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SIGNIFICANCE OF CONVULSIONS IN CHILDREN WITH PURULENT MENINGITIS
126 On the morning of the 5th day lumbar puncture was difficult, and only one drop of turbid C.s.F. came out. On the afternoon of the same day generalised convulsions started. Sodium gr. 1/4 intramuscularly : convulsions continued. Anaesthetised with ethyl chloride : temporary cessation. Intramuscular paraldehyde 1 ml. : convulsions continued, though diminished in intensity. Temperature 105°F ; tepid sponge. Convulsions ceased 4 hours after giving paraldehyde. During the next 3 days the baby was almost continually in a convulsive state and had to be tube-fed. Twitching and irregular respiration increased periodically, and the severity of the convulsions was controlled with repeated intramuscular paraldehyde or rectal thiopentone, the effect of the latter being rather short-lived. After convulsions finally ceased there was a slow but steady improvement in general condition, and the baby made an uninterrupted recovery. An abscess in the thigh developed as the result of one or several of the intramuscular injections; this was slow to heal, but finally closed satisfactorily. On follow-up at the age of 9 months the baby was perfectly tests for his normal and alert, and passed all the age. This might be considered a moderately severe case, judging by the acuteness of onset, the degree of toxaemia, and the c.s.F. findings. The meningitis was well con-
other groups was 40-26 and the highest 50-46. The statistical technique used to make allowance for this discrepancy is effective only if age, smoking, and the size of the various lung divisions increase or decrease together in a way that may be represented by a straight line on a graph. An examination of the figures given by the authors does not suggest that such a linear relation holds. It may thus be that a residual effect of the large differences in age was still inflating the final correlation coefficients obtained, few of which in any case reached the conventional level of statistical significance. It may well be that smoking produces changes in respiratory efficiency ; this has often been suggested, but it cannot be concluded from the work of Whitfield et al. that it has yet been proved.
phenobarbitone
Medical Research Council, Pneumoconiosis Research Unit,
Llandough Hospital, Penarth, Glam.
P. D. OLDHAM.
SIGNIFICANCE OF CONVULSIONS IN CHILDREN WITH PURULENT MENINGITIS
SiR,-The spectacular reduction
development
from
in
mortality meningitis, especially in epidemics of meningococcal meningitis, has given rise to a widespread impression that the dangers of this disease have greatly receded.
Dr. Ounsted1 has done well to draw attention to the trolled by chemotherapy ; from this point of view fact that the mortality in infants is, by and large, still treatment had certainly not " failed," but the convulsions in the region of 20%. very nearly proved fatal. The regular use of phenobarbi. Dr. Ounsted remarks that the ultimate result depends tone in meningitis, for which Dr. Ounsted appeals, more on the occurrence or absence of convulsions, parshould surely result in a further lowering of mortality. Psediatric Unit, ticularly after the start of treatment, than on the severity Royal Buckinghamshire Hospital, of the infection in the acute phase. In other words, the D. MACCARTHY. Aylesbury. result may be vitiated after the start of treatment by the onset of convulsions whether, by the usual criteria, the CONGENITAL HYPERTROPHIC PYLORIC case is acute or insidious in onset, early or late in receiving STENOSIS treatment, severe or mild in form. He implies that are four points in the article of July 7 by convulsions, while indicating the severity of the meningitis, Dr.SIR,-There Wood and Professor Smellie on which I should like are more decisive in their adverse effect than the degree to comment. of toxaemia or other features that go with very severe I.