1911 Encyclopædia Britannica/Meningitis
MENINGITIS (from Gr. μῆνιγξ, a membrane), a term in medicine applied to inflammation affecting the membranes of the brain (cerebral meningitis) or spinal cord (spinal meningitis) or both.
Tubercular cerebral meningitis (or Acute Hydrocephalus) is a disease due to inflammation of the meninges of the brain produced by the presence of a tubercle bacillus. This disease is most common in children under ten years of age, but may affect adults. The tubercular constitution is an important factor in this malady. In numerous cases it is manifestly connected with bad hygienic conditions, with insufficient or improper feeding, or with over exercise of the mental powers, all of which will doubtless more readily exert their influence where an inherited liability. exists, and the same may be said regarding its occasional occurrence as one of the after consequences of certain of the diseases of childhood, especially measles and whooping-cough.
There are certain typical features characterizing the disease in each of its stages. The premonitory symptoms are mostly such as relate to the general nutrition. A falling off in flesh and failure of strength are often observed for a considerable time before the characteristic phenomena of the disease appear. The patient, if a child, becomes listless and easily fatigued, loses appetite, and is restless at night. There is headache after exertion, and the child becomes unusually irritable. These symptoms may persist during many weeks; but on the other hand such premonitory indications may be entirely wanting, and the disease be developed to all appearance suddenly.
The onset is in most instances marked by the occurrence of vomiting, often severe, but sometimes only slight, and there is in general obstinate constipation. In not a few cases the first symptoms are convulsions, which, however, may in this early stage subside, and remain absent, or reappear at a later period. Headache is one of the most constant of the earlier symptoms, and is generally intense and accompanied with sharper paroxysms, which cause the patient to scream, with a peculiar and characteristic cry. There is great intolerance of light and sound, and general nervous sensitiveness. Fever is present to a greater or less extent, the temperature ranging from 100° to 103° F.; yet the pulse is not quickened in proportion, being on the contrary rather slow, but exhibiting a tendency to irregularity, and liable to become rapid on slight exertion. The breathing, too, is somewhat irregular. Symptoms of this character, constituting the stage of excitement, continue for a period varying from one to two weeks, when they are succeeded by the stage of depression. There is now a marked change in the symptoms, which is apt to lead to the belief that a favourable turn has taken place. The patient becomes quieter and inclines to sleep, but it will be found on careful watching that this quietness is but a condition of apathy or partial stupor into which the child has sunk. The vomiting has ceased, and there is less fever; the pulse is slower, and shows a still greater tendency to irregularity than before, while the breathing is of markedly unequal character, being rapid and shallow at one time, and long drawn out and sinking away at another. There is manifestly little suffering, although the peculiar cry may still be uttered, and the patient lies prostrate, occasionally rolling the head uneasily upon the pillow, or picking at the bedclothes or at his face with his fingers. He does not ask for food, but readily swallows what is offered. The countenance is pale, but is apt to flush up suddenly for a time. The eyes present important alterations, the pupils being dilated or unequal, and scarcely responding to light. There may be double vision, or partial or complete blindness. Squinting is common in this stage, and there may also be drooping of an eyelid, due to paralysis of the part, and one or more limbs may be likewise paralysed.
To this succeeds the third or final stage, in which certain of the former symptoms recur, while others become intensified. There is generally a return of the fever, the temperature rising sometimes very high. The pulse becomes feeble, rapid, and exceedingly irregular, as is also the case with the breathing. Coma is profound, but yet the patient may still be got to swallow nourishment, though not so readily as before. Convulsions are apt to occur, while paralysis, more or less extensive, affects portions of the body or groups of muscles. The pupils are now widely dilated, and there is generally complete blindness and often deafness. In this condition the patient’s strength undergoes rapid decline, and the body becomes markedly emaciated. Death takes place either suddenly in a fit, or more gradually from exhaustion. Shortly before death it is not uncommon for the patient, who, it may be for many days previously, lay in a state of profound stupor, to awake up, ask for food, and talk to those around. The duration of a case varies somewhat, but in general death takes place within three weeks from the onset of the symptoms. The disease may be said to be almost invariably fatal, yet cases presenting all the principal symptoms occasionally recover.
