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C. B. G. DEN ANC 1:1:1)12
fiPLES B, NANGREDE, M., D,

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y -. Sºº-3


EPIDEMIC MENINGITIS,
OR.
0EREBR0-SPINAL MENINGITIS.
BY
ALFRED STILLE, M.D.,
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE
UNIVERSITY of PENNSYLVANIA ; PHYSICIAN To ST. Joseph's HospitaL AND
TO THE PHILADELPHIA HOSPITAL.
“Looking at the disease as an object of study, I know of nothing which surpasses
it in interest.”—GASKOIN.
PHILADELPHIA :
L IN D S A. Y. A N D B L A K IS TO N.
1867.
Entered according to Act of Congress, in the year 1867, by
LIN D SAY & B L A KIST ON,
in the District Court of the United States in ànd for the Eastern District of
Pennsylvania.
HENRY B. As HMEAD, PRINTER.
TO THE CLINICAL CLASS OF THE PHILADELPHIA HospitaL,
FOR 1866–67.
GENTLEMEN:
It is a pleasure, and indeed it is almost a duty, to inscribe this
little work to you, who enjoyed with me the rare opportunity of
studying an epidemic of meningitis. It will, perhaps, serve to
recall many things which you would otherwise have forgotten,
and to impress you with a clearer idea of this curious disease
than you could obtain from the fragmentary remarks made at our
clinical conferences.
Availing myself of this opportunity to commend your diligent
and patient attendance upon our meetings, and to thank you for
the many other evidences of the interest which you manifested in
our common labors,
I remain, very faithfully, your obedient servant,
º
ALFRED STILLE.
1500 WALNUT STREET, September, 1867.
269283
(; 0 NTENTS.
INTRODUCTORY,
HISTORY, º ſº tº
GENERAL IDEA of THE DISEASE, .
SKETCH of THE SYMPTOMs, . © º
SYMPTOMs FURNISHED BY THE NERVous SYSTEM,
Headache,
Vertigo,
Debility, .
Delirium,
Coma,
Facies, º
Cutaneous sensibility,
Pain in the spine and limbs, .
Tetanoid phenomena,
Clonic spasms,
Paralysis, & © ge
SYMPTOMs FURNISHED BY THE ORGANs of THE SENSEs, .
The eyes—Conjunctivae, .
Double vision,
Blindness,
The iris,
The pupil,
The ears—Hearing,
Expression, º tº g e
SYMPTOMs FURNISHED BY THE DIGESTIVE ORGANs,
The tongue,
Nausea and vomiting, .
Diarrhoea; constipation,
The appetite, .
Thirst, . o *
Sore throat; aphthae, . • *,
Parotids, .
PAGE
10
17
19
22
22
24
24
26
28
29
30
31
32
39
40
41
41
43
43
44
45
46
46
47
47
47
50
50
51
52
52
vi CONTENTS.
SYMPTOMs FURNISHED BY THE URINARY ORGANs; THE
JoINTs, AND THE RESPIRATORY APPARATUS, .
SYMPTOMs FURNISHED BY THE PULSE,
SYMPTOMs FURNISHED BY THE SKIN,
Dryness and moisture,
Temperature, .
Eruptions, e
Meningitis without eruption, . &
Meningitis with non-petechial eruptions,
Gangrene,
DURATION,
CoNVALESCENCE, .
SEQUELAE-RELAPSES,
MoRTALITY,
FoRMs, &
ANATOMICAL CHARACTERS,
Exterior, . { } e tº
The scalp and cerebral membranes,
The ventricles of the brain,
Exudations, . º
The substance of the brain,
Spinal marrow,
The blood,
The joints,
CAUSES,
Season,
Weather, .
Local conditions,
Sex; age; occupation,
Debility, † e
War; poverty; filth; cold,
Contagion, &
PROGNOSIS,
DIAGNoSIs—Positive, º iº
Comparative: Sporadic meningitis
Hysteria, tº
Typhoid fever, . •º
Typhus fever, .
PAGE
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56
56
57
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61
64
67
67
70
71
72
72
76
77
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80
81
86
87
89
93
93
94
95
95
95
97
97
99
102
106
107
108
108
111
CONTENTS.
vii
NATURE, .
NAME,
TREATMENT, e e &
Antiphlogistic method—Emetics, .
Purgatives,
Depletion,
Cold,
External stimulants—Blisters,
Heat,
Internal stimulants—Alcohol,
Opium, .
Cinchona and quinia,
Alteratives—Mercury,
Arsenic,
Iodine, .
Miscellaneous—Belladonna; ergot,
Diet, .
Regimen,
BIBLIOGRAPHY,
PAGE
124
130
134
136
138
138
143
144
147
148
153
158
160
166
167
167
168
171
172
EPIDEMIC MENINGITIS.
As the epidemic meningitis which has ravaged the
United States for the last ten or eleven years, appears
to be approaching the termination of its career, the
present seems to be a fitting occasion for reviewing
its course, and studying its analogies with European
and other American epidemics of the same disease,
and for guarding, if possible, future generations of
physicians against the misconceptions and mistakes, the
confusion of ideas and the still greater confusion of
terms, which, even now, have not altogether ceased to
have currency among professional teachers and writers.
We have been the more strongly moved to attempt
placing the subject in a clear light, by the practical
acquaintance with it, which we acquired during the
first quarter of the present year, while studying
about one hundred and twenty cases of the disease
in the Philadelphia Hospital. Nearly one hundred
of them form the subject of a very valuable Report
Q
*d
10 EPIDEMIC MENINGITIS.
contributed by Dr. Githens to the American Journal
of the Medical Sciences. In the corresponding term of
the previous year we witnessed a still more exten-
sive and fatal epidemic of typhus fever in the same
Institution, where, also, thirty years before, we had
become familiar with that fever as a resident physician
of the hospital during the great epidemic, the history
of which is so honorably associated with the names
of Gerhard and Pennock. Such opportunities were
peculiarly fitted to reveal the grounds of the common
error of confounding epidemic meningitis and typhus
fever, into which physicians acquainted with one only
of these affections have been prone to fall, as well as
to illustrate the surprising variety of morbid phe-
nomena which the former exhibits by virtue of its
double character as a blood disease, and an inflamma-
tion of the cerebro-spinal membranes.
HISTORY.
Nothing illustrates more clearly the value of mor-
bid anatomy as an element of medical diagnosis than
the inextricable confusion which involves nearly all
of the descriptions of this disease which were written
before the scalpel revealed the lesions which essenti-
ally belong to it. There is no doubt whatever that
numerous histories of “Fever,” of “Typhus,” &c.,
related by authors of the last and previous centuries
included cases of epidemic meningitis; but it was not
recognized as a distinct affection until the beginning
of the present century. Some writers, who trace it
back to the fourteenth century would be sorely at
HISTORY. 11
fault if they attempted to disentangle it from the
various epidemic diseases which the history of medi-
cine records, and especially from that of typhus with
which it was, and by some persons continues to be,
confounded. When we remember that it was not
until 1836 that, in recent times, typhus was shown
to be a distinct disease from typhoid fever, and that
to this day the former term is applied by many Ger-
man writers to both affections indiscriminately, it is
not to be wondered at that epidemic meningitis should
have been involved in the same confusion. Indeed,
so accomplished an author as Hirsch, misled by some
of the early histories of the disease published in this
country, and unacquainted with the cotemporary post-
mortem investigations which would have enlightened
him, concludes that the old “spotted fever” had no-
thing in common with the affection we are about to
study. In all of these instances the lesions found
after death have brought order out of confusion,
and enabled us to distinguish typhus and typhoid
fever from one another, and epidemic meningitis from
both of them.
Restricting our historical review of the disease to
the epidemics of it which have occurred since the
beginning of the present century, and, rising for a
moment above its individual and local outbreaks, our
attention is at once arrested by a circumstance which
removes it from the category of endemic, and even of
epidemic diseases, in the ordinary sense of the latter
word, and entitles it to the name pandemic. Unlike
typhus, and typhoid and yellow fevers, its rise and
progress are connected with no antecedents of animal
12 EPIDEMIC MENINGITIS.
or other putrefaction; nor with any miasmatic, crypto-
gamic or analogous agent, like periodical fevers; nor with
any telluric or aqueous emanation like dysentery; nor
with a special poison like cholera, smallpox, or measles.
All of these diseases have, moreover, a distinctly ascer-
tainable starting point from which they widely extend;
or else their ravages are confined within comparatively
marrow limits; but with epidemic meningitis the case
is very different. Its outbreaks have occurred almost
simultaneously in regions as widely separated as
Europe is from America, and annually it has made a
mid-winter attack upon towns and rural districts, the
salubrious and unhealthy alike, completing the cycle
of its progress in a period varying between ten and
fifteen years. Three such periods, at least, have
occurred during the present century. The first, of
eleven years, began in 1805 and terminated in 1816;
the second, of thirteen years, occurred between 1837
and 1850; and the third extends from 1856 to the
present time, and has already lasted for eleven years,
during which the disease has been almost constantly
present in Europe, but absent during four years from
the United States. These two conditions, of simultane-
ous appearance in widely remote places, and of an-
nual recurrence for a series of years, characterize no
other disease whatever. The first, indeed, is ful-
filled by influenza; and it was perhaps a dim percep-
tion of the analogy we have pointed out which led
one writer, at least, (Wilson), to imagine the two dis-
eases to be identical, a proposition which at the present
day may provoke a smile, but hardly calls for refuta-
tion. But no other disease than influenza affords an
HISTORY. 13
example of the former condition singly, and none but
epidemic meningitis of both combined.
The first account of epidemic meningitis within the
period we have referred to was published in 1805, by
Vieusseux, who at once declared that neither he nor
any of his colleagues had ever seen a similar disease.
It is also worthy of remark, that in this particular
epidemic a petechial eruption was a prominent symp-
tom, that engorgement of the brain existed in most
of the fatal cases, and that its historian describes it
as “a malignant non-contagious fever.” If any doubts
should be entertained respecting the identity of this
disease with epidemic meningitis, they will perhaps
be dispelled by the account which Mathey furnishes
of a dissection made in one of the fatal cases. He
describes a gelatinous exudation as covering the con-
vex surface of the brain, and a yellow puriform matter
upon its posterior aspect, upon the optic commissure,
the inferior surface of the cerebellum, and the medulla
oblongata.”
In every one of the following years, until 1816,
the same disease prevailed either in Prussia, Holland,
Rhenish Germany, Bavaria, or the east of France,
but no where else in Europe; while in the United
States it began its course in 1806, at Medfield, in
Massachusetts, and between that time and 1816 it
* Bascombe, in his “Iſistory of Epidemic Pestilences,” speaks of a
local epidemic at Roettingen, in Franconia, in the autumn of 1802, in
which the young and strong were suddenly seized with pain and
anguish at the heart and lacerating pains in the nape of the neck. In
the worst cases the patient fainted, the limbs became rigid, and death
closed the scene frequently within twenty-four hours from the com-
mencement of the attack.
14 EPIDEMIC MEN1 NGITIS.
extended throughout New England and into Canada,
the State of New York, Pennsylvania, and other
States to the South and West, precisely as it has
done during the recent epidemic.
We possess no record of its occurrence between
1816 and 1822; but in the last named year, a local
and temporary appearance of the disease was observed
at Wesoul, in France; in 1823 at Middletown, Con--
necticut; in 1828 in Trumbull county, Ohio; in 1830
at Sunderland, England, and in 1833 at Naples.
. After four years of quiescence it entered again
upon a wide and destructive career, which lasted
from 1837 to 1850. During the first two years of
its recurrence in Europe, it was confined almost en-
tirely to France; but during the third and fourth
years it appeared also in Italy and Algeria and at Gib-
raltar, without, however, retreating from its original
territory, where it continued to prevail until 1849,
breaking out meanwhile at various points of the north
of England and in Dublin, and from 1845 to 1848 in
Denmark. While the epidemic was thus spreading
through Europe, it again appeared in the United
States at places as remote as possible from trans-
atlantic communication, and hundreds of miles distant
from one another; in Louisville, Kentucky, in Ruth-
erford county, Tennessee, and in Montgomery, Ala-
bama. This took place in 1842; and in the following
years, the disease appeared in Arkansas, Mississippi
and Illinois. In 1848 it occurred again at Mont-
gomery, Alabama, and simultaneously in Beaver
county, Pennsylvania; in 1849 it existed in Massa-
chusetts and in Cayuga county, New York, and finally
HISTORY. I5
at New Orleans, in 1850. It appears, therefore, that
although the American epidemic began later than the
European, it reached its period of extinction very
nearly at the same time.
Between 1850 and 1854 epidemic meningitis had
ceased to be heard of, when suddenly it broke out
with destructive violence in Sweden, a country which
had hitherto entirely escaped its ravages, and there it
continued to prevail during the six years from 1854
to 1860. During this period local epidemics of very
limited extent or sporadic cases occurred in Dublin,
London, and in Stafford, England; and simultane-
ously the disease prevailed in several parts of the
United States. On this, as on previous occasions, its
starting points were remote from one another, as in
North Carolina, where it appeared for the first time
in March, 1856, and in the central portions of New
York and Massachusetts at the commencement of
1857.
To return once more to Europe, we find that hardly
had the epidemic ceased in Sweden, than it reappeared
in Holland during the winter of 1860–61; and in the
following year, at the same season, it spread over a
large extent of the Portuguese territory. Germany,
which had remained almost entirely exempt from the
attacks of the disease since the first and very partial
outbreak of 1806, was now the seat of an epidemic
as widespread as that which had pervaded France.
