CEREBRO-SPINAL MENINGITIS. 
THE BOYLSTON PRIZE ESSAY 
EOR 1866. 
By SAMUEL G. WEBBER, M.D. 
Reprinted from the Boston Medical and Surgical Journal. 
BOSTON: 
PRINTED BY D. CLAPP & SON. 
1 8 6 6. By an order adopted in 1826, the Secretary of the Boylston Medical Committee was di- 
rected to publish annually the following votes:- 
1st. That this Board do not consider themselves as approving the doctrines contained in 
any of the dissertations to which premiums may be adjudged. 
2d. That in case of publication of a successful dissertation, the author is to be considered 
as bound to print the above vote in connection therewith. CEREBRO-SPINAL MENINGITIS. 
CHAPTER I. 
Ox several occasions an epidemic has prevailed, which, by its fear- 
fully rapid and excessive mortality, has given rise to great terror in 
the community. Popularly known as spotted fever, its more classic 
name is cerebro-spinal meningitis. It has also been known by the 
names " typhus syncopalis," " winter epidemic," " catarrhal fever," 
" peripneumonia notha," &c. 
The symptoms of the disease will be considered first, as exhibited 
in 164 cases during the last few years, together with its pathology 
and the most successful mode of treatment. Afterwards, it will be 
well to review the histories of similar epidemics in the past; the 
methods of treatment which have been advocated; and from these 
records discover, if possible, the causes of the disease and its nature. 
SECTION I. 
Symptoms. 
At the very commencement, a difficulty is encountered-the disor- 
ders of sensation or function caused by the disease are so various 
that it is impossible to include them all in a single description. 
" To describe a disease, so as to be readily recognized by one 
who has had some acquaintance with it, may easily be done; but so 
to exhibit or paint a disease, attended with multifarious symptoms, 
that it may be immediately apprehended by one, upon his first ob- 
servance of it, is more difficult, especially when it appears, in differ- 
ent cases, in a variety of forms."* 
* Dr. E. North on Spotted Fever. 4 
CEREBRO-SPIN AL MENINGITIS. 
Three varieties of the disease may be recognized-1, where the 
nervous centres are the principal seat of its action; 2, where its 
force falls upon the lungs; 3, other cases, involving especially the 
blood and the integuments, with no marked change in the internal 
organs. 
The first variety has been most prevalent during the late epidemic 
in this country, cases of the other varieties having been compara- 
tively rare. Its symptoms will therefore be considered first, and 
subsequently the differences between it and the other varieties will 
be noticed. 
I.-In the first variety, that, namely, in which the nervous centres are 
most seriously implicated, the attack sometimes commences with the 
usual precursory symptoms of fever; more frequently, however, the 
attack is sudden and unexpected; the patient continues his ordinary 
occupation until interrupted by severe headache, pain in the limbs, 
the back of the neck or along the spine; or the first symptom of 
disease may be nausea and vomiting, or a sense of chilliness. Fol- 
lowing these abnormal sensations come delirium, great restlessness, 
nausea and vomiting. The pain in the head, back and limbs con- 
tinues; fever sets in; the appetite is lost; the thirst is increased; 
the surface of the body becomes hot, or it may be warm and moist; 
in some cases it is cold to the touch, and a sense of chilliness is 
experienced by the sufferer, or the face only is hot and flushed; the 
conjunctivae are injected; the pupils are more frequently dilated 
than contracted, and insensible to light. Sometimes, especially in 
severe cases, spasms occur on the first day, and stiffness of the mus- 
cles of the neck, with retraction of the head. Coma and general 
collapse are very rare so early in the disease, except in grave cases. 
Occasionally, petechias appear the first day on the body and limbs, 
not commonly on the face. At the commencement the pulse is often 
normal, or only slightly increased infrequency; in many instances, 
however, it is more rapid than in health, and full, though wanting in 
strength; occasionally thin and hard, or weak and feeble. The 
respiration is not materially altered. The tongue is but little 
changed from its natural condition; sometimes it has a white fur 
and is rather dry. In very severe cases, it may be covered with a 
brownish fur even on the first day. Not unfrcqucntly the throat is 
sore, and on inspection is found more or less inflamed; the tonsils 
may be swollen. 
As the disease continues, the symptoms referable to the nervous SYMPTOMS. 
5 
system become more severe. Headache and pains in the back of 
the neck, along the spine and in the limbs, if not previously experi- 
enced are now felt; and where slight at first may become exces- 
sively severe, eliciting cries of agony even from the strong and robust. 
The surface of the body, especially at the neck and back, becomes 
tender, so as not to endure pressure. Delirium is a more constant 
symptom, usually of a talkative or muttering variety rather than 
wild, though sometimes the patient will struggle to rise from his bed. 
In place of the delirium, or succeeding it, occur stupor and coma, 
the patient falling into a heavy lethargy, from which he can be 
aroused only with difficulty, and which becomes deeper and deeper 
till it ends in death. Among other less frequent nervous symptoms 
are paralysis of some of the limbs, jactitation, subsultus tendinum, 
floccitation, sleeplessness, moaning and a general trembling, similar 
to that of mania a potu. 
The surface of the body remains hot, or is sometimes cool; it is 
not very often dry. The pupils continue dilated, are sometimes con- 
tracted, or unequal, and insensible to light; rarely there is strabismus. 
Spasms and opisthotonos continue, or occur where they did not previ- 
ously exist. Generally, there is nothing noticeable in regard to the 
decubitus. Petechiae appear in the course of from two to six or seven 
days. The pulse is variable, usually more rapid than in health; as 
death approaches it becomes slower, though at times its rapidity 
and force are retained until very near the last minutes of life. With 
the progress of the disease the tongue becomes darker colored and 
drier, and, with the teeth and lips, is covered with sordes, or it re- 
mains white and dry; sometimes it continues moist throughout the 
attack. Vomiting and nausea occur, but not so frequently as at the 
commencement. There is usually constipation, passages being ob- 
tained only by means of medicines; occasionally diarrhoea exists, 
which can be easily controlled. The urine is frequently loaded with 
lithates, and is sometimes secreted in only a small quantity. Cases 
have been recorded where albumen occurred. Both faeces and urine 
are often passed involuntarily, when the condition is very low. 
These symptoms are probably never all found together in any one 
case. In very severe cases time is allowed for only a few of them 
to become developed. The first shock of the attack may be sufficient 
to destroy life, and only intense headache will be noticed, followed 
quickly by delirium and coma. The following cases illustrate the 
rapidity with which the disease may terminate. • 6 
CEREBRO-SPIN AL MENINGITIS. 
Case I.*-"A. B., aet. 19, of good habits and vigorous health, 
complained in the night of severe pain in the head, and was at day- 
light found groaning, with his hands pressed upon his abdomen, as if 
suffering from colic. I saw him immediately; found him groaning, 
though insensible; paralyzed in one arm and leg; occasionally con- 
vulsed in every part except the face; pupils equally and moderately 
dilated and insensible to light; conjunctivae of a dull red hue; face 
darkly flushed; tongue and teeth coated with sordes; pulse frequent 
and full; breathing stertorous. He continued in the same state, and 
died in the afternoon." 
Case II. t-" When I first saw the patient, he had been sick but 
two or three hours, and was, at the time referred to, partially uncon- 
scious. Would respond, but not readily, to a question asked him; 
special and general sensation seemed not much impaired; in a few 
minutes he could not hear. The pupils were now much dilated, and 
did not respond to a strong light; nasal passages insensible to car- 
bonate of ammonia, and lips and tongue to tincture of capsicum. 
General sensation seemed, if not gone, much impaired; and spasmo- 
dic muscular movements ceased first in the upper, last in the lower 
extremities, and in both sides simultaneously. Diaphragm appa- 
rently ceased to act. A few attempts at purely thoracic respiration 
were made, and the patient ceased to breathe. The heart, however, 
continued to act well to this period, and did not cease to act until 
nearly two minutes after respiration ceased." 
Case III.-A case of a lady is reported by Dr. Lamb in the 
American Journal of Medical Sciences for July, 1863. "She took 
her tea as usual, about 7, P.M. At 8, she complained of acute pain 
in the head, and giddiness. She was carried up to the bedroom in 
the arms of her husband. Body warm and extremities cold; pulse 
irregular and intermittent, threadlike; pupils greatly dilated and 
vision very indistinct; delirious. She became comatose at 4, A.M., 
and died at noon, about fourteen hours from the first feeling of in- 
disposition." 
Another case is related in the same Journal by Dr. Lidell, which 
was fatal in about five and one half hours. Here excessive pain be- 
tween the shoulders, like that caused by " pressing a bar of hot iron 
into his backbone," was the principal symptom. He had three at- 
tacks of this, and died during the last one. 
* Recorded by Dr. William Frothingham, in the American Medical Times, April 30, 1864- 
f From Transactions of Illinois State Medical Society, 1864. SYMPTOMS. 
7 
Some of the symptoms which have been briefly enumerated in the 
general description, require a more extended and careful notice. 
Among the earliest symptoms have been mentioned those which 
are most frequent; but so varied is this disease in its manifestations 
that almost any part may become the seat of attack in the first in- 
stance. In one case hsematuria, with pain in the penis, introduced 
the disease; in another, the symptoms of a severe cold first attracted at- 
tention ; in another, tetanus; in a number of instances soreness of the 
throat was early witnessed. 
Pain is almost a constant attendant upon this disease, though va- 
rying in position and severity. Usually it is very severe; sometimes 
it is slight. So severe is it at times as to occasion syncope; and 
may not death in the fourth case, just related, have been caused by 
pain alone ? Almost every case is accompanied with headache, 
which is more frequent in the forehead; but the occiput and vertex 
are not spared. The back of the neck is a very common locality 
for pain, and so is the spine. The limbs not unfrequently are at- 
tacked with it, and in many cases it is confined to the joints, or most 
severe in them; in one case, as already stated, pain in the penis was 
among the first symptoms of the attack. Severe colic may be expe- 
rienced. The character of the pain is often rheumatic, especially 
when seated in the joints; at other times it is of a burning, stinging 
character; it is rarely dull and heavy. Closely connected with this 
symptom, and, indeed, constituting one variety of it, is the abnormal 
tenderness of the surface. This is not unusually general, and so 
exceedingly sensitive does the surface become that the least touch 
occasions cries of agony, even the bedclothes being insupportable. 
When local, it is most frequently situated at the back of the neck 
and along the spine. Sometimes tenderness is observable in the 
right iliac region, accompanied with tympanites, as in typhoid fever. 
Tenderness is found also in the epigastrium; it is most frequently 
experienced late in the disease. There is rarely intermission in the 
pain-this is particularly the case with the headache; when this 
symptom has once shown itself, it continues throughout the attack, 
and even during unconsciousness its existence may be proved by 
pressure upon the occiput or nucha causing uneasy movements, as if 
to escape the touch. 
Delirium is an almost constant symptom, and sets in early, if the 
attack is at all severe, even on the first day. It is not usually very 
wild; but is more frequently of a mild character and often so slight 8 
CEREB RO-SPINAL MENINGITIS. 
that the patient may be readily aroused sufficiently to answer ques- 
tions rationally, though as soon as he is left to himself he will re- 
lapse into a low moaning or muttering, and perhaps will become 
quite wild. As the disease continues, the delirium becomes more 
and more constant, and the difficulty of attracting his attention in- 
creases. At length stupor is observed, which may at first be noticed 
with a feeling of relief by his friends, as they suppose that sleep 
has brought a remission to his suffering; but after a while it is found 
that his breathing has changed, or the sleep continues so long that 
attempts are made to arouse him, and then it is discovered that the 
sleep is not sleep but coma, which gradually deepens until it is im- 
possible any longer to arouse him, and death occurs. 
The senses, especially sight and hearing, are sometimes impaired 
and not regained until convalescence has been established for many 
days. The same is true in regard to the use of the limbs. 
Spasms are usually of the tonic kind. The muscles of the back 
or neck are most frequently attacked, and thereby the head is bent 
backwards; the neck and spine may likewise be curved in the same 
direction, and complete opisthotonos occur. So great is the force 
by which this position is maintained, that even under the influence of 
ether or chloroform it is often impossible to straighten the body. 
Sometimes the position can be rectified, but then respiration may 
cease until the opisthotonos is allowed to return. Trismus may oc- 
cur without any other tetanic symptom. Deglutition is not unfre- 
quently difficult, seemingly from insufficiency of the nervous influ- 
ence ; sometimes it is impossible to introduce anything into the sto- 
mach, even the thought of swallowing causing spasms, as in hydro- 
phobia. The toes and thumbs, or either of these members alone, 
may be curved inwards. Opisthotonos is a symptom of the later 
stages of the disease. 
In connection with spasm, may be mentioned the state of restless- 
ness into which the patient usually falls, even upon the first day of 
the attack. He tosses from side to side of the bed, unable to find 
rest; he rises and turns over, then returns to his former position, 
fatiguing himself and his attendants; and even where the weakness 
is so extreme as to preclude voluntary motion, he will call upon his 
attendants to turn him, which requires great care, on account of the 
excessive tenderness. This restlessness is a very constant symptom 
and a very marked one. 
Fetechia are not alwTays present; when present, they vary from SYMPTOMS. 
9 
minute spots to blotches an inch or more in diameter, the most usual 
size being from one to three or four lines. They arc of every shade, 
from light red to livid purple. They are few, or so many as to give 
rise to a uniform reddish tint, similar to that of scarlet fever. They 
are usually even with the surface, and when the finger is passed over 
them cause no sensation of roughness. Occasionally, however, they 
have been found slightly elevated. They do not disappear under 
pressure, except sometimes the very lightest colored. They were 
first observed, in fifteen cases on the first day; in thirteen, on the 
second day; in four, on the third; in one, on the fourth; in one, on 
the fifth; in one, on the sixth; in one, on the eighth; in one, on the 
tenth; and in one, on the eleventh. They occurred most frequently 
on the limbs and body; on the legs more than on the arms; about 
as often on the chest as the abdomen; frequently on the face; more 
rarely on the shoulders, neck and back; in one or two cases there 
were ecchymoses under the conjunctivas, similar to petechias. Usu- 
ally, they were round and regular in form, though occasionally 
irregular, pointed or star-shaped. After their first appearance, they 
sometimes increase in size with the progress of the disease, and 
sometimes remain without change until they gradually fade away 
and disappear. They are mentioned in fifty-two out of one hundred 
and fifty cases where particulars more or less full are given with re- 
gard to the symptoms. 
Another eruption, herpes labialis, is not unfrequent about the 
mouth. 
Purpuric eruptions and vibices are also met with, though more 
rarely. 
The face or the surface of the body, instead of being covered -with 
petechias, may be of a uniform dusky, livid hue. 
The pulse cannot be employed in the usual way as a guide in de- 
ciding in regard to the severity of the attack. In the same case it 
may vary exceedingly, and in a few hours rise or fall a number of 
pulsations, as many as forty or fifty. In three or four cases an ir- 
regularity is mentioned, which " consisted in a frequency of about 
two and a half, then falling off to one pulsation in the second, and 
this alternating from four to six times during " the minute. In the 
majority of cases the pulse is rapid, over 90. It is usually full, but 
weak and compressible, almost never is it strong and hard. Occa- 
sionally it cannot be distinguished from a healthy pulse; sometimes? 10 
CEREBRO-SPINAL MENINGITIS. 
as in the second case related above, the heart continues to act even 
after respiration has ceased. 
The respiration is usually hurried, often it is difficult, and towards 
the fatal termination it becomes stertorous. 
The nausea and vomiting seem to depend on the disease of the en- 
cephalon. The vomitus consists of the ingesta, or of bile and 
mucus. 
The tongue is very variable in its appearance; it may be moist 
and natural, but is more frequently dry and more or less coated with 
a whitish or dark colored fur. In some cases it closely resembles 
the tongue of typhoid fever. 
The bowels are usually sluggish, and it is necessary to exhibit ca- 
thartics. When obtained the stool is not unfrequently dark colored 
and very offensive. Sometimes it is almost impossible to obtain a 
movement, and the patient does not seem to suffer from want of it. 
When there is diarrhoea at the commencement of the attack it can 
usually be easily controlled; but when it sets in during the later 
stages it is more difficult to arrest, and often points to a fatal termi- 
nation. 
Occasionally swellings and abscesses occur during the course of the 
disease in various parts of the body, or the swelling continues a few 
days and then subsides without suppuration. Abscesses also occur 
during convalescence. 
Epistaxis, haemorrhage from the bowels, and other signs of a 
haemorrhagic tendency occurred in four or five cases. In three or 
four women the catamenia appeared too early by a week or ten days. 
In three instances pregnant women were the subjects of the at- 
tack ; one aborted at about the sixth month, the other two carried 
their children to full term, though threatened with abortion. Both 
the children were sickly and died; one in the fourth month of diar- 
rhoea, and the other in the tenth month of " pulmonary catarrh." 
Not unfrequently after the disease has continued several days hy- 
postatic congestion of the lungs is developed; sometimes it is at- 
tended with cough and the expectoration of bloody sputa. 
In one or two cases great weight and oppression in the epigastri- 
um were experienced, seemingly like that described by Dr. Miner in 
his account of the epidemic of 1825. 
One sympton which occurs in almost every case, and which is quite 
characteristic of the disease, has not yet been mentioned. It is de- 11 
POST-MORTEM APPEARANCES. 
bility, which is excessive, and is found to exist in every variety of 
the disease. 
There is some danger of relapse: imprudence in diet or exposure; 
any cause which produces much mental agitation, may give rise to 
this accident; care on all these points is therefore necessary during 
convalescence. 
II. -In the second or pneumonic form there is less disturbance of 
the cerebral functions; delirium is wanting, though headache may 
exist. With great debility arc found the symptoms, rational and 
physical, of pneumonia. Petechiaa occur. Opisthotonos is not un. 
usually met with. Only two cases of this form occurred among those 
recorded; both recovered, both exhibited petechise. In one case 
with the cerebral symptoms pneumonia occurred on the fourteenth or 
fifteenth day, caused by accidental exposure. In the Boston Medical 
and Surgical Journal, vol. 72, p. 372, is the following in a letter by 
Dr. J. W. Goodell, upon this disease. 11 We have had some twenty 
cases of pneumonia since Jan. 1st, and most of them strongly ty- 
phoid; in fact, such a lot of black tongues I have never seen in real 
typhoid fever." May not these cases have belonged to this second 
variety ? 
III. -The third variety is marked by an absence of all the pecu- 
liar local symptoms; having the debility, the petechiae and complica- 
tions. Two cases occurred, one with suppuration of both parotids, 
the other with great swelling and excessive tenderness of the right 
knee; both were without cerebral symptoms; both recovered. 
Though these last two varieties have been so seldom observed du- 
ring late years, they were more frequent during former epidemics? 
especially the pneumonic form; formerly also sore throat was fre- 
quently a symptom of the third variety. 
SECTION II. 
POST-MORTEM APPEARANCES 
The emaciation is not great; rigor mortis is usually very strong, 
though sometimes wanting. The petechim and other eruptive dis- 
colorations seen during life are usually present after death; some- 
times they become developed then, though not previously visible; in 
a few cases the spots disappear during the last hours of life or im- 12 
CEREBRO-SPINAL MENINGITIS. 
mediately after. On incising them, they are seen to consist of an 
infiltration of blood into the cutaneous and cellular tissues, and they 
vary in color according to the amount of blood effused. 
The principal lesions are found in the brain and spinal cord. The 
morbid changes vary from slight increase of the number of haemor- 
rhagic points to extensive softening of the brain, with effusion of 
lymph and pus between the membranes. On removing the calvari- 
um, a congested appearance of the dura mater is seen, and there 
may be a flow of fluid of a serous or sero-purulent character, probably 
from beneath the dura mater, though not stated in the account. 
Sometimes ecchymosis is found under the pericranium. The arach- 
noid, in some instances, has lost its transparency and become opaque, 
especially at the vertex. Beneath it may be seen the vessels of the 
pia mater engorged with blood, that membrane being congested. Be- 
tween the membranes there is often an effusion of lymph, pus or se- 
rous fluid, which may also extend into the ventricles, distending them ; 
lymph occurs more frequently than scrum, and is deposited upon the 
under surface of the cerebrum, cerebellum, pons Varolii and medulla 
oblongata rather than upon their upper surface, and follows the sulci, 
nerves and vessels, imbedding them in its substance. Pus is often 
found in the same situations. The lymph is of a greenish or green- 
ish yellow color, varying in amount from a thin layer to nearly half 
an inch in thickness, and in consistency from a dense, almost fibrous 
membrane to a soft, semi-liquid substance. The veins and sinuses of 
the brain arc distended with dark fluid blood. The substance of the 
brain may be natural in appearance, but it is often congested, the 
haemorrhagic points being increased in numbers; it may be softened 
almost to a pus-like liquid, though such an extensive softening maybe 
partially cadaveric. On cutting into the brain, a serous liquid some- 
times exudes in great abundance. The same congested appearance and 
softening arc found in the cerebellum, pons Varolii and medulla ob- 
longata. The choroid plexus has been found thickened, injected and 
covered with lymph. The most frequent lesions are, effusion of serum, 
lymph or pus, and a congested condition of the membranes or sub- 
stance of the brain. 
In the spine, a similar condition may exist, the membranes being 
congested; there being an effusion of scrum, lymph or pus, and the 
substance of the cord being congested or softened. It is to be re- 
gretted that the spine has not been more frequently examined in 13 
POST-MORTEM APPEARANCES. 
post mortems performed on persons who have died of this disease. 
So few arc the cases recorded, that it would not be safe to enter 
upon any numerical statement of the comparative frequency with 
which lesions occur in this part of the nervous system. In twenty- 
nine instances the brain was examined; in only thirteen was the 
cord exposed, and in one of these to the extent of only three inches. 
In the lungs, the only lesion which is at all general, is a congested 
state. This congestion is usually in the dependent portion, and is 
undoubtedly hypostatic, sometimes probably cadaveric. Occasional- 
ly, there are haemorrhagic spots in the substance of the lung, such 
as have been called apoplectic. 
In the pneumonic form, or when pneumonia co-exists with the af- 
fection of the brain, there arc found the lesions of the lungs usual in 
that complaint. 
When there is sore throat during the course of the disease, marks 
of inflammation may be found after death. 
The heart is occasionally found surrounded by serum or other 
liquid, contained in the pericardium. Sometimes there is a thick 
deposit of lymph upon the surface of the pericardium, and sometimes 
the same substance is found in one of the cavities. The coagula in 
the heart arc often soft. 
Upon opening the abdomen a petechial condition of the mesentery 
or the intestines may be observed occasionally, spots appearing upon 
the peritoneum similar to those seen in many cases upon the skin. 
Among the viscera the liver and spleen are most frequently af- 
fected. They arc enlarged, congested, or have undergone both these 
changes. At times they are as large as twice their natural size. 
The stomach when not healthy is found to be congested or even 
softened; this latter change may, however, be cadaveric. 
Peyer's patches are sometimes slightly ulcerated, more frequently 
unduly prominent. The solitary glands arc occasionally enlarged. 
The kidneys are not unfrequcntly congested, though no mention 
has been found of any abnormal appearances under the microscope. 
The blood is frequently unnaturally fluid and dark colored; so 
general was this that it was occasionally considered characteristic of 
the disease. 
Worms are sometimes found in the intestines and stomach, usually 
the lumbrici, though they probably had no influence on the disease; 
the fact being interesting because a complication with worms has 14 
CEREBRO-SPINAL MENINGITIS. 
existed in some parts of France and was there considered one of the 
most prominent symptoms. 
In some instances, especially where death has followed close upon 
the attack, no lesion has been found in any part of the body suffi- 
cient to produce the fatal result. It must be supposed that then the 
shock has been sufficient to overpower the vital forces, or the change 
in the blood has been so great as to extinguish life immediately. 
SECTION III. 
Duration and Mortality. 
What data have-wo for answering the question so often asked, 
11 Doctor, how long shall 1 be sick ? " Tables I. and II., drawn up 
from the records of 1G4 cases found in various medical journals, may 
help to an answer. 
If a patient lives beyond the sixth day there is some chance of re- 
covery, less than one-sixth having died after that time; the most fatal 
period is from the second to the fifth day, more than half dying then. 
In regard to recovery it is not possible to give so precise informa- 
tion. As will be seen by table IL, health may be regained at any 
period from the third day to the tenth week. Many of the cases 
mentioned were not reported up to the restoration of full health. 
Convalescence is usually slow and tedious, and as soon as that was 
fairly established the record ends. This may perhaps account for 
the great difference in the length of the cases, some being recorded 
till health was entirely reestablished and others only until conva- 
lescence. 
The state of chronic ill health, or tedious convalescence, to which 
allusion has been made, and which is frequently found after an attack 
of cerebro-spinal meningitis, is the only sequela at all common, and 
postpones the return to health. Continued weakness of some of the 
limbs and general debility are the most usual symptoms of this con- 
dition. Occasionally abscesses occur, but not very often, and the 
impairment of the senses, which was noticed during the acute stage, 
may remain for many weeks. 
This disease attacks by preference youths and those in good 
health. The very young, the aged and the feeble are less liable to 
it. Table III. gives a comparative view of the ages of those who TREATMENT. 
15 
were attacked. It will be seen that from 15 to 21 is the most ex, 
posed age, one-third of the cases having occurred during that period, 
and only five were attacked who were over forty. 
Males were more frequently attacked than females, the former fur- 
nishing 114 cases, the latter only 36; sex not mentioned, 14. 67 
cases, however, were soldiers or midshipmen in the academy at New- 
port; deducting these, we have only 47 males, and the disproportion 
is not so marked, though still noticeable. 
The mortality was very great. Out of a total of 249 cases, death 
occurred in 147, and only 102 recovered. Of the 47 males not in 
the military service, 27 died; of the females, 18; showing a slightly 
larger proportion in the number of deaths among males. 
SECTION IV. 
Treatment. 
A very important consideration, and one which will especially in- 
terest the patient and his friends, relates to the means of cure. Can 
anything be done to arrest the progress of the disease and restore 
health to the sufferer, or is it true that " physicians seem not to un- 
derstand it " ? The preponderance of deaths over recoveries would 
seem to show either that the disease has not been understood, or 
rather that the remedies have not been; or that it is an unusually 
obstinate complaint. 
The natural tendency seems to be towards death. Treatment to 
be effectual must be early; in nearly every case where delayed long, 
death was the result. 
It is generally agreed that all debilitating measures should be 
avoided; general bleeding is rather injurious than otherwise, though 
in the first and fifth cases recorded by Dr. Robert Burns, of Phila- 
delphia, in the American Journal of Medical Sciences for April, 1865, 
bleeding seemed to be beneficial. In two other cases where this 
remedy was employed, death occurred. Local bleeding, especially 
by means of leeches to the back of the neck, or to the temples, and 
wherever inflammatory action has appeared, is beneficial. Emetics 
are useful only at the commencement when the stomach is oppressed 
with ingesta. Violent cathartics are contra-indicated. A support- 
ing and stimulating treatment is demanded. Counterirritation by 16 
CEREBRO-SPIN AL MENINGITIS. 
means of friction with stimulating liniments, sinapisms, dry cup- 
ping and blisters; heat applied externally to the body and 
lower extremities; cold to the head by means of ice-bags or cloths 
wrung out in cold water; stimulating enemata; gentle cathartics; 
quinine; opium to quiet restlessness and procure sleep ; stimulants, 
and nourishment in the shape of milk punch, beef tea, strong broths? 
