MENINGITIS BY
A. M. G. CAMPBELL, M.D., F.R.C.P.
Consultant
Physician,
United Bristol
Hospitals
INTRODUCTION 3
Inflammation of the meninges and brain in the past was always considered such serious and fatal disease that its early diagnosis was not stressed sufficiently. Since ^ introduction of antibiotics it has been shown that mortality figures are in direct portion to the delay in diagnosis and treatment. Therefore, the early
pr?j
diagnosis0
meningitis and establishment of the organism, which has infected the brain, are vitalInfection of the meninges may be via the blood stream, as is predominantly the in meningococcal meningitis, or by a direct spread from neighbouring structures, su as infected bone or sinuses. Meningitis may also be due to chemical irritation fr? anaesthetics or from virus and spirochaetal infection. spinal j ; The onset of a meningitis can be extremely acute and is accompanied by general^ severe headache but, in particular, the headache is very often localized to the back the neck. All the signs of a meningeal irritation depend on a reflex muscle spasm arlSl(.j; from stretching inflamed spinal roots, either in the cervical region accounting for peoI rigidity or in the lumbar region accounting for Kernig's sign, a sign which does11 allow of extending the flexed knee with hip flexion. It must be emphasized that. ^ irritation of the meninges such as that caused by blood in a sub-arachnoid haemorrtj'^, or by increased intracranial pressure associated with a cerebral tumour, may pr0 1 these signs. Again in certain febrile illnesses, particularly pneumonia and typ^ and occasionally tonsillitis, these signs may be positive and account for the s0"c?t[i? oI case of meningism, which is thought to be due to a fall in the osmotic pressure ^ serum and increased production of cerebrospinal fluid, but is not accompame cellular increase in the fluid. ^ The diagnosis of meningitis from other irritative lesions of the meninges oI be made by lumbar puncture, which is absolutely essential in any doubtful case kind, not only for diagnosis,but to establish the organism and its sensitivity. ^ The early symptoms of meningitis differ slightly in children and adults. Dr. has enlarged very fully on the difficulty of diagnosis in children and emphasize jji headache is not such a predominant symptom in childhood as it is in adults. A c $
^
.
number of adult cases will arrive in coma so that other causes of coma are a differe 0$ diagnosis in this disease. Other cases present with epilepsy or with some othe*.(j?; symptoms which I will mention later in connection with tuberculous men1110 one pneumococcal meningitis presented with sciatic pain. > All damage to the brain whether it is infective or traumatic leads to inte* impairment during the course of the illness. In many people this intellectual irlJr ment strikes at the very base of their personality and, even after recovery ^ 0 primary condition, they may become unduly worried about the question damage and often a secondary anxiety state is grafted on to any organic disease remains. If the individual previously had a somewhat neurotic personality, treated by careful reassurance and graduated convalescence. It is particularly tant to reassure him about his future attainments. These symptoms differ in from those shown by anxious people after a head injury. ^ Other possible complications of any meningitis are adhesions in the arachnoi c which may produce constriction of the spinal cord, paralysis, and hydrocepha Lastly, epilepsy can follow meningitis just as it can follow a head injury an .
.,
162
.p/
163
MENINGITIS
p?me
on several years after the acute attack; it is usually related lllltial illness and whether treatment has been instituted early.
to
the
severity
of the
MENINGOCOCCAL MENINGITIS
Meningococcal meningitis ults
is largely a disease of children, but it does attack young those living in the crowded conditions which occurs in wars. ^ the spring months, it can take an epidemic form. This was seen in 1915 and again the R-A.F. in 1940 I was in the position of looking after two wards of m 1(H0, eriingococcal meningitis. In this series in all we had 54 cases and 2 deaths. One tient died as the result of a fulminating attack accompanied by septicaemia, purpura d , into the suprarenals within twenty-four hours of the symptoms In this R.A.F. outbreak, we had two patients with deafness, which is e.to the disease infecting the labyrinth. We had one case of herpes zoster superand in
>
particular
?
