Document zz2YkQ8OZkRw7xe4VopGge9m

648 DISEASES OF THE NERVOUS SYSTEM might be assumed to be the greatest. It is quite evident that the instabil ity depends not upon the normal insufficiency of cerebral development, but upon the acquisition of tetany, which causes cerebral instability. I t has long been held that convulsions were caused by materials absorbed from the gastro-intestinal tract. It is certainly true that over feeding or indigestion may excite convulsions. This is usually, however, in children suffering from tetany and it is very likely that the convul sions frequently are not due to any specificity of the material absorbed, but that any irritation to the child's nervous system is likely to be fol lowed by convulsions. Convulsions are sometimes seen, it must be ad mitted, in infants when no evidence of organic disease can be detected, nor any symptoms of tetany and no hyperexcitability of the nervous system as shown by electrical examination. The cause of these is not clear. Convulsions are apparently at times of toxic origin. They may result from conditions like uremia and asphyxia arid also at the onset or in the course of various infectious diseases. They are more frequent in children who have or have had tetany, but may be found without any evidences of this. They are very frequent at the onset of certain diseases, particularly pneumonia, scarlet fever, malaria and severe intestinal dis ease. In pertussis, which, of all the infectious diseases, is the one. in which convulsions are most frequent, several factors may be present: asphyxia, due to a severe paroxysm, cerebral congestion or hemorrhage re- suiting from such a paroxysm, or simply a peculiar susceptibility of the patient brought about by the disease itself. One attack of convulsions, whatever the cause, renders the patient more liable to a second attack and when there have been several, they occur from causes which are less and less marked. An infrequent cause of convulsions in young children is an encephal opathy due to lead poisoning. We have seen eight such cases, six of which were fatal. The poisoning was caused in each instance by the child's nibbling and swallowing the paint from his crib or furniture. Convulsions ending fatally are not infrequently associated with en largement of. the thymus gland. We have seen many such where there was found at autopsy great enlargement of the thymus and the lymphatic structures. Some of these infants were previously healthy; some were rachitic. The similarity of all these cases indicated that the convulsions were in some way associated with the enlarged thymus, but the exact explanation of such cases is not understood. In infants who die during convulsions the brain may be the seat of punctate hemorrhages, and sometimes of more extensive ones. The lungs are also deeply con gested, and the right heart is generally distended with dark clots. The other lesions found are accidental. H | Symptoms.-- In s extreme restlessness, face, hands, feet, or quite suddenly with that the face is pale, 1 a moment or two, c eye or face, or in or until all parts of th become general, but a local cause-- a poi the facial muscles cs back; the hands are quick spasmodic con some frothing at the consciousness. Eesp The pulse is weak; i forehead is covered v becomes slightly blu sounds may be produ evacuated. The conv and extension occurr: spasm may be seen, i the two sides of the b from a few moments ually become less fre the patient in a cond: or there may be but follows the convulsiv dences of prostration tion of the nerve cen Death may take rare except in very yo may be no sequel to they may produce s hemorrhage; in suci hemorrhage is the ca convulsions is genen rapidly recurring attf several minutes have One attack of coi by several others, esp terval which has pass eially if the child has CLhd Childhood f\ ' 1! TAe? Q i s e w e s >( 1_M '{'<(LAC y Cd, )\y&w '(ork M 23 " , _ fn-'tW '/.*-.* . - ~v\ --- ILMXv 1\ o, i=>in TSTEM r four or five days, or lout perhaps being suf, unmistakable evidence 3S are often ascribed to nptom is persistent and eck of general convul1 a period of irritative re is headache,, usually ihotophobia; sometimes ng out at night, which ; sometimes during the ese frequent screaming hyperesthetic; the rethe neck may be rigid dity of the extremities, y be nystagmus. The if disturbed. In some suggest meningococcus >f marked apathy and miting, and the bowels somewhat accelerated, The respiration is of . g sleep or perfect quiet very significant. The to 100.5 F. When tuberculosis elsewhere is subside, and the stusturbed, the child may jed, and then appears mnd that the child can ; pupils respond slowly isionally there is seen e often there is hemises are often transient, unents of the extremiicular twitehings may constant. Ip infants ren especially, the ab" After drawing the ippears a distinct red is the tache cerebrate, TUBERCULOUS MENINGITIS 725 and it is almost always present. Other vasomotor disturbances may be seen. The-reflexes are variable; in the early part of the disease they are usually increased, later they are diminished or abolished. The pulse now becomes slowand irregular, often intermittent. The respiration is almost always irregular ; a very characteristic type consists in the movements be coming deeper and deeper until there is a sigh; followed by a complete arrest of respiration for several seconds. The