&c., have been generally adopted as the best means at our command 
to control this disease. Quinine and stimulants must be given freely 
and largely; opium is considered one of the most valuable remedies 
by many, and apparently with good reason, but it must be given in 
large doses frequently repeated. It was used thus in France by M. 
Chauffard with success, as mentioned below. It must, however, be 
acknowledged that a large proportion die under this treatment. 
In addition to these remedies Dr. Upham employed small and fre- 
quently repeated doses of calomel, or calomel and ipecac] they were 
also employed by others. Many cases did well, and about the same 
number died. 
The cases recorded by Dr. Robert Burns, of Philadelphia, include 
the largest proportion of recoveries, 9 in 12, and it may be inter- 
esting to attend to what he says in regard to treatment. 
" The treatment pursued was the early abstraction of blood gener- 
ally or locally, according to circumstances, to relieve the brain and 
spine. Stimulating frictions to the whole spinal column and extremi- 
ties. Warmth to the feet, with sinapisms to different parts to cause 
counterirritation. Blisters sometimes, but seldom necessary. Stimu- 
lants. Diaphoretics when feverish. The liver and bowels steadily 
acted on by mercurial purgatives at night and castor oil next morn- 
ing, and as soon as the violence of the symptoms abated, quinia free- 
ly administered to the amount of eight or ten grains per day for the 
first three or four days; this, however, to be varied according to cir- 
cumstances. The nourishment chiefly beef tea or essence, barley 
gruel, sago and such other articles of a similar kind as best suited 
the desire or inclination of the patient." It will be seen that his 
treatment differed from others in a more general use of leeches. 
Dr. McVey, of Morgan County, Ill., gave opium in large doses, 
Fowler's solution, and at length strychnia to counteract paralysis and 
nervous weakness. He had six recoveries and three deaths. His 
partner, Dr. Brown, had sixteen recoveries and five deaths.* Fow- 
* Transactions of Illinois State Medical Society, 1864. TREATMENT. 
17 
ler's solution was used with some success by Dr. Miner, in 1825, and 
by other practitioners during previous epidemics. Strychnia was 
used, though earlier in the attack, in many cases which occurred at 
Newport, recorded by Surgeon Wales, U. S. N., in the American 
Journal of Medical Sciences, April, 1863 j but it docs not appear to 
have contributed much to a favorable result. The 3d, 4th and 5th 
cases died under strychnia, while case 6 recovered without it. 
Aconite was used in three cases which resulted in recovery. 
There are three remedies which have been proposed, and which 
deserve notice: bisulphite of soda, permanganate of potassa, and 
ergot. 
Bisulphite of soda was employed by Dr. Le Baron Munroe at the 
hospital on Galloupe's Island, Boston Harbor, in two cases, both of 
which recovered.* The same remedy was employed by Dr. Pearce, 
of Mechanicsburg, Ohio, with favorable results.t It has been used 
with success in pyaemia and other diseases in which the character of 
the blood seems to be changed, and if the disease we arc considering 
is, as many think, caused by a vitiated state of that fluid, why may 
not the bisulphite be used with advantage ? It is a remedy worthy 
of further trial. 
Permanganate of potassa was used by Dr. Isaac Kay, of Ohio.f 
He says that of the first twenty cases of the disease in Springfield, 
O., only one recovered. Then the permanganate was employed, 
a one grain dissolved in one ounce of water and a tablespoonful 
given every hour." The patient to whom it was first given had been 
attacked thirty-six hours previously, and was delirious, breathing 
with difficulty and vomiting. u The vomiting ceased almost immedi- 
ately, and the brain, in less than one hour, was considerably relieved 
of congestion, and the patient, after lying for three days in a par- 
tially delirious state, began very rapidly to recover, and in five days 
could walk about the city. Permanganate of potash, in the dose 
above mentioned, every hour, with occasional doses of opium to quiet 
the delirium, and an application of cold, wet clothes to the occiput 
and over the cervical vertebrae, constituted the only treatment." He 
says, " Since the adoption of this treatment three-fourths of the cases 
have recovered." 
Ergot has been employed in five instances. In one case it was 
* Boston Medical and Surgical Journal, vol. 73. 
+ Cincinnati Lancet and Observer, May, 1865. 
I Boston Medical and Surgical Journal, vol. 70. 18 
CE R E BR O-SPI N A L MENINGITIS. 
not given until the twenty-sixth day of the attack, and did not bene- 
fit the patient. In the other cases it was given early and they all 
recovered; but it is perhaps worthy of remark that three of these 
are among the most protracted cases recorded, two having had a re- 
lapse. To decide the relative value of ergot and permanganate of 
potassa farther experience is necessary. 
Table I.-Duration of Fatal Cases. 
Duration. 
No. of 
Cases. 
Duration. 
No. of 
Cases. 
Duration. 
No. of 
Cases. 
Less than 1 day. 
9 
8 days. 
4 
30 days. 
1 
1 day. 
6 
10 " 
2 
34 " 
1 
2 " 
18 
11 " 
1 
36 " 
1 
3 " 
17 
j4 « 
1 
5-6 weeks. 
1 
4 " 
16 
18 " 
1 
Several davs. 
1 
5 " 
10 
20 " 
1 
Not mentioned. 
12 
6 " 
4 
22 " 
2 
7 " 
1 
24 " 
1 
Table II.-Duration of Recoveries. 
Duration. 
No. of 
Cases. 
Duration. 
No. of 
Cases. 
Duration. 
No. of 
Cases. 
3 days. 
1 
21 days. 
3 
58 days. 
1 
4 " 
2 
23 " 
2 
Few days. 
1 
5 " 
2 
26 " 
1 
6 weeks. 
2 
7 " 
3 
28 " 
2 
18 " 
1 
10 " 
1 
30 " 
1 
10 " 
2 
13 " 
1 
36 " 
1 
4 months. 
2 
14 " 
3 
37 " 
1 
5 
1 
16 " 
1 
40 " 
1 
17 " 
1 
48 " 
1 
Not mentioned. 
13 
20 " 
1 
50 " 
1 
Table III.-Age and Position. 
o 
Age. 
Military. 
Civilian. 
Total. 
Age. 
Military. 
Civilian. 
Total. 
1 
2 
2 
21 
5 
5 
14 
1 
1 
22 
3 
3 
2 
2 
2 
23 
2 
2 
3 
2 
2 
25 
2 
2 
44 
1 
1 
26 
2 
2 
54 
- 
1 
1 
27 
1 
1 
6 
4 
4 
28 
2 
2 
7 
3 
3 
29 
1 
1 
8 
2 
2 
30 
1 
2 
3 
9 
2 
2 
31 
1 
1 
2 
10 
4 
4 
32 
1 
1 
11 
4 
4 
34 
1 
1 
12 
1 
1 
37 
1 
1 
14 
1 
2 
3 
38 
1 
1 
15 
4 
3 
7 
40 
2 
2 
16 
3 
3 
5 
42 
1 
1 
17 
4 
1 
6 
46 
1 
2 
3 
18 
8 
2 
5 
68 
1 
1 
19 
11 
6 
10 
Not stated 
11 
37 
48 
20 
3 
2 
17 
68 
96 
164 HISTORY. 
19 
In the chronic state of ill-health into which many fall who have 
recovered from the acute form of the disease, the most beneficial 
course of treatment is the administration of tonics, iron and quinine, 
and good diet, with attention to hygienic conditions. A change of 
situation and removal to another part of the country or travelling 
might afford benefit; in short, the methods usually employed for the 
restoration of a shattered and debilitated constitution. 
The varied success of treatment in different places is, without 
doubt, due to variety in the severity of the epidemic, which in some 
places is very mild and in others rages with a mortality as great as 
that of the most fatal diseases. 
CHAPTER IL 
SECTION I. 
Foreign History.-It is difficult to judge with regard to the nature 
of many diseases described by old authors, and still more difficult to 
satisfactorily prove that they are speaking of complaints essentially 
the same as those which we at the present day observe. If petechiae 
were the prominent symptom of cerebro-spinal meningitis and con- 
fined to that disease alone, the task would bo comparatively easy. 
But there is such a variety of symptoms, some of which closely 
resemble those of typhus-not only the eruption, but also the ner- 
vous and other symptoms-that it is very difficult to draw the line 
of separation. 
The first distinct notice of petechias as a symptom is by Jacobus 
de Partibus, a French physician, who was driven from Paris on ac- 
count of his opposition to the abuse of the baths, and resided after- 
wards at Tournay, where he died in 14G5.* Though all the epidemics 
in which petechias are described among the symptoms may not have 
been instances of cerebro-spinal meningitis, yet from this date we have 
such descriptions more or less complete, and in some we can recognize 
History. 
* Sprengel's History of Medicine. 20 
CEREBRO-SPINAL MENINGITIS. 
a strong resemblance to the epidemics which have occurred in more 
modern times and borne that name. 
In 1480 and 1481, a putrid fever, accompanied with phrenitis, 
prevailed in Westphalia, Hesse and Friesland.* 
In 1503, an epidemic prevailed in Europe called fievre cWbrale, 
de cephalic, cephailalgie epidemique. The symptoms most generally 
observed were, a violent delirium, convulsions, contractions of the 
limbs, immediately followed by prostration and coma. The pulse 
was frequent, irregular, feeble. Death happened speedily, sometimes 
in a few hours, more often during the third or fourth day.f 
In 1505, an epidemic petechial fever raged in Upper Italy, of 
which we have a description. " This fever commenced with symp- 
toms of little gravity; subsequently, there were developed all the 
signs of malignancy, with an extreme prostration of the powers. 
Heaviness of the head, dulness of the senses, delirium, and redness 
of the eyes, announced the affection of the nervous system. The 
urine was white and turbid, and the alvine dejections exhaled a foetid 
odor. Towards the fourth or seventh day spots appeared, which did 
not lessen the intensity of the symptoms. The patient fell into a 
comatose state, or into complete insomnia; retention of urine occur- 
red, without remarkable thirst; and, finally, haemorrhages, which 
diminished his powers, and announced the approach of death." Such is 
the description, by Sprengel, of this fever, which carried off " an in- 
finite number of sick," and which prevailed also all over Europe. J 
In 1508, Germany suffered from epidemic encephalitis and malig- 
nant pneumonia. § 
In 1510, we again find mention made of jievre 
Buserius, in his Institutes, gives a good description of cerebro- 
spinal meningitis, under the name of petechial fever. He also men- 
tions the post-mortem appearances. 
11 Frequently the membranes of the brain are found to be of a 
dark color, their vessels distended with black blood, and the cortical 
part of the brain somewhat livid; the stomach and intestines swell- 
ed, hard and black; the pancreas, liver and mesentery enlarged. In 
patients who had been cut off by hiccup, the stomach has frequently 
* Bascome on Epidemics. London. 1851. 
+ Macartin, Poirsin et Bricheteau, in Bui. de 1'Acad. de Med., t. 9. 
J Sprengel and Bascome, op. cit. 
§ Bascome, op. cit. 
|| Macartin, Poirsin et Bricheteau, loc. cit. HISTORY. 
21 
abounded with black spots. In others tlie veins and the membranes 
of the brain were varicose; the lungs gangrenous and sphacelated, 
and the blood in the cavities of the heart black and dissolved. 
Sometimes also abscesses of the brain were present, as well as of 
the breast, or abdomen. Very frequently, however, no visible taint 
is discovered anywhere which can be considered as the cause of the 
patient's death." The account of the symptoms given by Buserius 
is also very good. Under this description he mentions an epidemic 
which occurred in 1528. Sprengel also mentions the same epidemic 
which, during the winter of 1527-28, prevailed in Upper Italy. 
In 1556 a disease similar to this occurred in England and Erance; 
in 1557 in Spain, where it was as mortal as the plague; in 1564 it 
occurred in many places; and from 1569 to 1574 continued to pre- 
vail with much mortality. It was at Trent in 1591, and Florence in 
1592.* 
The epidemic of 1557, mentioned by Sprengel as described by 
Coyttarus, prevailed in the environs of Poitiers, La Rochelle, Augou- 
leme and Bordeaux. It commenced in the month of May, and was 
so deleterious that, according to the expression of Coyttarus, the sick 
seemed to die rather from fear than from the disease itself. Spren- 
gel also mentions an epidemic which showed itself in 1587 in Lom- 
bardy, described by Andre Treviso, of Fontancto. It prevailed during 
the winter; in the spring it was complicated with pleurisy, buboes 
and parotitis, and sometimes by worms. The same author speaks of 
the epidemic of 1591, described by Octavien Roboreto, which occur- 
red at Trent after a warm summer. 
The epidemic of 1557, in Spain, is mentioned by Bascome. He 
also speaks of a spotted fever which prevailed the previous year in 
Spain, but seemingly different from that in 1557. He mentions the 
epidemic of 1564, which was accompanied by fatal quinsies. 
In the seventeenth century mention is not made so frequently of 
petechial fever. In 1604, Bascome says the "punticular fever" ex- 
tended and raged with great violence all over Spain, attacked old 
and young, none escaping. 
In 1677 Buserius mentions the occurrence of the petechial fever 
in Italy. 
In 1685, in the month of February, commenced the fever of which 
Sydenham gave a description under the name " febris nova." Inter- 
* Dr. Gallup. Epidemic Diseases of Vermont. Boston. 1815. 22 
CEREB R O-SPIN AL MENINGITIS. 
mittents had been the prevalent class of fevers from 1677 to 1683. 
The winter of the latter year was very severe, "ut nemo quisquam 
viventium illi parem, vel intentissimo eo frigoris gradu, vol prmlongo 
temporis tractu, videris unquam; " that is, the "oldest inhabitant" 
could not remember so severe a winter. The winter of 1684 was 
not quite so severe, though more so than usual. He first considered 
the new disease which appeared in February, 1685, to be the same 
as peripneumonia, but subsequently changed his opinion. " The 
symptoms observed with what care I could give them are and were 
nearly these. The patient is attacked by heat and cold alternately; 
oftentimes there is complaint of pain in both head and limbs; the 
pulse is not unlike the pulse of health; blood drawn from a vein is 
frequently similar to pleuritic blood. The patient often suffers from 
cough, which, with the other symptoms of peripneumonia, yielded the 
quicker, the longer after winter the attack occurred. Pain is some- 
times situated in the neck and fauces at the commencement of the 
attack, but lighter than in angina. Although the fever may be strict- 
ly continued, yet often most troublesome exacerbations occur at 
night, just as in double tertian or quotidian. However so lightly he 
may be covered with bedclothes, the patient does not lie in bed con- 
tinuously without great danger; for the fever being then turned to- 
wards the brain he falls easily into coma or delirium. And, as I 
truly acknowledge, there is such an inclination in this disease to fall 
into delirium that often it suddenly and spontaneously steals over 
the patient unawares, without any cause. But the delirium does not 
rise in this fever to that pitch of irascibility and fury observed in 
those who are attacked with variola and other fevers; indeed the sick 
have rather a tranquil delirium, from time to time chattering nonsense. 
From the untimely use of cordials and a regimen a little stimulating, 
petechia? often appear, and, in youths possessed of a sanguine tem- 
perament, maculae, even purpuras, a most certain sign of high inflamma- 
tion, appear in this as in any other kind of acute disease. Now and 
then miliary eruptions, as they are called, are scattered over the sur- 
face of the body, not very different from measles, unless they are 
more red, and when they recede do not leave those furfuraceous 
scales which arc seen in measles. These, indeed, sometimes break 
out of their own accord, but are oftener forced out by heat of the 
bed or the diet. The tongue, in proportion to the diet furnished, is 
moist or dry. When it becomes dry it is of a brown color in the HISTORY. 
23 
middle and white on the edges. But where the tongue is moist it is 
white in every part, having a rough surface and a white coating; for 
if the patient becomes heated by a diet justly forbidden, the tongue 
is generally brownish and arid; but if otherwise, it is moist and 
white. The same may be said of the perspiration, which exudes in 
proportion to the varying regimen above mentioned; for if the pa- 
tient is kept too warm, a viscous sweat constantly pours out, espe- 
cially from the head. Although the perspiration flows copiously and 
uniformly from every part, he feels but little relief, whence it follows 
that such sweats are symptomatic and not critical. If a sweat was 
excited on the first day of the attack by artificial means, usually it 
caused the transfer of the morbid action, if not to the head, at least 
to the joints. But when the fever is situated in the head and at the 
same time the delirium has increased, no sign of fever remains, except 
that the pulse is now fast, now slow; at length, however, when from 
bad management, the spirit is led into every kind of confusion, the 
pulse becomes irregular, with subsultus tendinum; and not long after, 
death occurs." 
From 1691 to 1694 the disease prevailed in Italy; in 1698, in 
England and at Halle.* 
During the eighteenth century it occurred first in Prussia in 1704. 
England in 1710 and 1741, and Piedmont in 1720, were visited by a 
disease called spotted fever, t 
In 1733 Edinburgh was under its influence. In this case the dis- 
ease was accompanied by sore throat.j: 
In 1746, 1756, '57, and '58, France experienced the ravages of an 
epidemic. During the latter year it prevailed in the French fleet at 
Brest, under Admiral Dubois de la Mothe, and extended into the 
city. Fonsagrives gives the following description of the symptoms : 
" The patients felt at the commencement a heaviness of the head with 
acute pain at the superciliary ridges; their powers were weakened; 
the pulse was full and frequent; the skin was dry and burning; the 
tongue red; vomiting or at least nausea was commonly experienced; 
the epigastric region was the seat of discomfort and of an indefina- 
ble anxiety; they complained of a very grievous aching of the spine; 
constipation existed. Such were the symptoms of the commence- 
ment. In six or seven days the symptoms became singularly grave; 
* Gallup and Buserius, op. cit. 
t Cop. Med. Diet., Webster on Pestilence. 
J Bnserius, op. cit. 24 
CEREBRO-SPINAL MENINGITIS. 
the pulse lost its fulness, it became small and deep; there was tym- 
panites ; subsultus tendinum, buboes, petechia; and parotitis appear- 
ed; the patient fell into coma, in which he usually died." In this 
epidemic about one in fifty passed worms.* The same year the epi- 
demic was seen at Vienna; in 1764, at Naples and Montecchi; in 
1765, at Tyrone, Ireland; in 1767, in Tuscany and the district of 
Acmilia; in 1771 and 1772, at Vienna.f 
Sir John Pringle, in his work on the diseases of the army, first 
published in 1752, gives an account of jail or hospital fever, which, 
in many respects, reminds one of cerebro-spinal meningitis. It was 
introduced by changes of heat and cold, trembling, numbness and 
loss of appetite; skin hot; pulse at first a little quicker than natu- 
ral; some pain and confusion of head, and dejection of spirits; 
pulse quick and varying in the same day, both as to strength and 
fulness. Bleedings were injurious, especially if repeated. Blood 
commonly little altered, sometimes fluid and the crassamentum re- 
solved. Sometimes diarrhoea, when patient is kept too cool; if kept 
warm, constipation rather. Calor niordax. After a while delirium 
sets in. A petechial efflorescence is a frequent but not inseparable 
attendant on the fever, which is sometimes of a brighter or paler 
red, at other times of a livid color, but never rises above the skin. 
The spots were small but generally confluent. In a few cases there 
were purple streaks and blotches. The duration was from seven 
to fourteen or twenty days." He docs not mention that any cases 
were so short as is sometimes seen in cerebro-spinal meningitis. In 
post-mortem examinations there were found cases of suppuration of 
the brain, which he calls abscesses. Purulent matter was found in 
the ventricles in one case, and the whole cortical and medullary sub- 
stance was uncommonly flaccid and tender. In one case the brain, 
in another the cerebellum, was suppurating. In two the cortical 
substance of the brain had an inflammatory appearance, but no sup- 
puration. In some the intestines were diseased. The cause he con- 
siders to be a vitiated state of the air. 
In 1788 an epidemic occurred in Cornwall, Eng., which was com- 
pared by Dr. Simmons with typhus. The account of the symptoms 
is not very full, but the disease strongly resembles cerebro-spinal 
In the early part of the nineteenth century there were not many 
* Annales d'llyg. Pub. ct de Med. Leg., 1.12. 
+ London Medical Journal, vol. x. 
+ Buserius. HISTORY. 
25 
epidemics of this disease, but about 1837 it became more prevalent, 
especially in France. 
In Geneva in 1805 a disease was seen which resembled cerebro- 
spinal meningitis in its sudden invasion, vomiting, pain in the head, 
rigidity of the spine, occasional petechias; the principal lesion was 
engorgement of the brain. One quarter died. Its attack was not 
general. It prevailed for only three months.* 
In the same year a case occurred at Strasbourg, terminating fatally 
after two relapses, the last one being accompanied by cerebral 
symptoms. At the post-mortem the vessels of the head and mem- 
branes were engorged with blood; serous fluid was found between the 
meninges above the hemispheres. The brain was soft, the ventricles 
were dilated and contained about four ounces of turbid serum, with 
a deposit of pultaceous, puriform matter lining their cavity. There 
wore also lesions of the lungs and heart.! 
On the 23d March, 1807, a family of fourteen persons who resid- 
ed on one of the high declivities of Dartmoor in Blackaton, near 
Ashburton, were attacked with a disease which had many of the 
characteristics of cerebro-spinal meningitis. Five persons were at- 
tacked, of whom four died. One of them, however, was not in the 
family, and had not been near any of the sick. The symptoms were 
briefly these: pain in the head with slight rigors, slight convulsions 
of the limbs, nausea, thirst, pupils dilated, pulse weak and rather 
rapid, occasionally soreness of the throat at the commencement, in 
two cases petechias, and in two pain in the foot and lower limbs. 
There was no post-mortem. This disease did not spread, and these 
were the only cases. Nothing is said with regard to the situation of 
the house or the circumstances of the family, and the disease may 
have been typhus from some local cause, though it had a strong re- 
semblance to cerebro-spinal 
In the same year the Spanish prisoners who were confined at Bri- 
were attacked by a disease which was said by M. Billerey, 
physician in chief of the civil and military hospital at Grenoble, to 
be the same as afterwards appeared at Grenoble andMayence, which 
was considered by M. Boudin as cerebro-spinal meningitis.§ 
* Vieusseux in Jour, de Med. Chir. et Phar., t. xi. 
+ Journ. de Med., Chir. et Phar., &c., vol. x. 
J Med. and Phys. Jour., vol. xxviii. 
§ Boudin on Cerebro-spinal Meningitis, in Arch. Gen. de Med., Avr., 1849. 26 
CEREBRO-SPINAL MENINGITIS. 
In 1814, a disease appeared at Grenoble, which is described by 
Comte as follows:-" It showed itself at Grenoble during the 
months of February, March and April, 1814, in the garrison. The 
larger part came from the army of Mont Blanc, where, during very 
severe cold, they had performed very hard service, always in the 
snow, and exposed day and night to great fatigue; those who were 
attacked were almost all among the new recruits. The disease be- 
gan as a true catarrhal, nervous or ataxic fever; at the end of two 
or three days the eyes became bright and flashing; the conjunctiva 
was injected, the muscles of the face exhibited convulsive move- 
ments, then appeared tetanic stiffness of the upper part of the body, 
the head being constantly bent back and immovable. The headache 
was sharp and constant, and was observed principally at the poste- 
rior part of the neck; a delirium, more or less violent, supervened. 
The disease frequently attacked persons in the hospital on account 
of other complaints. MM. Billerey and Belon, physicians attached 
to the hospital, and who saw the first patients, thought that this was 
the same disease as the nervous fever of Dresden, Leipsic and 
Mayence." 
u In every patient who died, there was constantly found dilata- 
tion of the cerebral bloodvessels, traces of inflammation, portions 
of that viscus apparently macerated and its various cavities filled 
with varying quantities of serum. The examination, extended even 
into the spinal canal, disclosed traces of inflammation of the inter- 
nal surface of the membranes; similar appearances of a livid or 
dull red color in the cord itself, with some portions of the surface 
macerated and showing undoubted evidences of suppuration."* 
The same disease also occurred at Metz, in 1815.t 
Biett, on the 14th of July, 1814, sustained a thesis before the 
Faculty of Medicine of Paris, wherein he asserted that the disease 
which had appeared in the army, and which he had observed at the 
Hospital Saint Louis, was not typhus, but a ccrebro-spinal me- 
ningitis. 
During the spring of 1815, there occurred at the University of 
Cambridge, Eng., an epidemic which in some of its symptoms and 
the post-mortem appearances very much resembled cerebro-spinal me- 
ningitis. The account of the symptoms is not very full, but the 
following case will serve to show the resemblance :- 
* Receuil Gen. de Med., t. Iviii. 
+ Boudin, Arch. Gen. de Med., Avr., 1849. 27 
HISTORY. 
" Mr. Joseph Wilson, aat. 19, had been in general good health, with 
the exception of occasional pain in the head. When I first saw him 
(March 25th, 2 o'clock in the morning), he complained of severe 
pain across the forehead, and heaviness over the eyes; his nurse 
observed that she had several times found him wandering; it is pro- 
bable that some slight delirium had existed from the commencement 
of the disease. My suspicions on this head arise from the mistakes 
he made in respect to dates. His skin was hot and dry, his coun- 
tenance flushed, his tongue white, his appetite good, and his pulse 
120 and full. From what I could collect, the disease had com- 
menced March 15th, with the symptoms I have mentioned, but in 
less degree. 26th.-Symptoms somewhat aggravated. 27th, 2 
o'clock in the morning, furious delirium came on, which left him at 
8 o'clock, and his mind returned to the state in which it was when 
I first saw him. At 2 o'clock in the afternoon his body became sen- 
sibly cold, and was followed by moisture of the skin." He lived till 
April 1st, sometimes seeming better, and sometimes all the symp- 
toms becoming more severe, and died at 1 o'clock on that day. 
" Post Mortem.-On removing the calvaria, the vessels of the 
dura mater appeared distended with blood; the other vessels of the 
brain were fuller than natural; between the dura mater and pia 
mater there was a large quantity of fluid. The medullary substance 
of the brain contained many blotches of blood. The lateral ven- 
tricles were much distended with fluid. The gall-bladder was found 
empty. The stomach and intestines were much distended with fla- 
tus. The thorax was not examined. 
"P. S.-He had also convulsive movements, especially of upper 
extremities, and subsultus tendinum and floccitation."* 
During the years 1813, 1814 and 1815, an epidemic occurred in 
Dublin, Ireland, and vicinity. It prevailed during most of the year, 
but worst in winter, and with a character somewhat different from 
that which' it had during the rest of the year. Dr. Edward Percival 
gives an account of it. He says :-" The worst forms of typhus fever 
prevailed at an advanced period of the winter. Livid blotches, a dry 
tongue, dark and tenacious mucus on the gums and lips, muttering 
delirium, singultus and lethargy, were frequent symptoms. Peripneu- 
monic distress attended at least the commencement of most of these 
cases. The hepatic viscus was also frequently engaged. But the 
* Med. Trans, of Col. of Physicians of London, vol. v., 1815. 28 
CEREBRO-SPINAL MENINGITIS. 
peculiar seat of sanguineous congestion appeared to be the brain 
and its investing membranes. 
" All ages, except infancy, were liable to the fever, the duration of 
which, under the circumstances above described, seldom fell short of 
fourteen days and often exceeded seventeen. It proved more fatal 
than any other form of epidemic or contagious fever." 
