Dr. Purcell of Cork[17] furnished a classification which is one of the
best for practical and clinical purposes--viz. 1, the _rapid_ variety,
attended with purple blotches, embarrassed respiration and
circulation, followed by sopor, insensibility, and coma; 2, the
_cerebro-spinal_ form, with retraction of the head, pain and cramps of
the muscles, hyperæsthesia of the skin, delirium, etc., accompanied by
fever, herpetic eruptions, etc. These two forms are apt to be more or
less associated in the same case.
[Footnote 17: _Dublin Quarterly Jour._, Aug., 1870, p. 243.]
Of the various forms admitted by different authors, and of which we
have seen examples, we would class together--(_a_.) The abortive, in
which the characteristic phenomena are often faintly defined, and yet
to the practised eye distinctive. (_b_.) The malignant, in which the
symptoms, of whatever kind, are exaggerated, the attack sudden, the
course short, and the issue fatal. (_c_.) The nervous, including 1,
the _Ataxic_--viz.--1, the _delirious_; 2, the _cephalalgic_; 3, the
_neuralgic_; 4, the _convulsive_; 5, the _paralytic_; and 6, the
_adynamic_ (_comatose_ and _typhoid_). (_d_.) The inflammatory. (_e_.)
The intermittent. Of these the _abortive_ and _intermittent_ call for
a brief explanation. Abortive meningitis is observed only during the
prevalence of the disease in a more characteristic form. Thus, the
mother of a boy who had died of the fully-developed disease
"complained of the head and back and limbs, and of chilliness, and
presented a petechial eruption. After active purgative and
counter-irritant treatment she was about her work on the second
day."[18] The late Dr. Burns of Frankford, Philadelphia, while
attending patients affected with the disease suffered from headache,
severe pains along the spine and in every joint of the body, and a
general languid feeling.[19] Kempf during the decline of an epidemic
observed "a great number of individuals, especially adults, who
complained of headache, malaise, neuralgic pains in various parts of
the body, and pain in the nape of the neck or other parts of the
spine."[20] In a case observed by the writer (June, 1867) most of the
characteristic symptoms were present in a mitigated form, and the
pulse was at 60. Within five days restoration was complete.[21] The
_intermittent_ and _remittent_ types are apt to be quotidian or
tertian, and in fatal cases the former has been taken for malignant
intermittent fever, which it resembles by a periodical febrile
movement, with pains, cramps, delirium, etc. This type sometimes first
manifests itself during the decline of an attack.
[Footnote 18: Sargent, _Amer. Jour. of Med. Sci._, July, 1849, p. 35.]
[Footnote 19: _Amer. Jour. of Med. Sci._, April, 1865, p. 339.]
[Footnote 20: _Ibid._, July, 1866, p. 55.]
[Footnote 21: _Epidemic Meningitis_, p. 42.]
SUMMARY OF THE SYMPTOMS.--Like other fatal epidemic diseases,
meningitis is sometimes sudden and sometimes gradual in its
development. In the former case the patient, who has gone to bed
apparently in perfect health, awakes suddenly from a sound sleep about
the small hours of the night to find himself in a severe chill. In the
case of young children a convulsion attends the awakening. Or the
patient, while {807} pursuing his ordinary avocations, may be seized
with a chill, prostration, vomiting, and headache, of which symptoms
the last is often intensely distressing. In this, as in other epidemic
diseases, such violent seizures are most common during the earlier
periods of its prevalence, but later in its course premonitory
symptoms are more frequently observed. They may last for an hour or
two, or may extend to several days; and, in general, it may be stated
that the longer their duration the milder will be the subsequent
attack. But the symptoms in either case are essentially the
same--prostration, chilliness, feverishness, and sometimes vomiting
and sharp pains in the head, back, and limbs. The character of the
vomiting, as well as the absence of all gastric lesions in fatal
cases, proves that it is occasioned by an irritation of the central
nervous system.
