Cerebro-Spinal Fever.

Synonyms.—Spotted Fever; Cerebro-Spinal Meningitis; Typhus Syncopalis; Malignant Purpuric Fever.

Definition.—An acute, infectious, although but slightly contagious disease, occurring sporadically, endemically, and epidemically, and characterized, anatomically, by hyperemia of the brain and spinal cord, and sometimes attended by a petechial eruption. Clinically, by excruciating pains in the head, back, and limbs, hyperesthesia often followed by anesthesia, contraction of the muscles of the nucha, and delirium of a varied character.

History.—Although it is possible that this disease prevailed before the present century, no authentic account was ever given till Vieusseux described an epidemic which occurred in Genoa, Italy, in the year 1805, and which he termed a malignant, although non-contagious, fever. In the first family attacked, two children died within twenty-four hours. In another, four died after an illness of less than a day; thirty-three dying during the epidemic, the victims living from twelve hours to five days.

The following year it crossed the Atlantic and appeared at Medfield, Massachusetts. From 1806 to 1816 the disease appeared in most of the New England States and in Canada. During this same period, 1805 to 1816, it visited France and Prussia.

From 1837 to 1849 France and Italy suffered more than any other countries, the armies bearing the brunt of the epidemic. The mortality was large. From 1854 to 1861 the Scandinavian peninsula was ravaged by the dread disease, more than forty-one hundred dying in Sweden during the seven years. From 1861 to 1868 Germany, Ireland, and the United States were the most afflicted.

While these are regarded as the four great epidemic periods, nearly every year since 1805 the disease has occurred at some point, the exception being from 1850 to 1854, when both hemispheres seemed spared. Since 1860 nearly every civilized country has been visited by this dread malady.

Although this disease was first regarded as occurring only epidemically—hence one of its names, epidemic cerebro-spinal meningitis—since 1860 it has assumed a new phase, becoming acclimatized, or, as Smith says, naturalized in the large cities, and from an epidemic disease it has gradually changed, becoming endemic in all our large cities. Such is true at least in New York, Philadelphia, Chicago, St. Louis, and Cincinnati. For several years, not a year has passed but cases have been reported in New York, Philadelphia, and Cincinnati. An examination of the reports, taken from the Health Department of our city, shows that during the past sixteen years there has not been a break, in its steady march, and, notwithstanding our boasted advance in medicine and sanitation, we begin the twentieth century with the deadly fever thoroughly intrenched and ever present.

Etiology.—As in many other diseases, the exciting cause has not yet been determined, although the meningococcus intracellularis of Weichselbaum is believed to be a factor in the disease. The peculiar fact that this disease occurs in isolated sections where there has been no connection with other cases, is one of the strongest proofs, to my mind, that it is not microbic in its origin. We can not believe in the spontaneous generation of life, and hence we must look elsewhere for the cause. That there is a toxin which is intense in character, there can be no doubt; but we are inclined to believe that it is generated in the body in the metabolic changes which so rapidly take place on great exertion.

Exertion.—One of the most prominent predisposing causes is overexertion, either physical or mental, and where the tissue changes are rapid, and where there is a failure in the excretory organs to remove the poisons, it must affect the fluids of the body for harm. Soldiers after severe and prolonged marches are especially susceptible, and we are often told by the parents that great mental worry or work in school preceded the attack.

Age.—Children and young adults are more frequently attacked than those of maturer age, although none are exempt except the very aged.

Climate.—The disease prevails largely in the north temperate zone, and is unknown in the tropics.

Overcrowding and Filth.—Dirt, especially human dirt, is a rich soil for the generation of poisons of various kinds and intensity; hence, in the poorer quarters, where but little attention is paid to cleanliness and ventilation, where filth accumulates and fairly reeks with the stench of its decomposition, we find the susceptibility very great.

Modes of Conveyance.—We do not understand the method by which the infectious material is carried from the sick to the well, as it is considered non-contagious, or, if contagious, to but a very slight extent, the best proof being that it very rarely attacks more than one member of a household. J. Louis Smith found single cases occurring in seventy families, dual cases in nine families, three cases in one family, and four cases in one other family; intercourse with the sick-room was not restricted in any of these cases, the children frequently assisting in the nursing.