Beginning slightly in the summer of 1863, it acquired
new vigor during the next winter, and for the two
following years devastated almost every part of
northern Germany, but, so far as we are informed,
16 EPIDEMIC MENINGITIS.
penetrated but slightly into the Austrian empire.
Simultaneously (1865) a local epidemic of the disease
occurred in Dublin.
The counterpart of this epidemic, as on former
occasions, appeared in the United States. The first
point at which it broke out was Livingston county,
Missouri, in the winter of 1861–62; and during the
same season it invaded Indiana, Kentucky and Con-
necticut. From 1860 to 1864 it prevailed in Ohio,
and during the last named year in Illinois. Cases of
the disease occurred at Newport, Rhode Island, in
1863, and in Vermont in 1864. In 1863 the epi-
demic began in Philadelphia, and has renewed its
appearance annually until the present time. During
the same period it prevailed in Maryland, Virginia,
North Carolina, Alabama, and other Southern States.
The coincidences which have now been pointed
out are among the most striking occurrences in the
history of this singular disease, and they are, as
before remarked, characteristic of it alone. If there
had been anything common in the origin of its
epidemics, as climate, soil, or water, or the social
condition, age, sex, occupation, or habits of the
patients, a plausible, although even then an untenable,
explanation of their simultaneous occurrence might
be suggested; but, in point of fact, no single circum-
stance was common to all, or nearly all of them, except
their outbreak in mid-winter. It follows, therefore,
that, even at this stage of our inquiry, epidemic men-
ingitis must be regarded as an exceptional affection,
and, as before intimated, a true pandemic disease.
Along with the more or less wide spread epidemics
GENERAL IDEA OF THE DISEASE, 17
which have now been considered, several instances
are on record of this disease occurring in groups of
two, three or four cases, in localities where it never
at any time assumed the epidemic form. Not to cite
instances of doubtful import, we shall refer only to
those observed in England, where epidemic meningitis
has never yet been known to prevail. In 1807, Dr.
Gervis, of Ashburton, reported four such cases; in
1859, Dr. Day met with two such at Stafford; and in
1865, three cases were observed in London by Dr.
Wilks, three by Dr. Ogle, and one by Dr. Martin.
We shall not attempt to suggest an interpretation of
these facts, which are not, however, without their
significance.
GENERAL IDEA OF THE DISEASE.
The strangely contradictory opinions concerning
epidemic meningitis which have been held by physi-
cians of more than ordinary intelligence and inform-
ation, are clearly traceable to their having seen but
few cases of the disease, to their limited acquaintance
with its diversified forms, or to their superficial
study of its recorded history. No disease whatever
wears such various masks of symptoms, behind
which there is, nevertheless, a great uniformity of
characteristic lesions. While one writer classifies its
several forms as nervous, inflammatory and comatose,
another describes them as neuralgic, delirious, con-
vulsive, paralytic and comatose; and a third recog-
nizes abortive, malignant, intermittent and typhoid
forms, to which a fourth adds the chronic form, the
18 EPIDEMIC MENINGITIS.
lesions are essentially the same in all, although vary-
ing in degree as much as congestion does from exuda-
tion, and in extent from what is invisible to the naked
eye to a profuse accumulation of inflammatory pro-
ducts. Yet the degree and extent of these lesions,
and the greater or less energy in the primary impres-
sion of the morbid cause of the disease are the two
elements, out of which this great variety in its phe-
nomena arises. Just as in typhoid fever the blood
disorder and the intestinal lesion combine to impress
upon that disease a characteristic expression which is
compounded of those two elements in various propor-
tions, so that in one case the attack may terminate
in coma before intestinal symptoms arise, or marked
intestinal lesions are developed; and in another a
prolonged diarrhoea and moderate fever may be almost
the only prominent phenomena; so in epidemic menin-
gitis the blood disease may vary through every grade,
from extreme hypinosis to extreme hyperinosis, from
typhoid symptoms to inflammatory, and the nervous
disorder present those infinite diversities in degree
and kind which depend upon the existence of conges-
tion or of exudation in the membranes of the nervous
centres, on the participation of one part or another of
the brain or spinal marrow in the change, its degree
and extent, and on the relative proportion of the
blood and tissue changes in the aggregate lesions.
Hence it is, that, in the description which is to follow,
the reader must not expect to find a photographic
miniature of the disease, by which any one may reco-
gnize it at a glance, but rather a succession of impres-
sions differing very much from one another, but all
SKETCH OF THE SYMPTOMS. I9
of them necessary to form an accurate picture of this
chameleon-like disorder. It will greatly simplify the
subject, however, to bear in mind the existence in
every case of the two elements referred to above,
the blood disorder and the nervous disorder; for to
one or the other of the two all of the symptoms may
be referred.
SKETCH OF THE SYMPTOMS.
It will readily be anticipated that, like other fatal
epidemic diseases, meningitis is sometimes sudden
and sometimes gradual in its development. In the
former case, the patient on awaking suddenly from a
sound sleep, or, while pursuing his ordinary avoca-
tions, may be attacked with chilliness, prostration,
vomiting and headache, of which symptoms the last
is often intensely distressing. As in other epidemic
diseases, also, such seizures are most common during
the earlier periods of its prevalence; but, later in its
course, premonitory symptoms are more frequently
observed. They may last for an hour or two, or may
extend to several days; and, in general, it may be
stated that the longer their duration the milder will
be the subsequent attack. But the symptoms in
either case are essentially the same; prostration, chil-
liness, feverishness, and sometimes vomiting and
sharp pains in the head, back and limbs. The cha-
racter of the vomiting, as well as the absence of all
gastric lesions, prove that it is produced by an irrita-
tion of the brain. All of these symptoms, their suc-
cession and degree of gravity, were as fully described
20 EPIDEMIC MENINGITIS.
and appreciated by North, Hale, Fish, and their co-
temporaries during the first occurrence of the disease
in the United States, as by Tourdes, Hirsch, Niemeyer,
Mannkopf and other historians of recent European
epidemics.
In the cases which may be called regular, these
phenomena more or less gradually assume a graver
aspect, or usher in a heavy chill, which, in its turn,
is followed by alarming symptoms, and especially by
excruciating pain in the head, a livid or pale and
sunken countenance, and extreme restlessness. The
pulse is as often slow as frequent, and the skin but
little, if at all, warmer than natural. The vague pains
which opened the attack are now concentrated, and
seem to dart in every direction from the spine, which
is also, especially at its upper part, the seat of severe
aching; and, in a large proportion of the cases, its
muscles become more or less rigidly contracted, so
that the head is drawn backwards, or the whole trunk
is arched, as in tetanus. Trismus is not uncommon,
and clonic spasms frequently affect the extremities;
even general convulsions are occasionally observed. As
these phenomena grow more decided, delirium of various
degrees is often manifested, from mere wandering and
hallucinations during the sleepless watches of the
night, to violent maniacal ravings, or incoherent mut-
terings, or the stertor of coma. As the attack
advances, the pulse usually rises above the normal
rate, and sometimes becomes extremely frequent; and
the skin, although it grows warmer does not acquire
the temperature observed in idiopathic fevers, nor
sustain it as equably as in them. In many cases
SKETCH OF THE SYMPTOMS. 2I
eruptions appear upon the skin. During some epi-
demics the only one observed is herpes labialis; in
in others the eruption resembles roseola, measles, or
the mulberry rash of typhus, or, from the first, it
consists of petechiae, vibices, or extensive ecchymoses.
The tongue presents the appearances which belong
generally to the typhoid state; it is at first moist, then
coated with a mucous secretion, then red and shining,
or brown and fuliginous. There is a complete loss of
appetite, and the thirst is not usually urgent. One or
two liquid stools at the commencement are generally
followed by constipation, which continues throughout
the attack, although in very grave and protracted
cases diarrhoea may exist and even become colliqua-
tive. When the attack tends to a fatal issue, the
patient generally, but by no means always, sinks into
a soporose condition, in which muscular relaxa-
tion, debility, and tremulousness, such as are com-
mon in typhus fever, are associated with paralysis of
the sphincters and of other muscles. But we have
seen rigid opisthotonos persist until within a few
hours of death in a case of more than the average
duration.
In cases which tend to terminate favorably the
symptoms are rarely, if ever, so grave; and this re-
mark applies more especially to the typhoidal symp-
toms than to the derangement of the nervous functions.
Yet, wherever the latter has been decided, the return
to health is tedious and uncertain, and not unfre-
quently a perfect restoration of all the functions is
very long delayed, or, it may be, is never attained.
Such, very briefly described, are the characteristic
22 EPIDEMIC MENINGITIS.
symptoms of epidemic meningitis and the usual order
of their succession. But, as before intimated, no
single typical case, nor any general description, can
accurately represent this Protean affection, as a
whole, nor convey a just idea of its numerous
grades and multiform aspects. They can best be
apprehended after studying the variations presented
by the individual symptoms. To these we shall
now direct the reader's attention. As the earliest,
usually, to make their appearance, and as most directly
connected with the characteristic lesions of the dis-
ease, we shall study the
SYMPTOMS FURNISHED BY THE NERVOUS SYSTEM.
HEADACHE-This is certainly one of the most con-
stant of all the symptoms pertaining to epidemic men-
ingitis. Except in those malignant and rapidly fatal
cases, where the death-blow falls with lightning speed
(méningite foudroyante), it is always present. It was
signalized by Vieusseux and by Mathey, in the Geneva
epidemic of 1805, by whom it was described as
“acute” and “violent;” by North, in the same terms;
by Fitch, as “a distressing heavy pain;” by Fiske, as
“distress amounting almost to torture, particularly
through the temples;” by Williamson, as so “excru-
ciating” that the patient cries, “oh, my head! my
head!” Fish uses the terms “sharp and lancinating”
to represent this pain, which he adds, “is confined to
a small spot sometimes;” Gallup speaks of it as being
felt “in the forehead between the eyes;” Hale says,
“that in a few instances it increased until it produced
SYMPTOMS.—HEADACHE. 23
2
and Danielson and Mann refer to a child
of fifteen months in whom the fontanelle opened
during a paroxysm of pain. Ames includes in his
graphic description all of these varieties in the seat
and character of the pain. Equally characteristic
are the terms used by European writers. Tourdes
states that this pain “extorted cries and groans that
could not be repressed;” it was throbbing, boring, or
lancinating; sharp or crushing, “as if the head were in
a vice, or nails or screws were forced into the brain.”
Even during partial coma the severity of the pain is
sometimes attested by the contortions or cries of the
patient, the movements of the head, or the manner
in which the hands are raised towards it. It is gene-
rally described as persistent in a greater or less degree
throughout the attack; but that this is not always the
case, the recent epidemic at the Philadelphia Hospital
proves, where not only this pain but those which
usually accompany it, in the spine and limbs, were
always mitigated, and generally removed, by means
of cups, dry or scarified, according to circumstances,
and blisters applied upon the nape of the neck. Yet
in epidemics of a graver type the persistence of the
symptom is most usual, even although the degree of
its severity may not be uniform.
It is to be presumed that the headache, with such
peculiarities as we have seen it to possess, ought never
to be confounded with the constant dull and heavy
pain in the head which is peculiar to typhus and
typhoid fevers; on the contrary, we may reasonably
conjecture that the material condition of the brain
must resemble, not that belonging to the fevers named,
delirium;’
24 EPIDEMIC MENINGITIS.
where no meningeal lesion exists, but that of the
same organ when its membranes are inflamed by
tuberculous or other deposits, or by traumatic causes.
And such, it will be found, is the fact.
VERTIGO is another symptom of the same class. In
the New England epidemic of 1823, it was thus de-
scribed by Miner. “In all the severe, and in a
majority of the mild cases, there was from the very
access, before a particle of medicine had been taken,
a peculiar deficiency of vital energy in the brain and
the whole nervous system, so that raising the patient
into an erect posture, would generally produce the
same sort of vertigo, anxiety at the stomach, accele-
ration and irregularity of the pulse, nausea, and even
fainting, which result from a similar position after a
great loss of blood.” Ames refers to “excessive de-
bility, giddiness, and dimness of sight,” among the
initial symptoms, but not as constant. This singular
symptom attracted also the attention of Tourdes in
the Strasburg epidemic of 1840–41. “Vertigo,” he
remarks, “was among the earliest symptoms. . . . Some-
times it confused the mind and rendered walking im-
possible. In two cases the patients were seized with
a giddiness, which compelled them to whirl round,
when they fell and did not rise again.” Hirsch speaks
of an adult patient, not yet confined to bed, who was
suddenly seized with maniacal delirium, and such
violent vertigo that he staggered about the room like
a drunken man.
DEBILITY.-‘A great, surprising, and sudden loss
of strength,” North describes as “a constant and
prominent symptom,” and he adds, “syncope some-
SYMPTOMS.—DEBILITY. 25
times occurs.” Hence the proposed name for the
disease, “typhus syncopalis,” or “sinking typhus.”
Miner speaks of it as occurring “in some degree in
almost every instance” and as “sometimes constitut-
ing the first access of the disease,” and describes it
as “a death-like sinking sensation in the epigastrium.”
Fish says that “the strength of the patient, from the
moment of the attack, was completely prostrated.” . . .
“The debility was astonishing and formed a striking
feature of the disease.” . . . The patient “found him-
self unable to raise his hand before he was sensible
of being ill.” The symptom had previously been de-
scribed by Strong in nearly the same terms. “The
pulse,” says Foot, “was asthenic, and every symptom
indicated a great and sudden prostration of the ‘energy
of the brain and nervous system.' ... I have never
witnessed a disease in which the powers of life are so
suddenly and entirely prostrated.” Tourdes mentions
“a sense of lassitude as one of the initial symptoms.”