In the cases which are regularly developed these phenomena more or
less gradually assume a graver aspect or usher in a heavy chill, which
in its turn is followed by alarming symptoms, and especially by an
excruciating pain in the head, a livid or pale and sunken countenance,
and extreme restlessness. The pulse is as often slow as frequent, and
the skin is rarely hot, and, indeed, is generally but little, if at
all, warmer than natural. The vague pains that began with the attack
are now concentrated, and seem to dart in every direction from the
spine, which is also, at its upper part, the seat of severe aching;
and in some cases hyperæsthesia of the skin is very marked. In a large
proportion of cases the spinal muscles become more or less rigidly
contracted, so that the head is drawn backward or the whole trunk is
arched as in tetanus. Trismus is not uncommon, and clonic spasms
frequently affect the limbs. Even general convulsions are occasionally
observed. As these phenomena grow more decided delirium of various
degrees is often manifested, from mere wanderings and hallucinations
during the sleepless watches of the night to violent maniacal ravings
or incoherent mutterings, or the stertor of coma. Frey and others have
noted a remission of the symptoms occurring on or about the third day
in cases of a regular type. The rigidity of the cervical muscles
becomes relaxed, the headache subsides, and the mental condition
improves. But this amelioration lasts but a short time, and then the
normal course of the symptoms is resumed.
As the attack advances the pulse gradually or rapidly rises above the
normal rate, and sometimes becomes very frequent, and the skin,
although it grows warmer, does not often acquire the temperature
observed in idiopathic fevers or sustain it as they do. In many cases
eruptions appear upon the skin. During some epidemics the only one
observed is herpes labialis; in others the eruption resembles roseola,
measles, or the mulberry rash of typhus, or from the first it consists
of petechiæ, vibices, or extensive ecchymoses. The tongue presents the
characters which belong generally to the typhoid state. At first moist
and coated with a whitish fur or a mucous secretion, it afterward, if
life is prolonged, grows red and shining or brown and fuliginous.
There is usually a complete loss of appetite, and the thirst is not
commonly urgent. One or two liquid stools at the commencement are
generally followed by constipation, which continues throughout the
attack, although in very grave and protracted cases diarrhoea may
persist, and even become colliquative. When the attack tends to a
fatal issue the patient generally, but by no means always, sinks into
a soporose condition, in which {808} muscular relaxation, debility,
and tremulousness, such as are common in the typhoid state of fevers,
are associated with paralysis of the sphincters and of other muscles.
But we have seen rigid opisthotonos continue until within a few hours
of death in a case of more than the average duration.
In cases that tend toward recovery the typhoid condition is rarely so
grave, but patients have often survived very severe nervous symptoms.
It is true that the return to health may be tedious and uncertain, and
not unusually a perfect restoration of all the functions is very long
delayed, or, it may be, is never attained.
INDIVIDUAL SYMPTOMS.--Pain in the head is one of the most
characteristic symptoms of epidemic meningitis. It is always present,
except in those malignant cases in which the morbid poison seems to
spend its fatal power upon the blood. In some, however, of a less
rapid but still malignant type, in which after death no exudation is
found, but only an extreme venous congestion of the membranes, or it
may be an effusion of blood beneath them, this symptom may be more or
less marked. It is generally an excruciating pain, sometimes darting
apparently through the head from the nuchæ to the forehead, extorting
cries and groans, and is variously described by the sufferers as
throbbing, boring, lancinating, sharp, or crushing, "as if the head
were in a vice or nails or screws were being forced into the brain."
Its paroxysms arouse the patient from his apathetic stupor or his
coma, and cause him to become restless or violent or to shriek with
agony. Even when this evidence of anguish is wanting the patient often
attests his suffering by contortions or cries, or by frequently
carrying his hands to his head. That it depends upon mechanical
pressure upon the sensitive ganglia within the cranium and upper part
of the spine is shown by the relief which revulsive and
counter-irritant measures afford when applied to the occipital region
and the back of the neck. Identical in cause and quality with this
pain is the spinal pain proper. No better description of it has been
given than that of Fiske in 1810. It is in these words: "Its bold and
prominent features defy comparison.... In some a pain resembling the
sensation felt from the stinging of a bee seizes the extremity of a
finger or toe; from thence it darts to the foot or hand or some other
part of the limbs, sometimes in the joints and sometimes in the
muscles, carrying a numbness or prickling sensation in its progress.
