Tubercular Meningitis in the Adult.
Tubercular meningitis may occur at any age, but after the period of childhood it is most frequent between the ages of sixteen and thirty years. About 75 per cent. of the patients are males, and 25 per cent. females.15 The disease does not differ essentially in its course and symptoms from that in children. A family history of tuberculosis is common, or the patient may be already suffering from phthisis, scrofulous glands, cheesy deposits in various organs, caries of the bone, syphilis, or other constitutional affections. According to Seitz, in 93.5 per cent. out of 130 cases with autopsies chronic inflammatory conditions or caseous deposits were found in various organs of the body. Many cases are examples of acute tuberculosis in which the brunt of the disease has fallen upon the brain rather than the other organs.
15 Seitz, op. cit., p. 9.
When cerebral symptoms supervene upon acute disease, such as typhoid fever, pericarditis, acute rheumatism, pneumonia, the exanthemata, etc., the diagnosis between tubercular and simple meningitis is important, because the latter is not necessarily fatal, while the former is almost never recovered from. If the patient were previously healthy and presumably free from tubercular disease, the chances would be in favor of the simple form. A rapid course of the disease would also speak for acute meningitis, and recovery would almost certainly preclude tubercular meningitis. In some cases the diagnosis is difficult or impossible in the beginning.
In cases beginning without acute antecedents—in adults as in children—there is no pathognomonic symptom, but the combination and succession of the phenomena are usually sufficient for the diagnosis. Headache, depression or irritability of temper, delirium, half-closed eyes, ptosis of one lid, squinting, inequality and sluggishness of the pupils, moderate fever, sunken belly, vomiting, constipation, slow and irregular pulse, sopor gradually deepening to coma, with occasional convulsions or paralysis of the limbs, followed in the course of two or three weeks by death, especially if occurring in a patient who has already presented signs of tuberculosis in other organs, point almost unmistakably to tubercular meningitis. Some of the symptoms may not be strongly pronounced, one or two may be absent, but the general picture will suggest no other disease. According to Seitz, tubercle of the choroid is rare in tubercular meningitis of the adult. It is usually associated with tuberculosis of other organs, the pia being free. The subjoined cases are illustrations of the disease in adolescence and adult life:
Case I.—A lad sixteen years old, always somewhat delicate, with a cough and morning expectoration of some months' standing, exerted himself immoderately in gymnastic exercise on the afternoon of Sept. 24, 1875. That night he was awakened by cough and hæmoptysis. Signs of consolidation were found at the apices of both lungs. In three months there were swelling, induration, and suppuration of one testicle. Some months later, pain in the right arm, stiffness of the shoulder-joint, and an abscess communicating with the joint, from which small spicula of bone were discharged. He was about, and even attended school, for more than a year from the time of the attack of hæmoptysis. About Jan. 1, 1877, he began to complain of severe pain in the forehead, with nausea (but no vomiting) and constipation. Jan. 27th he took to his bed, complaining chiefly of pain in the forehead and eyes. Feb. 1st he was drowsy, irritable, and delirious. Feb. 3d incontinence of urine and constant delirium. Up to this time the pulse had not been above 76 in the minute, and on this day it was 64. The next day, Feb. 4th, he was wholly unconscious; pulse 96, pupils dilated. Feb. 5th, left hand in constant motion; pulse 112. From this time the pulse steadily increased in frequency. Feb. 6th he swallowed food, notwithstanding his stupor. Feb. 7th he answered questions; there was oscillation of the eyeballs, and epistaxis from constant picking of the nose. He died Feb. 9th, the pulse being 144 and the respirations 60 in the minute for several hours previous. The temperature never rose above 101.7° F. There was never any vomiting. The duration of the case was thirteen days, in addition to the prodromic period of twenty-seven days.—Autopsy by R. H. Fitz: The pia of the base of the brain from the medulla to the optic thalamus contained a large number of gray miliary tubercles, old and recent, and the same condition was found in the surfaces of the fissure of Sylvius. Ventricles distended with fluid, ependyma thick and translucent. A moderate-sized cavity in the apex of the left lung, with cheesy contents. Both lungs contained an abundance of hard, gray, miliary tubercles. Left kidney contained a wedge-shaped, cheesy mass of the size of a walnut, with numerous tubercles. Left testicle contained a cheesy mass of the size of a walnut; both epididymes were cheesy. The mucous membrane of the bladder contained tubercles near the neck. The vesiculæ seminales contained softened cheesy masses with openings into the urethra. There was a fistulous opening into the right shoulder-joint.
Case II.—Emeline K. L——, 32 years old, single, nurse, had become much exhausted by taking care of a difficult case, and entered Massachusetts General Hospital March 6, 1883, complaining since four days of a little cough, slight expectoration, and chilliness, but no rigor. She seemed hysterical. There was complaint of severe pain in the head, chest, and abdomen. A slight systolic murmur was found at the apex of the heart, and a few moist râles at the base of the chest on both sides behind. The urine was normal. Temperature, 103° F. Three weeks after entrance she began to be delirious, especially at night. April 13th, five weeks and three days after entrance, she was semi-conscious, but would put out her tongue and open her eyes when requested to do so; the abdomen was distended, the pupils were dilated and unequal; there was twitching of the muscles of the right side of the face. Careful examination only disclosed occasional fine râle at the base of right chest. She died April 16th, having been completely unconscious for twenty-four hours. There was no vomiting throughout the case. The temperature was very irregular, ranging between 100° and 103° F., and once as high as 104° F.; it was usually one or two degrees higher at night than in the morning. Pulse, generally from 100 to 110; it rose steadily during the last few days to 160 at the time of death.—Autopsy: Pia mater of brain œdematous, slightly opaque; its lower surface, especially at the base of the brain, showed numerous minute gray tubercles; enlarged cheesy glands at the base of the neck; small, opaque, gray tubercles scattered rather sparsely throughout both lungs. There was also miliary tuberculosis of the liver, spleen, and kidneys.