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Full text of "Diseases Of The Nose Throat And Ear"

356                                           THE EAR

(2) in which they have invaded the subarachnoid space. The dura mater,
arachnoid and pia mater are all resistant to infection. In very severe cases
the superficial layers of the brain itself are infected and the condition is
one of meningo-encephalitis.

Circumscribed Serous Meningitis. This may occur in the middle cranial
fossa associated with petrositis or Gradenigo's syndrome (p. 348). When
found in the posterior cranial fossa—Bardny's syndrome—it may follow an
otitis media or occasionally a radical mastoid operation. The patient com-
plains of giddiness, occipital headache, deafness and tinnitus, and on exami-
nation there is nystagmus on looking towards the healthy side, and falling
and past-pointing to the diseased side. There may or may not be optic
neuritis. On lumbar puncture the cerebrospinal fluid is normal. There may
be spontaneous disappearance of the symptoms after a feeling that some-
thing has burst in the back of the head. Treatment is by antibiotics.
Diffuse Purulent Meningitis. The first sign of meningitis in a case of laby-
rinthitis is slight torpidity and confusion without irritability, but with evi-
dence of premonition regarding an eventual recovery. This stage may have
been recognized by the patient's friends. Males are affected in 75 per cent
of cases. The early features associated with this disease are headache, neck
stiffness and loss of the superficial abdominal reflexes. Should these be
present in combination with a diminution of the chlorides and sugar in
the cerebrospinal fluid the diagnosis of diffuse purulent meningitis is no
longer in doubt. The temperature in the early stage is usually between 38
and 38-5 °C and the patient suffers from frontal or occipital headache,
with tenderness and rigidity of the muscles at the back of the neck. This is
most easily tested by lifting the patient's head off the pillow or by pressure
over the atlanto-occipital membrane.

In the earlier stages of meningitis arising from extradural abscess in the
posterior cranial fossa the symptoms are not definite. There may be an
initial rigor. Pain is localized at first to the side or back of the head, but
later becomes general. Accompanying the headache are fever, restlessness,
and marked irritability of temper; vomiting is often present and the tongue
is heavily coated, and the teeth covered by sordes. The patient frequently
lies with his knees drawn up and head turned away from the light (photo-
phobia). Periods of excitement come on at times, during which he may
cry out or talk incoherently. In meningitis the strength of the cry gradually
increases, whereas in brain abscess the cry is strongest at first and tails off
as the patient relapses into a semi-comatose condition. Delirium is common
in children and convulsions are not infrequent. Herpes labialis may be
present. Occasionally severe pain in the back is complained of. The reflexes
are increased and, especially in children, the abdomen is retracted. An in-
ability to extend the knee when the thigh is flexed (Kernig's sign) is generally
present. The temperature rises sharply and remains elevated (39-5 to 40 °C)
and towards the end may rise to 41 or 42 °C. The pulse, at first strong and
slow considering the presence of fever, soon becomes weak and fast, and
the blood pressure becomes very low. Blood examination usually shows a
leucocytosis of about 20 x 109/1.

In meningitis arising in the middle cranial fossa, headache and fever may
be the only symptoms, or the case may closely resemble one of temporal
lobe abscess.