After traversing the extremities, generally of one side only, it
seizes the head, and flies with the rapidity and sensation of
electricity over the whole body, occasioning blindness, faintings,
sickness at the stomach, with indescribable distress about the
præcordia--a numbness or partial loss of motion in one or both limbs
on one side, with great prostration of strength. The horrible
sensation of this process no language can describe."[22] These spinal
pains are always aggravated by pressure made on either side of the
spinous processes of the vertebræ, and, like the cephalic pains, are
more or less mitigated by revulsive applications. Accompanying the
pains is a hyperæsthesia or morbid sensibility of the skin, rendering
it painfully sensitive to the slightest touch; in the advanced stages
of the disease, when the spinal phenomena predominate, the irritation
of the nerves by the pressure of the exudation on their roots is
exchanged for numbness or {809} absolute insensibility, due to the
increase and continuance of that pressure. Moving the limbs or
separating the closed eyelids will sometimes provoke resistance, and
even extort cries; and especially is this true of attempts to
straighten the rigidly bent spine or the flexed extremities. Lewis
states that such outcries were so often excited by slowly introducing
the thermometer into the rectum that he was forced to believe that the
anal and perhaps the rectal surface was hypersensitive.
[Footnote 22: North, on _Spotted Fever_, p. 176.]
The physical causes that give rise to the pains which have just been
described likewise occasion the spasmodic and tetanoid phenomena that
are so peculiar to this disease. In general terms, they are most
marked in cases attended with inflammatory exudation, and least so
when, instead of this lesion, there is only vascular congestion of the
meninges of the spinal cord. But the rule is, of course, not absolute,
for individuals are so differently constituted that one will remain
impassive under an irritation that will throw another into
convulsions. There is no doubt that spinal rigidity may be produced by
mere congestion of the cord, and, on the other hand, that it may be
absent even when plastic exudation is abundant. This symptom is,
however, more than any other one, characteristic of the disease. It
existed in the original epidemic at Geneva, attracted the attention of
the earliest American observers of the disease, and elsewhere has
marked a greater or a smaller proportion of the cases in every
epidemic. It was described by such terms as these: "a drawing-back of
the head;" "a corpse-like rigidity of the limbs;" "the form of tetanus
called opisthotonos;" "spastic rigidity of the muscles of the lower
jaw and the posterior muscles of the neck;" "rigidity of the posterior
cervical muscles, retracting the head considerably backward." The
historians of the disease in Europe are, if possible, still more
emphatic in their elaborate descriptions of this phenomenon, and, on
the Continent at least, it seems to have been more uniformly present
than it was in Ireland or in this country. Tourdes, in describing the
epidemic of 1842 at Strasburg, said: "The decubitus of the sick was
distinguished by a backward flexion of the head and spine; most
frequently the neck alone was affected, but sometimes the whole trunk
was arched." And again: "The contraction often involved all of the
extensor muscles of the spine, and the trunk formed an arch opening
backward and resting upon the occiput and sacrum." In Ireland, Gordon
says of a patient, "Her spine presented a most wonderful uniform curve
concave backward; her head was also curved backward on the spine of
the neck." During an epidemic at Birmingham in 1875 in one case "the
retraction was so marked that a slough formed from the occiput
pressing between the scapulæ."[23] In some cases rigid flexion of the
body forward or laterally has been noticed. The rigidity persists, as
a rule, until death, but sometimes ceases a short time before that
event. If recovery takes place, this symptom gradually subsides, and
disappears within a few days; but, on the other hand, more or less
stiffness of the spine may last for several weeks. In one case it
continued for more than two months, and in another until death on the
forty-ninth day.
[Footnote 23: Hart, _St. Bart's Rep._, iv. 141.]
The same physical cause that occasions rigidity, when acting less
intensely or when a special susceptibility of the nervous system
exists, also excites clonic convulsions. They are oftenest observed in
patients of the {810} age especially liable to spasmodic
affections--in children before the completion of the first dentition.