" In typhus, with subdelirium and comatose affection, the brain ex- 
hibited, on inspection, all the usual marks of vascular congestion. 
These were not less observable in cases more protracted. On re- 
moving the upper part of the cranium, blood was frequently effused. 
The vessels of the pia mater and plexus choroides were often turgid 
and the capillaries occupied with blood; a glairy fluid, sometimes 
tinged with blood, was interposed between this membrane and the 
arachnoid tunic. More or less serous effusion was found in the ven- 
tricles. The substance of the brain was in some cases firmer, in 
others softer than natural. On dividing its substance, numerous 
bloody points usually presented themselves on the surface of the 
separated parts. No case of abscess of the brain occurred to my 
observation." 
Either the lungs, pleura, liver, peritoneum or intestines were al- 
most always diseased. 
He considered it contagious, though only slightly so.* 
An account of a fever which prevailed in Italy and many parts of 
Germany during 1817, is given by Dr. John Bell. He says that it 
seems to have been imported into Italy several centuries previous, 
and sporadic cases appeared every year. " The premonitory symp- 
toms of the disease are pain in the head, muscles and bones, espe- 
cially in the loins and inferior extremities, want of appetite, little 
sleep, universal prostration of both physical and intellectual power. 
" After the disease is completely formed, the patient suffers from 
an increased pain in the head, greatest over the eyebrows, watchful- 
ness, involuntary shedding of tears, stillicidium from the nose, heat 
and pain of the fauces, violent thirst-the tongue moist, covered with 
a whitish-yellow crust, red at its edges, depraved taste, a sense of 
bitterness in the mouth, and weakness of stomach, with a desire to 
vomit-eyes inflamed and sparkling, cough and a troublesome sensa- 
tion of tightness at the scrobiculus cordis, dry skin, a sense of burn- 
ing heat attended with cold fits all over the surface of the body- 
* Transactions of Fellows of King's and Queen's College of Physicians, vol. i., 1817. 29 
HISTORY. 
pulse weak and quick, although sometimes full and vibrating, bowels 
constipated. The fever often presents itself with the character of 
an intermittent, but soon takes that of a remittent or continued fever. 
Most commonly, the patients are affected from beginning to end with 
a violent acute fever, though cases are related where the fever was 
scarcely perceptible. The physiognomy is of a wretched and des- 
ponding cast. 
" Such was generally the first stage of the disease. In the second, 
that is from the fourth to the eleventh day, it became more aggrava- 
ted-the pain in the head is augmented-some tension of the ab- 
domen is felt, and, according to the particular viscus attacked, 
succeed cither delirium or the symptoms of peripneumony and 
a sthenic affection of the liver and intestines, or of all the 
viscera at the same time. Delirium, the effect of cerebral in- 
flammation, is often united to the inflammatory symptoms of the 
breast, and those of the liver and intestinal tube; the tongue is ob- 
served to be red at its apex, dry, and loaded at its base; the looks 
of the patient are languid and vibrating; the tongue and hands 
tremble; there is pain, or tinnitus aurium; the pulse is weaker and 
more frequent; the excretions are small at this time; petechial erup- 
tions, muttering and delirium at night next succeed. 
" As respects petechim, Palloni remarks that from the third to the 
seventh day red spots, pointed, irregular and slightly scabrous and 
elevated, and also petechial spots on the neck and shoulders, extend 
to the body." 
They do not desquamate, are uniform in shape, and have no effect 
on the progress of the disease. 
Appearances on dissection were, effusion into the thorax or abdo- 
men of lymph; brain engorged, effusion between the dura and pia 
mater, sinuses full of blood, membranes adherent, substance of the 
brain softened.* 
There is no account of any similar epidemic until 1823, when a 
disease appeared in the Milbank Penitentiary, near London, of which 
a good description is given by Dr. P. M. Latham, attending physi- 
cian. The disease exhibited such various symptoms, and was in 
some respects so dissimilar to the varieties now observed, that a 
pretty full extract will be interesting. 
In the autumn of 1822 the health of the prisoners began to de- 
* Philadelphia Journal of Medical and Physical Science, vol. i. 30 
CEREB RO-SPINAL MENINGITIS. 
cline. They became pale and languid, thin and feeble. Still, there 
was no manifest sign of any particular disease. In the beginning of 
February, 1823, Mr. Hutchinson reported some marks of scurvy in 
a few individuals. In the last fortnight of February, nearly fifty 
cases of diarrhoea and dysentery were admitted to the hospital, sus- 
pected to be scorbutic dysentery. 
Dr. Latham entered on his duties March 1st, and found scurvy 
prevailing, complicated with diarrhoea and dysentery, and, on 
mortem examination, a state of the intestines was found resembling 
the state of the skin, viz., having ecchymotic spots of various sizes. 
It was found that the diet of the prisoners was very deficient in 
animal food, as only one and a quarter ounces of meat for each man 
and less for each woman, was allowed to make soup. More meat 
was allowed, and the health of the prisoners improved, and in a re- 
port made to Parliament April 5th it was so stated: but after that 
date the diarrhoea and dysentery returned. During the first part of 
the attack of scurvy, various degrees of nervous affection, as tremors, 
cramps, spasms and mental despondency, were noticed, and attribu- 
ted to constitutional debility. It was not long, however, before the 
nervous symptoms became more marked; and a man, 31 years old, 
suffering from cramp and diarrhoea, died suddenly apoplectic. On 
examination, the vessels of the brain were found slightly turgid, and 
a few spots of ccchymosis on the intestines were observed. 
The bowel complaints were peculiar in their nature. " There was 
every degree and species of flux that was ever seen or described, re- 
sembling cholera, dysentery and common light diarrhoea, and there 
were cases entirely different from either. In the evacuations there 
appeared nothing that had any visible quality of feces, bile, blood, 
or mucus; they consisted, sometimes, of a mass, like green or black 
grapes in a state of fermentation; sometimes a matter like yeast; 
sometimes they were in color and consistence like half-slaked lime, 
when it is beginning to crumble, and sometimes like a thin mixture 
of chalk and water, and always intolerably sour and offensive, and in 
enormous quantity." With this diarrhoea there were still more mark- 
ed cerebral symptoms. " There were several cases of phrenitis. To 
sudden and acute pain in the head, were added vertigo, confusion of 
intellect, twitching of the tendons, strabismus, dilated pupils-and, 
lastly, distortion of the mouth and hemiplegia." That the bowel 
complaint and the nervous disorder were due to the same morbid HISTORY. 
31 
agency, is proved by the fact that they were coincident and occurred 
together in the Penitentiary, and the same person was affected by 
both, and the same remedies were beneficial in relieving both. 
The accession was sudden in botli the bowel complaint and the 
nervous disorder, when one was not accompanied with the other; and 
the premonitory symptoms, when occurring, were very similar. The 
fever attending both was very moderate. One symptom, which gives 
it a strong resemblance to spotted fever, or cerebro-spinal meningi- 
tis, as described by Dr. Miner, is a terrible "sinking at the pit of 
the stomach. What this sinking is, those only know who have suf- 
fered it. All patients speak of it by the same name, but do not de- 
scribe it further. I suspected it to consist of a certain degree of 
actual pain, combined with a feeling which is akin to approaching 
syncope, and spreads from the stomach, as from a centre, over the 
whole frame. It is a painful and overpowering sensation, as if ani- 
mal life itself was hurt and lessened." 
When any morbid appearances were found after death in the brain, 
there was some degree of vascular fulness of the brain and also of 
the membranes, and some serous effusion between the latter and 
into the ventricles. 
Dr. Latham did not consider that the disease was contagious.* 
During the winter of 1829-30, this disease prevailed among the 
galley slaves confined at Toulon, of which a very interesting account 
is given by M. Fleury. The symptoms were essentially the same as 
those which we sec at the present day, and the changes of structure 
revealed by the post-mortem appearances were likewise similar, con- 
sisting in congestion of the meninges, serous infiltration and exuda- 
tion into the ventricles, the sub-arachnoid space and the spinal canal; 
congestion of the lungs approaching gray hepatization. The abdo- 
men exhibited also the familiar appearances of cerebro-spinal 
meningitis. 
In 1832, during the winter months, an epidemic pneumonia ap- 
peared at Aubin (Aveyron) similar to the same disease which ap- 
peared in New York in 1813-15, and which is only another form of 
cerebro-spinal meningitis, as will be seen when the nature of that 
epidemic is considered.'!' 
In the same year, Grenoble was again visited by an epidemic simi- 
lar to that of 18144 
* Reviewed in Johnson's Med.-Chir. Review, July, 1825. 
f Monthly Journal of Med.-Chir. Knowledge. 
X Boudin in Arch. Gen. de Med., Avr., 1849. 32 
CEREBRO-SPINAL MENINGITIS. 
In the London Lancet for June 10th, 1837, is an account of the 
spotted fever, which was attended with pneumonic and throat symp- 
toms; there were slight rigors, or they might be absent; 
pain in the bones. Next day there was acute pain, commonly in the 
side, sometimes in the praecordial region, rarely in the epigastrium, 
darting thence to the shoulder-blades and the intervening space. 
There were sounds of pleurisy, with pneumonic symptoms. Head- 
ache existed, frontal, occipital, or general; but it was often absent. 
There was not, usually, lumbar pain. Sore throat, with redness of 
the fauces, was often found, though sometimes it was very slight. 
The face and upper part of the thorax were frequently flushed. 
There was restlessness; and the bowels were not freely opened, 
though w'ithout pain or tenderness. The patients numbered thirty- 
eight. The rate of mortality and post-mortem appearances are not 
given. 
In another journal, however, this deficiency is partially supplied. 
In the London Medical Gazette, vol. xx., is an account of the disease 
by Dr. John Wilson, in which the lesions in three cases are given. 
In two, the body was covered with port-wine-like stains or spots; 
the blood was fluid and dark in all. In two, the lungs were gorged ; 
in one, there was extensive extravasation of blood into the pelvis 
behind the peritoneum. In one, he found a large quantity of clear 
fluid in both lateral ventricles of the brain. These cases occurred 
in April, May and June, 1837. 
The following year, 1838, during the month of February, the same 
disease was observed, and an account of it is given by Dr. John 
Burns. 
In the British and Foreign Medico-Chirurgical Review, vol. xxiii., 
is a review of a paper by Casimir Broussais on an epidemic of ce- 
rcbro-spinal meningitis which prevailed among the different garrisons 
in France from 1837 to 1842. 
"It commenced at Bayonne in 1837 among the military, and soon 
spread into Les Landes, many cases occurring among the inhabitants 
of the communes surrounding Dax. Thence it extended to Bordeaux, 
and in the same year to La Rochelle, in both of which places it was 
confined to the garrison. It then suddenly appeared at Versailles 
and St. Cloud, where it raged from 1839 to 1842. From Versailles 
it spread eastward to Caen and Cherbourg in 1840 and '41; west- 
ward to Metz, Strasbourg, Nancy, Chateau Gonthier, Tours, Blois HISTORY. 
33 
and Joigny, and finally appeared in the neighborhood of Rambouillet. 
From La Rochelle it reached Poitiers in 1840, L'Orient in 1841, and 
Ancenis and Nantes in 1841 and '42. In all these places the dis- 
ease was chiefly confined to the military. 
" But while it thus extended in a northerly direction, it also 
spread among the garrisons to the west of Bayonne, appearing in 
1837 at Narbonne and Foix, in 1838 at Toulon, and in 1839 at 
Nimes. It prevailed at Avignon in the winter of 1839-40, and again 
in the following year; at Montbrison in 1840 ; and at Lyons in the 
winter of 1841-42. It appeared also at Pcrpignam in the winter 
of 1840-41, and the following year at Aigues Mortes. 
" The progress of the epidemic was not marked by regularity, nor 
did it pursue a steady course from one garrison to another. Occa- 
sionally it appeared at a distant point, from which it sometimes re- 
turned to places it had passed over, while at other times it remained 
stationary for a considerable period. In some garrisons the disease 
did not prevail as an epidemic, but merely a few sporadic cases oc- 
curred ; in others it appeared to become naturalized and to take an 
endemic character. 
" The disease, as has already been stated, was confined chiefly to 
the military, but in a few instances extended its ravages also to the 
civil population; for instance, at Strasbourg in 1841." 
Selestat (Bas Rhine) in 1839 was visited by this disease, which 
seemed to have been introduced by a body of soldiers who had been 
formerly stationed at Strasbourg, where the disease prevailed. Soon 
after their arrival, some of the corps were attacked, and then it ap- 
peared in the neighborhood of their barracks and afterwards extend- 
ed to the interior of the city.* 
Such is a brief account of the progress of the disease in France 
during those years. Other countries were also visited by the scourge, 
as Caivano (Naples) in 1837. Here the principal symptoms were 
frontal headache, with injection of the conjunctivae, which was a con- 
stant and pathognomonic symptom; general articular pains; loss of 
appetite, but great thirst; tongue dry, covered with a yellowish coat- 
ing, and sometimes dark; delirium; subsultus tendinum; constipa- 
tion ; slight increase in the heat of the skin; the pulse small, rapid 
and hard; petechial eruption over the skin on the seventh or eighth 
* Encyclographie des Sciences Med., 1841, t. vi. 34 
CEREBRO-SPINAL MENINGITIS. 
day of the disease; alvine dejections accompanied with lumbricoides; 
typhoidal symptoms when the eruption appeared early. 
Dr. Orofino noticed that the disease ran through regular periods 
and sometimes terminated by sweats. He considered the critical 
days to be the fourteenth, the seventeenth, and rarely the twenty- 
first.* 
Various districts in the kingdom of Naples were invaded in the 
winter and spring of 1840. The disease made its appearance dif- 
ferently in different cases. In some persons the first symptom was 
a sense of formication, beginning at the feet and extending over the 
whole body; others suffered from general uneasiness, pain in the 
head and neck, particularly in the cervical and dorsal region, at- 
tended with difficulty on stooping forward or bending the neck. 
Sometimes the disease was ushered in by an apoplectic seizure, with 
loss of speech and consciousness, lasting for some hours, and follow- 
ed by a kind of febrile reaction. Other persons fell down in con- 
vulsions, with trismus, the neck being drawn forcibly backward, the 
whole trunk rigid, spasms of the extremities and efforts to vomit, 
sometimes without anything being rejected, while at other times the 
patient would throw up some lumbrici. 
" The stage of reaction was accompanied with fever, a hard, quick 
and frequent pulse, cephalalgia and a painful sense of retraction of 
the head; the pain in the head increasing in severity, affecting 
principally the occiput and extending to the neck and along the 
spine. In some instances the pain in the spine was dreadfully 
severe, and the sacrum was referred to as the seat of the greatest 
suffering. When very violent the pain was followed by opisthotonos 
so complete as to bend the spine into the form of the Roman S. 
Trismus, difficult deglutition, with disinclination for all drinks, sub- 
sultus, a tremulous state of the limbs, existed in the severest cases. 
The tongue was dry, the teeth wore coated with sordes, the patient 
could scarcely speak. The bowels were costive, and lumbrici wore 
voided by stool, or crept out of the mouth." 
On post-mortem examination the vessels of the meninges of the 
brain were found much congested; the thoracic viscera also engorg- 
ed ; the blood dark and liquid, with similar changes in the abdo- 
men.j' 
* Rev. Med., t. Ixvi., 1838. 
t Med. Examiner, N. 8., vol. i., 1842, Rev. of account by Prof, de Kenzi. HISTORY. 
35 
Iii 1840, and again in 1845, Douera in Algeria was visited by an 
epidemic in many respects resembling the disease under considera- 
tion; it prevailed especially during February and April, 1845.4 
In France this disease prevailed more or less in some of the de- 
partments from 1843 to 1849. In 1843, in the department of Seine 
et Marne, and one case is recorded which was observed at Paris; in 
1844 in the Haute Loire, and also one case at Paris; in 1847, at 
Vai de Grace, Avignon and Orleans; again at Orleans in 1848 and 
also at Versailles, Petit Bourg, Luneville, and Dijon; in 1849, at 
Vai de Grace again. 
It is hardly necessary to give the accounts of each of these epi- 
demics as related by various authors. An abstract of the symptoms 
and post-mortem appearances as described by M. Vallcix in his Guide 
du Medecin Praticien will be sufficient to show the identity of the 
disease with what we now call ccrebro-spinal meningitis. 
Precursory symptoms were more frequent than in the late epi- 
demic in this country, existing in nearly half the cases, according to 
M. Tourdes; they were cephalalgia, chills, nausea, and vomiting, pain 
in the spine and limbs, vertigo, malaise, diarrhoea, delirium, trem- 
bling, feverishness; though M. Valleix thinks that most of these 
ought to be considered not as precursory symptoms, but as phenome- 
na of the settled disease. 
Cephalalgia was a constant symptom, sometimes preceding all 
others and persisting to the end of the attack. It was generally 
very severe, occupying the forehead usually, becoming more severe 
towards evening. Pain in the spine was not so constant as the head- 
ache, though very frequently seen, especially in the cervical region. 
The pain extended to the extremities, and there was increase of cu- 
taneous sensibility. The pupils were generally dilated, sometimes 
contracted; the sight was occasionally lost; the eyes were inflamed. 
Deafness or abnormal sounds were observed. There was trismus, 
and cramps of the legs and thighs. M. Forget observed a trembling 
similar to that of delirium tremens. Paralysis was not common, and 
was observed only at a late stage of the disease. A delirium almost 
always existed, sometimes very violent, but usually easy enough to 
overcome momentarily by questioning. The delirium finally changed 
to coma. There were nausea and vomiting, loss of appetite, great 
thirst and constipation, succeeded by diarrhoea; the stools were fre- 
t Dr. Magail in Rec. de Mem. de Med., de Chir. et de Phar. Mil., t. lix. 36 
CEREB RO-SPINAL MENINGITIS 
quently involuntary. Petechial eruptions occurred, and also herpes 
labialis. 
" Je ne peux m'cmpechcr de joindre a cette description detaillee 
un tableau succinct do la maladie trace par M. Tourdes, parce qu'il 
resume parfaitement tout cc qui vient d'etre dit. 
" Tableau de la maladie. i La maladie debute, dit cet auteur, par 
une cephalalgie cruelle accompagnec de vertigcs, de nausecs et de 
vomissemcnts. La douleur se propage a la nuquc et an rachis; elle 
envahit les extremites, les idees s'egarent, la connaissance se perd; 
le malade est on proic a uno agitation convulsive; la teto est ren- 
versee en arrierc; la face, rouge ou pale, offre 1'expression de la 
douleur; la temperature de la pcau est normale ou diminuee; le 
pouls naturel ou ralenti. Cet etat dure jusqu'au troisieme jour, 
epoque a laquelle se devcloppcnt leruption labiale, les petechias, 
les taches lenticulaires et les epistaxis; I'lirinc dcvient abondante et 
scdmenteuse, la constipation est opiniatre. 
"' Bientot la connaissance rcparait, et avec elle le sentiment des 
douleurs. Une amelioration legere se manifesto; elle fait naitrc des 
esperances qui se realisent rarement. Les phenomenes cerebraux et 
rachidiens reprennent leur acuite; la reaction febrile s'allume, la 
langue jaunit, rougit et se seche. La diarrhee succede a la consti- 
pation. Tantot les symptomes ncrvcux conservent leur violence 
jusqu'au dernier moment, tantot ils se calment et persistent opinia- 
trcment avec une intensite moyennc. Leur marchc est entrecoupee 
des remissions et d'exacerbations. La faiblcsse et 1'amaigrissement 
font d'effrayants progres. La reaction febrile revet une forme ty. 
phoi'de ou hcctique, et le malade expire dans le marasme apres une 
tranquille agonic. 
"1 Si 1'issuc doit etre heureuse, les accidents no sc calmcnt qu'avec 
lenteur. Une longue et perillcuse convalescence precede le reta- 
blisscment de la sante.' " 
The duration was sometimes very short, a few hours; at other 
times very long, eighty or a hundred days before death. When re- 
covery took place, convalescence was long and tedious. The mean 
duration of fatal cases was fifteen days, of recovery twenty-five days. 
The disease was usually fatal. 
The anatomical lesions were injection of the membranes, deposit 
of lymph and formation of pus in various portions of the encephalon 
and spinal canal, occasionally also softening of the cerebral sub- HISTORY. 
37 
stance or the cord. In the intestines Peyer's patches were some- 
times abnormally prominent, and there were slight traces of inflam- 
mation. 
At Versailles, lumbricoides were found in almost every case, and 
were considered as one of the pathognomonic symptoms, but at Stras- 
bourg and other places they were wanting. 
M. Lefevre believed that he found in the muscles a peculiar nau- 
seous odor, entirely sui generis. 
The disease prevailed also elsewhere than in France. It was met 
with at Gibraltar, under the name of epidemic meningitis, a report 
of which was drawn up by Dr. Gillkrest, Deputy Inspector-General of 
Army Hospitals. It prevailed during the first five months of 1844. In 
a population of 16,000, 450 were attacked, and of these 45 cases 
were fatal. " The invasion of the disease was in many instances 
sudden, while in others certain prodromes existed. In some the 
commencement of the attack was indicated merely by slight disturb- 
ance of the cerebral functions, with a little rigidity of the muscles 
at the back of the neck, and vomiting; these symptoms, perhaps, 
yielded to treatment in two or. three days. In many, however, the 
headache, particularly frontal or occipital, but sometimes general, 
was most intense from the commencement of the attack; the head 
being thrown back, and so retained by the rigidity of the muscles, 
for perhaps several (in some many) days; extreme anxiety and rest- 
lessness for the greater part of the time, frequently with spasms or 
convulsions, or both; pulse not always disturbed in a degree corres- 
ponding with the gravity of the other symptoms; injection of the 
adnata;, with high febrile movement, only taking place in a very lim- 
ited number. Vomiting and costiveness, in the early period of the 
attack, have been among the most constant symptoms; and it has 
been observed that after the vomiting had ceased for several days, 
during which the patients seemed likely to do well, this and the other 
acute symptoms have recurred, followed by a fatal termination. The 
absence of thirst throughout was among the most remarkable circum- 
stances accompanying the attack." 
Before and during this epidemic, it was noticed that in other dis- 
orders there was a tendency to headache, usually of the occiput.* 
In Dublin and vicinity, principally if not exclusively in the work- 
houses and hospitals, a disease called by Dr. Robt. Mayne " cercbro- 
* London Medical Gazette, vol. xxxiv. 38 
CEREBRO-SPINAL MENINGITIS. 
spinal arachnitis," made its appearance in January, 1846, and con- 
tinued throughout February, March, April and May, and a few cases 
were met with in June; also, in March, 1847, Dr. Mayne had two 
cases under treatment. In this epidemic the spinal arachnoid suffer- 
ed more severely than the cerebral.* 
In 1849, Logrono and Ribafrecha, in Spain, were visited by the 
epidemic under consideration; the natives called it clavo or sar- 
From this date no mention is made in any of the journals to which 
I had access, of any disease similar to this until 1856, when an epi- 
demic appeared at Niort, in the Hospice des Enfants Trouves, which 
in many of its features resembled it, but which was wanting in its 
fearful 
A similar disease appeared in Sweden in 1857.§ 
During the last few years only sporadic cases have been noticed, 
especially at Paris. A case is recorded in the Lancette Frangaise, 
1860, which occurred in La Charite; another case, which was ob- 
served in 1861, is recorded in the same Journal for 1862; and an- 
other case at Hotel Dicu in 1861, in the same Journal for 1861. 
In October, 1862, M. Axenfeld exhibited to the Medical Society of 
the Hospitals, specimens obtained from the examination of a young 
woman, 26 years of age, who died after four days, with symptoms of 
meningitis. There was found serum mixed with pus, not only in the 
cerebral meninges, but throughout the spinal pia mater. He did not 
think it a case of epidemic cerebro-spinal meningitis, though he under- 
stood that similar cases were then frequent, especially among females. 
It is, indeed, difficult to decide whether these cases were really the 
disease under consideration or merely cases of simple meningitis.|| 
In 1865, an epidemic disease appeared at Dantzic and other cities 
in Germany, and as there was a great deal said with regard to that and 
another epidemic in a neighboring empire, known as the Russian 
fever, and some fears lest it should be communicated by commerce 
and thus invade England, the Lords of the Privy Council appointed 
a committee to investigate it. Dr. Sanderson, a member of the Com- 
* Dublin Quarterly Journal of Medical Science, vol. ii. 
t London Lancet, Dec. 8, 1849. 
+ Lancette Frangaise, 1858. 
§ Dr.JWistrand on the Epidemic Diseases of Sweden in 1857, Dublin Quarterly Journal of 
Medical Science, vol. xxviii. 
|| Gazette IIebdomadairc,M862. HISTORY. 
39 
mittee, made a report to the Pathological Society of London. He 
considered it cerebro-spinal meningitis. Herpes labialis was seen; 
he saw only one case with petechias on the skin; hypostatic pneu- 
monia was common; generally, the blood was found uncoagulated 
after death; in two cases the spleen was excessively hyperaemic and 
soft, as in typhus, though he considered the two distinct diseases.* 
It is not unlikely that some of the epidemics recorded in the pre- 
vious pages were typhus fever; but the majority, and all those of 
which it has been possible to obtain accurate accounts, correspond 
very closely with this disease, not only in the symptoms, but also in 
the changes discovered after death. Those early epidemics which 
are recorded as instances of the disease, have been mentioned on 
the authority of Buserius, Sprengel and others, who have given de- 
scriptions agreeing with the appearances found at the present day. 
Where it has been possible, contemporary authors have been quoted; 
or, if their accounts have been abridged, care has been taken to give 
all that is important for forming a correct diagnosis. 
SECTION II. 
History. 
Domestic History.-Having reviewed the history of this disease as 
it has appeared in foreign countries, we now come to the history of 
its prevalence in this country, which, though extending over a shorter 
period, is even more important, and concerns ourselves at the pre- 
sent day more nearly. Its importance is increased by the fact that 
in this country, during the present century, the disease has shown it- 
self in its different varieties and with complications more frequently 
than in foreign countries. 
Some have supposed that this disease was seen in this country 
during the last .century, but most of the accounts do not seem to fully 
sustain such a conclusion. A " malignant pleurisy " was observed 
on Long Island in 1749, and had some resemblance to the pneumonic 
form. " The patient was first seized with a shivering or rigor, which 
is soon succeeded by a pain in his back and head, an early disposition 
to vomit, with great oppression and anxiety. Soon after the fever is 
formed, these appearances arc followed with an attack of pain in the 
* London Lancet, May 6,1865. 40 
CEREBRO-SPINAL MENINGITIS. 
breast and side, resembling peripneumonia symptoms, attended with 
a labored and painful respiration, a frequent cough, by which a crude, 
glazy, frothy spittle, slightly tinged with blood, is discharged; light 
deliriums through the whole progress of the disease, not constant, 
but frequently returning; the tongue for the most part parched and 
dry, but the skin inclined to be moist and sweaty, which, if en- 
couraged, the skin and coats of the eyes become extremely yellow; 
the blood appears rather dissolved and thin than viscid; the pulse 
in most cases soft and frequent. This disease ends generally in the 
death or safety of the patient on the fifth day, sometimes on the third 
or fourth from the invasion of the distemper. In those that have 
died it has been observable that, some hours before death, they have 
recovered their senses and appeared easy, but soon after have unex- 
pectedly and suddenly expired."* 
Dr. J. Comstock, in a letter to Com. Perry, which was published 
in the Medical Repository, new series, vol. iii., states that a few cases 
of a similar disease were seen in Connecticut during 1799, but it did 
not then become epidemic. 
