An Address on Meningitis, Delivered before the Birkenhead Medical Society
Authors: J. Barr
Journal: BMJ (1899)

iENTLEMEN,-When I selected the subject of Meningitis for this address I was well aware that I was coming before an audience of practical men who would appreciate any serious attempt to reduce the fearful mortality which has hitherto attended this disease.I may now speak of it as a protean mnalady, because there are not only many varieties of the disease, but many of the symptoms-more or less common to all the varieties-are very varied in their obtrusiveness, and very closely resemble those of other acute diseases, so that this affection is frequently not recognised at an early stage.In the Liverpool Medico-Chirurgical Journal for January, 18 89, I published an account of 13 cases, with only one death.This exceptionally good result was no doubt largely due to fortuitous circumstances, to the fact that the cases came early under my observation, and to the fact that I then excluded all tuber- culous cases.However under any circumstances 12 recoveries from meningitis was a result with which anyone might feel pleased.Since then I have copious notes of 26 cases with deaths; of these 3 died within 24 hours of admission.I ,, ,,96 Moreover three of the deaths were from tuberculous mening- itis, and one from cerebro-spinalfever.Of all the cases 20 were males and 6 females.The ages of the males ranged from 5to 30, the average age being i6.6; of the females from 2 to 28,the average age being I5 years.I have seen many other cases in the practice of my colleagues and in consultation, but these 26 cases will suffice " to point a moral or adorn a tale."I have taken the subject of meningitis in its widest sense to include all inflammatory processes of the meninges,how- ever originated; but pachymeningitis, externa and interna, chiefly come under the care of the surgeon and alienist re- spectively, so that I need not do more than mention them here except to point out that in many cases of extension of inflammation from the middle ear to the pia the dura mater is also involved, and over the petrous bone all the membranes may be matted together.Here again the treatment is largely surgical.We shall now come to the subject proper of the paper, leptomeningitis.The classification of the various types of disease which are grouped under this generic head is still very indefinite, and an anatomical basis is frequently adopted accordingly as the base, the vertex, or the ventricles of the brain are chiefly affected.This division is sometimes con- venient, but not of much practical importance, except for explaining variations of clinical symptoms, as in very few cases is the affection limited to one particular area.Of much more value would be a classification founded on the etiology, and in this direction we may hope in the future to learn much from bacteriology.So far it has not taught much more, except in the caee of cerebro-spinal fever, than that a great variety of micro-organisms have been found; consequently we have still to speak, as our fathers did before us, of simple, purulent, tuberculous, and syphilitic meningitis.All these varieties present many features in common, so our first object should be to determine whether the patient be suffering from mening- itis, and then as far as possible settle its location, and from a careful study of the history and symptoms of the case determine its nature.Etiology.-Thedisease, especially the tuberculous variety, is most common in childhood, but the incidence in adult life is greater than is generally supposed.In the Liverpool Medico- 7hirurgical Journal for July, 1885, the late Dr. Oxiey recorded 63 cases with 62 deaths, all under the age of 1o years.These occurred in a practice of 22 years' duration, which was almost exclusively amongst children.It is more prevalent among males than females.Among other predisposing causes may be mentioned heredity, bad sanitary surroundings, deficient nourishment, and mental over-work.However predisposed the individual, the lighting up of the inflammation must in every case be ascribed to an infective process.In fact it is doubtful whether such causes as insolation, traumatism, with even laceration and hsemorrhage.can be looked upon as other than remote agents.The meninges, like other serous mem- branes, injured or uninjured, are liable to inflammatory pro- cesses which may be started by various pathogenic micro- organisms or their tox-ins.It has been often stated that the presence of tubercles in the meninges is capable of setting up irritation and inflammation, but it is moie highly probable that the tubercles and meningitis are the results of a common