N. Hamilton Fairley, M.B., Melbourne Hospital.
Definition:
Cerebro-spinal Fever is a specific and infective disease, slightly contagious, due to infection with the meningococcus.
It occurs in sporadic and epidemic form, manifesting itself initially as a septicaemia with generally secondary localisation in the meninges.
Etiology:
This disease is pre-eminently one of childhood and adoles- cence without prediliction for either sex. Its seasonal inci- dence is winter and spring, possibly explained by the frequency of colds at these periods.( 1 ) In the Victorian Epidemic of 1915-16, male adults have been most frequently affected. The primary incidence of the infection was undoubtedly in our military camps.
Bacteriology:
The meningococcus of Weichselbaum is almost universally accepted as the causative organism, and is a member of the large Gram-negative group.
In microscopic examination of fresh cultures 18-24 hrs, the meningococcu,s occurs as two hemi-ellipses apposed by their flat surfaces. They generally occur in pairs, sometimes in tetrads or small clumps. In older cultures 48 hrs, many de- generation forms are seen and staining reactions are poor. Its staining is invariably Gram-negative. It grows luxuriantly on a variety of solid media—ascitic agar being commonly used.
The colonies appear in 18-24 hrs as isolated flat circular discs 2-3 mm in diameter with transparent edges, slightly more opaque centre and opalescent sheen. The fermantative reac- tions are important in identifying the meningococcus from the other Gram-negative cocci occurring in the naso-pharynx of suspected carriers. Thus the meningococcus ferments both dextrose and maltose, whilst the micrococcus catarrhalis fer- ments neither.
Specific agglutination and absorption tests, Precipitin and complement fixation reactions have all been described, but their value has yet to be estimated.
Mode of Transmission:
Carriers spread the disease in the acts of sneezing and coughing.( 2 ) Only 2-5 per cent. of carriers develop menin- gitis. Some carriers show neither signs nor symptoms of nasopharyngeal catarrh ; others show reddened mucosa with viscid mucopurulent secretion without associated symptoms ; while in others a definite coryza develops.
Pathology:
In acute cases, on removing the skull-cap, there is increased dural tension. The leptomeninges present congested vessels, with general signs of inflammation. According to the site of deposition of the exudate (the exudate varies from gelatinous lymph to definite pus), cortical, basal and cortico-basal types of meningitis may be described.( 3 )
The ventricles on section are slightly dilated and contain turbid fluid.
The choroid plexus is engorged and the ependymal lining softened.
In the subacute and chronic cases, organisation of the exudate is taking place. Frequently fibrinous pus in the cis- ternae pontis and magna occurs ; there may be a truer posterior basic meningitis causing relative or absolute obstruction of the foraminae of Luschka and Magendie and giving rise to Internal Hydrocephalus. This tendency is especially marked in children.
86 THE SPECULUM. May, 1916.
The Spinal Cord and thecal membranes show similar changes. Microscopically, an acute superficial encephalitis is
found (cloudy swelling of the parenchyma dilatation of vessels, engorgement, leucocytic and endothelial infiltration causing microscopic opacity of the meninges).
Other Organs:
Nasal sinuses. Sinusitis does occur and may become sup- purative, but it is such a rare finding that operative treatment as advocated by Peters cannot be regarded seriously.( 4 )
The Lungs show frequently hypostatic congestion; in some 3o per cent. there is a definite terminal infective pneumonia.
The myocardium may show increased pallor and friability.
Pericarditis is present in some 6 per cent. of cases.
The Gastro-Intestinal tract frequently shows injection of vessels, haemorrhagic erosion and diffuse pink staining of the mucosa, due to a toxic spoiling of vessels. The findings do not support the gastro-intestinal portal of entrance of the meningococcus as claimed by Goeppert.( 6 )
The Liver is somewhat enlarged and friable and frequently nutmeg on section. Microscopically, there is cloudy swelling of the parenchyma and marked engorgement of the intra- lobular veins, giving rise to this macroscopic nutmeg appear- ance and indicating a terminal Right Heart Failure.
