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

by Unknown

Eclampsia, or sudden convulsion, is common in infants and young children, and, since the occurrence of a fit may be the first or the most striking symptom in tubercular meningitis, it is important to ascertain its origin. In the majority of cases convulsions in children arise from some peripheral irritation, such as difficult dentition, worms in the alimentary canal, constipation, fright, etc., acting through the reflex function of the spinal cord, which is unusually sensitive in the early period of life. The absence of previous symptoms, and the discovery of the source of the irritation, with the favorable effect of its removal by appropriate treatment, will in most cases suffice to eliminate structural disease of the brain. In others we must withhold a positive opinion for a reasonable time in order to ascertain whether more definite symptoms follow. Convulsions also occasionally form the initial symptom of the eruptive fevers, especially scarlatina. Here the absence of prodromal symptoms, and the speedy appearance of those belonging to the exanthematous affection, will remove all sources of doubt. Convulsions, with or without coma, occurring in the early stage of acute renal inflammations, may simulate the symptoms of tubercular meningitis. An examination of the urine will show the true nature of the disease.

In addition to the above diseases there are some cerebral affections of uncertain pathology which resemble tubercular meningitis, but which are not generally fatal. As Gee justly remarks,¹² “Every practitioner from time to time will come across an acute febrile disease accompanied by symptoms which seem to point unmistakably to some affection of the brain, there being every reason to exclude the notion of suppressed exanthemata or analogous disorders. After one or several weeks of coma, delirium, severe headache, or whatever may have been the prominent symptom, the patient recovers, and we are left quite unable to say what has been the matter with him. To go more into detail, I could not do otherwise than narrate a series of cases which would differ from each other in most important points, and have nothing in common excepting pyrexia and brain symptoms. There is, generally, something wanting which makes us suspect that we have not to do with tubercular meningitis. Brain fever is as good a name as any whereby to designate these different anomalies; cerebral congestion, which is more commonly used, involves an explanation which is probably often wrong, and certainly never proved to be right.” No doubt such cases are occasionally cited as examples of recovery from tubercular meningitis.

¹² “Tubercular Meningitis,” by Samuel Jones Gee, M.D., in Reynolds's System of Medicine, Philada., 1879, vol. i. p. 832.

PROGNOSIS.—Although there are on record undoubted instances of recovery from tubercular meningitis, yet their number is so small that practically the prognosis is fatal. It is safe to say that in almost all the reported cases of recovery the diagnosis was erroneous.¹³ Even should the patient survive the attack, he is usually left with paralyzed limbs and impaired mental faculties, and dies not long afterward from a recurrence of the disease or from tuberculosis of the lungs or other organs.

¹³ Hahn, “Recherches sur la Méningite tuberculeuse et sur le Traitement de cette Maladie” (Arch. gén. de méd., 4^e Série, vols. xx. and xxi.), claims to have cured 7 cases, but of 5 of them there is no evidence that they were examples of tubercular meningitis at all. The subject of the curability of tubercular meningitis is ably treated by Cadet de Gassicourt (Traité clinique des Maladies de l'Enfance, vol. iii., Paris, 1884, p. 553 et seq.). His conclusion is that most of the alleged cures are cases of meningitis of limited extent, arising from the presence of tubercular tumors, syphilitic gummata, cerebral scleroses, and neoplasms of various kinds.

