Ethical Practice in the Human Services

From Knowing to Being Richard D.

Parsons
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Ethical Practice in the Human Services

2
We dedicate this book to those who have modeled and given shape to our own sense of “being ethical.” To our parents
who raised us in households where ethics were lived; to Ginny and John, our patient and supportive partners; and to
all those in the helping professions who not only practice ethically but make the concerted effort to “be ethical.”

3
SAGE was founded in 1965 by Sara Miller McCune to support the dissemination of usable knowledge by
publishing innovative and high-quality research and teaching content. Today, we publish over 900 journals,
including those of more than 400 learned societies, more than 800 new books per year, and a growing range of
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independence.

Los Angeles | London | New Delhi | Singapore | Washington DC | Melbourne

4
Ethical Practice in the Human Services
From Knowing to Being

Richard D. Parsons Karen L. Dickinson

West Chester University of Pennsylvania, USA

Los Angeles
London
New Delhi
Singapore
Washington DC
Melbourne

5
 Copyright © 2017 by SAGE Publications, Inc.

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval
system, without permission in writing from the publisher.

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6
This book is printed on acid-free paper.

16 17 18 19 20 10 9 8 7 6 5 4 3 2 1

7
Brief Contents
1. Preface
2. Acknowledgments
3. About the Authors
4. Part I: Helping: The Role and Influence of the Helper
1. Chapter 1. Ethics: Core to Professional Helping
2. Chapter 2. Helper Variables: What the Helper Brings to the Helping Relationship
3. Chapter 3. Ethical Standards: Guidelines for Helping Others
4. Chapter 4. Ethical Practice in an Increasingly Diverse World
5. Part II: Ethics and Standards of Practice: The Professions’ Response
1. Chapter 5. Ethics and the Law
2. Chapter 6. Conflict: The Reality of “Being Ethical” Within the Real World
3. Chapter 7. Ethical Decision-Making
6. Part III: Applying Ethical Standards
1. Chapter 8. Informed Consent
2. Chapter 9. Confidentiality
3. Chapter 10. Boundaries and the Ethical Use of Power
4. Chapter 11. Efficacy of Treatment
5. Chapter 12. Evaluation and Accountability
6. Chapter 13. Ethical Challenges Working With Groups, Couples, and Families
7. Chapter 14. Competence and the Ethics of Self-Care
7. Appendix A. Professional Organizations
8. Appendix B. Codes of Ethics and Standards of Professional Practice
9. Index

8
Detailed Contents
Preface
Acknowledgments
About the Authors
Part I: Helping: The Role and Influence of the Helper
Chapter 1. Ethics: Core to Professional Helping
Objectives
The Helping Process: A Blending of Art and Science
The Helping Process: The Meeting of Client and Helper
Helping: A Special Kind of Interpersonal Process and Response
The Role of the Client in the Process of Change
Freedom and Responsibility to Choose Wisely
Assume Control of Their Participation in the Helping Process
Make Use of the Information Provided?
The Role of the Helper in the Process of Change
Defining and Maintaining a Helping Relationship
Facilitating the Development of a Helping Alliance
Facilitating the Client’s Movement Toward Some Specific Outcome
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 2. Helper Variables: What the Helper Brings to the Helping Relationship
Objectives
Helper Values
Helpers: Detached and Objective
Helper Values and Expectations: Shaping the Helping Relationship
When Values Conflict
Helper Orientation: A Theoretical Agenda for Helping
Reflecting and Validating Interpretations
Helper Competence: Beyond Knowledge and Skill
Care of the Helper: Essential to Maintaining Competence
The Ethics of Therapeutic Choice
Selecting the Appropriate Treatment
Professionalization, Professional Ethics, and Personal Response
Codes of Ethics

9
 Moving Beyond Professional Standards to Personal Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 3. Ethical Standards: Guidelines for Helping Others
Objectives
Formal Ethical Standards: The Evolution of a Profession
Across the Professions: A Review of Ethical Standards of Practice
Common Concerns and Shared Values Across the Professions
Informed Consent
Confidentiality
Appropriate Boundaries for Professional Relationships
Helper Competence
Beyond Knowing: A Call to Being Ethical
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 4. Ethical Practice in an Increasingly Diverse World
Objectives
Prejudice: Pervasive in and Throughout the Helping Profession
Increasing Awareness of Personal Worldview
Potential Bias: Beyond the Personal to the Profession
Responding to the Challenge
The Ethical Practitioner Is AWARE
Culture, Worldview, and the Nature of Professional Relationship
Defining and Assessing a Presenting Concern
Establishing and Implementing a Treatment Plan
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Part II: Ethics and Standards of Practice: The Professions’ Response

10
Chapter 5. Ethics and the Law
Objectives
The Helping Process as a Legal Contract
The Legal Foundation of Ethical Practice
Ethical Does Not Always Equal Legal
Unethical, Yet Legal
Ethical, Yet Illegal
When Ethics and Legalities Collide
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 6. Conflict: The Reality of “Being Ethical” Within the Real World
Objectives
Serving the Individual Within a System
Ethical Culture of Social Systems
Who Is the Client?
When There Are Multiple Masters
Beyond Professional Standards: A Personal Moral Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 7. Ethical Decision-Making
Objectives
Codes of Ethics: Guides Not Prescriptions
Ethical Decision-Making: A Range of Models
Ethical Justification Model
Step-Wise Approach
Values-Based Virtue Approach
Integrating Codes, Laws, and Personal-Cultural Values
Common Elements: An Integrated Approach to Ethical Decision-Making
Awareness
Grounding
Support
Implementation

11
 Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Part III: Applying Ethical Standards
Chapter 8. Informed Consent
Objectives
The Rationale for Informed Consent
Informed Consent Across the Profession
Competence
Comprehension
Voluntariness
Special Challenges to Informing for Consent
Working With Minors
Third-Party Involvement
Working With the Cognitively Impaired or the Elderly
Beyond Professional Standards: A Personal Moral Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 9. Confidentiality
Objectives
Confidentiality: What and When Warranted?
Confidentiality Is Not Privileged
Confidentiality Across the Professions
Limits and Special Challenges to Confidentiality
Professional Support
Client as Danger to Self or Others
Persons With AIDS
Mandated Reporting
Records: Court Ordered
Confidentiality and Working With Minors
Confidentiality in the Technological Era
Legal Decisions: Confidentiality and Privileged Communications
Professionals With Privilege

12
 Extending the Duty to Protect
Extending Tarasoff
Protecting the Practitioner
Beyond Professional Standards: A Personal Moral Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 10. Boundaries and the Ethical Use of Power
Objectives
Setting and Maintaining Professional Boundaries
Professional Objectivity: Essential to Professional Boundaries
Simple Identification
Transference
Dual Relationships: Crossing and/or Mixing Boundaries
Sexual Intimacy: A Clear Violation of Professional Boundaries
Legal Decisions
Beyond Professional Standards: A Personal Moral Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 11. Efficacy of Treatment
Objectives
Practicing Within the Realm of Competence
Competence
Professional Development: Knowing the State of the Profession
Formal Training
Continuing Education
Supervision and Consultation
The Standard of Care: Appropriate Treatment
Defining an Appropriate Treatment
Employing Effective Treatments
Defining Efficacious
Managed Care: Compounding the Standard of Care Issue
Employing an Action Research Approach to Practice