-The view is expressed that, with increased survival of infection. those suffering from congenital pyloric stenosis, the incidence This conclusion will be acceptable by anyone with of the anomaly is likely to increase in future generations. experience of meningitis in children. It would have been Cockayne and Penroseare, however, of the opinion satisfactory to see the point illustrated by Dr. Ounsted’s that the faulty genes responsible are common genes with own clinical material grouped in order of severity ; but a low frequency of expression. If this be so-and we do an assessment of this kind is certainly difficult and can know that a positive family history is the exception with in be made confidence extreme only examples. rather than the rule-then in most cases the gene is The following case seems to illustrate well how the onset so that transmitted an carrier, by apparently healthy the of convulsions may jeopardise prognosis in a child the incidence of the condition is unlikely to be increased who by all the usual criteria is progressing well. the survival of the small proportion of materially by A male infant, aged 5 months, was admitted to Amersham carriers who manifest symptoms. General Hospital on Feb. 3, 1951, with signs of meningitis. 2.-Reference is made to the finding at birth or in the There was a history of 24 hours’ listlessness, irritability, immediate postnatal period, and occasionally in a stillborn refusal of feeds, and vomiting. On admission he was moder-
and very drowsy ; colour normal. Lumbar puncture yielded turbid cerebrospinal fluid (C.S.F.) under pressure, with cells 15,000 per c.mm., protein 300 mg. per 100 ml. Film : many gram-negative intracellular and extracellular diplococci. Culture : Neisseria meningitidis. Treatment.-Intrathecal penicillin 20,000 units daily. Intramuscular penicillin 250,000 units 6-hourly. Sulphadiazine by mouth 0-5 g. 4-hourly. Bottle-feeds taken well; intravenous fluids not given. .Process.—General condition satisfactory during next 4 days. c.s.F. examination as follows :
ately ill
Day 1 2 3 4 *5 *6 *7
Red cells
White cells
c.mm.)) (per (per 400
c. mm.)) 15,000
Turbid 1380 90
a
(mg.
per
100
ml.)
300
Film
Culture
200 140
Sterile Sterile Sterile
Diplococci +
+
..
Diplococci + ..
..........
..
Few
39
(Lymphs + polys)
70
Sterile
No
organisms
pyloric
tumour.
few days of birth. 3.-A
.
12
Meningococci
a
I should welcome specific reference to this finding occurring with sufficient frequency to suggest that it is of importance in pathogenesis and not just the exception to prove the rule. The hypothesis that the tumour is commonly present at birth is attractive but has little evidence in its support. Wallgren2 has produced convincing evidence that in 5 infants developing the symptoms of pyloric stenosis, out of a series of 1000 consecutive newborn male infants, the tumour was not present within
Protein
....
Few + + + +
infant, of
cases
of bile-staining of the vomit was obtained in and this was " confirmed in hospital in several."
history
I should like to know if this confirmation was by chemical methods. Yellow coloration of the vomit in pyloric stenosis is well recognised ; and I have seen it on a few occasions out of several hundred cases, but when tested the yellow pigment did not give the reactions of bile.
*ronv1l1Ri()n
1. Ounsted, C. Lancet, 1951, i, 1245.
1. Cockayne, E. A., Penrose, L. S. Ohio J. Sci. 1943, 43, 1. 2. Wallgren, A. Amer. J. Dis. Child. 1946, 72, 371.
other groups was 40-26 and the highest 50-46. The statistical technique used to make allowance for this discrepancy is effective only if age, smoking, and the size of the various lung divisions increase or decrease together in a way that may be represented by a straight line on a graph. An examination of the figures given by the authors does not suggest that such a linear relation holds. It may thus be that a residual effect of the large differences in age was still inflating the final correlation coefficients obtained, few of which in any case reached the conventional level of statistical significance. It may well be that smoking produces changes in respiratory efficiency ; this has often been suggested, but it cannot be concluded from the work of Whitfield et al. that it has yet been proved.
phenobarbitone
Medical Research Council, Pneumoconiosis Research Unit,
Llandough Hospital, Penarth, Glam.
P. D. OLDHAM.
SIGNIFICANCE OF CONVULSIONS IN CHILDREN WITH PURULENT MENINGITIS
SiR,-The spectacular reduction
development
from
in
mortality meningitis, especially in epidemics of meningococcal meningitis, has given rise to a widespread impression that the dangers of this disease have greatly receded.
