in a marked degree until the approach of death. If anything is
surprising in epidemic meningitis, it is the absence of that deep and
prolonged stupor that characterizes the typhoid state, notwithstanding
the pressure of the exudation upon the brain in most cases, and in
others such a profound alteration of the blood that it exudes through
the tissues as water passes through a porous body. Another striking
phenomenon of the disease is that the patient after recovery has
generally a complete oblivion of all that happened to him between the
beginning of the attack and convalescence. This is true even of cases
in which the brain symptoms are far from being conspicuous.
Another symptom closely related to the local lesion and the
blood-change in this disease is vertigo. As originally described by
Miner in 1823, it occurred from the very commencement of the attack,
and was even then regarded as denoting a deficient supply of the blood
to the {813} brain, so that when the patient rose to an erect posture
it was felt along with uneasiness in the stomach, acceleration of the
pulse, dimness of sight, nausea, and fainting. Tourdes, speaking of it
as it occurred in the Strasburg epidemic, says that it confused the
mind and rendered walking impossible. In two cases patients were
seized with a giddiness which compelled them to whirl around, when
they fell and did not rise again. According to Moos (1881) unilateral
affections of the labyrinth give rise to vertigo, and bilateral
lesions to a staggering gait. Bilateral hemorrhage or acute
suppuration of the ampullar terminations of the auditory nerve
occasions paralysis and staggering. Children, and those who at the
same time have the sight impaired, are apt to remain affected for a
long time. Otherwise, prolonged and systematic muscular exercise may
remove the tottering walk.
To the same causes must doubtless be attributed the debility which is
so early and so conspicuous a symptom in this disease, and which gave
it one of the names, typhus syncopalis, by which it was first known in
this country. It was manifested by the vertigo already noticed, by a
sense of sinking in the epigastrium, by a quick, frequent, feeble, and
irregular pulse, and by a sudden and extreme loss of muscular power,
so that the patient found himself unable to raise his hand before he
was sensible of being ill. This state of asthenia is conspicuous
throughout the whole of the disease, and is the immediate cause of the
slow and irregular convalescence which is characteristic of it.
Of the symptoms peculiar to the digestive apparatus hardly any belong
to it directly. They are nearly all the effect of reflex influences.
The condition of the tongue is for the most part quite unlike that
which belongs to the typhoid state. The fuliginous condition of the
tongue, gums, cheeks, and lips which characterizes that state is
seldom met with in epidemic meningitis. The older writers agreed that
even when the tongue does grow dry and brown the condition is not of
long continuance, and later observers have confirmed their statements.
Thus, J. L. Smith (1872) says, "Occasionally, in cases attended with
great prostration, the fur of the tongue is dry and brown, but only
for a few days, when the moist whitish fur succeeds." We have
generally found it moist, whitish in the centre and at the tip and
edges.
Nausea and vomiting are very constant among the initial symptoms of
the disease, and, as already pointed out, are due to irritation of the
cerebro-spinal ganglia. Very often the vomiting is not preceded by
nausea, and is brought on by the patient's raising himself, etc. The
stomach itself undergoes no change. Both symptoms are usually
accompanied by faintness or giddiness, and are more decided in the
initial than in the later stages of the attack. The matters vomited,
varying with the contents of the stomach and the urgency and duration
of the symptom, consist of ingesta, mucus, serum, or bile, and in some
grave cases of a dark grumous matter taken to be altered blood. In
some epidemics, apparently, more than in others, this symptom is very
distressing, as it was at Birmingham in 1875.[31] The inability of the
stomach to retain food necessarily leads to a rapid wasting of the
flesh, which is aggravated by the patient's suffering, restlessness,
and want of sleep. Nevertheless, no sooner is the vomiting appeased
than a desire for food is felt, and when {814} it is retained it
generally undergoes digestion. Indeed, in no other disease is the
return of a good appetite and digestion so prompt and complete. It is
true that the recovery of flesh and strength is not always in
proportion to the appetite. As might be expected in a disease in which
fever plays so subordinate a part, there is seldom urgent thirst. But
epidemics differ in this as in so many other respects. In that which
we witnessed in the Philadelphia Hospital in 1866-67 the patients were
clamorous for liquids. Constipation is the rule among patients with
this disease, as, indeed, might naturally be expected, for no lesion
affects the bowels and little or no food is retained by the stomach.