13
 Action Research Defined
Action Research: An Ethical Consideration
The Use of Referral
Knowing When to Refer
Knowing Where to Refer
Making the Referral
Recent Legal Decisions
Beyond Professional Standards: A Personal Moral Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 12. Evaluation and Accountability
Objectives
Monitoring and Evaluating Intervention Effects
Formative Evaluation
Summative Evaluation
Setting Treatment Goals and Objectives
Measuring Outcome and Goal Achievement
Record Keeping
Nature and Extent of Records
Storage and Access
Database and Computer Storage
Recent Legal Decisions
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Chapter 13. Ethical Challenges Working With Groups, Couples, and Families
Objectives
Competency to Practice
Identifying the “Client”
Informed Consent
General Components
Working With Couples, Families, and Groups
Confidentiality

14
 Secrets as Confidential?
Limits to Ensuring Confidentiality
Maintaining Confidentiality
Boundaries
Responsibility: Client Welfare
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Additional Resources
References
Chapter 14. Competence and the Ethics of Self-Care
Objectives
Competency: More Than Knowledge and Skill
Helping: Being With, Not Doing To
Burnout
Compassion Fatigue
The Ethical Challenge
A Challenge to Core Values
A Challenge to Developing and Maintaining an Ethical Therapeutic Relationship
A Challenge to Enacting Ethical, Effective Treatment Plans
Ethical Response
Preventative Measures: An Ethical Response to Self-Care
Intervening in the Face of Burnout and Compassion Fatigue
Awareness and Self-Care
Responding to Impairment
Collegial Corrective Response
Concluding Case Illustration
Cooperative Learning Exercise
Summary
Important Terms
Additional Resources
References
Appendix A. Professional Organizations
Appendix B. Codes of Ethics and Standards of Professional Practice
Index

15
16
Preface

For those working in the helping profession, the power of the helping relationship and the helping dynamic,
be it as a counselor, psychotherapist, social worker or consultant, is more than evident. Equally evident is the
fact that engaging in a helping relationship as a professional carries a very powerful and awesome set of
responsibilities. Sadly, by omission or commission, not all those serving as professional helpers respect the
power of the helping dynamic and as a result, fail to protect the welfare of their clients.

As helpers, we are given the responsibility to care for individuals who, by definition of needing help, are often
those who are most vulnerable to manipulation. And while premeditated and blatant abuses of client welfare
are the exception within human services, they do occur and demonstrate the power of the helping relationship,
even when the “helper” chooses to do harm. Equally deleterious to client welfare are those instances when
ignorance of ethical standards and codes of conduct mitigate client help or cause harm. In these situations,
helpers may appear to be acting on behalf of the client, but their ignorance of or their failure to embody the
established codes of conduct and standards of practice impeded the progress of both client and profession.

17
Standards of Practice
Professional help-givers need standards of practice and guidelines for making the many complex ethical
decisions encountered in the practice and performance of their duties. The recognition of the need for
education in standards and codes of ethics is commonplace across the human services profession. To this end,
numerous texts have been created to describe, explain, and illustrate the specific ethical principles guiding the
practice of various human service providers.

This book, while addressing ethical issues and principles in human service professions, including social work,
counseling, psychology, and marriage and family therapy, moves beyond mere explanation and illustration to
highlighting the underlying moral principles and values that serve as foundation for these codes and attempts
to facilitate the reader’s ownership of these principles and the resulting specific ethical codes.

18
To Be Ethical
This is not the first text to discuss the unique challenges and needs for ethical professional practice. As with
many of the other texts, this books cites the latest ethical standards as explicated by professional organizations
such as the American Counseling Association (ACA), the American Association for Marriage and Family
Therapy (AAMFT), the American Psychological Association (APA), the American School Counselor’s
Association (ASCA), the International Association for Group Psychotherapy and Group Processes (IAGP),
and the National Association of Social Workers (NASW) (Appendix A). Throughout the book, the principles
advanced by these organizations are defined and illustrated with fictional case illustrations. Knowing one’s
professional codes of ethics is essential. However, knowledge alone is insufficient.

There is abundant evidence, both research and anecdotal, that illustrates that while the understanding of the
codes of conduct is core to professional training, understanding/comprehension alone is insufficient to
guarantee these principles will be lived out in practice. Frequency of ethical violation highlights the fact that
knowledge sometimes fails to take form in actual practice decisions. It is this gap between “knowing” and
“doing” or, if you will, between understanding the ethics of one’s profession and “being” the embodiment of
those ethics that serves as the raison d’etre for this text. The unique and primary focus of the text is in helping
the reader go beyond comprehending their profession’s codes of ethics to assimilating, owning, and personally
valuing these standards of ethical practice. The text, while providing a review of the ethical principles which
frame practice, is focused less on knowing ethics … and more on being ethical.

19
Text Format and Chapter Structure
Research suggests that procedural knowledge is acquired as the result of practice accompanied by feedback.
Practice and feedback will be central to this text. Case illustrations and directed practice activities will be
employed as teaching tools throughout the text. Each chapter, with the exception of the preface, will provide a
blending of theory, practice, and guided personalized application. The chapters will include the following:

A listing of chapter objectives

Explanation of the constructs presented with the chapter, along with the supportive research
Explanation of specific, core elements of one’s professional code of ethics
Case illustrations demonstrating the constructs/concepts presented within the chapter
Guided practice exercises, in order for the readers to “experience” the constructs and concepts under
discussion
A concluding case illustration
A cooperative learning exercise
A list of web-based and literature-based resources of additional material

As a teaching tool, the text not only highlights the cognitive domain facilitating the readers comprehension of
the what and why of their profession’s code of ethics but also the affective domain as well. Throughout the
text, guided exercises are provided and designed to engage the reader’s awareness of their own valuing
processes. The purpose of the exercises is twofold. First, it is hoped that the exercise will help to clarify the
points under discussion. Second and more importantly, it is hoped that the exercises will help the reader
personalize the materials presented and assimilate values, which are in line with professional ethics, into his or
her practice.

20
Chapter Overview
As noted above, the focus of each chapter is on helping the reader not only understand the what and why of
each component of one’s professional code of conduct but more importantly to see and own the value of
adhering to the ethical principle at a personal and professional level. The resounding theme is the calling to
“BE” ethical, and LIVE one’s ethics … not merely employing them as a professional duty.

Each chapter will include extensive case illustrations along with guided exercises to assist the reader to move
from comprehension to application and valuing.

21
A Final Thought
This book, like most other texts, can be an impersonal compendium of information. Hopefully, the case
illustrations and the exercises will help to make it less impersonal. The real key, however, is you, the reader.
As you read this book, make the material personal. Invest yourself in the exercises: The more of you placed
into your reading, the more the material will be able to stimulate your growth as an ethical helper.

