Cerebrospinal Fever.
Synoryms:—Epidemic cerebrospinal meningitis; cerebrospinal meningitis; petechial fever; spotted fever.
Definition:—A severe, acute, inflammatory disorder, involving the meninges of the brain and spinal cord; epidemic endemic and sporadic in occurrence; characterized by an abrupt onset, with chill, fever, headache, pain in the spinal column, stiffness and contraction of the muscles of the neck and back, and, in violent cases, early opisthotonos, with impairment of the brain and mental function, mild coma or delirium, dulness of the eyes and irregularly contracting pupils, or pupils irresponsive to light
Etiology:—The specific cause of the disease in a typical epidemic manifestation is the diplococcus of Weichselbaum, the meningococcus or diplococcus intracellularis meningitidis. Cases of acute cerebrospinal meningitis occur isolated, and in endemic, or sporadic form, which do not exhibit this specific micrococcus, but are caused either by the streptococcus or staphylococcus pyogenes, and in some cases by the pneumococcns, or by the bacillus of influenza. The disease also results from septicemia and pyemia or from gonorrhoea. It may result from injury, from acute cold, or it may follow as the sequel from infection conveyed from the presence of mastoid disease, or disease in the various sinuses, or from disease of the middle or internal ear. It is the epidemic form only we are now considering.
The disease is most common among children and those of early youth, but it attacks adults up to perhaps twenty years of age quite commonly. No age, however, is free from liability to attacks during an epidemic. The disease prevails more commonly in the colder portions of the temperate zone, and during the winter and early spring months. It is unknown in tropical climates. It occurs among those living with unhealthy surroundings and with poor hygienic conditions, as well as among those who are well situated. Under some circumstances it has been known to attack those of the better environment first.
Symptomatology:—This disease has a variety of manifestations, with a few typical symptoms. In the epidemic form, as a rule, there are no prodromes, the patient being suddenly stricken down, from previous good health. Usually there is a chill, which is almost immediately accompanied with headache and dizziness, with an abrupt development of fever. The temperature usually is not high, but severe cases will reach 104° F. and hold that point steadily, with but slight variations for from twenty-four to thirty-six hours. A temperature of 102.5° F. is more common, and is usual with the milder cases, or with those of slow development. In many cases there is no marked variation in the temperature, often there is no change for a long period, but a reduction or increase of one degree perhaps within twelve or eighteen hours is not uncommon. There are no intermissions and but slight remissions, with no regularity in their appearance.
The headache, which is one of the first symptoms, rapidly increases until it becomes almost unbearable. This is accompanied with severe pain in the spinal cord, involving the muscles of the back. These muscles soon become rigid and the tenseness involves the muscles also of the thighs, arms and neck. Brain symptoms appear quickly, and consciousness is soon lost, the patient becoming dull and stupid and developing a mild delirium. In other cases the patient lies with the eyes open, but takes no notice of things around him and is soon found to be partially unconscious. In other cases there is great restlessness, with a high degree of nervous excitability.
A profound convulsion may occur early, usually in the form of opisthotonos, although this is rare. Commonly the stiffness occurs in the muscles of the back of the neck, the head is drawn backward and forced into the pillow, the head can be moved from side to side, but flexion and extension will result in excruciating pain, the posterior cervical muscles are hard and in a state of tonic contraction from irritation of the anterior roots of the cervical nerves. In infants the constant movement of the head from side to side, with the crowding of the occiput into the pillow, is almost a classic symptom. The author has also observed that infants and young children will close the thumb across the palm of the hand, with the fingers closed over it, in the developing stage of this disease. This may be a positive diagnostic symptom before other characteristic evidences have appeared.
The pulse should be carefully studied in this disease. At first it is of good volume, with no increased tension and from 120 to 130 beats per minute. Later it increases in rapidity, but becomes soft and easily compressible. With nervous irritation it becomes rapid, small, hard and wiry, and in the fatal cases it is small, feeble, very rapid and usually thread-like. The respiration is apt to be irregular if there be any degree of nervous irritation or convulsions. If there is stupor, it will be regular, slow, and in severe cases stertorous. In advanced cases sighing respiration with Cheyne-Stokes breathing is common.
Hyperesthesia develops very soon after the appearance of muscular rigidity. The skin and muscles become very tender and sensitive, so that slight pressure produces pain, and, as in strychnin poisoning, may produce convulsions. Voluntary movement of any of the muscles causes more or less severe pain. In contradistinction to this condition is anesthesia, which occurs in a few cases, over circumscribed areas.
