The pupils are at first contracted, but dilate as the stupor deepens. They are often sluggish, and may be unequal in size. A squint is some Blindness may occur from keratitis owing to imperfect closure of the eyelids, or from neuro-retinitis due to the spread of the purulent inflammation along the optic nerve ; and in some rare cases the eyeball has been known to be completely destroyed by suppuration. The hearing may be also affected. A temporary deafness with noises in the head may occur during the first clays of the disease and be afterwards re covered from. If it occur later, it is probably due in most cases to purulent inflammation within the labyrinth. This form of deafness is usually bi lateral, complete, and permanent ; and if the patient be a young child, may lead to deaf-mutism.
The pulse is seldom otherwise than quickened ; but it rarely attains at first a high degree of frequency, and is subject to rapid alternations. It is not often intermittent, but is usually very feeble. The breathing is also quickened, and is often irregular and interrupted with sighs. The normal relation between the pulse and the respiration is preserved.
The urine is often natural in quantity, color, and reaction. It has been known to contain albumen and even blood.
There are many differences in the various cases of cerebro-spinal fever met with in the course of the same epidemic. In some the symptoms from the first are indicative of profound blood-poisoning. Consciousness is af fected from the beginning ; there is extreme prostration, a feeble flutter ing pulse, and labored breathing. Then spots appear early and are ex tensively distributed. The stupor deepens into coma, and death takes place with startling rapidity. In these cases the more special symptoms arising from the local inflammation are overshadowed by those dependent upon the general condition, and the patient dies from blood-poisoning. In another class of cases the symptoms of cerebro-spinal inflammation pre dominate, and the more marked phenomena are the convulsions, the draw ing backward of the head, the hypercesthesia, and the tetanic contraction of muscles. In this form if the disease end unfavourably, death is owing mainly to the local lesion. As a rule, the affection is most severe when the epidemic is still young. As the cases get more numerous they become milder ; and at the end of the epidemic it is common for recoveries to take place.
In some instances c'urious intermissions occur in the disease. These may be found quite at the onset, evident premonitory symptoms appearing, passing off and returning, perhaps several times, before the actual out break occurs. In other cases during the course of the disease more or less complete remission of the symptoms lasting for several hours or a day may take place. According to Dr. Frey, this is very common at the end of the second or third day. Again, during convalescence the same variations may be seen, the headache and retraction of head being at times distress ing, at other times scarcely noticeable.
According to Dr. Oscar Meclin, of Stockholm, infants under twelve months old are especially liable to the disease. At this early age the ill ness generally ends fatally ; but sometimes mild cases are observed lasting from a day to a week. This physician, who at the Orphan Asylum of Stockholm had many opportunities of observing the malady, states that the mild cases began with fever, somnolence, and twitchings during sleep. In most instances there were other symptoms, especially during sleep, such as restlessness, great heat of head, changes in the colour of the face and in the sensibility of the body. In a few of the milder cases slight convulsive spasms were noticed, with rigidity of the limbs andneck, strabismus, and di latation of the pupils ; but in such cases these symptoms soon disappeared. In all the epidemics which came under Dr. Medin's observation such mild cases were the exception, and a large proportion of the infants died. In the severer forms the symptoms did not differ from those observed in older children.
Dr. Meclin, like other observers who have had opportunities of study ing this form of illness, speaks of a pneumonia of a low type, occurring without nervous symptoms, as being frequently present in epidemics of cerebro-spinal fever ; and holds with them that in such cases, the infective material attacks the lungs in place of the cerebral membranes. Still, meningitis may be present in such cases, although it gives rise to no symp toms ; for in some instances where during life the symptoms were exclu sively pulmonary, inflammation of the cerebral and spinal meninges was discovered on post-mortem examination of the body. Besides pneumonia, peri- and endo-carditis, pleurisy, parotitis, and purulent effusion into the joints may be complications of the disease.