The Spleen varies much in size, being largest and most friable in the septicaemic types. Generally these changes are not very marked. •
The Lymphatic System may show marked glandular en- largement, especially of the cervical, submaxillary and mesen- teric nodes.
Urinary System.—Pyelitis of mild grade is frequent. Cys- titis may occur. Vesical petechial haemorrhages are often due to Urotropin administration.
Symptomatology:
The clinical picture varies with the type of case, as well as with the stage of the disease. Cases may be divided into:
( ) Acute, (2) Fulminating, (3) Abortive, (4) Sub- acute or Chronic.
Acute Type.
According to Lundi, Thomas and Fleming ( 6 ), the initial lesion is a nasopharyngitis followed by a septicaemia with later
localisation in the meninges. These three stages can be fol- lowed clinically in a certain percentage of cases.
(a) The Naso-pharyngeal stage calls for no further com- ment. It may be primarily meningococcal or engrafted on an ordinary coryza.
(b) The Septicaeinic stage is manifested by fever, remittent in type ; pains in back and limbs, chilliness, rigors, nausea, vomiting, irritability, headache, rash and herpes. The patient is toxic and looks it ; the pulse is rapid, and of poor volume;
the B.P. is low, a leucocytosis of 20-40 thousand may be pre- sent. Blood cultures show pure growth of meningococci.
Lumbar Puncture demonstrates clear fluid under increased pressure. Pneumonia, Ulcerative Endocarditis or Arthritis may all occur several days before meningitis ensues.
(c) The Meningeal stage, in which a vast majority of hospital cases is seen, is differentiated from stage (2) by its definite nervous symptoms and signs. Mental excitability, convulsions, delirium and coma are variable symptoms ; also stiffness of neck, head retraction, the Neck Sign, Kernig's and Brudzenski's Signs, exaggerated reflexes, retention of urine or incontinence of sphincters and McEwan's sign. Lumbar Puncture demon- strates turbid or opalescent fluid under a pressure averaging 36o m.m. of water. The effects of local meningeal sepsis are persistent even when the septicaemic stage has subsided.
Fulminating Type.
Here, the patient may die of an overwhelming toxaemia, in a condition of profound coma within a few hours of onset and before even petechial rash develops.
Abortive Type.
Characterised by a temp. of ioo, headache, vomiting, chill or perhaps a shiver. Transient meningeal irritation as evi- denced by stiff neck and Kernig's sign are present. Lum- bar Puncture shows clear fluid under increased pressure, with a few pus cells, lymphocytes according to Culpin, who also states that the slow pulse in convalescence is characteristic.
Subacute and Chronic Types.
The meningeal stage is prolonged, often accentuated and frequently accompanied by intermittent fever, malarial in type.
Perfect recovery may ensue after many months. More fre- quently, internal hydrocephalus and posterior basic meningitis result, especially in children. Internal hydrocephalus is to be suspected in such a case, when there is a diminishing or dry increasing drowsiness, dilated pupils, nystagmus, a rising McEwan's Sign in adults and bulging fontanelles in chil-
88 THE SPECULUM. May, 1916.
dren. The marked emaciation and intense nervous signs of posterior basic meningitis make its diagnosis more easy.
For a detailed analysis of signs and symptoms, other papers should be consulted.
The onset is frequently sudden, and is usually accompanied by headache, vomiting and chills. In some 4o per cent. of cases, a history of naso-pharyngeal catarrh may be obtained.
The headache is intense and very persistent, usually frontal and generally relieve'l by Lumbar Puncture. The vomiting is explosive with nausea, or effortless without nausea when it is invariably green. Chills are common, and vary from co feelings to actual rigor. Generalised pain, photophobia, con-
ld vulsions and joint involvement can frequently be noted. Vaso motor instability is shown by the flushed or pallid countenance and invariable "tache cerebrale."
• The tongue is early white furred, later dry, brown and fis- sured; while the pharynx early shows injected vessels, later it is raw, rough and red, with thick yellowish brown muco-pus.