The eruption of meningitis occurs in perhaps one-half of the sporadic or endemic cases. In epidemics it is present in the larger number of cases. It may occur in the form of herpes, first on the lips, as in malaria—herpes-labialis, and subsequently upon the face—herpes-facialis—an eruption which is peculiarly characteristic of this disease. Herpes may appear also upon the trunk, upon the thighs or around the genital organs.
In other cases, and by far the most common, is the petechial eruption, from which the disease has the name of spotted fever. This occurs in the form of irregular purpuric spots, which may be diffused or limited to a small area. At first the eruption is quite red, later it occasionally becomes dark and appears as ecchymoses. Other forms of eruption are present in individual cases, and bed sores with circumscribed gangrene should be anticipated.
To those who are experienced, the appearance of the eye assists greatly in diagnosis. Most commonly the eye is dull, with a dilated pupil. The eye may be very bright, with contracted pupil, or the pupils may be unequal in size, and in all cases not readily responsive to light. The conjunctivae usually assumes an injected or chemosed appearance, and photophobia is common. Strabismus is frequent, but may appear and disappear, to recur at a later interval, sometimes recurring several times during the course of the disease. Ptosis is usually present and keratitis may occur. In some cases the patient has become permanently blind.
In the isolated cases, dulness of the mind, with somnolence, or stupor may occur early. In fatal cases this increases to coma, with no recurrence of consciousness. With the dulness there may be mild delirium, or nocturnal delirium only may occur, independent of any tendency to stupor. Active delirium with violent manifestations is not uncommon in the early stage. This may be accompanied with hallucinations, and in the female with hysterical manifestations.
Vomiting is not an uncommon symptom. It is often of cerebral origin, but may be induced by faults of the stomach. The tongue is usually thick and pale, but slightly coated, and the appetite is early lost, but later the tongue becomes dark and dry, the secretions are all suppressed and sides appears. Constipation is apt to be present, with tympanitic distention of the bowels.
At first the patient passes a large quantity of pale urine of low specific gravity. Later it is reduced in quantity, until but little is passed, which has a high specific gravity. Retention, suppression and incontinence are not uncommon during the later stages of the disease, and albumen and sugar are found in rare isolated cases.
A septic arthritis is apt to occur with this disease, which may induce serious changes in the joints, or deformity.
In 1884 Kernig showed that where the membranes of the cord were inflamed, if the thigh was placed at right angles with the plane of the body, it was impossible to then extend the leg upon the thigh. This results from irritation of the meninges of the cord, and of the nerve roots in the cauda equina. This is known as Kernig's sign.
Diagnosis:—The abrupt occurrence, with the conspicuous cerebral symptoms, the head usually being intensely hot, will suggest the seat of the disease. The author has observed the inturned thumbs in small children before any other manifestation appeared. Retraction of the head and rigidity of the limbs are suggestive, but not positively diagnostic. The hyperesthesia, extreme pain in the head, rapid prostration, tonic or clonic convulsions and tonic contractions of the muscles of the neck and the purpura are usually sufficient. The presence of the diplococcus of Weichselbaum in the cerebrospinal fluid will confirm the diagnosis.
Prognosis:—The prognosis must always be guarded, as in severe epidemics from fifty to seventy-five per cent of the cases will die. In mild epidemics from twenty to thirty per cent are fatal. In sporadic cases the mortality is very high, especially in young children.
In mild forms the case will run from four to seven days. In severe forms it is apt to terminate before the fourth day. Isolated cases may develop slowly and vary greatly in the length of the course, running from two to six weeks.
Treatment:—The care of the patient is of great importance. Medical treatment has been unsatisfactory. We have much to learn in the adaptation of drugs in the cure of this disease. The patient must be confined in an isolated room, away from confusion and noise of every kind, with a most careful and conscientious nurse, and the room should be darkened. In the pronounced cases good results have been obtained by placing the patient in a medium hot bath which contains mustard sufficient to produce a marked redness of the skin, within from fifteen to twenty minutes. This may be repeated on the second and sometimes on the third day to good advantage. Other patients have been benefited by applying a warm, sharp mustard poultice the entire length of the spine and over the spinal ganglia and repeating this poultice as often as the skin will permit. Profound derivation has produced good results in a number of cases.
