Meningitis

“ If anything is surprising in epidemic meningitis, it is the absence of that deep and prolonged stupor that characterizes the typhoid state, notwithstanding the pressure of the exudation upon the brain in most cases, and in others such a profound alteration of the blood that it exudes through the tissues as water passes through a porous body. Another striking phenomenon of the disease is that the patient after recovery has generally a complete oblivion of all that happened to him between the beginning of the attack and convalescence. ”

“ One of the most fatal and distressing diseases, confined largely to children, is epidemic and sporadic cerebro-spinal meningitis. Before the working out of the anti-meningitis serum by careful, scientific experimentation on animals, there was no method of preventing the growth, and appalling effects of the meningococci that caused the disease. Now we have a serum that not only directly destroys or inhibits the growth of the germs, but also indirectly acts by stimulating the white blood cells to overcome the germs. ”

“ The probability would be greatly increased if the patient had a syphilitic or alcoholic history. The diagnosis should exclude tumor of the brain, chronic pachymeningitis, and chronic hydrocephalus, but as these diseases are often complicated with chronic meningitis, the distinction might be very difficult. As already stated, chronic meningitis is almost a constant lesion in general paralysis, as well as in other forms of chronic insanity, but there are no special symptoms by which its presence can be ascertained during life. ”

“ If the cerebro-spinal fluid be clear and sterile, diffuse meningitis can usually be excluded, although at the same time it must be remembered that it does not negative a localized meningitis without increased intracranial pressure. Increased flow of cerebro-spinal fluid indicates increased intracranial pressure, perhaps the result of serous meningitis. Slight turbidity suggests early purulent meningitis, especially if bacteria are present, but not necessarily that the case is hopeless. If the fluid be definitely purulent, operation may be considered out of the question ”

“ Operation is indicated as soon as the onset of meningitis has been diagnosed and should be performed without delay. Waiting for all the cardinal symptoms of meningitis to occur will never save life. The only possibility of doing so is to operate while the inflammatory process is still localized. At the same time it must be recognized that whenever symptoms of meningitis occur the prognosis is most serious.
Lumbar puncture should always be performed as an aid to diagnosis. ”

“ True meningitis is rare in chronic Bright's disease, the symptoms resembling it being caused, in the majority of cases, by uræmia. Meningitis complicating pneumonia is also rare, although cerebral symptoms are common enough in that disease, especially in young children with inflammation of the upper lobes. C. Neuwerk16 reports seventeen cases of purulent meningitis complicating acute pneumonia. It was more frequent in men, especially in alcoholic subjects, than in women. ”

“ When cerebral symptoms supervene upon acute disease, such as typhoid fever, pericarditis, acute rheumatism, pneumonia, the exanthemata, etc., the diagnosis between tubercular and simple meningitis is important, because the latter is not necessarily fatal, while the former is almost never recovered from. If the patient were previously healthy and presumably free from tubercular disease, the chances would be in favor of the simple form. A rapid course of the disease would also speak for acute meningitis, and recovery would almost certainly preclude tubercular meningitis. ”

“ But how far there is an absolute increase in meningitis over the past, and whether it is tending at present actually to increase, may be a matter for question. In view of the possibility that the disease was not sufficiently accounted for in the past, and in the absence of any knowledge to indicate a reason for its less prevalence in earlier years, at least not to the extent indicated by the statistics, it may be that its increase is, after all, more apparent than real. ”

“ In poisoning by narcotics the history will often aid us in the diagnosis; moreover, except in the case of opium, the pupils are dilated instead of being contracted. In traumatic cases, with fracture of the cranial bones, it is always difficult, and often impossible, to distinguish between the symptoms of meningitis and those due to other lesions. In concussion without fracture we must be guided in our diagnosis by the same rules as in idiopathic cases. The distinction between extreme congestion of the pia mater and meningitis must be based chiefly upon the duration of the symptoms. ”

“ It is, of course, possible that a marked degree of meningitis might be so localized as to produce the same symptoms. The diagnostician would crave a pleocytosis of the spinal fluid if a diagnosis of meningitis is to be made; and there was no such pleocytosis. On the whole, we do not feel that it is possible to make a diagnosis either of Meningitis or of Gumma. ”

“ Ivy Mackenzie and Martin, pointing out that the cerebro-spinal fluid, even of patients who have recovered from this form of meningitis, contains no antibodies, tried and recommended injections of the patient’s own blood serum into the spinal canal. In all cases the action seems to be much the same. These sera contain immune body and complement, and are distinctly bactericidal, acting on the meningococcus and rendering it much more easily taken up and digested by the white blood corpuscles. It is possible that these sera may also exert some slight anti toxic action. ”

“ Meningitis is an equally dangerous complication. It may arise without direct injury to the cerebral wall of the sinus. If, during removal, the anterior end of the middle turbinal be damaged too high up, the lymph channels around the olfactory nerve may be opened so freely that infection spreads along them to the meninges. Or the cerebral wall may sometimes be broken through without a serious result, if the dura mater be left intact behind it. ”

“ 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 serous meningitis a large quantity of cerebro-spinal fluid may escape, and the dressings must be changed frequently. If recovery be going to take place, the temperature gradually becomes normal and the symptoms of meningitis disappear. In involvement of the posterior fossa, the head retraction gradually diminishes and after a few days free movement is noticed. Adhesions form rapidly, binding together the surface of the brain, meninges, and the overlying bone. For this reason the drainage tubes, already inserted between the dura mater and brain, can be removed within a day or two. ”

