Steyr 6270_6300 TERRUS CVT Stage

IV Tractor Service Manual 48193184

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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, 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.
34
Amer. Jour. of Med. Sci., July, 1867, p. 38.

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 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 187338 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.
36
Louisville Med. Jour., June, 1872, p. 705.

37
Louisville Med. Jour., Dec., 1872, p. 782.

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.
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 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.
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 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 Gordon43 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
41
Amer. Jour. of Med. Sci., July, 1864, p. 133.

42
Dublin Quart. Jour., 1867, ii. 441.

43
Loc. cit.

44
Med. Press and Circular, May, 1866. For other cases see ibid., pp. 296, 298-300.

The character of the convalescence from epidemic meningitis must

evidently be affected by the causes that determine its duration, the
grade of the disease, the development and extent of the lesions,
etc.; but it is certain that, except in those imperfect and, as it were,
shadowy cases which denote a very slight action of the morbid
cause, its subjects do not recover rapidly. The essential lesion of the
fully-formed disease requires time for its removal, just as in typhoid
fever the intestinal ulcers are often slow of healing, and hence
become a cause of tardy recovery and even of unlooked-for death.
The convalescence, then, from the disease we are now studying is
slow and irregular, is attended often with debility and emaciation,
and sometimes with persistent headache, neuralgia, convulsions,
stiffness of the neck and pain in moving it, hyperæsthesia of
portions of the skin, palpitation of the heart, dyspepsia, etc.
Relapses are very far from being uncommon.

Among the causes of tardy convalescence in this disease are those

lesions and disorders which may be embraced by the term sequelæ.
Impaired vision, due to various affections of the eyes, has already
been considered among the symptoms proper of the disease, but
they are not infrequently developed after the acute attack has
subsided. Thus, in a case reported by Larrabie:45 "Just as
convalescence seemed beginning the left eye became affected in all
its parts, with entire loss of vision and also complete deafness. After
a short remission hydrencephaloid symptoms appeared, followed by
the same changes in the hitherto sound eye, complete blindness and
deafness, general cachexia and marasmus, rigid flexion of the right
limbs, and death by exhaustion at the end of sixteen weeks." The
impairment of hearing, which also was described as a symptom of
the acute attack, is apt to become more marked after the acute
stage has passed by, and, as before stated, is very often permanent.
Occurring in young children, it then involves deaf-mutism. It is in
many cases associated with defective vision, weakness or loss of
memory, mania, impairment of intelligence, persistent pains in the
head or chronic hydrocephalus. Sometimes to one or more of these
symptoms is added more or less general paresis or complete
paralysis. Southhall46 mentions the case of a child two years old
whose attack was followed by incomplete paralysis, and death at the
end of eight months with softening of the brain. Gordon thus
describes the conclusion of a case: "The man has gradually passed
into a state of almost organic life; he eats, drinks, and sleeps well;
he passes solid feces and urine without giving any notice, yet,
evidently, not unconsciously; ... he seems to understand, but cannot
answer; ... he can draw up his legs and arms, but he cannot use his
hands at all." Hirsch has remarked that disorders of speech are met
with, due apparently to an inability to articulate certain sounds. Von
Ziemssen regards chronic hydrocephalus as not a rare consequence
of epidemic meningitis, and as one not absolutely or immediately
fatal. Its symptoms include severe paroxysmal pain in the head or
neck or extremities, with vomiting, loss of consciousness,
convulsions, and involuntary evacuation of excrements. Between the
paroxysms, which sometimes occur periodically, the patient generally
suffers from neuralgic pains, hyperæsthesia, and various motor and
even mental disorders; but in other cases the intervals are free, or
nearly so, from all morbid manifestations. Davis (1872) and many
others speak of severe neuralgic pains following this disease;
according to Dr. D., they are most frequent at the heads of the
gastrocnemii muscles, in the abdomen, and the head; a very fretful
disposition, variable appetite, and disturbed sleep are often
observed. Relapses have been noticed in almost all the epidemics,
and it seems probable that they are often due to the influence of
accidental exciting causes, mental or physical, in renewing the
inflammation around the cerebro-spinal lesions. Miner (1825)
remarked that they were most apt to occur within the first week, but
that when the disease had once run its course there were very few
relapses during convalescence. But, he adds, there were several
repeated attacks after the most perfect recovery, and several of the
patients had had the disease the preceding year.
45
Richmond Journal of Med., Dec., 1872, p. 779.

