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.