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.