This was followed by convulsive phenomena, and then
“a stage of debility in which the muscular power
seemed annihilated,” and if the patient reached con-
valescence he was “thoroughly exhausted, and re-
quired a long time to renew his strength.” Neither
vertigo nor prostration can, in themselves, be regarded
as more characteristic of epidemic meningitis than of
typhus and typhoid fevers; but their degree, the pro-
portion of cases presenting them, and the uniformity
with which they both, but especially vertigo, occur
at the very commencement of the attack, in certain
epidemics, are circumstances which have not been
recorded of any epidemic of the two last diseases.
26 EPIDEMIC MENINGITIS.
DELIRIUM is described as a prominent symptom by
all of the writers upon this disease, but it is also one
which presents extreme varieties both in degree and
kind. Sometimes it occurs among the first symptoms
(North), but in the more regular cases it is not mani-
fested until the second or third day. Strong refers to
various degrees of mental disturbance, as mild, furious,
hysterical and reasoning delirium. Haskell, Spooner
and Holmes describe it as less frequent in males than
in females, and in them as often being hysterical, a
statement corroborated by later observations; and
Bestor, on the other hand, describes cases in adult
males “commencing with symptoms of violent in-
Sanity, and great muscular strength, the patient
showing alternately signs of real madness and high
merry delirium. I have known it require three or
four smart men to take care of one of those maniacs.”
Fish states it to be of this description when it ushers
in the disease, the patients sometimes being without
sleep for a week, but adds, that when it “began at a
later period, as it did in most cases, it was more mild,
sometimes of a playful kind, the patient being sociable
and humorous.” Precisely similar conditions are de-
scribed by Jackson and Warren, who also associate
the occurrence of active delirium with severe pain in
the head. Hale, indeed, regards pain.as a cause of
the delirium. Miner speaks of an extraordinary
clearness of intellect as usually followed by delirium
or coma, the former of which often resembled
intoxication, or again hysteria. In the epidemic
of 1823, this symptom was not very prominent.
The same is also true of the greater number of
SYMPTOMS.—DELIRIUM. 27
local outbreaks of the present epidemic. Thus during
the winter of 1863, it is stated that among the
cases that occurred at Sturgis, Michigan, “there
was not complete delirium in any case.” We may
add, that in the recent epidemic at the Philadelphia
Hospital, there were not more than two or three cases
of maniacal delirium. But, to return to the history
of this symptom. The epidemic of 1848, at Mont-
gomery, Alabama, presented remarkable contrasts.
Wild and furious as well as playful delirium, like
that above described by Bestor, was observed; but
the general tone of the mental aberration was de-
sponding and apprehensive. The recent epidemic in
Massachusetts exhibited equal varieties in the cha-
racters of the mental condition, but some degree of
delirium was present in all of the cases.
If we turn to European histories of epidemic men-
ingitis an equal and perfectly similar diversity appears.
“It was rarely that delirium was absent” says Tourdes
“during the whole of the attack. Most frequently it
was transient; it ceased and was renewed, and it
alternated with other symptoms, as pain and coma. . . .
Sometimes, excited and furious the patients struggled
with their attendants and endeavored to escape, some-
times vented themselves in complaints and groans, or .
incoherent words, and were restlessly active without
any object; others remained sombre and silent.”
Several times the delirium merged into persistent
monomania. In the epidemic of 1864, at Dantzic,
the proportion of cases of violent delirium appears to
have been unusually large. Gordon describes a case
in which the patient “woke suddenly in the middle
28 EPIDEMIC MENINGITIS.
of the night, delirious, began to hum tunes, to fancy
that different people were conversing with him, &c.”
CoMA has been incidentally referred to as following
delirium. It is met with sooner or later in nearly all
fatal cases, but rarely in a marked degree until the
approach of death. If anything is surprising in this
disease, it is the absence of that deep and prolonged
stupor which characterizes the typhoid state; although
in some cases such grave lesions affect the brain upon
both its upper and lower surfaces, and in others so
profound a disintegration and devitalization of the
blood has taken place that it exudes through the
tissues as water passes through a porous body.
These different varieties and degrees of delirium
are not absolutely peculiar to epidemic meningitis;
they occur in typhus and in typhoid fever, but in the
greater number of cases of those fevers the symptom
is more constant and uniform, and of much longer
duration, and is associated in general with a much
more obscure and obtuse condition of the mental
faculties. Another circumstance is in a great degree
peculiar to epidemic meningitis. We have repeatedly
observed it with surprise. It was noticed by Ames
and other American writers, but it is best described
by Tourdes, who says “it shows how profound the
mental disturbance must have been, even where it
was least exhibited. Most of the patients on recover-
ing had totally forgotten the commencement of their
illness. Many were astonished to find themselves in
the hospital,” &c. This complete loss of memory was
observed in cases which had not presented such symp-
SYMPTOMS.—FACIES. 29
toms at the commencement of the attack as would
explain its occurrence.
The FACIES, or expression of countenance in this
disease is also peculiar. When pain in the head is
severe and paroxysmal, the features are contracted
and distorted in every manner that is indicative of
severe suffering; when it is more persistent, the face
assumes a fixed and rigid expression, or is at the
same time dull, particularly after a long continuance
of the pain has produced exhaustion. In the apop-
lectic form, i. e. with sudden or a very rapid loss
of consciousness, the expression is said (Tourdes)
to be fixed and stupid, like that of a person dead
drunk; but such terms do not imply that the features
are turgid and purplish. In this disease we observe
neither the dark, dull, swollen and duskily flushed
face of typhus, nor the languid, sleepy expression
and circumscribed flush on the cheek which are so
characteristic of typhoid fever. Except during abso-
lute insensibility occurring in rapidly fatal cases—and
even then the face is more frequently sunken than
bloated,—there is a look of greater intelligence than
belongs to the diseases mentioned, more mobility of
the eyelids, more life in the eye, a less degree of de-
composition of the natural expression of the features.
Upon this very characteristic and distinctive facies
Hirsch remarks, that the pale and sunken counte-
nance at the beginning of the attack is altogether
remarkable. Forget asserts that paleness of the face
and skin generally was perhaps the most ordinary
condition. So says Corbin, who observed it in eighteen
out of twenty cases; and Mayne compares the ap-
30 EPIDEMIC MENINGITIS.
pearance in the worst cases to that of cholera. Hirsch,
also, adds, that the condition in question was observed
by him, not in the gravest cases only, but in a con-
siderable number of patients who were less danger-
ously ill.
Mºrrrn A nºr TN Arººrt ºw Sr*., cºrrºr •ry wºry Tſ--~~ ar, ºv, c. 4-l- ^ ºn tº re ... ſ” ll. * ~l-3-
V-/ U Ji ſã LV.I.MVU C X-). Cui Y NOll) Llull L = 11,y Mul OC, NY Ulil U S I C1, U L ULI U. S.I.A.LIL
is a symptom which, when it occurs, may be con-
sidered as characteristic of this disease, and as sharply
distinguishing it from the two fevers with which it
has been more or less confounded. Strong remarks,
that “the nerves, in some few cases, had such a
morbid degree of sensibility, as rendered the whole
surface of the body sore to the touch.” Tourdes re-
marked its presence even in those violent cases in
which consciousness appeared to be extinguished. In
many of such cases, however, it is quite possible that
movements developed by reflex irritation were mis-
taken for proofs of sensibility. He states that “cuta-
neous sensibility was the last of the sensorial functions
to be lost, and never until the immediate approach of
death.” In 1846, during the epidemic in Dublin,
McDowel described the patients as being sore all
over, and wincing upon the slightest touch, or refus-
ing to change their position in bed, from the pain
consequent upon the slightest movement. Burdon-
Sanderson found it a very prominent symptom of the
disease as it prevailed about the Lower Vistula; and
Niemeyer, who also describes it, states, as Strong
did long ago, that it is sometimes followed by cutane-
ous numbness or insensibility, which he ascribes to
pressure upon the posterior roots of the spinal nerves
by exudation matter. In many cases during the
SYMPTOMS.—SENSIBILITY. 31
recent epidemic we observed this symptom. It was
often strongly marked upon the anterior surface of
the trunk.
PAIN IN THE SPINE AND LIMBs is a symptom of the same
origin as the one just considered, and is even more
characteristic because more uniformly present. Among
American observers, it has from the beginning at-
tracted attention. North refers to violent pain in
the limbs mounting up to the head, and often followed
by numbness of the extremities. Fiske describes it
in a passage, which deserves to be quoted in full:
“Its bold and prominent features defy comparison. . . .
In some, a pain resembling the sensation felt from the
stinging of a bee, seizes the extremity of a finger or
toe; from thence it darts to the foot or hand, or some
other part of the limbs, sometimes in the joints, and
sometimes in the muscles, carrying a numbness or
prickling sensation in its progress. After traversing
the extremities, generally on one side only, it seizes
the head, and flies with the rapidity and sensation of
electricity over the whole body, occasioning blindness,
faintings, sickness at the stomach, with indescribable
distress about the praecordia; a numbness or partial
loss of motion in one or both limbs on one side, with
great prostration of strength. The horrible sensation
of this process no language can describe.” In equally
precise terms it is mentioned by Fiske, Jackson, Gal-
lup, Hale, of the earliest, by Ames and others of the
middle period, and by Lidell, Armstrong, Borland,
Baldwin, Parks and others of the most recent epoch
of the prevalence of the disease in America. Quite
as prominently it appeared in all of the European
32 EPIDEMIC MENINGITIS.
*.
epidemics and sporadic groups of meningitis. Thus
Curry described it in the cases he observed in 1806,
in England; Gaskoin, in the Portuguese epidemic of
1861–62; Tourdes, in France, in 1841; and all the
historians of the recent outbreak in Germany. The
pain most frequently begins, and generally is most
severe in the neck, but sometimes extends to the whole
length of the spine. It may last throughout the dis.
ease, or be limited to its early stage, or again it may
persist even after convalescence. Our own observa-
tion has furnished many cases of extreme suffering
from the symptom here described, but none in which
it was not relieved by appropriate treatment. Tourdes
speaks of the spinal pains, associated as they are in
this disease, as the true pathognomonic sign of cerebro-
spinal meningitis. They usually occur in connection
with neuralgic pains in the extremities; but either may
be present without the other, and, of the two, the
pain in the spine is the more frequent. It may not
be superfluous to mention that whatever the seat of
the spinal pain, it is generally aggravated by pressure.
TETANOID PHENOMENA.—These are still more charac-
teristic of epidemic meningitis than the symptom just
described, although both originate in the same spinal
lesions, congestion of the membranes of the cord,
or its compression by an effusion either of serum
or of lymph, or by changes in its proper tissue.
These lesions will be described hereafter; we recall
them at present to keep in mind that only true
idea of the disease which embraces the reciprocal
relations of its symptoms and their material causes.
Tetanoid symptoms are by no means necessary to
SYMPTOMS.—TETANOID PHENOMENA. 33
constitute a characteristic picture of the disease.
Their presence unequivocally denotes the existence of
spinal lesions; but the converse of this proposition is
far from being true. There may be almost any grade
of meningeal spinal inflammation without muscular
rigidity. In this, as in other cases, the degree of
irritability of the affected part is just as important an
element in developing functional phenomena, i.e. cha-
racteristic symptoms, as are the material tissue changes
of the part itself. Both factors must coöperate to
produce the result. Hence it is that in some epidemics
the symptom is present in a small proportion only of
the cases, even of those patients in whom character-
istic lesions of the cerebro-spinal axis are found after
death. This fact was repeatedly observed in the re-
cent epidemic at the Philadelphia Hospital. A want
of absolute uniformity in the occurrence of this symp-
tom has led to various extravagant notions which
have prevailed in regard to the nature of the disease,
and to doubts, entertained even by some enlightened
judges, of the true character of certain epidemics of
meningitis, especially in its early history in this
country. A more thorough study of them, however,
and particularly a comparison of cases occurring in
different localities, and in successive years, removes
all doubt upon the subject, and proves the unity of
the affection beneath its diversified phenomena.
Thus, in one of the earliest histories of the Ameri-
can epidemics, that of North, we find among “the
more unusual symptoms,” “a drawing back of the
head, with a kind of clonic spasm of the muscles of
the neck” and a “corpse-like rigidity of the limbs.”
3'ſ EPIDEMIC MENINGITIS.
But for this brief statement we might almost feel un-
certain whether the disease described by himself and
several of his cotemporaries was really epidemic men-
ingitis. Fortunately, other testimony which is equally
emphatic, remains. Thus, Lyman says, there is “pain
and rigidity of the muscles of the neck, often, and the
head is in many instances inclined backward;” Wood-
ward describes the “head drawn back with spasm;”
Jackson says the “head is sometimes drawn back
as in opisthotonos,” and Gallup states that “the form
of tetanus, called opisthotonos, comes on sometimes
towards the close of severe cases.” To this point the
testimony of Strong is very pertinent: “During the
first two years,” he remarks, “the extensor muscles
of the head and neck, were, in almost every case,
affected with true spasm. . . . This symptom, how-
ever, disappeared with the petechial spots, and during
the last two years was rarely observed.” In an epi-
demic which prevailed in the Valley of Virginia, in
1812–13, Dunbar described “the head as drawn back,
and the spine curved rather more than even in the
worst cases of tetanus,” at the same time that “pe-
techiae and vibices appeared generally over the body.”