46
Ibid., Aug., 1872, p. 141.

Like other epidemic diseases, meningitis presents itself with every

possible degree of gravity between that of a slight indisposition and
that of a malignant and deadly malady. The mortality in a number of
epidemics compared by Hirsch varied between 20 per cent. and 75
per cent. It changes with the locality. Thus, nearly at the same time
that the death-rate from this disease in Massachusetts was 61 per
cent., it was but 33 per cent. in the Philadelphia Hospital. In 1872
the whole number of deaths caused by it in Philadelphia was 133,
while at St. John's College, Little Rock, Ark., 21 cases out of 29 were
fatal (Southhall). It differs, also, at different periods; for while ten
epidemics in various places, occurring between 1838 and 1848,
presented an average mortality of 70 per cent., a similar number,
occurring between 1855 and 1865, gave an average mortality of only
30 per cent. It must, however, be confessed that such statistics
cannot be relied upon as accurate, for in private practice many cases
occur that are never reported unless they end fatally.

MORBID ANATOMY.—The lesions found after death from epidemic

meningitis consist essentially of congestion or inflammation of the
cerebro-spinal meninges, but they also include in many cases
hemorrhage, serous effusion, plastic exudation, and tissue-changes
in the brain and spinal marrow, and in many other cases an impaired
constitution of the blood. As the signs of the latter, and not the
former, alterations are met with in the more malignant cases, it is
evident that, looking at the disease as a whole, it must involve a
toxic element of whose operation the various post-mortem lesions
are only effects. These lesions, on the whole, vary with the type of
the disease, and also with its duration, but some are chiefly met with
in cases of a malignant and others in cases of an inflammatory type.

The exterior of the body after death in the early stages of this
disease almost always presents the marks of transudation of the
contents of the blood-vessels. The dependent parts of the body
exhibit large livid patches or a uniform discoloration of the same
hue. In acute cases the muscles are more deeply colored than
natural, and when the attack is prolonged they are said to have their
cohesion impaired by fatty degeneration. Congestion of the brain is
an unfailing accompaniment of the first stage of the disease; its
blood-vessels are all distended with dark blood; the sinuses of the
dura mater are usually filled with coagula of the same hue, though
sometimes very dense. Serum abounds in the arachnoid cavity and
in the ventricles of the brain; it may be clear or milky, and
sometimes it is quite purulent. It is alleged by one reporter that no
less than three pints of turbid serum escaped in a case in which,
however, death did not occur until the thirty-fifth day. Craig found
eight and twelve ounces of a limpid fluid in two cases; and Tourdes
found pus in more than one-half of his cases, either unmixed or
forming a milky liquid. J. L. Smith refers to the case of an infant who
had the disease at the age of five months, and two months
subsequently great prominence of the anterior fontanelle, and other
symptoms which indicated the presence of a considerable amount of
effusion within the cranium. In a case in Dublin,47 there was no
meningeal lesion except in a "few dark spots like sanguineous
effusion under the arachnoid." White48 mentions the case of an adult
that terminated fatally in thirty-six hours, in which the vessels of the
pia mater were very much congested, and sanguineous effusions
existed above and below the cerebellum, and a clot of blood three
inches long and external to the theca extended downward from the
lowest portion of the medulla oblongata. In all of these instances,
then, congestion, the first stage of inflammation, existed. That such
was its real nature is proved by what follows.
47
Dublin Jour., July, 1867, p. 441.

48
Med. Record, iii. 198.

The most characteristic lesion is a fibrinous or purulent exudation in

the meshes of the pia mater. American physicians described it as
early as 1806 in such terms as these: "The dura mater and pia
mater in several places adhered together and to the substance of
the brain; ... between the dura mater and the pia mater was a fluid
resembling pus" (Danielson and Mann). In 1810, Bartlett and Wilson
found "an extravasation of lymph on the surface of the brain;" and in
the same year Jackson and his colleagues, after describing the
congestion and serous effusion found within the cranium "in those
who perished within twelve hours of the first invasion," state that
the arachnoid and pia mater present an effusion between them of
"coagulated lymph or semi-purulent lymph" both on the convexity
and at the base of the brain. These descriptions correspond in all
respects with those of Mathey relating to the epidemic at Geneva in
1805, for he says: "The meningeal blood-vessels were strongly
injected. A jelly-like exudation tinged with blood covered the surface
of the brain; ... on its lower surface and in the ventricles a yellowish
puriform matter was found." Such lesions have been described by a
long line of observers—by Wilson in 1813, Gamage in 1818, Ames
and Sargent in 1848; by Squire, Upham, and a host of others since
1860 in the United States, and by Tourdes, Gilchrist, Ferrus, Wilks,
Gordon, Banks, Gaskoin, Niemeyer, Burdon-Sanderson, and many
more in Europe.

