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. 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, 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.