Hazeltine, also, in his account of the epidemic which
he witnessed in York, Massachusetts, between 1810
and 1815, says, “there were, in some cases, great
rigidity, immobility and soreness of the limbs and
surface; spastic rigidity of the muscles of the lower
jaw and the posterior muscles of the neck.” In all of
the fatal cases petechiae and vibices were observed.
It is evident, therefore, although certain historians of
the first epidemic in this country omit all mention of
SYMIPTOMS.—TETANOID PHENOMENA. 35
this symptom, that others observed and recorded it,
which positive testimony outweighs a whole volume
of negative evidence, and establishes the nosological
character of the epidemic in question. As we shall
see hereafter the anatomical proofs are similar, and
equally strong.
When the epidemic began in the Southwestern
States of the Union, it was, as elsewhere, a strange
visitor, and gave rise to the usual confusion between
it and the ordinary local diseases. In New England
it was confounded with “typhus,” in the South with
malarial affections. When Boling first described its
appearance at Montgomery, Alabama, he committed
this error, but he did not fail to mention the charac-
teristic phenomena of the disease, so that its nature
cannot be doubted. Very possibly, however, its type
was modified by malarial agencies. However this
may be, he says, “after a few exacerbations of fever,
suddenly and unexpectedly, at the period of an ap-
proaching paroxysm spasms resembling those of
tetanus supervene. . . . The muscles of the abdomen,
of the neck and jaws, and of the superior extremities,
after the commencement of the spasms, remain gene-
rally in a firm and rigidly contracted state. Those
of the neck were in two instances affected, as the
spine was bent and the head drawn permanently back
as in opisthotonos.” So, in 1847, Drs. Hicks and
Taylor, of Whitesville, Tennessee, describe as some-
times an initial and sometimes an advanced symptom,
“rigidity of the posterior cervical muscles, retracting
the head considerably backward, as in tetanus;” so
Dr. Chester, of Union county, Arkansas, mentions
36 EPIDEMIC MENINGITIS.
opisthotonos in all of the four cases reported by him
in 1847; so Dr. Love, describing several forms of the
disease, as it occurred in a regiment of Mississippi
volunteers, at Wicksburg, in 1847, refers to one in
which furious delirium ushered in the attack, and
adds, “these cases were always attended with opis-
thotonos of the muscles of the neck;” and, finally, as
regards the same epidemic, Dr. Ames, in his well known
and model essay on the subject, dwells upon the
tetanic symptoms exhibited, the continued opistho-
tonos, or the retraction of the head, merely, which took
place in a very large proportion of the cases, while
many other patients were affected with stiffness and
soreness of the back. In a few cases the affection
was confined to the sterno-mastoid muscles of one or
both sides; and in others the head was held stiffly and
not inclined forwards or backwards.
During the next epidemic this symptom was equally
characteristic wherever the disease was carefully ob-
served. In 1857, says Dr. Kendall, of Onondaga
county, New York, “others lie in a torpid state, the
head drawn back upon the nuchae.” In the same
year we find that, in Chemung county, New York,
the disease prevailed, and out of the forty-three cases
of it reported by Dr. Squire, only three presented
tetanic phenomena. Two of these, which proved
fatal, were examined after death, and a purulent exu-
dation was found in the one, and congestion only in the
other, although muscular rigidity during life had been
equally manifested in both. During the same period,
in Madison county, New York, Dr. Saunders observed
among the usual symptoms “contraction of the muscles
SYMPTOMS.—TETANOID PHENOMENA. 37
of the back and back of the neck, not unfrequently
producing complete opisthotonos.”
The last epidemic furnishes evidence of precisely
the same kind. Dr. Upham says, “the decubitus
was mainly on the right side, with the head not un-
frequently thrown back—the neck rigid and stiff—a
partial opisthotonos.” Dr. A. P. Woodward illustrates
a proposition already laid down by us, in a case in
which there was no opisthotonos, although the exu-
dation upon the brain and spinal marrow was singu-
larly profuse. Not to multiply citations, we may
add that the symptom is prominently described by Drs.
Frothingham, A.T.Watson, W. H. Draper, E.W.Jenks,
and J. K. Reid, who found it in every one of ten cases;
F. B. Poley, J. L. Oliver, W. Anderson, and C. G.
Page, in eight out of seventeen cases; M. Kempf, J.
H. Hutchinson, and W. G. Armstrong, of Mobile, who
speaks of tetanic rigidity of the cervical muscles with
pain in the head and neck as the most prominent and
almost universal symptom; W. O. Baldwin, of Mont-
gomery, Alabama, J. W. Moorman, of Kentucky, and
Dr. O. B. Fassett, of Vermont, who made the same
observation in the epidemic of 1864; and, finally, Dr.
Parks, analyzing the results of observation in Massa-
chusetts, finds that out of 261 cases severe opistho-
tonos existed in 107, slight in 80, and in “nearly all”
of 26 cases; so that the symptom was absent in only
48, or in less than one-fifth of the whole number.
European epidemics of meningitis have exhibited,
even still more uniformly than our own, the distinctive
phenomena of spinal irritation. It was observed, but
only in a few cases and not in an aggravated form,
38 EPIDEMIC MENINGITIS.
during the Geneva epidemic of 1805, and still more
slightly in the local outbreak of the disease at Ash-
burton, England, in 1807. At Naples, in 1833, De
Renzi found it “frequently.” In his account of the
epidemic of 1842, at Strasburg, Tourdes says, “the
decubitus of the sick was distinguished by a backward
flexion of the head and spine; most frequently the
neck alone was affected, but sometimes the whole
trunk was arched.” “This symptom was exhibited
only after the disease had reached a certain degree of
development, and remained until death in fatal cases,
and in others so long as the general symptoms con-
tinued grave. From time to time it underwent remis-
sion or exacerbation, or alternated with convulsive
movements, after which the trunk resumed its arched
position. . . . Muscular contraction with rigidity was
sometimes partial and local, and sometimes general.
In some cases it affected the flexors of the upper ex-
tremities. Trismus was also observed, but only in
fatal cases.” The manifestation of this symptom is
well described by Gillkrest in his history of the Gib-
raltar epidemic of 1844. In Leipsic, in 1851, Wun-
derlich found opisthotonos in all of his cases. Nie-
meyer, in 1865, stated that during the epidemic in
Baden, “this symptom was wanting in extremely few
cases.” In some that terminated fatally it ceased a
short time before death, but much more generally it
persisted as long as life lasted. In one case it con-
tinued for more than two months, and in another until
death on the forty-ninth day. The testimony of
Hirsch is to the same effect. During the epidemic
about the Lower Vistula, Dr. Burdon-Sanderson ob-
SYMPTOMS.—CLONIC SPASMS. 39
served this symptom in a modified form. The head
was thrown back as if to alleviate the muscular spinal
pains, and it was only when attempts were made to
draw the head forward that the muscles became rigid,
and even then less firmly than in tetanus. Among
the sporadic cases occurring in London, in 1865, this
symptom was observed by Drs. Ogle, Martin, Simon,
and others. In the recent Irish epidemic a case oc-
curred to Gordon, of which he says: “The patient lay
on her abdomen, and refused to allow herself to be
moved on her back or on either side. Her spine pre-
sented a most wonderful uniform curve concave back-
wards; her head was also curved backwards on the
spine of the neck.”
TREMORS AND TWITCHING OF TENDONS, so common in
typhus, are much less frequent in this affection; in-
deed many cases do not present them at all.
CLONIC SPASMs, or convulsions, although less common
than rigidity of the muscles, have also been frequently
observed. They were seen especially in children, by
Vieusseux, described by Mathey, Danielson and
Mann, Fitch, North, Miner, and many others. Forget
pictures the violent agitation of some patients pro-
duced apparently by extreme pain, and also speaks
of the “wretched spectacle presented by young men,
who but a short time before were full of health and
strength, struggling desperately in frightful convul-
sions which were the mournful harbingers of inevitable
death.” This statement does not imply that convul-
sions, even when general, are necessarily fatal, for they
often occur at the commencement of the attack in
patients who recover. They vary in degree from
40 PIDEMIC MENINGITIS.
subsultus affecting particular muscles, as of the eyes,
the face, a limb, &c. to general and epileptiform con-
vulsions with loss of consciousness, and may be asso-
ciated with paralysis of other parts; as where the two
halves of the body are affected with the opposite con-
ditions.
PARALYSIs, or loss of muscular power in different
degrees, has also been repeatedly met with, but less
so than abnormal muscular contraction. North ob-
served paralysis of the arm or leg, or of both at once,
the latter occurring among the initial symptoms of
the attack: to this statement Jackson adds paralysis
of the muscles of deglutition. At Gibraltar, Gillkrest
met with two cases of temporary hemiplegia. In
1865, a man was ill of the disease, in Dublin, of whom
Dr. Law says: “all his members seemed to be para-
lyzed; he could move neither arms nor legs.” A re-
markable case is recorded by Wunderlich, of a man
who, on the second day of the disease, lost both sen-
sibility and motility in the lower limbs and over the
greater part of the trunk, while the left arm was also
partially paralyzed. Yet he did not die, and five
months afterwards had partially regained his muscular
power. The persistence of the paralysis in this case
is very remarkable. More frequently, if the patient
survives, the loss of muscular power or of sensibility
is temporary, continuing only for a few days or weeks,
and indicating therefore with probability that the
paralysis resulted from pressure on the nerve roots or
centres and not from interstitial lesions. Perhaps it
will be thought not improbable that the sudden or
rapid and extreme prostration which occurs in many
SYMPTOMS.—THE SENSES. 41
cases of epidemic meningitis, and sometimes in all
that arise in a particular locality, may be due to the
congestion or the serous effusion which precedes or
takes the place of fibrinous exudation. That it is not
due to the blood, or at least not to the condition of it
which exists in typhus, is shown by the abscence of
the peculiar stupor which belongs to that disease.
The prostration referred to acquired for this affec-
tion the name of “sinking typhus,” and is well de-
scribed by Miner, who particularly attributes it to a
want of nervous power transmitted through the par
vagum. Our present knowledge of the nature of the
anatomical lesions in the disease would seem to justify
an explanation of these symptoms by the pressure
which the congestion, effusion or exudation exerts
upon the origin of the pneumo-gastric nerve which
associates the actions of the lungs, the heart and the
stomach.
SYMPTOMS FURNISHED BY THE ORGANS OF THE
SENSES.
THE EYES.—Abnormal conditions of these organs
and of their functions are among the most striking,
and, when they exist, distinctive phenomena of epi-
demic meningitis, and add one more to the many
striking contrasts of the disease with typhus and
typhoid fevers. In the former of those affections a
dark or dusky, almost purplish, color of the eye, with
a watery condition of the conjunctiva, is a common
and characteristic phenomenon. But it is totally un-
like the appearance of the eye in epidemic meningitis.
4
42 EPIDEMIC MENINGITIS.
In typhoid fever the eye is occasionally red, and of a
lighter tint than in typhus; but this symptom is not
uniform, is not even common, and the redness, when
it does occur, is rather striated, while in the disease
before us it is generally diffused and uniform. It
has been observed in all epidemics of meningitis; in
some of them characterizing every case, in others
occurring more or less frequently. In the recent epi-
demic which we witnessed it was scarcely ever absent.
Strong speaks of it as “a peculiar redness of the albu-
ginea.” North describes it as “redness or suffusion;”
Ames says, very clearly, “in a few cases, principally
among children, the conjunctiva has a pinkish tint,
when there were no distinct vessels to be seen;” in
one of Curry's cases “the tunica albuginea was com-
pletely suffused with blood.” In the epidemic de-
scribed by Tourdes, on the other hand, it was seldom
observed, except as a symptom of conjunctivitis with
mucous or muco-purulent secretion, and a similar ob-
servation has been made by other historians of the
disease, too numerous to mention. While writing
these pages, (June, 1867,) we visited a young lady of
twenty-four, who presented the peculiar redness of
the eye of which we have spoken. Two evenings
previously she went to bed perfectly well, and was
awaked about midnight by a violent frontal headache
accompanied with bilious vomiting and severe pain in
the back, but only in the loins. There was said to
have been at the same time chilliness and fever. On
our visit the skin was cool, the pulse feeble, and about
60; the mind clear. On inquiry, assurance was given
that the skin presented no discoloration; but struck
SYMPTOMS.—THE SENSES. 43
by the sudden onset of the illness and the peculiar
appearance of the eyes, we urged an examination of
the body, when the chest and upper portion of the
abdomen were found covered with light red or pinkish
spots of irregular form and unequal size, disappearing
upon pressure. Within five days from the commence-
ment of the attack, the eruption, the injection of the
eyes, and the headache had vanished, and the pulse,
which had risen to 70, was of good volume and
strength. Among recent authors, Gordon states
that the conjunctivitis is sometimes severe, with a
profuse purulent discharge. But much more alarm-
ing and serious affections of the eyes are frequently
observed, some of which are transient and others per-
manent.
DOUBLE AND EVEN TRIPLE VISION was noticed by
North, and has been observed by many others since
his time, its cause being, doubtless, the strabismus
which is also a frequent incident of the disease.