The temperature is remittent or intermittent in type, ordin- arily lasting i i days under serum therapy and about 3-4 weeks without. The irregular graphic results of B.P., Respiration and pulse readings, in comparison with their constancy in the other septicaemias like Pneumonia and Typhoid, are of im- portance. The explanation of the graphic and other irregulari- ties lies in the superadded factor of hydrocephalus on sepsis, whether it be generalised hydrocephalus of the acute or the internal hydrocephalus of more chronic cases. Petechial and purpuric rashes recur in a variable percentage in different epidemics. Its distribution is on either extremity or trunk.
Erythema about the elbows and knees may occur. A measley rash is rarely present. Herpes is even more common than in Pneumonia. Leucocytosis varies from 20 to 40,000. Stiff- ness of neck and Kernig's sign are almost constantly found.
Retention of urine is a frequent complication. Febrile albuminuria is the rule. Pyuria is common.
The cerebro-spinal fluid is slightly alkaline in reaction, con- taining albumen globulin and always giving a Pot. Permang.
reduction test. At the onset of meningeal symptoms, the C.S.
fluid is opalescent, of about 300 m.m. water pressure, and shows a dominant lymphocytosis.( 8 ) This changes in 24 hours to a polynuclear leucocytosis.
Complications.
Acute Cases: Convulsions, transient nerve palsies, especially strabismus, ptosis, facial paresis occur. Permanent affection of the second and eighth nerves may ensue.
Arthritis, Neuritis, Conjunctivitis and Pyelitis are frequent.
Pericarditis and Pneumonia are common terminations.
Chronic Cases: Posterior basic meningitis and internal hydrocephalus may result.
Diagnosis:
In the Septicaemic stage, the diagnosis is from certain infec- tious diseases like typhoid, pneumonia (especially apical), in- fluenza and septic pyaemia. Miliary tb and Ulcerative enclo- carditis are also fallacies. Blood culture is of importance.
In the Meningeal stage, meningitis is diagnosed on the clinical picture ; but bacteriological examination is necessary to differ- entiate between the various forms. Intra-cranial basal haemorrhage can simulate meningitis. In children, polio- myelitis and meningism of gastro-enteritis, broncho-pneun-onia, etc., are common fallacies.
Prognosis depends on several factors :
(I) The age and general health of the patient. Infants and old people die readily.
(2) Presence of severe symptoms, i.e., persistent and increasing coma, with incompetent sphincters, hyperpyrexia, diffuse purpura, etc.
(3) Presence of complications such as pneumonia and peri- carditis, etc.
(4) The institution of serum therapy ; the earlier the better the prognosis.
Treatment:
Prophylaxis involves the isolation and treatment of carriers and contacts. Active immunisation of the carrier by vaccine treatment, administration of urotropin, which is excreted in the nasal mucus, and the application of anti and bactericidal agents have been all advocated. They are of doubtful value.
Active.—In the Septicaemic stage every effort must be made to dilute the toxin by purgatives, diuretics, venesection, and intra-venous injections of warm anti-meningococcal serum is indicated.
In the Meningeal stage, hydrocephalus and sepsis have to be treated.
Generalised hydrocephalus is best treated by median- lum- bar puncture. Cerebro-spinal fluid is allowed to escape till normal pressure is reached (r drop every 2 seconds; using an ordinary Barker's needle).
Meningeal Sepsis is best treated by lumbar puncture com- bined with specific serum therapy. A quantity, generally 20-30
THE SPECULUM. May, 1916.
c.c.s., of warm serum (37° C.), not exceeding the amount of C.S. fluid withdrawn is injected intrathecally slowly (taking io minutes) by the syphon method. The general condition of the patient re pulse respiration, pupils and colour, is noted carefully during administration and careful observations are made of the B.P. A fall of over 20 m.m. Hg. is an indication to stop ( 9 ) intrathecal injection. The foot of bed is then raised. This procedure is repeated daily, according to indi- cations. Recently, complement reinforcement (10 ) of anti- meningococcal serum with human serum has been suggested, and, in a limited number of cases, used with satisfactory re- sults.
