=Definition.=—A specific, infectious disease caused by the diplococcus
intracellularis meningitidis, occurring sporadically and in epidemics.
It is characterized by inflammation of the membranes of the brain and
spinal cord and an irregular course.
=Osteopathic Etiology= and =Pathology=.—The specific exciting cause of
the cerebrospinal meningitis is due to the diplococcus intracellularis
meningitidis of Weichselbaum. Lesions are found in the vertebræ
corresponding to the cervical and dorsal enlargement of the cord, as
well as in corresponding deep muscles; also, as is well known, the
muscles of the entire back are severely contracted, especially of the
cervical, upper and lower dorsal regions. More commonly it attacks
the young, although it may occur at any age. Overexertion, exposure,
overcrowded and illy-ventilated buildings, barracks and tenements, and
depressing mental influences are predisposing causes. Many times the
disease occurs among the poorer classes. Sometimes the disease prevails
in the country rather than in the city.
In cases that prove speedily fatal there may be no characteristic
changes; simply marked congestion. Other cases in which death occurs
after the disease has been fully developed, there is found every degree
of inflammation from slight hyperemia to suppurative changes. There can
be no doubt that the osteopathic lesion, as vertebral and rib lesions
and deep muscular contractions, affects the circulation of the meninges
of the brain and cord and thus favors the invasion of the specific
micro-organism. The arteries, veins and sinuses are greatly engorged.
The walls of the ventricles soften and the ventricles contain serous
exudate. The brain matter may be congested and softened in spots. In
the spinal membranes similar changes take place and at times there is
extravasation of blood. The changes are more marked on the posterior
than the anterior surface of the cord. Abscesses sometimes form. The
exudate may follow the lymph sheaths of the cranial nerves, especially
the auditory and optic. In long standing cases the membranes become
thick and adherent and areas of softening or atrophy of the cortex
develop. The thickening and adhesions of the membranes may cause
various symptoms for months or even years after recovery from the acute
disorder.
The spleen may be normal in size, but when the fever has been intense,
it is apt to be slightly enlarged. Bronchitis, pneumonia, endocarditis
and pleurisy may occur. The liver may become hyperemic and the kidneys
congested.
=Symptoms.=—The prodromes vary, although the onset is apt to be
sudden with a decided chill; headache; vomiting, and pain in the
neck and back, which is usually severe, but may be so slight as not
to be noticed by the patient. The temperature rises to 101 to 102
degrees F., in most cases. However, it may rise to 105 degrees or
106 degrees and even to 108 degrees in fatal cases, and the pulse is
full. Hyperesthesia, photophobia, and dread of noise are apt to be
prominent symptoms. The muscles of the neck and back become rigid,
and there are pains in the limbs. Orthotonos occurs more frequently
than opisthotonos. Convulsions are common in children. There may be
paralysis, especially of the muscles of the face and eyes. Delirium
usually appears early; it may be mild, but it is often maniacal. The
bowels are usually confined, though there may be diarrhea. There is
moderate and constant leucocytosis and jaundice has been met with.
The urine is sometimes albuminous, and sugar has been noted in rare
cases. The urine may be increased, but more often it is lessened as in
other infectious diseases.
Herpes facialis occurs shortly after the onset in more than half the
cases. The contents of the vesicles may be purulent and one or two may
coalesce. The petechial eruptions are occasionally numerous and cover
the entire skin; they do not disappear upon pressure and the number of
spots varies greatly. Other eruptions as sudamina, ecthyma, pemphigus,
urticaria, erysipelas, rose colored spots, and gangrene of the skin
(rarely) have been met with.
In cases that are =rapidly fatal=, the onset is sudden, usually
with violent chills, headache, depression, and in a few hours coma
and collapse, which are soon followed by a fatal termination. The
temperature may rise slightly, but it is often subnormal. The pulse is
feeble; breathing is labored. These cases occur more frequently at the
beginning of an epidemic. They occasionally occur sporadically.