TREATMENT.—In view of the fatality of the disease, and of its frequent occurrence in childhood, the prophylactic treatment is of great importance. Every effort should be made to protect children whose parents or other near relatives are tuberculous or scrofulous, and who are themselves delicate, puny, or affected with any constitutional disorder, from tubercular meningitis, by placing them in the best possible hygienic conditions. Pure air, suitable clothing, wholesome and sufficient food, and plenty of out-of-door exercise are indispensable. Sedentary amusements and occupations should be sparingly allowed. Especial pains should be taken to prevent fatigue by much study, and school-hours should be of short duration. The hygiene of the school-room is of paramount importance, and if its ventilation, temperature, and light are not satisfactory, the child should not be permitted to enter it. The bed-chamber should be well ventilated night and day. A sponge-bath, cold or tepid according to the season or to the effect on the patient, should be given daily, followed by friction with a towel. The bowels must be kept regular by appropriate diet if possible, or by simple laxatives, such as magnesia or rhubarb. For delicate, pale children some preparation of iron will be useful. The choice must be left to the practitioner, but one of the best in such cases is the tartrate of iron and potassium, of which from two to six grains, according to the age, may be given three times daily after meals. Cod-liver oil is invaluable for scrofulous patients or where there is a lack of nutrition. A teaspoonful, given after meals, is a sufficient dose, and it is usually taken without difficulty by children, or if there be much repugnance to it some one of the various emulsions may be tried in proportionate dose. Along with this, iodide of iron will in many cases be found useful or as a substitute for the oil when the latter cannot be borne. It is best given in the form of the officinal syrup, in the dose of from five to twenty drops. Change of air is useful in stimulating the nutritive functions, and a visit to the seashore or mountains during warm weather will often be followed by general improvement.

Since it is not possible to arrest the disease when once begun, the efforts of the physician must be directed toward relieving the sufferings of the patient as far as possible. In the early period the restlessness at night and inability to sleep will call for sedatives, such as the bromide of sodium or of potassium, in the dose of ten or fifteen grains at bedtime or oftener. This should be well diluted with water, sweetened if necessary. The addition of five to twenty drops of the tincture of hyoscyamus increases the effect. Sometimes chloral hydrate, either alone or combined with the bromide when the latter fails, will procure quiet sleep. From five to ten grains may be given at a dose, according to the age. Compresses wet with spirit and water or an ice-cap may be applied to the head if there be much pain in that region, or it may be necessary to give opium in some of its forms by the mouth, such as the tincture or fluid extract, in doses of from one to five drops. Constipation is best overcome by means of calomel in three- to five-grain doses, to which may be added, when necessary, an equal amount of jalap powder, or an enema of soapsuds may be administered. Active purging should be avoided. Liquid nourishment, such as milk, gruel of oatmeal, farina, or barley, beef-tea, broths, etc., must be given in moderate quantities at intervals of a few hours so long as the patient is able to swallow. Occasional sponging of the whole surface with warm or cool water, and scrupulous attention to cleanliness after defecation, especially when control of the sphincters is lost, will add to his comfort. He should occupy a large and well-ventilated chamber, from which all persons whose presence is not necessary for his care and comfort should be excluded. He should be protected from noise and from bright light, and should lie on a bed of moderate width for convenience of tending.

There is no specific treatment at present known which is likely to be of any benefit in this disease, any more than in tuberculosis of other organs than the brain. Common experience has shown that mercury, which formerly had so high a reputation in the treatment of cerebral diseases of early life, not only fails completely, but adds to the sufferings of the patient when pushed to salivation. The iodide of potassium is recommended by almost all writers, but, so far as I know, there is no proof that it possesses any virtue in meningeal tuberculosis. It has the high authority of Charles West,¹⁴ however, who thinks the remedy is more encouraging than any other, and who mentions one instance in which recovery took place under its employment. He recommends that two grains be given every four hours to a child three years old, the bowels being kept free. Most authorities recommend much higher doses, such as ten or fifteen grains, three or four times daily.

¹⁴ Op. cit., p. 102.

Counter-irritation to the head or back of the neck was formerly much employed, but is now generally abandoned, as giving rise to much discomfort without obvious beneficial effect. In the cases reported by Hahn, already alluded to under the head of Prognosis, recovery is attributed to the energetic application of tartar-emetic ointment to the scalp, producing extensive ulceration, which in one of them lasted more than ten months before cicatrization took place. A careful examination of the reports of these cases satisfies me that but two out of the seven were really examples of tubercular meningitis. How far the recovery in the successful cases is to be attributed to the treatment is very doubtful. Small blisters applied to the vertex or back of the neck are alluded to favorably by West, but he quotes no observations in which they were followed by benefit.