Pathology.—In the cases which speedily prove fatal, there are but little, if any, changes in the blood and tissues, the only marked or characteristic lesion being the. hyperemia of the meninges of the brain and cord. Where the disease has continued for several days, however, we find the characteristic suppurative exudation. The character of this material depends upon the degree of the inflammation; at first it is seroplastic, but later it changes to a purulent fluid.

The sinuses of the dura mater contain blood clots. The ventricles are filled with a serous or sero-purulent fluid. The pia mater, says Dr. Netter, is the seat of the characteristic lesion. "The exudation upon its surface presents different aspects; sometimes it is a yellowish, false membrane, resembling a layer of butter spread over the surface of the brain." The exudation sometimes follows the course of the auditory and optic nerves, pus having been found in the internal ear and chamber of the eye.

The lesions of the cord are similar in character; first congestion, followed by suppurative changes already noted. The septic character is seen in the various viscera, and tissues generally. The white corpuscles are largely increased in numbers in the blood. Reider reports a case where there were twenty thousand, one hundred cells to the cubic millimeter. The lesion of the pleura, lungs and bronchi are such as would be found as complications in any malignant disease.

The liver, spleen, and kidneys are usually slightly engorged and somewhat softened. The muscular tissues may undergo granular degeneration. There occurs in quite a number of cases a petechial eruption; the purpuric spots may be quite profuse, or but one or two may be seen; these, however, are not constant.

Symptoms.—The symptoms of this fever have a wide range, although some are characteristic and constant.

Incubation.—The period of incubation is not determined; it may last for a few hours or for several days, although most frequently the invasion is sudden. Where we have a forming stage, the prodromal symptoms are similar to those of all fevers, but more intensified, the headache being more severe and vertigo almost constant, the patient staggering when he attempts to walk.

Invasion.—The invasion is usually sudden, the patient having but little warning. It is announced by a chill, accompanied by a pain in the head. There is often nausea and vomiting, and in children a convulsion is not rare.

The excruciating pain in the head is characteristic and one of the constant features during the disease, and while it may be lulled by coma or delirium, it recurs with the first ray of returning consciousness. "My head, my head!" is the familiar cry. The pain in the back is almost as great, especially in the cervical and lumbar regions. There is also general hyperesthesia, and the patient cries if touched or moved. The patient generally lies passive or immobile on this account, the least motion adding to his sufferings. Occasionally, however, a patient is restless and tosses about. There is contraction of the muscles of the nucha, and the head is drawn back. There is great sensitiveness to light and sound.

The fever is usually asthenic in character, the temperature range being low, and the extremities cold. In exceptional cases the temperature may reach 104° or 105°, the pulse being very rapid, but weak; or slow and feeble; again wiry and rapid. The breathing is usually increased in frequency.

Delirium is one of the most constant symptoms, and but few patients pass through all stages without it; the character of it varies, however. In some it will be wild and intense, the patient requiring two or more assistants to keep him in bed; this may be followed by coma. Again the delirium may be passive and of a low muttering character. Coma may come on early, within twenty-four or forty-eight hours, when it is an unfavorable symptom. Where the disease is of long duration, the symptoms are legion, the typhoid being the most prominent. A case under my care lasting ten weeks, assumed a different phase every few days. A return to consciousness does not necessarily mean an improvement; for after one or more lucid days, he may again relapse into unconsciousness. In perhaps one-third of the cases a petechial eruption makes its appearance. At first it may be bright in color, but soon becomes of a dusky hue; it may be discrete or confluent. Vesicles upon the face—herpes facialis—is also quite common, although not constant.

The tongue, after a few days, becomes dry and shrunken, although it may be moist and dirty. After the first twenty-four or forty-eight hours the irritation of the stomach disappears, and the patient retains food and drink. There is usually constipation.