Much may be done in the way of prevention of this disease, and, in its earlier stages, even in the way of cure. It is most important in families where the history indicates a tuberculous or scrofulous tendency, and particularly where acute hydrocephalus has already occurred, that every effort should be used to fortify the system and avoid the causes already alluded to as favouring the development of the disease during that period in which children are liable to suffer from it. With this view wholesome food, warm clothing, cleanliness, regularity, and the avoidance of over-exertion, physical and mental, are of the utmost consequence.
Timely use of remedies may mitigate and even occasionally remove. the symptoms when they arise. The maintenance of the patient’s strength by light nourishment and the use of sedatives to compose the nervous system are the measures most likely to be attended with success. Bromide, combined with iodide of potassium, is the medicinal agent of most value for this purpose. Should convulsions occur, they are best treated by chloral or chloroform.
In what is known as suppurative, or simple acute meningitis (non-tubercular), the disease arises from various causes, and the symptoms are similar to those described above.
In posterior-basic meningitis, inflammation of the membranes investing the posterior basic spinal cord, the chief symptoms are fever, with severe pain in the back or loins shooting downwards into the limbs (which are the seat of frequent painful involuntary startings), accompanied with a feeling of tightness round the body.
The local symptoms bear reference to the portion of the cord the membranes of which are involved. Thus when the inflammation is located in the cervical portion the muscles of the arms and chest are spasmodically contracted, and there may be difficulty of swallowing or breathing, or embarrassed heart’s action, while when the disease is seated in the lower portion, the lower limbs and the bladder and rectum are the parts affected in this way. At first there is excited sensibility (hyperaesthesia) in the parts of the surface of the body in relation with the portion of cord affected. As the disease advances these symptoms give place to those of partial loss of power in the affected muscles, and also partial anaesthesia. These various phenomena may entirely pass away, and the patient after some weeks or months recover; or, on the other hand? they may increase, and end in permanent paralysis.
Some observers regard these forms as sporadic cases of cerebrospinal fever; and Still, William Hunter and George Nuttall have isolated an organism similar to the diplococcus intracellularis, while Henry Koplik in New York found cases of typical posterior basic meningitis due to the diplococcus intracellularis.
The treatment is directed to allaying the pain and inflammatory action by opiates. Ergot is recommended by many physicians. The patient should have perfect rest in the recumbent, or better still in the prone, position. Cold applications to the spine may be of use, while attention to the functions of the bladder and bowels, and to the condition of the skin with the view of preventing bedsores, is all-important.
Cerebro-spinal fever or epidemic cerebro-spinal meningitis, popularly called “spotted fever,” is an infectious disease occurring sporadically or in epidemics, and due to the diplococcus intracellularis discovered by Weichselbaum in 1887. This disease was not recognized until the 19th century. It was first described at Geneva in 1805 and small outbreaks followed in Paris (1814), Metz and Genoa (1815), and Westphalia (1822), but in the United States there was a widespread epidemic, including New England and spreading as far as Kentucky and Ohio. Fresh outbreaks in Europe took place between 1837 and 1850. In 1837 it prevailed in the south of France chiefly amongst troops in garrison, and fresh outbreaks continued throughout France in 1846 with epidemics in Algiers, Italy and Sicily. In Great Britain it first showed itself in the Irish workhouses ip 1846, where it was known as “the black death” or “malignant purpuric fever.” After 1866 except for sporadic cases it disappeared from Great Britain, but small outbreaks took place in 1885 to 1900 in Dublin. In 1905 there was an extensive epidemic in New York, followed by an outbreak in Scotland in 1906, and in Scotland and Ireland in 1907–1908. The registrar-general’s returns for 1907 give 1018 deaths in Scotland due to the disease, of which 711 were at Glasgow and 148 at Edinburgh. In the same year Belfast was visited by a severe epidemic, 495 deaths out of the total death-rate of 631 taking place in that district.
The mode of infection is obscure, but the organism is thought to gain access to the circulation through the mucous membrane of the nose and conjunctiva, as the organism has been isolated from the mucous membrane of the nose, not only of those suffering from the disease but from healthy persons who have been in contact with cases. Cerebro-spinal fever has an undoubted tendency to follow bad sanitary conditions and to prevail in damp, sunless houses. It is a disease of temperate climates, and the outbreaks usually take place in the spring of the year. The victims are mostly children and young adults, and Koplik states that few recoveries take place in children under two years of age.