This preface ends with a reminder that ethics is not simply a thing to be memorized. The principles, and
standards of ethical practice go beyond a demand for comprehension and a demonstration of that
comprehension by performance on a pencil and paper test. Ethical principles in and of themselves are
valueless. It is in the embodiment of those principles in being ethical that life is given to these principles and
our desires to be effective human service providers can be fulfilled.

Richard D. Parsons

Karen L. Dickinson

22
Calling All Instructors!
SAGE’s password-protected companion website includes the following text-specific instructor resources:

Test banks provide a diverse range of pre-written options as well as the opportunity to edit any question and/or insert
personalized questions to effectively assess students’ progress and understanding.

Editable, chapter-specific PowerPoint® slides offer complete flexibility for creating a multimedia presentation for the course.

Please sign in at http://study.sagepub.com/parsonsethics.

23
Acknowledgments

As with any text, while the names on the cover identify the authors, the credit for the book’s creation extends
well beyond those so identified. From those whose research is cited within to the many who have helped take
our ideas and help craft them into the words you are about to read, we truly are appreciative.

We particularly would like to acknowledge the encouragement and direction provided by those who reviewed
the materials in their initial stages. Special thanks go out to Gary Schilmoeller, University of Maine; Keith M.
Wismar, Dillard University; and Marie K. (Mickey) Crothers, University of Wisconsin-Eau Claire. Their
candid feedback made this text better than it would have been without their insights.

We would like to acknowledge the support and guidance provided by the wonderful people at SAGE. To our
friend and one time editor at SAGE Publishing, Kassie Graves, your vision has been inspiring and we thank
you. To Abbie Rickard, Carrie Montoya, Bennie Clark Allen, and Karin Rathert, your professional expertise
and guidance has provided the scaffolding we needed to produce this work.

Additionally, we thank Emily DeVivo, our graduate assistant who helped us with hours of updating codes.
Finally and most heartfelt, we would like to acknowledge the tireless assistance provided by our graduate
assistant Jennifer Toby. Her competence in checking our research, investigating resources, and simply keeping
us gently on task was key to the creation of this final product. Thank you, Jen, we’ll miss you.

SAGE Publishing gratefully acknowledges the following reviewers:

Judith Beechler, Midwestern State University

Ellen Behrens, Westminster College
Steven Berman, University of Central Florida
Kananur Chandras, Fort Valley State University
Kathleen Curran, NHTI-Concord’s Community College
Steven Farmer, Northern Arizona University
Perry Francis, Eastern Michigan University
Charles Kelly, Northwestern Connecticut Community College
Julie Koch, Oklahoma State University
Candace McLain, Tait Colorado Christian University
Emeka Nwadiora, Temple University
Lisa Ray, University of Central Arkansas
Sharon Sisti, Hilbert College
Anna Viviani, Indiana State University
Ginger Welch, Oklahoma State University
Christine Wilkey, Saint Mary-of-the-Woods College
Shannon Wolf, Dallas Baptist University
Kathleen Woods, Chadron State College

24
25
About the Authors

Richard D. Parsons, PhD, is a full professor in the Counselor Education Department at West Chester
University. Dr. Parsons has over 40 years of university teaching experience in counselor preparation programs.
Prior to his university teaching, Dr. Parsons spent nine years as a school counselor in an inner city high
school. Dr. Parsons has had a private clinical practice for over 30 years and serves as a consultant to
educational institutions and mental health service organizations throughout the tri-state area of Pennsylvania,
New Jersey, and Delaware, and he has been the recipient of many awards and honors, including the
Pennsylvania Counselor of the Year award.

Dr. Parsons has authored or coauthored over 80 professional articles and books. His most recent books
include the series of four training texts for school counselors Transforming Theory Into Practice (Corwin Press);
and individual texts including Becoming a Skilled Counselor, Field Experience and Counseling Theory (Sage), and
Counseling Strategies That Work! Evidenced-Based for School Counselors (Allyn & Bacon).

Karen L. Dickinson, PhD, is an associate professor in the Counselor Education Department at West Chester
University of Pennsylvania and coordinator of the School Counseling Certification program. Dr. Dickinson
has over 10 years of experience teaching at the university level in counseling preparation programs. Dr.
Dickinson spent over three decades in the K–12 educational system, supporting students as a general
education and special education teacher and school counselor. In addition to her numerous state, regional, and
national presentations, and articles addressing the needs of college students with disabilities, she is a
contributing author for the text: Working with Students with Disabilities: Preparing School Counselors (Sage).

26
PART I Helping: The Role and Influence of the Helper

27
CHAPTER 1 Ethics: Core to Professional Helping

Maria: Hi. Are you Ms. Wicks? I’m Maria. Mr. Brady told me that I had to come talk with you.

The opening exchange between Maria and Ms. Wicks, while on the surface appearing quite typical of many
exchanged within a school social counselor’s office, belies the fact that the relationship that will unfold and the
dynamics of their exchanges will be challenging and fraught with ethical challenge.

While the process of helping can appear so natural and most of the time relatively easy, when viewed from the
perspective of those in the human service professions, it is in truth complex and filled with challenges for both
the helper and the client. Those within the human service professions understand that helping another person
cope with a problem or facilitating that person’s movement toward a specific outcome is a very responsible
process. It is a process that is done with intention and reflection and demands training and professional
competence. It is also true that this helping process is not and cannot be formulaic. One cannot simply follow
a step-by-step recipe in progressing toward the desired goals.

Within any helping encounter, the professional helper is called upon to make numerous decisions, decisions
that call to question his or her own personal values as well as his or her professional codes of conduct and
ethics. The unique role and influence of the helper within the developing ethical helping relationship is the
focus of the current chapter.

28
Objectives
The chapter will present the role that the helper’s beliefs, values, and ethics play in shaping the decision-
making that occurs within the helping dynamic.

After reading this chapter, you should be able to do the following:

Define helping as a dynamic process, reflecting both an artistry and a science.

Describe the unique ethical responsibilities and roles of the professional helper within a helping
relationship.
Identify the salient characteristics of the effective helper and the degree to which you currently possess
these characteristics.
Identify the reciprocal roles and responsibilities of both the client and the helper in an ethical helping
relationship.