phenomenon is then re peated. An examination with the ophthalmoscope usually shows the pres ence of choked discs, and in a very considerable number of the cases, if they are closely studied, tubercles may be seen in the choroid. Their presence is of much diagnostic importance. The blood picture in this disease is fairly characteristic. From 230 observations made in our hospital service, it was shown that early in the attack the total leucocytes are only slightly increased, they may be even below the normal. As the disease progresses they increase-.in. number, the average during the last week of the disease being 29,600. The proportion of polymorphonuclears also shows a marked increase. The.early range was 60 to 65 per cent; during the last week it was from 70 to 85 per cent. The progress of the disease is subject to great variations, especially in children over two years old. The advance of symptoms is slower and is interrupted by periods of remission which may continue two or three days. After being in quite deep stupor, a child may recover conscious ness, and even sit up and play with toys, leading to the view that an error in the diagnosis has been made. But this respite is only temporary; soon the child passes again' into coma. From this time the duration of the disease is from three to ten days. The child cannot be roused at all. The pupils are widely dilated, and do not respond to light. There is general muscular relaxation. There may be retention of the urine. Deglutition -is difficult, often impossible. The respiration is more rapid, but still irregular.-..-The. pulse'becomes very rapid and feeble, often 160 to 180 a minute. -Toward the end the temperature often rises rapidly to 104 F.,- sometimes to 106 or 107 F. (Fig. 88). Death usually, takes place from exhaustion in deep coma; or convulsions develop and continue from twelve to twenty-four hours until death. Sometimes a patient will live for days in a condition of prostration so extreme that death is hourly expected. A rapidly rising temperature or the occurrence of late convulsions usually indicates ap proaching death. Of fifty-seven cases, fifty died in coma, seven in con vulsions. The entire duration of the disease from the beginning- ofdefinite nervous symptoms is rarely over three weeks,, and in infants it is usually shorter than this. Lead encephalopathy gives symptoms in young children very muchlike those of tuberculous meningitis. There are present, vomiting, head- -*I --- . .. *.' . v \i *.'-.e-v; - , II 4 v. Interlibrary Loan For: j ? ' i i l C / f J U lik l n -Phone:,.' 728 DISEASES OF THE NERVOUS SYSTEM ache, convulsions and stupor or coma with a slight elevation of tempera ture or none at all. The cerebrospinal fluid is clear but has an increased number of cells and gives a positive reaction for globulin. In lead encephalopathy a history of nibbling at furniture is frequently obtained. A lead line about the teeth, stippling of the red blood-cells and retinal hemorrhages are also usually present. The condition is very fatal. Of eight patients that we have seen with this condition, seven have died. Diagnosis.-- Tuberculous meningitis is often overlooked because the patients do not give outward evidences of tuberculosis. Its frequency should always lead one to suspect it whed protracted nervous symptoms are present in infants. There are no diagnostic symptoms in the early cells are greatly in e. our experience of no Tubercle bacilli i in the early 6tage t But at. the height c found microscopical! of 137 consecutive ca They are more nun The technic is tubes and the last on as the bacilli are r should not be shake preferably in an inci the fluid, and in th spread out entire a may be found after bacilli present is nc necessary; but not discovered in a few The globulin te normal cerebrospin, tinguishing betweei action is obtained w Fio. 88.-- F airly Typical T emperature Curve in T uberculous Meningitis. Boy, twenty months old; death on seventeenth day. stage. The indefinite symptoms that belong to this stage of the disease are frequent in young children suffering from chronic indigestion asso ciated with constipation. Cases of cyclic vomiting may present many of the symptoms of meningitis. The most diagnostic symptoms of tuberculous meningitis enumerated in the order of their frequency are as follows: persistent drowsiness, obstinate constipation, vomiting without apparent cause, irregular respi ration, irregular pulse, convulsions, opisthotonus, and fever which is usually slight A positive diagnosis is made only by lumbar puncture; by this means this form is distinguished from other forms of acute meningitis. The fluid drawn by lumbar puncture is usually perfectly clear, but sometimes after standing there is a slight deposit present. In rare cases the fluid may be turbid. As compared with the other forms of acute meningitis the cells are few in number. The usual cell count is from 100 to 250 c. mm. Nearly all the cells, over 95 per cent in most cases, are mononuclear. Very exceptionally the polymorphonuclear gitis. Bacilli have beer one-half the cases i; gitis, although in r monary disease. The tuberculin cases, in those exe positive reaction w of much assistant If, then, a chile reaction to the tub< are greatly strengt been found' in the The cerebral s; sometimes closely such the diagnosis ingitis in a young culous form, since gococcus meningii diseases. Differen I*:.