^
haemorrhage
^eloping. lng
on
the disease and
two cases
ningitis and producing arthritis.
of
meningococcal septicaemia
associated with
PNEUMOCOCCAL MENINGITIS
Its ^umococoil meningitis is a disease of all ages, but occurs very frequently in adults. is usually an infection from the mastoid air cells, sinuses or middle ear, but q^jCause e aU
a
few
irifeUl-ng
cases are
^n^ecti?n
In t?tl0n
?f the
the result of trauma and
a
fracture of the inner wall of
a
sinus
spread to the meninges. Another important cause is pneumococcal chest or the spread of infection from bronchiectasis or lung abscess. to
^ast 8rouP the
occurrence of serious disease both in the chest and in the head for many difficulties in treatment for many of the cases die as a their chest condition rather than from their meningitis, or a combination of f0H c?nditions. Sometimes the disease follows operation and two cases recently have operation for polypi in the antrum. ?re the days ot antibiotics, pneumococcal meningitis was almost always fatal, the introduction of sulphonamides, the mortality was reduced to approxitw' 7? per cent, and with the addition of penicillin to the treatment, the outlook CCn greatly improved and the mortality has been reduced to between 30 and 40 Per Results in certain Units, such as Oxford, have been strikingly good and the ^OrM^t" *ty has been as low as 24 per cent. The difficulty in comparing mortality figures in ^Sease is the association of other diseases, which is quite common with pneumeningitis in elderly individuals. ?Ccurrence ?f this type of meningitis in the old-age group is quite striking and Mthin last year, I have treated two cases of this disease in patients over sixty-five age. The first recovered and the second died. The second case was sent to Presen ^ate because the doctor imagined that the epileptic fit which the patient )yith, was due to cerebral vascular disease and not due to meningitis, Th of the onset of this type of meningitis is quite remarkable. For example, the e ?f a doctor went to bed with ear-ache one night. She complained of ear-ache ^ 5evere adache the following morning and by 1.0 p.m. was found unconscious, with 4-o symptoms. Treatment with intrathecal penicillin was instituted at p an
A. M. G. CAMPBELL, M.D., F.R.C.P.
Consultant
Physician,
United Bristol
Hospitals
INTRODUCTION 3
Inflammation of the meninges and brain in the past was always considered such serious and fatal disease that its early diagnosis was not stressed sufficiently. Since ^ introduction of antibiotics it has been shown that mortality figures are in direct portion to the delay in diagnosis and treatment. Therefore, the early
pr?j
diagnosis0
meningitis and establishment of the organism, which has infected the brain, are vitalInfection of the meninges may be via the blood stream, as is predominantly the in meningococcal meningitis, or by a direct spread from neighbouring structures, su as infected bone or sinuses. Meningitis may also be due to chemical irritation fr? anaesthetics or from virus and spirochaetal infection. spinal j ; The onset of a meningitis can be extremely acute and is accompanied by general^ severe headache but, in particular, the headache is very often localized to the back the neck. All the signs of a meningeal irritation depend on a reflex muscle spasm arlSl(.j; from stretching inflamed spinal roots, either in the cervical region accounting for peoI rigidity or in the lumbar region accounting for Kernig's sign, a sign which does11 allow of extending the flexed knee with hip flexion. It must be emphasized that. ^ irritation of the meninges such as that caused by blood in a sub-arachnoid haemorrtj'^, or by increased intracranial pressure associated with a cerebral tumour, may pr0 1 these signs. Again in certain febrile illnesses, particularly pneumonia and typ^ and occasionally tonsillitis, these signs may be positive and account for the s0"c?t[i? oI case of meningism, which is thought to be due to a fall in the osmotic pressure ^ serum and increased production of cerebrospinal fluid, but is not accompame cellular increase in the fluid. ^ The diagnosis of meningitis from other irritative lesions of the meninges oI be made by lumbar puncture, which is absolutely essential in any doubtful case kind, not only for diagnosis,but to establish the organism and its sensitivity. ^ The early symptoms of meningitis differ slightly in children and adults. Dr. has enlarged very fully on the difficulty of diagnosis in children and emphasize jji headache is not such a predominant symptom in childhood as it is in adults. A c $
^
.