It was not until March, 1806, that the epidemic form was seen; 
then it first appeared in Medfield, Mass. " Without any apparent 
predisposition, the patient is suddenly taken with violent pain in the 
head and stomach, succeeded by cold chills, and followed by nausea 
and vomiting; matter discharged from the stomach of no unusual or 
morbid appearance; respiration short and laborious; tongue a little 
white toward the root, and moist; velocity of fho blood increased, 
with a very sensible diminution of momentum in the radial, while in 
the carotid arteries it was much augmented; and in a child of 15 
months old, a very violent pulsation was discovered at the fontanelle; 
the eyes have a wild, vacant stare, without much, if any appearance 
of inflammation; the heat of the skin soon becomes much increased, 
yet the skin is not remarkably dry; these symptoms are accompanied 
by a peculiar fearfulness, as if in danger of falling from the bed or the 
nurse's arms, and continue from six to nine hours, when coma com- 
mences, with increasing debility; extremities become cold; livid 
spots, resembling petechia?, appear under the skin, on the face, neck 
and extremities; pulse small, irregular and unequal; spasms occur 
at intervals, which increase in violence and frequency in proportion 
as the force of the circulation decreases; at this time the eyes ap- 
* Dr. John Bard, in American Medical and Philosophical Register, vol. i. HISTORY. 
41 
pear glassy, and the size of the pupil varies suddenly, from almost 
wholly obliterating the iris down to the size of a millet seed, and 
then again as suddenly dilating. These symptoms seem to mark the 
second period of the disease, and continue from three to five hours- 
The third and last stage is distinguished by a total loss of pulsation 
at the wrists ; livid appearances become more general; spasms more 
violent; coma more profound: death! The patient has, in general, 
continued in the last stage from six to twelve hours."* 
On post-mortem, examination, there was found serous effusion be- 
tween the membranes, which adhered to each other and to the brain 
in several places; congestion and softening of the brain. The sto- 
mach was partially softened, and the lungs were darker than usual. 
In the fall of the same year it appeared in Mayslick, Ky., and con- 
tinued to prevail through the winter. 
In the spring of 1807, Hartford, Conn., was visited by this dis- 
ease, and a short time after it appeared in Windsor, and subsequent- 
ly in other towns in Hartford and Litchfield Counties, and continued 
to be noticed for three or four years. It was most prevalent during 
the last of the winter and the spring months. 
A very good description of this epidemic, by Dr. Sam'l Woodward 
may be found in the Medical Repository, 3d hexade, vol. i., or in Dr. 
North's treatise, with other papers equally interesting. He says :- 
" This disease appeared in the town of Winchester, in Litchfield 
County, in April, 1807, when the frost was dissolving and the ground 
breaking up, and was noticed to make the attack most frequently in 
rainy weather. Young people, under the age of 20, were most lia- 
ble to it; and among adults, females more liable than males. No 
age nor sex, however, were free from the attacks. It assumed, in 
different subjects, all grades of disease, from a mild fever to a per- 
fect plague. The symptoms were various, according to its invete- 
racy. It attacks with lassitude, chills, great prostration of strength, 
eyes red and watery, pupils dilated in some cases, in others small, 
like dying persons; often delirium, with exquisite pain in the head; 
great anxiety at stomach, with tossing of the body, nausea, and often 
a troublesome vomiting; a pain and lameness in some of the limbs 
often ushered in the disorder; there was a soreness of the flesh, and 
generally spots on the skin, the size of half a common turkey-shot, 
* Drs. Danielson and Mann, communicated to the Massachusetts Medical Society, Febru- 
ary, 1809. 42 
CEREBRO-SPINAL MENINGITIS. 
were scattered over the body, resembling blood-blisters; like- 
wise efflorescences, of various sizes and shapes, in different parts? 
which were dark or florid; and a dark or light color of these spots 
and efflorescences gave a clue to a favorable or unfavorable progno- 
sis. The darker, the more dangerous. In some, after the chills, 
there was great heat, which was of the thrilling, stinging kind. The 
pulse, like other symptoms, was various, sometimes considerably full, 
but generally very weak, quick and irregular. The disease some- 
times in this season assumed the inflammatory type, sometimes the 
synochus, but generally the typhus. The violent symptoms were: 
great lassitude, with universal pains in the muscles; chills; heats, if 
any, were of short duration; unusual prostration of strength; deli- 
rium, with severe pain in the head; vomiting, with indescribable 
anxiety at the stomach; eyes red and watery, and rolled up, and 
head drawn back, with spasm; pulse quick, weak and irregular; pe- 
techiae and vibices all over the body, and a cadaveric countenance 
and smell. Death often closed the scene in ten or fifteen hours after 
the first attack; some, however, survived all these symptoms. Those 
who died generally appeared to sink away under the load of disease, 
became cold and low, and died comatose, with all the marks of gene- 
ral mortification; others went off suddenly, apparently apoplectic. 
The body, near the fatal period, and soon after, became as spotted 
as an adder, and demonstrated a general dissolution of the fluids. 
When the vital flame began to be rekindled in the system, some 
grievous external affection most certainly appeared-such as inflam- 
mations of the joints, like the acute rheumatism, or an erysipelatous 
affection of the skin, or racking pains, without any morbid external 
appearance, convulsions, spasms, &c. These external affections often 
proved very lingering and tedious. This, however, generally proved 
a manageable state of the disease." 
Dr. Elisha North has given an account in most respects resembling 
the above; but it will be interesting to notice a few symptoms which 
he met with, and which are not mentioned by Dr. Woodward. " If I 
have not deceived myself, almost all had a kind of oedematous feel 
of the skin, especially about the hands and wrists." 
"Upon inquiry, almost all would tell you that they had, in the 
commencement of the complaint, a slight sore throat, although few 
would mention it of their own accord. In a few, but very few, how- 
ever, I have been able to discover aphthae on the tonsils. In gene- HISTORY. 
43 
ral, they would tell me the soreness was a little lower down in the 
throat. 
" In the bad cases, the most distressing symptoms were, pain of 
the head and universal distress and agony, which would cause chil- 
dren to draw back their heads, and toss and throw about their 
limbs." 
Petechias were by no means constant. He speaks of a 11 sinking 
state," but does not describe it further. He seems to refer to the 
condition mentioned above by Dr. Latham (see page 96), and which 
was subsequently noticed by Dr. Miner, in 1825. The worst form 
this disease ever assumes, particularly in children, is that of coma? 
or cholera morbus." 
During the summer of 1807 and 1808, the disease was seen at 
Hallowell, Me., by Dr. Page.* 
At Minisinck, Orange Co., N. Y., in 1808-9, it was seen and describ- 
ed by Dr. Arnell. He speaks of an " indescribable distress about 
the prascordia," and says sight was at times temporarily lost.f 
In 1810, this disease was seen in York County, Maine, and was 
observed until 1812; it was again seen in the autumn of 1814 and 
spring of 1815. It is said to have "differed from all other diseases, 
and yet it assumed in different subjects the livery of 
It was in 1810 that a committee was appointed by the Massachu- 
setts Medical Society to receive communications and report on this 
then new disease. The committee consisted of Drs. Thomas Welsh? 
James Jackson and John C. Warren, and on the 21st of June they 
made their report, which was afterwards published. It appeared in 
Dana at the beginning of that year, and more cases after the middle 
of January. Also, it appeared at Petersham in the latter part of 
February; at Barre, Oakham, Rutland, Paxton, Hardwick, New 
Braintree, Brookfield, Spencer, Sturbridge, Winchendon, Athol, Ger- 
ry, Leicester and Worcester, during March; Cambridgeport on the 
24th of March, and at Lancaster in April; in April and May at Bos- 
ton, and also in many towns in Worcester and Middlesex Counties; 
during May in Springfield. The headache is noticed as a universal 
symptom and as one of the first, or the very first occurring. Deli- 
rium seems to have attracted more attention than in previous years; 
* Medical Repository, N. S., vol. iii. 
t American Medical and Philosophical Register, vol. i. 
X New England Medical Journal, vol. iv. 44 
CEREB RO-SPINAL MENINGITIS. 
the varieties of the disease, the following is given as a description 
of some cases which occurred, especially among females. 11 Univer- 
sal, deadly coldness; skin white as polished marble, and smooth; 
countenance perfectly placid, not one distorted muscle; pulse at the 
wrist imperceptible; motion of the heart scarcely to be felt; respi- 
ration visible only by gasping, and that not frequent; and, as it were, 
only a step between this imperfect state of life and death." Even 
from this state of deadly stillness patients were restored to life and 
health. 
A good description of the usual eruption is given, together with 
some anomalous appearances of the skin. " The spots on the skin 
are of various descriptions. They occur in all stages of the dis- 
ease ; less frequently, however, on the first than on the subsequent 
days. Frequently a rash or miliary eruption only appears, or a few 
blotches on the inside of the elbow and other similar parts; and it 
has been suggested that these may be produced by the mode of treat- 
ment usually adopted. The blotches are florid, or red and fiery. 
An appearance like measles has also been noticed, and likewise vesi- 
cles and pustules, which have been compared to the vaccine and 
variolous eruptions. In some cases these spots and eruptions have 
appeared at succeeding periods, two or three times in the course of 
the disease. The vesicles and pustules are very frequently torn by 
scratching; after which, or without being torn, they are commonly 
followed by scabs of a brown color, but occasionally they are fol- 
lowed by ulcerations, which do not heal until after recovery. These 
affections of the skin are often attended with itching; and indepen- 
dent of them itching very frequently occurs, especially on the third 
day, when the symptoms become more favorable at that time. This 
itching is sometimes extremely violent, so that the patient will almost 
tear up his skin in endeavoring to alleviate it. All these affections are 
frequently noticed at the time when the more important symptoms abate 
or subside. In a few cases, vesicles containing a bloody fluid occurred 
in the county of Worcester. These vesicles were compared to blood- 
blisters, and were about the size of a large pea; they appeared on vari- 
ous parts of the body and limbs; in a few days they broke, discharged a 
bloody fluid and scabbed over. In one case, in which the attack was 
very violent, blisters resembling those produced by cantharides ap- 
peared on the second or third day on the breast and on one foot. They 
were about five inches in length and nearly one in breadth. On the fourth HISTORY. 
45 
day from the attack, some of those on the breast and that on the foot 
became black and dry, and the skin was sphacelated. The eschars, 
with due treatment, left clean ulcers, which healed without scars." 
The pctechiae and vibices " occur in comparatively few cases of 
the disease. They are of worse portent in proportion as they are 
more dark colored." They were not always found in fatal cases nor 
confined to such. 
In the appearances upon examination after death, there was a close 
resemblance to the disease as seen at the present day. When the 
cranium was separated from the dura mater blood was discharged; 
serum was found beneath that membrane, being sometimes of a red 
color. The sinuses, especially the longitudinal, were filled with 
blood; there was also congestion of the surface of the brain. Be- 
tween the arachnoid and pia mater there was found an opaque sub- 
stance-coagulated lymph-which followed the course of the vessels. 
The hemispheres were sometimes adherent to the dura mater and to 
each other. There was serum in the lateral ventricles; and the cho- 
roid plexus was thicker and harder than usual. 
The blood was unusually dark in the heart. 
" In one case the cavity of the thorax was the seat of very consi- 
derable disease. The heart was inflamed, and exhibited a large, 
thick flake of yellow lymph on its anterior face. The pleura of the 
right side, both of the ribs and lungs, was covered with the same 
substance, and the cavity of the pleura contained a very large quan- 
tity of half-formed pus. The color of the lungs externally was an 
ill-looking purple, and the pleura over them seemed to be shrivelled, 
and adhered to the diaphragm. Their consistence was uniformly 
firm in this case. 
In 1811 Dr. Elisha North published his treatise on "Spotted Fe- 
ver," extracts from which have already been given. In speaking of 
the diagnosis, he says:-" It is obvious, however, from the great va- 
riety of symptoms which this disease exhibits, that there will be 
great liability to mistake it for several other diseases, particularly 
cynanche maligna, scarlatina, common typhus, rheumatism, hydro- 
cephalus interims, cholera morbus, hysteria, mania, phrenitis, apo- 
plexy, nettle-rash, colic, &c." 
Until this time the epidemics had borne a very strong resemblance 
to what we have seen in our own day, the nervous centres being 
especially affected; but during the next three or four years the pneu- 46 
CEREBRO-SPIN AL MENINGITIS. 
monic form was in many places prevalent, sometimes to the exclusion 
of all others. 
During this time the disease was seen, in the spring of 1812, in 
various towns of Vermont and Maine, and in Salisbury and other 
towns of New Hampshire; in the State of New York, especially in 
the vicinity of Albany among the soldiers, in the pneumonic variety, 
and at Blackrock, near Buffalo, in the autumn of the same year; at 
Burlington, Vt., Granville, N. Y., and at Niagara in the winter of 
1812-13, It appeared in Maine, at Lyme and Waterford, Conn,, in 
Western New York, Philadelphia, and Winchester, Va., during the 
winter and spring of 1813; in Southern Virginia, at Chowan Biver, 
N. C., Natchez and in Eastern Mississippi in the autumn of 1813; at 
Bardstown, Ky., and in Talbot and Queen Ann's Counties, Maryland, 
during the winter of 1813-14; at Hallowell, Gardiner and Kenne- 
beck, Me., Malone, N. Y., Natchez and in Eastern Mississippi during 
the winter and spring of 1814; at Berwick, Me., York County, Me., 
Edenton, N. C., and in Southern Virginia during the summer and 
winter of 1814; at East Greenwich, R. I., at what was called North- 
ern Neck, Va., at Falmouth, Richmond and Middlebury, Va., in South- 
ern Virginia, at Salisbury, N. C., Columbia, S. C., and Milledgeville, 
Ga., during the year 1815. 
During this period the type of the disease was rather more sthenic 
in its action than that previously observed. This change in the 
grade of the fever was coincident with a change in the part affected. 
The lungs received the weight of the disease, and pneumonia was 
very generally observed: so general was this, and so free were the 
patients from all affection of the head, that the disease was consider- 
ed by many as differing materially from the so-called spotted fever of 
former years. 
Dr. James Mann, in his " Medical Sketches of the Campaigns of 
1812, '13 and T4," has left us valuable information with regard to 
this epidemic as it appeared among the soldiers in Greenbush and 
other places. He says :-11 It has been already observed, the sudden 
change of weather in October (1812) introduced additional forms of 
disease among the men. We have to notice one of more formidable 
and more questionable symptoms-pneumonia, or inflammation with- 
in the breast. This disease was, in some instances, accompanied 
with diarrhoea, or supervened where diarrhoea previously existed 
which last disease had not entirely disappeared. The following are HISTORY. 
47 
the most prominent symptoms:-pain in the chest; in some cases 
one side, in others both were affected; short and difficult respiration ; 
dry cough; the pulse of those whose condition was most alarming 
was small and hard; the heat of the body and extremities not above 
the standard of health, sometimes below. 
" This disease, when it first appeared at Greenbush, was not con- 
sidered as being connected with an epidemic state of the atmo- 
sphere. 
" In proportion to increase of cold, this disease became more fre- 
quent and severe. 
"It may be necessary to observe, the winter epidemic of 1812-13 
was a form of disease distinct from that which, in the northern dis- 
tricts of the Eastern States, the preceding winters, had been known 
by the name of spotted fever, although the exciting causes may have 
been similar. In the spotted fever, mental derangement was an almost 
general concomitant of the disease. In many instances, this affec- 
tion of the brain was the first symptom of morbid action. Whereas, 
pneumonia, especially among the troops, was never accompanied with 
mental derangement, at its first attack, and but seldom in its more 
advanced stages; nor until the laborious respiration, which was a 
most prominent symptom at its first attack, had somewhat subsided, or 
the patient was at the point of death. 
" This epidemic appeared under the forms of both sthenic and 
asthenic diathesis; although under the last it was often, if not al- 
ways deceptive. In many of the first cases at Burlington, the disease 
proved fatal in two, three and four days, by the violence of the first 
attack; in some instances, in less than twenty-four hours after the 
first symptoms of indisposition supervened. 
" The following were the most conspicuous features of the disease 
under its most deadly form. At the first attack the heat of the body 
and extremities was below the standard of health; the pulse con- 
tracted and hard, sometimes scarcely perceptible; respiration ex- 
tremely laborious-not apparently so much from sharp pains through 
the sides and breast, as from a sense of suffocation. The patients 
say, upon inquiry, that they do not suffer from extreme pain, but a 
weight upon the chest-an oppression from inability to inhale the 
air. 
" This epidemic was wide spread in its influence, prevailing from CEREBRO-SPINAL MENINGITIS. 
48 
Lake Erie down to Lake Champlain; over Vermont, the northern 
counties of Connecticut, Massachusetts and New Hampshire." 
" In the second stage of the disease and where there was a weak, 
soft pulse, bleeding was injurious; yet the antiphlogistic regimen 
was necessary. Here the respiration was difficult, but not suffocated, 
accompanied with pain in the side, and expectoration of bloody mu- 
cus ; the bronchi® were so crowded as to be incapacitated to free 
themselves from the load with which they were oppressed; the heat 
of the body was never much above the common standard of health. 
This form of the disease was frequently accompanied with diarrhoea* 
" The third form of this disease showed itself with less question- 
able symptoms. At the first onset of the disease, there were strong 
rigors, with acute pain through the chest. The rigors were soon 
followed by much heat, strong pulse, cough, and no expectoration. 
The efforts of coughing always increased the pain in the breast." 
Dr. Silas Fuller, stationed on the Niagara frontier, observed the 
same disease, which was not so much confined to the army, but 
spread more among the citizens. He says:-•" The disease appears 
evidently to depend on some peculiar state of atmosphere as a 
remote cause; and an exposure to wet, cold and fatigue as an excit- 
ing cause. In proportion as these causes have operated, a more 
or less violent form of the disease is produced. The most common 
form under which it has presented itself is that of sthenic pneumo- 
nia; the most fatal and unmanageable of the pneumonia notha of the 
old books. Under this last form it has seldom appeared. 
" The asthenic form most commonly commenced with cold shiver- 
ing. After some time there is a sense of heat. In some instances, 
the common symptoms of pyrexia are noticed. The pulse, however, 
for the most part is small, and the heat not higher in degree than 
natural. During the course of the disease respiration is extremely 
laborious, with slight erratic pains through the chest. 
" A sense of weight and fulness is felt through the whole extent 
of the thorax, which are increased to an insupportable degree, while 
the patient is in a horizontal position. There is a peculiar paleness 
and wildness not easily described. 
« This epidemic, in its sthenic form, is not always a pneumonia. 
The fever has sometimes appeared without any local affection, under 
the type of synocha. In a few instances, the inflammation has attack- 
ed the brain and its meninges, producing phrenitis. Inflammation, HISTORY. 
49 
with suppuration in the throat and frontal sinuses, are varieties of 
the disease. 
" The sinking stage of the disease is known by the smallness of 
the pulse, coldness of the extremities, dark or shining appearance of 
the tongue, extreme debility, with some degree of delirium, and sub- 
sultus tendinum." 
Jaundice during convalescence, discolored faeces, and haemorrhages 
from the intestines also occurred. 
During the campaign of 1814, Dr. Mann met with the same dis- 
ease at the Malone Hospital:-it " was accompanied with all the 
same symptoms under which it appeared the preceding winter, but 
its attacks were less frequent. There were a few cases of disease 
which assumed the form of spotted fever-in which the brain seemed 
to be the seat of the disease; a mental derangement having been 
the first alarming symptom, without any pneumonic affection. All of 
these died within the first twenty-four hours; two of the number 
within six hours." 
In an account of the epidemic of 1815-16 at Sharon, Mass., and 
vicinity, he says :-" In four or five instances this epidemic made its 
assault upon the head." Afterwards pneumonia supervened. Three 
cases out of seventy had symptoms of erysipelas. 
" At Rochester, County of Plymouth, there were cases where the 
disease was not confined to the lungs; but the inflammation appeared 
under the form of cynanche trachealis, pharyngea and parotidea, as 
the trachea, tonsils and parotid glands were successively or simulta- 
neously affected." 
" It should be understood that, notwithstanding all the above con- 
ditions, the most prominent symptoms of typhous fever do not exist 
in this complaint-as debility and low delirium. In a very few in- 
stances, delirium has accompanied the other symptoms of the disease, 
but it is always phrenitic." 
I have given such copious extracts from this work by Dr. Mann, 
because by his position in the army he had great advantages for the 
study of the disease as it appeared among the soldiers, and more 
clearly than any one else has given the symptoms and the objections 
against considering it spotted fever. It must be acknowledged that 
its action was much more sthenic; but the head symptoms were not 
absent; they did not appear at Greenbush, but were seen at Niagara, 
and again in another year at Malone, and afterwards at Sharon. 50 
CEREBRO-SPINAL MENINGITIS. 
Other symptoms, too, were present which are often found to accom- 
pany spotted fever, as sore throat, and even debility was noticed in 
some cases. We shall see, by other accounts, that elsewhere the 
disease yet more closely resembled that which we are considering; 
and even in the vicinity of Albany the pneumonic form was not inva- 
riably met with. The following post mortem, which was performed 
at that city in the last part of March, 1812, presented no morbid ap- 
pearances in the lungs. The young man was attacked March 28th, 
and died in thirty-two hours. " The claret color on the surface ap- 
peared to have been produced by a slight effusion of blood into the 
cellular substance; the omentum was of a pink color; the bloodves- 
sels of the mesentery and the vena portarum were distended with 
blood; the spleen was about four times its usual size, but of a 
healthy color and consistence. On cutting into it, a great quantity 
of grumous blood of a very foetid smell oozed out of it; the stomach 
was empty; the gall-bladder full of yellow bile. Nothing further 
was discovered in the abdomen differing from a healthy state. The 
lungs were of a healthy appearance; the heart and large vessels con- 
nected with it, particularly the aorta, were distended with blood; 
the coronary vessels were as minutely injected as I have ever seen 
them in the best preparations. On removing the skull-cap, the dura 
mater and brain were distended with blood; on making incision into 
any part of the brain, the cut surface was instantly covered with the 
blood which oozed from its vessels; the right lateral ventricle con- 
tained about a tablespoonful of serum."* 
Dr. Southwick, of Albany, has given an account of the symptoms 
as he found them in his practice. His first case occurred in October, 
1812, a young man who had been living at Greenbush; his second case 
was seen in November. Afterwards the disease became more common, 
and he treated many who were thus attacked. In his account he 
says :-■" The patients now complained of pain in different parts of 
the body-the heels, ankles, knees, hips, small of the back, shoulders, 
breasts, sides and head-a heavy, painful sensation in the eyeballs; 
they suffered under these pains at different times, and often at the 
same time. 
" The most distressing chills ushered in the disease. My patients 
told me the chills were different from anything they ever felt before; 
* Medical Repository, 3d Hexade, vol. ill. HISTORY. 
51 
they were peculiarly agonizing in some, and in the language of two, 
1 they were like throwing cold water on their hearts.' The tongue 
at first always pale, and its secretions inactive. This paleness of 
the tongue continues in the worst stages; pulse in almost all these 
cases little different in frequency from natural, but the sensation 
given to the finger by the artery peculiar and new to me; it appeared 
that during the intermission of each pulsation the vessel had com- 
pletely emptied itself. The pulsations, though they appeared to dis- 
tend the artery to its usual capacity, were weak and languid. In 
short, it exhibited every mark that would deter a prudent physician 
from bleeding. 
"In the majority of cases they complained of pain in the right side 
and across the breast; with the last symptom a slight but frequent 
cough was frequently attendant." 
" In the second stage the pulse became quick, feeble, and often 
hardly perceptible. This generally took place on the third day. 
" If no favorable crisis had taken place at this time, the pain in the 
head or side would return sometimes with a burning sensation at the 
stomach attended with more or less nausea; now the breast suffered 
the most distressing sensations from an incapacity to fill the lungs by 
inspiration."* 
Dr. Hunt, of the U. S. Navy, writing from Washington, says con. 
cerning the cases which came under his observation:-" The disease 
frequently comes on in the form of a common cold, attended with 
cough, sore throat, redness of the eyes, and a pain in the right pap. 
In about forty-eight hours a fever takes place, with increased pain in 
the breast, and frequently delirium. The pain is so severe for seve- 
ral days as to keep the patient in a state of constant agony." " This 
disease was certainly a pneumonia, attended in the commencement 
with typhoid symptoms, which quickly changed to a typhoid state."!' 
Dr. Robert Dunbar, of Winchester, Va., under date of February 
22d, 1813, says that the subjects were generally from 12 to 20 years 
of age. " The symptoms were not uniform, but varying in propor- 
tion as the disease was marked with malignancy or mildness. Its 
attacks were accompanied with great lassitude, rigor, long-continued 
chills, great prostration of strength, unusual depression of spirits; 
eyes suffused, with a slight tinge of redness, accompanied with a 
glassy appearance. The pupils, in the cases I attended, were but 
* Medical Repository, N. 8., vol. i. t Ibid. 52 
CEREBRO-SPINAL MENINGITIS. 
little dilated; stupor, delirium and coma, with pain in the head, sto- 
mach a little affected with nausea, occasionally amounting to a pro- 
pensity to vomit." 
There was soreness over nearly the whole body; in almost every 
case sore throat and difficult deglutition were found. In a few hours 
after the attack the jaws were sometimes fixed; opisthotonos existed, 
the head being drawn back and the spine curved. The pulse was 
irregular, generally weak, and often not perceptible. Petechia; and 
vibices were seen generally over the whole body.* 
A committee of the Medical Society of the County of Saratoga 
made a report in regard to what was called the " winter epidemic," 
in which they say:-" The bilious pneumonia became epidemic in 
some towns in this County early in December, 1812, in most others 
in January, 1813. In one or two it did not appear earlier than the 
first part of February. 
" The first stage commenced with a cold chill, which has sometimes 
lasted from four to twenty-four hours or longer, but it generally con- 
tinued from thirty minutes to two hours. 
" During the continuance of the chill, the patient is generally 
affected with a violent pain in the head, back, loins and some part of 
the thorax. It sometimes, at the first, extends to the limbs, resem- 
bling acute rheumatism; at other times to the bowels, resembling 
enteritis." 
There were pneumonic symptoms-pain, cough and bloody sputa. 
Nausea was common. The pulse during the cold stage was weak, 
small, and sometimes imperceptible at the wrist. 
" Second stage. When the fever did not terminate about the fifth 
or seventh day by a favorable crisis, the following symptoms gene- 
rally ensued:-the pulse became full, soft and weak, from 90 to 100 
strokes in a minute; the tunica adnata of the eye and skin became 
yellow, the tongue dry and coated with a dark brown, except in a 
few cases where it was smooth and glazed, of a dark red; heat and 
dryness of skin much more considerable than in the former stage; 
the bowels swollen and elastic." 
They did not consider it different from the pneumonias of fifteen 
or twenty years before.t 
Dr. Job Wilson, in his treatise on the "Nature and Treatment of 
* Medical Repository, N. S., vol. i. 
t Ibid vol. ii. HISTORY. 