Jenks mentions a case in which it continued after
recovery from the other symptoms; Armstrong
met with it in several cases, affecting one or both
eyes; Gillkrest found it not unfrequent; Banks met
with divergent strabismus, as did others, including
Burdon-Sanderson, who observed twelve cases of
squinting. In seven the affection was transitory, not
lasting more than a few days; in three cases it lasted
from one to five weeks or more. In the epidemic
studied by Tourdes, on the other hand, this symptom
was quite uncommon. -
BLINDNESS has also been repeatedly observed. Fis
states that in a few instances it was the first deviation
44 EPIDEMIC MENINGITIS.
from health, and was generally followed by raving
delirium. It was sometimes attended with general
“numbness” or partial anaesthesia, and when this
condition was extreme, blindness, with dilated pupils,
Quickly succeeded. In some cases sight was restored
in a few hours, in others after a few days; but in no
case was it permanently lost. This very brief dura-
tion of blindness is also noted by Ames. Jenks,
however, refers to an example of the permanent loss,
by amaurosis, of one eye. Lente reports a case in
which several months after the attack, the conjunc-
tiva was much injected, the globe shrunken and soft,
the cornea hazy, and the lens cataractous. Similar
cases, but of a more rapid course with entire destruc-
tion of the eye are referred to by Love. In Europe
analogous statements are made by Gillkrest, Ziemssen,
Corbin, Wilson, and others.
INFLAMMATION OF THE IRIS OR OF THE Conjunctiva
... was frequently observed by Love, Upham, Jenks,
and others, in the United States, and by Tourdes,
Lionnet, Niemeyer, Wilson, and many more, in Eu-
rope. Niemeyer regards all these various affections
of the eyes as consequences of inflammation of the
neurileme of the trunks of the nerves which supply
the eyes. He calls attention particularly to the
analogy between the various destructive lesions in-
volving the eye in this disease,_the purulent ophthal-
mia, the softening of the cornea, and hypopion,-and
the changes produced in the organ by the destruction
of the Gasserian ganglion. It seems probable that in
some cases superficial ulceration of the cornea may be
owing to its exposure to the air in consequence of
SYMPTOMS.—THE SENSES. 45
paralysis of the orbicularis muscle. Burdon-Sander-
son gives as the results of ophthalmoscopic examina-
tion in some cases of consecutive blindness, opacity of
the vitreous humor, synechia posterior, &c.
The PUPIL has always been observed to vary in
shape and size in this disease. North and Strong
mention its alternate contraction and dilatation, and
Danielson and Mann say “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.” To this Fish adds, “in some
cases this alternate contraction and dilatation con-
tinued for an hour or two, when it disappeared; being
succeeded by a more matural state of the eye, or per-
manent dilatation with coma.” Ames says, “the
pupils were dilated in seven out of forty-one cases; in
the rest they were either contracted or natural;” while
Armstrong found them dilated in a majority of cases,
and sometimes one pupil was contracted and the oppo-
site one dilated. In Europe Tourdes observed dilata-
tion most commonly; Gillkrest, oscillation; according
to Burdon-Sanderson contraction of the pupil was
most common at the commencement of the attack,
even when the patient was more or less stupid, but
dilatation took place when he was roused in any way.
Such alternations of size, however, were observed in-
dependently of all apparent cause. In cases of long
duration with great exhaustion “the pupils were
almost invariably dilated.” Photophobia is not un-
common, (Ames refers to six cases of it); and
occasionally spasmodic movements of the ball have
been witnessed.
46 EPIDEMIC MENINGITIS.
HEARING.—Fish observed that hearing and smelling
were natural; but some patients lost their hearing,
when recovering, “without any perceptible injury
about the ear.” Strong refers to three such cases.
Jackson and Warren state that “in a small number
of cases the disease has been followed by deafness,
from which the patients have not speedily recovered;”
in a few instances “purulent discharges from the ears
have been noticed.” Ames noticed “spontaneous
deafness in a few patients,” and other cases in which
there were temporary exacerbations of deafness.
Sometimes, also, purulent discharges from the nose
took place; and in one case the sense of smell in one
nostril was lost. The loss of hearing is stated by
Draper to have been observed at Carbondale.
Wunderlich noted it at Leipsic, and Burdon-San-
derson about the Lower Vistula. The last mentioned
reporter met with it in ten cases, of which three
were patients under ten years of age, the rest
between ten and seventeen. In six of them the affec-
tion appeared during the first few days, and in three
during the second week. In one case it was not
observed until the fourth week. This symptom
appears to depend chiefly upon the pressure of the
plastic exudation in which the auditory nerves are
imbedded. -
Finally, as regards the PHYSIOGNOMY, it may be
stated that its expression is, from time to time, as
different as the conditions which have now been de-
scribed. Although it may vary as much as the look
of maniacal fury does from that of profound stupor,
yet it must be said that its average condition does
SYMPTOMS.—THE DIGESTIVE ORGANS. 47
mot indicate either excitement or coma, or even a
great degree of dullness. The patient moves his eyes
more briskly than in the two forms of fever several
times referred to, and winks their lids in a manner
Quite unknown in those affections.
SYMPTOMS PRESENTED BY THE DIGESTIVE ORGANS.
The TONGUE presents no characteristic appearances.
Miner said long ago: “on the whole, the state of the
tongue was of very little service in diagnosis or prog-
nosis.” He and other writers describe nearly every
possible aspect of this organ as regards moisture, dry-
ness, and the color and consistence of its coating. But
all agree that it rarely grows very black and dry, and
that this condition, when it does occur, is not of long
continuance. North speaks of “a bloodless appear-
ance” of the tongue as “a certain token of approach-
ing death,” and Fish expresses a similar opinion. Our
own observation in the recent epidemic showed that
the tongue was generally moist, whitish in the centre
and at the tip and edges. In a comparatively small
number of cases it was dry, and more or less brown.
The fuliginous condition of the tongue, gums, cheeks
and lips, so common in typhus and typhoid fevers
was not observed in any case.
NAUSEA AND WOMITING are very constantly present
among the initial symptoms. In yellow fever, peri-
odical fevers, and typhoid fever, they occur as the
direct effects of gastric irritation; in typhus they are
rarely met with, and then as a remote consequence of
cerebral disturbance. In the present affection they
48 EPIDEMIC MENINGITIS.
are evidently of a similar origin. But as the cerebral
lesions here are more considerable and constant, the
Symptom, as might be expected, is more uniform and
severe. Wherever the disease has prevailed it has
attracted attention. North describes “sickness at
stomach and vomiting;” Danielson and Mann “nausea
and puking, the matter discharged from the stomach
having no unusual or morbid appearance;” Fitch,
Woodward and Haskell describe the symptom in
analogous terms. The terms employed by Fish in
regard to it are similar to those previously used by
Strong, and are worthy to be recalled as indicating
its cerebral origin: “the affection of the stomach is
not easily described. . . . Some called it a faintness;
some a coldness, others a deadly feeling. . . . Nausea
and vomiting were general, and in most cases vio-
lent. . . . In a few instances vomiting was the first
symptom that indicated disease.” It is emphatically
referred to by Jackson, and both he and Fish state
that bile was rarely vomited during the first few
weeks of the epidemic. But at all periods there were
some patients who threw up a dark green or bluish
liquid. Gallup alludes to cases in which the vomiting
was incessant and very copious; and he as well as
others speak of the regurgitation rather than the
vomiting, of large quantities of liquid. In a few cases
the ejecta “resembled black vomit.” Perhaps these
were the same as the bluish matters referred to above.
In other cases the liquid was rather white and viscid,
resembling mucus. Hale furnishes a similar statement,
and also says that “nausea and vomiting were nearly
universal at the commencement of the fever, in every
Q
SYMPTOMS.—THE DIGESTIVE ORGANS. 49
stage of progress of the epidemic.” “It often lasted
six or eight hours, and sometimes for two or three
days.” “It was often excited by the patient's sud-
denly raising himself up,” thus denoting its cerebral
origin. Miner, indeed, says “vomiting or nausea, in
this disease, seemed ordinarily to be entirely symp-
tomatic of an affection of the brain.” In the epidemic
of Montgomery, Alabama, (1848,) this symptom was
frequent, but less constant; Kendall, of Onondaga,
New York, (1857,) speaks of it as constant and dis-
tressing; and in 1863, it was an initial symptom du-
ring the epidemic at Newbern, North Carolina. It
was equally constant and characteristic in European
epidemics from that of Geneva to the present time.
Tourdes states that nausea and vomiting almost
always attended the onset and the first stage of the
disease; describes the vomited matters as a greenish
bilious liquid; and adds, as we have said had been
done by others, that the vomiting cannot be regarded
as primarily gastric, that “it is without doubt a sym-
pathetic phenomenon occasioned by the cerebro-spinal
affection.” “Womiting of food, with bilious matters,
often green,” was observed by Gaskoin, in Portugal,
and by Burdon-Sanderson at Dantzic. Niemeyer
gives similar testimony, and dwells on the sympa-
thetic character of the symptom, but thinks it less
urgent,and persistent than in tuberculous meningitis.
Hirsch states that in eight of thirty-nine cases there
was no vomiting, and in four only retching, yet speaks
of it as one of the first and most constant symptoms;
notices the important fact that it often occurs without
any previous nausea, and, like others, maintains that
50 EPIDEMIC MENINGITIS.
“its sympathetic character does not admit of any
doubt.”
In some epidemics, or in isolated cases, diarrhoea has
accompanied the vomiting, and many writers describe
the conjoined symptoms as a cholera morbus; but the
painful spasmodic character of that affection is wanting.
Tourdes found this symptom in a large proportion of
cases which survived the sixth or seventh day. But
when it is known that the treatment he employed con-
sisted, interalia, of purgative enemata, calomel, jalapand
Croton oil, the peculiar occurrence is no longer surprising.
If any symptom, without being characteristic, is yet
almost uniformly present, in this disease, it is consti-
pation. In this respect it resembles other forms of
meningitis. “The intestines were not disordered,
except from torpor,” says Fish; “the bowels are com-
monly “quiet” says Jackson; “the intestines,” writes
Gallup, “are as little affected in this disease as the
head is in dysentery.” The bowels are mentioned by
Hale among the organs “that continued to perform
their functions with nearly the same regularity as in
health.” . . . “There was much more often a tendency
to costiveness than to diarrhoea.” “The bowels were
either natural or constipated” says Ames; and Hirsch
found them to be so in all of sixty cases observed by
himself.
The appetite is naturally, and, as it were necessa-
rily, impaired or quite lost during the painful stage
of the disease, but once this period has passed a desire
for food is generally exhibited. Fish thus alludes to
the symptom in question: “The appetite is diminished,
but it is not always so entirely destroyed as in most
SYMPTOMS.—THE DIGESTIVE ORGANS. 51
other acute diseases. Children particularly some-
times express a strong desire for food.” A similar
statement is made by Jackson, and by Hale, who also
says, “some patients would take food in considerable
quantity, with almost as much relish as in health.”
“No sooner is the violence of the disease abated”
says Strong, “than the appetite generally returns,
and the stomach craves, receives, and digests animal
food with great freedom and without any ill effect.”
Tourdes states that “a premature desire for food was
generally remarked; the patients, even while in im-
minent danger, clamored for food and endeavored to
procure it. Digestion was easy, but the restoration
of flesh and strength was by no means proportioned
to the reëstablishment of this function.” It need
scarcely be remarked that these conditions of the ap-
petite contrast very strongly with such as are common
in typhus and typhoid fevers.
It is very noticeable that, as Jackson remarks,
“there is seldom any remarkable thirst; in a few cases
it has not been at all greater than natural.” An ap-
parent contradiction to this statement is given by
Hale, when he says “the thirst was extremely
urgent.” But he immediately adds that it was
“peculiar in its nature.” It was not a desire for
“cool and acid drinks,” which, “except in a few
instances were disagreeable, and those which were
warm and aromatic were demanded in their stead. . . .
Their aromatic quality seemed to operate like a cor-
dial, to remove the sensation of depression, which
was constantly felt at the stomach.” Tourdes states
that “thirst was slight and appeared late; in only
52 EPIDEMIC MENINGITIS.
two cases did it exist at the commencement of
the attack.” And such is the general testimony upon
this point. But it is not without exceptions. In the
recent epidemic in the Philadelphia Hospital, the
patients were clamorous for fluids. -
In certain of the early American, and in some other
epidemics, sore throat is mentioned among the symp-
toms. North found it an almost constant premonitory
indication; Fish states that “some patients complained
of a sore throat, which, on examination, presented the
same appearance as in cynanche maligna, except the
swelling of the tonsils.” Jackson, referring to such
cases, remarks that “the fauces are found very red,
but not swollen in any part.” Hale adds that some-
times there was “a swelling and inflammation of the
gums and fauces, which was accompanied with partial
salivation.” Among European observers, Levy is the
only one, as far as we know, who mentions any simi-
lar condition. He speaks of a thin pearl-colored, or
whitish band upon the gums, which, in one case, in-
vaded the fauces. ©
APHTHE have occasionally been met with; and
both American and European reporters mention the
occurrence now and then of swelling of the parotid
glands. Jackson refers to it as “slight.” Jenks saw
“swelling of the cervical and submaxillary glands in
one fatal case.” For ourselves, we met with two or
three cases of suppurating parotids in the late epi-
demic. Tourdes observed parotitis in two fatal cases;
and Hirsch ranks this affection among the rarer acci-
dents of the disease.
SYMPTOMS.—THE URINARY ORGANS, JOINTS, ETC. 53
THE URINARY ORGANS, JOINTS, AND RESPIRATORY
APPARATUS.
