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MENINGITIS: RATIONALE of DIAGNOSIS by JOHN APLEY, M.D., M.R.C.P

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MENINGITIS: RATIONALE of DIAGNOSIS by JOHN APLEY, M.D., M.R.C.P Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from 362 POST GRADUATE MEDICAL JOURNAL July 1948 Serous Meningitis or Aseptic Meningitis c.cm. Organisms are not present. In some cases an actual meningitis may supervene. This is the name given to the syndrome in which A lymphocytic meningitis is not an infrequent a meningeal reaction occurs as the result of an occurrence in the early stages of Weil's disease and infective focus adjacent to the meninges, e.g. an example came under my own observation mastoiditis, lateral sinus thrombosis, extradural recently. The lymphocytes were several hundreds abscess, intra-cerebral abscess, etc. The pressure per c.cm. and took two-three weeks to return to of the C.S.F. is increased, and there is an increase normal. There was no jaundice in this patient in cells, generally polymorphs, but sometimes and the diagnosis was made by finding a high lymphocytes predominate. The protein is slightly agglutination titre in the blood. but the and chlorides are normal. BIBLIOGRAPHY increased, sugar ALEXANDER, H. E., 'Treatment of Haemophilus Influenzae In- The cell count is usually in the neighbourhood of fections, and of Meningococci and Pneumococci Meningitis,' Amer. Jour. Dis. Child., Aug., 1943, lxvi, x60. 200-300, but occasionally it is as high as I,ooo per DINGLE, J. N., FINLAND, M. (1942), War Med., 2, I. MENINGITIS: RATIONALE OF DIAGNOSIS By JOHN APLEY, M.D., M.R.C.P. Department of Child Health, Bristol University Increased power entails increased responsibility. tion of the meningeal nerves and those portions of With the advent of chemotherapy delay in the the cranial and spinal nerves which traverse the by copyright. diagnosis of purulent meningitis can no longer be theca. The mechanism is identical with that excused, for diagnosis at leisure is condonable obtaining in peritonitis, and the results are similar. only when dealing with an incurable or benign The three characteristic features of meningeal disease. Virtually all the common varieties of irritation are :--() pain, (2) hyperaesthesia, and purulent meningitis are now curable, yet even now (3) muscular rigidity. The first two of these arise many patients die, or survive only with distressing from irritation of sensory components, and the residua. Inadequacy of laboratory facilities and third through the mechanism of a meningeal- improper selection of therapeutic agents are con- motor reflex. tributory factors in the production of these The various signs, such as those of Kernig and http://pmj.bmj.com/ failures; but the most important single factor is Brudzinski, and the demonstration of neck rigidity, delay in diagnosis. which are employed in the diagnosis of meningitis, It is axiomatic in medicine that urgent diagnosis depend for their effects upon increasing the depends on leisurely preparation. The diagnos- irritability of the meninges by mechanical stretch- tician who has failed to discipline himself by re- ing. peated observation, analysis and synthesis will fail also to attain that maturity of judgment which Correlation of Symptomatology with Site permits diagnosis to be made rapidly yet without of Meningeal Irritation on September 28, 2021 by guest. Protected the sacrifice of accuracy. The study of meningitis The production of the three characteristic provides an example of the preliminary, catholic features of meningeal irritation can be clearly preparation which is essential for urgent diagnosis. illustrated by contrasting anterior poliomyelitis Though the present discussion is centred on with meningococcal meningitis. At the same time purulent meningitis the logical approach must be the discussion can be taken a stage further to through the subject of lepto-meningitis in its provide evidence on which to attempt localization wider aspects. of the site of meningeal involvement. In anterior poliomyelitis, when the' site of pre- Features of Meningeal Irritation dilection is in the lumbar region of the cord, the The essential feature common to the many manifestations of meningeal irritation appear first forms of meningitis is meningeal irritation. This in the back and the legs; from these regions they phenomenon may occur even in the absence of may spread or remain localized, according as the infection of the meninges; but, whatever the disease process spreads or is halted. In menin- cause of the irritation, the clinical features which gococcal meningitis, when, as commonly occurs, the may be observed result in all cases from stimula- site of predilection is at the base of the brain, the Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from July 1948 APLEY: Meningitis: Rationale of Diagnosis 363 results of meningeal irritation are manifest first in tend, therefore, to occur at an early stage. In the head and neck, to become widespread only as pneumococcal meningitis, on the contrary, the the infective process extends. Since the anterior yellow-green exudate may predominate at the and middle cranial fossae are supplied by the vertex of the brain. As a result, though headache trigeminal nerve, the results of irritation in these is severe, neck rigidity is minimal or absent. In areas will be manifest in the frontal, facial and influenzal and in streptococcal meningitis the dis- temporal regions; the posterior fossa is supplied tribution of the exudate is capricious, following no by the upper cervical nerve roots, so that dis- set pattern, and the symptomatology is corres- turbances originating in stimulation of these nerves pondingly unpredictable. Post-basic meningitis of will be referred to the occipital and post-nuchal infants, a chronic 'variety of meningococcal regions. In practice the three fossae are, however, meningitis, derives its unique features from the generally involved concurrently, so that clinical special conditions pertaining in infancy. Because localization of the infection to one or other of them of the comparative softness of the infantile brain is usually not possible. the sulci become closed at an early stage in the As between the different types of infective disease process, so that the exudate is confined meningitis, the variations in symptomatology may almost exclusively to the basal cisterns. be explained, at least in part, by what is known of their applied pathology. In the meningococcal Mechanisms of Production of Meningeal variety, as also in tuberculous meningitis, the in- Irritation flammatory exudate tends to be concentrated at Comprehension of the widely different mechan- the base of the brain. It fills the interpeduncular isms by which meningeal irritation may be pro- space, spreading thence with the flow of cerebro- duced is of more than academic interest; without spinal fluid down into the spinal theca, forward it differential diagnosis remains as unsatisfying as along the optic nerves, backward into the cisterns, it is superficial. The conditions which give rise to or upward along the middle and anterior cerebral meningeal irritation will be described in five arteries to the vertex. In the natural history of groups, a division which appears natural and by copyright. these diseases neck rigidity and occipital pain contributes to clarity of diagnosis (see Table i), PATHOGENESIS OF FIG. MENINGEAL REACTIONS arachnoid villi / / http://pmj.bmj.com/ venous blood / / // --// - MENINGEAL INFECTION / nervous /, CEREBROSPINAL nervous C.N.S. INFECTION WITH SUBSIDIARY on September 28, 2021 by guest. Protected tissue // ) FLUID / MENINGITIS lepto- / meninges /NON-INFECTIVE MENINGEAL / / - // IRRITATION // // ASEPTIC MENINGEAL REACTION TO ///// / / EXTRA-MENINGEAL SEPSIS arterial // / / V blood / / / MENINGISM: INCREASE IN C.S.F. FROM // / / / / / / / // / BLOOD OSMOTIC DISTURBANCES · choroid plexus Reproduced by permission from ' The Clinical Apprentice,' by J. M. Naish and J. Apley, published by J. Wright, Bristol Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from 364 POST GRADUATE MEDICAL JOURNAL July 1948 TABLE i frequently characterized, in its early stages, by a meningeal reaction which is transient. CAUSES OF MENINGEAL IRRITATION 2. Infection of C.N.S. with subsidiary meningitis GROUP I.-Predominantly Meningeal Infections In accordance with the general statement pre- (commonly bacterial). viously made, the majority of virus infections of Cocci: meningo-, strepto-, pneumo-, staphylo-. the central nervous system fall into this group. Others : B. tuberculosis, H. influenzae, The more of these are shown in Table i. B. coli, B. proteus, Brucellosis, B. typhosus. important Virus: benign lymphocytic meningitis. Conversely, suppurative encephalitis, though of bacterial origin, is invariably preceded by GROUP 2.-C.N.S. Infection with Subsidiary meningeal inflammation. Meningitis (commonly virus). Some diseases due to organisms other than Anterior poliomyelitis, polioencephalomyelitis, viruses also fall into this group. Of these, the only encephalitis (especially in association with specific common one is syphilis. Extremely rarely Weil's fevers), infectious mononucleosis. disease, actinomycosis and some fungus and Syphilis, Weil's disease, actinomycosis and other similar diseases are concerned. fungus infections, infections with yeast-like organisms similarly (e.g. torula, coccidioides). 3. Non-infective mechanical irritation of meninges GROUP 3. Non-infective Mechanical Irritation Various non-infective causes may give rise to of Meninges. direct irritation of the meninges. Even normal Intra-thecal
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