29
Another random document with
no related content on Scribd:
organs, as the lung, the testicle, the liver, the spleen, etc. The
dependence of miliary tuberculosis of the pia upon previously-
existing caseous or other inflammatory deposits in some part of the
body is acknowledged by most modern pathologists. Seitz3 states
that out of 130 cases, with autopsies, of adults, upon which his work
is based, such deposits were found in 93.5 per cent. General
constitutional weakness, either congenital or resulting from grave
disease or from overwork, from insufficient or unwholesome food,
and from bad hygienic surroundings, also favors the deposit of
tubercle in the meninges. Sometimes two or more predisposing
causes exist at once. Thus, a child born of tuberculous parents may
be fed with artificial diet instead of being nursed, or may live in a
house whose sanitary condition is bad. Hence the disease is
common among the poor, although by no means rare in the higher
classes of society. In some cases it is difficult or impossible to assign
any predisposing cause. A single child out of a numerous family may
be stricken with the disease, while the rest of the children, as well as
the parents and other ascendants, are healthy. For instance, while
writing this article I had under observation a little boy six years old
whose parents are living and healthy, with no pulmonary disease in
the family of either. The only other child, an older brother, is healthy.
While apparently in perfect health the child was attacked with
tubercular meningitis, and died in seventeen days with all the
characteristic symptoms of the disease. At the autopsy there was
found much injection of the cerebral pia everywhere, a large effusion
of lymph at the base of the brain and extending down the medulla,
abundance of miliary tubercles in the pia and accompanying the
vessels in the lateral regions of the hemispheres, lateral ventricles
distended with nearly clear fluid, ependyma smooth, choroid
plexuses covered with granulations, convolutions of brain much
flattened. Careful investigation, however, will usually enable us to
detect some lurking primary cause, either in the family predisposition
or in the history of the patient himself.
3 Die Meningitis Tuberculosa der Erwachsenen, von Dr. Johannes Seitz, Berlin, 1874,
p. 317.
Season appears to have but little influence on the production of the
disease. The largest number of cases is observed during winter and
spring, owing doubtless to the influence of the temperature and
weather, and to the exclusion from fresh air, in favoring the
development of tubercle and the scrofulous diathesis. Males, both
children and adults, are somewhat more frequently attacked than
females.

In regard to the exciting causes it may be said that where a

disposition to the deposit of tubercle exists, anything which tends to
lower the vitality of the individual is likely to hasten the event. In
infants with hereditary tendency to tubercle, an improper diet is
especially liable to develop meningeal tubercle. In older children,
besides unwholesome or insufficient food and unfavorable hygienic
surroundings, the acute diseases common to that period of life, such
as the eruptive fevers, intestinal disorders, whooping cough, etc.,
often act as immediate causes. Sometimes the development of the
disease may be traced to over-stimulation of the nervous system by
excessive study, often aided by imperfect ventilation or overheating
of the school-room. Caries of the temporal bone from disease of the
middle ear may act as an immediate cause of tubercular meningitis,
although simple meningitis is of course a more frequent result of that
condition. The disease has been known to follow injuries of the head
from blows or falls. In a larger number of cases the exciting cause is
not discoverable, especially when the meningeal affection is simply
an extension of the disease from some other part of the body, as the
lungs, the bronchial or mesenteric glands, etc. This is often the case,
both in adults and in children, when tubercular meningitis
complicates pulmonary consumption.

SYMPTOMS.—The disease is most frequently observed in children

between the ages of two and seven years. It is much less common in
adults, who are generally attacked between the ages of twenty and
thirty years. In the majority of cases the invasion of the malady is
preceded by a prodromic stage, usually occupying from a few days
to several weeks, though sometimes extending over a considerably
longer period. This stage probably represents the process of deposit
of miliary tubercles in the pia mater before their presence has given
rise to much structural change in the tissue. The characteristic
symptoms of the prodromic stage consist chiefly in an alteration of
the character and disposition of the patient, varying in extent in
different cases. In general, it may be said that he becomes sad,
taciturn, apathetic, irritable, indisposed to play, often sitting apart
from his companions, gazing in a strange way into vacancy. There is
diminution or loss of appetite and some emaciation. He is restless at
night, is disturbed by nightmare, or grinds his teeth. The digestion is
deranged. Usually there is constipation, but occasionally diarrhœa,
or these conditions may alternate with each other. Squinting and
twitching of the facial muscles are sometimes noticed. Headache
may occur early in this stage, but it is usually observed later, and it
then forms a prominent symptom. Vomiting is also frequent, usually
not preceded by nausea, sometimes provoked by sudden
movement, as in sitting up in bed, and is apt to occur when the
stomach contains little or no food. These symptoms vary much in
degree, and they are often so slight that they pass unnoticed by the
parents or friends. Occasionally the patient, if a child, will manifest a
strange perversity or an unusual disobedience, for which he is
perhaps punished under the belief that his misconduct is intentional.
In older children and in adults delirium, especially at night,
sometimes followed by delusions which may be more or less
permanent, is frequent at this stage. The above symptoms often
remit from time to time, and during the interval the patient may seem
to have recovered his health. The prodromic symptoms are rarely
altogether wanting in children, although they may have escaped
notice from lack of opportunity of observation on the part of the
physician. On the other hand, as Steffen4 justly observes, the most
characteristic symptoms may be present, and lead even an
experienced observer to a confident diagnosis of tubercular
meningitis during the early stage of a case of typhoid fever or of
cerebral congestion without tuberculosis.
4 “Meningitis Tuberculosa,” by A. Steffen, in Gerhardt's Handb. der Kinderkrankheiten,
5 B., 1ste Abth., 2te Hälfte, p. 465.
For convenience of description it is customary to divide the disease
proper, after the prodromal period, into three stages—viz. of
irritation, compression, and collapse. In some cases it is not difficult
to observe these divisions, but it must be borne in mind that in others
the symptoms do not follow any regular sequence, so that no
division is possible. In infants profound slumber may be the only
morbid manifestation throughout the entire disease. Steffen records
such a case, and I have seen two similar ones.

First Stage: The interval between the prodromic period and the first
stage is usually so gradual that no distinction between the two can
be detected. In other cases the disease is ushered in suddenly by
some striking symptom, such as an attack of general convulsions,
with dilated pupils and loss of consciousness. This is not often
repeated, though partial twitchings of the limbs or of the muscles of
the face may follow at intervals. In young children a comatose
condition, with unequal pupils, is apt to take the place of these
symptoms. The principal phenomena of the first stage are headache,
sensitiveness to light and sound, vomiting, and fever. The latter
varies much in intensity from time to time, but is not usually high, the
temperature seldom rising above 103° F., and usually, but not
always, higher at night than in the morning; but there is no
characteristic curve. The pulse varies in rate, but is usually slow and
irregular or intermittent. The respiration is irregular, with frequent
sighing. The tongue is dryish and covered with a thin white coat. The
bowels are costive. Delirium is frequent at night, and the sleep is
disturbed, the patient tossing about and muttering or crying out. The
eyes are half open during sleep. These symptoms become more
marked from day to day. The pain in the head is more frequent and
severe; the patient presses the hands to the forehead or rests the
head against some support if sitting up. During sleep he occasionally
utters a loud, sharp cry, without waking. There is increasing apathy,
and some intolerance of light, shown by an inclination to turn toward
the wall of the room or to lie with the face buried in the pillow. The
appetite is lost, the constipation becomes more obstinate, the
slowness and irregularity of the pulse persist. With the rapid
emaciation the belly sinks in, so that the spinal column can be easily
felt. Soon the child falls into a state of almost continual somnolence,
from which, however, he can be awakened in full consciousness,
and will answer correctly, generally relapsing again immediately into
slumber. His restlessness diminishes or ceases altogether, and he
lies continuously on the back with the head boring into the pillow. He
becomes more passive under the physician's examination, in strong
contrast to his previous irritability. At the end of a week or more from
the beginning of this stage symptoms of irritation of some of the
cerebral nerves begin to show themselves, in consequence of
pressure from the increasing exudation at the base of the brain and
into the ventricles. Strabismus (usually convergent), twitching of the
facial muscles and grimaces, grinding of the teeth, or chewing
movements of the mouth are noticed. The somnolence deepens into
sopor, from which it becomes more and more difficult to arouse the
patient, who gradually becomes completely insensible.

