Early Diagnosis 
OF 
Tubercular Meningitis 
IN CHILDREN. 
BY 
H. L. ELSNER, 
Professor of Clinical Medicine, Syracuse Medical College. 
Reprinted from the Buffalo Medical and Surgical Journal. 
BUFFALO: 
Times Printing House, 193 Main St. 
JNO. LAUGHLIN & CO. 
1888. Gempliments the fluth@p. EARLY DIAGNOSIS 
OF 
TUBERCULAR MENINGITIS IN CHILDREN. 
The early diagnosis and prognosing of any given case is 
a source of great satisfaction and profit to the physician as well 
as to the patient. This must necessarily be so for a large num- 
ber of reasons, which flash through our minds almost simultane- 
ously. If the physician can, during the prodromal stage of a 
disease, accurately diagnose and prognose, he not only benefits 
the patient, but aids in raising the standard of his profession. 
There are many diseases which begin with similar symptoms, 
yet the subsequent course of each is different. It is often not 
only difficult, but impossible, to diagnose a case accurately dur- 
ing the first days of attendance. By carefully grouping symp- 
toms, by a process of elimination and a knowledge of the previous 
history of our cases, we are better able to diagnose correctly. It 
will be my object in this paper to give you a few hints and 
symptoms which will aid in making an early diagnosis of cerebral 
tuberculosis. When we consider the comparatively large number 
of cases that we are called upon to treat, the fatality of the malady, 
and the chronic course of the disease in many instances, we will at 
once agree that any symptoms which aid in early diagnosis require 
our careful attention and closest study. In giving the symptoms 
which have seemed to me sufficient for an early recognition of 
the disease, I am not drawing from the experience of others, but 
am giving the conclusions which have been deduced from a care- 
ful consideration of the cases seen in private practice. It matters 
little whether or not we accept, as proven, that a deposit of tuber- 
cles at the base of the brain cannot give rise to symptoms before 
inflammatory action takes place in the piamater, or that simple 
tubercular deposit is sufficient to cause symptoms without menin- 
gitis. The fact remains, that in my cases there have been symp- 
toms of disease before the meningitis proper manifested itself by 2 
TUBERCULAR MENINGITIS IN CHILDREN. 
an uninterrupted train of symptoms. The presence of any one 
symptom alone would not justify us in making the diagnosis of 
tubercular meningitis. It is in this disease, as in all others, a 
consideration of all that the case presents, that justifies a diag- 
nosis. These symptoms are to be considered as prodromata, not 
as symptoms of the disease after it has manifested itself openly, 
and is marching rapidly from the stage of irritation to that of 
pressure; but as they often appear when they are followed by 
days of apparent health, only to renew themselves and finally 
merge into the continuous meningitis, which runs a rapid course 
and terminates fatally in from fifteen to twenty days. The symp- 
toms to which I wish to call your attention are: 
First-Altered disposition. 
Second-Headache.. 
Third-Vomiting and constipation. 
Fourth-Cerebral macule. 
Fifth-Ptosis and facial paralyses. 
Sixth-Convulsions. 
Seventh-Pulse and fever. 
I. Altered Disposition.-For several weeks before the out- 
break of the disease, by well-defined symptoms, the mother or 
nurse, playmate or companion, notice a decided change in the 
disposition of the child. Whenever a child, who has previously 
found pleasure in its toys, suddenly, for a day or longer, turns 
from them, or has moments when they are truly enjoyed, quickly 
followed by a dislike, manifested by its actions, we may safely 
(when cottplcd with other symptoms) look for some abnormality. 
In some cases, older children suddenly, while in the midst of 
their play, discontinue, lie down for a few moments, and are then 
again ready to resume. Other children, who have naturally a 
mild and quiet disposition, become unruly, unmanageable-seem 
entirely changed. Children who have been affectionate, fond of 
the caresses of parents, become at times petulant and irritable. 
In the case of a child nine years of age, who finally died of 
tubercular meningitis, one of the first early symptoms, and one 
which greatly annoyed the parents, was a dislike which the 
patient took to a younger sister with whom she had always 
played and for whom she had always evinced the strongest affec- TUBERCULAR MENINGITIS IN CHILDREN. 
