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 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 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.
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.
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 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
24 Dublin Quart. Jour., xlvi. 187.
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