A system of practical medicine. By American authors. Vol. 1

by Unknown

EPIDEMIC MENINGITIS.	TYPHUS FEVER.
A pandemic disease. Occurs simultaneously in places remote from one another and without intercommunication.	An endemic disease, due to local causes and spreading by intercommunication.
Attacks all classes of society. Is never primarily developed by destitution, squalor, or defective ventilation.	Attacks the poor, filthy, and crowded alone.
Is not contagious.	Contagious in a high degree.
Attacks more males than females.	Both sexes equally affected.
Attacks more young persons than adults.	More adults than young persons.
Generally occurs in winter.	Epidemics irrespective of season.
Eruptions are absent in at least half of the cases; they occur within the first day or two.	Eruption rarely absent, and appears about the fifth day.
The eruptions are various; they include erythema, roseola, urticaria, herpes, etc. Ecchymoses are common.	Eruption always roseolous, and then petechial. Ecchymoses are rare.
Headache is acute, agonizing, tensive.	Headache dull and heavy.
Delirium often absent; often hysterical, sometimes vivacious, sometimes maniacal. Generally begins on the first or second day.	Delirium rarely absent; usually muttering. Rarely begins before the end of the first week.
Pulse very often not above the natural rate; often preternaturally frequent or infrequent. Is subject to sudden and great variations.	A slow pulse exceedingly rare. Its rate usually between 90 and 120.
"The temperature is lower than that recorded in any other typhoid or inflammatory disease." It is also very fluctuating.	The temperature is always elevated, and does not fall until the close of the attack. "The skin is hot, burning, and pungent to the feel."
The body has no peculiar smell.	The mouse-like smell is characteristic.
The tongue is generally moist and soft, and if dry is not foul. Sordes on teeth rare.	The tongue is generally dry, hard, and brown, and the teeth and gums fuliginous.
Vomiting is an almost constant and urgent symptom, especially in the first stage.	Vomiting is rare and not urgent.
Pains in the spine and limbs of a sharp and lancinating character are usual.	The pains, if any, are dull, and apparently muscular.
Tetanic spasms occur in a large proportion of cases and within the first two or three days. They are due to an exudation on the medulla oblongata and spinalis.	Tetanic spasms are unknown in typhus. Convulsions sometimes occur, due to pyæmia.
Cutaneous hyperæsthesia is a prominent symptom.	The sensibility of the skin is generally blunted.
Strabismus is common.	Strabismus is rare.
The eyes, if injected, have a light red or pinkish color.	The blood in the conjunctival vessels is dark.
The pupils are often variable and unequal.	The pupils are equal and contracted.
Deafness and blindness are often complete and permanent.	Deafness almost always ceases with convalescence. Blindness never follows typhus.
Duration very indefinite, but generally from four to seven days.	Duration from twelve to fourteen days.
Relapses are common.	Relapses are rare.
The blood is often fibrinous.	The blood is never fibrinous.
The lesions, except in the most rapid cases, consist of a plastic or purulent exudation in the meshes of the cerebro-spinal pia mater.	In typhus no inflammatory lesions exist.
Mortality from 20 to 75 per cent.	Mortality from 8 to 40 per cent.