Notwithstanding the alarming and often hopeless condition which

this assemblage of symptoms indicates, intervals of temporary
amendment not unfrequently take place. The child may awake from
his lethargy, recognize those about him, converse rationally, take his
food with relish, and exhibit such symptoms of general improvement
that the parents and friends are led to indulge in fallacious hopes,
and sometimes the physician himself ventures to doubt the accuracy
of his diagnosis. Such hopes are of short duration; the unfavorable
symptoms always return after a brief interval. The duration of the first
stage may be reckoned at about one week.

Second Stage: This period is not separated from the preceding one
by any distinct change in symptoms. The patient lies in a state of
complete insensibility, from which he can no longer be aroused by
any appeal. The face is pale or of an earthen tint, the eyes are half
closed. If the anterior fontanel be still open, the integument covering
it is distended by the pressure beneath. Often one knee is flexed, the
opposite leg extended; one hand applied to the genitals, the other to
the head. Sometimes one leg or arm is alternately flexed and
extended. The head is apt to be retracted and bores into the pillow.
The pupils are dilated, though often unequal and insensible to light:
the sclerotica are injected; a gummy exudation from the Meibomian
glands forms on the edges of the lids. The patient sighs deeply from
time to time, and occasionally utters a loud, piercing cry. Paralysis,
and sometimes rigidity of one or more of the extremities, are often
observed, and occasionally there is an attack of general convulsions.
The pulse continues to be slow and irregular, the emaciation
progresses rapidly, and the abdomen is deeply excavated. The
discharges from the bladder and rectum are involuntary. The
average duration of the second stage is one week.

Third Stage: No special symptoms mark the passage of the second

stage into the third, which is characterized by coma, with complete
resolution of the limbs. The constipation frequently gives place to
moderate diarrhœa. The distended fontanel subsides, and often
sinks below the margin of the cranial bones. A striking feature of this
stage is a great increase in the rate of the pulse, the heart being
released from the inhibitory influence of the par vagum in
consequence of the complete paralysis of the latter from pressure.
The pulse varies in rapidity from 120 to 160 or more in the minute.
For the same reason the respiration also increases in frequency,
though not to the same degree. The eyelids are widely open; the
pupils are dilated and generally motionless, even when exposed to a
bright light. The eyes are rolled upward, so that only the lower half of
the iris is visible; the sclerotica is injected from exposure to the air
and dust. Convulsions may occur from time to time. Death
terminates the painful scene, usually in from twenty-four to forty-
eight hours, but sometimes the child lives on for days, unconscious,
of course, of suffering, though the afflicted parents and friends can
with difficulty be brought to believe it.

Certain points in the symptomatology of tubercular meningitis

demand especial consideration.

I have already observed that the division of the disease into definite
stages is purely arbitrary, and is employed here merely for
convenience of description; in fact, few cases pursue the typical
course. A period of active symptoms and another of depression can
often be observed, but these frequently alternate. Stupor and
paralysis may characterize the early stage, and symptoms of
irritation, with restlessness, screaming, and convulsions,
predominate toward the end. Certain characteristic symptoms may
be wholly or in part wanting, such as vomiting, constipation, or
stupor.

The temperature shows no changes which are characteristic of the

disease. Throughout its whole course it varies from time to time,
without uniformity, except that it usually rises somewhat toward
night. It seldom exceeds 102° or 103° F., unless shortly before
death, when it may rise to 104° F., or even higher, and may continue
to rise for a short time after death.

During the premonitory stage the pulse offers no unusual

characteristics. Its frequency is often increased, as is usual in any
indisposition during the period of childhood, but it preserves its
regularity. Toward the close of this period, and especially during the
first stage of the disease proper, a remarkable change takes place. It
becomes slow and irregular, the rate often diminishing below that in
health. The irregularity varies in character; sometimes the pulse
intermits, either at regular or irregular intervals. An inequality in the
strength of different pulsations is also observed. These peculiarities
of the circulation are due to the irritation of the medulla and the roots
of the par vagum, by which the inhibitory function of that nerve upon
the action of the heart is augmented. During the last period, on the
other hand, the increasing pressure on the vagus paralyzes its
function, and the heart, freed from its control, takes on an increased
action, the pulse rising to 120 beats, and often many more, in the
minute. Robert Whytt, in his interesting memoir,5 dates the beginning
of the second stage from the time that the pulse, being quick but
regular, becomes slow and irregular; the change again to the normal
frequency, or beyond it, marking the commencement of the third
stage.
5 “An Account of the Symptoms in the Dropsy of the Ventricles of the Brain,” in the
Works of Robert Whytt, M.D., published by his son, Edinb., 1768, p. 729.
In the early stage the respiration presents nothing abnormal, but
when the pulse becomes slow and irregular the breathing is similarly
affected. Sighing is very common in the prodromal period and first
stage. Toward the end of the second stage the increasing paralysis
of the respiratory centre gives rise to the phenomena known as the
Cheyne-Stokes respiration, consisting of a succession of respiratory
acts diminishing in force until there is a complete suspension of the
breathing, lasting from a quarter to three-quarters of a minute, when
the series begins again with a full inspiration. In general, the
variations in the rate of the respiration follow those of the pulse,
though the correspondence is not always exact.

In the early stage of the disease the pupils are usually contracted
and unequal. They are sluggish, but still respond to the stimulus of
light. At a later period they become gradually dilated, and react even
more slowly to light or not at all, the two eyes often differing in this
respect. Ophthalmoscopic examination frequently shows the
appearance of choked disc and commencing neuro-retinitis. In rare
cases tubercles are seen scattered over the fundus of the eye. They
are about the size of a small pin's head, of a yellowish color, and of
sharply-defined contour. Neuro-retinitis and choked disc are not, of
course, pathognomonic of tubercular meningitis, and choroidal
tubercles are so rarely seen as to be of little avail in diagnosis. In
fact, they are less frequent in this disease than in general
tuberculosis without meningitis. In twenty-six cases of tubercular
meningitis examined by Garlick at the London Hospital for Sick
Children they were found only once.6 The effect upon the conjunctiva
of the unclosed lids has been already described.
6 W. R. Gowers, M.D., Manual and Atlas of Medical Ophthalmoscopy, Philada., 1882,
p. 148. See, also, Seitz, op. cit., p. 347; Steffen, op. cit., pp. 452 and 472; and
“Tubercle of the Choroid,” Med. Times and Gazette, Oct. 21, 1882, p. 498.