In chronic cases drug treatment with Mercury and Pot.
Iod. and vaccine therapy are worthy of trial.
Internal hydrocephalus is treated by tapping the lateral ventricle.
Drug treatment and intrathecal injection of antiseptics like lysol and urotropin have been used with disappointing results.
General medical treatment, good nursing and full milk dietary are of prime importance.
Bibliography.
(1) Heinman and Feldstein—Meninococcus Meningitis, p. 84.
(2) Meningococcus Carriers—Royal Army Medical Jour- nal, Jan., 1916.
( 3 ) Cerebro-spinal Fever—A.M.J., October 23rd, 1915.
(4) Peters—Journal of Laryn: Rhinol. and Otol., May, 1915.
(5) Goeppert—Ergebnisse d. Innere Med. u. Kinderhk, 1909, iv., 165.
(6) Lundi, Thomas and Fleming—B.M.J., May i5th, 1915.
(7) Culpin—B.M.J., Abortive Meningitis, Feb. 26th, 1916.
(8) T. H. Horder—Cerebro-spinal Meningitis, 1915, p. 49.
(9) Complement reinforcement—A.M.J., Feb. 5th, 1916.
(10) Whitla—Treatment of C.S.M., Practitioner, May, 1915.
(11) Sophian—Epidemic. C.S.M., p. 208.
191
A Discourse on Treatment of Wounded.
(Made available by courtesy of Dr. A. E. Rowden White.)
5:_
Major Ted White writes from Gallipoli, 26th October,Yesterday morning there was a great gathering of medi- coes ; Australian, English, and Indian medical services were represented by quite seventy men, gathered together at the new site (near Reserve Gully) of the Australian Clearing Hospital, to hear Lt.-Col. Sir Victor Horsley speak.
He was working in the Western theatre at first—as an R.A.M.C. Captain! Five months ago he came to Alexandria to No. 21 General Hospital, Rasel-Tin, close to Hume Turn- bull's Convalescent Home. Later he obtained his majority, and now you'll be glad to hear he is Lieutenant-Colonel !
His lecture was a pleasant chatty discourse on the "Treat- ment of Wounded."
His easy style impressed one, and he made his discourse both impressive and practical.
I.—Cleaning of Wounds.
His experience at base hospitals impressed him with the fact that more early "cleansing of wounds" was necessary in the Advanced Dressing Stations and Field Ambulances.
E.g., for Scalp Wounds.—Shave if time. Then cleanse with petrol 1-3 and spirit 2-3. He doesn't like iodine here, as, unless washed off with spirit, it is very liable to blister.
For tetanus, which is increasing on the peninsula, a pro- phylactic dose of 15oo units is advised. A rash may be seen near site of injection, often in to days, and is apt to be con- fused with "septic rash."
Every wound is washed out with Peroxide (anti-anaerobic) before anything else ; then with I in 20 Carbolic or I in moo Perchloride.
II.—Shock.
This is generally neglected. Heat is advisable ; by hot bottles, hot lotions or hot drinks. • He has striven hard to have the ambulances provided with rubber hot-water bottles. Hot coffee, and, failing this, caffeine are effective. Strychnine lowers the blood-pressure, and is given only if there is respi- ratory failure. Adrenalin raises pressure only for one hour, but Pituitrin is valuable, as it raises the B.P. for 4-5 hours.
Alcohol is rarely to be given.
III Inju..ries and Fractures of Lower Limbs.
Capt. H. Groves, of the 21st General Hospital, Alexandria, has formed a splint factory there ; and, among other things, has provided a very handy "Balkan" or Cradle Splint for fractures of the lower limb, "thus doing away," he stated, "with that awful abomination—the long Liston !" It consists of two Parallel supporting bars united by a cradle of soft leather,
92 THE SPECULUM. May, 1916.
keeping the limb semi-flexed; so that with the foot fixed, muscles absolutely relaxed and natural extension by the thigh and gravity, practically all fractures come into position. The patient feels comfortable, and can be easily nursed.