3 
tion. In another case, it was useless for the mother to attempt to 
quiet a previously affectionate and loving boy of twelve, who 
finally yielded to tubercular meningitis. The only person whom 
he would mind was a neighbor for whom he had never shown 
the slightest regard, but who was now given the preference. 
Altered disposition, taken alone, may not be of much value as a 
prodromal symptom, but when, added to it, there is marked ema- 
ciation and one or more of the symptoms mentioned, it becomes 
one of great value. 
2. Headache.-The headache which was found in those chil- 
dren who were old enough to describe their symptoms, was not 
the same in character in all cases. I have frequently watched 
children, to note the expression of their face during the hydro- 
cephalic cry, and have come to the conclusion that it is caused by 
a pain of a shooting or darting character. If you will watch the 
facies of a child during the cry, I am satisfied that you will agree 
with me in my conclusion. Frequently, older children have for 
weeks before the manifestation of continuous meningeal symp- 
toms complained of a very severe and acute cephalalgia. Often 
you will find the only early symptom in a case the severe headache, 
which may last for several hours, followed by days or weeks of 
health, to be renewed at shorter intervals. Some describe a dart- 
ing pain, quickly put their hand to the head, and as quickly 
appear perfectly normal, and in a few moments are again deeply 
interested with their playmates. A number of cases will offer, as 
their only early symptoms, acute and passing cephalalgia, fol- 
lowed by characteristic vomiting, which I have learned to con- 
sider almost pathognomonic of brain trouble, and which will be 
explained in the following pages. I think that I am safe in say- 
ing that persistent or. recurring headaches in children, with nor- 
mal temperature, when not dependent upon errors in diet or 
other explainable transient causes, and when accompanied with 
vomiting or other symptoms enumerated above, partaking of the 
character of the headaches described, are to be looked upon with 
suspicion, and meningeal tuberculosis may be expected in a large 
proportion of the cases. 
3. Vomiting and Constipation.-Among the most frequent early 
symptoms of tubercular meningitis, we find vomiting and consti- 4 
TUBERCULAR MENINGITIS IN CHILDREN. 
pation. It is to the first of these symptoms that T wish more 
particularly to call your attention. The vomiting A^hich we find 
as an early symptom is characteristic; it is one of the symptoms 
of greatest import in making the diagnosis during the prodromal 
period. I think that my readers will agree with me, after 
watching their cases to note this symptom and the man- 
ner in which it manifests itself, that from it alone can the 
early diagnosis be made in eighty per cent, of all cases in 
children. Now, let me tell you what we consider almost char- 
acteristic of this vomiting. A child, previously healthy, without 
any error in diet, suddenly, and without warning, vomits large 
quantities of fluid and mucus without color, but watery. No 
sooner has the child vomited, than it is ready to run-along to its 
play; or if it suddenly awakens to vomit, it readily falls back 
into a natural sleep. The parents are usually surprised to find 
the child vomit, for they can attribute it to no error of diet or 
any assignable cause. The child will probably, after the first 
emesis, continue enjoying (to all appearances) perfect health, 
until, in the course of from three to five or seven days, it again, 
without one moment's nausea or any expression of sickness, 
vomits the same large quantities, and seems entirely unaffected by 
the act, but ready to resume its occupation. If you have noticed 
children before they eject the contents of their stomachs when 
suffering from indigestion, you will find at first a pallor, the body 
covered with perspiration ; in fact, you find all the attendants of 
nausea preceding the act of vomiting. Vomiting is followed by 
a relaxed and enfeebled state, during which the child wishes to 
rest, and its color is changed: In the vomiting of brain lesions in 
children, a different state of affairs is found. The vomiting is not 
preceded (as a rule) by symptoms of nausea. The child, while 
playing or during its sleep, while we are looking into its face and 
are not able to notice the slightest change in expression, without 
retching, suddenly throws up large quantities of fluid, and at first 
seems entirely unaffected. During the prodromal stage, you will 
frequently be consulted by parents, and asked to relieve this vom- 
iting. The history of a large number of cases could be given 
where I have been asked to relieve this symptom, and in which 
the diagnosis of tubercular meningitis in its incipiency was made, TUBERCULAR MENINGITIS IN CHILDREN. 