Yet in a few cases diarrhoea accompanies persistent vomiting.
[Footnote 31: Hart, _St. Bart's Rep._, xii. 112.]
The fauces appear to have been more or less inflamed in some
epidemics; swelling of the parotid glands is an occasional occurrence,
and sometimes they undergo suppuration. Aphthæ have also been met
with.
The secretion of urine is not affected in any uniform manner.
Sometimes it is diminished and sometimes increased in quantity. The
latter symptom has occasionally long survived the disease. It retains
its normal acidity. In rare cases either albumen or sugar has been
detected; the former may have been due to the action of blisters of
cantharides used in the treatment of the disease.
One of the most curious and unintelligible phenomena occasionally met
with in this disease is a peculiar affection of the joints, which
first was observed in this country. Jackson (1810 and 1813) wrote: "In
some cases swellings have occurred in the joints and limbs. They have
been very sore to the touch, and their appearance has been compared to
that of the gout. The parts so affected feel as if they had been
bruised. These swellings arise on the smaller as well as on the larger
joints, and are often of a purple color." So Collins[32] reports: "The
joints sometimes become swollen, red, and tender; at other times red
and painful without any swelling; while, again, intense pain and rapid
enlargement from effusion have occurred unattended with redness. The
joints most usually attacked are the knee, elbow, wrist, and the
smaller articulations of the fingers and toes." In an epidemic which
occurred in Greece in 1869 articular swellings similar to those of
inflammatory rheumatism were observed.[33] These descriptions, which
apply to some cases in most epidemics, are of more than casual
interest, for they demonstrate conclusively, as we think, the truth
which the whole history of the disease confirms--viz. that it is a
systemic and not a local affection, and is dependent for its existence
upon a specific poison which is absolutely unlike every other morbid
poison known to pathology.
[Footnote 32: _Dublin Quart. Jour._, Aug., 1868, p. 170.]
[Footnote 33: _Archives générales de med._, Mai, 1883, p. 622.]
The act of respiration is variously modified in this disease, as
might, indeed, be expected from the seat and nature of the
cerebro-spinal lesions. It is sighing, labored, and interrupted.
Burdon-Sanderson describes its differences from the so-called
Cheyne-Stokes respiration; it is, he says, "marked by a slow, labored
inspiration, followed by a quick expiration and a long pause." When
opisthotonos is very great and persistent, it necessarily interferes
with the dilatation of the lungs, and leads to oedema of those organs,
and even to sanguineous effusions into them. {815} Pneumonia is not an
unusual complication of the disease when it prevails in cold weather.
The distinguishing characters of the pulse are diminished force and
volume, and a tone so much impaired that slight causes produce extreme
variations in its rate and rhythm. If the disease be a fever, as is by
some maintained, then it is the only fever in which the pulse-rate is
often far below the normal, and at the same time neither full nor
tense, unless transiently and in altogether exceptional cases. In no
other disease attended with inflammation do the rate and quality of
the pulse vary so greatly within short intervals. It may be said, in
general terms, to be variable in rate and strength even in the most
sthenic cases of the disease, and in those which tend to a fatal issue
to be small, thready, weak, intermittent, or imperceptible for a
longer or shorter time before death. It is no uncommon thing for the
pulse-rate at the beginning of an attack to fall as low as 40, or even
27, and afterward rise to 120 or even more, in a minute, without
necessarily indicating a fatal issue. Muscular exertion, rising from a
recumbent posture, etc., will sometimes double its frequency, besides
producing irregularity. Read, describing the pulse as he observed it
in Boston in 1873-74, speaks of cases in which "both the rhythm and
the force of the beats are entirely destroyed; ... one moment, while
beating very fast, it will suddenly drop to a much lower rate....
