contained in the foregoing discussion. Of its essential cause and of
the conditions that call it into existence nothing whatever is known.
The disease is most probably due to some atmospheric agency that is
capable of acting at the same time upon widely separated localities.
Its specific cause appears to enter the blood first of all, and
doubtless through the lungs, and to be capable of destroying life by
its action upon the blood alone. Failing this effect, its force is
spent upon the cerebro-spinal pia mater, and it may become fatal by
the mechanical interference of the products of inflammation with the
nutrition of those parts of the central nervous system which are
essential to life. An inflammatory and a septic element together
constitute the fully-developed disease; either may be in excess and
overshadow the other. According to the relative predominance of one or
the other, the disease assumes more of a typhoid or more of an
inflammatory type, and it is doubtless this diversity in its
physiognomy, as well as in the lesions that attend it, which has led
to the most opposite doctrines respecting its nature and its
nosological affinities.
DIAGNOSIS.--The most distinctive phenomena of epidemic meningitis are
suddenness of attack and rapidity of development of the following
symptoms: acute pain in the head, neck, spine, and limbs; faintness,
vomiting; stiffness or spasm of the cervical or spinal muscles;
hyperæsthesia of the skin; delirium, alternating with intelligence and
merging afterward into dulness or coma; occasional convulsive spasms;
paralysis of the face or of one side of the body. The evidences of
associated blood-poisoning are, the epidemic prevalence of the
disease, various eruptions upon the skin (herpes, roseola, petechiæ,
etc.), ecchymoses, debility out of proportion to the evidences of
local disease, redness of the eyes, {827} foulness of the tongue and
mouth, and more or less of the other conditions which characterize the
typhoid state. To these features must be added the rate of mortality,
which is greater in most epidemics of meningitis than that of any
disease with which it is liable to be confounded.
It is distinguished from sporadic meningitis by the fact that the
latter disease is never primary, but is always either an epiphenomenon
of some other and previous malady (various fevers and chronic blood
diseases) or is traumatic in its origin. The thermometer readily
distinguishes it from various functional nervous affections, chiefly
hysterical, in which the temperature remains normal.
From typhoid fever it differs as widely as possible by its rapid
onset, the exquisite pain in the head, the neuralgic pains, the
opisthotonos, and the convulsions. The alternate delirium or coma and
clearness of mind in meningitis contrast with the persistent hebetude,
stupor, or muttering delirium and the muscular relaxation in typhoid
fever. The sordes on the tongue, the diarrhoea, the meteorism, the
intestinal hemorrhage of the latter, instead of the moist or merely
dry tongue and the transient vomiting and torpid bowels of the former;
high or continuous fever on the one hand, slight or variable increase
of temperature on the other; diffluence of blood in the one and an
increase in the proportion of its fibrin in the other; in the one
suppurative inflammation of the cerebro-spinal meninges, in the other
specific lesions of the intestinal and mesenteric glands,--these, as
well as the very different modes of origin of the two affections, draw
a broad and manifest line of distinction between them.
It would scarcely be necessary to point out the contrasts between
epidemic meningitis and typhus fever were it not that, notwithstanding
the abundance of instruction on the subject in medical treatises and
lectures, a large number of physicians confound typhus fever, typhoid
fever, and the typhoid state of inflammatory diseases with one
another. The confusion was intensified at one time by designating the
disease we are studying as spotted fever--a term originally applied
and properly belonging to typhus fever (typhus petechialis). It is
true that New England physicians soon became aware of their error,
which was distinctly pointed out and condemned by North, Strong,
Miner, Foot, Fish, and others in the early part of this century. A
similar error was at first committed both in Ireland and England, but
was corrected by maturer experience. In order to contrast the two
diseases as strongly as possible, we place their distinctive features
side by side in the following table:
EPIDEMIC MENINGITIS. | TYPHUS FEVER.
|
A pandemic disease. Occurs | An endemic disease, due to local
simultaneously in places remote | causes and spreading by
from one another and without | intercommunication.
intercommunication. |
|
Attacks all classes of society. | Attacks the poor, filthy, and
Is never primarily developed by | crowded alone.
