage, and symptoms of irritation, with restlessness, screaming, and convulsions, predominate toward the end. Certain characteristic symptoms may be wholly or in part wanting, such as vomiting, constipation, or stupor.

The temperature shows no changes which are characteristic of the disease. Throughout its whole course it varies from time to time, without uniformity, except that it usually rises somewhat toward night. It seldom exceeds 102° or 103° F., unless shortly before death, when it may rise to 104° F., or even higher, and may continue to rise for a short time after death.

During the premonitory stage the pulse offers no unusual characteristics. Its frequency is often increased, as is usual in any indisposition during the period of childhood, but it preserves its regularity. Toward the close of this period, and especially during the first stage of the disease proper, a remarkable change takes place. It becomes slow and irregular, the rate often diminishing below that in health. The irregularity varies in character; sometimes the pulse intermits, either at regular or irregular intervals. An inequality in the strength of different pulsations is also observed. These peculiarities of the circulation are due to the irritation of the medulla and the roots of the par vagum, by which the inhibitory function of that nerve upon the action of the heart is augmented. During the last period, on the other hand, the increasing pressure on the vagus paralyzes its function, and the heart, freed from its control, takes on an increased action, the pulse rising to 120 beats, and often many more, in the minute. Robert Whytt, in his interesting memoir,⁵ dates the beginning of the second stage from the time that the pulse, being quick but regular, becomes slow and irregular; the change again to the normal frequency, or beyond it, marking the commencement of the third stage.

⁵ “An Account of the Symptoms in the Dropsy of the Ventricles of the Brain,” in the Works of Robert Whytt, M.D., published by his son, Edinb., 1768, p. 729.