These conditions also may outlast apparent convalescence." Some fatal
cases are attended by distressing palpitations of the heart.
Nothing is more remarkable in the early histories of this affection
than their unanimous statement that it is not distinguished by a
febrile temperature. It is true that the observers of those days had
not the advantage of using clinical thermometers, but they were too
nearly agreed in their judgments and harmonious in their descriptions
to permit any serious doubt of the substantial accuracy of their
conclusions, which were expressed in such terms as these: "A
diminution of heat may be considered as among this most striking
symptoms of this disease" (Strong); or, "the temperature never
exceeded the standard of health in more than three or four cases, ...
and a great majority of the patients had no fever at all" (Miner); or,
again, "A high febrile movement took place only in a limited number"
(Gilchrist); or, "The heat of the surface was less in all cases than
is usually observed in acute diseases" (Jenks). It will be observed
that these statements, and very many others which agree with them,
were founded upon the perception of the patients' temperature by the
hand, which was of course applied to the most accessible parts of the
body--the face, neck, arms, and hands--but they have more real value
and significance than the more recent measurements taken in the mouth,
axilla, rectum, or vagina, for we know that, however valuable the
temperatures of these parts may be for comparative studies, they do
not really indicate the condition of the individual who presents them.
It is a familiar fact that the difference of temperature in cholera
when taken in the rectum and the axilla may be 4° F., or even more
than this.
Since the thermometer has been used in the study of epidemic
meningitis greater accuracy of results has been attained, and yet the
general statements of the earlier observers have been confirmed. Thus,
Githens has shown that the temperature of the body in this disease is
lower than that recorded of any other fever or inflammatory affection;
the average, {816} indeed, of his cases was lower by four or five
degrees than that of typhus or typhoid fever, pneumonia, etc. In 2
cases only did the thermometer in the axilla reach 105°. The highest
temperature in 15 cases was between 104° and 105°; in 12, between 103°
and 104°; in 7, between 102° and 103°; in 6, between 101° and 102°;
and in 2 it was below 100°.[34] Tourdes, Niemeyer, and others have
noted the slight rise of temperature during the first and second days
of the attack, and Wunderlich found fever of very unequal degrees and
with very variable maxima, but the highest temperatures were observed
by him as well as others in fatal cases and immediately before death.
In one instance it reached 107.5° F. Burdon-Sanderson and others have
found that an increased temperature always attended exacerbations of
pain. Von Ziemssen gives the average temperature as varying from
100.4° to 103° F., but with variations between higher and lower
points, and particularly notes the persistence of a normal temperature
while the other symptoms are undergoing a variety of changes, as well
as the fact that, unlike other febrile affections, this disease has no
representative temperature curve. In his clinical observations Hart
found for several successive days as much as six degrees of difference
between the morning and evening temperatures. A morning rise for
several days was noticed in four cases, and usually there was no
relation between the pulse and the temperature, nor any uniformly
between the temperature and the gravity of the attack.[35] But not
rarely it has been noticed that the daily exacerbations, if any, did
not occur in the afternoon, but with great irregularity, so that the
maxima and minima might occur on successive days and at the same hour
of the day. Dr. J. L. Smith, whose thermometric observations in this
disease seem to have been carefully made, used the thermometer in the
rectum, and thus obtained temperatures higher that the average of
other observations, such as 105.4/6° to 107.2/6° in several cases. Yet
he found the fluctuations of rectal temperature remarkable, though
less so than the surface temperature, of which he states that
sometimes it rose above or fell below the normal standard several
times in the course of the same day.
[Footnote 34: _Amer. Jour. of Med. Sci._, July, 1867, p. 38.]
[Footnote 35: _St. Bart's Reports_, xii. 112.]