destitution, squalor, or |
defective ventilation. |
|
Is not contagious. | Contagious in a high degree.
|
Attacks more males than females.| Both sexes equally affected.
|
Attacks more young persons than | More adults than young persons.
adults. |
|
Generally occurs in winter. | Epidemics irrespective of season.
|
Eruptions are absent in at least| Eruption rarely absent, and
half of the cases; they occur | appears about the fifth day.
within the first day or two. | {828}
|
The eruptions are various; they | Eruption always roseolous, and
include erythema, roseola, | then petechial. Ecchymoses are
urticaria, herpes, etc. | rare.
Ecchymoses are common. |
|
Headache is acute, agonizing, | Headache dull and heavy.
tensive. |
|
Delirium often absent; often | Delirium rarely absent; usually
hysterical, sometimes vivacious,| muttering. Rarely begins before
sometimes maniacal. Generally | the end of the first week.
begins on the first or second |
day. |
|
Pulse very often not above the | A slow pulse exceedingly rare.
natural rate; often | Its rate usually between 90 and
preternaturally frequent or | 120.
infrequent. Is subject to sudden|
and great variations. |
|
"The temperature is lower than | The temperature is always
that recorded in any other | elevated, and does not fall until
typhoid or inflammatory | the close of the attack. "The
disease." It is also very | skin is hot, burning, and pungent
fluctuating. | to the feel."
|
The body has no peculiar smell. | The mouse-like smell is
| characteristic.
|
The tongue is generally moist | The tongue is generally dry,
and soft, and if dry is not | hard, and brown, and the teeth
foul. Sordes on teeth rare. | and gums fuliginous.
|
Vomiting is an almost constant | Vomiting is rare and not urgent.
and urgent symptom, especially |
in the first stage. |
|
Pains in the spine and limbs of | The pains, if any, are dull, and
a sharp and lancinating | apparently muscular.
character are usual. |
|
Tetanic spasms occur in a large | Tetanic spasms are unknown in
proportion of cases and within | typhus. Convulsions sometimes
the first two or three days. | occur, due to pyæmia.
They are due to an exudation on |
the medulla oblongata and |
spinalis. |
|
Cutaneous hyperæsthesia is a | The sensibility of the skin is
prominent symptom. | generally blunted.
|
Strabismus is common. | Strabismus is rare.
|
The eyes, if injected, have a | The blood in the conjunctival
light red or pinkish color. | vessels is dark.
|
The pupils are often variable | The pupils are equal and
and unequal. | contracted.
|
Deafness and blindness are often| Deafness almost always ceases
complete and permanent. | with convalescence. Blindness
| never follows typhus.
|
Duration very indefinite, but | Duration from twelve to fourteen
generally from four to seven | days.
days. |
|
Relapses are common. | Relapses are rare.
|
The blood is often fibrinous. | The blood is never fibrinous.
|
The lesions, except in the most | In typhus no inflammatory lesions
rapid cases, consist of a | exist.
plastic or purulent exudation in|
the meshes of the cerebro-spinal|
pia mater. |
|
Mortality from 20 to 75 per | Mortality from 8 to 40 per cent.
cent. |
PROGNOSIS.--In the section relating to the mortality of epidemic
meningitis it has been seen that its death-rate varies at different
times and places between widely remote extremes. This fact must be
borne in mind in estimating the influence of various circumstances in
controlling the issue of the disease. The relative as well as the
aggregate mortality is far greater in childhood than in adult life.
After the age of thirty or thirty-five it decreases rapidly until old
age, when recovery from the disease is quite exceptional. A sudden or
rapidly developed attack is generally unfavorable, especially when the
symptoms are adynamic and there is a purplish discoloration of the
skin. Indeed, even apart from evidences {829} of blood-change,
cerebral are, on the whole, of graver importance than spinal
phenomena, and the more so the more typhoidal their type. Of still
more serious significance is a want of perception of the gravity of
the situation or unconcern about its issue. A preternaturally slow and
compressible pulse implies danger, and so does coolness of the skin,
especially if it grows purplish from a diffusion of blood beneath it
or even from venous stasis. The various eruptions that have been
described including petechiæ, are not necessarily dangerous signs.