The urinary organs have not exhibited any charac-
teristic or uniform phenomena in this disease. Some-
times the flow of urine has been diminished, sometimes
profuse. From the beginning of its history cases of
retention, and sometimes of incontinence of urine have
occurred, and others of dysury. Some of these have
evidently been due to an impaired muscular power
in the bladder, others to a blunted perception in
the nervous centres, and others probably to the in-
fluence of cantharides absorbed from blistering plas-
ters. The urine has been found, in some cases, to
contain albumen, in others cylindrical casts, or blood
corpuscles. These deposits have sometimes occurred
when blisters had not been applied. Hirsch, Greene,
Morland and others report cases in which albumen
existed, or there was a phosphatic deposit, while the
chlorides were diminished. In one case the urine
contained albumen, granular casts, and pus cells, but
no urea could be detected in it.
The condition of the joints illustrates the predomi-
nance of the blood element in some cases. In the
Report of Jackson and others, it is said, “In some
cases swellings have occurred on the joints and limbs.
These have been very sore to the touch, and their
appearance has been compared to that of gout. The
parts so affected feel as if they had been bruised.
These swellings arise on the smaller as well as on
the larger joints, and are often of a purple color.”
Gallup says “the joints are sometimes affected with
54 EPIDEMIC MENINGITIS.
Swelling and extreme soreness, resembling rheumatism,
but not attended with so much swelling.” Upham
mentions “synovitis” as an occasional incident of the
disease; and Niemeyer remarks that “inflammatory
effusions in the joints which were frequently observed
in France, were not entirely wanting in the epidemic
of Rastatt.” In one case various joints of the upper
and lower extremities were moderately swollen and
exceedingly painful when handled. Effusion, without
rédness, affecting the knee joint was observed by
Gordon.
RESPIRATION.—Jackson reports that it was much
and variously affected; but, in general, difficult.
Tourdes states that it was sighing, labored, and in-
terrupted. Burdon-Sanderson says “its embarrass-
ment was marked by a slow labored inspiration, fol-
lowed by a quick inspiration and a long pause.” In
fatal cases the approach of death was often denoted
by gurgling rhonchi, due to a serous effusion in the
air-tubes. Pneumonia is not a very unusual accom-
paniment, of which we have seen several examples.
The suspirious and interrupted respiration just re-
ferred to is of the same character, but not so marked,
as in tubercular meningitis. It is most distinct in
cases which present tetanic symptoms, paralysis, and
other evidences of central cerebral compression.
SYMPTOMS FURNISHED BY THE PULSE.
In the last named author's history of epidemic
meningitis, it is said to be quite impossible to
establish a rule for the variations of the pulse in fre-
SYMPTOMS.—THE PULSE. 55
quency, and that it can only be stated, in general, to
be small, thready, weak, and intermittent in cases
tending to a fatal issue, and especially in those which
rapidly run to such a termination. Only in rare and
altogether exceptional cases is it full and tense.
Moreover, its rate and other qualities are subject to
repeated and often inexplicable variations. These
general statements are borne out by the authors to
whom we shall now refer.
North declares that “increased frequency of the
pulse” is not “a prominent symptom of this disorder.”
Fish says “the pulse was always extremely weak,
feeble, and depressed: in most cases more frequent
than in health; in others it was imperceptible on the
attack, and until it was restored by stimulants. There
was not, before or after the chill, any increase of
arterial action; on the contrary, where the disease
was left to its own course, the pulse grew more feeble
until death took place. In some instances, though
rarely, in fullness and frequency it did not vary from
a healthy state.” Jackson, besides the characters
just described, remarks that the pulsations “are re-
markably variable, so that in the course of an hour,
and indeed in much less time, they change from quick
to slow, and from strong to feeble, and vice versa.”
Gallup confirms these statements, adding, that “in
fatal cases the pulse increases in frequency until
nothing but a faint, tremulous, retiring motion is
felt.” A.remark of this author is confirmed by Hale,
viz., that in a certain number of cases the pulse is at
first full and hard. Miner reports that, during the
epidemic he described, “every variety of pulse oc-
56 EPIDEMIC MENINGITIS.
curred, except the strong and hard, and this often in
the same patient.” In many mild cases, and in most
of the others, until the period of fatal sinking, it was
rarely so frequent as in health. It also, sometimes,
from being preternaturally slow became very rapid,
rising from forty, or even twenty-seven, in a minute,
to a hundred and thirty. Nor was this sudden change
always a fatal sign. Muscular exertion, rising from
the recumbent posture, &c. sometimes doubled its
frequency, besides producing considerable irregularity.
Some fatal cases were attended with distressing pal-
pitation of the heart. Not to prolong these citations,
however important they may be for exhibiting the
peculiarities of the disease, we will simply add that
substantially the same account of the pulse is given
by Kendall, Jenks, Armstrong, Morland, Githens,
and other American observers, and by Mathey,
Tourdes, Gillkrest, Lionnet, McDowell, Gaskoin,
Law, Gordon, Wunderlich, Niemeyer, and Burdon-
Sanderson, among European writers. Diminished
force, and volume, and a tone so much impaired that
slight causes produce extreme variations in its rate
and rhythm, are, therefore, the characteristic qualities
of the pulse in this disease, and those by which it is
distinguished from the fevers to which it bears a
superficial resemblance.
SYMPTOMS FURNISHED BY THE SEIN.
The condition of the skin as regards dryness and
moisture is various. Jackson states that, “in the
early stages the skin is perhaps invariably dry; at a
SYMPTOMS.—SKIN, TEMPERATURE. 57
later period spontaneous sweats have broken out on
the head, chest, and superior extremities.” On the
other hand, Fish declares that “it was very difficult
to excite a sweat or preserve a moist skin after it had
been procured.” Hale says that the skin “was moist
and rather inclined to profuse sweats.” He however
seems to refer to the effect of diaphoretic measures
rather than to spontaneous perspiration, for he adds,
“after a diaphoresis was once produced, if the measures
which caused it were pursued with the same vigor, it
ran into a profuse sweat.” Any one who is acquainted
with the violent measures then employed for the pur-
pose, will feel no surprise at the result. Yet Miner,
who condemned such treatment, points out the fact
that although the skin “was seldom much inclined to
spontaneous moisture, there was in a few instances a
morbid drenching perspiration.” Precisely similar
observations were made during European epidemics,
as Hirsch relates. l
TEMPERATURE.-Conditions of the pulse such as
have been described would hardly be compatible with
an uniformly high temperature of the skin, and, in-
deed, the variations are equally striking in both. As
the pulse never acquires the force and sustained fre-
quency which belongs to it in pure inflammations or in
idiopathic fevers, so the heat of skin is always less
than in those affections, and is constantly undergoing
vicissitudes such as are observed in no other disease.
The early remarks of North upon this subject have
been too little heeded. Speaking of frequency of
pulse and heat of skin as involved in the definition
of fever, he adds, “neither of these are prominent
5 -
58 EPIDEMIC MENINGITIS.
symptoms in the disorder. Cases occur, it is true, in
which the temperature is increased above the natural
standard, but these are rare.” In relating a case,
also, he remarks, “her heat, as often as it was mea-
sured, was found matural; pulse eighty.” According
to Strong, “a diminution of heat may be considered as
among the most striking symptoms of this disease.”...
“In more than a hundred cases there were few in
which the heat was up to the natural standard, and
rarely any in which it was above.” Foot says, “the
degree of heat rarely exceeded the healthy standard,
and fever constituted a very inconsiderable item of
the complaint.” Fish states that “sometimes the
skin was of a natural temperature, but more gene-
rally it was below it;” Gallup mentions coldness of
the skin at the beginning of the disease, but adds,
that in the act of sweating a high heat was sometimes
observable. During the early part of the epidemic
of which Hale records the history, he found “the
skin dry and parched,” but “the limbs often cold and
numb;" and at a later period the initial coldness per-
sisted until it was dispelled by external means. Miner, .
writing of the epidemic of 1823, states that “in almost
every case the skin was preternaturally cool for seve-
ral of the first days, and subsequently, in temperature,
ſt never eaceeded the standard of health in more than
three or four cases. . . . Sometimes, though rarely, the
patient would complain of a general sensation of heat,
though to the feel of the attendants, he would be
actually cold. . . . If increased heat and increased fre-
quency of the pulse are a part of the definition of
fever, a great majority of the patients had no ſever at
SYMPTOMS.—TEMPERATURE. 59
all.” Jenks says that “the heat of the surface was
less in all cases than is usually observed in acute dis-
eases.” In forty-two cases, with dry skin, Ames
found that “the natural temperature preserved in four-
teen, the heat was below the normal standard in
seventeen cases, and above it in eleven. . . . There
was never any pungent heat in the skin; in the greater
number in which it was above the natural tempera-
ture, it was still below ordinary febrile heat.” And,
finally, as regards American testimony, we may add
that the conditions above described were all repre-
sented in the cases of the late epidemic at the Phila-
delphia Hospital. The calor mordax which, the year
before, had been so prominent a symptom in the
typhus epidemic, was no more met with, and the
thermometrical observations of which Dr. Githens
has furnished an account, prove that the temperature
of the body in this disease is lower than that recorded
of any other fever or inflammatory affection. The
highest temperature in different cases varied between
100° and 105°, while in two cases it was below 100°.
In European epidemics the same conditions of the
bodily temperature were observed. Tourdes describes
them very distinctly in the following passage. “At
the onset there was no fever, even when the pulse
, was accelerated. The temperature of the skin was
natural or sometimes even lowered; and there was
always a complete absence of fever in cases which
terminated fatally within the first few days. But when
the attack was of more than a week's duration, a true
fever was lighted up which remained until convales-
cence or death. This fever was of the continued type,
60 FPIDEMIC MENINGITIS.
but presented marked and regular exacerbations, which
took place in the afternoon along with an aggrava-
tion of the other symptoms. The form of the fever
was sometimes, although rarely, inflammatory; more
generally it was typhoid.” Gillkrest states that “a
high febrile movement took place only in a limited
number.” Lionnet says that the skin “rarely felt
hot.” The following observations, if not more posi-
tive, are, at least, more precise. Niemeyer calls
attention to the very slight increase of temperature
during the first and second days of the attack, viz. to
101°–103°. In one case, on the second day, the
temperature in the rectum was only 99°. Wunder-
lich's special study of temperature in disease gives a
peculiar value to the following results. He found
fever, but of very unequal degrees, in all cases. The
maxima of temperature were also various. In three
cases, at the point of death, the temperature was 107°,
108° and 110°, respectively; in another case at the
beginning 101.7°, and after several days 103°. In
two rapidly fatal cases the temperature rose as death
approached. In another fatal case the temperature,
morning and evening, on two successive days, was
101.5° and 103°, 100° and 103.4°; and on the third
day, 103°,106.2°, 106° and 107.5°. Burdon-Sanderson
found that in adults the temperature varied from 100°
to 104°, and in children was still higher. Exacerba-
tions of pain were always accompanied with an in-
crease of the heat of the skin amounting to 2° or 3°.
The extreme irregularity of the thermometrical results
in this disease is regarded by Hirsch as one of its
most distinctive characters. Ziemssen, quoted by
syMPTOMS.—ERUPTIONS. 61
the last named author, states, as the result of his
examinations, that “the temperature is so fluctuating
that few of the curves representing it coincide.” This
irregularity in the results of thermometrical observa-
tions in epidemic meningitis adds another to the many
features which distinguish that disease from typhoid
fever and typhus. The maxima and minima in these
several affections may not be materially different, but
while in the two last named the temperature is pro-
gressive and is steadily maintained for several, or
even for many days; in the former it is irregular and
unsteady, now advancing, now subsiding, and all
within a period of time much shorter than in the two
fevers with which it is compared. And further, while
in nearly every case of typhoid fever and of typhus
the temperature is high, viz. above 103°, in one-third,
at least, of the cases of epidemic meningitis it is below
that degree.
ERUPTIONS.—A personal study of the disease, as
well as an examination of the recorded observations
of others, makes two points very plain, viz: that
in a large proportion of cases no eruption at all is
present; and that eruptions of the most various
characters may appear upon the skin. Following the
plan hitherto pursued, we shall cite the records upon
each of these two propositions.
CASEs of EPIDEMIC MENINGITIS WITHOUT ANY ERUP-
TION.—North emphatically testifies that “eruptions
are by no means a necessary attendant upon the dis-
ease;” and again, “they are by no means a constant
or frequent symptom.” Strong says, “these spots,
which in 1806–7 marked almost every case, in 1808–9
62 . EPIDEMIC MENINGITIS.
were rarely observed.” Fitch writes, “there are,
however, some even among fatal cases without any
such appearances (petechiae and vibices) on the skin.”
Dr. Woodward says “an eruption on the skin so sel-
dom appeared that it could no longer be considered a
characteristic symptom of the disease.” Haskell
makes the statement that “neither the spots nor the
eruptions are inseparably connected with the disease.”
All of these quotations are taken from the single
volume of North on “Spotted Fever,” and more might
easily have been added. “In 1807, when the spot-
ted fever first appeared at Hartford,” writes Fish,
“there were but few cases without petechiae or livid
spots: in the following years they were less common,
and since then they have not been seen in that place,
before death.” Jackson and his colleagues declare
that “they occur in comparatively few cases of the
disease.” Hale remarks very pointedly, “I have
hitherto said nothing of any spots upon the skin,
although their real or supposed appearance has in
many places given a name to the disease. ... I have
never observed any tendency to the production of .
these spots, while the skin was moist, except in the
fatal cases already mentioned.” According to Gallup,
“the eruption is not a constant attendant. . . . The
proportion of cases which had distinct eruptions may
be estimated at one-sixth;’ and Miner informs us that
“not more than two or three cases were, this season
(1823), attended with petechiae.” Coming now to
the Southwestern epidemic of 1846 and subsequent
years, we find no mention of any eruption among the
first cases which were reported by Boling; and in the
SYMPTOMS.—ERUPTIONS. 63
minute and accurate history furnished by Ames, it is
stated that petechial spots existed in only one case.