PROGNOSIS.—In the section relating to the mortality of epidemic meningitis it has been seen that its death-rate varies at different times and places between widely remote extremes. This fact must be borne in mind in estimating the influence of various circumstances in controlling the issue of the disease. The relative as well as the aggregate mortality is far greater in childhood than in adult life. After the age of thirty or thirty-five it decreases rapidly until old age, when recovery from the disease is quite exceptional. A sudden or rapidly developed attack is generally unfavorable, especially when the symptoms are adynamic and there is a purplish discoloration of the skin. Indeed, even apart from evidences of blood-change, cerebral are, on the whole, of graver importance than spinal phenomena, and the more so the more typhoidal their type. Of still more serious significance is a want of perception of the gravity of the situation or unconcern about its issue. A preternaturally slow and compressible pulse implies danger, and so does coolness of the skin, especially if it grows purplish from a diffusion of blood beneath it or even from venous stasis. The various eruptions that have been described including petechiæ, are not necessarily dangerous signs. Profuse sweats during a soporose state, bullæ and gangrenous spots, obstruction of the bronchia with mucus or serum, pneumonia or pericarditis,—these are all grave indications. So, too, are a dry, fissured, shrivelled, and pale tongue or a fuliginous state of the mouth, swelling of the parotids, obstinate vomiting, and profuse diarrhoea at an advanced stage of the disease. Among the most unfavorable nervous symptoms are great restlessness, rigid retraction of the head, spasms of other than the spinal muscles, general convulsions, extensive hyperæsthesia, deep coma, dilatation and insensibility of the pupils or their rapid change from a dilated to a contracted state, retention or incontinence of urine, and all cerebral paralyses, including that of the muscles of deglutition. The favorable indications comprise a general mildness of the symptoms, a moderate loss of strength, a slight degree of pain and muscular stiffness, the absence of petechiæ or vibices (although in many grave epidemics they are of rare occurrence), a desire for food and the ability to digest it. Yet it is imprudent to make an absolute prognosis in any grave case of this disease. Recovery has sometimes occurred when it appeared impossible, and some have died when the period of danger seemed to have passed on the sudden accession of cerebral or spinal nervous symptoms.

TREATMENT.—The difficulties that attend the solution of therapeutical questions regarding diseases which are comparatively regular in their evolution, and are produced by definite causes acting in an intelligible manner, are very numerous and often insuperable. They become multiplied in relation to a disease which, like this one, stands alone in many respects; whose causes, phenomena, and lesions—in a word, whose laws—are specific; and whose varieties of type are as numerous as can be formed by the combination, in a constantly varying proportion, of a special (hypothetical) alteration of the blood, deranging the molecular actions of the economy, and at the same time of an inflammation of the cerebro-spinal meninges, and even of the substance of the great nervous centres. These reasons are sufficient to account for the diverse and often opposite methods of treatment that have been applied to the disease. As in almost all other cases, the methods have consisted in using remedies to counteract certain symptoms—now a stimulant or tonic regimen to combat the debility which conferred the name of "sinking typhus" on the disease; now an antiphlogistic course to allay the inflammation of the brain and spinal marrow denoted by the neuralgic pain and the tetanoid phenomena; and, again, large doses of narcotics to blunt the pain and subdue the spasm. Still other medications have been used with a similar purpose, and some, as we shall see, with more or less theoretical views. It may be said, with Von Ziemssen, "that we are far from having it in our power to decide whether a rational treatment of the symptoms has cured the disease or lessened its mortality;" but a review of the methods that have been employed and their results leads to no doubtful conclusion that some are mischievous and others more or less salutary.

Emetics were among the first medicines used in the treatment of this affection, and were probably suggested by the vomiting which is one of its most constant initial symptoms. But we can readily understand why they failed to afford relief. The vomiting and retching are not gastric symptoms at all, but, as already stated, are due to the irritation of the congestive or inflammatory process at the base of the brain. These medicines may therefore be omitted. The employment of purgatives is even less rational; they debilitate without affording any relief.

Venesection was probably employed as a part of a routine treatment which neither sound reason nor clinical experience justified. It was generally found to fail of its curative purpose, and often induced, especially in young persons, dangerous exhaustion. No better illustration is needed to show that the disease we have been studying is far more than a local inflammation of the cerebro-spinal meninges. On the other hand, local depletion is often of marked utility. Our own experience would lead us to conclude that in the more sthenic cases scarified cups, applied to the nape of the neck and along the cervical vertebræ, are of essential service in mitigating—and generally, indeed, in wholly removing—the neuralgic pains which form so prominent and severe a symptom in many cases of this disease. When any abstraction of blood appears to be contraindicated by the patient's debility, even dry cups will afford him signal relief. Leeches have been applied to the parts mentioned, and over the mastoid processes have sometimes been used with advantage, but their depletory surpasses their revulsive action, and is, so far, injurious. Cold to the head and spine is among the most efficient means of relieving certain symptoms. In the Massachusetts Medical Society's Report of 1810 we read: "Cold water, snow, and ice have been applied to the head when there was violent pain in that part with heat and flushed face, and when there was violent delirium. They afforded great comfort to the patient, and mitigated or removed those important symptoms." It is probable, however, that the value of the remedy is almost entirely restricted to the forming—or at least the early—stage of the attack, when the pain in the head is most intense. Its soothing influence is then very marked, as well as its indirect action in promoting sleep. Heat of head is not an essential condition for its use, for even in the most violent cases it is rarely extreme, and is often entirely wanting. Pain calls more distinctly for the application, and when that symptom has subsided cold is apt to be more annoying than grateful to the patient. Cold is best applied to the head in the form of pounded ice enclosed in a bladder or rubber bag; but cold affusions are also very valuable, especially for children. For the application of cold to the spine the most efficient apparatus is the long, flat rubber bag, either single or double.