Profuse sweats during a soporose state, bullæ and gangrenous spots,
obstruction of the bronchia with mucus or serum, pneumonia or
pericarditis,--these are all grave indications. So, too, are a dry,
fissured, shrivelled, and pale tongue or a fuliginous state of the
mouth, swelling of the parotids, obstinate vomiting, and profuse
diarrhoea at an advanced stage of the disease. Among the most
unfavorable nervous symptoms are great restlessness, rigid retraction
of the head, spasms of other than the spinal muscles, general
convulsions, extensive hyperæsthesia, deep coma, dilatation and
insensibility of the pupils or their rapid change from a dilated to a
contracted state, retention or incontinence of urine, and all cerebral
paralyses, including that of the muscles of deglutition. The favorable
indications comprise a general mildness of the symptoms, a moderate
loss of strength, a slight degree of pain and muscular stiffness, the
absence of petechiæ or vibices (although in many grave epidemics they
are of rare occurrence), a desire for food and the ability to digest
it. Yet it is imprudent to make an absolute prognosis in any grave
case of this disease. Recovery has sometimes occurred when it appeared
impossible, and some have died when the period of danger seemed to
have passed on the sudden accession of cerebral or spinal nervous
symptoms.
TREATMENT.--The difficulties that attend the solution of therapeutical
questions regarding diseases which are comparatively regular in their
evolution, and are produced by definite causes acting in an
intelligible manner, are very numerous and often insuperable. They
become multiplied in relation to a disease which, like this one,
stands alone in many respects; whose causes, phenomena, and
lesions--in a word, whose laws--are specific; and whose varieties of
type are as numerous as can be formed by the combination, in a
constantly varying proportion, of a special (hypothetical) alteration
of the blood, deranging the molecular actions of the economy, and at
the same time of an inflammation of the cerebro-spinal meninges, and
even of the substance of the great nervous centres. These reasons are
sufficient to account for the diverse and often opposite methods of
treatment that have been applied to the disease. As in almost all
other cases, the methods have consisted in using remedies to
counteract certain symptoms--now a stimulant or tonic regimen to
combat the debility which conferred the name of "sinking typhus" on
the disease; now an antiphlogistic course to allay the inflammation of
the brain and spinal marrow denoted by the neuralgic pain and the
tetanoid phenomena; and, again, large doses of narcotics to blunt the
pain and subdue the spasm. Still other medications have been used with
a similar purpose, and some, as we shall see, with more or less
theoretical views. It may be said, with Von Ziemssen, "that we are far
from having it in our power to decide whether a rational treatment of
the symptoms has cured the disease or lessened its mortality;" but a
review of the methods {830} that have been employed and their results
leads to no doubtful conclusion that some are mischievous and others
more or less salutary.
Emetics were among the first medicines used in the treatment of this
affection, and were probably suggested by the vomiting which is one of
its most constant initial symptoms. But we can readily understand why
they failed to afford relief. The vomiting and retching are not
gastric symptoms at all, but, as already stated, are due to the
irritation of the congestive or inflammatory process at the base of
the brain. These medicines may therefore be omitted. The employment of
purgatives is even less rational; they debilitate without affording
any relief.
Venesection was probably employed as a part of a routine treatment
which neither sound reason nor clinical experience justified. It was
generally found to fail of its curative purpose, and often induced,
especially in young persons, dangerous exhaustion. No better
illustration is needed to show that the disease we have been studying
is far more than a local inflammation of the cerebro-spinal meninges.