The onset of symptoms is sudden, as contrasted with tubercular meningitis, in which the onset is gradual. The attack comes on sharply with intense headache, rigors and vomiting. The pain soon localizes itself in the back of the neck and occiput, and may thence radiate down the spine, limbs and abdomen. The pain is soon followed by a characteristic symptom, namely retraction of the head. The head is drawn back and rigidly fixed, the spine arched and the limbs drawn up, and muscular spasms may take place. There is general hyperaesthaesia, the slightest contact producing pain. More or less fever is present, but the temperature is not characteristic. The headache continues with great severity and restlessness and delirium supervene, or there may be long periods when the patient is comatose. Twitching of the limbs and general convulsions may occur and facial paralysis is frequent. Paralysis of the ocular nerves causing squint, dilatations and contractions of the pupil are common as in other varieties of meningitis.
Some of the most striking symptoms are the rashes. These usually occur about the fourth day of illness and vary widely in character, resembling erythema, urticaria, rose spots or purpuric spots. The rashes have usually no relation to the gravity of the disease, but severe cutaneous haemorrhages usually indicate a severe form of illness. Should the patient survive the first shock of the attack serious complications may arise; the eyes may be attacked by severe conjunctivitis, iritis or keratitis or inflammation of the deeper parts may take place leading to detachment of the retina. More frequent even is disease of the auditory apparatus, and purulent otitis media or disease of the labyrinth may lead to permanent deafness. Serous effusion may take place into joints which are painful, red and swollen as in acute rheumatism.
Certain forms of the disease are rapidly fatal, these are known as the fulminant type, and death may take place within 12 to 24 hours of the onset. Death usually occurs between the fifth and the eighth day, but many cases drag on for weeks with rapid and progressive emaciation, and recovery is slow. The mortality has varied in different epidemics. Hirsch’s tables of forty-one epidemics give a mortality of from 25 to 75%, and Koplik rates it at 48 to 90%. During 1907, 623 cases of cerebro-spinal fever were notified in Belfast, and the deaths numbered 495. During that year the disease was made notifiable in 48 Irish urban and 55 rural districts. The mortality in Dublin was 75%. Osler states that in children under one year (in New York) the mortality reached 87·6%.
The changes found after death from cerebro-spinal fever are an acute inflammation of the pia-arachnoid membrane both of the brain and spinal cord, with effusion of serum or pus into the ventricular and subarachnoid spaces. With such rapidity may the effusion become purulent that it has been found purulent in a case where death took place within five hours from the apparent onset. The operation of lumbar puncture (or puncture of the spinal canal between the lumbar vertebrae) has enabled the physician to make an accurate diagnosis by bacteriological examination of the contents of the spinal fluid. Lumbar puncture too has been found to be of eminent service in many cases, the withdrawal of from 30 to 50 cc. of the spinal fluid serving to relieve pressure and at least temporarily ameliorate the symptoms.
Up to a few years ago it may be said that there was no effective treatment for cerebro-spinal fever but that of endeavouring to alleviate pain by the administration of opium, but with the recent introduction of serum therapy the future is full of hope. In the epidemic in New York (1905) the serum of Flexner and Jobling was used, and the most striking results were seen in young patients, the death-rate where the serum was used sinking to 46·3% as against 90% without. Like other serum treatments, to get the best results the serum must be administered early in the disease. Of 221 patients injected during the first week of illness the mortality was only 18%, while of 107 others injected after the first week of the disease the mortality was double that amount. When given subcutaneously, as in diphtheria, the serum has little or no effect, and to obtain good results it must be injected directly into the spinal canal after the removal of a certain amount of the spinal fluid. The injections are then continued daily as required according to the severity of the case. Dr Robb of Belfast reports that during the epidemic there, of 275 cases treated by ordinary means, the death-rate was 72·3%. but in 90 cases treated with injections of Flexner and Jobling’s serum the death-rate was only 30%. Dr Ivy McKenzie and Dr W. B. Martin of Glasgow have published a series of cases treated with the highly immune serum of patients who have recovered from the disease with encouraging results.