COURSE.—In young children the course of meningitis differs somewhat from that which is observed in adults, though the symptoms are essentially the same. It is more sudden in its onset and shorter in its duration. The prodromal stage may be brief or hardly noticeable; but in older children restlessness, sensitiveness to light and sound, wakefulness, slight twitchings of the features or of the limbs, a half-open condition of the eyelids during sleep, occasional vomiting, etc., are more commonly noticed. Convulsions are more common than in the adult, and sometimes constitute the chief symptom. They may be confined to a single extremity, but in general they shift from one limb to another. The muscles of the eyeball are usually implicated, causing strabismus. Retraction of the head is rarely absent, especially in young infants. These convulsions are almost always tonic, but occasionally they alternate with clonic ones. Distension and increased pulsation of the anterior fontanel is always observed in infants a few months old affected with this disease. When meningitis is secondary to some other disease, the first symptom noticed in children is apt to be vomiting, with delirium. According to Steffen, pneumonia is the disease most frequently complicated with meningitis in children. As in tubercular meningitis, the most prominent symptom may be mere sopor, sometimes with intervals of intelligence. Simple meningitis in children is generally a rapid disease, proving fatal in most cases within a week, and sometimes even in a few hours. Exceptionally, it may last much longer. A case occurring in a girl six years old, the duration of which was fifty-five days, is reported by J. Bokai, Jr.;17 the diagnosis was substantiated by autopsy. Another case, which recovered after seven weeks, is mentioned by Henoch.18
17 Jahrb. f. Kinderkrankheiten, N. F., xviii. 1, p. 105; and Schmidt's Jahrb., 1882, No. 6, p. 269.
18 Eduard Henoch, Vorlesungen über Kinderkrankheiten, Berlin, 1881, p. 277.
PATHOLOGICAL ANATOMY.—The lesions, which are rarely general, may occupy a greater or less extent of the membrane. They are usually disposed symmetrically with regard to the two hemispheres, or occupy corresponding regions of the base. The vessels are in the beginning of the disease distended, the finest ramifications being injected, giving a red color to the membrane, which varies in different places from crimson to light pink. The perivascular spaces of the larger vessels are filled with a grayish or yellowish fluid composed of extravasated liquor sanguinis and white blood-corpuscles. The meshes between the two layers of the pia are soon infiltrated with pus, and the thickened membrane can be stripped off from the surface of the brain, which is, however, adherent to it in places and is torn in the process. Sometimes a thin layer of pus, which can be scraped off with the knife, is found upon the surface of the pia. The extent of the lesion varies much in different cases. It may be confined to a limited region of the hemispheres, or it may spread to the fissure of Sylvius, where two surfaces become adherent. Sometimes the concrete pus and fibrin are deposited in thick masses upon the base of the brain, often completely surrounding the cranial nerves, and even the medulla. The inflammation may extend to the lateral ventricles, which become filled with a turbid fluid containing pus-cells, and sometimes wholly purulent. The choroid plexuses are often covered with flecks of pus. When the distension of the ventricles is very great, the gyri of the brain are more or less flattened by compression against the cranium, and the outer layer of the cerebral substance is bloodless and œdematous. The cerebral sinuses are distended with blood, and frequently contain thrombi due to an early stage of the inflammatory process, besides recent coagula.
DIAGNOSIS.—The diagnosis of acute meningitis is often difficult, and sometimes impossible, especially in the early stages, when the line between congestion and inflammation cannot be drawn, and in complicated cases. The typical symptoms are sudden and acute pain in the head, with sensitiveness to light and sound, contracted pupils, rapid pulse, and vomiting, followed by delirium, convulsions, and coma. If these symptoms were observed in an individual previously in good health, they would be strongly suggestive of the disease, and yet many of them are often present in the beginning of pneumonia, erysipelas, typhoid, typhus, and other eruptive fevers, uræmia, and poisoning from narcotic substances. Hence it is important to eliminate these sources of error before coming to a conclusion, and a neglect of this precaution is a not infrequent source of error in the diagnosis. A careful examination of the urine will generally enable us to exclude uræmia. The presence or absence of the eruptive fevers can usually be determined by the attendant circumstances, and yet cases of scarlatina, typhoid fever, variola, etc., beginning with active cerebral symptoms, are sometimes hastily pronounced to be meningitis by inexperienced observers. 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. The former is usually brief in its course; the latter lasts one or two weeks, and in cases which recover is often followed by after-effects which are more or less permanent in their duration, such as paralysis or rigidity of the limbs, mental defects, etc. Rapid recovery from the acute symptoms would be strongly suspicious of congestion, and doubtless in many such cases the treatment has been credited with a success to which it was not entitled. The diagnosis from tubercular meningitis will be reserved for the article on that disease.