On the other hand, local depletion is often of marked utility. Our own
experience would lead us to conclude that in the more sthenic cases
scarified cups, applied to the nape of the neck and along the cervical
vertebræ, are of essential service in mitigating--and generally,
indeed, in wholly removing--the neuralgic pains which form so
prominent and severe a symptom in many cases of this disease. When any
abstraction of blood appears to be contraindicated by the patient's
debility, even dry cups will afford him signal relief. Leeches have
been applied to the parts mentioned, and over the mastoid processes
have sometimes been used with advantage, but their depletory surpasses
their revulsive action, and is, so far, injurious. Cold to the head
and spine is among the most efficient means of relieving certain
symptoms. In the Massachusetts Medical Society's Report of 1810 we
read: "Cold water, snow, and ice have been applied to the head when
there was violent pain in that part with heat and flushed face, and
when there was violent delirium. They afforded great comfort to the
patient, and mitigated or removed those important symptoms." It is
probable, however, that the value of the remedy is almost entirely
restricted to the forming--or at least the early--stage of the attack,
when the pain in the head is most intense. Its soothing influence is
then very marked, as well as its indirect action in promoting sleep.
Heat of head is not an essential condition for its use, for even in
the most violent cases it is rarely extreme, and is often entirely
wanting. Pain calls more distinctly for the application, and when that
symptom has subsided cold is apt to be more annoying than grateful to
the patient. Cold is best applied to the head in the form of pounded
ice enclosed in a bladder or rubber bag; but cold affusions are also
very valuable, especially for children. For the application of cold to
the spine the most efficient apparatus is the long, flat rubber bag,
either single or double.
From the earliest history of epidemic meningitis in this country
blisters formed a conspicuous element in the treatment. They were
used, as they had been in other forms of meningitis, to relieve the
pain and diminish the congestion in the cerebro-spinal centres. The
results of their use were by no means uniform, for not only were they
employed in many of the cases which must almost necessarily have been
fatal before inflammation could be established, but even in the
inflammatory cases {831} they were often applied when time enough had
elapsed to allow the exudation to be fully formed, and when,
therefore, they were too late to be useful. Again, they were sometimes
used so as to vesicate too deeply, and thus by the pain they caused at
first, and by the exhaustion that resulted from the excessive
discharges they maintained, the patient was more injured than
benefited. Our own experience proves that in the early stage of the
inflammatory form of the disease blisters applied below the occipital
ridge and upon the back of the neck, and only allowed to vesicate
superficially, not only remove the pain in the head, but diminish the
delirium, spasms, and coma, and therefore contribute as directly as
other remedies, if not more so, to the favorable issue of the attack.
But such salutary effects are not to be looked for when the disease
assumes a malignant type nor after its constitution has become
definitely fixed. The application of stimulant and even vesicating
agents to the spine below the neck has not been generally practised
because, probably, the seat of the spinal lesions was known to be
chiefly at the upper part of the organ. Still, the neuralgic pains
felt in the spinal nerves may be mitigated by stimulant and anodyne
liniments applied with friction to the spinal column.
American physicians early recognized coolness of the skin among the
most striking phenomena of the disease; and this probably suggested
their use of diaphoretic remedies, among which were the external
application of moist heat in baths and warm wrappings, as well as
"bottles of hot water or billets of wood heated in boiling water and
wrapped in flannel," or the patient "was wrapped in flannel wrung out
of boiling water, sinapisms were applied to the feet, while hot
infusions were administered, made from the leaves of mint, pennyroyal,
and other similar plants, and also wine-whey, wine and water, wine,
brandy, and other ardent spirits more or less diluted, camphor,
sulphuric ether, and opium. It was not generally thought useful to
excite profuse sweating, but important to maintain the activity of the
skin from twenty to forty hours, and even longer in some instances.
Soup and cordials were at the same time administered. Under this
treatment most commonly the violent symptoms, and not very rarely all
the appearances of disease, have subsided" (Jackson). Beyond all
doubt, this method was a rational one, for it tended to promote an
elimination of the morbid poison, while it depleted the blood-vessels
and acted revulsively upon the local inflammation of the
cerebro-spinal meninges. Yet it seems not to have been revived during
the more recent epidemics of the disease, unless, partially, by Gordon
(1867), who says: "What I have seen most useful in the stage of
collapse is external warmth applied to the entire surface by means of
flannel bags containing roasted salt, applied along the spine, along
the chest, inside the arms, and to the feet and legs and between
them."