5 
giving a grave prognosis. It has become routine practice with 
me, after getting the previous history, to ask every parent pre- 
senting a child for treatment of vomiting as the foremost symp- 
tom, whether or not the child is sick long before vomiting, 
whether the child vomits unexpectedly, and what change is 
noticed in the condition of the child after vomiting. Given the 
case of a child who, without previous sickness, nausea or error 
in diet, vomits suddenly, possibly repeatedly, each time without 
preceding sickness, followed by a return to the same condition in 
which the child was found before the act, with or without some 
of the symptoms above mentioned, we may strongly suspect in- 
cipient meningeal tuberculosis. If this characteristic symptom 
is accompanied by constipation, we have an additional symptom 
which aids us in diagnosis. Constipation, as an early symptom, 
is only of value when associated with other symptoms. Children 
are prone at times to suffer from constipation, and it is not a 
symptom that will justify us in making a diagnosis. If, however, 
a child presents who is constipated, at the same time has " men- 
ingeal vomiting " (allow me to suggest the term), and possibly 
one or more of the symptoms above mentioned, there could be 
no hesitation in making a diagnosis of meningeal tuberculosis in 
its incipiency. 
4. Cerebral Macule.-At the Poliklinik, in Vienna, it was 
routine practice with Monti to run his finger-nail along the skin 
of a child in whom he suspected brain trouble, and await the 
resulting macule. If the redness resulting was no more than it 
would be in a healthy child, and faded rapidly, he would exclude 
tubercular meningitis, but if the skin was suffused with a bright, 
red tint, and this remained for from five to ten or even fifteen 
minutes, he would turn to the class and invariably say, "prog- 
nosis infausta estd The cerebral macule is a symptom .which 
Trosseau brought most prominently before the profession, and 
one which he considered of the greatest importance, yet not 
always pathognomonic of " cerebral fever." I cannot describe 
it better than to use the words of this renowned teacher: 
" When I gently made on her abdomen (speaking of a case), with 
my nail, cross markings, longitudinally and transversely, in less 
than half a minute the portion of skin which I had touched was 6 
TUBERCULAR MENINGITIS IN CHILDREN. 
suffused with a very bright red tint, which was diffused at first, 
but grew by degrees fainter, leaving lines along the track where 
the nail had passed, lines of a deeper red color, which persisted 
for a pretty long time." "This is what I mean by cerebral 
macule." This cerebral, macule is not always to be considered 
as a certain and unfailing symptom of tubercular meningitis, but 
I am satisfied that it is present in the larger number of cases. In 
many cases, it has materially aided me in making an early diag- 
nosis. In August, 1879, was called to see a male child, two 
years old, who, without warning, was suddenly seized with con- 
vulsions, severe, and involving all extremities alike. In spite of 
the usual remedies, including ether, these convulsions continued 
for three hours. At this time, the cerebral macule was well 
marked; so well, indeed, that it was plainly noticeable wherever 
the child was touched. For three months after these convulsions, 
the child was, to all appearances, perfectly healthy. At the end 
of this time, it was brought to me with the characteristic menin- 
geal vomiting, cerebral macule well marked; gave a grave prog- 
nosis and diagnosed incipient tubercular meningitis. For six 
months after this time I observed the child, the cerebral macule 
was always present; finally, the child passed into the hands of 
another physician, but it died about twelve months after the first 
convulsion, of tubercular meningitis. In looking over my notes, 
I find many cases in which I was enabled, at my first visit, to 
make a diagnosis and prognosis of these cases, feeling justified 
in doing so after considering the symptoms, including the cere- 
bral macule. You naturally ask : " Does this symptom show 
itself in any other disease ? " It is occasionally noticed in other 
diseases: among them, broncho-pneumonia, with marked menin- 
geal symptoms; also in cases where the diagnosis of meningeal 
congestion had been made. It is only exceptionally present in 
other than cerebral fevers. I have always looked for this symp- 
tom, and have, as a rule, found it present in the early days of 
tubercular meningitis. In the differentiation of typhoid fever 
with brain symptoms from tubercular meningitis, the presence of 
this symptom is invaluable in making the diagnosis. 
