fortified in 1578, and in 1685 Vauban made it one of the strongest places on the French frontier, but the fortifications were razed in 1748 by the treaty of Aix-la-Chapelle.
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.