It is evident, therefore, that in a certain number of fatal cases only

sanguineous congestion of the membranes of the brain and spinal
cord are found, and in certain others—constituting, it may be added,
nine-tenths of the whole number—evidences exist of cerebro-spinal
meningitis. Hence the natural conclusion is that the congestive
lesions represent the first stage of a process which if prolonged and
perfected occasions the lesions peculiar to inflammation. For the
development of the latter two factors would seem to be essential—
not only a fibrinous condition of the blood, but also sufficient time
for exudation to occur. But when we come to study the actual results
of examinations post-mortem, it is found that the duration of the
attack does not determine absolutely the nature of the lesions. On
the one hand, in a case which terminated fatally after a week's
illness there was found reddish serum between the arachnoid and
the pia mater and in the lateral ventricles, with intense injection of
the pia mater of the base, medulla oblongata, and upper part of the
spinal cord, but no exudation of lymph.49 And, on the other hand,
numerous cases have been published in which, although death
occurred within twenty-four hours from the onset of the attack,
coagulated lymph and also pus were found upon the brain and
spinal marrow. For example, during the winter of 1861-62, in the
army, that then lay near Washington, D.C., a soldier was attacked
with a chill, severe fever, and headache, followed by opisthotonos
and repeated convulsions before his death, which occurred in about
twenty-four hours. No eruption or discoloration of the skin is
mentioned in the history. On examination there was found beneath
the arachnoid a thin layer of lymph and abundant exudation over the
posterior lobes of the cerebrum, and also at the base of the brain
and on the medulla oblongata.50 In a case reported by Gordon51 the
entire duration of the illness was under five hours, and after death
the cerebral arachnoid was more or less opaque, and in some spots
had a layer of very thin purulent matter beneath it. And, again, not
only may the symptoms belonging to blood-dissolution be consistent
with a certain prolongation of life, but also with decidedly
inflammatory tissue-changes. Thus, in another case of Gordon's the
duration of the illness was at least six days, and the patient
presented all the characteristic symptoms of the disease, including
"a most wonderful and uniform curve of the spine and head
backward," "spots black as ink," "bullæ which rapidly became
opaque and dusky," "herpetic eruption, etc." After death the body
had a very frightful appearance. It was still prominently arched
forward. It was of a dusky blue color, with a copious eruption of
black spots of various sizes, and one or two of them were
gangrenous.... When the theca vertebralis was opened purulent
matter flowed out, and a purulent effusion was found in patches on
the brain. The cerebral arachnoid was all opaque, the lateral
ventricles were filled with serum, and the blood in all the cavities
was very fluid and dark colored. From all that precedes, therefore, it
must be inferred that the nature of the lesions in this disease
depends not on the type alone, nor on the duration merely, of the
attack—that a very brief course is compatible with marked
inflammatory lesions, and a prolonged one with profound alterations
in the condition of the blood. In other words, it seems that there
must be something besides the appreciable lesions that influences, if
it does not determine, the issue of an attack of this affection. While
bringing forward prominently this proposition, and the facts on
which it rests, we have no intention of under-estimating the relative
significance of the two most conspicuous types of the disease, the
purely inflammatory and the adynamic, or calling in question the fact
that the evolution of the former is most usually comparatively slow
and regular, and of the latter rapid and irregular. In the one, when
death takes place early, congestive changes are found, and when
later these have merged into exudative lesions; in the other or
adynamic cases congestion and liquid transudation prevail, and the
results of complete inflammation are seldom seen. When the disease
has been very much prolonged the exudation becomes tough,
adherent, and shrivelled.
49
Davis, Richmond Med. Jour., June, 1872, p. 709.