number of adult cases will arrive in coma so that other causes of coma are a differe 0$ diagnosis in this disease. Other cases present with epilepsy or with some othe*.(j?; symptoms which I will mention later in connection with tuberculous men1110 one pneumococcal meningitis presented with sciatic pain. > All damage to the brain whether it is infective or traumatic leads to inte* impairment during the course of the illness. In many people this intellectual irlJr ment strikes at the very base of their personality and, even after recovery ^ 0 primary condition, they may become unduly worried about the question damage and often a secondary anxiety state is grafted on to any organic disease remains. If the individual previously had a somewhat neurotic personality, treated by careful reassurance and graduated convalescence. It is particularly tant to reassure him about his future attainments. These symptoms differ in from those shown by anxious people after a head injury. ^ Other possible complications of any meningitis are adhesions in the arachnoi c which may produce constriction of the spinal cord, paralysis, and hydrocepha Lastly, epilepsy can follow meningitis just as it can follow a head injury an .
.,
162
.p/
163
MENINGITIS
p?me
on several years after the acute attack; it is usually related lllltial illness and whether treatment has been instituted early.
to
the
severity
of the
MENINGOCOCCAL MENINGITIS
Meningococcal meningitis ults
is largely a disease of children, but it does attack young those living in the crowded conditions which occurs in wars. ^ the spring months, it can take an epidemic form. This was seen in 1915 and again the R-A.F. in 1940 I was in the position of looking after two wards of m 1(H0, eriingococcal meningitis. In this series in all we had 54 cases and 2 deaths. One tient died as the result of a fulminating attack accompanied by septicaemia, purpura d , into the suprarenals within twenty-four hours of the symptoms In this R.A.F. outbreak, we had two patients with deafness, which is e.to the disease infecting the labyrinth. We had one case of herpes zoster superand in
>
particular
?
^
haemorrhage
^eloping. lng
on
the disease and
two cases
ningitis and producing arthritis.
of
meningococcal septicaemia
associated with
PNEUMOCOCCAL MENINGITIS
Its ^umococoil meningitis is a disease of all ages, but occurs very frequently in adults. is usually an infection from the mastoid air cells, sinuses or middle ear, but q^jCause e aU
a
few
irifeUl-ng
cases are
^n^ecti?n
In t?tl0n
?f the
the result of trauma and
a
fracture of the inner wall of
a
sinus
spread to the meninges. Another important cause is pneumococcal chest or the spread of infection from bronchiectasis or lung abscess. to
^ast 8rouP the
occurrence of serious disease both in the chest and in the head for many difficulties in treatment for many of the cases die as a their chest condition rather than from their meningitis, or a combination of f0H c?nditions. Sometimes the disease follows operation and two cases recently have operation for polypi in the antrum. ?re the days ot antibiotics, pneumococcal meningitis was almost always fatal, the introduction of sulphonamides, the mortality was reduced to approxitw' 7? per cent, and with the addition of penicillin to the treatment, the outlook CCn greatly improved and the mortality has been reduced to between 30 and 40 Per Results in certain Units, such as Oxford, have been strikingly good and the ^OrM^t" *ty has been as low as 24 per cent. The difficulty in comparing mortality figures in ^Sease is the association of other diseases, which is quite common with pneumeningitis in elderly individuals. ?Ccurrence ?f this type of meningitis in the old-age group is quite striking and Mthin last year, I have treated two cases of this disease in patients over sixty-five age. The first recovered and the second died. The second case was sent to Presen ^ate because the doctor imagined that the epileptic fit which the patient )yith, was due to cerebral vascular disease and not due to meningitis, Th of the onset of this type of meningitis is quite remarkable. For example, the e ?f a doctor went to bed with ear-ache one night. She complained of ear-ache ^ 5evere adache the following morning and by 1.0 p.m. was found unconscious, with 4-o symptoms. Treatment with intrathecal penicillin was instituted at p an
