Early mental disease.

Date:
1912
Catalogue details

Licence: In copyright

Credit: Early mental disease. Source: Wellcome Collection.

Provider: This material has been provided by King’s College London. The original may be consulted at King’s College London.

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    increasing intensity. For some days the child m-ay reply to questions, if roused, and even take a transient interest in his surroundings. At a slightly later stage, photophobia and considerable irritabihty may be shown, the child being most resentful of disturbance. The patient then con- tinues in a state of lethargy, which may be inter- rupted by periods of delirium, teeth-grinding, convulsive attacks, or an occasional short cry. Finally, the lethargy gradually passes into coma in which death occurs. The duration of the course in children varies from one to four weeks, not including possible prodromal symptoms. Diagnosis. The diagnosis is made by careful attention to the nature of the onset, the presence of headache, vomiting and pyrexia, the mental condition, and the physical signs. The vast majority of cases of tuberculous meningitis are secondary to some tuberculous focus elsewhere, such as caseous mediastinal or mesenteric glands, pulmonary infec- tion, or as part of a general miliary tuberculosis ; it is doubtful, indeed, if a reaUy primary tuberculous meningitis exists. Nevertheless, it is by no means frequent that a definite primary tuberculous focus can be demonstrated clinically. Apart from the mental state, the pupils may be unequal and react sluggishly to light, but neck rigidity and Kernig's sign, if present, are, as a rule, moderate only and much less pronoimced than in other forms of meningitis. Papilloedema may sometimes be found, and retention of urine is occasionally a very early symptom. Complete diagnosis rests on the results of cerebro-spinal fluid examination. On withdrawal, the fluid is either clear to the naked eye or only very slightly turbid. The protein content is invariably increased, and the globulin tests (Noguchi, Nonne-Apelt) strongly positive. Both the sugar and chlorides, however, are considerably diminished. In com- parison with other forms of meningitis, the cells are relatively fewer and lymphocytes predominate often up to 90 per cent., although these cells are constantly associated with a small number of polymorphonuclear, plasma, and large endothelial cells. After a long and patient search, tubercle baciUi may be found in films of the centrifugahsed deposit stained by the Ziehl-Neelsen method. Hemenway considers that the bacilli could be demonstrated in 90 per cent, of cases, but in our experience the percentage does not reach this figure. Occasionally, difficulty may be met with in distinguishing cases of tuberculous meningitis from those of encephaUtis lethargica, or, more rarely, from hydrocephahc cases of cerebro-spinal fever coming under observation only late in the disease. The cerebro-spinal fluid of encephalitis lethargica, however, differs from that of tuber- culous meningitis in that cells, when present, consist entirely of lymphocytes with an occasional plasma cell; also, the protein content shows only a small increase which is not proportional to the cellular increase (dissociation albumino-cytolo- gique). Further, in encephalitis lethargica the chlorides are normal or increased, while the sugar content is not diminished and may be increased. In chronic hydrocephalic cases of cerebro-spinal fever, the cerebro-spinal fluid may present an almost identical picture both chemically and cytologically (meningococci being absent) with that of tuberculous meningitis. Diagnosis may rest entirely upon careful attention to the previous history and nature of the onset, and upon either the demonstration of tubercle baciUi or the cultiva- tion of meningococci after enrichment of the cerebro-spinal fluid by incubating it for 24 hours at 37° C. CEREBRO-SPINAL FEVER. Cerebro-spinal fever may be defined as an infectious disease occurring both sporadically and in epidemics, and caused by the meningococcus of Weichselbaum. It occurs at all ages up to 50 years ; after this the disease is rare. In most epidemics the greater number of cases have occurred in children below 15, but in a few outbreaks the number of patients over 20 years have exceeded the younger. Mental State in Adults. In acute adult cases, at a variable time from the onset and following the initial vomiting, delirium occurs in most instances. Its appearance varies from within a few hours of the onset in fulminating cases, to several days in subacute cases ; in the average case delirium is present by the second or third day. The actual character of the delirium varies according to the type of case ; in some it may be merely nocturnal, consciousness appearing qmte normal during the daytime ; in others it may consist of a low muttering for the first few days of illness. At times a patient wiU be delirious when undisturbed, yet when roused answer ques- tions quite intelligently ; or periods of dehrivim will alternate with phases during which the mind is perfectly clear. In acute cases, however, there is often great restlessness and considerable excite- ment, difficulty being experienced in keeping the patient in bed. Such patients may be noisy, violent and maniacal, and many, in the writer's experience, have been mistaken for examples of acute mania or acute alcohoHsm. The initial delirium in most cases is succeeded by stupor, considerable irritabihty, however, being exhibited to sensory stimuh. As a rule, the patient lies on his side with the limbs flexed, takes no notice of questions, but is extremely resentful of any interference, especially of an attempt to turn him into a supine position. This irritability is also well shown by the active withdrawal of the leg on plantar stimulation. It is usually impossible to rouse the patient sufficiently to obey a command or reply to a question, and he may mumble inco- herently when addressed. Fluids poxired into his mouth from a feeding cup, however, are often swallowed quite well. In many cases the response to the initial lumbar puncture and serum injection is dramatic, the stupor rapidly passing off and