The tongue is somewhat coated soon after the beginning of the

disease, and the breath is offensive. The appetite is lost, and there is
decided emaciation in many cases during the prodromic period. The
thirst is usually moderate. Vomiting is one of the most constant
symptoms during the first period, and its occurrence on an empty
stomach is characteristic of tubercular meningitis. It is not usually
preceded by nausea, and often takes place without effort, by mere
regurgitation, the rejected fluid consisting chiefly of bile mixed with
mucus. Although constipation is the most common condition in the
early stage, and is often rebellious to treatment, yet in some cases
diarrhœa is observed, which may mislead the physician in respect to
the diagnosis. From the beginning of the second stage, and
sometimes earlier, the discharges from the bowels and the bladder
are involuntary.

DURATION.—The duration of tubercular meningitis, apart from the

prodromic period, which often can hardly be determined, averages
from two weeks to two weeks and a half. In exceptional cases death
may take place in a few days or a week, and occasionally a patient
may linger for several weeks,7 the difference being apparently due to
the rapidity of the tubercular deposit and of the resulting
inflammation and exudation. The patient usually takes to his bed at
the beginning of the first stage, but he may be up during a part of the
day until the beginning of the second. In rare instances the child will
be about, and even out of doors, until a few days before death.
7 Such a case is reported by Michael Collins in the London Lancet, March 8, 1884.

PATHOLOGICAL ANATOMY.—The essential lesion of tubercular

meningitis consists in a deposit of miliary tubercles in the pia mater
of the brain, giving rise to inflammation of that membrane and
exudation of serum and pus. In the early stage both surfaces of the
pia are reddened and more or less thickened, and present an
opaline appearance, while between them—that is, in the meshes of
the pia—we find a colorless and transparent fluid which is effused in
greater or smaller amount, resembling jelly when viewed through the
arachnoid. These conditions are sometimes observable on the
convexity of the hemispheres, but are much more abundant on the
lateral surfaces, and especially at the base. More distinct evidence of
inflammation is shown by the presence of a yellowish or greenish-
yellow creamy deposit on the surface of the pia, consisting chiefly of
pus, which is also much more abundant at the base than elsewhere,
especially about the optic commissure, infundibulum, pons Varolii,
and the anterior surface of the medulla. The cranial nerves may be
deeply imbedded in the deposit, which often extends into the fissure
of Sylvius, gluing together the adjacent surfaces of the lobes, and
accompanies the vessels, forming narrow streaks along the sides of
the brain up to the convexity.

The miliary tubercles or granulations consist of semi-transparent

bodies, grayish or whitish in color, varying in size from that of the
head of the smallest pin, indeed almost invisible to the naked eye, to
that of a millet-seed (whence their name). Larger masses are
frequently seen, formed by the aggregation of smaller granulations.
The tubercles are usually found on the inner surface of the pia,
always in the immediate neighborhood of the blood-vessels, which
they accompany in their ramifications, and are also scattered, in
greater or less numbers, throughout the purulent exudation from the
surface of the pia. They are most abundant at the base of the brain,
ascending the sides along the course of the vessels. Sometimes,
though rarely, they are more abundant on the convexity. The total
number varies; it is usually very large, but sometimes only a limited
number exists, even in well-marked cases, and along with intense
inflammation of the pia. The granulations are found in different
degrees of development—sometimes all of them similar in color,
size, and consistency, at others in various stages of fatty
degeneration. The distribution may be symmetrical in the two
hemispheres or irregular. Under the microscope (after suitable
preparation of the part) the bacillus tuberculosus in considerable
numbers may be found in the pia, in places adjacent to the
arterioles.8
8 See a case reported by Y. Dawson in the London Lancet, April 12, 1884, in which
tubercles were visible only by the microscope with numerous bacilli.

The ventricles of the brain are usually distended with a clear or

opalescent, rarely bloody, fluid, the amount of which generally
corresponds to the intensity and extent of the meningeal
inflammation, although sometimes it is not above the normal
quantity. The two lateral ventricles are affected in an equal degree;
the third and fourth ventricles are more rarely implicated. According
to Huguenin,9 it is doubtful whether acute inflammation of the
ependyma takes place in tubercular meningitis. Steffen also10 says
that the ependyma is not inflamed, and that it is not the seat of the
deposit of tubercles. This latter statement is denied by other
authorities, and Huguenin is inclined to believe that they may exist in
that membrane. In the following case, under my care, abundant
granulations were found on the surface of the ependyma:
9 G. Huguenin, op. cit., p. 499.

10 Op. cit., p. 449.

Olaf M—— (male), æt. 8 years, born in Denmark, entered

Massachusetts General Hospital Sept. 13, 1881. Maternal
grandmother died of consumption; paternal grandfather lived to the
age of ninety-five years. One brother had some disease of hip.
Patient was the child of poor parents and lived in an unhealthy
suburb of Boston. During the two preceding winters he had a bad
cough. He was apparently well till four weeks before his entrance,
when he complained of bellyache, and became listless, but he was
out of doors ten days before he came to the hospital. It was noticed
that he was sensitive to sound. No vomiting, no diarrhœa, no
epistaxis, no cry; some cough. He had been somnolent, and was
observed to swing his arm over his head while asleep. June 14,
when first seen by me, he was lying on his back, unconscious, eyes
half closed, pupils dilated, jaw firmly closed, much emaciated, belly
retracted, left leg occasionally flexed and extended. No priapism.
The optic discs were reddened. June 15, there is some intelligence,
he answers questions; keeps one hand on the genitals. June 16,
pupils contracted, does not swallow. June 18, left eye divergent,
conjunctiva injected, whole surface livid, cries out occasionally. Died
at midnight.

FIG. 30.
Autopsy.—General lividity of surface, much emaciation. Much fine
arborescent injection on outer surface of dura mater. Numerous
Pacchionian bodies. Yellow matter beneath arachnoid along course
of vessels on each side of anterior lobes. Abundant fine granulations
along course of vessels on each anterior lobe, on upper margins of
median fissure, along fissure of Sylvius, and on choroid plexuses.
Very little lymph at base of brain. Six or eight ounces of serum from
lateral ventricles, and abundant fine transparent granules over
ependyma of both. Numerous opaque granulations in pia mater of
medulla oblongata. Surface of right pleura universally adherent.
Mucous membrane of bronchia much injected; a considerable
amount of pus flowed from each primary bronchus. No tubercles in
lungs nor in peritoneum. No ulcerations in intestines. No other
lesions.

The choroid plexuses are generally involved in the inflammatory

process, and are sometimes covered with yellow purulent
exudations. As in the above case, large numbers of tubercles may
be found in them, notwithstanding the opinion of Huguenin that their
number is always small.

The substance of the brain in the vicinity of the tubercular deposit is

generally found in a more or less œdematous condition, owing to the
obstruction of the circulation resulting from compression of the
vessels by the tubercles and effused lymph. Softening, sometimes
even to diffluence, not unfrequently occurs in the neighborhood of
the deposit, probably from ischæmia (necrobiosis). If there be any
considerable amount of exudation in the ventricles, the convolutions
are flattened by compression against the cranial bones.