53 
Spotted Fever," has given an account of the disease as it appeared 
previous to 1815 in New England. February 16th, 1812, he was 
called to a case in which sudden and violent pain in the head was 
the first symptom; this was soon followed by severe pain in the right 
side of the thorax. The patient recovered. In March, Dr. Wilson 
saw other cases, in which the lungs were affected. He describes the 
symptoms of the disease thus:-11 Extreme cold shivering, acute pain 
in the side or head, but occasionally in the hands or feet. Sometimes 
it affected the bowels and back in the form of colic or dysuria. In 
other cases, the most acute pain would be felt in the ear, the jaw, or 
even in a tooth. The breathing was in most cases difficult, attended 
with cough, and often with a bloody expectoration. Delirium was 
frequent, but not a uniform symptom. Some were affected with an 
unmanageable, furious delirium, similar to that which attends phre- 
nitis. Others were affected with low muttering and comatose deli- 
rium, attended with a disposition to sleep. Some few, as the disease 
declined, became insane; but the insanity was of short duration, and 
entirely left them on the recovery of their strength. Difficulty in 
voiding the urine was almost a constant symptom; the hands and 
face were generally of a leaden color, and moderately swollen; a 
very slow motion of the blood in the capillaries was very percepti- 
ble, by making a slight pressure on these parts with the point of the 
finger; effusion of blood or lymph in the rete mucosum and cellular 
membrane, as likewise effusions in the sockets of the eyes (the eye- 
balls were occasionally suffused with blood); deep effusions in the 
extremities, lying in immediate contact with the periosteum, and oc- 
casionally occupying the whole limb, and extending from joint to 
joint; effusions of blood and lymph in the cavity of the thorax, in 
the cells of the bronchiae, and in the brain, &c.. Blood was occa- 
sionally discharged with the urine, and in some cases from the bow- 
els, resembling dysentery. Raising blood from the lungs was fre- 
quent. A discharge of blood from the nose was frequent, and not 
an unfavorable symptom. He mentions, also, an eruption of hard, 
white pimples, and likewise a rash " similar to ring-worms." 
In 1813, the same disease occurred in New Hampshire and Ver- 
mont ; in some places with great mortality, in others in a very mild 
form. " In 1812, the lungs were almost universally affected, and death 
was caused by suffocation, Ac. In all the cases which I witnessed in 
1813, the lungs were not so generally affected; the head appeared 54 
CEREBRO-SPINAL MENINGITIS. 
to be the part which suffered most, and the patients appeared to die 
in convulsions, apoplexy, palsy, &c." Subsequently this disease 
occurred less frequently and was less fatal. 
Dr. Wilson gives two post-mortem examinations, which have not 
yet been noticed. One was of a lady, who was attacked April 27th, 
1812, and died on the fourth day, from suffocation. On opening the 
thorax, there was found extravasation of lymph of a yellowish ap- 
pearance in the cellular membrane; and also extravasations of blood 
into the substance of the lung, having a dark color. The same was 
seen on the internal surface of the pericardium, though much larger. 
The pericardium contained nearly a pint of serum. The upper por- 
tion of the lung was heavy, sinking in water; the air-cells were 
filled with a yellowish lymph. " This viscus was of a dark ■red color? 
and adhered, throughout its whole surface, to the pleura and dia- 
phragm, saving the posterior surface, where there was a large col- 
lection of lymph." The cavities of the heart were distended with 
very dark blood. The liver was very much engorged and of a dark 
red color, except in spots where it seemed to be healthy. 
In another case where the patient, a young man, 17 years of age, 
died on the eighth day of the disease, there was found extensive ex- 
travasation of blood into the lungs, some of which had been absorbed; 
the upper portions were very much engorged with blood. In the 
brain also was found more or less extravasation in the membranes, 
and several small deposits of lymph on the surface; much of the 
blood which had exuded from the vessels had been absorbed. 
Dr. Utley, of Lyme, Conn., recognized two varieties, one where 
pneumonia existed, the other without any affection of the lungs. 
The second was " ushered in with a sense of distress at the prae- 
cordia or pit of the stomach, thence ascending to the head, as a pain 
or dimness of sight; this returned down along the spine, attended 
sometimes with universal paralysis." Prostration was extreme.* 
Dr. Kercheval, of Bardstown, Ky., says, " It happens in a certain 
proportion of the cases that the head is the primary seat of the dis- 
ease ; the chest at the same time remaining free from any local 
disorder."! 
Dr. Ira Bascomc, of Granville, N. Y., says that petechia} seldom 
appeared. He found the lungs more severely affected than in the 
spotted fever described by Huxham, Pringle, and others. Among 
* Medical Repository, N. S., vol. ii. 
t Ibid. 55 
H I S T,0 R Y . 
the symptoms, he mentions, chills, a low quick pulse, languor, pain in 
one side, nausea, dull pain in the head, livid countenance, soreness 
across the temples and eyeballs. The sickness, vomiting and headache 
were sometimes severe from the beginning. In others common 
catarrh first appeared; suddenly it assumed the most alarming symp- 
toms ; a violent pain, most frequently in the right side. These are 
the principal symptoms; " but others too numerous to mention have 
appeared in various parts of the country." " As far as I have been 
able to learn it is the same disease which had prevailed in some 
parts of New England and New York for several years previous, 
under the various denominations of spotted fever, catarrhal fever, 
peripneumonia notha, &c."* 
Dr. B. Vaughan, of Hallowell, Me., found the spots to be usually 
wanting. He adds to the list given by Dr. North of the diseases for 
which it may be mistaken-" pleurisy and other diseases of the chest, 
nervous headache, palpitation of the heart, earache, sometimes fol- 
lowed by discharges from the ear, lethargy, stretched and shining 
skin as in dropsy, and stiffened muscles," sometimes epilepsy. He 
mentions the affection of the throat. The head was not specially 
affected.! 
The disease occurred in Maine in 1811, T2, '13 and T4. Dr. 
Hazeltine considered it the same as spotted fever, and the symptoms 
agree with the description given by Drs. North, Woodward, <fcc4 
Ennalls Martin, M.B., of Maryland, in the winter of 1813 and T4, 
found headache a very prominent symptom and the pain in the thorax 
less marked.§ 
Dr. Joseph Trent, of Richmond, says that the force of the disease 
was sometimes expended on the throat and fauces. The muscles of 
respiration and the glottis were spasmodically affected. Large 
glandular swellings occurred about the neck.|| 
Thomas P. Hereford, of Middlebury, Va., found that it appeared 
under varied forms affecting the lungs, brain and throat, and gen- 
erally of a typhoid character.il 
Dr. E. Simpson Davis, of Milledgeville, Ga., met with cases from 
April 21st to April 28th, 1815. Glandular affection of the throat 
was common, and there was no apparent congestion of the lungs. ** 
Dr. John Kerr notices the disease as it appeared during 1813 and 
* Medical Repository, New Series, vol. iii. f Ibid. | Ibid. § Ibid. 
|| Ibid. T Ibid. ** Ibid. 56 
CEREBRO-SPIN.AL MENINGITIS. 
'14 in Natchez and Eastern Mississippi. In the winter of 1814 he 
saw many cases of unusual malignancy where the breast, head and 
throat were affected. The disease was not so frequent nor so severe 
as at the North. * 
Dr. E. Hale published a work on the spotted fever as it appeared 
in Gardiner, Me., in the spring of 1814. His account of the symp- 
toms is very full and interesting. He noticed the sudden and vio- 
lent manner in which it frequently made its attack, and the great 
variety in the symptoms. " In the earlier part of the epidemic period 
the disease always commenced with severe pain in some part of the 
body, which, if it did not begin there, soon extended to the head and 
back; and in a few cases the pain increased, till in a short time it 
produced a delirium. Later in the season, however, pain was a less 
constant symptom." " Besides the varieties of pain which I have 
mentioned, there was in several cases, during the first day or two, 
acute pain in the chest, accompanied by a cough and expectoration of 
thick mucus, often streaked with blood. Early in the season this symp- 
tom was pretty common, but afterwards it seldom appeared. The 
cough and expectoration were considerably common in cases where 
there was no pain in the thorax." Nausea and vomiting, thirst, chil- 
liness and a weak, rapid pulse are mentioned among the symptoms. 
He mentions a second stage, in which vomiting was the principal 
symptom, the pain being in many cases removed. There was often 
a feeling of lightness about the head; diaphoresis occurred, and the 
countenance was less expressive of anxiety. The vomiting was ob- 
stinate and required remedies to control it. 
His third stage was the comatose, in which the patient gradually 
became unconscious, and after a while it was impossible to arouse 
him; his breathing became stertorous and he died. 
He does not seem to have met with many cases in which there re- 
mained, after the acute stage, the state of chronic ill health so often 
seen elsewhere. 
He mentions seven or eight cases in which the lungs appeared to 
be more or less affected, but as no post-mortem examinations were 
allowed, it is impossible to say how far the disease of the lungs 
extended. It does not seem generally to have been severe, and was 
in each case, except two, attended with symptoms referable to the 
head. 
* Medical Repository, N. S., vol. iii. H I S T, 0 R Y . 
57 
Dr. James Davis, of Columbia, S. C., published an account of the 
disease as it appeared in that section of the country during 1815 
and '1G. He states that the disease commenced as an epidemic of 
common cold in November, 1815, was at its height during the middle 
of January, and had nearly subsided by the second week of Februa- 
ry. Not a single case of a formidable nature occurred without a 
chill; after the chill there was more or less fever and pain in the 
thorax. The pneumonic form, with the usual symptoms, was the 
most common and prevalent. Next in frequency was the form with 
a determination of the disease upon the brain and meninges, with 
violent pain in the head, suffused countenance, redness of the eyes and 
delirium. 
11 In another form, the disease fixed on the bloodvessels only, in 
the form of a violent fever; and in the third, but in very few in- 
stances, there was a local determination to the throat, producing cy- 
nanche pharyngea."* 
Under date of February 22d, 1815, Dr. J. Comstock wrote a let- 
ter to Com. Perry, which was published in the Medical Repository, 
Now Series, vol. iii. Though it does not give a detailed account of 
the symptoms, it touches upon many points of interest. He consi- 
dered the disease which prevailed at that time in the Southern States 
a modification of that which had for nine years been epidemic in 
various parts of New England. 
His reasons for believing the two diseases essentially the same 
are:-"1st. The unity of period in which the disease first invaded. 
2d. The complaint being aggravated in both sections of the country 
by bloodletting. 3d. Its being in both places a disease of great 
malignancy and mortality, at a very unusual season of the year, viz., 
in the winter-the greatest number of deaths happening in cold 
weather and diminishing at the approach of summer, contrary to 
most fevers, and just the reverse of what happens in yellow fever, a 
disease of hot weather, and which is checked by cold, and which, I 
may add, requires a very opposite method of cure. 4th. The case 
of G-en. Washington (who, he thought, died of the disease) shows 
the tendency of the complaint there to affect the throat from the first 
in a greater degree than here; yet a slight sore throat is thought by 
some accurate observers amongst us to be the most certain sign of 
* Medical Repository, New Series, vol. iii. 58 
CEREBRO-SPINAL MENINGITIS. 
the disease, and I have had several cases in which it put on the form 
of malignant sore throat." 
11 It is now proper to observe that very little uniformity has taken 
place anywhere in this very eccentric disease." " From different 
symptoms attending it, it has in different places been called by other 
names, as spotted fever, pmeumonia typhoides, typhus fever, cold plague, 
malignant pleurisy, cholera morbus, bilious pleurisy, palsy, dysentery, Ac. 
Ac. And it is an acknowledged fact that it has attacked in almost 
every shape and form that any human malady ever assumed, among 
which I may reckon toothache, common cold or catarrh, sore throat, 
numbness, pain in one of the fingers, a sensation like the stinging of 
a bee, sudden blindness, a failure of senses, loss of the use of the 
limbs, convulsions, coldness, paleness and shrinking of the features, 
and, on the contrary, with fulness of the face and redness, sometimes 
with and sometimes without heat, rheumatism, Ac. 
" Sometimes a vomiting of a thin black matter, resembling soot- 
water, or rather bilge-water, takes place early or late in the disease, 
and denotes such a tendency to gangrene as leads to an unfavorable 
prognosis." " With this, sometimes without it, are pitch-like dejec- 
tions, and often those of a bottle-green color, sometimes foaming, as 
though in a state of active fermentation. I believe from hence that 
in some places it has been denominated a violent bilious fever." 
" In two patients, the vomitus resembled blue dye; more frequently 
of a green or bottle-green, and once claret. In other cases, nothing 
unusual in any of the discharges, and these were cases which yielded 
most readily to the stimulant treatment-viz., to bark, wine, opium 
and alcohol. Some other cases required stimulants for the first day 
or two, because the debility was extreme, and afterwards emetics 
and cathartics to cleanse the first passages." 
"Morbid matter was not always brought up by vomiting, but in the 
worst cases by eructation or belching." 
" There was a tendency to intestinal haemorrhages, especially in 
1810." 
Dark, bloody and frothy matter, and sometimes small particles of 
the lungs, were coughed up. The fever was sometimes converted 
into complete mental derangement, upon cessation of which the fcVer 
returned." 
It " seems difficult to find anything specifically diagnostic to dis- 
tinguish it from other distemperaturcs. The pulse, however, is the 59 
HISTORY. 
guide." " It may not always be quicker than it is in health, which is 
the case perhaps in all other fevers, and yet it is sometimes extremely 
quick, even to 130 or 140 in a minute. It may not at first seem 
much weaker upon a slight examination than the pulse of a person 
who is able to be about, although it is often very much so. But one 
thing in all cases is certain-viz., that it is easily compressible and 
always void of that full, high, hard, resisting beat, which is the plain- 
est indication of inflammatory disease. The feeling of the flesh also 
has often something peculiar. It has a soft, flabby feel, somewhat 
like velvet; and if there is much heat, it is of a penetrating, prickly 
kind, instead of giving a burning sensation, like the skin of inflam- 
mation. The softness of the flesh has been noticed in dissections, 
the muscular parts having lost their tone, like meat that had been 
frozen and suddenly thawed. It is from hence that there is a ten- 
dency to those effusions which constitute danger and cause death, and 
which seems to be in that particular part, as we suppose, in which 
the loss of energy is greatest. If this be the brain, the consequence 
of the effusion may be apoplexy, palsy or convulsions; if in the 
thorax, symptoms like pleurisy and peripneumonia; if under the 
skin, spots; if in the throat, swelling, even to strangulation, or a sud- 
den sphacelation; if in the stomach, it may be so abundant as to 
waste the body with marasmus, accompanied with puking or diar- 
rhoea." 
" That particular form of the disease which affects the lungs may 
have its origin from effusion into that viscus, with cough and bloody 
expectoration, and perhaps some peculiar symptoms which may have 
given rise to the appellation of lung fever."* 
In 1815, Dr. Joseph A. Gallup published a work on the u Epidemic 
Diseases in the State of Vermont." He devotes a portion of this 
to spotted fever. His account of the symptoms agrees in most re- 
spects with what has been already given. " The eyes are generally 
dull and heavy, inclining to shed tears without being conscious of it." 
" The lungs are pressed with blood, but seldom any cough. Respi- 
ration is often laborious, and patient inclines to be quick of speech." 
" The region of the heart is sometimes the principal seat of the dis- 
ease, and not so violent in the head." " The eruption which has 
given name to this disease, is not a constant attendant." " It was 
very common for relapses to occur, or for the disease to be repeated, 
* Medical Repository, New Series, vol. iii. 60 
CE REBRO-SPINAL MENINGITIS. 
after the patient had returned to his ordinary employment." He 
docs not mention the pneumonic form, though his next article is de- 
voted to peripneumony, in which he says:-" The disease of 1811 
and 1812, called petechial fever, and the present epidemic, seem to 
have many things in common." " The chief difference seems to con- 
sist in the locality of the principal affection." 
The post-mortem appearances were those so often observed in other 
places where the head was affected-congestion and exudation. 
a The thorax exhibits similar traits of membranous inflammation. 
The heart is most commonly the seat of its greatest violence, when 
the seat is in the thorax; the small bloodvessels seem beautifully in- 
jected." " The outer coat is frequently covered with extravasated 
lymph of different degrees of consistence or firmness." The pleura 
was also at times inflamed. 
In considering these various accounts of the epidemics of 1812-1G, 
we sec that in many of them the symptoms differ from what was seen 
before and from what wo witness at the present time. The question 
arises, is it the same disease in both cases ? There is not only a 
difference in the particular organ affected, but in many cases the 
grade of action is different. In some places the fever ran high, with 
a full, hard pulse, and depletion was useful; in others, the pulse was 
small and weak, or if full was easily compressed and soft, and de- 
pletion was rather injurious. In some places the head was not at 
all affected; in others, the lungs were entirely free. Were they, 
then, the same disease ? 
Dr. Hunting Sherrill, in an address before the Dutchcss County 
Medical Society, delivered in November, 1819, speaking of the dis- 
eases which had prevailed in the County during the previous ten 
years, says :-" We met with cases putting on nearly the character 
of usual phlegmasial fever; and we saw it receding from that, 
through the varied grades of excitement, to the typhoid state of dis- 
ease. It may now readily appear why the disease was called and 
described by the different names of peripneumonia, peripneumonia 
notha, peripneumoniatyphoides, bilious pleurisy, bilious fever, typhus 
fever, spotted fever, and many others, either of which was probably 
more correct than the delusive ones of typhus fever or spotted fever." 
And so it was elsewhere, the disease took varied forms and degrees 
of action; in one person being a frank open fever with quick, hard 
pulse; in another being essentially asthenic; and both occurring at HISTORY. 
61 
the same time and in the same place. The affection of different 
organs was also noticed at the same time, in the same place; even 
in the same individual both forms were seen. Dr. Gallup says, 
"Neither of the diseases was strictly confined to one of these parts 
or the other (head or lungs). When most in the head, the diseased 
affection would be slightly traced in the thorax; and when in the 
thorax, some could be traced in the membranes of the head." * 
It may be worthy of notice, that when the lungs were affected the 
fever was more severe and had more of a sthenic character, than 
when the brain was the principal seat of disease. 
Both forms occurred during the same years and during the same 
season, being most frequently seen in the winter; both occurred in 
the same immediate vicinity; both were acknowledged to depend on 
the same causes-atmospheric changes, assisted by fatigue, cold, 
wet and other debilitating influences: both required nearly the same 
treatment, allowance being made for the greater debility in one than 
in the other; symptoms peculiar to each occurred in the same indi- 
vidual ; the symptoms which were not strictly local were similar in 
each; both were marked by the peculiar erratic character of their 
symptoms; they were recognized and spoken of by many able prac- 
titioners, who saw and treated cases of both, as only different forms 
of the same disease. Hence it may be safely concluded that the two 
forms we have been considering are only different manifestations of 
the same complaint. 
It will not be necessary to consider so minutely the symptoms 
observed in succeeding epidemics, as they are not materially different 
from what has already been recorded. 
In 1816 and '17, the disease we arc considering appeared in vari- 
ous parts of South Carolina, in Salem County early in 1816, and in 
Claremont during the winter of 1816-17 ; from 1818 to 1822 it was 
seen in Mecklenburg, Lunenburg, and Brunswick, Ya.; in some parts 
of the Western States during the spring of 1819, and also in North 
Carolina and the mountainous parts of Virginia; in 1821 in Frank- 
lin County, Penn.; in 1823 it was recognized at Saco, Me., Berlin, 
Conn., in the Shenandoah Valley, Va., and possibly at Marietta, 0., 
though the account of that epidemic is not very satisfactory. In 
1823, '24 and '25, it was seen in the vicinity of Middletown, Conn., 
also in some parts of that State in 1826, and likewise at New Orleans 
* Epidemics of Vermont. 62 
cerebro-spinal meningitis. 
and Fort Adams; and in 1827 in Trumbull County, 0. In 1832; 
sporadic cases occurred at New London, Conn., which in many 
respects resembled this disease; there was extreme exhaustion and 
great sinking at the epigastrium; a chronic state of debility and 
nervous exhaustion frequently remained after the attack. There is 
no mention made of this disease from that date, till in 1845-46 an 
epidemic pravailed in Clark County, Ill., called " black tongue," 
thought by Dr. McCoy to be cerebro-spinal arachnitis on account of 
the post-mortem appearances. In the early part of 1847 it was seen 
in Mississippi, Tennessee, Missouri and Arkansas, and " resembled 
a modified pneumonia; " in the winter of 1847-48 at Washington, 
D. C. Dr. Ames has given a very interesting account of it, as it ap- 
peared in Montgomery, Ala., during the winter and spring of 1848. 
He saw cases which were attended with inflammation of the fauces; 
others with pneumonia; and two patients had at the same time 
roseola, which was then prevalent. Dr. Sargent read a paper before 
the Massachusetts Medical Society on this disease as it manifested 
itself in Millbury and Sutton during 1849; it was also noticed, the 
same year; at Mecklenburg, N. Y. Again, a few cases were seen in 
New Orleans during the last days of January, 1850; in central and 
western New York during 1857, as recorded in the Transactions of 
the New York State Medical Society, for 1858. In October, 1859, 
there commenced an epidemic at Castle Craig in Virginia, which 
continued nearly a year. Dr. R. T. Lemmon, who gives a report in 
regard to it, considered it to be dengue, but the severity of the dis- 
ease was much greater than is usual in that complaint, and the 
symptoms seem to more nearly resemble cerebro-spinal meningitis. 
One symptom is more fully described by Dr. Miner than by any 
other American writer. In a little work on the Spotted Fever of 
New England in 1825, he speaks of the variations in the pulse, find- 
ing it usually less rapid than in health; in less than twelve hours he 
found it to vary from 40 to 130. He describes the symptoms usually 
seen, and speaks more fully than most of the peculiar sensation in 
the region of the stomach. "A very prominent symptom which 
occurred in some degree in almost every instance even in mild cases, 
and probably without exception in all the severe, and happened in 
every stage, sometimes constituting the first access of the disease, 
consisted of paroxysms of subsidentia or a death-like sinking sensa- 
tion in the epigastrium, sometimes very distressing, attended with 63 
HISTORY. 
coolness or numbness of the skin, and lividness of the extremities." 
Subsidentia is also mentioned by Dr. Keit, in an account of the 
epidemic in Trumbull County, 0., about 1827. * 
The earliest records of the late epidemic, which I have been able 
to find, arc during the winter of 1861-62, when it was seen in the 
army of the Potomac, and in Livingston County, Ind. In the fall of 
1862, it appeared among the negroes who were taken to Memphis, 
Tenn., by the Union Army; and one or two cases were met with 
among the soldiers in the vicinity of Newbern, N. C.; during the 
winter of 1862-63, and spring of '63, it appeared in La Grange 
County, and other portions of northern Indiana, at Newbern, N. C., 
during January, February and March; and during those months and 
also April, at Newport, R. I., among the midshipmen at the Naval 
Academy; in February and March it was seen at Philadelphia, and 
during the latter part of the year at Cambridge, 0. During the two 
successive winters of 1862-63 and 1863-64 it was epidemic in 
Morgan County, Ill. 
The year in which I have found the largest number of accounts of 
this epidemic is 1864. During the winter of 1863-64 the negroes 
at Memphis were again visited by it, and during the same winter 
and succeeding spring, Darwin in the southern part of Clark County, 
and York in the northern part of Crawford County, Ill.; in the 
north-western part of Pennsylvania and parts of New Jersey it was 
noticed during this year, and also in 1862 and in 1863; only a few 
cases occurred around New York. During January it was in Brat- 
tleboro', Vt., during January and February in Philadelphia and at 
Benton Barracks, near St. Louis, Mo. During March it was seen 
in Brandon and St. Albans, Vt., and Louisville, Ky., and during Jan- 
uary, April and March, cases were seen in Boston, Mass.; during 
May at Chicago, at Leland and in Williamson County, Ill.; during 
the last part of July three cases occurred at the Stanton General 
Hospital, Washington, D. C. In October, Mechanicsburg was visited 
by it, and in November, Marshall, Ill., and during the latter part of 
the year, St. Paul's, Ind. During the winter of 1864-65, a few cases 
were seen at the City Hospital, Boston; in January, 1865, at Green- 
wich, and in April at Palmer, Mass.; in the latter .month at Kewana, 
Fulton County, Ind., and early in the year at Palestine, near Indian- 
apolis, Ind.; in May at Nittany Hall, Penn. From September 1864, 
* Medical Record, vol. xiv. 64 
CEREB R O-SPIN AL MENINGITIS. 
to May 1865, this disease appeared among the troops on Gallop's 
Island, Boston Harbor, Mass. 
During February, 1866, Dr. D. W. Cheever, of Boston, had charge 
of a case of this disease. 
CHAPTER III. 
Treatment. 
It is necessary to quote only a few authors to show the similarity 
between the treatment adopted previous to the late epidemic and 
that which is now followed. 
General bloodletting was not considered judicious; Dr. Woodward 
says: " Bleeding was tried, but, I believe, always did harm." 
Dr. Gallup, however, considers that bleeding may in some cases 
be employed with advantage, but he does not advocate its indiscrimi- 
nate or excessive use. " As it has fallen to my lot to speak in favor 
of bloodletting and against opium, some might begin to think that 
my whole intention might be to trust the cure to evacuations and de- 
bilitating remedies. But when reference is had to the indication laid 
down in the first number, this will be set right." 
Dr. Hale says :-" I mention evacuation among the remedies for 
this disease, although I did not employ it myself, nor see any case in 
which it had been employed; because it has generally been consider- 
ed a powerful remedy, and because it gives me an opportunity to 
say that I have had no experience of its efficacy. I was deterred from 
practising it by the great tendency to debility which I witnessed in 
the disease, as well as by the reports which I had heard of the dis- 
astrous effects which were said to have followed its use in other 
places." 
M. Valleix quotes M. Tourdes, who is in favor of bloodletting, 
and then adds:-"If, now, we inquire what has been the effect of 
these losses of considerable blood, we see that they have been 
scarcely noticeable, and that in spite of copious and numerous bleed- 
ings, in spite of leeches, in spite of wet-cups, the disease did not 
the less continue its course, and, which ought to be noticed yet more TREATMENT. 
65 
particularly, the principal symptoms were not essentially amended. 
Here is, moreover, how M. Tourdes judges definitively in relation to 
the value of this remedy. 
"1 To deny absolutely, says he, the utility of bleeding, would be 
to fall into an exaggeration as false as the unlimited confidence in 
the employment of that remedy. The facts would contradict this 
unjust proposition. There are a certain number of cases in which 
leeches applied at the commencement and in the two first stages have 
caused the happiest cures. We could add several successful exam- 
ples to those which have been mentioned above. In spite of the too 
frequent inefficacy of bleedings, they have rendered us, in this sad 
epidemic, more real service than other medicaments.' 
" This conclusion docs not appear to me as exact as could be 
wished. It was important to quote the cases in which the recovery 
has been attributed to blood-letting; for it is difficult to understand 
how a means, which remains without action on all the symptoms, and 
which in so many cases has no real influence, can succeed in pro- 
ducing in some prompt and rapid cure." 
The Committee of the Massachusetts Medical Society did not ad- 
vocate bleeding, as it was generally thought to be injurious. 
Dr. Mann, it will be remembered, saw the disease in its most 
sthenic form; he says, " the practice was warranted by repeated and 
acknowledged success, which followed bloodletting." 
Dr. Miner recommends to avoid " every thing that might waste 
the vital powers." 