They vary in degree from twitching or subsultus affecting particular
muscles, as of the eyes, the face, a limb, etc., to general
epileptiform convulsions with loss of consciousness. They may be
associated with paralysis, as where the two halves of the body are,
the one convulsed and the other paralyzed. A case occurred in Dublin
which "presented the very striking phenomenon of continued and violent
convulsions during the whole of the brief course of the illness."[24]
These convulsions, like others occurring at the commencement of acute
diseases, are by no means always fatal, even when they are general. In
the case of a robust adult convulsions occurred repeatedly during the
first two days, and less frequently during the two following days, but
the patient ultimately recovered.[25]
[Footnote 24: _Dublin Quart. Jour._, xlvi. 187.]
[Footnote 25: _Boston Med. and Surg. Jour._, Feb., 1884, p. 121.]
Paralysis, it may be inferred from the statements already made, is an
incident of this disease, for an excess of the action causing tonic or
clonic spasm must induce paralysis. Paralysis of an arm or leg or of
the muscles of deglutition was long ago noticed among even the initial
symptoms of the attack. In Dublin (1865) it was said of a patient,
"All his members seemed to be paralyzed; he could move neither arms
nor legs." Wunderlich describes the case of a man who "on the second
day of the disease lost both sensibility and motility in the lower
limbs and over the greater part of the trunk, while his left arm also
was partially paralyzed." In another case complete paralysis of the
right side occurred on the third day, the left side being rigid.[26]
Baxa relates the case of a soldier in whom paralysis of the left side
persisted after recovery from the disease,[27] and that of a woman in
whom paralysis of the left lower limb continued along with right
ciliary paralysis. Ptosis, strabismus, paralysis of the bladder and
rectum, of the muscles of deglutition, and even general paralysis,
have been observed. Aphasia also has been recorded by Hirsch and by
Hayden.[28]
[Footnote 26: _Dublin Quart. Jour._, 1867, p. 431.]
[Footnote 27: _Wiener med. Presse_, No. 29, p. 715.]
[Footnote 28: _Dublin Quart. Jour._, xlvi. 187.]
The condition of the eyes and of vision in this disease is directly
due to pressure of the exudation at the base of the brain upon the
nerves and blood-vessels that supply these organs. One of the most
striking peculiarities of the countenance of a patient at the
beginning of an attack is the diffused and uniform redness of the
conjunctivæ. In children it has a light tint, but a darker one in
adults, and in some cases the eye becomes suffused with an
extravasation of blood. The conditions of the pupil are also very
peculiar. Very long ago it was observed to undergo sudden changes from
contraction to dilatation, or the reverse. Dilatation is, however, its
ordinary condition, especially in the fully-formed attack. Very often
the pupils of the two eyes are in opposite states. In cases of long
duration, with great exhaustion, they are almost invariably dilated.
Photophobia is not uncommon, and oscillation of the pupils and
spasmodic movements of the eyeball have frequently been observed.
Strabismus is a symptom of very ordinary occurrence, particularly when
other paralytic or spasmodic phenomena exist. It may be convergent or
divergent, but most commonly is the former, and may be either a
transient or a {811} permanent symptom. Like other individual
symptoms, it may be present rarely or frequently in a particular
epidemic.
Blindness has been repeatedly observed. At first it seemed to be
noticed as a transient symptom only. Fish (1809) states that it was
sometimes the first deviation from health, and then was followed by
paralytic spinal symptoms. He also observed that sight was sometimes
restored in a few hours, and in no case did he know it to be
permanently lost. American as well as European physicians, however,
have met with many cases in which the sight was seriously and
permanently impaired or altogether destroyed. In 1873 the changes
affecting the eye were more fully and accurately described, especially
those which tend to the structural injury of the organ. The abnormal
appearances included cloudiness of the media, discoloration of the
iris, irregularity of the pupils, and their obstruction with exudate.
In exceptional cases the cornea ulcerated, and the globe collapsed
after losing its contents. Ordinarily, however, says Lewis, "no
ulceration occurs, and as the patient convalesces the oedema of the
lids, the hyperæmia of the conjunctiva, the cloudiness of the cornea
and of the humors gradually abate, and the exudation in the pupils is
absorbed. The iris bulges forward, and the deep tissues of the eye,
viewed through the vitreous humor, which had a dusky color from
hyperæmia, now present a dull white color. The lens itself, at first
transparent, after a while becomes cataractous, and sight is lost
totally and for ever."