The author prefers the persistent and uninterrupted use of heat to the entire length of the spine and at the base of the brain, using cool or cold applications on the forehead or top of the head. It is good treatment to first apply libradol the entire length of the spinal column till mild nausea is induced. This may then be replaced with any other plastic dressing, and dry heat should be applied by means of hot-water bags outside of the dressing and retained for a period of twenty-four hours. The bowels should be unloaded with an active saline cathartic, but this should not be too often repeated.
Where there was profound nervous irritation, with great excitability and restlessness, with opisthotonos within two hours after the onset of the disease, in one case, in the first year of my practice, following the instructions of the patient at the onset, who was an old, experienced Eclectic physician, I administered extreme full doses of gelsemium with a hot infusion of capsicum and ginger, applied a strong mustard poultice to the entire back and persisted in this treatment for eighteen hours, with most satisfactory results. Where there is dulness, with cool skin, the patient sleeping with the eyes partly opened and the pupils dilated, belladonna is of much service. If with these symptoms there is restlessness and irritability, the head being very hot, ergot should be given in full doses for the first forty-eight hours. In strictly sthenic cases, with great excitability, the pulse being very strong, the patient restless and uneasy, with deficient excretion, a single full dose of pilocarpine hypodermically will do much to abort the disease. Jaborandi in two or three drop doses may be continued through the progress of sthenic fever. In very small children, aconite and ergot, in combination, in minute doses frequently repeated during the first stage of the disease will often produce very satisfactory results. Aconite is of great service if persisted in in those cases that are prolonged. Where there is much soreness over the spine it should be given in larger doses four or five times a day only. The author has much confidence in the persistent use of small doses of bryonia to overcome the inflammatory reaction and to control the temperature. It may be necessary to give it in conjunction with gelsemium or passiflora for the spasms.
There is no doubt that calabar bean is an important remedy in the treatment of this disease. If the author was to designate specific indications he would select those cases where the skin is cool, but where the pupils are contracted, the pulse small and feeble, but Dr. Edson of Indiana has used it indiscriminately with excellent results, expecting, however, better results where there is feebleness with weak pulse. The dose is from one-fourth of a drop to a drop, for a child, every thirty minutes; to an adult two drops may be given every fifteen minutes. The doctor expectsgood results within a few hours, but has known cases where the remedy was necessarily continued for two weeks or more.
Dr. Webster is enthusiastic concerning echinacea in meningitis, and we believe that it will yet prove a most valuable addition to our best known methods. It may be given in full doses from the first and continued through the entire course of the disease, without regard to the indications for other remedies. It antagonizes sepsis, restrains undue temperature, preserves the functional action of the various organs and encourages nutrition.
The bromides or hydrobromic acid will be found of much service in this disease at times, the latter indicated when a sedative is needed with the presence of the usual indication for an acid remedy. Given in conjunction with ergot, it will sometimes control delirium when all other measures have failed. Chloral hydrate given in doses of from fifteen to thirty grains, in solution, in the rectum will often prove satisfactory in controlling or preventing convulsions. Veratrum may be given for convulsions during high temperature with rapid pulse. A few large doses of perhaps five minims may be given until slight nausea is induced, or until the pulse is slowed to normal. The use of opium has been advised in this disorder, but we would proscribe it except in cases of excruciating pain, otherwise uncontrollable. Apocynum is of service from the very first, in preventing the development of effusions and later in removing effusions and sustaining the action of the heart.
It must be borne in mind that no two cases can be treated alike. Each case will present its characteristic indications, and indications will be found present often, for a remedy which is not usually considered as essential in the treatment of this disease. The indications must be carefully studied, and closely followed with the administration of the exact remedy.
The patient should receive a concentrated and highly nutritious diet, and the digestion and appropriation of all food should be assisted by the administration of artificial digestives. The disease is rapidly exhausting in its character and all measures must be adopted that will sustain the strength. Milk, eggs, beef juice, rice, and fruit juices must be given freely.
When the active symptoms have abated, the physician should in no wise relax his assiduous attention, as the period of convalescence is apt to be long and recovery very slow. If the spine remains tender, dry cups, the persistent use of plastic dressing, perfect rest and the use of carefully selected tonics are of much importance. Iron, phosphorus, small doses of quinin, hyoscyamus and calabar bean will be among the indicated remedies.