Except typhus fever, there is no disease in which a due administration
of alcoholic stimulants may become more important. In cases of the
inflammatory type they are rarely needful, and are frequently hurtful,
but in those which exhibit signs of blood disorder with nervous
exhaustion they are often indispensable. Nothing demonstrates their
necessity more clearly than the extraordinary tolerance of alcohol
exhibited in some cases of the disease. Among the earlier American
authorities may be found many illustrations of this statement.
Woodward (1808) {832} observed that very large quantities of wine or
ardent spirits may be given without injury. Arnell said: "In some
cases I have given a quart of brandy in six or eight hours with the
happiest effect." Haskell maintained that "the bold and liberal use of
diffusible stimuli is the only safe and efficacious mode of
treatment." In Ireland the habitual use of alcohol in the treatment of
typhus fever no doubt suggested its liberal employment in this
disease, but such stimulants have never been in vogue among the
physicians of France or Germany. This difference may in part be
accounted for by the generally asthenic type of the disease in the
first-named country and its more inflammatory character in the others.
Similar contrasts of type mark different epidemics, and individual
cases during the same epidemic. We have no doubt that while these
agents are indispensable in the treatment of cases of the former type,
they must even then be exhibited discreetly, for their too lavish
exhibition entails the gravest peril by intoxicating the patients and
oppressing instead of arousing their vital energies. In 1866, on
taking charge of the medical wards in the Philadelphia Hospital, we
found that the patients were using as large quantities of alcohol as
are given in typhus fever, but a very short period of observation
showed that this use of the stimulant was excessive; consequently the
dose of it was first reduced, and finally it was omitted altogether
unless special indications for it arose. This change was followed by a
manifest improvement in the general aspect of the sick and the
subsidence of symptoms which, it then became evident, were due to a
lavish use of stimulants rather than to the gravity of the disease.
Alcohol is no more essential to the treatment of epidemic meningitis
than of any other acute affection; it is a cordial to be held in
reserve to meet those signs of failure of the heart and nervous system
which may arise in all acute diseases attended with changes in the
condition of the blood.
The use of opium in the treatment of this disease was strongly
advocated by nearly all of the early American writers upon the
subject, and by many of them enormous doses were given. It was
observed not to produce narcotic effects in ordinary doses. In one
case, marked by excruciating pain in the head and maniacal delirium,
sixty drops of laudanum were given every hour until nearly half an
ounce had been taken within eight hours (Strong). Haskell states: "We
have been obliged frequently to exhibit ten grains of opium for a dose
in some of the violent cases attended with strong spasms, and have
never known it to produce stupor in a single instance." Miner relates
that "a few cases imperiously required half an ounce of the tincture
of opium in an hour, or half a drachm [of opium] in substance in the
course of twelve hours, before the urgent symptoms could be
controlled, and even some cases required a drachm in the same time.
All these patients recovered." In Europe, Chauffard administered opium
in doses of from three to fifteen grains, and Boudin frequently
prescribed from seven to fifteen grains at a single dose at the
commencement of the attack, and subsequently one or two grains every
half hour, until the patient grew sleepy or his symptoms subsided.
This tolerance of the drug is remarkable, and so is the fact that it
does not cause constipation. These and many similar statements agree
entirely with our personal experience. We were in the habit, during
the epidemic above referred to, of prescribing one grain {833} of
opium every hour in very severe and every two hours in moderately
severe cases, and in no instance was narcotism induced, or even an
approach to that condition. Under the influence of the medicine the
pain and spasm subsided, the skin grew warmer and the pulse fuller,
and the entire condition of the patient more hopeful. It seemed
probable, however, that the benefit of the opium treatment was most
decided in the early stages of the attack, and hence in those in which
the inflammatory and spasmodic elements predominated. The hypodermic
injection of morphia is to be preferred before the internal
administration of other preparations of opium, not only on account of
its prompter action, but because it avoids the rejection of the
medicine by vomiting. On the whole, Von Ziemssen is within the bounds
of truth when he says, "Beyond all doubt morphia may be considered the
most indispensable medicine in the treatment of epidemic meningitis."