The above-described lesions are not confined to the brain, but may
extend to the cerebellum, the pons, the medulla, and the spinal cord.
If examinations of the latter were more frequent in autopsies of this
disease, we should doubtless find, as has been done in some
instances, that the membranes often show the characteristic
alterations of tubercular meningitis, and even the presence of
granulations in the cord itself. The lesions may extend throughout
the cord, and are especially noticed in the dorsal region and in the
vicinity of the cauda equina. Their presence explains some of the
symptoms evidently due to spinal origin, such as retraction of the
head with rigidity of the neck and of the trunk, contractions of the
limbs, tetanic spasms, priapism, paralysis of the bladder and rectum,
etc., which are common in simple spinal meningitis.
The deposit of miliary tubercles in the pia mater, with little or no
accompanying meningitis, is met with in rare instances. The
tubercles are few in number, but vary in dimensions, being
sometimes united together in masses of considerable size, which are
frequently encysted. Beyond thickening and opacity of the
membrane, their presence seems to excite but little inflammatory
reaction, but they are generally accompanied by ventricular effusion
which by its pressure gives rise to characteristic symptoms.

The principal lesions found in other organs of the body consist of

tubercle in various stages of development, caseous matter, diseases
of the bones, etc. Miliary granulations are chiefly seen in the lungs,
peritoneum, intestinal mucous membrane, pleura, spleen, liver, and
kidneys. The bronchial and mesenteric glands often contain caseous
masses, some of which are broken down and suppurating. The
testicles sometimes present the same appearances. In adults, the
most frequent lesion which is found external to the brain is
pulmonary tuberculosis in a more or less advanced stage. Tubercles
are also sometimes present in the eye. Angel Money11 states that out
of 44 examinations made at the Hospital for Sick Children, London,
the meninges were the seat of gray granulations in 42. The choroid
(one or both) showed tubercles 14 times (right 3, left 5, both 6), and
11 times there were undoubted evidences of optic neuritis. Twice the
choroid was affected with tubercle when the meninges were free; in
one of these instances there was a mass of crude tubercle in the
cerebellum; in the other, although there were tubercles in the belly
and chest, there were none in the head. So that 12 times in 42 cases
of tubercles in the meninges there were tubercles in the choroid—i.e.
about 31 per cent.
11 “On the Frequent Association of Choroidal and Meningeal Tubercle,” Lancet, Nov.
10, 1883.

DIAGNOSIS.—In many cases tubercular meningitis offers but little

difficulty in the diagnosis. Although the symptoms, taken singly, are
not pathognomonic, yet their combination and succession, together
with their relation to the age, previous health, and antecedents of the
patient, are usually sufficient to lead us to a correct opinion. The
prodromic period of altered disposition (irritability of temper or
apathetic indifference), headache, constipation, vomiting, and
emaciation, followed by irregularity and slowness of the pulse,
sighing respiration, sluggishness and irregularity of the pupils; the
progress from somnolence to unconsciousness and coma; the
sudden lamentable cry; the convulsions and paralysis; the return of
rapid pulse and respiration in the last stage,—are characteristic of no
other disease. Our chief embarrassment arises during the insidious
approach of the malady, before its distinctive features are visible or
when some important symptom is absent. Its real nature is then apt
to be overlooked, and, in fact, in some cases it is impossible to
decide whether the symptoms are indicative of commencing cerebral
disease, or, on the other hand, are owing to typhoid fever, to a
simple gastro-intestinal irritation from error in diet, to worms in the
alimentary canal, to overwork in school, or to some other cause.
Under these circumstances the physician should decline giving a
positive opinion until more definite signs make their appearance. It
must be remembered that very important symptoms may be absent
in cases which are otherwise well marked. In all doubtful cases the
family history should, if possible, be obtained, especially whether
one or both parents or other near relatives have been consumptive
or have shown symptoms of scrofula or tuberculosis in any form, and
whether the patient himself has signs of pulmonary tuberculosis, of
enlarged or suppurating glands, or obstinate skin eruptions. The
presence or history of those conditions would add greatly to the
probability of tubercular meningitis.

The diseases for which tubercular meningitis is most liable to be

mistaken are acute simple meningitis, typhoid fever, acute gastro-
intestinal affections, eclampsia of infants and children, worms in the
intestines or stomach, the hydrencephaloid disease of Marshall Hall,
and cerebro-spinal meningitis.

Acute meningitis is distinguished from the tubercular disease by its

sudden invasion without prodromatous stage, by the acuteness and
intensity of the symptoms, the severity of the headache, the activity
of the delirium, the greater elevation of the temperature, and by its
brief duration, which rarely exceeds one week. In those exceptional
cases of tubercular meningitis in which the prodromal period is
absent or not observed and the course is unusually rapid, it would be
perhaps impossible to distinguish between the two diseases. A
family history of tubercle, or the discovery of the granulations in the
choroid by ophthalmoscopic examination, might save us from error
under such circumstances. The great rarity of idiopathic simple
meningitis should be remembered. Meningitis from disease of the
ear sometimes resembles the tubercular affection, but the history of
the attack, usually beginning with local pain and otorrhœa, will in
most cases prevent any confusion between the two forms of
disease.

The early period of typhoid often bears considerable resemblance to

that of tubercular meningitis. Headache, languor, restlessness, and
mild delirium are common to both. Typhoid can be distinguished by
the coated tongue, the diarrhœa, the enlargement of the spleen, the
tympanites, abdominal tenderness and gurgling, the eruption, and,
above all, by the characteristic temperature-curve, which, if
accurately observed, is conclusive. The course of typhoid fever is
comparatively uniform, while that of tubercular meningitis is often
extremely irregular. It should not be forgotten that the two diseases
may coexist.

The presence of worms in the alimentary canal may cause

symptoms somewhat like those of tubercular meningitis, and the
symptoms of the latter disease are occasionally erroneously
attributed to those parasites. The administration of an anthelmintic,
which should never be omitted in doubtful cases, will clear up all
uncertainty.

Cerebro-spinal meningitis is usually an epidemic, and therefore not

likely to be confounded with the tubercular disease. In sporadic
cases it can be recognized by its sudden onset and acute character,
by the eruption, and by the prominence of the spinal symptoms.
The so-called hydrencephaloid disease of Marshall Hall is a
condition of exhaustion and marasmus belonging to infancy, caused
by insufficient or unsuitable nourishment, by diarrhœa, and by the
injudicious depletive treatment so much in vogue in former times,
when the affection was much more common than at present. Some
of its symptoms, such as sighing respiration, stupor, pallor, and
dilated pupils, bear a certain resemblance to those of tubercular
meningitis, though it would be more easily confounded with chronic
hydrocephalus. The absence of constipation, headache,
convulsions, and vomiting, and the favorable results of suitable
nourishment and stimulants, serve to distinguish it from cerebral
disease.