The =abortive= form terminates abruptly after the development of one or
more pronounced, characteristic symptoms.
The =mild= form can only be recognized during the prevalence of an
epidemic. The symptoms are very mild; slight vomiting, little or no
fever, headache and slight pain in the back and limbs.
The =intermittent= form is characterized by increase in the fever
every day or second day. The strict periodicity seen in malaria is not
observed; the fever resembles that of pyemia.
In the =chronic= form the condition may persist for weeks or months.
=Complications.=—Pneumonia (lobar and lobular) is a frequent
complication. Pleurisy, pericarditis, parotitis, arthritis, enteritis,
optic neuritis and otitis media may be other complications.
=Sequelæ.=—Blindness, deafness, keratitis (rarely), persistent
headache, chronic hydrocephalus, abscess of the brain, mental
feebleness, defective articulation, aphasia, and paralysis of certain
cranial nerves or of the lower extremities have occurred.
=Diagnosis.=—=Typhoid fever= begins slowly and is unaccompanied by
vomiting, muscular spasms or rigidity, or hyperesthesia. In typhoid
the fever is higher and there is a characteristic temperature curve.
Widal’s test will confirm.
=Tubercular meningitis= is not epidemic and has no characteristic
eruption. It is usually less sudden in its development and is
invariably fatal. Retraction of the neck, muscular spasms of the legs
and arms are not so marked as in spinal meningitis.
=Pneumonia= may be complicated with meningitis, especially when the
meningitis is confined to the cerebrum. If the case is not seen early,
it is almost impossible to say which is the primary affection, as
pneumonia may have meningeal complications or cerebrospinal meningitis
may be associated with pneumonia. There will be motor spasms and
tremors, but the head is rarely retracted, and there is less myalgiac
pain than in cerebrospinal meningitis.
=Prognosis.=—This varies according to the severity of the type. It
is a grave disease. Cases have been treated successfully by several
osteopaths. The duration is very variable—from two or three days to
weeks or even months, but probably in all cases this time can be
materially shortened by judicious osteopathic treatment. Convalescence
is very slow and relapses are prone to occur.
=Treatment.=—The osteopathic treatment of cerebrospinal meningitis
requires most thorough, but very careful, work along the spinal column,
especially the cervical region and the region of the dorsal enlargement
of the spinal cord, in relaxing and keeping relaxed the deep muscles
on either side of the spine and correcting the derangements of the
vertebræ, particularly in the upper cervical spine. Such treatment
has a marked effect on the circulation of the spinal cord and brain.
Probably, a large amount of the work along the spine, in all cases
where muscles are relaxed, has a direct effect upon the circulation of
the spinal cord. This treatment constitutes the primary osteopathic
work in cerebrospinal fever and should be frequently applied until a
cure is obtained. Even in chronic cases where limbs have been greatly
affected by pressure upon the nerve centers, due to a thickened
membrane, continued osteopathic treatment along the spine has had a
marked effect in absorbing the pathological condition and restoring
strength.
The preceding spinal treatment is also a very great safeguard in
keeping the various viscera healthy and thus preventing complications.
In all constitutional diseases of an acute nature, it is a wise
precaution to thoroughly examine the entire length of the spinal
column at each visit; and if such precaution is taken many serious
complications will never occur that might otherwise have taken place.
The patient should be isolated in a somewhat darkened room, and care
taken that the disease is not allowed to spread. Keep the patient upon
his sides as much as possible. The diet should be a nutritious one of
milk and broths. They should drink freely of water. Cold to the head
and spine will be of service in controlling the inflammation; it should
be applied with an ice-cap and a spinal ice-bag. Sponging the body
should be employed if the temperature is above 102° F. The general
bath, as in typhoid fever, may be employed if practicable. Direct
treatment to the bowels, kidneys, liver and spleen should be given at
each treatment.
Lumbar puncture and the Flexner-Jobling serum are considered of value
by those who have had an extensive experience.