War Surgery and Medicine
CHAPTER 10 — Cerebro-spinal Fever and Meningitis
Cerebro-spinal Fever and Meningitis
MENINGOCOCCAL meningitis (cerebro-spinal fever) is essentially a primary infection which occurs often in epidemics and has therefore to be guarded against in a mobilised military population. On the other hand, acute meningitis caused by bacteria other than the meningococcus is almost always sporadic and is usually secondary to infection elsewhere, or to an injury to, or an operation on, the head.
Factors contributing to the susceptibility of young soldiers to meningococcal meningitis are the communal living and change of environment with the transfer from civil to military life, and the fatigue incidental to military training under varying conditions of weather. Circumstances tending to lower the resistance of the individual, such as previous attacks of disease, especially of influenza, may be considered predisposing causes. Therefore overcrowding, bad ventilation, chill and over-fatigue should be guarded against in troops.
Cerebro-spinal fever, which was made a notifiable disease in New Zealand in 1907, came into prominence in the First World War. There was a mild epidemic of the disease in the civil population in 1915 and 1916 and an outbreak of an aberrant type in Trentham Camp in July 1915, when there were 32 cases with 22 deaths. The camp was closed, but was reopened for a restricted number of troops in the summer months after the epidemic had subsided. In July 1916, after an outbreak of febrile catarrh, and later of measles, cerebro-spinal fever reappeared in the two principal camps. It became epidemic in August, but died out gradually in the summer months. In all, 51 cases with 36 deaths were recorded.
Between the wars the incidence of the disease in New Zealand declined. It rose again in 1941 and became epidemic in 1942, when 932 cases were recorded with 116 deaths. Of this total, 85 cases occurred in military camps. The incidence and fatality rates in the Army were not out of proportion to the civilian rates. (There had been epidemics in England in 1940 and 1941.) In later years the disease again abated.page 567
In 2 NZEF in the Middle East no epidemic of cerebro-spinal fever occurred—a satisfactory achievement. Sporadic cases totalling fewer than fifty were recorded in a period of five years, with only one death. The remarkable reduction in the mortality rate compared with the First World War was due to the introduction of the sulphonamides. When penicillin was introduced it was equally effective as a treatment.
This form of meningitis frequently occurs as a primary condition, but is sometimes secondary to a form of pneumococcal infection elsewhere—the middle ear, the accessory sinuses of the nose, the lungs—or as part of a pneumococcal septicaemia. In the primary form, a nasal catarrh frequently precedes the onset of meningitis, which is, as a rule, somewhat sudden.
In July 1943 the Consultant Physician 2 NZEF reported the recovery of a case of pneumococcal meningitis. Recovery in such cases was exceedingly rare and this was thought to be the first such case which had recovered in a New Zealand General Hospital. This soldier had been treated with intravenous sulphadiazine, and, in addition, sulphapyridine by mouth.
At this date there had been five deaths in 2 NZEF from pneumococcal meningitis, and there were two deaths after this date.
Results in other forces indicated that pneumococcal meningitis often failed to respond to sulphonamides, but treatment with penicillin produced better results.
Other Types of Meningitis
There were only a few cases of any other types in 2 NZEF and they were not severe. In August 1944 there were some twenty cases of a mild lymphocytic meningitis. Meningitic signs were obvious in each case at admission, and the cerebro-spinal fluid showed an increase in lymphocytes, but was always sterile on culture. The cases all made a rapid recovery.
There were a few deaths from streptococcal meningitis associated with mastoiditis, and from meningitis associated with peritonitis. Meningitis in all its forms, including tubercular, accounted for 18 deaths in 2 NZEF in the Middle East—the highest single cause of death from disease. In the Pacific Force it caused no deaths. This compares favourably with 1 NZEF overseas, which had 115 deaths from meningitis (109 from cerebro-spinal type), excluding tubercular meningitis.page 568
Recommendations on Treatment by Consultant Physician 2 NZEF, July 1943
M & B 693 (Sulphapyridine)
For the first 3 days a total of 8–10 gms. daily.
For the next 6 days a total of 3 gms. daily.
Thus—1st day: 1st and 2nd doses 4 tabs each then 2 tabs every 4 hours.
2nd and 3rd day: 6 doses of 3 tabs every 4 hours.
4th to 9th day: 6 doses of 1 tab each every 4 hours.
In fulminating cases or with vomiting, use Sulphapyridine soluble—
First dose: 1 gm. in saline intravenously.
and the same dose intramuscularly.
Second dose: 1 gm. intramuscularly 4 hours later.
After six days' treatment, a daily leucocyte count to forestall agranulocytosis.
During treatment: 4 to 6 pints of fluid daily, and some alkali, e.g. sod-bicarb. No purges; enemas or liquid paraffin, if required. Symptomatic treatment as required.
Pneumococcal and Pyogenic
Sulphadiazine—10 c.c. of a 30 per cent sol. (3 gms.) in P. aeq. normal saline intravenously—
2 injections daily for 4 days.
1 injection daily 5th and 6th days.
The drug is obtainable in 10 c.c. ampoules. Instructions given by ME say the drug requires no further dilution. This, in our experience, obliterates the veins by thrombosis, and soon no suitable vein can be found. Fluids, etc., as in the meningococcal variety.
We have reason to believe that while Sulphadiazine may clear pneumococci out of the CNS [central nervous system], the blood may still act as a reservoir—e.g., a case, apparently cured of pneumococcal meningitis, and after ten days of apparent normal convalescence, suddenly developed rigors and died of acute pneumococcal endocarditis. We have since used in addition to Sulphadiazine from the 4th day onwards, M & B 693 in the same way as in pneumonia.