5. Ptosis and other Paralyses (Facial).-In a few cases 
which have come under my observation, ptosis was the first TUBERCULAR MENINGITIS IN CHILDREN. 
7 
symptom which was noticeable. I well remember the case in 
which I first found this symptom. In the winter of 1878, I was 
called to see a lady who was in the last stages of tubercular con- 
sumption, treated her for some weeks, when, one day, the baby, a 
female, sixteen months old, was brought into the room for 
examination. The father said that the child was well, but could 
not keep its left eye open. He thought the " upper lid too 
long." Upon examining the child carefully, I was unable to find 
other symptoms that would aid in making a diagnosis. In a few 
weeks, there was ptosis of the right lid also. Then followed a 
time during which the child could only see when its lids were 
raised by others. In six months from the time of the first ptosis, 
the child died of tubercular meningitis. In the case of a girl, ten 
years of age, ptosis was associated with headache, vomiting, and 
the cerebral macule. She died on the seventeenth day of the dis- 
ease. Paralyses in children in the domain of the motor oculi, 
facial and hypoglossal, arising gradually with or without other 
symptoms of brain disease, are of the greatest importance, and 
are usually followed by tubercular meningitis. Though I have 
watched the condition of the pupils, I don't believe that they 
present any features which assist in the diagnosis of the disease 
under consideration. 
6. Convulsions.-The fact that a child has convulsions, when 
taken alone, is of no value in making the diagnosis. Of all the 
children that we are called upon to attend during convulsions, 
only a small proportion succumb to tubercular meningitis. In a 
few cases, we do find convulsions during the prodromal period ; 
they are exceedingly rebellious and likely to recur. In these 
cases, there is no error in diet or other causes than tubercular 
deposit. In the case above mentioned, there must have been a 
tubercular deposit, giving rise to the convulsions twelve months 
before the child died, and almost as many months before the 
appearance of continuous symptoms. From anatomical appear- 
ances of the brains of children who have died before the mani- 
festation of symptoms referable to meningitis, but after con- 
vulsions, the tubercular deposit has been found in some at the 
base, in others upon the convexity of the brain. In the majority 
of the cases which the writer has studied, convulsions were not 8 
TUBERCULAR MENINGITIS IN CHILDREN. 
present, as a rule, during the prodromal period; and when they 
were, they were associated with other symptoms which aided in 
making the diagnosis easy. 
7. Pulse and Fever.-With regard to pulse and temperature, 
I do not believe that I cqn give anything characteristic. In some 
cases, the pulse is slow, in others irregular, and in another class 
of cases very rapid. As a rule, the temperature does not run 
high during the prodromal stage, and when these symptoms 
which we have considered appear many weeks before the final 
and continuous illness, the temperature during that time is not 
actually above ioo° Fahrenheit. There are cases in which, for 
several days, we find elevation of temperature with all other 
symptoms of a rapidly fatal tubercular meningitis; suddenly, a 
decided fall, disappearance of the symptoms, and a return to ap- 
parent health. We begin to doubt the correctness of our diag- 
nosis, when suddenly there is a fresh outbreak of all the symp- 
toms, increased in severity, leading to a fatal termination. The 
end is caused by paralysis of the centers in the medulla oblon- 
gata. The appearance of tubercular meningitis without prodro- 
mal symptoms appears to me to be exceptional. That we do 
have these cases, I cannot deny, but they are exceedingly rare. 
There are other symptoms than those which have been men- 
tioned that aid us in making up the picture of the disease, but to 
these I wished to call your attention and invite a careful study of 
their relative importance. It would be unfortunate, indeed, for us 
to treat a case of incipient cerebral tuberculosis for simple gastric 
indigestion ; yet this mistake is frequently made. There is not 
one pathognomonic symptom of the disease under consideration, 
but we may conclude that the association of several of the symp- 
toms point strongly to the true seat and character of the disease. 
The eloquent words of Trousseau again occur to me: 
"We must not look at a portion of the picture only, but at 
the whole at once. In order to know the drama well, the whole 
play must be seen, and not one scene alone."