Dr. Ames, of Montgomery, thinks 11 blood-letting not very satis- 
factory." 
Casimir Broussais was in favor of bleeding, and considered it 
the only means of treatment during the early stages likely to be 
attended with success. 
Prof. Forget is in favor of general and local depletion, considering 
the local preferable.* 
So also with regard to emetics and cathartics, the opinion of the 
profession was generally opposed to their employment. Stimulants 
and tonics were more commonly favored. Sweating, by the applica- 
tion of external heat, was by many held in much esteem. 
In the account of Haskell, Spooner and Holmes, it is said, " From 
* American Journal of Medical Sciences, New Series, vol. v. 66 
CEREBRO-SPINAL MENINGITIS. 
these facts it is easy to conceive how cautious we should be in the 
use of emetics and cathartics in this very singular disease." 
Dr. Hale says, 11 The only object for which I ever prescribed 
cathartics in the epidemic, was to avoid costiveness. For this pur- 
pose, those were always preferred which would be the least likely to 
give pain in their operation, and would produce the least prostration 
of strength." He was more favorably disposed to emetics. He also 
considered that diaphoretics, tonics and stimulants were beneficial, 
and favored the application of blisters. 
Dr. Gallup advises the cautious use of emetics and cathartics, and 
says in regard to opium and other stimulants, that their indiscrimi- 
nate use ought to be discountenanced, but " it will be acknowledged 
that in certain conditions a judicious use of them may be useful." 
Dr. North says, " That the tonic and stimulating method of cure, 
as opposed to the debilitating plan, is the correct one, I have not the 
least doubt." 
Dr. Woodward says, "Having no guide but experiment, bleeding, 
vomiting, purging, sweating and stimulating were all tried; sweating 
appeared to give the most relief." " Bark, opium, ether, peppermint, 
ardent spirit, wines, stimulating teas, and sweating, with external 
heat, have been the remedies used, and when applied in season, have 
seldom failed of success." 
So also the Committee of the Massachusetts Medical Society re- 
commend sweating by both internal and external means, and the 
judicious use of stimulants, as cordials and opium. 
Dr. Jared P. Kirtland, of Trumbull County, 0., favors light cathar- 
tics to move the bowels and obviate costiveness, artificial warmth, 
tonics and stimulants. He says, with regard to opium: " Opium is 
almost the sole remedy for general irritability, and when correctly 
managed, supersedes the necessity for other support even in the 
most inveterate cases of fever of this variety. It must be so given 
as to control the system, and continued till the morbid action be 
subdued."* 
Dr. Amos, of Montgomery, Ala., does not consider blood-letting 
very satisfactory, thinks blisters are beneficial, and does not value 
opium very highly.! 
M. Chauffard considered opium the principal if not the sole remedy 
* Medical Recoi'dcr, vol. xiv. 
t American Journal of Medical Sciences, New Scries, vol. xvii. TREATMENT. 
67 
necessary. The account which he gives of the manner in which he 
was led to try that drug is very interesting. He reports cases 
wherein he failed of success in treating with antiphlogistics and re- 
frigerants, including bleeding, purgatives, emetics and calomel; he 
also found tonics powerless, either alone or combined with the previ- 
ous methods. At length he was influenced by the failure of other 
remedies and the character of the symptoms to employ opium, and 
was successful. He then remembered that in other cases opium had 
seemed to check the progress of the disease; and even when given in 
large doses, instead of aggravating the cerebral symptoms, seemed to 
have a quieting influence and produced refreshing sleep. Subse- 
quently he used opium in many cases, sometimes combining it with 
quinia, and found that in large doses it was beneficial, if not pro- 
ducing a cure, relieving the pain and rendering the patient much 
more comfortable. He employs from four to seven grains of opium 
in twenty-four hours. 
Valleix does not consider blisters beneficial, and quotes Tourdes 
in opposition to their use. Quinia is thought to be rather beneficial 
than otherwise. Other tonics he would postpone until the period of 
convalescence. 
Thus we see that there was a diversity of opinion on many points. 
This may have arisen partly from a diversity in the character of the 
epidemics, or, what is perhaps more probable, from the different sys- 
tems of practice employed in different countries or at different times. 
Depletion was generally condemned. Cathartics, except the mildest 
to merely open the bowels, and emetics, were likewise generally dis- 
countenanced. Diaphoresis, especially when procured by external 
means, was advocated on this side of the Atlantic; not so much in 
Europe. The opinion was divided with regard to stimulants and 
especially opium, though generally in their favor. 68 
CEREBRO-SPINAL MENINGITIS. 
CHAPTER IV. 
Causes. 
The cause of this disease is generally considered to be atmosphe- 
ric change; there arc other influences, which are better known, and 
which cooperate with this in producing the disease: such are the 
predisposing causes. 
The atmospheric change is not perceptible by any of the means of 
analysis at our command; its origin may be from sudden changes in 
temperature, unusual dampness or warmth, or, on the other hand, 
cold and damp weather, or it may arise from circumstances not now 
considered related to it. M. Faure Villar says, with regard to the pre- 
valence of this disease at Versailles:-" The epidemic had two out- 
breaks-one in April, the other in May. They appeared to arise 
from atmospheric variations, and from the fatigue of military ex- 
ercises."* 
u No particular change in the atmosphere that can be 
though probably the disease sprang from atmospheric causes."t 
" It could so much the more properly be attributed to the influence 
of the air, as it attacked every station and different quarters of the 
city and of the country, without any trace of contagion. 
It is frequently epidemic, prevailing with great violence, and at 
such times is very mortal. Such epidemic seasons have been seen 
in this country during 1807-14, 1819-27, 1847-50, and since 1861. 
But the disease has been noticed during other years, as the previous 
pages abundantly show, in a less severe form; indeed, since its first 
well-authenticated appearance in 1806, there have been only twenty- 
four years in which it has not been found to exist in some part of 
the United States, and it probably prevailed during many of those 
years, but no records have been left to testify with regard to its pre- 
sence, at least none have been found by the author. In foreign coun- 
tries the same epidemic seasons have been encountered, as in France 
from 1837 to 1849. 
* Revue Medicale, t. Ixxi. 
f M. Vieusseux on Cerebro-spinal Meningitis at Geneva, in the Jour, de Med., Chir., Pliar., 
&c., t. xi. 
j At Geneva, in 1850, Jour, de Med., Chir., Phar., &c., t. xi. CAUSES. 
69 
Sporadic cases arc comparatively mild, and it is only when this 
disease rages with the violence of an epidemic that the notice of the 
public and of large numbers of the medical profession is attracted 
to it sufficiently to record the results of their observations. During 
epidemics, the mortality has been sometimes very great, even as high 
as 60 or 80 per cent., generally more than 50 per cent. The ques- 
tion then arises, is the disease contagious, or. can it in any way bo 
propagated from one individual to another perfectly healthy ? The 
general opinion among those who have seen much of the disease is, 
that it cannot be thus communicated; though many consider it slight- 
ly so, and give instances where it certainly seems to have been com- 
municated, though most of the persons affected by that means have 
been a long time residing with the sick, in the same houses, even in 
the same rooms, as nurses and attendants. 
The Committee of the Massachusetts Medical Society, in 1810, 
reported that it was very generally agreed that the disease was not 
contagious. 
Dr. Daniel Hudson, of Niagara, says:-" I am, from actual expe- 
rience, enabled to assert that it is not of that class of diseases which 
may be communicated by contagion."* 
Dr. J. L. Miller, in speaking of the epidemics of Virginia, says :- 
" I saw nothing to justify the opinion of its being contagious."t 
Dr. Vaughan, of Hallowell, Me., writes:-"If the disease be con- 
tagious, the contagion fortunately so operates that the humane at- 
tendants on the sick scarcely suffer more by it than those who shun 
their duty in this 
Dr. Hale, of Gardiner, Me., says :-The epidemic which has so 
extensively ravaged our country is generally believed not to be con- 
tagious. This is fully my own opinion." 11 That contagion was not the 
sole cause of the extension of the epidemic, is obvious from only a 
very slight attention to the facts mentioned in the chapter upon the 
character of the disease. It often attacked persons who previously 
had never been within the sphere of its influence, however contagious 
it might be supposed to be. At the same time, it frequently hap- 
pened that one individual in a family was affected and went through 
a course of it, while all the rest of the family escaped; and in two 
* American Medical and Philosophical Register, vol. iii. 
t Philadelphia Journal of Medical and Physical Science, vol. v. 
+ Medical Repository, N. S., vol. iii. 70 
CEREBRO-SPINAL MENINITGIS. 
instances the fever proved fatal to the only person in the family who 
was attacked. These facts are not consistent with the supposition 
of a very active degree of contagion. 
" It is indeed true, that when the fever appeared in a family, there 
seemed many times a disposition to extend the number of its victims 
beyond those first attacked. But besides that they all must probably 
have been equally exposed to the remote cause of the disease, this 
may be accounted for by the great fatigue and anxiety which a state 
of sickness occasions. Wherever this happened, those members of 
the family who had been the least constantly in the sick room, were 
as frequently attacked as others who had been uniformly engaged 
about the sick bed. There were a few persons who were almost 
constantly employed, through the whole period of the epidemic, in 
attending upon the sick, and occasionally in performing the last 
offices for the dead, without being at any time attacked by the fever. 
These facts appear to prove, as strongly as a negative can well, be 
proved, that this was not a contagious disease." 
M. Valleix says, in his "Guide du Medecin Praticien," "In no 
locality has it been possible to verify the evident existence of con- 
tagion." 
During an epidemic of this disease among the galley slaves at 
Toulon, of which M. Fleury has given an account, there seemed to 
be no tendency to spread by contagion beyond those in immediate 
contact with the sick and residing with them. He says :-" Those 
who went out in the morning from this galley to return thither only at 
evening, have been employed with, and have had constant intercourse 
with their comrades and the free workmen from the 15th December 
even to the end of January, and nothing resulted from that commu- 
nication. 
" The same observation was made at St. Mandrier, where, although 
separately lodged, they have been employed in works in common 
with those who have dwelt there a long time. There was no patient 
who entered the hospital on that account; they came from the foci of 
infection; and it was in approaching them to keep them constantly 
clean, to administer to them the consolations of religion, to watch 
the employment of medical prescriptions, to apply and dress blisters 
and sinapisms; it was in breathing near them a heavy, nauseating 
odor, which affected unpleasantly the sense of smell, that an ordina- 
ry, three sisters of charity, twelve officers of health, agents of inspec- CAUSES. 
71 
tion and several servants were attacked. More than twenty days 
had elapsed before an appearance of contagion was manifested, and 
it must be remarked that none of the persons treated in the city in 
the midst of their families, or in the principal hospital, have trans- 
mitted the disease either to their relations or to their nurses. A 
chaplain, an officer of health and a servant have been the only victims 
of their zeal." 
At Blakaton, near Ashburton, one family was attacked, and one 
other person who had not been near them while sick, but the disease 
did not spread farther.* 
Dr. Savage, in his account of the epidemic which occurred in New 
London, Conn., in 1832, says that no trace could be discovered to 
favor the idea of its introduction from abroad, and the physicians of 
the town were unanimously of the opinion that its origin and progress 
were entirely unconnected with contagion in the proper acceptation 
of that term.f 
11 As to infecting causes, none of my observations have furnished 
me with proof that they have had the least influence on the develop- 
ment of 
At the present time, and during the late epidemic, Dr. Gerhard, of 
Philadelphia, writes :-" In this State it has struck particular locali- 
ties, not, however, rigidly confined to them, but extending to detached 
habitations, and attacking persons who had not been in the neighbor- 
hood of any sick. It presented a tendency to be confined to fami- 
lies. It did not necessarily extend itself to the neighbors who were 
constantly engaged watching the sick, nor was the reception of one 
patient into a house at all the cause of attack of disease to others. 
There is no reason to conclude that it is in any way contagious."§ 
Dr. Liddell says, in regard to three cases which occurred at the 
Stanton General Hospital, Washington, D. C., in 1864:-"These 
cases occurred in portions of the hospital widely separated from each 
other, and that no relation by contact whatever can be traced between 
them."|| 
Dr. Luther Parks, jr., of Boston, in the Boston Medical and Sur- 
gical Journal, vol. Ixii., gives as a reason why this disease is not the 
* Medical and Physical Journal, vol. xxviii. 
+ Boston Medical and Surgical Journal, vol. viii. 
J M. Rollet, in Mem. de 1'Acad. de Med., t. x. 
§ American Journal of Medical Sciences, vol. xlvi., July, 1863. 
|| Ibid. January, 1865. 72 
CEREBRO-SPINAL MENINGITIS. 
same as scarlatina, u that there has been no evidence of contagion 
among the cases. My case, it will be remembered, occurred in a 
school of thirty-five boys, among whom there was no second case." 
Some of the above opinions are expressed strongly in opposition 
to the doctrine of contagion; but, on the other hand, instances have 
been known where there seemed to be reason to suspect contagion, 
at least in a slight degree. The cases of nurses and attendants at 
Toulon, who suffered with the disease after taking care of the sick, 
would favor the doctrine of contagion• but it was not communicated 
by the galley slaves who lived near the sick and worked with those 
who were healthy. It was only those who lived in the midst of an 
impure atmosphere, who were constantly engaged in attending the 
sick, and who may be supposed to have been exposed to many of the 
influences which first aroused the disease into action, who were 
attacked. 
Dr. Mistier says, with regard to the disease at Selestat:-" The 
epidemic of cerebro-spinal meningitis which prevailed at Strasbourg 
for some time past, has been brought to us, at least according to all 
appearances, by the battalion of the 29th regiment of the line, which 
left Strasbourg about two months since and came to garrison Seles- 
tat." A few soldiers had the disease after their arrival, and then it 
appeared in the neighborhood of their barracks, and afterwards ex- 
tended to the interior of the city. He says :-" The 1st, 2d, 5th and 
6th companies of the 3d battalion of the 29th regiment of the line 
left Strasbourg on the 4th of last February and arrived at Selestat 
the next day, the 5th, after having passed the night at Estein, where 
they lost a man from the meningitis. On the 7th, that is to say two 
days after their arrival in our city, a drummer attacked with that 
disease was admitted to the hospital, and died there. On the 9th, I 
saw the first case, in a public house which is exclusively frequented 
by the troops of the line. In short, it is in the quarter called the Quai 
des Pecheurs, and in the neighborhood of the barracks, that nine 
tenths of the cases have been observed up to the present time. How- 
ever, that quarter was not found in worse hygienic conditions than all 
the lower part of the city, comprising the Rue des Feves, the Quai 
des Tanneurs, the Place de la Prison, which are thus far exempt. 
This epidemic coincided perfectly with the arrival of the above-men- 
tioned battalion, and it prevailed exclusively among that corps, with- 
out attacking the squadron of the seventh lancers, which also keep CAUSES. 
73 
garrison here, and who as yet have had only one man sick with the 
meningitis."* 
M. Corbin, of Orleans, speaking with regard to contagion, says 
that, during the epidemic of the winter of 1847-48, a young woman, 
mistress of a soldier, sickened and died, but it is not certain whether 
the soldier was attacked. This girl was the only civilian who had 
the disease well marked, though three children seem to have had it, 
two of whom lived distant from the soldiers.! 
M. J. B. Comte, who saw the epidemic at Grenoble in 1814, says: 
11 Several persons living in the country, who quartered Austrian sol- 
diers, died of the disease. A young woman of Grenoble, who had 
been to visit her sick relations in the country, returned to the city, 
where she died of the disease, with complications of tetanic rigidity4 
The epidemic at Cambridge, Eng., during the spring of 1815, 
spread, apparently by contagion, more than some others. A servant 
girl who was employed in one of the colleges returned home, where she 
had the disease; some members of her family sickened, and her 
father died. Other cases of a* similar nature arc said to have been 
known; but nurses and medical attendants did not suffer more than 
others.§ 
M. Poggivli says that, during the prevalence of the disease at Saint 
Etienne, in the month of October, 1848, "two men of the 22d regi- 
ment of the line, occupying the same bed, were attacked in town, one 
two days after the other, and died; when I was called to t4ie first, 
his comrade presented none of the prodromes of this disease. 
"From the barracks of Jarre a man was carried to the hospital 
affected with the disease in a very severe form; a soldier, who comes 
off guard, lies in his bed, and is also fatally attacked twenty-four 
hours after."|| 
M. Leroy Dupre, Surgeon to the 55th regiment of the line at 
Avesnes, states, in confirmation of the doctrine of contagion: " In 
the month of February last, a man was taken all at once, and with- 
out known cause, with violent pain in the head, accompanied with 
fever and vomiting. Forty leeches and a proper diet caused these 
symptoms to disappear, and convalescence commenced, when the 
* Encyclographie des Sci. Med., 1841, t. vi. 
t Encyclographie des Sci. Med., 1845, t. v. 
J Recueil Gen. de Med., t. Iviii. 
§ J. Haviland in Med. Transactions of the College of Physicians in London, vol. v., 1815. 
|| Bui. de 1'Acad. de Med., t. xiv. 74 
CEREBRO-SPINAL MENINGITIS. 
same phenomena were seen in his son. They were so intense that 
they put his life in the greatest danger. All the symptoms which 
characterize what is known as meningitis, left no doubt in regard to 
the certainty of the diagnosis. The little patient recovered under 
the influence of a treatment in which the antiphlogistics were em- 
ployed only with reserve. During the course of his disease, the 
house servant was herself confined to her bed, complained of an 
acute headache, with fever, which showed itself by a frank inflamma- 
tory angina. Certainly there was nothing very remarkable in this ; 
but that which is not uninteresting to mention is the following fact. 
The comatose state of the young man having necessitated the appli- 
cation of a blister on the head, I passed nearly an hour in stooping 
over the patient to shave his hair. The length of the operation, the 
fatigue, together with an abundant perspiration, caused in me consi- 
derable languor, to which succeeded a cephalalgia, which lasted three 
days. At length, in the commencement of the month of May, the 
sister of the young patient was taken in her turn with an intense 
cephalalgia, with vomiting and fever. This was the only person of 
the family who had not been sick, for the mother herself had been for 
a certain time subject to pain in the head and vomiting. The cepha- 
lalgia of the young girl lasted several days; it was the prelude of an 
eruption resembling scarlatina and miliaria, which was happily cured 
by a rational treatment. Taken alone, these facts are far from be- 
ing convincing, but joined with the documents, already numerous, 
presented by M. Boudin, I believe that they can only contribute to 
clear up the origin and method of propagation of the disease."* 
M. Gaultier de Claubry, in his report to the Academy of Medicine 
on the memoir of M. Boudin, says :-11 With regard to contagion, M. 
Boudin has collected numerous documents which show the meningitis 
affecting sometimes in an exclusive manner the soldiers of different 
garrisons, sparing completely the civil population, who have little 
or even no intercourse with these soldiers; sometimes, on the con- 
trary, existing in the heart of the civil population and not extending 
among the soldiers; here circumscribing its action on the soldiers of 
a barrack, sparing the military prison, whose inmates have no inter- 
course with their comrades remaining free; there attacking exclu- 
sively the prisoners, and sparing the soldiers in the barracks; else- 
where seeming to travel with the regiment, so that, starting from a 
* Bulletin de 1'Acad. de Med., t. xiv. CAUSES. 
75 
city where the disease prevails, and going far away to garrison an- 
other city, where the affection had hitherto remained completely un- 
known, it was manifested in a short time after the arrival of the 
regiment, it may be among the companies into which the new arrivals 
were incorporated, it may be even among the inhabitants who had 
had intercourse with them; then again, the disease seems as if it 
was permanently settled in certain garrisons, in spite of the frequent 
changes of the troops; and, on the other hand, seeming to follow 
everywhere the same corps, in spite of frequent changes of garri- 
sons ; besides, M. Boudin shows the disease of the soldiers propa- 
gated among the surgeons, the sisters of charity, the ward tenders, 
the sutlers, the women who frequently visit the soldiers of the regi- 
ments where it prevails. 
" Considered in globo, these considerations give matter for reflec- 
tion, because of a certain analogy which they seem to indicate with 
that which takes place in the case of typhus of the armies. On the 
other hand, if they are examined more critically, it is found that 
some of these documents are purely administrative, coming from the 
council of administration of a regiment, or from the bureau of an 
intendant, and hence of medium value for physicians somewhat par- 
ticular with regard to facts for proofs; others indicate only in a 
laconic manner the wanderings of various corps from one garrison to 
another, without indicating the number of the sick, the ratio of these 
to the healthy portion of the regiments, or the civil population; a 
small number contain the formal opinions of some physicians. Seve- 
ral of these agree with M. Boudin; a large number cannot admit 
contagion." 
M. Claubry does not think the disease contagious. 
After quoting thus much of the report, it is hardly necessary to 
give the statements made by M. Boudin. 
In the early part of this century, during the prevalence of the dis- 
ease in one of the towns in the interior of New York, search was 
made to discover its origin. It was learned that a young man who 
had just arrived from a village in Connecticut, where the disease 
prevailed, was the first person attacked. Afterwards, others who 
lived near where he was during his sickness, became ' sick, and sub- 
sequently it spread to other parts of the town.* 
Dr. Walter F. Atlee, speaking of an epidemic which occurred 
* The reference to this case was mislaid. 76 
CEREBRO-SPINAL MENINGITIS. 
among the children in a charitable institution in Philadelphia during 
1864, says:-"It is worthy of mention that the disease broke out 
two days after clothing had been placed upon the children, that came 
from Manayunk. It is impossible to find, however, that this clothing 
had been in contact with any persons affected with the so-called 
spotted fever, which is said to prevail in that part of the country. 
The sister (of charity) who was attacked was not the one who was 
attached to the infirmary, or one more in contact with the sick than 
another."* 
Dr. Wm. T. Cleland, of Kewana, Fulton Co., Ind., under date of 
July, 1865, says:-"My observations, although limited, have con- 
vinced me that this disease, under an epidemic condition of the ner- 
vous system, and a vitiated condition of the secretions and circula- 
tion, is contagious. 
"In proof of this assertion, I will present a case or two which 
came under my own observation. On the 12th day of April last, I 
was requested to visit Wm. H., aet. 15 years, who was taken with a 
violent chill in the night, after an excessive day's labor. At 2 o'clock, 
April 14th, he died. 
" Miss J. M., a schoolmate, who was in attendance upon this young 
man during his sickness, was attacked on the 16th in a milder form, 
there being not as much excitement of the nervous system. On the 
fifth day, she died. 
"In another locality, some five miles southeast, I was, on May 9th 
last, requested to visit the infant child of Dr. S. In two days after I 
visited this child, two of the older children of the same family had 
a violent attack of the disease while in the field." 
The above facts show that the disease which we arc considering is 
not generally contagious; but if a large number of patients are col- 
lected under circumstances favoring such a result, it may be commu- 
nicated to persons apparently healthy, especially if fatigue, anxiety, 
or any depressing influences cooperate. The contagious principle is, 
however, very slight, and readily dissipated, so that only occasionally 
docs a single patient in a family cause it in others, and no instance 
has been found in which it could be proved that the disease was con- 
veyed by means of clothing or other fomites, and there seems to be 
no danger that a person after attending upon the sick will communi- 
cate it. 
* American Journal of Medical Sciences, July, 1864. CAUSES. 
77 
The high rate of mortality and the extensive prevalence of the 
disease during an epidemic cannot, then, be due to contagion, and 
other cause must be sought. 
In many cases in foreign countries, and in some instances in our 
own, especially where the disease has appeared in the army, the at- 
tendant surgeons have asserted that unusual fatigue, together with 
neglect of hygienic rules, seemed to be the principal predisposing 
causes which were found most frequently among the new recruits, 
and hence the conscripts who had lately joined their regiments were 
the most frequently attacked during the prevalence of the disease in 
France. 
"Its severity in the army (of the United States in 1812-14) is to 
be attributed to the sudden change of the mode of living of the newly 
enlisted soldiers, to intemperance, and to exposure to the weather."* 
M. Rollet says :-" There can, then, be mentioned as predisposing 
causes, the recent incorporation of young soldiers and their want of 
training in military exercise. It is necessary to observe, also, that 
it is among soldiers arrived in the corps since less than a year, that 
the greatest number of grave cases is found-ten out of fifteen whose 
time of arrival is notcd."t 
M. Claubry, in his report before the Academy of Medicine on the 
epidemics which occurred in France during 1848, says of this dis- 
ease :-" The garrison of St. Etienne was composed of two squad- 
rons of dragoons, all old soldiers; of 1100 men of the 13th regi- 
ment of light infantry, and of an equal number of the 22d light; the 
greater part of the latter were novices. 
" The barracks of the 22d were in favorable hygienic condition, 
well aired, sufficiently ventilated, without crowding in the chambers; 
the food of the soldiers was of good quality and abundant. There 
was a ration of wine. The discipline was mild. 
" It is a curious fact to note relative to the epidemic of St. Etienne, 
while the 22d has had 107 men attacked with cercbro-spinal menin- 
gitis, and has lost thirty of them; it was when this regiment present- 
ed no new cases that the turn of the 13th regiment came, which has 
had only five sick, of whom two have died; and the dragoons had 
only one case, which was fatal. What is otherwise remarkable is, 
that the barracks where were lodged these two last corps of the gar- 
* New England Journal of Medicine and Surgery, vol. ii. 
t Mem. de 1'Acad. de Med., t. x. 78 
CEBEBRO-SPINAL MENINGITIS. 
rison of St. Etienne were far from offering hygienic conditions as 
favorable as those where the 22d was lodged."* 
Valleix, after mentioning that new recruits were most frequently 
the victims, says :-" Fatigues to which the young soldiers were not 
accustomed, exposure to inclemencies of the weather, prolonged ex- 
ercises, are the causes which,, according to all appearances, have de- 
termined the appearance of the disease." 
Dr. Frothingham, who saw several cases while connected with the 
Army of the Potomac during the winter of 1861-62, speaks of this 
cause as follows :-" Here was a large army, living under almost 
exactly the same circumstances as to food, beds, ventilation, clothing, 
Ac., and within a few miles of space; yet a few cases (enough to in- 
dicate some common cause) of an unusual disease occurred in one 
brigade (as I did not hear of any other cases, I take it for granted 
there were none). Malarious and continued fever prevailed in all 
the camps throughout the army. The only circumstance influencing 
disease in which this brigade differed from others, was in the severity 
of its labors. Under Gen. Daniel Butterfield, a stern disciplinarian, 
who always, sick or well, did his own entire duty and would receive 
no less from his subordinates, the men were drilled to the full extent 
of their powers-often to exhaustion. I did not at the time recog- 
nize this as a cause of the disease in question, but I learn that in 
the present epidemic in Pennsylvania, the attack generally follows 
unusual exertion and exposure to cold." t 
Thus, in civil life, great fatigue has been mentioned as the cause of 
the appearance of this disease, and this was likewise noticed by Dr. 
J. Norcom, of Edenton, N. C., in 1815, who gives as the causes- 
excessive fatigue and long-continued exposure to cold, violent, exer- 
cise, sitting up nights, irregularities of living, intemperance of every 
kind, more especially intoxication; everything that has a tendency 
to dcbilitate4 
Here he mentions other influences as cooperating with fatigue and 
violent exercise; and so in other places there were found influences 
which seemed to predispose to the disease: badly ventilated residences 
causing a vitiated atmosphere, unwholesome food, sudden changes in 
temperature, dampness, <fcc. 
