Part 6

The symptoms just described, separately or collectively, gradually increase; the children finally take to their bed and now the real cerebral affection developes.

Now the principal symptoms are: vomiting, constipation, slow pulse, irregular abrupt breathing, increased temperature of the skin, contracted abdomen, headache, great excitement alternating with drowsiness, beginning decrease of reason, and deranged ability of moving the limbs.

As regards vomiting, this is almost a continuous symptom and generally appears in the earlier stages. But the duration of vomiting is very different. Some children vomit only for one or more days and not all they have eaten, while others vomit continuously from the beginning of the disease till they are relieved by death, and no food can be found that is not thrown up shortly after its being eaten. In this connection it is a peculiar fact that vomiting will not recur if it has once ceased for twenty-four hours.

Very important for the recognition of the disease is the manner of vomiting. For a child suffering from a spoiled stomach will be troubled with nausea, belching, choking and cold sweat long before it is forced to vomit, while children with acute hydrocephalus will throw up without any previous symptoms of that kind, just as though they filled the mouth with water and spit it out again. Vomiting is facilitated when children are raised or placed on their side. It ceases for the time the stomach is empty, but as soon as fluid or even solid food is taken in it will be cast out at once without causing any particular distress or inconvenience to the child. Gall is very rarely mixed with the vomit.

A second and nearly as constant a symptom is constipation from which nearly three-fourths of the diseased children suffer. As a rule cathartics have no effect and are generally thrown out through the mouth. This constipation will not last till the end, for a few pappy stools appear later on whether purgatives are administered or not. Violent diarrhoea resulting from intestinal tuberculosis may be discontinued at the beginning of acute hydrocephalus. But the later stools will again be thin and of cadaverous odor.

During the latter stages of the disease children will often fail to pass urine for twenty-four hours, so that the physician is obliged to draw it off with a catheter.

The appetite does not disappear entirely as a rule. There may not be any desire for food, but generally little difficulty is experienced in inducing children to take milk or broth, which is all the more surprising as vomiting regularly follows.

The fever is generally not very intense. The temperature of the head, especially the forehead, is considerably increased in all cases and remains so until death ensues, while the feet have great tendency to getting cold.

The pulse is characteristic in many cases. In the beginning of the disease the pulse is quickened only to slacken after a few days. The number of beats may be reduced to 40-60 a minute (normal 90-100), however it does not commonly remain at a certain figure, but varies, often inside of an hour, so that at one time 40, then 60 and again 80 beats may be counted inside of twenty-four hours.

The pulse again increases 1-3 days before death and then to such a rate that it is almost impossible to count it. It may reach 180 and 200 beats a minute. As soon as this rate of the pulse follows one of the reductions described above a speedy death may be predicted.

Of great importance are the variations in respiration. In the beginning stages of the disease breathing is normal except in such case where tuberculosis has made great progress in the lungs and in the case of high fever. Then of course breathing becomes more rapid. Acute hydrocephalus influences respiration in such a way that it slackens and becomes irregular. In one minute children may breath fifteen times, in another thirty, then again 20 times; at one time breathing may be very slight with almost invisible expansion of the chest and without any noise whatever, then again it may consist of deep sighs; these are also characteristic of this particular disease. Sometimes breathing is completely discontinued for ten seconds and more.

If the pulse attains that extreme rate shortly before death the rate of breathing will also be increased.

As regards the skin, the same is generally damp from the beginning of the disease; severe sweats are observed on the head; with progressing disease the skin becomes dry, brittle, comes off in flake-like scales and only when the death-predicting increase of the pulse sets in, there appears a profuse sweat, the cold sweat of death.

Headache is also a prominent and pretty nearly constant symptom. As has been mentioned before, it does not as a rule attend the precursory symptoms. It generally begins with vomiting and soon becomes so violent that older children constantly cry aloud and lament, while the smaller ones put their little hands up to their head, pull their hair and ears and restlessly roll about on the pillow.

These expressions of pain last as long as children retain consciousness, a particular part of the head is not commonly pointed out, but asked about it the majority point to the forehead. With small children automatic movements are noticed that also seem to refer to headache, and which consist in rapidly placing the hand on the head and then drawing it back.

The larger children complain of pains in the bowels, especially in the region of the stomach, which remarkably often, though not regularly, become more intense by pressing and may become so violent that the children cry out aloud with pain, when the stomach or other portion of the abdomen is but slightly touched. But these pains do not last as long as the headache, they often stop suddenly, at times return.

The shape of the abdomen is extraordinarily characteristic. In the beginning nothing remarkable can be noticed, but after the symptoms of acute hydrocephalus, vomiting, constipation, etc., have lasted for some time, the abdomen gradually decreases in size, becomes wrinkled and collapses until it finally assumes a scaphoid shape and by slight pressure the large iliac artery can be felt on the spinal column.

This contraction of the abdomen is attendant in every case of tuberculous meningitis.

If the large fontanel on the head is not yet closed, the same will gradually bulge out as the disease progresses.

The mental activity suffers premature derangements, such as have been fully mentioned in the description of the precursory symptoms. The most striking is the confused, staring look, the peevish and surly behavior, and again in other cases the extreme indifference toward otherwise well-liked persons and things. Later on actual delirium sets in, but generally of a quiet nature.

A very common symptom is a loud, plaintive outcry, that is repeated at longer or shorter intervals. Children often cry out at partly regular intervals during a whole night; these cries are always accompanied by a loud sigh. These symptoms of excitement being extremely tormenting and depressing for the sympathizing relatives, fortunately last no longer than 6-8 days at the most, and are succeeded by a deep stupor.

If the children have once become unconscious, they do not recover again as a rule but remain so until death; delirium and stupor may alternate with each other in certain cases, but the former process is by far the most frequent.

Convulsions appear only in the later stages. At first the interval between the attacks are long, often as many as three or four days intervene. Commonly however they come much oftener and may in some cases last for hours. All extremities are affected by these convulsions, the eyes become red, are rolled in every direction and turning way up are fixed so that nothing but the whites is visible. After several minutes, often after two or three hours, these general convulsions subside, the children, now very pale, drop into a deep sleep and their general condition appears much reduced.

Different muscular groups especially those of the face are subject to local cramps. The upper lip may become distorted, convulsive smiles have been observed, also peculiar sucking motions. The children point their lips and flatten them again, sometimes for hours in succession.

In the latter stages a squinting of one or both eyes may be noticed but this may again disappear.

Grinding of the teeth is another very peculiar symptom which is well-known and feared by experienced nurses. The arms are subject to various motions, at times sweeping automaton like, then again convulsive contractions, sometimes trembling of the muscles, at others a throbbing of the tendons. Many patients put their hands to their sexual organs and make motions tending to onanism.

The legs are not subject to cramps as much as the arms; they are mostly bent and drawn up in a half paralyzed condition.

The muscles of the neck and back are very much contracted and most children, when raised or laid on their side, bend the head far back.