Dr. Ounsted1 has done well to draw attention to the trolled by chemotherapy ; from this point of view fact that the mortality in infants is, by and large, still treatment had certainly not " failed," but the convulsions in the region of 20%. very nearly proved fatal. The regular use of phenobarbi. Dr. Ounsted remarks that the ultimate result depends tone in meningitis, for which Dr. Ounsted appeals, more on the occurrence or absence of convulsions, parshould surely result in a further lowering of mortality. Psediatric Unit, ticularly after the start of treatment, than on the severity Royal Buckinghamshire Hospital, of the infection in the acute phase. In other words, the D. MACCARTHY. Aylesbury. result may be vitiated after the start of treatment by the onset of convulsions whether, by the usual criteria, the CONGENITAL HYPERTROPHIC PYLORIC case is acute or insidious in onset, early or late in receiving STENOSIS treatment, severe or mild in form. He implies that are four points in the article of July 7 by convulsions, while indicating the severity of the meningitis, Dr.SIR,-There Wood and Professor Smellie on which I should like are more decisive in their adverse effect than the degree to comment. of toxaemia or other features that go with very severe I.-The view is expressed that, with increased survival of infection. those suffering from congenital pyloric stenosis, the incidence This conclusion will be acceptable by anyone with of the anomaly is likely to increase in future generations. experience of meningitis in children. It would have been Cockayne and Penroseare, however, of the opinion satisfactory to see the point illustrated by Dr. Ounsted’s that the faulty genes responsible are common genes with own clinical material grouped in order of severity ; but a low frequency of expression. If this be so-and we do an assessment of this kind is certainly difficult and can know that a positive family history is the exception with in be made confidence extreme only examples. rather than the rule-then in most cases the gene is The following case seems to illustrate well how the onset so that transmitted an carrier, by apparently healthy the of convulsions may jeopardise prognosis in a child the incidence of the condition is unlikely to be increased who by all the usual criteria is progressing well. the survival of the small proportion of materially by A male infant, aged 5 months, was admitted to Amersham carriers who manifest symptoms. General Hospital on Feb. 3, 1951, with signs of meningitis. 2.-Reference is made to the finding at birth or in the There was a history of 24 hours’ listlessness, irritability, immediate postnatal period, and occasionally in a stillborn refusal of feeds, and vomiting. On admission he was moder-
and very drowsy ; colour normal. Lumbar puncture yielded turbid cerebrospinal fluid (C.S.F.) under pressure, with cells 15,000 per c.mm., protein 300 mg. per 100 ml. Film : many gram-negative intracellular and extracellular diplococci. Culture : Neisseria meningitidis. Treatment.-Intrathecal penicillin 20,000 units daily. Intramuscular penicillin 250,000 units 6-hourly. Sulphadiazine by mouth 0-5 g. 4-hourly. Bottle-feeds taken well; intravenous fluids not given. .Process.—General condition satisfactory during next 4 days. c.s.F. examination as follows :
ately ill
Day 1 2 3 4 *5 *6 *7
Red cells
White cells
c.mm.)) (per (per 400
c. mm.)) 15,000
Turbid 1380 90
a
(mg.
per
100
ml.)
300
Film
Culture
200 140
Sterile Sterile Sterile
Diplococci +
+
..
Diplococci + ..
..........
..
Few
39
(Lymphs + polys)
70
Sterile
No
organisms
pyloric
tumour.
few days of birth. 3.-A
.
12
Meningococci
a
I should welcome specific reference to this finding occurring with sufficient frequency to suggest that it is of importance in pathogenesis and not just the exception to prove the rule. The hypothesis that the tumour is commonly present at birth is attractive but has little evidence in its support. Wallgren2 has produced convincing evidence that in 5 infants developing the symptoms of pyloric stenosis, out of a series of 1000 consecutive newborn male infants, the tumour was not present within
Protein
....
Few + + + +
infant, of
cases
of bile-staining of the vomit was obtained in and this was " confirmed in hospital in several."
history
I should like to know if this confirmation was by chemical methods. Yellow coloration of the vomit in pyloric stenosis is well recognised ; and I have seen it on a few occasions out of several hundred cases, but when tested the yellow pigment did not give the reactions of bile.
*ronv1l1Ri()n
1. Ounsted, C. Lancet, 1951, i, 1245.
1. Cockayne, E. A., Penrose, L. S. Ohio J. Sci. 1943, 43, 1. 2. Wallgren, A. Amer. J. Dis. Child. 1946, 72, 371.