Eclampsia, or sudden convulsion, is common in infants and young

children, and, since the occurrence of a fit may be the first or the
most striking symptom in tubercular meningitis, it is important to
ascertain its origin. In the majority of cases convulsions in children
arise from some peripheral irritation, such as difficult dentition,
worms in the alimentary canal, constipation, fright, etc., acting
through the reflex function of the spinal cord, which is unusually
sensitive in the early period of life. The absence of previous
symptoms, and the discovery of the source of the irritation, with the
favorable effect of its removal by appropriate treatment, will in most
cases suffice to eliminate structural disease of the brain. In others
we must withhold a positive opinion for a reasonable time in order to
ascertain whether more definite symptoms follow. Convulsions also
occasionally form the initial symptom of the eruptive fevers,
especially scarlatina. Here the absence of prodromal symptoms, and
the speedy appearance of those belonging to the exanthematous
affection, will remove all sources of doubt. Convulsions, with or
without coma, occurring in the early stage of acute renal
inflammations, may simulate the symptoms of tubercular meningitis.
An examination of the urine will show the true nature of the disease.

In addition to the above diseases there are some cerebral affections

of uncertain pathology which resemble tubercular meningitis, but
which are not generally fatal. As Gee justly remarks,12 “Every
practitioner from time to time will come across an acute febrile
disease accompanied by symptoms which seem to point
unmistakably to some affection of the brain, there being every
reason to exclude the notion of suppressed exanthemata or
analogous disorders. After one or several weeks of coma, delirium,
severe headache, or whatever may have been the prominent
symptom, the patient recovers, and we are left quite unable to say
what has been the matter with him. To go more into detail, I could not
do otherwise than narrate a series of cases which would differ from
each other in most important points, and have nothing in common
excepting pyrexia and brain symptoms. There is, generally,
something wanting which makes us suspect that we have not to do
with tubercular meningitis. Brain fever is as good a name as any
whereby to designate these different anomalies; cerebral congestion,
which is more commonly used, involves an explanation which is
probably often wrong, and certainly never proved to be right.” No
doubt such cases are occasionally cited as examples of recovery
from tubercular meningitis.
12 “Tubercular Meningitis,” by Samuel Jones Gee, M.D., in Reynolds's System of
Medicine, Philada., 1879, vol. i. p. 832.

PROGNOSIS.—Although there are on record undoubted instances of

recovery from tubercular meningitis, yet their number is so small that
practically the prognosis is fatal. It is safe to say that in almost all the
reported cases of recovery the diagnosis was erroneous.13 Even
should the patient survive the attack, he is usually left with paralyzed
limbs and impaired mental faculties, and dies not long afterward from
a recurrence of the disease or from tuberculosis of the lungs or other
organs.
13 Hahn, “Recherches sur la Méningite tuberculeuse et sur le Traitement de cette
Maladie” (Arch. gén. de méd., 4e Série, vols. xx. and xxi.), claims to have cured 7
cases, but of 5 of them there is no evidence that they were examples of tubercular
meningitis at all. The subject of the curability of tubercular meningitis is ably treated
by Cadet de Gassicourt (Traité clinique des Maladies de l'Enfance, vol. iii., Paris,
1884, p. 553 et seq.). His conclusion is that most of the alleged cures are cases of
 meningitis of limited extent, arising from the presence of tubercular tumors, syphilitic
gummata, cerebral scleroses, and neoplasms of various kinds.

TREATMENT.—In view of the fatality of the disease, and of its frequent

occurrence in childhood, the prophylactic treatment is of great
importance. Every effort should be made to protect children whose
parents or other near relatives are tuberculous or scrofulous, and
who are themselves delicate, puny, or affected with any
constitutional disorder, from tubercular meningitis, by placing them in
the best possible hygienic conditions. Pure air, suitable clothing,
wholesome and sufficient food, and plenty of out-of-door exercise
are indispensable. Sedentary amusements and occupations should
be sparingly allowed. Especial pains should be taken to prevent
fatigue by much study, and school-hours should be of short duration.
The hygiene of the school-room is of paramount importance, and if
its ventilation, temperature, and light are not satisfactory, the child
should not be permitted to enter it. The bed-chamber should be well
ventilated night and day. A sponge-bath, cold or tepid according to
the season or to the effect on the patient, should be given daily,
followed by friction with a towel. The bowels must be kept regular by
appropriate diet if possible, or by simple laxatives, such as magnesia
or rhubarb. For delicate, pale children some preparation of iron will
be useful. The choice must be left to the practitioner, but one of the
best in such cases is the tartrate of iron and potassium, of which
from two to six grains, according to the age, may be given three
times daily after meals. Cod-liver oil is invaluable for scrofulous
patients or where there is a lack of nutrition. A teaspoonful, given
after meals, is a sufficient dose, and it is usually taken without
difficulty by children, or if there be much repugnance to it some one
of the various emulsions may be tried in proportionate dose. Along
with this, iodide of iron will in many cases be found useful or as a
substitute for the oil when the latter cannot be borne. It is best given
in the form of the officinal syrup, in the dose of from five to twenty
drops. Change of air is useful in stimulating the nutritive functions,
and a visit to the seashore or mountains during warm weather will
often be followed by general improvement.
Since it is not possible to arrest the disease when once begun, the
efforts of the physician must be directed toward relieving the
sufferings of the patient as far as possible. In the early period the
restlessness at night and inability to sleep will call for sedatives, such
as the bromide of sodium or of potassium, in the dose of ten or
fifteen grains at bedtime or oftener. This should be well diluted with
water, sweetened if necessary. The addition of five to twenty drops of
the tincture of hyoscyamus increases the effect. Sometimes chloral
hydrate, either alone or combined with the bromide when the latter
fails, will procure quiet sleep. From five to ten grains may be given at
a dose, according to the age. Compresses wet with spirit and water
or an ice-cap may be applied to the head if there be much pain in
that region, or it may be necessary to give opium in some of its forms
by the mouth, such as the tincture or fluid extract, in doses of from
one to five drops. Constipation is best overcome by means of
calomel in three- to five-grain doses, to which may be added, when
necessary, an equal amount of jalap powder, or an enema of
soapsuds may be administered. Active purging should be avoided.
Liquid nourishment, such as milk, gruel of oatmeal, farina, or barley,
beef-tea, broths, etc., must be given in moderate quantities at
intervals of a few hours so long as the patient is able to swallow.
Occasional sponging of the whole surface with warm or cool water,
and scrupulous attention to cleanliness after defecation, especially
when control of the sphincters is lost, will add to his comfort. He
should occupy a large and well-ventilated chamber, from which all
persons whose presence is not necessary for his care and comfort
should be excluded. He should be protected from noise and from
bright light, and should lie on a bed of moderate width for
convenience of tending.

There is no specific treatment at present known which is likely to be

of any benefit in this disease, any more than in tuberculosis of other
organs than the brain. Common experience has shown that mercury,
which formerly had so high a reputation in the treatment of cerebral
diseases of early life, not only fails completely, but adds to the
sufferings of the patient when pushed to salivation. The iodide of
potassium is recommended by almost all writers, but, so far as I