From the earliest history of epidemic meningitis in this country blisters formed a conspicuous element in the treatment. They were used, as they had been in other forms of meningitis, to relieve the pain and diminish the congestion in the cerebro-spinal centres. The results of their use were by no means uniform, for not only were they employed in many of the cases which must almost necessarily have been fatal before inflammation could be established, but even in the inflammatory cases they were often applied when time enough had elapsed to allow the exudation to be fully formed, and when, therefore, they were too late to be useful. Again, they were sometimes used so as to vesicate too deeply, and thus by the pain they caused at first, and by the exhaustion that resulted from the excessive discharges they maintained, the patient was more injured than benefited. Our own experience proves that in the early stage of the inflammatory form of the disease blisters applied below the occipital ridge and upon the back of the neck, and only allowed to vesicate superficially, not only remove the pain in the head, but diminish the delirium, spasms, and coma, and therefore contribute as directly as other remedies, if not more so, to the favorable issue of the attack. But such salutary effects are not to be looked for when the disease assumes a malignant type nor after its constitution has become definitely fixed. The application of stimulant and even vesicating agents to the spine below the neck has not been generally practised because, probably, the seat of the spinal lesions was known to be chiefly at the upper part of the organ. Still, the neuralgic pains felt in the spinal nerves may be mitigated by stimulant and anodyne liniments applied with friction to the spinal column.

American physicians early recognized coolness of the skin among the most striking phenomena of the disease; and this probably suggested their use of diaphoretic remedies, among which were the external application of moist heat in baths and warm wrappings, as well as "bottles of hot water or billets of wood heated in boiling water and wrapped in flannel," or the patient "was wrapped in flannel wrung out of boiling water, sinapisms were applied to the feet, while hot infusions were administered, made from the leaves of mint, pennyroyal, and other similar plants, and also wine-whey, wine and water, wine, brandy, and other ardent spirits more or less diluted, camphor, sulphuric ether, and opium. It was not generally thought useful to excite profuse sweating, but important to maintain the activity of the skin from twenty to forty hours, and even longer in some instances. Soup and cordials were at the same time administered. Under this treatment most commonly the violent symptoms, and not very rarely all the appearances of disease, have subsided" (Jackson). Beyond all doubt, this method was a rational one, for it tended to promote an elimination of the morbid poison, while it depleted the blood-vessels and acted revulsively upon the local inflammation of the cerebro-spinal meninges. Yet it seems not to have been revived during the more recent epidemics of the disease, unless, partially, by Gordon (1867), who says: "What I have seen most useful in the stage of collapse is external warmth applied to the entire surface by means of flannel bags containing roasted salt, applied along the spine, along the chest, inside the arms, and to the feet and legs and between them."