* Mem. de 1'Acad. de Med., t. xvi. 
+ American Medical Times, April 30, 1864. 
J Eclectic Repertory, vol. v., 1815. CAUSES. 
79 
M. Corbin, in regard to the epidemic at Orleans, in 1847-48, says, 
" The principal cause in our eyes is crowding, which supposes the 
alteration of the air, combined sometimes, for the soldier, with un- 
healthy habitation, and often, during the winter, with a temperature 
too elevated in the guard-houses or in the quarters. The barracks 
of St. Charles, which has furnished the greatest proportion of sick, 
is an old building, situated below the level of the ground. The lower 
story, it is true, is uninhabited; here are cellars which serve for 
magazines; the first story had been inundated the year before to a 
very great height; the walls were damp, even so that the water 
dripped from them." The troops were removed into the upper 
stories; and then they crowded together, and saving wood by using 
only one or two rooms, heated those excessively, keeping the doors 
and windows constantly closed.* 
MM. Porral and Raphael consider the cause of the disease at 
Puy and Vannost was, that the inhabitants became warmed by their 
labor in the valley, and then ascending the mountains became too 
suddenly cooled.f 
M. Valleix says, 11 At Rochefort fatigue has not been greater than 
usual, but it was learned from an extensive examination made on 
this point, that the convicts were badly clothed, badly shod, and that 
the place where they passed much of their time was remarkable for 
its dampness. These are the only circumstances to which can be 
referred the appearance of the epidemic." 
M. Rollet considers as determining causes-cooling after having 
been heated by the sun, or succeeding to a violent exercise, and 
vicissitudes of temperature. $ 
At Toulon, previous to the outbreak of the epidemic of 1829-30, 
among the galley slaves, they were confined on board three old hulks. 
M. Fleury says in regard to the one on which the disease appeared, 
that it was moored near a dock, where much refuse had accumulated, 
lying half decomposed, and which was being cleaned out. The 
thousand convicts quartered in this old hulk were distributed in nearly 
equal proportion among the three decks, of which the lowest was 
almost on a level with the water. These decks were sixty feet long, 
forty-four and a half feet wide, and five and a half feet between. 
* Encyclo. de Sci. Med., 1848, t. v. 
+ Report of M. Claubry, in Mem. de 1'Acad. de Med., t. xiv. 
t Mem. de 1'Acad. de Med., t. x. 80 
CEREBRO-SPIN AL MENINGITIS. 
The men lay in four ranks on mattresses of tow eighteen inches wide. 
The air ports were open during the day, but frequently closed at 
night. During the night the decks became very filthy, and though 
cleaned every morning, the planking must have become saturated 
with excrementitious matters. In addition to this, the upper decks 
were imperfectly caulked, and allowed the rain to pass through more 
or less freely. The food and clothing seemed to be sufficient for 
health. 
Dr. Savages says of the disease which appeared in New London, 
Conn., in 1832, "The streets of the low and intemperate were its 
birth-place, and their dwellings its cradle; and upon this class of 
persons was its fury spent, for theirs was the condition most con- 
genial to its evidence and growth."* 
But these causes did not operate everywhere, and many looked 
upon a malaria as concerned in the production of the complaint. 
Dr. Latham, who observed the epidemic at the Millbank Penitentiary, 
thought that malaria was probably one of the causes; and so also 
Dr. Sanderson, with regard to the disease at Dantzic, during the last 
year (1865). 
By examining the reports of the weather during the prevalence of 
this disease, we may be able to find some peculiarity in the tempera- 
ture, the dryness or dampness of the atmosphere, which, with other 
influences, bears a part in producing it. 
It will be remembered that Sydenham mentions the severity of the 
winter of 1683, exceeding any that could be remembered,- and that 
of 1684 was very severe, but not so much so as the previous one. In 
February, 1685, the " Febris Nova " appeared. 
Dr. Bush remarks: " Upon the recurrence of cold damp weather, 
the cases immediately multiplied, and those who had been previously 
ill never failed to become worse. Exposure to the external atmos- 
phere and cold seemed constantly to predispose to the disease."! 
Dr. Folchi, writing concerning the epidemic resembling cerebro- 
spinal meningitis, which prevailed at Rome during the winter of 1817; 
attributed its spread to the extraordinarily mild temperature of the 
atmosphere during that 
Dr. Hazeltine, of Maine, gives as one cause, "coldness and hu- 
midity of the spring, summer and autumnal seasons.§ 
* Boston Medical and Surgical Journal, vol. viii. 
f Medical Repository, N. S., vol. iii. 
+ Quarterly Journal of Foreign Medicine and Surgery, vol. i. 
§ Medical Repository, New Scries, vol. iii. CAUSES. 
81 
M. Vieusseux says, with regard to the climate of Geneva, that the win- 
ter preceding 1805 was long, cold, not very severe. The spring was 
very cool and vegetation was singularly retarded. In 1805, this 
disease appeared.* 
Dr. Henry Fish, of Hartford, Conn., says that "the winter of 
1808-9 was unusually severe, the cold weather commenced earlier 
and continued longer than in the six or eight years preceding. The 
snow fell in December, in large quantities, and was not wholly re- 
moved until late in March. It was generally a foot or more in 
depth, and the air was intensely and uniformly cold. Snow-storms 
wore frequent and severe, without being succeeded by thaws." This 
disease appeared in 1807, and was seen again in 1809. 
The Committee of the Massachusetts Medical Society in 1810 re- 
ported that the previous summer was cold; the weather from Novem- 
ber to the 12th of January was calm and moderate, with more heat 
than usual; after December 1st, there was considerable rain and but 
little snow; occasionally the change in temperature was very great. 
In January the epidemic commenced. 
J. Wilson, of Salisbury, N. H., says : "It seems probable that the 
changes of temperature have for five years past (preceding 1813) 
been much greater than ever before were known. That many ani- 
mals expired by its immediate operation, is a fact. That the organi- 
zation of vegetables suffered a derangement which eventually proved 
fatal to many of them, is a circumstance that any person may ascer- 
tain.! 
J. Haviland says, with regard to the temperature of Cambridge, 
Eng., that the winter of 1814 was mild; in the latter part of Janu- 
ary the epidemic commenced, which so much resembled cerebro- 
spinal 
At Toulon, during the winter of 1829-30, the weather was ex- 
tremely variable, and presented differences of temperature unknown 
to aged men who had preserved the remembrance of the most severe 
winters. " In December the winds blew from the east and west; 
there were six rainy days, the weather remained moist and cold, and 
the thermometer gave, at its greatest elevation, 13° and some tenths 
centigrade, and at its lowest 3° below 0. In January, there were 
the same winds; snow and hail fell, and there were six sunny days; 
* Jour, de Med., Chir., Phar., &c., t. xi. 
+ Medical Repository, New Series, vol. i. 
i Med. Trans, of Col. of Physicians, London, vol. v. 82 
CEREBRO-SPINAL MENINGITIS. 
the moist and cold weather was constant. The greatest elevation of 
the thermometer was 12° and its lowest 7° below 0. In February, 
the prevalent winds were the same. Snow fell during the beginning, 
rain followed so as to preserve the same temperature. The thermom- 
eter, which had descended to 3° below 0, rose to 17° towards the 
end of the month." It was during these three months that the dis- 
ease prevailed. 
M. Rollet, in a memoir read before the Academy of Medicine, says : 
11 As to the changes of temperature, I will observe, that since the 
commencement of May, even to the end of July, the atmosphere has 
been frequently charged with electricity, that the heat, without being 
very elevated, has often been oppressive, and sudden variations of 
temperature have been quite frequent."* 
M. Claubry, in a report on the epidemics of France during the 
years 1841-46, says, that to the very warm summer of 1842 had 
succeeded a very cold and wet autumn, and a very severe winter. 
In February, 1843, appeared the cerebro-spinal meningitis.f 
Job Wilson, of New Hampshire, has given extensive observations 
on the climate of New England for about twenty-five years. He says, 
11 From about 1792 to 1804, a period of about 12 years, the winters, 
with a few exceptions, appear to have been shorter and milder than 
the preceding winters were, and the summers longer and hotter than 
those of former years." 
11 On the 8th of October, 1804, a new era appears to have com- 
menced. On this day a most tremendous snow storm happened." 
" The first permanent snow did not happen till near the 20th of 
December; but the quantity of snow that fell from this time to about 
the middle of February, 1805, was immense." "The spring and 
first summer months were unusually cool." In the preface he says, 
" Our climate (particularly the climate of New England) though at 
best very changeable, for many years prior to 1804, has been com- 
paratively mild and steady." " But since 1804, a new era has com- 
menced. The changes of our climate have been greater and more 
frequent. The effects of these changes have been very remarkable, 
both in the animal and in the vegetable kingdoms. To many indi- 
viduals of each of these kingdoms, they have proved immediately 
fatal." " The late changes, or some other cause, have produced a 
* M. Rollet, in Mem. de 1'Acad. de Med., t. x. 
t Mem. de 1'Acad. de Med., t. xiv. CAUSES. 
83 
disease, or rather diseases, with which our mother country appears 
never to have been acquainted, as she never suffered so great and 
sudden extremes of heat and cold." 
In regard to 1806 he remarks, " This year I conceive to have been 
rather more changeable than former years have been, when com- 
pared with succeeding years; it was comparatively mild and temper- 
ate." 11 The ten last days in February were uncommonly warm; the 
mean temperature of the days was 41, and the nights 28. On the 
26th day, the mercury fell suddenly from 40 to 12 at night; and 
rose the next day to 50." It will be remembered that it was in 
March of this year that the so-called " spotted fever " appeared in 
Massachusetts. 
" The mean variations in the month of February, March and April, 
are 35, 36 and 34; but in this year (1807) they are 39, 53 and 55; 
the diurnal variations are comparatively great, which great changes 
of temperature we should readily conclude would produce violent 
disease, which indeed we find has been the case." August was 
changeable, rainy and chilly. In 1808 there was less variation of 
temperature, with rains in February. In 1809 also there was 
nothing unusual except an uncommon low temperature. In Janu- 
ary, 1810, the variations were greater. During these years, from 
1807 to 1809, the " spotted fever" appeared in many parts of New 
England, especially in Connecticut. In the early part of 1810 the 
disease appeared, especially in Massachusetts, where it was noticed 
by the State Medical Society, in Connecticut and Vermont: it was 
also seen in Canada. 
The summer and autumn of 1810, and the whole of 1811, were 
moderate, without great variation and generally warm. No exten- 
sive epidemic prevailed during that time. 
January of 1812, and also February, were subject to great varia- 
tions of temperature. In the former month there were seven ex- 
ceedingly cold days, commencing about the middle of the month. 
In the latter month " seven extraordinary variations happened." 
" The variations will stand thus : 48, 36, 33, 33, 35, 40, 43; and the 
period of most of these great variations is from 12 to 18 hours only." 
In March also there were great variations of temperature. " It 
should be remarked, that the periods of these variations are but 
little more than 12 hours. The number of degrees of variation are 
as follows: 34,46,30,38,30, 31, 35, 36, 46, 31." Rain fell in 84 
CEREBRO-SPINAL MENINGITIS. 
both February and March. The other months were not essentially 
different from usual. Cerebro-spinal meningitis prevailed, especially 
in New Hampshire, Vermont and Maine, during the spring. 
In February, 1813, there was one variation of 61° and several 
others of less amount. " March was not so pleasant a month, but 
more stormy." " No less than six great and sudden changes hap- 
pened; as great as 61, 50, 35, 30, &c." April was warm, with chil- 
ly nights. The other months were in no way remarkable. " Spotted 
fever " appeared in January, and by the middle of February prevail- 
ed extensively in New Hampshire. It extended its ravages into the 
summer months, but was then much less severe. 
During 1814 the winter and spring months were quite moderate, 
without any remarkable changes. In June there was a variation of 
45° in 31 hours, and from then till September less variations about 
once a fortnight. In the latter month there was a variation of 55° 
in 32 hours. In October there were also several variations, and 
November was more changeable than usual. During this time the 
disease appeared in New England. 
Dr. T. F. Prewitt, in the St. Louis Med. and Surg. Journal, vol. 2, 
says that the disease which we are considering " first made its ap- 
pearance among the soldiers stationed at Chillicothe, during an un- 
usually severe and protracted spell of dry, cold weather." 
Dr. Frothingham found it to prevail during mild and damp 
weather in the winter.* 
This record of the weather and temperature is not very full, and 
hence extensive generalization would not be proper; but if we take 
into consideration that the sudden variations mentioned by J. 
Wilson were usually attended with wet weather, and then notice 
that eight out of fourteen of the authors quoted in the previous pages 
mention the occurrence coincident with this disease of changeable 
and damp weather, or of coldness and dampness, we shall find some 
reason for believing that such a state of the atmosphere is favorable 
to the action of those influences which produce this disease. It 
would, however, be gratifying to have more facts upon this subject. 
Not only cold and damp and variable weather were favorable to 
the production of this disease, but situation seems also to have had 
some influence. 
Thus the Committee of the Massachusetts Medical Society remark 
* American Medical Times, April 30, 1864. 85 
CAUSES. 
that most of the places where the disease occurred are inland and 
elevated, with ponds and streams. In Cambridgeport most of the 
cases occurred near a marsh, and in Boston in that portion of the 
city exposed to the flats and water. 
The town of Minisinck, N. Y., is bounded on the east by the great 
drowned lands of the Wallkill, which renders the inhabitants liable 
to intermittent, remittent and bilious fevers in the fall of the year.* 
Dr. Rush says that it 11 prevailed most in the interior; the sea 
coast was exempt or suffered little. And yet in the interior of the 
State, the most swampy situations, margins of rivers and places the 
most subject to the endemical, autumnal, bilious fevers have suffered 
most severely."! 
Dr. Mann, in his work on the diseases of the army, already re- 
ferred to, gives a description of Greenbush where the pneumonic form 
appeared, and also of Albany where there were some cases of the 
cerebral variety. He says, " Greenbush is a township on the east 
bank of the Hudson, directly opposite Albany. The town, which 
occupies eight miles square, has a diversity of soil and surface. 
Alluvial flats border the river. Hills present themselves in the rear, 
distant from the bank of the river from one quarter to one mile, 
gradually rising until they gain an elevation of 200 feet or more. 
The soil'in some places is clay, in others a mixture of clay, loam 
and sand. 
" The cantonment is on an elevated plane, one mile east of the 
Hudson. Here are barracks for the troops of the United States 
army, sufficiently capacious to accommodate 4000 men, with adequate 
quarters for their officers. On an eminence 60 feet higher, is the 
Hospital, which may accommodate 100 patients. The wards of this 
hospital are too small in their dimensions, both for health and con- 
venience, being only 20 feet by 16, and 9 feet in height. 
11 The elevation of the hospital is so great above the surface of 
the river, that the fogs, which, during the hot season, are suspended 
over the flats and villages on the banks, seldom rise to its summit. 
11 The temperature of the climate on the Hudson is more regular 
than in the same latitude on the Atlantic shores; where are ex- 
perienced greater and more sudden transitions of weather than here. 
The cantonment, at Greenbush, has the reputation of being healthful; 
and the country in its vicinity salubrious. 
* Dr. D. R. Arnold, in American Medical and Philosophical Register, vol. i. 
f Medical Repository, New Series, vol. iii. 86 
CEREB R O-SPIN AL MENINGITIS. 
" The city of Albany, the capital of the State of New York, is 
situated one mile in length on the west bank of the Hudson. It rises 
from the river by a gradual ascent nearly 200 feet to the elevated 
plain. The width of this city is from one quarter to one half a mile. 
On the margin of the river, the lands are alluvial and rich; while 
those more elevated and uneven, are a mixture of clay and sand, and 
barren. That part of the city, on the alluvial flats, has the reputa- 
tion of being less salubrious than that on the hill. The want of a 
rigid health police is manifested by the filthiness of some of the 
streets; more especially of the back yards connected with stables 
and kitchens." 
Dr. Lucas, of Brunswick, Va., thus describes the topography of 
Mecklenburgh, Lunenburg and Brunswick, Va., where the disease 
appeared in 1818-22. " The country is one, as to elevation, tolerably 
high; although not mountainous, yet it is uneven and broken. 
There are few, if any marshes at all to be found, but many mill- 
ponds and two rivers. The Roanoke runs through part of Mecklen- 
burg, has extensive low grounds on each side of it, varying from a 
quarter to a half mile in width. The Meheria divides Lunenburg 
from Mecklenburg and runs through a part of Brunswick, in which 
country there are a few places having low ground of a few hundred 
yards in width. The low grounds on both these streams are well 
drained by means of ditches. The country lying generally hilly, the 
mill-ponds are not very broad but tolerably long. The water com- 
monly used is fine spring-water. A line running north and south, 
would about place the part of the counties that have suffered most 
by this disease, on a parallel with the head of tide water in the Ap- 
pomattox river; perhaps ten or fifteen miles above it."* 
There is some doubt with regard to the identity of the disease which 
occurred at Marietta, 0., in 1823. The situation of that town is at 
the confluence of the Muskingum and Ohio rivers. The former 
divides the town into two unequal parts. The soil is alluvial. The 
houses are wet during floods.! 
At Toulon, in the winter of 1829-30, the convicts who were quar- 
tered on shore escaped; but those on board the centre one of three 
old hulks were attacked. It will be remembered that this was not 
only unfavorably situated for ventilation, but was also in close proxi- 
* Medical Recorder, vol. v. 
t Dr. Hildreth, Philadelphia Journal of Medical and Physical Sciences, vol. ix. CAUSES. 
87 
mity to an old dock, where the deposit of many years was being 
cleaned out. This galley was also the most dilapidated, allowing 
the rain to penetrate through the decks; and it is not improbable 
that much bilge water was constantly present. 
Prof. Rienzi, speaking of the epidemic which occurred during the 
spring of 1840, at S. Marzano, mentions that in January, 1840, the 
Saono overflowed its banks, and left S. Marzano as an island.* 
In 1843, the province of Seine et Marne, and in 1844, Haute 
Loire, were attacked with this disease. M. Claubry, who made a 
report with regard to it to the Academy of Medicine, says: " The vil- 
lage of Bannost (district of Provins) is situated on a hill in the midst 
of valleys which it overlooks, and in the bottom of which the rain 
waters collect. 
" The village of St. Venerand (district of the Puy) is, on the contrary, 
situated on a hill sufficiently elevated above the course of the Allier, 
from which, however, it experiences damp vapors. Placed on that 
hill, about 1,200 metres above the level of the sea, this village enjoys 
a naturally cold temperature, by reason of the long duration of fogs 
and snows which surround it during the winter season. The inhabi- 
tants of this village are in the habit of descending from it into the 
plain below, to engage in agricultural labors. There they generally 
encounter moderate temperature, and after being warmed by their 
rural occupations, ascend again to their village upon the approach of 
night, and are exposed to a very cold temperature." f 
We see here that those who live at a distance from marshes or bodies 
of water may feel the influence of their presence by means of fogs 
and vapors; and also may by their daily occupation be obliged to 
expose themselves to unhealthy influences at a distance from their 
homes, or by changes of place may experience great changes of 
temperature. 
Montgomery, Ala., where this disease appeared in 1848, is situated 
on a bend in the Alabama river. An amphitheatre is formed by the 
hills, which are in the back part of the town and circle round to the 
river on either side. The land on the opposite side of the river is 
alluvial, and is often overflowed; above the city, on the same side, 
are prairie lands. Thus a part of the city is on low land in the im- 
mediate neighborhood of inundated and flat land; a part is also ele- 
* Medical Examiner, New Series, vol. i. 
t Mem. de 1'Acad. de Med., t. xiv. 88 
CEREBRO-SPINAL MENINGITIS. 
vated, well drained and dry. About 250 cases occurred, and only 
100 of these were above the base of the hills.* 
During the late epidemic, a few cases have been recorded in which 
the situation of the places where this disease occurred was noticed. 
Dr. J. B. Upham gives a very full account of the circumstances in 
which the subjects of the epidemic at Newbern were placed. The 
town of Newbern is described as " built on a flat and sandy soil, 
raised but a few feet above the water. The country around is level, 
alternating with sandy plains and swamps for the distance of a mile 
or more from the outskirts of the town, beyond which begin the 
endless pine forests, almost impenetrable, with marshes and tangled 
undergrowth." The troops were protected partly by tents and partly 
by barracks. The latter " were built late in. the autumn. They 
were made of green stuff-hard pine mostly-the logs being taken 
newly cut from the forest, or drawn out from the water, where they had 
been lying for a few weeks, sawn into joists and boards, and used in 
the fabrication of all parts of the building. Thus constructed, they 
were necessarily cold and damp, and redolent of pitch and paludial 
moisture." He describes the manner in which the barracks were 
built and the internal arrangement, and then says:-" In the best of 
circumstances it will be seen, the supply of air is entirely inadequate 
and the ventilation imperfect; while light and warmth, owing to the 
projection of the bunks, cannot be generally diffused throughout the 
apartment." The regiments which suffered most were those recently 
enlisted and that were quartered in the barracks. " The 44th (Mass.), 
which suffered most, was nearest the bank; quite near the camp lay 
a couple of marshy bogs, small in extent, through which flowed a 
sluggish stream to the river." Some cases occurred also among the 
troops quartered in tents, but there were only a few such.j' 
Dr. Robert Burns says:-" The first point requiring consideration 
is the hygienic condition of the dwellings and the locality in which 
patients reside." He then mentions these circumstances with regard to 
the residence of his first case, an Irishwoman, 36 years old, who 
lived in a frame house without any cellar; on one side of the house 
there was a lane with very imperfect drainage, having at all times in 
its deep gutters stagnant water. Hog-pen and other outbuildings 
were in position close to the house. On the lower story one room 
* Dr. Ames, American Journal of Medical Sciences, vol. xvii. 
t Boston Medical and Surgical Journal, vol. Ixviii. CAUSES. 
89 
was occupied as a vegetable store and grocery, the other as a kitch- 
en. The second case reported was that of a woman who lived near 
the first one, in a brick building, very damp, with water in the cellar. 
His third case resided in a low,- wet situation, and had exerted her- 
self in taking care of several fatal cases of the disease about 150 
feet in the rear of her house. The fourth case was that of the bro- 
ther of the second, and he was with his sister much during her 
sickness.* 
Dr. Stille reports the case of a young man, who resided in a 
healthy situation and was employed in a wholesale dry-goods store; 
nothing unhealthy seems to have been connected with his business.! 
Prof. J. S. Jewell, of Chicago, gives a brief account of the dis- 
ease as it appeared in Williamson County, Ill. He describes that 
portion of the State as generally level and somewhat low, though 
occasionally broken, and furrowed by sluggish streams, which are 
frequently bordered by extensive alluvial bottoms, with marshes in- 
terspersed here and there, and as a general thing heavily timbered, 
except when removed for the purposes of agriculture or interrupted 
by occasional oak openings, or barrens and small prairies.! 
In nearly every instance above recorded, and which are the only 
cases where the nature of the locality in which the disease occurred 
has been mentioned, lakes, rivers, swamps and low ground likely to 
be inundated, or damp houses with water in the cellars are noticed 
as found in where the disease appeared. Can it be doubt- 
ed that such situations are favorable to its prevalence ? 
The influences, then, which have been recognized as causes of this 
disease are-unusual fatigue, which seems to have a peculiarly pow- 
erful effect on soldiers lately enlisted; all debilitating influences ; 
over-crowding in badly ventilated apartments; want of cleanliness ; 
sudden variations of temperature, especially when combined with 
damp and wet weather; a situation near marshes or considerable 
bodies of water, and lack of proper drainage. Contagion has but 
little influence, except, as previously stated, under very favorable cir- 
cumstances. Malaria has been mentioned by some observers; but if 
they mean that condition of the atmosphere which causes periodical 
diseases, and not a peculiar influence, sui generis, upon which this 
epidemic depends, there is no evidence of its existence. 
* American Journal of Medical Sciences, April, 1865. + Ibid, July, 1864. 
J Transactions of the Illinois State Medical Society, 1864. 90 
CEREBRO-SPINAL MENINGITIS. 
Undoubtedly an epidemic condition of the atmosphere is the prin- 
cipal cause of this affection. The other causes do not all exist at 
the same time, and sometimes none of them can be discovered; and, 
again, most of them may co-exist without giving rise to this peculiar 
disease. We must, then, refer it to some hidden and hitherto undis- 
covered cause operating upon all and producing the disease only in 
those most susceptible to its influence, or who have been most expos- 
ed to the predisposing causes, and that cause has been called " an 
epidemic condition of the atmosphere," which will answer well 
enough until its true nature is discovered. Whatever this influence 
is, it has frequently affected other diseases, assimilating them more 
or less to this one. 
Dr. Comstock says, with regard to the epidemic which occurred in 
Rhode Island in the early part of this century:-" It has a great 
aptitude to combine with other diseases, and even to modify and alter 
those of the most stationary kind, as consumption. It has been 
known to combine with bodily injuries."* 
Dr. Hale says, " It influences the nature of all diseases."f 
Dr. Miner remarks :-" For eight or nine months it was difficult to 
find a case of acute disease that did not partake of the epidemic 
constitution, under whatever head it might be nosologically classed." 
Prof, de Rienzi says that almost all the inhabitants of Mignano, in 
February, 1840, were affected by the epidemic influence, and suffered 
from giddiness, lassitude and great depression of spirits.J 
At Gibraltar, in 1844, both before and during the epidemic of me- 
ningitis, it was noticed that in indisposition from any cause, there 
was a tendency to headache, more or less severe; the occiput being 
oftener than usual the seat of pain, and the muscles of the back part 
of the neck being also frequently affected with aching.§ 
Dr. Nivison says that this disease " impressed its own character 
on other diseases, so that a decided typhoid tendency was visible in 
almost all diseases." He also mentions that it appeared in one case 
during an attack of mumps. The mumps disappeared, and returned 
after recovery from this disease.|| 
* Medical Repository, New Series, vol. iii. 
f Philadelphia Journal of Medical and Physical Science, vol. i. 
+ Medical Examiner, New Series, vol. i. 
§ Dr. Gillkrest, London Medical Times and Gazette, vol. xxxiv, 
|| New York Journal of Medicine, September, 1849. NATURE. 
91 
At New Orleans, January, 1850, the negroes were principally 
affected, yet among the whites several patients presented strange head 
symptoms.* 
I have found no notice of this tendency to influence other diseases 
during the late epidemic, though in a few cases persons otherwise 
healthy have been troubled with severe headache. 
CHATTER V. 
Nature. 
Cerebro-spinal meningitis is usually considered a disease of de* 
bility. The name is, perhaps, unfortunate, for there is not a simple 
inflammation of the meninges; indeed, sonictimes they are not in the 
least affected, the force of the disease being expended upon other 
organs. 
This disease seems to be dependent, at least in part, upon a change 
in the character of the blood. What the change is, we cannot say; 
but w,e know it exists, for we see its effects. 
In a large majority of the cases where the condition of the blood 
was noticed, it was much more fluid than natural and of a very dark 
color; where clots existed they were unusually soft. Moreover, 
similar morbid appearances were found in different parts of the body, 
as the brain, lungs, heart, abdomen and glandular structures; in each 
of these there were marks of inflammatory action; they were not all 
found in the same person, but in one there was effusion of lymph in 
the cranium, coating the membranes and penetrating into the ventri- 
cles ; in another, the lungs were inflamed, as in pneumonia, and in 
others lymph was found in the pericardium surrounding the heart; 
again, the intestines exhibited marks of inflammation and even ulce- 
ration, or the glands-the parotid, the lymphatic and mesenteric 
glands-were inflamed and even suppurated. 
