MENINGOCOCCAL MENINGITIS (Cerebrospinal Fever—Spotted Fever)

Curative Treatment.—The first essential, when meningitis is suspected, is to perform a lumbar puncture. The presence of acute bacterial infection will immediately be declared by the appearance of a turbid or purulent fluid which must be sent for bacteriological examination at once to determine the infecting bacterium. At the same time its sugar content should be estimated for this is usually reduced and the degree of reduction reflects the severity of the case.When turbid fluid has been obtained 10,000 to 20,000 units of crystalline penicillin is slowly injected intrathecally. This ensures that treatment has begun, no matter what bacteria are ultimately found to be present. At the same time a dose of 500,000 to 1,000,000 units of penicillin is given intramuscularly and a similar dosage is administered at two- to four-hourly intervals, depending on the severity of the infection.
The sulphonamides were, of course, responsible for the dramatic change in the fatality rate of meningococcal meningitis and under certain circumstances their use may still be preferred. Thus in situations where epidemic prevalence can be assessed fairly accurately but admission to hospital is impossible and medical and nursing resources are limited, sulphonamides have the advantage that they can be easily distributed and administered. A few strains of menin-gococci have now been isolated which are sulphonamide-resistant and since it is essential to begin effective chemotherapy as quickly as possible, these agents are no longer the drugs of first choice.
The single advantage of the sulphonamides is their ready transport compared with penicillin across the blood-brain barrier. Nevertheless, it is now known that when there is meningeal inflammation penicillin passes across in effective concentrations. In order to ensure that an adequate concentration is achieved, however, the dosage of penicillin should be greatly in excess of that normally used, and this is especially important at the beginning of treatment. The duration of treatment is a minimum of seven days; in the most severe cases this may be extended up to 10 or 12 days but prolonged therapy is unnecessary.
Dehydration is often present and in the most severe infections may require energetic treatment by intravenous infusions. Vomiting is often a marked feature of the early illness and, when sulphonamides were the standard method of treatment, the reduced renal flow resulting from dehydration could encourage tubular blockage. This risk does not arise with penicillin. It is important, however, to estimate the urea and electrolytes at the start of treatment and, in regard to fluid replacement, to be guided by the results obtained.
The assessment of progress is as a rule straightforward and in mild infections the obvious improvement of the patient makes special tests unnecessary. The severity of the illness is declared by the shocked state of the patient when first seen as well as by the initial features of the cerebrospinal fluid. In the most severe cases the fluid contains a large number of organisms, easily seen in a direct film, with most of them situated extracellularly. The sugar content may be less than 10 to 15 mg. per 100 ml. In such cases a lumbar puncture twenty-four hours later is prudent. When treatment has been effective, meningococci should be greatly reduced and should be mainly intracellular; in the most favourable cases indeed meningococci may not be seen. The sugar has often risen drama­tically and may even approach normal levels. When this is the sequence of events further lumbar puncture is unnecessary and the progress of the infection can be gauged by the normal clinical evidence of improvement. When the fluid is still markedly turbid at this second lumbar puncture a further intrathecal injection of penicillin is indicated, and the results of bacteriological and chemical examinations obtained as quickly as possible. When the expected improvement has not occurred the systemic dose of penicillin should be given more frequently and the sensitivity of the meningococcus to different antibiotics should be assessed urgently. Daily lumbar puncture in such severe infections will be necessary until the results make it apparent that chemotherapy is being effective.
Complications.—Involvement of cranial or peripheral nerves may be expected in from 5 to 10 per cent. of cases. An unduly gloomy view of such complications is unjustified ; a considerable proportion clear up satisfactorily.
Blindness, often cortical in type, is usually permanent. Acute arthritis—a result of the initial septicaania—often declares itself after treatment has stopped. It rapidly responds to a second course of therapy.Convalescence.—The patient may be allowed out of bed towards the beginning of the third week of illness. A lumbar puncture should be performed on or about the twenty-first day of illness ; the best criteria of recovery are a normal cell count and a normal content of sugar in the fluid, which should be clear. The patient may now resume normal activities and a reasonably long holiday should be advised. Adult patients often complain of a general weakness for some time after their recovery ; their relatives often complain of the patient's easy irritability. Such changes, however, gradually disappear.

CHRONIC MENINGOCOCCAL SEPTICAEMIA
This condition is particularly to be expected during epidemics. Unfortun­ately, blood culture, which is the essential method of diagnosis, is not always positive. The bacteriologist should be advised regarding the type of case from which the culture has been taken. A course of sulphonamide appropriate to the age of the patient (most often an adult) should be given here­after the patient should be observed for a few days for the recurrence of fever, headache, or skin rash.