Moreover in subacute fatal cases, the temperature before death may bc normal or subnormal; usually, however, it exhibits in the last days a gradual rise persisting till death, such as we observe usually in purulent and not infrequently also in tuberculous meningitis.
The pulse, unlike that in tuberculous meningitis, is usually very rapid from the start, only retarded occasionally in intervals of apyrexia.
Taking into consideration the differential points previously de scribed, together with Iieubner's description, the clinical picture contains to a greater or less degree all the typical symptoms of meningitis. Gen eral epileptiform convulsions may, especially in young children, accom pany the rise in temperature in the beginning of the disease; in its further course arc observed clonic spasms involving a limb or one side of the body; and which are sometimes succeeded by paralysis of the part affected. Paraplegic paralyses without antecedent convulsions are no doubt usually of spinal origin (Striimpell). Clonic twitchings in the region of the facial, of the external ocular muscles (nystagmus) and of the 1-13.-poglossus occUr not infrequently. In all of this there is no typical difference from the other meningitides.
The hypertony of the entire musculature appears especially as extreme cervical rigidity with board-like tension of the upper portion of the sternocleidomastoid muscle, often as trismus and grinding of the teeth. Correspondingly increased reflexes are rarely absent.
A very unpleasant hypermsthesia and hyperalgesia occurs quite as constantly.
Every sudden glaring light, every loud noise, every forcible touch of the skin, every passive motion and change of position, usually evokes distinct signs of pain. During the attacks the face (notably the cheeks and conjunctiv(e) is congested and the vasomotor excitability of the skin is increased (dermatography). Eating is occasionally inhibited by the exce.ssive retraction of the head, and restricted to fluids and semi-solids, often however at least during the respites astonishingly in creased. Emesis is frequent. -When constipation exists it is no doubt partially the result of insufficient eating, partially of a contracted con dition of the intestinal musculature, which is deducible from the presence of the boat-shaped abdomen.
The urine is, notwithstanding the high fever, usually light colored and abundant; small quantities of albumin and occasionally also of sugar have no diagnostic or therapeutic significance.
Very frequently there appears, between the third and sixth (lay of the disease, herpes labialis or nasalis: as yet meningococci have never been found in the vesicles. If the physician first sees the patient during an interval when the symptoms of irritation are not apparent, this herpes may assist in the diagnosis.
The observations of Goppert illustrate in an interesting manlier the great diagnostic difficulties which may exist if the course of a whole (lay at least is not reviewed, but if conclusions must be drawn from a single observation. He found that only twenty of his forty-four cases showed cervical rigidity at isolated examinations, and indeed that only eight of twenty-three children less than a year old showed this which is counted the most constant symptom. On the other hand. besides fever and rapid pulse, the disease may present a complete clinical picture without "meningeal" apathysomiting, anorexia, etc.
Goppert distinguishes three types among the cases without cervical rigidity. In the first type intracranial pressure and expansion of the cranium dominate the clinical picture. The course resembles also in its malignity, simple purulent meningitis. "The second type of the cases without cervical rigidity comprises those. in which tension of the fontanelles also fails us. The children, who have high fever, rapid pulse and hurried respiration, present not a single symptom except pain on passive motion, e.g., when they are propped up, unless some rigidity may be perceived: there is not a trace of cervical rigidity. How easily this type may be overlooked is obvious." He distinguishes as the third type cases with waxy pallor and high fever; these may be mistaken for certain septic forms of purulent cystitis in infancy which they resem ble. Here careful urinalysis is decisive.