50
Frothingham, Amer. Med. Times, Apr., 1864, p. 207.

51
Dublin Quart. Jour., May, 1867, p. 409.

The brain-tissue has generally been found softer than natural, and,
although in some cases this diminished consistence might be
attributed to post-mortem changes, yet on the whole it must be
associated with the inflammatory lesions of the meninges. As a rule,
it is greater the longer the attack has lasted, and is by no means
equally diffused, but is more marked where the meningeal
alterations are greatest. Ames found softening in nine out of eleven
cases, and chiefly in the cortical substance, but also in the fornix and
septum lucidum; and Chauffard states that in protracted cases "the
interior surface of the ventricles, the fornix, and septum lucidum,
were reduced to a pultaceous and creamy consistence." But it is by
no means true that softening is met with in all cases of long
duration.

The lesions of the spinal marrow and its membranes correspond with
those of the brain. The dura mater is often very dark, its blood-
vessels engorged, its arachnoid cavity distended with serum more or
less bloody, turbid, or purulent. Two ounces of pus have been
removed from it through a puncture. Fibrinous and purulent
exudation fills the meshes of the pia mater, and is usually most
abundant in the cervical and dorsal portions, and generally upon the
posterior rather than upon the anterior surface of the organ; but
sometimes large accumulations of lymph and pus are found at the
lower end of the cord. Gordon52 relates of a case that "when an
opening was made into the lower part of the theca vertebralis
purulent matter flowed out, and the entire surface of the pia mater
was covered with a coating of thin purulent matter, which, like a thin
layer of butter, remained adherent to it." Occasionally the cavity of
the spinal arachnoid contains blood. Softening of the spinal cord has
been often noticed. Chauffard states that in some cases of
particularly long duration it was reduced to a mere pulp, and he
adds, "in the place of portions of the spinal marrow, completely
destroyed, was found only a yellowish liquid, or the empty
membranes fell into contact where it was wanting." Similar
disorganization has been described by Ames, Klebs, and others.
Fronmüller reports the case of a girl aged fourteen years in whom
the central canal of the spinal cord was distended with pure pus.
52
Dublin Quart. Jour., xliii. 414.

The lesions of the internal auditory apparatus consist of softening in

the fourth ventricle and of the root of the auditory nerve, yet such
lesions are said to have been found even when no defect of hearing
had existed. In other cases in which deafness did occur the lesions
consisted of inflammatory changes in the cavity of the tympanum
and suppuration of the labyrinth. They probably arose from an
extension of inflammation from the pia mater along the trunk of the
auditory nerve (Von Ziemssen). In like manner, the inflammatory and
destructive changes in the eye which have been elsewhere described
arise from an analogous cause affecting the optic nerves.

It is unnecessary to dwell upon the condition in which other organs

are found after death from epidemic meningitis. In cases that
present a typhoid type, and even in such as are rapidly fatal with
ecchymotic discoloration of the skin, the various organs present no
distinctive tissue-change, but only such engorgement as is common
to all diseases of a similar type. It deserves to be particularly
mentioned that in this affection the spleen is not enlarged, as it
always is in a greater or less degree in diseases whose primary stage
involves an altered condition of the blood. This fact becomes all the
more important in view of the remarkable contrast which the
constitution of the blood presents in epidemic meningitis and in
various typhous affections.

The state of the blood in this disease is one of peculiar interest,

dominating as it does its whole pathology and determining its
nosological position. It is the blood of a phlegmasia rather than of a
pyrexia. This fact was early established by American physicians who
observed the disease, and the opportunities for doing so were not
wanting, since venesection was used by every one who treated it. In
1807-09 a rapidly fatal case or two was found in which the "blood
was darker and had a larger proportion of serum than usual," but in
others "it did not present any uncommon appearance, and no
inflammatory buff, nor was it dissolved" (Fish). In 1811, Arnell stated
that "the blood drawn in the early stage appeared like that of a
person in full health; there was no unusual buffy coat, neither was
the crassamentum broken down or destroyed." In the epidemic
studied by Mannkopff (1866) he found that blood obtained by
venesection gave a clot with a thick buffy coat. Andral, seeking to
establish the law that in every acute inflammation there is an
increase in the fibrin of the blood, remarks that in a case of cerebro-
spinal meningitis it was very marked.53 Ames states that "the blood
taken from the arm and by cups from the back of the neck"
"coagulated with great rapidity." "Its color was generally bright—in a
few cases nearly approaching to that of arterial blood; it was seldom
buffed; in thirty-seven cases in which its appearance was noted it
was buffed in only four." Analyses were made in four cases, "the
blood being taken early in the disease from the arm, and was the
first bleeding in each case. They furnished the following results:

Fibrin. Corpuscles.
I 6.40 140.29
II 5.20 112.79
III 3.64 123.45
IV 4.56 129.50
The first was from a laboring man thirty-five years old; the second
from a boy twelve years old, while comatose; and the two others
from stout women between thirty and thirty-five."54 Tourdes, whose
analyses follow, states that "blood drawn from a vein was rarely
buffed; if a buffy coat existed, it was thin, and generally a mere
iridization upon the surface of the clot."55

Fibrin. Corpuscles.
I 4.60 134.00
II 3.90 135.54
III 3.70 143.00
IV 5.63 137.84

Maillot gives, as the result of an analysis of six cases, an increase of

fibrin to six parts and more in a thousand. This summary represents,
as far as is known, all of the analyses of blood taken from living
patients in this disease, and it shows that in every case the
proportion of fibrin exceeded that of healthy blood, and
corresponded exactly to that observed in the blood of inflammatory
diseases, while the proportion of red corpuscles varied within the
normal limits. How different is this condition of the blood from that
of typhus fever, in which there is a marked diminution of fibrin, and
a falling off in the red corpuscles as well, or from that of typhoid
fever, in which neither element declines until the disease affects the
body by inanition! (Murchison).
53
Path. Hæmatology, p. 73.

54
New Orleans Med. and Surg. Jour., Nov., 1848.

55
Epidemie de Strasbourg, p. 160.

In regard to the condition of the blood after death the historians of

the disease are not so well agreed; nevertheless, the preponderance
of the testimony is in favor of the statement that the blood presents
appearances resembling those belonging to the continued fevers
rather than to the inflammations. It is true that even in this the
agreement is neither general nor complete. Tourdes, for example,
states that in an autopsy "the blood was remarkable for the
abundance and toughness of the fibrinous clots," but the greater
number have reported it as being dark and liquid. Such was its
condition in the epidemic which we studied at the Philadelphia
Hospital in 1866-67, and it has been correctly described by Dr.
Githens as follows: "The blood was fluid, of the color and
appearance of port-wine lees; under the microscope the corpuscles
were shrivelled and crenated, and there was a space apparent
between them as they were arranged in rouleaux. There were in two
cases white, firm, fibrinous heart-clots extending through both
ventricles and auricles and into the vessels leading to and from the
heart."56 It may be added that the red corpuscles are often crenated
and shrivelled when the case has been protracted, and it has been
stated—from limited observation, indeed—that "the white corpuscles
are three times more numerous than the red."57 The blood has been
scrutinized to discover, if possible, some of those bodies which are
judged by Koch and his disciples to differentiate general diseases,
but it is stated that the investigation has been without definite
result.58
56
Amer. Jour. of Med. Sci., July, 1867, p. 23.

57
Dublin Quart. Jour., May, 1867, p. 441.

58
Jaffé, Phila. Med. Times, xii. 599.

It does not seem difficult to reconcile the conflicting statements now

given of the condition of the blood in epidemic meningitis. One of
them points to an excess and the other to a loss of the
spontaneously coagulable element of the blood. It is evident that
venesection, which was necessary for procuring the living blood for
analysis, would only be performed when the type of the disease
authorized it—that is, when the type was sthenic; whereas the blood
examined after death had necessarily undergone changes which
tended to, if they did not actually, occasion death. Hence we find
among the former cases, when fatal, the most extensive and
massive exudation, and always among the latter less evidence of
inflammation, but, on the other hand, a greater or less manifestation
of those appearances which denote a loss of the vitality and
organization of the blood. In the one case death may fairly be
attributed, above all other causes, to the pressure upon, and the
disorganization of, the cerebro-spinal organs essential to life; in the
other, primarily, to the death of the vital elements of the blood
produced by the specific cause of the disease. It is probable that the
post-mortem fluidity of the blood exists under two conditions. In the
one the morbid cause is powerful enough from the very
commencement rapidly to destroy the life of that fluid, and in the
other it acts less violently, but continuously, to exhaust the powers
of life.

Our conception of the pathology of epidemic meningitis is implicitly

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, 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
simultaneously in places remote local causes and spreading by
from one another and without intercommunication.
intercommunication.
Attacks all classes of society. Is Attacks the poor, filthy, and
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.