The special senses are greatly impaired, photophobia being often present, while loss of taste and hearing is quite common. The emaciation, where the disease runs a long course, is extreme.

One peculiar feature of this dread malady is, that, after having run a course of several weeks, all the symptoms give way, the force of the disease seems to have spent itself, the pulse and temperature become normal, the appetite is good, a sufficient amount of nourishment is taken, but the patient gradually fails, and finally dies of exhaustion, or, remaining in this weakened condition for days, the tide is finally turned in his favor and the patient slowly regains his health.

Paralysis may occur at any stage of the fever, although usually in the latter stage. This may be but temporary, as noticed in one of my cases, the paralysis, involving the entire right side, disappeared in a few weeks. I have met with one symptom which I have not seen described; viz., a cadaveric odor, like that sometimes noticed a few hours before dissolution, and, although unfavorable, it is not necessarily fatal.

Convalescence may be followed by impairment of the hearing. Although the brain bears the brunt of the attack, the mental faculties, on recovery, are usually unimpaired.

Complications.—Pleurisy, pericarditis, and pneumonia are the most dreaded complications, and lessen the hope of recovery. They are recognized by their characteristic symptoms.

Diagnosis.—The diagnosis is comparatively easy. The suddenness of the attack; the extreme pain in the head; the contraction of the muscles of the nucha; the tenderness on pressure along the cervical region causing the patient to flinch, even although unconscious; the great pain in the cervical and lumbar regions; the active delirium; the eruption, when present; the irregular fever,—make a group of symptoms which can not be mistaken for those of any other disease.

Prognosis.—This is one of the gravest of diseases, and the prognosis must always be guarded. The character of the epidemic, the condition of the patient when attacked, the nature of the complication, if any, would influence the prognosis. If seen. early, the prognosis is favorable in many cases.

Treatment.—As in other infectious diseases, where possible, the patient should be isolated in a large, airy room, where good ventilation can be secured. The room should be darkened, and, as far as possible, everything which would tend to excitement avoided, and the patient kept perfectly quiet. The diet should consist of milk and broths, and be administered at regular intervals.

In the administration of remedies it is well to remember its twofold character,—the hyperemia of the brain and cord, and the intense sepsis. For the great irritation of the nerve centers, we will administer with our sedatives in full doses, gelsemium; if the pulse be small and quick,—

Aconite.—Where the pulse is small and frequent,—

If the pulse is full and strong and the delirium active,—Veratrum.—Where the pulse is full and bounding,—

At the same time we would sponge the head with hot water, that being more soothing than the cold pack. The hot sponge bath may also be used along the spine with benefit. Dr. Webster speaks highly of jaborandi, which may be used in three or four-drop doses.

Rhus.—Rhus tox. is an agent which is of excellent use where the patient starts in his sleep, where the pulse is quick, sharp, and wiry. If, in addition to the irritation of the cerebro-spinal centers, there is nausea and vomiting, it is doubly indicated.

Belladonna.—If the patient is dull and drowsy, coma early making its appearance, we would give,—

Sodium Sulphite.—Where the sepsis is shown by the broad, pallid, moist, dirty coating upon the tongue, sulphite of soda will be our remedy.

Chlorate of Potassium.—Where the odor is cadaveric, I have seen the tongue clear and the odor disappear within ten hours, on,—

Echinacea.—This is one of our best remedies in this disease. It is called for with the first appearance of sepsis. It may be given alone or in combination with the sedative:

It may be given from the beginning to convalescence.

Hyoscyamus.—For the delirium, hyoscyamus is often useful; if of an active character, the remedy may be combined with stramonium, which makes it more effective. These remedies are similar in their effect, hyoscyamus being superior.

Passiflora.—From what we know of passiflora in quieting the nervous system in infants, especially where convulsions intervene, we would be inclined to try this agent. If given, it should be in quite large doses,—from a half to a teaspoonful of the tincture.

Convalescence.—Where the disease has run a long course, the vitality is very much reduced and the danger is from extreme exhaustion; hence the patient must be careful as to overexertion. The best tonic is good, nourishing food, which is easily digested.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.