EPIDEMIC CEREBRO-SPINAL MENINGITIS. 251 



ed, and must be evacuated with the catheter. The now unconscious 

 patient falls into deep stupor, the moaning respiration is accompanied 

 by moist rales, and death occurs with the symptoms of acute oedema 

 of the lungs. 



In some particularly severe cases the above symptoms develop far 

 more rapidly; consciousness is lost even during the first day, while 

 severe tetanic spasms of muscles of the neck and back draw the head 

 far backward. Death may occur even on the first or second day, when 

 the disease is very malignant. 



Lastly, in some few cases (of which there can be no doubt) the dis 

 ease runs a still more rapid course, and causes death in a few hours, 

 from general paralysis, occasionally even without the appearance of 

 the most characteristic tetanic symptoms (mkningitefoudroyante). 



But the disease does not by any means always terminate fatally 

 when it has commenced and run its course for the first few days in the 

 manner above described. As favorable signs, we usually first notice 

 that there is less jactitation, and the mind becomes clearer, while the 

 complaints of pain in the head and back and the tetanus of the cervi- 

 cal and dorsal muscles continue, or only slightly decrease. If the im- 

 provement progresses, all symptoms of the disease may disappear in 

 a few days, and the patient begin his tedious convalescence. 



Occasionally improvement begins, but does not continue, and the 

 disease drags on. In such cases convalescence may not occur for 

 weeks. Headache, contraction of the neck or opisthotonus continue. 

 Paralysis of the motor and psychical functions causes a complicated 

 series of symptoms, and the majority of such patients finally die of 

 gradually-increasing marasmus. 



Lastly, I must mention the occasionally intermittent course of the 

 disease. I have only seen one such case. Hirsch distinguishes three 

 forms of the intermittent course : in the first it only occurs in the first 

 stage ; one or more attacks of evident premonitory symptoms pass 

 away, but another follows which is immediately succeeded by the out- 

 break of the disease. In the second form there is a sudden remission 

 of the symptoms ; these again grow worse the next day, and occasion- 

 ally this alternation occurs several times, usually with a more or less 

 regular quotidian type. In the third form, which is far the most fre- 

 quent (to which my case belonged), perfect intermissions are seen 

 during convalescence. The symptoms remaining after the disease, 

 particularly headache and stiff neck, regularly increase very consider- 

 ably for some time, usually with a quotidian type, while in the inter- 

 val the patient feels quite comfortable. 



To the above view of the symptoms and course of cerebro-spinal me- 

 ningitis I will now add a short description of the individual symptoms, 