Now here are different organs, situated in distant parts of the 
body, affected in almost precisely the same manner. Evidently the 
cause of these changes, whatever it may be, must exert an influence, 
* Fenner's Southern Medical Reporter, vol. ii. 92 
CEREBRO-SPINAL MENINGITIS. 
direct or indirect, wherever the diseased action is found. The blood 
and the nervous influence, so far as we know, are the only agents 
which can do this. We can realize that blood whose visible charac- 
ter is so much changed as is the case in cerebro-spinal meningitis, 
may produce an abnormal influence. The derangement in the ner- 
vous power we do not so easily recognize nor so fully understand, yet 
it is very reasonable to suppose that it cooperates with the abnormal 
blood in producing the changes referred to. The tissues may, doubt- 
less, by their condition be so circumstanced that in one person one 
organ, and in another person some other organ may be first affected; 
they are predisposed by previous disease, hereditary influence, the 
influence of occupation, one part being excited and overworked, while 
another is allowed a larger proportion of rest, or by the peculiar 
epidemic condition of the season, to yield more readily to the excit- 
ing cause found in the morbid blood. And a change having com- 
menced, they may react on the blood so as to perpetuate its diseased 
condition. 
Paget says :-" We may speak much less equivocally of the influ- 
ence of the state of the blood itself in causing inflammation; for 
there can be little doubt that a very great majority of the so-called 
spontaneous or constitutional, as distinguished from traumatic in- 
flammations, have herein their origin. In all these cases local inflam- 
mations are the external signs of the general affection of the blood. 
" If it be asked why a morbid material is determined to one part 
or tissue rather than another, or why, for example, the skin is the 
normal seat of inflammation in smallpox, the joints in rheumatism, 
and so on; I believe we must say that we are on this point in the 
same ignorance as we are concerning the reason why the materials of 
sweat are discharged at the skin, those of urine at the kidneys. We 
cannot tell why these things are so, but they are familiar facts, and 
parallel with what I here assume of the incorporation of the morbid 
materials derived from the blood." 
It is worthy of notice, however, that in many cases where seeming- 
ly different organs have been affected, it was the serous membrane 
which suffered most. If it could be proved that that membrane was 
alone affected, the argument with regard to the influence of the blood 
would be weakened; but other portions of the organs besides the 
s crous lining have usually been found changed: in the brain, the cere- 
bral substance; in the lung, the parenchyma; in the heart, the mus- NATURE. 
93 
cular fibre; in the stomach and intestines the mucous membrane, have 
been found softened or otherwise diseased. 
That there is inflammation of the brain or its membranes, the 
symptoms and post-mortem appearances indicate; and so likewise 
when the disease attacks especially the lungs, there are evident signs 
of inflammation; the swelling, pain and suppuration in the vicinity of 
the parotid and lymphatic glands, or in the neighborhood of the 
joints, would under other circumstances be called inflammation. 
It may be objected that the disease is not active enough to be in- 
flammatory ; possibly not, as that term was formerly understood, but 
now it is admitted that it may coexist with a general decrease in 
vital power, with debility, in fact. 
Dr. Tanner says, in the last edition of his Practice of Medicine:- 
" In many instances of inflammation there is depressed nervous pow- 
er and impaired action of the heart." 
Mr. John Simon says :-" Further, the quality of the pulse during 
inflammation, and generally that look of vehemence in the febrile 
process which depends upon the circulatory system taking an active 
part in the production of symptoms, will be almost unlimitedly influ- 
enced by the more or less vigor of the patient. With weakened 
nerve power, with feeble heart structure, there can be no strong, hard 
pulse; nor can the pulse be otherwise than soft or small when the 
bloodvessels are half emptied of their contents."* 
Paget remarks :-" So far, then, as the proper substance of the 
inflamed part is concerned, there appears to be decreased action; that 
is, decreased formation. There may be, indeed, an increased absorp- 
tion; but this is also, in one sense, characteristic of decreased exer- 
cise of vital force; since all absorption implies a previous degenera- 
tion of the part absorbed. Nor can we justly call this, in any sense, 
1 increased action,' till we can show how absorption is an action of 
vessels." 
" From these considerations we may conclude that the productive 
part of the inflammatory process is not declaratory of the exercise of 
a large amount of formative or organizing force; and this conclusion 
is confirmed by observing that development, which always requires 
the highest and most favored exercise of the powers of organic life, 
does not occur while inflammation lasts. The general conclusion, 
* See Holmes's Surgery. 94 
CEREBRO-SPINAL MENINGITIS. 
therefore, may be as well from the productive, as from the destructive 
process, that it is accomplished with small expenditure of vital force; 
and that even when large quantities of lymph are lowly organized, 
such an expression as ' increased action ' cannot be rightly used, 
unless we can be sure that the defect of the formative power exer- 
cised in the proper tissue of the inflamed part, is more than counter- 
balanced by the excess employed in the production and low organiza- 
tion of lymph." 
Dr. Chambers, in his book entitled " Renewal of Life," also advo- 
cates that all diseased action is diminished action, that there is no 
increased vitality in parts abnormally changed. 
If this disease is, as has been supposed, dependent upon an altered 
condition of the blood, whether produced by the introduction of a 
poisonous principle from without, or by a change within itself in its 
usual constituents, it would not be reasonable to expect this altered 
blood to sustain as great vitality and as high action as healthy blood; 
debility might be expected. 
We have, then, evident marks of local inflammation, and there is 
nothing in this naturally opposed to debility as the two terms are 
now understood. 
It may be concluded that cerebro-spinal meningitis is a disease of 
debility, accompanied with or complicated by local inflammation, caus- 
ed by an altered or morbid blood. What the alteration is, how the 
morbid material is communicated to that fluid, whether it is crypto- 
gamic, as has lately been discovered with regard to the cause of mea- 
sles and of periodical fevers, or whether it is animal or gaseous, we 
do not know. Probably the condition of the tissues and the nerves 
also operates largely in producing the disease. 
Cerebro-spinal meningitis has been considered by some identical 
with influenza. But the symptoms are not the same; coryza is want- 
ing, and sneezing is not general in cerebro-spinal meningitis ; the 
head symptoms arc not so severe in influenza; the rate at which they 
travel over the country is entirely different; influenza is rapid, pass- 
ing quickly from one place to another, and not remaining long any- 
where; cerebro-spinal meningitis, however, passes from place to place 
with much less rapidity, and sometimes remains so long as to become 
almost endemic. Influenza, also, is a slight affection, when the small 
number of deaths in proportion to the number attacked is considered; 
and the fatal cases are found principally among the very young or NATURE. 
95 
very old. Just the reverse of this is seen in meningitis-it is very 
fatal among all classes and ages. 
There is more similarity between the disease we are considering 
and typhus fever; indeed, many have concluded that it is only a spe- 
cies of that disease, with determination to the head. 
The following table will show at a glance wherein these dis- 
eases are similar and dissimilar. 96 
CEREBRO-SPINAL MENINGITIS. 
Symptoms of Typhus 
resembling 
Cerebro-spinal Meningitis. 
Symptoms of Typhus 
not resembling 
Meningitis. 
Symptoms 
of 
Cerebrospinal Meningitis. 
Sometimes prodromes; of- 
Occasionally prodromes; 
ten commences suddenly. 
Eruption rarely absent. 
usually commences suddenly. 
Eruption often absent. 
Eruption appears on the 
Eruption appears on the 
Purpura and vibices. 
4th to 7th day. 
first or second day. 
Purpura and vibices. 
Herpes on lips and else- 
Herpes, especially on lips. 
where. 
Tongue occasionally dark 
Tongue generally black or 
colored. 
brown. 
Occasionally nausea, rarely 
Nausea and vomiting not 
vomiting. 
uncommon. 
Delirium seldom before end 
Delirium early, often on 
of first week. 
first day. 
Delirium often furious. 
Delirium usually talkative 
Delirium becoming coma 
and quiet. 
Delirium becoming coma 
Pupils sometimes dilated. 
on ninth or tenth day. 
much earlier. 
When delirium sets in, pu- 
Pupils usually dilated. 
pils contracted. 
Headache ceases when de- 
Headache continues after 
lirium commences. 
delirium begins. 
Tenderness of surface. 
Tenderness of surface. 
Subsultus tendinum. 
Subsultus tendinum, tho' 
Convulsions not earlier than 
not so common. 
Convulsions earlier. 
Rigidity, especially of the 
seventh day. 
Rigidity of muscles. 
flexors. 
Opisthotonos very rare. 
Opisthotonos common. 
Rarely inflammation of the 
Inflammation of the brain 
brain. 
common. 
Skin usually dry. 
Skin not often very dry. 
Pulse 80 to 140. 
Pulse 80 to 140. 
Pulse generally regular. 
Pulse generally irregular. 
Great prostration. 
Great prostration. 
Usually constipation; oc- 
Usually constipation; oc- 
casionally diarrhoea; stools 
casionally diarrhoea; stools 
often dark. 
often dark. 
Urine often diminished. 
Urine sometimes dimin- 
Sometimes albuminuria. 
ished. 
Sometimes albuminuria. 
Sometimes complicated 
Sometimes complicated 
with pneumonia. 
with pneumonia. 
Accompanied by sore 
Complicated with sore 
throat. 
throat. 
Inflammatory swellings and 
Inflammatory swelling of 
buboes, especially of the pa- 
the parotid, lymphatics about 
rotid and submaxillary. 
the neck and in other places. 
Amendment on tenth to 
No stated period of amend- 
sixteenth day. 
ment. 
About one in five dies. 
About one in three dies. 
Fatal between twelfth and 
Fatal earlier, between se- 
twentieth day, sometimes on 
cond and sixth day, not un- 
Moderately contagious. 
first day. 
frequently on the first day. 
Moderately contagious. N A T U B E . 
97 
Pathology in 
Typhus resembling Cerebro- 
spinal Meningitis. 
Pathology in 
Typhus not resembling 
Cerebrospinal Meningitis. 
Pathology in 
Cerebrospinal 
Meningitis. 
Blood fluid and dark. 
Blood fluid and dark. 
Lungs rarely healthy; usu- 
Lungs, when affected, 
ally hypostatic congestion, 
showing hypostatic conges- 
sometimes amounting to con- 
tion; sometimes exudation of 
solidation; both equally af- 
fected ; oedema at times. 
blood into their parenchyma. 
Pneumonia not common, 43 
Pneumonia not so com- 
in 288 cases. 
mon, except when that form 
is epidemic. 
Occasionally recent pleu- 
risy. 
Pleurisy not observed. 
Not mentioned. 
Effusion of lymph into the 
pericardium. 
Rarely signs of inflamma- 
Marks of inflammation in 
tion in heart. 
heart. 
Spleen enlarged and soft- 
Spleen enlarged and soft- 
ened. 
ened. 
Liver softened. 
Liver softened. 
Liver not enlarged. 
Liver enlarged. 
Peyer's glands healthy; no 
Inflammatory spots on the 
signs of inflammation in the 
intestinal mucous membrane; 
intestines. 
Peyer's patches enlarged and 
sometimes ulcerated, though 
not as in typhoid fever. 
" Post mortems show that 
Principal and most frequent 
inflammation of the brain or 
lesions show inflammatory 
its membranes rarely if ever 
action within the cranium and 
occurs, even as complication, 
in typhus." 
spinal canal. 
These two diseases resemble each other in almost every respect, ex- 
cept in reference to the eruption and where the functions of the brain 
are implicated; also, cerebro-spinal meningitis is by far the more 
severe, being fatal in a shorter time and in a larger proportion of 
cases. 
Murchison, speaking of the convulsions which are often met with 
in typhus, says, " No appearance is ever found within the head to 
account for the convulsions." "It is now tolerably certain that con- 
vulsions occurring in the course of typhus have always a uraemic 
origin." Again, in speaking of the cause of the palsy which some- 
times occurs, he says :-" Although the nervous system may be pri- 
marily at fault, the palsy is really due to an exaggeration of the mus- 
cular atrophy which, to some extent, is always produced by typhus." 
lie remarks, with regard to the post-mortem appearances found in the 
head, that they rarely, if ever, show that inflammation of the brain 
or its membranes has been present, even as a complication. " The 98 
CEREBRO-SPINAL MENINGITIS. 
cerebral membranes often exhibit increased vascularity, but never 
any deposit of lymph or pus, indicative of recent inflammation." 
" The increased vascularity of the cerebral membranes in typhus 
must not be regarded as a sign of inflammation, and does not account 
for the cerebral symptoms observed during life." " In the majority 
of cases, where there is increased vascularity of the cerebral mem- 
branes in typhus, some impediment will be found in the pulmonary 
circulation, or there has been evidence of greatly impaired cardiac 
action. The congestion, in fact, is mechanical or passive, never ac- 
tive." Haemorrhages on the arachnoid occur, but have no connection 
with cerebral symptoms. " Increased effusion of serum within the 
cranium is one of the frequent morbid appearances." "It never 
contains any flakes of lymph or exudation corpuscles." " The in- 
creased amount of serosity within the cranium is no sign of inflam- 
matory action, and accounts, in no way, for the cerebral symptoms 
during life." 
These are the strongest statements I have been able to find oppos- 
ed to the presence of inflammation within the cranium during typhus; 
and if they were correct, it would be necessary to admit that what 
has been called spotted fever, or cerebro-spinal meningitis, is a dis- 
ease distinct from all others. But other authors do not agree with 
Dr. Murchison, and he has published an article in the London Lancet 
for April 22d, 1865, wherein he declares himself to have been in 
error with regard to the presence in typhus of inflammation of the 
brain. He says:-" In rare cases, typhus fever is complicated with 
unmistakable inflammation of the membranes of the brain. At the 
time of the publication of my work on Fevers, I was under the im- 
pression that this complication never occurred, but subsequent expe- 
rience has convinced mo that I was mistaken. In the interval I have 
met with two unequivocal cases of typhus complicated with true me- 
ningitis and the effusion of lymph on the surface of the brain." He 
also mentions having lately noticed tetanic contractions and opis- 
thotonos. 
Dr. Bartlett notices the symptoms referable to the head, pain, deli- 
rium, coma and perverted sensations; he mentions, also, the lesions 
of the brain observed by Gerhard, Reid, Jenner and Shattuck-en- 
gorgement of the sinuses and larger vessels of the brain, effusion of 
serum under the arachnoid and into the ventricles, and the presence of NATURE. 
99 
extravasated blood within the cavity of the arachnoid; and Dr. 
Clark, the editor of the fourth edition of Bartlett's " Fevers of the 
United States," says :-" The morbid condition of the cerebral mem- 
branes corresponded with the severity and duration of the coma." 
He noticed, also, a loss of transparency in the arachnoid, which was 
" in many instances dotted over with opaque white or yellowish white 
spots, without perceptible elevation, sometimes with distinct elevated 
grains." He noticed, occasionally, softening of the cortical substance. 
Dr. Watson says:-" The unnatural conditions that have been 
sometimes noted are-slightly diminished consistence of the sub- 
stance of the brain; congestion of its bloodvessels." " Now to 
what conclusion do these facts lead us ? Why, in the first place, to 
the conclusion that those pathologists are in error who maintain that 
the essence of continued fever is inflammation of the brain." " Never- 
theless, there may be, and there not seldom is, in these fevers, actual 
inflammation of the brain or its membranes; but this is an inciden- 
tal complication." 
Dr. Wood says :-" No clearly ascertained connection exists be- 
tween the stupor and the anatomical appearances of the brain. 
Sometimes, however, clear evidences of encephalitis, such as injec- 
tion of the membranes, opacity of the arachnoid, fibrinous exudation, 
and injection and softening of the substance of the brain, are pre- 
sented in cases which have exhibited signs of active cerebral inflam- 
mation during life." 
Cerebral inflammation is, then, acknowledged to occur in typhus, 
but it is a very rare complication. 
The other point in which there is a dissimilarity, is the time at 
which the spots appear. The character of the eruption is nearly 
the same in both diseases. Dr. Murchison says:-"It is composed 
of numerous spots of irregular form, varying in diameter from three 
or four lines to a mere speck, which are either isolated or grouped 
together in patches, presenting a serpigenous or very irregular out- 
line, and often closely resembling the eruption of measles. At first 
these spots are of a dirty pink or florid color, and very slightly ele- 
vated above the skin, and they disappear upon pressure; but after 
the first or second day, they usually become darker and more dingy, 
they resemble reddish-brown stains, are no longer elevated above the 
skin, and do not disappear, but only become a little paler on pres- 
sure. They have no defined margin, but merge insensibly into the 100 
CEREBRO-SPINAL MENINGITIS. 
color of the surrounding skin. These spots usually come out first 
over the abdomen and spread thence to the chest, back, shoulders, 
thighs and arms." He mentions elsewhere that in the centre of the 
spots there occurs at times a change into petechiae, giving rise to 
three stages in their progress, though the last may not always be 
seen. Other accounts of the eruption of typhus so nearly agree with 
this that it is unnecessary to quote them. 
We find almost precisely the same description of the eruption in 
cerebro-spinal meningitis. Surgeon Wales, U.S.N., says :-" The 
spots assumed the form of small, round ecchymoses, of various sizes, 
from the head of a pin to the size of a split pea, of a light red color, 
like the bites of fleas. As the case advanced, the splotches increased 
in size and coalesced, forming larger ones, or, properly, patches, and 
in bad cases assuming a livid or purplish color. Again, the form 
was that of reddish streaks, as if caused by striking the parts with 
a bundle of twigs. In all cases the eruption was even with the skin, 
and appeared first upon the extremities, generally the upper, and 
then on the face and trunk."* 
Dr. Woodward, of Brandon, Vt., in an article in the American 
Medical Times for May 14, 1864, says, "The spots from wfliich the 
disease has taken its name are not unlike the spots seen in enteric 
and typhus fever, presenting in a few cases all grades, from the rose- 
colored rash to the deep and permanent (under pressure) petechias." 
Many mention that the eruption resembled that of typhus. Dr. J. B. 
Upham notices the similarity. " Petechias were not an unfrequent 
manifestation-in appearance almost identical with the true typhus 
eruption, and like that seen upon every part of the body, except the 
face."! The color, as noticed by others, was sometimes light and 
sometimes dark. Dr. Burns, in one of his cases, found it bright col- 
ored, like Dr. Gerhard gives a very minute description 
of the eruption. They varied in size from the head of a pin to a 
quarter of an inch-were sometimes confluent. " Each spot was of 
a dull-red color, almost purple in some cases, varying in shade, for 
the most part not at all affected by pressure." " The spots were not 
in the slightest degree elevated above the surface." " The spots ap- 
* American Journal of Medical Sciences, Jan., 1864. 
+ Boston Medical and Surgical Journal, vol. Ixviii. 
J American Journal of Medical Sciences, Jan., 1865. NATURE. 
101 
peared usually at the end of twenty-four hours, but sometimes even 
sooner."* 
In previous epidemics, the eruption is also described as being 
sometimes light colored and sometimes dark. The committee of the 
Massachusetts Medical Society, in 1810, described the spots as " flo- 
rid and fiery. An appearance like measles has also been noticed." 
Dr. North says, "they varied from a common to a very dark purple." 
Dr. Gallup says, " they sometimes resemble petechiae. or flea-bites, 
as described by writers, happening in other diseases, of a dark hue; 
sometimes of a brighter color." 
Foreign observers do not so frequently mention the color, merely 
saying that petechiae were present. Maillot says:-" The skin is 
very warm, dry, and presents disseminated over the body and limbs, 
a large enough number of spots of a deep red, irregular in form, un- 
equal, not disappearing under pressure."! 
The eruption was, then, if not identical, at least nearly so, in the 
two diseases, not only during the late epidemic, but in former times 
and in other countries. 
It is necessary to account for the difference of time at which it 
appears. It has been stated that the eruption is due to an effusion 
or extravasation of blood beneath and into the cutaneous tissue. The 
earlier and more thoroughly the blood is disorganized the sooner this 
extravasation might be supposed to occur, and the darker would the 
eruption be, even in the first instance. The fearful rate of mortality 
and the very short duration of the fatal cases would lead to the con- 
clusion that this disease causes more sudden changes in the tissues 
and blood than common typhus. Supposing it, then, to be only an 
unusually severe form of that affection, the early disorganization of 
the blood would be expected to occur, and the early appearance and 
darker hue of the eruption follows as a natural sequence, and can no 
longer be stated as an argument against the identity of the diseases. 
The eruptions in the two diseases being identical in character, the 
difference in the date of their appearance being explained by the 
much greater severity of the disease in one case than in the other, 
there remain no differences between typhus and ccrebro-spinal me- 
ningitis to be reconciled, except those which refer to the lesions of 
the brain and spinal cord. 
* American Journal of Medical Sciences, July, 1863. 
f Gaz. Med. de Paris, 1848. 102 
CEREBRO-SPINAL MENINGITIS. 
The earlier appearance of convulsions and delirium would depend 
on the brain being directly affected at that time, whereas in common 
typhus these symptoms are not usually exhibited until a later stage, 
when the blood has been charged with urea or ammonia. It has, 
however, been mentioned that lesions of the encephalon have been 
noticed as one of the complications in typhus. 
The difference in the regularity of the pulse may also depend on 
the affection of the cerebral centres. 
There is one appearance which has not been explained, the effu- 
sion of lymph in the pericardium, which occurred in two cases, and 
has not been mentioned in connection with typhus. But ecchymotic 
spots on the heart and softening of that organ have been noticed; 
also pericarditis and endocarditis, by Jacquot. 
With regard to the treatment of typhus, Dr. Murchison, after 
speaking of the means to bo used to prevent the generation and ex- 
tension of the disease, considers the means of cure. He advocates 
free ventilation, supporting diet and pleasant, cooling drinks. He 
discountenances bloodletting. " Modern observation has shown that 
the effect of bloodletting in typhus is to increase the mortality; while 
even in the patients who recover after it, the nervous symptoms occur 
sooner, and with greater intensity, and arc of longer duration, the 
eruption is darker and more copious, and convalescence is greatly 
retarded." He is in favor of alcoholic stimulants only to a mode- 
rate extent, and when the heart's action is weakened. Emetics are 
useful only at the commencement, and violent purgation is injurious. 
He does not speak of opium in such high terms as some who have 
employed it in cercbro-spinal meningitis, but he recommends its use 
when there is delirium, restlessness or sleeplessness; that is, when 
cerebral symptoms appear. 
Dr. Graves advises the employment of nearly the same course of 
treatment. 
And so, also, other authors advocate the judicious use of stimu- 
lants and a supporting diet; discountenance all that debilitates, and 
allow abstraction of blood only to counteract local affections. 
By referring to the treatment of cerebro-spinal meningitis in the 
preceding pages, it will be seen that essentially the same method of 
treatment is used in that disease as in typhus. 
If we compare, also, the causes of the two diseases we shall find 
a striking similarity. " Typhus is often observed to be most prevalent NATURE. 
103 
in the latter half of winter, in the spring and beginning of summer, and 
many epidemics have declined rapidly towards the end of summer; " 
but "epidemics of typhus appear to commence and progress irre- 
spective of the season, so long as other known causes of the disease 
continue in operation." Again, " the ordinary variations of tempera- 
ture, in this climate, have little influence over the prevalence of ty- 
phus."* The same author enumerates the causes of typhus-debili. 
tating influences, as intemperance, fatigue, previous illness, destitu- 
tion and privation; " exposure to cold and wet, especially if long 
continued, has a depressing influence on the nervous system, and so 
favors the advent of typhus." 
" Over-crowding of human beings, with deficient ventilation, is one 
of the most powerful predisposing causes of typhus." 
All the influences here enumerated have been noticed in preceding 
pages as predisposing causes; the evidence would rather indicate 
that season and the state of the weather had more influence than Dr. 
Murchison concedes to them; but the facts are not, perhaps, suffi- 
ciently numerous to make any positive statement. 
The principal agent, in many cases, in causing typhus, the exciting 
cause-contagion-is thus mentioned by Dr. J. B. Upham in his lit- 
tle book, " Typhus Fever in Great Britain " :- 
" And yet the disease should not be held as contagious in the same 
sense that smallpox is contagious; i. e., that it is invariably and vi- 
rulently so. Certainly the sphere of action is more limited-the 
communication of the poison more dependent on circumstances- 
and the morbific influence more within the control of sanitary laws 
and regulations, than in the usual zymotic or so-called contagious 
maladies. It may be stated as a general rule, that the contagion, to 
be effectual, must be concentrated by the crowding together of pa- 
tients-or accumulated and aggravated in ill-ventilated and pent-up 
rooms-or stimulated by the conjunction of other unfavorable hygi- 
enic conditions-ill draining, filth, effluvia, <fcc. &c.-or the recipient 
have been previously subjected to the predisposing causes by depri- 
vations, hardship and want, excesses, anxiety, fear, despondency, 
mental and physical exhaustion or debility from any cause, till his 
system has been brought to a point below the power of resistance." 
In a note he adds :-" I am aware there are many apparent excep- 
* Murchison. 104 
CEREBRO-SPINAL MENINGITIS. 
tions to this rule. Instances are on record, some of which have oc- 
curred in the experience of the writer, where persons exposed to 
isolated cases have received the contagion." 
It is hardly necessary to extend the quotations; all authors agree 
on these points in every important respect. Possibly Dr. Upham 
does not lay so much stress on the influence of contagion as some. 
If it is possible to classify any epidemic under a disease already 
described and recognized, it would be erroneous to establish a new 
species on account of slight differences which are easily account- 
ed for. 
There is almost an exact agreement between these two diseases in 
the symptoms and post-mortem appearances, except in reference to those 
dependent upon lesions of the cerebro-spinal system. The causes 
and treatment are essentially the same. We must conclude, then, 
that epidemic cerebro-spinal meningitis is only epidemic typhus, 
wherein, from some cause, the cerebro-spinal system is the principal 
seat of the attack.* By this classification the great variety in the 
symptoms is more easily explained, and the epidemics in which the 
pneumonic form was most frequently seen were true typhus, less fre- 
quently complicated with lesions of the brain. 
* It may not be uninteresting to notice that about the time when the cerebral form has 
prevailed, on each occasion, there has been a subject which agitated the people very gene- 
rally, and caused much public discussion. Thus between 1807-14 there were the difficulties 
with Great Britain ; from 1819 to 1827 there was more or less discussion of the slavery ques- 
tion, resulting in the Missouri Compromise in 1821, and parties were so nearly equal that no 
election of President was made in 1824, and the choice devolved upon the House of Repre- 
sentatives. In 1846, the war with Mexico commenced and continued two years. In 1861 
was the commencement of the late epidemic, synchronous with the late rebellion, though 
excitement existed previously in a slighter degree. In France, from 1836 to 1848, political 
excitement existed, which ceased only after Louis Napoleon became Emperor. Later, at 
Dantzic and other German cities, where the disease has prevailed, there has been the Schles- 
wig-Holstein question, which has aroused the people. 
Thus, we see that, during each of the great epidemics, there has existed one or more ques- 
tions upon which the people thought much, having their sympathies and passions excited. 
Had this mental agitation any influence in causing the cerebro-spinal form of the complaint ?