Hicks, Taylor and White appear to have observed
them “in many of the more violent cases.” Due al-
lowance must here be made for the fact that many of
the patients were negroes. If we study the history
of the late epidemic, the evidence is to the same pur-
pose. Kendall remarks, “probably a majority have
no petechiae at all; even some of a fatal character
have not exhibited them.” In Squires' very interest-
ing narrative an eruption is mentioned in twenty-five
out of forty-three cases. Upham found petechiae
“not an unfrequent manifestation.” Black reports
Seven cases, in one only of which petechiae are men-
tioned. Corson speaks of observing petechiae “many
times; Anderson, “in some cases;” Fassett, in only
seven out of twenty, and Page, in eight out of six-
teen cases; and in the Massachusetts returns we find
that rather more than one-half, 59 per cent., presented
Some morbid appearance of the skin. Finally, during
the recent epidemic observed at the Philadelphia
IIospital, there was no eruption whatever in thirty-
Seven out of ninety-eight cases. An eruption of some
sort was therefore present in 62 per cent. of these cases.
In European epidemics of meningitis the proportion
of cases in which a general eruption existed was
smaller still. In the Geneva epidemic of 1805, a
considerable proportion of cases at the point of death
presented purplish spots, some earlier than this, and
some after death only. The same circumstance was
observed in 1807, at Ashburton, England; in the
Neapolitan epidemic of 1833, and in that which oc-
64 EPIDEMIC MENINGITIS.
curred in Dublin in the present year (1867), ecchy-
moses were often present and in a very marked degree.
In the Strasburg epidemic, on the other hand, only
three cases of petechiae were observed by Tourdes;
at Rochefort and at Versailles, in 1839, they were
“rarely” noticed; at Gibraltar, in 1844, they do not
seem to have been observed; in 1848–9, at the Val de
Grace, they do not appear to have attracted atten-
tion; at Petit-Bourg they were not noticed, although
the state of the skin in other respects was fully de-
scribed. In Prussia, in 1865, neither Burdon-San-
derson nor Wunderlich mentions petechiae or vibices
as occurring during life; Niemeyer saw petechiae in
one case only; Klebs found them in “several” rapidly.
fatal cases; and Hirsch, after mentioning their “occa-
sional” presence, is obliged to draw upon American
authors for an account of their aspect and time of ap-
pearance. Finally, among the ten cases reported by
Dr. Law, of Dublin, in 1866, not one had a “pete-
chial” eruption. Thus it is evident that, taking the
whole of the cases of epidemic meningitis in Europe
and in this country, the number of those in which
petechiae were present formed but a small propor-
tion, probably not one-tenth—of the whole.
CASEs OF EPIDEMIC MENINGITIS WITH VARIOUS ERUP-
TIONs, NOT PETECHIAL-Strong speaks of efflorescences,
carbuncles, pustules and buboes; North describes a
“bright red” eruption; Woodward, “efflorescences of
various sizes and shapes;’ Haskell, &c. “a red fiery
eruption, sometimes in clusters and sometimes in large
and distinct pustules;” Bestor, “bright red spots,” an
“efflorescence resembling measles,” and an “uniform
SYMPTOMS.—ERUPTIONS. 65
redness like erysipelas;” Fiske, “a miliary eruption,”
and sometimes “like the nettled-rash;” Fish, an “efflo-
rescence resembling that of scarlatina;” Jackson, all of
these different forms, and also large bullae, as if pro-
duced by cantharides; and Gallup, Hale and Miner
confirm these statements from their own observation.
Ames observed “herpes labialis,” so common in cer-
tain European epidemics, in several instances; Ken-
dall, spots of “a scarlet or red rose color,” as well as
petechiae; Squire, “cherry-colored spots,” as well as
petechiae and ecchymoses; Jenks, “large elevated
spots of the size of a twenty-five cent piece, of very
dark color, presenting outside of the dark color a blis-
tered appearance;” Reid, “an exanthematous eruption
of short duration;” Poley, “peculiar small spots of a
Spanish-brown color;” and Fassett, “an eruption
which was petechial in four and erythematic in three”
cases. The recent epidemic which we witnessed fur-
nished examples of nearly every form of eruption
met with in this disease. They have been correctly
enumerated by Dr. Githens as “erythema, urticaria
and petechial mottlings.” He adds, “hemorrhagic
ecchymoses, or vibices, were not present in any case.
Of ninety-eight cases recorded, thirty-six had marked
petechial eruptions, not disappearing under pressure;
thirteen had mixed petechiae and erythema; nine ery-
thema and urticaria.” Herpes labialis was noticed in
a few cases. Tourdes was, we believe, the first who
regarded the last mentioned exanthem as character-
istic, at least by its frequency, of this disease, and
other observers have noticed it; but it is certainly
much less common as a symptom of epidemic menin-
66 . EPIDEMIC MENINGITIS.
gitis than either the roseolous or the petechial spots.
This author, as well as a few others, occasionally
met with the lenticular rose-colored spots so usual
in typhoid fever; and the other exanthematous erup-
tions have occurred in a greater or less number of
cases in nearly all European epidemics; but none
of any kind, except herpes, occurred so frequently
as to suggest to any one, except the Neapolitan, De
Renzi, the idea of employing it to designate the dis-
€8 Sę. - - &
In the Dublin epidemic of 1866–67, and for the
first time in Ireland, a great variety of eruptions such
as herpes, a general vesicular eruption, urticaria,
bullae, &c., was observed. Gordon described “a dis-
tinct eruption, which comes out with great rapidity,
is found over all parts of the body, but chiefly on the
lower extremities; is of a very dark color, sometimes
very deep brown or purple, or even black; the spots
are of various sizes and shapes, some small and round,
others large and irregular; some appear like large
spots of very black purpura, only more mottled and
more irregular in color and shape; others are more
confined and raised above the level of the skin, con-
sisting in effusion into its substance.” These appear-
ances lead the author to remark that they do not
“constitute or indicate any new type of disease;” but
he did not suggest that they denote any affiliation
with typhus. On the contrary, he resorted to the
history of epidemic meningitis in this country and on
the continent of Europe, to show that they especially
belong to that disease. These various eruptions have
been regarded by Law, Gordon and Hayden, as being
SYMPTOMS.–CAUSE OF DEATH.-DURATION. 67
directly dependent upon the cerebro-spinal lesions
which are characteristic of the disease. In support
of this view, cases are cited in which traumatic and
other lesions of the brain and spinal marrow, chorea,
and powerful mental emotions have been accompanied
or followed by eruptions upon the skin. In some
cases gangrene of the skin has been noticed where the
spots have been peculiarly dark, and occasionally, as
in typhus, from prolonged pressure.
The cause of death in many of the more rapid cases is
sometimes coma; but in some others, equally rapid, and
attended with all the marks of dissolution of the blood,
consciousness is but little impaired until the actual
imminence of death. In many others, fatal in the midst
of a well marked attack, death appears to depend
upon asphyxia due to a pressure upon the medulla
oblongata; in others, again, a slow and gradual asthenia
exhausts the powers of life, sometimes leaving the
mind clear until the approach of dissolution.
DURATION, CONVALESCENCE, SEQUELAE, MOR-
TALITY.
This affection, which in so many respects is singu-
lar, is altogether peculiar in the irregularity of its
duration. In typhus the usual date of convalescence
is between the thirteenth and sixteenth days, and that
of death in fatal cases very nearly the same; in typhoid
fever the attack exceeds three weeks, on an average,
whether the patients recover or die. In contrast with
this long duration, and this regularity of development,
decline, and death, all observers of epidemic meningitis
68 EPIDEMIC MENINGITIS.
agree that it runs its course with such unequal speed .
in successive cases that no general average of practical
utility can be formed in regard to it. Strong says,
“the disease appears in every shape, from the dread-
ful plague, which baffles all medical skill, and destroys
life in five hours, down to the mild disease, which, if
properly treated, will confine the patient only a few
days.” . . . Of twenty patients, “seven died in less
than twenty-four hours, five in less than forty-eight
hours, three in less than seventy-two hours, and the
remaining five from the third to the seventh day.”
North states that “unless the patient recovers, he
commonly dies within the first twelve, twenty-four or
forty-eight hours.” If he recovers, the “attack runs
into the form of a mild typhus of uncertain duration.”
In the epidemic described by Fish, “death took place,
at different periods, between eighteen hours and seven
days,” and, he adds, “there have been instances of
patients living ten or twelve days, and then sinking.
under the disease.” Jackson, &c. besides confirming
these statements, show “that even in cases where the
attack has been very violent, and the powers of life
overwhelmed at first, the patient has so far recovered
as to be very comfortable in three or four days, suf-
fering only a slight debility.” Of such, we, also, have
seen numerous examples. Gallup confirms all of these
statements, and adds, “the common period of termi-
nation was somewhere between the fourth and the
seventh day;” and this was precisely the average du-
ration of Upham's cases at Newbern, North Carolina.
Hale remarks: “in more than half the cases my visits
were not extended beyond the first week.” Ames
SYMPTOMS.—DURATION. 69
gives the extremes of duration as fifteen hours and
fifty days; but by far the greater number terminated
on the fourth day. This substantially was the result
of Armstrong's observations in the recent epidemic at
Mobile. Fassett, indeed, states that during the Ver-
mont epidemic, “in no case did recovery take place
in less than from three to five weeks;” but Ketchum
describing the same epidemic says, “several lived five
or six weeks from the date of the attack and then
died” with brain symptoms, “while some lingered for
three or four weeks with dilated pupil, deafness, opis-
thotonos, pain in the head, semi-delirium, and then
died. In most of the patients that recovered the
symptoms improved in forty-eight hours. . . . It is my
experience that the duration of the disease is indefi-
nite.” Kempf says, “the duration of cerebro-spinal
meningitis is from twenty-four hours to two or six
days.” The returns analyzed by Parks show that of
ninety-five fatal cases, the duration was five days or
under in sixty-six; eight days in one; and ten days
or over in twenty-eight. In cases of recovery the
duration was altogether indefinite, viz. from ten days
to four or five months. Githens also shows the dis-
ease to be of uncertain duration. The acute attack
rarely lasted through a fortnight; in a few cases the
patients were declared convalescent in the first week.
We have seen many slight but distinctly marked
cases fully convalescent within the period last named.
These references will perhaps suffice to impress upon
the reader the peculiar uncertainty of the duration of
epidemic meningitis. We might, were it not super-
fluous, illustrate the point more fully by citations from
70 EPIDEMIC MENINGITIS.
European writers. Let it suffice to quote the expres-
sive phrase of Tourdes, “the disease is distinguished
by the slowness of its cure and the rapidity of its
fatal issue;” and the conclusion of Hirsch that “its
duration is between a few hours and several months.”
CONVALESCENCE.-It will be inferred from the last
paragraph that convalescence from epidemic menin-
gitis is very irregular and uncertain. In this respect
it bears a certain analogy to typhoid fever; for in
both affections the long and unsteady progress of the
return to health is owing to a local lesion, which may
be present in every possible degree. Fish and Gallup
among American, and Tourdes and Gillkrest among
European authorities, dwell upon the rapid and ex-
treme prostration and emaciation which attend the
attack, and speak of a tardy and irregular convales-
cence as characteristic of the disease. In many cases
it is, indeed, otherwise; and of numerous patients in
the late epidemic, it may be said, as Hale remarked
of his own, “in most instances the patients were out
of their chambers within a week or ten days from the
commencement of convalescence.” Still, the general
statement continues to be true, as it is expressed by
Hirsch : “convalescence is irregular and protracted;
in spite of good food and regular digestion, emaciation
and debility are sometimes of long duration.” Per-
sistent headache, neuralgia, convulsions, stiffness of
the neck or pain in moving it, morbid sensibility of
some portions of the skin, palpitation of the heart,
dyspepsia, &c., embarrass the return to health. “It
is highly probable,” as Gallup remarks, “that the in-
SYMPTOMS.—CONVALESCENCE.—SEQUELAE. 71
ternal membranous inflammation is always present
more or less.”
SEQUELE.—These, which are merely the phenomena
of a retarded and imperfect convalescence, are deserv-
ing of notice. Deafness, or dullness of hearing, is a
very frequent consequence of this disease, which has
been observed by all European and native writers on
‘the subject. In our recent epidemic it existed to a
greater or less extent in sixteen cases. Very often
the deafness is permanent. Out of twenty-four cases
observed by Fassett, one half recovered; but three of
them with entire loss of hearing, and one with partial
deafness as well as strabismus. Impaired vision pro-
duced by opacity of the cornea, amaurosis, iritis, &c.
are occasionally met with. Paralysis of one or more
limbs, and general impairment of muscular power, are
rare consequences of the disease; and loss of memory,
and even insanity have sometimes been observed.
Gordon thus describes the conclusion of a severe
case: “the man has gradually passed into a state of
almost organic life; he eats, drinks, and sleeps well;
he passes solid faeces and urine without giving any
notice, yet, evidently, not unconsciously . . . he seems
to understand, but he cannot answer . . . he can draw
up his legs and arms, but he cannot use his hands at
all.” Relapses are very far from being uncommon.
