The treatment of tuberculous meningitis

Abstract

Summary Two hundred and thirty consecutive unselected cases of tuberculous meningitis have been treated at Oxford and observed for at least one year. The first 80 patients were treated with streptomycin alone and the survival rate was 52 per cent. The next 70 patients also received streptomycin but in addition certain patients were treated with intrathecal tuberculin (PPD). The survival rate rose to 61 per cent. The last 80 received intrathecal tuberculin as a routine except when some special contra-indication was present and the survival rate again rose to 75 per cent. Of those 80 patients, the last 33 received isoniazid in addition to the streptomycin. The case material is presented broken down according to the different factors of established prognostic significance. Reasons are advanced for attributing the improvement in the survival rate to the use of the PPD. The chemotherapeutic regime is summarized, and details are given of the administration of PPD. The use of PPD is potentially dangerous, as it has little to offer until given in sufficient doses to provoke a reaction. These reactions are described, together with certain practical measures for minimizing their danger. The limitations of this method of treatment are discussed. Cortisone has proved life-saving in a few carefully selected cases. As, however, it is in many respects antagonistic to tuberculin it has seldom been used in the treatment of these cases. It is concluded that intrathecal medication is still required for the optimal treatment of tuberculous meningitis; that PPD is a useful adjuvant to the chemotherapy; that these cases are best treated at special centres; and that if the very advanced case could be climinated by earlier and more accurate diagnosis, recovery could be expected in approximately 100 per cent of cases.