“ Serous meningitis.—One of the first signs is the increasing headache, at first localized, usually near the seat of the perforation or path of infection, and soon becoming diffuse over the head. The patient loses his appetite, his tongue becomes coated, the emunctaries become sluggish in their action, and nausea is a very common symptom. The temperature rises, and, if the septic form is going to follow, this rise is often quite rapid, so that there may occur small chills from the infection of the cerebrospinal fluid. The pulse and respiration rate is now considerably increased. ”

“ Differential Diagnosis.—In the early stages it is often difficult to distinguish between meningitis and cerebral abscess. The chief points on which reliance is to be placed are that in meningitis the pulse shows an irregularity, both in rate and force, which is wanting in cases of uncomplicated abscess. In meningitis the temperature is raised, while in abscess it is persistently subnormal. The superficial reflexes, particularly the abdominal reflexes, disappear early in meningitis and the disturbance is bilateral; in abscess they are slower to disappear, and one side only is affected. ”

“ In this as in other elements of its pathology the disease stands absolutely alone. While the acute affections of the pulmonary and digestive organs, which were just now alluded to, affect large districts, and even sweep over a whole continent, epidemic meningitis breaks out in limited localities, and may for years prevail in a populous city within a hundred miles of another still more populous which during that time may altogether escape its ravages. Of this curious fact the cities of Philadelphia and New York present a striking illustration. ”

“ Diagnosis. The condition is often confused with meningitis, and the mistake is not serious, because meningitis and encephalitis frequently accompany one another.
Prognosis. The prognosis must be regarded as fatal. The patients very seldom recover, and there is no reason for keeping them alive.
Treatment. Here, again, blisters may be applied to the upper extremity of the neck, or setons may be passed. Cooling applications to the cranial region have also been suggested. None of these methods produces more than a temporary palliative effect. ”

“ If the symptoms of meningitis in these cases be as yet indefinite, and if pus be found under tension within the mastoid cavity, or if an extra-dural abscess exists, the dura mater should not be incised at once, but a delay of twenty-four hours should be advised; in many cases complete recovery will take place. If, however, the symptoms continue, intracranial exploration will be necessary.
3. In chronic middle-ear suppuration, meningitis is usually secondary to, or accompanies, other intracranial complications or internal-ear suppuration, the symptoms of which it may mask. ”

“ In meningitis the headache is much more severe, and does not disappear upon the occurrence of delirium. It may be so severe as to cause the patient to cry out. The senses are painfully acute. There are intolerance of light and sound, and some hypersensitiveness of the surface, [p. 359] strabismus, inequality of the pupils or some other local paralysis, and retraction of the head. Nausea and vomiting are more common than in typhus, while the utter prostration of the latter disease is wholly wanting, and so is of course the characteristic eruption. ”

“ It is usually dull and heavy, but in a few cases is throbbing. It is said by authors rarely to be severe, but I have known it so intense and acute as to cause the disease at its commencement to be mistaken for meningitis, and Jackson asserted that it is sometimes so severe that local bloodletting, and even venesection, had to be employed for its relief. It would appear to be as common in children as adults. ”

“ By far the greatest number of the subjects of epidemic meningitis are young persons. In Sweden, according to Hirsch, of 1267 fatal cases of the disease, 889 occurred in persons under fifteen years of age, 328 between sixteen and forty years, and 50 in persons of forty years and upward. ”

“ We can compare the epidemic features of influenza with these other contagious diseases, but we will always find some points of difference from one or another. Let us consider again for a moment epidemic meningitis. There is no combination of predisposing causes, environmental, meteorologic or bacteriologic which will produce epidemics of cerebrospinal meningitis in the absence of the meningococcus itself. The organism causing the disease must be present before the disease will occur. ”

“ Meningitis is derived from the Latin Meninges, membrane, and—itis, an affix denoting inflammation, so that, strictly speaking, meningitis is the inflammation of a membrane, and when applied to the spine, or cerebrum, is called spinal meningitis, or cerebro-spinal meningitis, etc., according to the part of the spine or brain involved in the inflammation. Meningitis is a characteristic and result of so-called spotted fever, and by many it is deemed identical with it. ”

“ The facts above stated are of much importance in combating the spread of this disease. People who are exposed to those having meningitis should be exceedingly careful not to get [Pg 211] upon their persons any of the secretions that come from the patient, and during periods of epidemics those who observe a bad cold coming on should promptly consult their physicians, and do everything to prevent the development of all catarrhal conditions in their noses. ”

“ 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. ”

“ In other words, it is probably true that the vast majority of people who are attacked by this organism simply get colds as a consequence, and only now and then does a person get meningitis as a result. This explains why the disease does not ordinarily appear contagious. ”

“ Both of these have an extraordinary and deadly preference for the nervous system from the very start, and this is what gives them their frightful mortality and discouraging outlook. Even of this small number of exceptions, we are not altogether certain as to epidemic meningitis, inasmuch as we do not know how long the germ may have existed in the other tissues of the body before it succeeded in working its way to and attacking the brain and spinal cord. ”