Difficulties in the Diagnosis of Meningitis

Harold W. Dana
1920 Boston Medical and Surgical Journal  
It is not claimed that the cases included in this paper prove any theory, nor that they add any new facts to the means of diagnosis. Taken simply as interesting cases demonstrating some particular sources of error in the diagnosis of meningitis, possibly they may be of value. Probably we are all more or less familiar with the meningismus which children are prone to show under a variety of conditions. While it is probable that many of these cases, not due to meningitis might by definition be
more » ... y definition be called examples of "meningismus," none of these patients could properly be said to have a menim gismus as I understand the term. Elsewhere I have reported a series of cases of pyelitis,1 in which, from the presence of tenderness and rigidity of the neck, and in some instances, in which the Kernig sign was also present, the existence of a meningitis was strongly suspected. Pyelitis is therefore one of the conditions to be considered in making a diagnosis of meningitis; in fact, this is, T believe, a most treacherous possibility of error, which I will not elaborate further here. Recently there has been much discussion as to what constitutes a serous meningitis, so called, and how one is to distinguish such a "meningitis" from a non-paralytic form of poliomyelitis. A case in which I took great interest along the above line, is recorded as Case 1. This boy, when he first entered the hospital, was semicomatose, in tremendous pain, and crying out from headache. He had a high fever, with marked retraction and rigidity of neck, and seemed to be in an extremely critical condition. A lumbar puncture was done at once. When I saw the boy 24 hours later, he was sitting up eating a hearty breakfast. He had in his spinal fluid a cell count of 300 cubic mm. Since the boy got well practically from one spinal puncture, and since we then did not know much about non-paralytic poliomyelitis, his entrance diagnosis of tuberculous meningitis was changed to a discharge diagnosis of "serous meningitis." Later, when every one was discussing poliomyelitis, I felt that my boy with the serous meningitis and the high spinal cell count must really have been a case of poliomyelitis without signs of paralysis, Recently. however, I followed up the case, and discovered that the boy actually died of tuberculous meningitis a. few weeks after leaving hospital. I suppose that if we had put more stress on this high cell count and on the large predominance of lymphocytes in this fluid, I might have avoided this error in diagnosis; yet it seemed impossible to stick to the admission diagnosis when we had watched the patient for two weeks, during which time he had been perfectly well. Case 2 exhibits a condition with which I fancy that orthopedic men are more familiar than are internists. The patient was a poor little child in a plaster jacket with all the symptoms of a tuberculous meningitis That was the diagnosis which I made, and the same diagnosis was made by a pediatrist who saw the child in consultation. We both felt that the child might be more comfortable without her plaster jacket. When we consulted an orthopedist as to this, he stated that removal of the plaster often relieved the symptoms of a meningitis. So it proved in this case. The case cleared up immediately when the plaster was cut, relieving pressure over the kyphos. Here again I do not know what the condition of the spinal cord and meninges was,--whether there was a backing up of more or less infected spinal fluid through the pressure of the plaster upon the tuberculous lesion, or whether carious bone was pressing upon the cord. It would seem as if bone pressure would have given signs of a transverse myelitis rather than of a tuberculous meningitis. Is it possible in such a case to have a non-tuberculous condition of the spinal fluid sufficiently acute to give rise to such a serious condition in the patient? It does not seem so ; and in this case, because of the plaster and the Pott's disease, we did not do a lumbar puncture, so we never had any definite evidence on this point. I do knpw, however, that this child was perfectly well except for her caries of spine, for months afterwards, without any later signs of any further meningitis. Another patient (Case 3) who twice came under my care as an interne in hospital, and who was also primarily suffering from caries of the spine, dying finally of a meningo-myelitis. is of interest chiefly as showing how much better hindsight is than foresight, and as an example of the tendency, when one cannot ñnd a cause for the pain, to consider the patient's complaints imaginary or neurotic. This pa-
doi:10.1056/nejm192001221820402 fatcat:7qmwl63mlncrbpl4mxgprg3gue