IV:Head Injuries.
(I) Where possible, shave first, thus cutting off the heads of sebaceous ducts and removing a good deal of suitable nidus for bacteria. Then petrol-spirit and then field dressing, wet with 1-50o Perchloride, first washing, if possible, with Per- oxide. Evacuate patient at once to ship. If there is delay of more than two hours, then—
(2) Field Ambulance or Casualty Clearing Station does more, such as—
(a) Perforating Wounds : Cleansing, etc. Excise the wound with a sharp scalpel ; turn back "flap of scalp" and re- move any fragments, really cleaning the "opening" of the tube into the brain ; don't injure the dura, remembering that with the pia, it soon seals up the wound from the meninges just as the peritoneum shuts off a local infection abdominally. He had seen very little septic meningitis (except in very gross head injuries) after this protective shutting off ; but nearly every case of damage done was due to a "progressive cerebritis."
Hence the extreme importance of excising the small bullet wound and cleaning up as much as possible. Then a wet dressing is applied.
Next, on the Hospital Ship, look, with X-rays, for further fragments and the bullet. (The previous cleansing and flap, already prepared, are useful.) A bullet left in the brain usually means abscess and death, though he had seen some interesting, but not very frequent, exceptions. ,
(b) Groove Fractures:—Similar treatment. The great thing is to clean at the earliest possible moment.
(c) Hernia Cerebri. (I'm not too sure whether I fol- lowed this well.)—He cleans hernia well, plunges in a small perforating needle about half an inch and draws off the softened tissue and makes a culture. If staphylococcus albus, prognosis fair. Vaccine is made (and, I think, hernia is cut off level).
If staph. aureus—same. If streptococci, prognosis is very grave. Generally an inflammatory hydrocephalus supervenes with death. He doesn't believe in trephining elsewhere to re- lieve pressure. Often a patient does well for 10 days, then rapidly becomes worse and dies. What happens is that there is a progressive cerebritis which opens into the lateral ven- tricles, the walls of which soften and lessen the pressure. For
a time the patient improves; then with invasion of the fourth ventricle and base comes death. Hence, the urgent need for immediate and thorough cleansing of the part.
V.—Wounds of the Abdomen.
Operation is a matter of selection. In the upper abdomen, the al. canal is generally uninjured. Operate if there is any haemorrhage. Operate when possible if there is perforation of the intestine.
VI.—Wounds of Chest.
Keep in Ambulance or Casualty Clearing Station for 48 hours, sitting up; then convey to ship in that position. When at the base, X-ray.
VII.—Morphia.
He advocates its use, as it lessens shock and comforts the patient. Give hypodermically. (It is our experience, too, that tabloids orally are rarely useful.)
Adelaide Letter.
This letter is the result of an agreement between the Editor of the Melbourne "Speculum" and the Adelaide "Re- view" to start once more the ancient custom of exchanging communiques. At such a time as this, when, quite apart from the great war, the scouts of nationalisation are already har assing the medical profession, hitherto one of the freest
institutions of .a fiPee country, it behoves the medical students to stick together to meet the advancing enemy. Far too few bonds unite the students of the three Australian Schools, and it is only by presenting an unbroken front that we can hope to overcome our common foes. The Medical School in Ade- laide is possessed by an obsession, almost unknown before in the Holy City—our elders think otherwise, no doubt dreaming of their own student days—to wit, the DESIRE TO WORK.
Many remarkable metamorphoses have been witnessed of late.
No longer does the dissecting-room re-echo with the sounds of coins pitched in play, no longer are the Common Rooms fair rivals to Monte Carlo. The man who was wont to parade the Block with "some fair female" confines his attention to his Eden. The "sounds of revelry by night" are no longer heard except when results of any kind come out, on which occasions the time-honoured customs are observed, in some instances with rather disastrous results.
The time-table has been changed considerably to meet