Impairment or loss of hearing has been occasionally observed during
the successive epidemics of this disease, even from the beginning of
its history, and it was early noticed that the symptom was often quite
independent of any cognizable lesion of the ear itself. It was also
observed that the sense of smell sometimes became impaired or was lost
at the same time with that of hearing. More recently, Collins reported
a case in which the patient lost the sight of one eye and became
permanently deaf in both ears. Knapp states that in all of thirty-one
cases examined by him the deafness was bilateral, and, with two
exceptions of faint perception of sound, complete. Among twenty-nine
cases of total deafness only one seemed to give some evidence of
hearing afterward.[29] This surgeon holds that the deafness results
from a purulent inflammation of the labyrinth, and his judgment has
been confirmed by Keller and Lucas. When the impairment of hearing
occurs simultaneously, or nearly so, in both ears, it is probable that
the chief cause of the deafness is the pressure of the plastic
exudation in which the auditory nerve is imbedded. Such deafness is
rarely permanent. When the loss of hearing, whether complete or
partial, does not improve, there is reason to believe that the
internal ear has suffered great and incurable changes of structure.
Sometimes this follows a distinct attack of suppurative inflammation
of the middle ear; but as complete and permanent deafness sometimes
occurs without being preceded by any such affection, it must be
inferred that atrophic changes have taken place in some portion of the
nervous apparatus of hearing. It is stated by Moos that of sixty-four
cases of recovery from cerebro-spinal meningitis, which showed
disturbance of hearing as a sequel, one-half manifested in addition a
more less disordered equilibrium. Of these twenty-nine were totally
deaf on both sides, two totally deaf on one and hard of hearing on the
other side, and one case had merely {812} impaired hearing in both
ears. The disturbance of locomotion had existed for periods varying
from three weeks to five years from the inception of the disease, and
was chiefly characterized by a staggering or waddling gait.[30] In the
deaf-mute institutions at Bamberg and Nürnberg it is said that out of
91 pupils, 80 owed their infirmity to this disease (Ziemssen). Salamo
states that some awake out of sleep totally deaf, and remain so for a
long time, or, it may be, permanently (Moos).
[Footnote 29: Smith, _loc. cit._]
[Footnote 30: _Mening. Cerebro-spinal epid._, p. 11.]
The expression of countenance in this disease is peculiar. When the
pain in the head is severe and paroxysmal the features are apt to be
violently distorted; when it is more persistent the face assumes a
fixed or rigid expression, or is at the same time dull, particularly
after a long continuance of the pain. In the apoplectic form the
expression may be set and stupid, but the features have neither the
dark, dull, swollen, and duskily-flushed aspect of typhus, nor the
languid, sleepy expression, and circumscribed flush on the cheek which
are so characteristic of typhoid fever. Except during absolute
insensibility in rapidly fatal cases there is a look of greater
intelligence than belongs to either of the diseases mentioned. Indeed,
in the beginning of the attack in regular cases the distinctive facies
presents pale and sunken features, with paleness of the skin over the
whole body.
Delirium in this disease exhibits a great many degrees and varieties.
It may occur among the earliest symptoms in certain rapid cases not of
the congestive type, but is more apt to arise on the second or third
day in those more typically developed. It may be mild, reasoning,
hysterical, or maniacal, or it may change from one to another of these
forms during the same attack. Fish states that it is apt to be violent
if it comes on at the commencement of the illness, but that when it
begins at a later period it is milder, and sometimes playful, the
patient being sociable and humorous. All good observers have furnished
similar descriptions of this symptom; some have added that the mental
condition is often desponding and apprehensive, and others that
certain patients remain sombre and silent; and it sometimes happens
that the delirium comes on abruptly, as when a patient "woke suddenly
in the middle of the night and began to hum tunes, to fancy that
people were conversing with him," etc. (Gordon).