Nothing can be more irregular, uncertain, or various than the
eruptions and other cutaneous symptoms that have been met with in this
disease. When it first appeared in New England a large proportion of
the cases, and especially of the grave cases, exhibited petechial
eruptions and ecchymotic spots, whence the disease presently received
the name of spotted fever. Yet even then, North and the other
historians of its epidemics were careful to state that spots on the
skin were by no means characteristic of the disease, and very often
were not present at all, especially in cases that terminated
favorably. Woodward, for example, wrote (1808): "An eruption on the
skin so seldom appeared that it could no longer be considered a
characteristic symptom of the disease." In various American local
epidemics an eruption of some kind seems to have existed in about
one-half of the cases. In one that we observed in the Philadelphia
Hospital no eruption whatever was observed in thirty-seven out of
ninety-eight cases. In the epidemic at Chicago in 1872, N. S. Davis
says:[36] "About one-third of the cases presented some red
erythematous spots" between the third and the seventh day. In mild
cases they were few and {817} bright red; in grave cases, darker and
larger, with some swelling of the skin; and in the worst cases, purple
spots one or two or more inches in diameter. In that of
Louisville,[37] Larrabie states that the eruption "was generally
herpetic in its character, and accompanied by sudamina; but in several
instances an urticarious eruption suddenly appeared and disappeared."
Nothing is said of petechiæ or ecchymoses. In the New York epidemic of
1873[38] the skin in grave cases presented dusky mottlings, especially
when the animal temperature was reduced; also a punctated red
eruption, bluish spots a few lines in diameter, and large patches of
the same color. Herpes also was common. It is chiefly in cases of a
malignant type and rapid and fatal course that ecchymoses have been
observed. Of this statement illustrations will be given in the
paragraph relating to the duration of the disease.
[Footnote 36: _Louisville Med. Jour._, June, 1872, p. 705.]
[Footnote 37: _Louisville Med. Jour._, Dec., 1872, p. 782.]
[Footnote 38: _Amer. Jour. of Med. Sci._, Oct., 1873, p. 329.]
In continental European epidemics of meningitis the proportion of
cases in which a general eruption existed seems to have been smaller
than it was in this country. In the Geneva epidemic of 1805 a
considerable number of cases at the point of death presented purplish
spots, some earlier than this, and some after death only. In the
Neapolitan epidemic of 1833, and in that which occurred in Dublin in
1867-68, ecchymoses were often present, and in a very marked degree.
Stokes and Banks mention that in some rare instances the spots ran
together and coalesced over some portions of the body, so as to cover
a large extent of the skin and render it completely black, as though
it were wrapped in some dark shroud. The entire right arm and half of
the right side of the chest in one case, and in the other the whole of
the lower portion of one leg and foot, were thus affected.[39] In
Strasburg, on the other hand, only three cases of petechiæ were
observed by Tourdes; at Rochefort and Versailles, in 1839, they were
rarely noticed; at Gibraltar, in 1844, they do not seem to have been
observed; in 1848-49, at the Val de Grâce Hospital (Paris), they
appear not to have attracted attention; and at Petit Bourg they were
not noticed, although the state of the skin was fully described. In
Prussia, in 1865, neither Burdon-Sanderson nor Wunderlich mentions
petechiæ or vibices as occurring during life; and Hirsch, after noting
their occasional presence, is obliged to draw upon American authors
for an account of them.
[Footnote 39: _Dublin Quart. Jour._, xlvi. 199.]
Of the eruptions other than petechiæ and ecchymoses, several of which
have already been mentioned, it is necessary to take some notice here.
They are, chiefly, and in general terms, exanthems, including
erythema, roseola, and urticaria, and in addition herpes, particularly
of the lips. The last has no special relation to this affection, as it
is met with in almost every febrile disease, but it has sometimes
extended to the whole face in this one. The former may be connected
pathologically either with the altered condition of the blood or with
the irritation produced by the exudation in the spinal nervous
centres. They have frequently been compared to measles and to
scarlatina, but sometimes they have assumed the form of bullæ. Thus,
in the case of a child four years old, described by Grimshaw,[40] an
eruption of pemphigus occurred over the whole body. Jackson long
before had mentioned, as one of the eruptions belonging to this
disease, "large bullæ, as if produced by cantharides." Jenks {818}
described "large elevated spots of a very dark color, presenting
outside of the dark color a blistered appearance." In some cases
gangrene of the skin has been observed when the spots have been
exceptionally dark, and occasionally has been produced by pressure.
