On the other hand complications due to metastatic pyogenic processes occur not so infrequently. Of these articular and periarticular. some times also intermuscular purulent processes, purulent pleuritis, endo and pericarditis, rarely dysentery-like enteritis, and nephritis may be mentioned. Of greater clinical importance than these, whieh often completely recover, are the disease of the eye and of the labyrinth, (which we shall later discuss more fully) since they heal—if ever—only with severe permanent defects.
clinical picture, the individual characteristics of which justify the classiffitation of meningoeoccus meningitis as an inde penclent disease, requires an accurate deseription. Tieubiter has so skilfully treated the points in differential diagnosis that we shall clo well to repeat his words. Speaking of the sporadic eases, he says: "Their connection with the epidemic form is clinically characterized by the marked prominence of the motor and sensory symptoms of irritation: by the rigidity of the neck, spinal colunin. muscles, the violenee of headache and of dorsal pain, the frequent recurrence of etnesis, by the striking inferiority of the. psychic disturbanees, the clear intellect preserved throughout the greater part of the sickness. which renders the numerous painful experienees particularly tormenting and thereby creates extreme moodiness, by incessant variations in its eourse, general imprcreement lasting hours or days, which is always associated w-ith striking change of temperament and is always dissipated by a fresh relapse, by the indefinite course, protracted for weeks or months, which however may still terminate in complete recovery, by the decidedly higher percentage of reeoveries than appears in all other forms of men ingitis." Any one who has frequently had the opportunity of observing these usually sharply defined charaeteristics of epidemic meningitis, will hardly comprehend how- these cases can be so indiscriminately classed with other forms of meningitis: the differentiation from some forms of tubereulous meningitis might perchance offer the greatest difficulty; but with purulent meningitis of other etiology only the fulminating epidemic eases can be confused.
As we have above described the clinical pictures of purulent and tuberculous meningitis and having here presented the characteristic features of typieal eases of meningoeoccus meningitis in the quotation from Heubner, there remains the completing of the symptomatology at least in some respects, and the description of atypical courses.
We are indebted to Sorensen's researches for important eonclusions: The disease most frequently begins suddenly. indeed turbulently, with fever, sometimes with a chill, vomiting and pains especially in the head, less frequently in the limbs. Soon cloudiness of the intellect appears: the patient may be confused or delirious or stupefied; at tittles also isolated twitehings in certain muscle areas, or general convul sions occur.
Although this turbulent onset is the rule, there oecur cases with more gradual or intermittent beginning, without having on this aeeount a better prognosis.
To facilitate a better understanding of the eomplieated course of the disease—characterized also by sudden changes of symptoms—Sorensen analyses it into what he calls its elementary parts, w-hich "in their sim plest form consist of fever and evidences of pain, to which symptoms very frequently vomiting and somnolence, at times symptoms of decidedly depressing character are added." If these individual elements, which can without distorting the facts, be gleaned from the history of the case, are separated by greater intervals more or less free from fever and pain, then there exists. a plainly remittent character as well of fever as of the other symptoms. If on the contrary the elements directly succeed each other, then a more continuous course results.
Of course, besides these two types all imaginable variations occur in a disease so prone to ehange.s and this also is exemplified by Sorensen.
In making a decision at the bedside it is important to know that, especially during the stage of invasion, the fever may not progress pari passu u-ith the severity of the meningeal symptoms; but that with a rise of fever a diminution of the disturbances, previously very torment ing, may occur.
It must be regarded as a very unfavorable prognostic sign if neither exacerbations nor remissions of the fever induce noticeable changes in the general condition, and especially if the symptoms of exhaustion are not sometimes dissipated, at least (luring short periods of increased irritation.