Except typhus fever, there is no disease in which a due administration of alcoholic stimulants may become more important. In cases of the inflammatory type they are rarely needful, and are frequently hurtful, but in those which exhibit signs of blood disorder with nervous exhaustion they are often indispensable. Nothing demonstrates their necessity more clearly than the extraordinary tolerance of alcohol exhibited in some cases of the disease. Among the earlier American authorities may be found many illustrations of this statement. Woodward (1808) observed that very large quantities of wine or ardent spirits may be given without injury. Arnell said: "In some cases I have given a quart of brandy in six or eight hours with the happiest effect." Haskell maintained that "the bold and liberal use of diffusible stimuli is the only safe and efficacious mode of treatment." In Ireland the habitual use of alcohol in the treatment of typhus fever no doubt suggested its liberal employment in this disease, but such stimulants have never been in vogue among the physicians of France or Germany. This difference may in part be accounted for by the generally asthenic type of the disease in the first-named country and its more inflammatory character in the others. Similar contrasts of type mark different epidemics, and individual cases during the same epidemic. We have no doubt that while these agents are indispensable in the treatment of cases of the former type, they must even then be exhibited discreetly, for their too lavish exhibition entails the gravest peril by intoxicating the patients and oppressing instead of arousing their vital energies. In 1866, on taking charge of the medical wards in the Philadelphia Hospital, we found that the patients were using as large quantities of alcohol as are given in typhus fever, but a very short period of observation showed that this use of the stimulant was excessive; consequently the dose of it was first reduced, and finally it was omitted altogether unless special indications for it arose. This change was followed by a manifest improvement in the general aspect of the sick and the subsidence of symptoms which, it then became evident, were due to a lavish use of stimulants rather than to the gravity of the disease. Alcohol is no more essential to the treatment of epidemic meningitis than of any other acute affection; it is a cordial to be held in reserve to meet those signs of failure of the heart and nervous system which may arise in all acute diseases attended with changes in the condition of the blood.

The use of opium in the treatment of this disease was strongly advocated by nearly all of the early American writers upon the subject, and by many of them enormous doses were given. It was observed not to produce narcotic effects in ordinary doses. In one case, marked by excruciating pain in the head and maniacal delirium, sixty drops of laudanum were given every hour until nearly half an ounce had been taken within eight hours (Strong). Haskell states: "We have been obliged frequently to exhibit ten grains of opium for a dose in some of the violent cases attended with strong spasms, and have never known it to produce stupor in a single instance." Miner relates that "a few cases imperiously required half an ounce of the tincture of opium in an hour, or half a drachm [of opium] in substance in the course of twelve hours, before the urgent symptoms could be controlled, and even some cases required a drachm in the same time. All these patients recovered." In Europe, Chauffard administered opium in doses of from three to fifteen grains, and Boudin frequently prescribed from seven to fifteen grains at a single dose at the commencement of the attack, and subsequently one or two grains every half hour, until the patient grew sleepy or his symptoms subsided. This tolerance of the drug is remarkable, and so is the fact that it does not cause constipation. These and many similar statements agree entirely with our personal experience. We were in the habit, during the epidemic above referred to, of prescribing one grain of opium every hour in very severe and every two hours in moderately severe cases, and in no instance was narcotism induced, or even an approach to that condition. Under the influence of the medicine the pain and spasm subsided, the skin grew warmer and the pulse fuller, and the entire condition of the patient more hopeful. It seemed probable, however, that the benefit of the opium treatment was most decided in the early stages of the attack, and hence in those in which the inflammatory and spasmodic elements predominated. The hypodermic injection of morphia is to be preferred before the internal administration of other preparations of opium, not only on account of its prompter action, but because it avoids the rejection of the medicine by vomiting. On the whole, Von Ziemssen is within the bounds of truth when he says, "Beyond all doubt morphia may be considered the most indispensable medicine in the treatment of epidemic meningitis."

There is no evidence sufficient to show that epidemic meningitis has ever been cured by quinia alone. In the early prevalence of the disease it was treated by large doses of cinchona, but unavailingly, and subsequently smaller doses were given during the convalescence, as it was in that of other acute diseases. In some parts of this country where miasmatic diseases prevail, and epidemic meningitis, like all other acute, and especially febrile, disorders, displayed more or less of a periodical or paroxysmal type, quinia was used in large doses, but the expected result was not realized. Upham states that in some instances it was given to the extent of sixty, or even eighty, grains within twelve hours from the beginning of the attack, but without effect. In Europe it was extensively tried and unanimously condemned. It may very properly be left out of the list of medicines suitable for this disease, particularly since it is no longer probable that any physician would be rash enough to employ it in the so-called antipyretic doses with or without their usual associates, cold baths. According to Karl Jaffé, the medicinal antipyretics (quinia, salicylic acid, and also sodium benzoate) may be entirely discarded, because they ruin the already weakened digestion.⁵⁹