PURULENT MENINGITIS (Meningitis simplex) Purulent meningitis differs both anatomically and clinically from tuberculous meningitis, at least from typical cases with wide dissemina tion. In the former the onset is sudden, with high fever and extensive participation of the cerebral cortex; in the latter the onset is insidious, with slight fever, a duration of weeks and a preponderance of basal exudation. In the former type there is purulent, in the latter gelatinous, infiltration of the pia rnater.
characteristics justify the classification of pur ulent meningitis as a separate group, but it is to be noted that it repre sents no etiologic entity. All known pyogenic organisms may cause it. Arranged with reference to their frequency these are: first, the pneurno- and streptococcus; second, the staphylococcus pyogenes (usually aureus) and Friedlander's diplobacillus; lastly, the bacilli of the coif group, the bacillus pyocyaneus and Pfeiffer's bacillus hamophilus (influenza bacillus). The discovery of a definite microbe as yet has only scientific interest ; but it appears as though the course and also the prog nosis (within limits) are dependent upon the nature of the infective agent.
Purulent meningitis is without doubt more frequent in early child hood than later and, unlike tuberculous meningitis, does not spare the newborn. The protected position of the central nervous system, the investments of which nowhere reach the surface of the body, explains the rarity of primary or at least of cryptogenetic purulent meningitis. Apart from cases of general pytemia it originates by extension of an inflam mation in the vicinity of the brain or spinal cord, or by metastasis from an abscess. Examples of sources of infection belonging to the first class are the orbit, the nose and the ear. Pus may reach the pia mater by extension along the sheath of the optic nerve (seldom however) after operation on a phlegnion of the orbit with subsequent infection of the wound.
Schmidt-Rimpler reports such a ease in a boy seven years of age, in whom purulent basilar meningitis ensued months after the primary injury to the orbit had healed. It is remarkable, as this author alleges., that after panophthalmia and all inflammations confined to the bulb, optic neuritis and sympathetic ophthalmia occur; but meningitis does not unless the lymph-spaces of the optic nerve have been opened by the enucleation.
It is our experience that more frequently the ethmoid bone is the portal of entrance for the germs which had previously infected the nose.
Meningococci and pneurnococci, which often are found in the nasal cavity in normal individuals, arc probably the only cocci which can infect the meninges without clinically obvious disease of the nasal MUCOUS membrane; however we have observed purulent meningitis in a series of infants with severe hereditary syphilitic coryza. In these eases the oldest and richest purulent foci were found at the base of the brain. This fact accords best with the assumption of an infection pro ceeding from the nose, although purulent otitis media, which existed in all of the cases, cannot be easily eliminated as the cause.
There is no reason to consider at this time the passages from the tympanum to the meninges which can serve as avenues for the purulent factors. But we desire to state that there is hardly any danger of meningitis in the cases in which the disease is confined to the tympanum u-ithout iinplicating the labyrinth. Involvement of the labyrinth is the rule in infancy. We cannot consider fully otogenetic meningitis, the peculiarities of which rarely appear in children.
We contend that otitis media concomitans is a thoroughly benign disease. This is the experience of clinicians and differs from the view of many pathologists who regard purulent otitis media as one of the commonest causes of death in infancy, without taking into consideration the fact that it is usually a terminal disease in a child succumbing to digestive disturbance. Without pursuing this sitbjeet further, we only add here as relevant that when, according to Ponfick ninety-one out of one hundred autopsies on children one to four years old (from the Breslau Children's Clinic) presented purulent otitis media with or with out other visible organic disease, while only eight had meningitis (with or without pneumonia), the etiologic dependence of meningitis upon the otitis is not at all self-evident. It may be considered to be a fact only if an anatomical connection is show» and the otitis preceded the menin gitis. Usually it can be proven that the meningitis was already fully developed before the first symptoms of the terminal (concomitant) otitis appeared. At most a secondary- infection of the ear from the meninges may be assumed, by no means the converse. The otitides sueceeding measles and scarlet fever appear to induce leptomenin gitis, particularly by means of an infectious sinus thrombosis, more frequently than the otitis concomitans of infants to which our remarks above refer.