[Footnote 40: _Jour. of Cutaneous Med._, ii. 37.]
The cause of death in many of the more rapid cases is coma, which is
often preceded by convulsions, especially in children; but in many
others, even when attended with all the marks of dissolution of the
blood, consciousness may be but slightly impaired until the actual
imminence of death. In many other cases, which are fatal in the midst
of an attack with spinal symptoms, death is due to asphyxia, partly
owing to pressure on the medulla oblongata, and partly to the
interference with the respiratory act due to this pressure, and
occasioning excessive bronchial secretion. Again, death may occur
through a gradual exhaustion of the powers of life, without marked
spasm, blood-change, or complication. In these cases also the
intelligence remains unimpaired almost until the moment of
dissolution. Death is not very rarely due to pneumonia, and when the
disease is greatly prolonged or the convalescence from it is imperfect
a fatal termination by dropsy of the brain is still among its dangers.
Hirsch once declared that the duration of epidemic meningitis "is
between a few hours and several months," and, however hyperbolical the
phrase may seem, it is quite accurate. Such inequalities are more
characteristic of acute blood diseases than of inflammations, and in
this case the coexistence of elements of both kinds doubtless accounts
for the extreme irregularity of the symptoms and duration of the
attack. The early American writers insisted strongly on this as a
characteristic feature of the disease. They record an unusually large
proportion of cases that were fatal within the first day, and even
after an illness of five hours, although they agree that the most
usual date of death was between the fourth and seventh days--a result
that has been confirmed by subsequent observation. Dr. N. S. Davis
gives the duration of the disease, as seen by him, as between twenty
hours and twenty-eight days. Out of 469 fatal cases in the city of New
York in 1872, 334 are said to have terminated within eleven days, and
of this number 270 were fatal in the first six days of the attack,
including 52 who died on the first day, and 51 in from one to two
days. It is perhaps worthy of note that while from the eleventh to the
fourteenth day only 11 deaths occurred, 20 took place on the
fourteenth and fifteenth; and while from the fifteenth to the
twenty-first day only 16 died, yet from the twenty-first to the
twenty-second 12 deaths were reported. This would seem to indicate a
peculiar danger on the days represented by multiples of seven. Of
cases that recover, the duration is even more indefinite than that of
fatal cases, owing to complications that occur in many, and especially
such as involve the cerebro-spinal centres. When death takes place
within a few hours it usually, if not always, is attended with
symptoms that denote a disorganization of the blood. In 1864 we
attended a young man previously in perfect health, but who died in
twenty-one hours after the first seizure. His mind was unclouded
throughout his brief but fatal illness. Within seven hours of death a
purpurous discoloration of the skin began, and about an hour before
that event the surface everywhere assumed a dusky hue. The forearms
and hands were almost uniformly purple and the face turgid; many
ecchymotic spots on the trunk and lower limbs were nearly black and
measured {819} one or two inches in diameter.[41] In the case of a
child of five years death in convulsions took place after an illness
of ten hours, the skin presenting purpurous spots, some of them very
large and of a deep bluish livid hue. On post-mortem examination there
was not the slightest appearance of any meningeal lesion, except a few
dark spots like sanguineous effusion under the arachnoid. The heart
was full of dark blood in a semi-coagulated state, and the white
corpuscles were three times as numerous as the red.[42] A case is
reported by Gordon[43] in which the entire duration of the illness
until death was five hours. This is probably the shortest case on
record. A lady aged twenty-two years died in sixteen hours, the skin
covered with livid ecchymoses, some of them measuring an inch or an
inch and a half in diameter.[44]
[Footnote 41: _Amer. Jour. of Med. Sci._, July, 1864, p. 133.]
[Footnote 42: _Dublin Quart. Jour._, 1867, ii. 441.]
[Footnote 43: _Loc. cit._]
[Footnote 44: _Med. Press and Circular_, May, 1866. For other cases
see _ibid._, pp. 296, 298-300.]