PROGNOSIS.—Acute meningitis is fatal in the majority of cases, though recovery is possible. A gradual diminution of the severity of the symptoms, especially in respect to temperature, pulse, pain in the head, and other cerebral phenomena, would afford encouragement, but we must not trust too much to the brief appearances of amendment so often observed.
TREATMENT.—The indications for treatment are threefold: 1st, to prevent or arrest the inflammation; 2d, to modify its violence and shorten its duration when arrest is no longer possible; and 3d, to place the patient in the best condition to withstand the violence of the disease and to recover from its effects. It is only by prompt action that we can hope to attain the first object, that of preventing the passage of hyperæmia into inflammation. The patient should be placed in a cool and well-ventilated apartment of good size, from which a bright light is excluded. His head, moderately raised, should be kept cool by means of pounded ice enclosed in a rubber bag or a bladder. One or more leeches, according to his age, should be applied behind the ears, or blood may be drawn from the temples or back of the neck by means of cupping. The bleeding should be encouraged by poultices if necessary, but with young children the abstraction of blood should be done with caution. An active purge should be given, such as ten grains each of calomel and jalap, followed by castor oil or infusion of senna; for children, from three to six grains, according to age, followed by oil, would be sufficient. The medicine should be repeated in a few hours if there be no effect. Counter-irritation by means of blisters is recommended by most authorities as a valuable aid in the first stage of the disease. Unless the application be very extensive, it is not likely to be of any avail, and extensive blistering would hardly fail to greatly reduce the strength of the patient, and also is likely to irritate the kidneys. There are no medicines which can be relied upon to arrest the inflammatory process. Nevertheless, the tincture of aconite-root, in the dose of from one to three drops, according to the age of the patient, every two hours, might be given early, with the view of fulfilling the second indication by its sedative property. The bromide of potassium or of sodium, combined with small doses of chloral hydrate or of sulphate of morphia, will also calm the excitement and pain, and diminish convulsions. The success which sometimes follows the employment of ergot in the epidemic cerebro-spinal meningitis warrants its trial. Bartholow recommends the wet sheet two or three times a day if the temperature is high. Steffen advises four grains of sulphate of quinine with one grain of salicylate of soda, from two to four times daily, for young children, and in double these doses for older ones. The alimentation of the patient should be carefully attended to during this stage. Nourishing liquid food, such as milk, gruel, broth, eggs, with stimulants if indicated, should be given at proper intervals, care being taken not to overload the stomach, as is frequently done. When the patient can no longer swallow the food must be given by the rectum. During the stage of compression it is useless, in the present state of our knowledge, to expect any benefit from the further administration of drugs, and the treatment then consists mainly in giving small quantities of food at regular intervals, and in such external applications as the bodily temperature may require. The bladder must be relieved by the catheter when necessary. Simple enemata are generally sufficient to prevent constipation.
Chronic Cerebral Meningitis.
Chronic inflammation of the pia mater rarely follows the acute form, but is generally secondary to other conditions, such as inflammation and tumors of the dura, tumors and abscess of the brain, disease of the vessels of the brain, suppurative otitis, and to constitutional diseases, especially alcoholism, syphilis, and pulmonary tuberculosis. It is one of the most common lesions found after death from general paralysis of the insane. As a distinct affection, unconnected with constitutional disease, it is extremely rare, though less so, according to Flint,19 than the acute form. He cites a case in which the symptoms were intermittent. The patient, fifteen years old, died after a month's illness. The autopsy showed cerebral hyperæmia, lymph at the base of the brain, and distension of the ventricles with transparent fluid. There were no tubercles. In most cases in which the results of chronic meningitis are found after death the cortical substance of the brain is involved in the disease; hence the difficulty in defining its symptoms, which are usually extremely vague, and not always distinctive of cerebral disease. The principal are pain in the head, vertigo, vomiting, impairment of the memory, mental apathy, drowsiness, and muscular weakness. The anatomical changes are thickening and opacity of the membrane by the deposit of lymph upon its surface and into the connective tissue, adhesions to the dura and to the cortical substances of the brain, together with hyperæmia of the latter. These appearances are usually distributed in irregular patches of greater or less extent.
19 Austin Flint, M.D., Principles and Practice of Medicine, 5th ed., Philada., 1881, p. 701.