Jackson, &c. state that they occur “in many in-
stances;” Gallup speaks of them as “very commoa;”
Hale notices “several cases;” and in numerous exam-
ples referred to by Parks, they were met with. It is
remarkable that a large proportion of the last men-
tioned cases were fatal, while the earlier reporters
72 EPIDEMIC MENINGITIS.
remark upon the usual termination in cure of second
attacks. : * *
MORTALITY-Like all epidemic diseases, meningitis
presents itself in every possible degree of gravity be-
tween a slight indisposition and a violent and deadly
malady. Hirsch has published a table exhibiting the
mortality of the greater number of epidemics of menin-
gitis between 1838 and 1865, from which it appears
that the death rate varied between 75 per cent. and
20 per cent. So, while the percentage of mortality
was a little over 61 per cent. (170 deaths in 278 cases)
during the recent epidemic in Massachusetts, it was
but 33 per cent. (43 deaths in 130 cases) in the Phila-
delphia Hospital. It is to be observed, moreover, that
while ten epidemics, in various places, occurring be-
tween 1838 and 1848 presented an average mortality
of 70 per cent., a similar number occurring during the
decade from 1855 to 1865 give an average mortality of
about 30 per cent. This remarkable fact would seem
to indicate a gradual decline of power in the epidemic
CºlllSé.
FORMS.
We have several times, in the course of this his-
tory, referred to the multiplicity of forms assumed
by the disease we are examining. To those who have
not studied its records, nor had occasion to behold its
multiform physiognomy, this peculiarity has been a
source of innumerable errors and mistakes, the most
serious of which consists in assimilating it to typhus,
FORMS. 73
and in applying to it a system of treatment, which,
however it may be tolerated, or even necessary, in
the former disease, is unequivocally mischievous in
the latter. Forget classified the cases he observed at
Strasburg as follows: A. CEREBRO-SPINAL: 1. Eaplosive
(foudroyante); 2. Comatose-convulsive , 3. Inflamma-
tory; 4. Typhoid; 5. Weuralgic; 6. Hectic ; 7. Para-
lytic B. CEREBRAL: 1. Cephalalgic; 2. Cephalagic-
delirious; 3. Delirious; 4. Comatose. In the first of
these divisions three-sevenths belong to the first
and fourth varieties; and in the second division
five-sevenths to the first and second varieties, from
which it may be inferred that coma in some degree,
and pain in the head were predominant characters.
But “there were slight and severe cases; violent
and hectic forms; cerebral symptoms predominant
in some, and spinal in others, and the functions of
the nervous system were variously disturbed.” Ames
arranged his cases in two general divisions, viz:
The Congestive and The Inflammatory. The Conges-
tive he subdivided into the Malignant and the Mild.
Malignant congestive cases were distinguished by pros-
tation, coma or delirium, or both; opisthotonos; and a
pulse of wide range. In Mild congestive cases a good
degree of strength was preserved; the pulse was
below 90; there were marked pain in the head and
tenderness of the spine; and no coma, delirium or
tension of any except the cervical muscles. The
Inflammatory cases were, in general, distinguished by
a temperature of the skin above that of health, and a
full, firm pulse; but the malignant among them were
marked by the early occurrence of delirium or coma,
6
74 EPIDEMIC MENINGITIS.
great irregularity of the pulse, opisthotonos, convul-
sive spasm, strabismus and occasional amaurosis, with
vomiting and a rapid and fatal course; the grave by a
slighter development of the same symptoms, except
coma and delirium; and the mild by a lower grade of
febrile excitement, the preservation of a good degree
of strength, a tendency to become chronic, and by the
absence of coma, drowsiness, delirium, and a cold
stage. Wunderlich classifies the cases according to
their relative degrees of severity and the rapidity of
development of the symptoms, and describes: 1, the
gravest and most rapidly fatal cases; 2, the less grave,
and 3, the lightest cases. The following classification is
proposed by Hirsch: 1, the abortive; 2, the eaglosive
(m. siderans, the same as m. foudroyante of Tourdes);
3, the intermittent; 4, the typhoid. Of the various
forms admitted by different authors, and of which we
have seen examples, we would class together A. The
ABORTIVE, in which the characteristic phenomena are
often faintly defined, yet to the practised eye distinc-
tive. B. The MALIGNANT, in which the symptoms are
exaggerated, the attack sudden, the course short, and
the issue fatal. C. The NERVOUs, including a, the
aławie, viz.: 1, the delirious; 2, the cephalalgic; 3, the
neuralgic; 4, the convulsive; 5, the paralytic ; and 6,
the adynamic, viz: a, the comatose, and b, the typhoid.
D. The INFLAMMATORY. E. The INTERMITTENT.
It would not comport with the purpose of this
essay to describe in detail the several forms of epi-
demic meningitis. The greater number of them have
been included in the analysis of symptoms already
presented. But there are two which perhaps require a
FORMS. 75
few words of separate notice, viz. the Abortive and the
Intermittent; the one because its real nature may be
misunderstood, and the other on account of the peculiar
circumstances under which it sometimes arises. Abor-
tive meningitis is observed only during the prevalence
of the disease in a more characteristic form. Thus, the
mother of a boy who had died of the fully developed
disease, “complained of the head and back and limbs,
and of chilliness, and presented a petechial eruption.
After active purgative and counter-irritant treatment,
she was about work on the second day,” (Sargent.)
In Dublin, in 1846, Dr. McDowell remarked, that
“when inflammation of the membranes of the spinal
cord was frequent, and in many instances terminated
fatally, it was observed that the symptoms of excite-
ment of the spinal cord became developed in the pro-
gress of ordinary continued fever, without in any way
tending to produce an unfavorable result.” Gauné,
in 1856, saw nineteen cases of the disease in the Chil-
dren's Hospital, at Niort. All of them recovered.
Dr. Burns, of Frankford, Philadelphia, while attend-
ing patients affected with the disease, was affected
with headache, and severe pains along the spine and
in every joint of the body, and a general languid feel-
ing. Purgation and full doses of sulphate of quinia
arrested the disorder in two or three days. Kempf,
during the decline of an epidemic observed “a great
number of individuals, especially adults, who com-
plained of headache, malaise, neuralgic pains in vari-
ous parts of the body, and pain in the nape of the
neck or other parts of the spine.” The case of a
76 g EPIDEMIC MENINGITIS.
young woman to which we referred upon a previous
page was of the same nature.
The intermittent type has been described by Ames
and other physicians in malarial districts, but it is by
no means confined to such localities. According to
Hirsch, the paroxysms are more or less regular,
assuming the quotidian or the tertian type; the heat
of skin, when this is present, the pains, cramps, deli-
rium, &c. manifesting regular exacerbations and re-
missions, so that in fatal cases the attack resembles
pernicious intermittent or remittent fever. Some-
times the intermissions are manifested during the
prodromic stage, suggesting a delusive idea of the
nature of the attack; sometimes the characteristic
symptoms are intermittent; and sometimes this type
first manifests itself during the decline of the disease,
and naturally suggests the suspicion of a relapse.
This occurrence is not to be confounded with a true
relapse, of which some notice has already been taken.
ANATOMICAL CHARACTERS.
No other epidemic disease presents more definite
and characteristic lesions, post mortem, than cerebro-
spinal meningitis. According to its type and its
duration there never fail to be found some of those
changes in the membranes or in the substance of the
great nervous centres which denote the existence of
inflammation. Congestion of the blood-vessels and
exudation of serum fibrin or pus beneath the men-
inges, and different degrees of alteration in the nerv-
ous pulp attest the nature of the process. And since
ANATOMICAL CHARACTERS. 77
all or any of these may be found, it follows, that
however essential the lesions may be to the idea of
the disease, they do not constitute its exclusive
manifestation. As death is compatible with the early
and forming stage of the inflammatory process, as
well as with its complete evolution, and as the former
is not always sufficient to account for the fatal issue,
it is clear, on this ground alone, that, as in other epi-
demic affections, there is a constitutional element, a
morbid condition of the blood, which underlies all of
the phenomena of the disease, and modifies, more or
less, its physiognomy, just as the features of a man,
which are material, assume the most varied expres-
sions under the influence of the particular emotion or
passion which at the time may be supreme.
ExTERIOR.—In most cases cadaveric rigidity is well
marked and long continued. Burdon-Sanderson states
that this does not apply to the muscles which had
been rigid during life. Strong, Jackson, Gallup and
others have pointed out, and in the same terms, the
discoloration of the dependent parts of the body which
takes place after death; the purplish spots on the an-
terior surface, the redness of the eyes. &c. disappear
or grow paler, while large patches of a livid color, or a
uniform discoloration of the same hue may sometimes
be observed along the posterior parts of the neck, back,
nates and thighs. In a case of which we have pub-
lished the details, the whole body became rapidly
almost black during two hours before death; but
afterwards the countenance nearly regained its natu-
ral hue. It was early noticed that the muscles every-
where exhibit a deeper shade of color than natural,
78 EPIDEMIC MENINGITIS.
which is now said to be of a distinctive brownish red
shade; but Gallup states that there is no evidence of
a weakening of their texture. Klebs has, however,
shown that the rapid and extreme emaciation observed
in protracted cases of the disease is owing to atrophy
of the muscular fibres, as well as of the interstitial
connective tissue. The same observer has also de-
tected by the microscope a granular deposit between
the muscular fibres analogous to that which he found
in typhoid fever and in acute poisoning by phos-
phorus.
THE SCALP AND CEREBRALVESSELS AND MEMBRANES.—
In the very earliest account published in this country
(1806) of the anatomical lesions of the disease, it is
stated by Danielson and Mann that the veins of the brain
were uncommonly turgid; Bartlett and Wilson repeat
the statement (1810); and Stuart found the blood-ves-
sels of the dura mater and brain distended. Jackson
describes the flow of blood on separating the calvarium,
and of serum on cutting the dura mater, (the latter
liquid being of a reddish color,) and the great disten-
sion of the sinuses in cases of rapid death. In Ames’
examinations the venous congestion was less, but the
arterial vascularity greater. In some cases this ex-
tended to the dura mater, in others “the vessels
lying across the convolutions were uniformly red,
numerous and large.” They were also found in great
numbers on the walls of the lateral and other ventri-
cles. In like manner, at the commencement of the
recent epidemic, Squire said, “the large veins in their
way to the several sinuses appear remarkably turgid;”
and, during its continuance, the same report was
ANATOMICAL CHARACTERS. 79
made by all who investigated the subject. So, in
the European epidemics, from Vieusseux, who de-
scribes a “sanguineous engorgement of the brain,”
and Mathey, who speaks of the meningeal vessels as
being “excessively injected,” and from Tourdes, who
states that the sinuses of the dura mater are filled
with very dense coagula, and the vessels of the pia
mater distended with blood, to Banks, who uses
almost the same terms in his description, and Bur-
don-Sanderson, who found hyperaemia of the cranial
diploe, distended blood-vessels of the dura mater
whose internal surface was highly colored and mi-
nutely injected, and excessive congestion of the
arachnoid covering the hemispheres,-the testimony
is uniform, that congestion of the brain is an unfail-
ing accompaniment of the first stage of the disease.
Next, we find that the transparency of the arachnoid
is impaired, as it is described, among others, by
Lidell, Hutchinson, C. M. Clark, and as we have
always found it when death did not take place in the
congestive stage. Precisely the Sãme condition is
reported by European writers, who also, as well as
our own observers, found the pia mater often adhe-
rent to the brain, and sometimes so closely that it
could not be raised without lacerating the cerebral
substance. This condition is particularly described
by De Renzi, Tourdes, Gillkrest, Lionnet and others.
An effusion of serum is an ordinary condition post
mortem. It is found in the arachnoid cavity and in
the ventricles. In the former situation it was men-
tioned by Danielson and Mann. “As soon as the
dura mater is cut through, a quantity of serous fluid
80 EPIDEMIC MENINGITIS.
commonly escapes from under it. This is not always
transparent like water, but sometimes quite red
colored.” Gamage says, “a serous fluid was contained
between the tunica arachnoidea and the pia mater;
the first membrane being raised from the latter in
numerous cells.” Ames found the effusion in many
cases, and states that “pus globules were mixed with
it in every case in which they were sought. In two
cases the effusion consisted almost entirely of pus.”
Lidell reports a case in which at least six ounces of
serum were discharged. In another case (Moorman),
in which death took place on the thirty-fifth day, “on
attempting to remove the brain, about three pints of
turbid serum escaped.” So, among European authori-
ties, De Renzi refers to a case in which a pound and
a half of serum was found between the dura mater
and the pia mater. Tourdes says, “the arachnoid
cavity ordinarily contained a small amount of serum;
occasionally it was dry, or marked by flakes of pus.”
The wentricles are also the seat of an effusion in
many cases. The first record of the fact is, we
believe, in Stuart's case, in which “the right lateral
ventricle contained about a tablespoonful of serum;’
Jackson says “the lateral ventricles always contain a
notable quantity of water.” Ames met with a purulent
effusion in several cases; Craig, eight and twelve
ounces of a limpid fluid in two cases; and Armstrong
and Clark saw the ventricles distended with sero-pus.
Serous effusion was observed by Mathey in these cavi-
ties; and Tourdes found pus in them in more than half
of his cases, forming sometimes a milky fluid, sometimes
the true yellow pus of phlegmonous inflammation.
ANATOMICAL CHARACTERS. 81
Similar appearances are described by Gillkrest, Wilks,
Burdon-Sanderson, Hirsch, Klebs and others. The
last mentioned observer in one case found the lateral
and the fourth ventricles and the aqueduct of Sylvius
fully distended by thick yellow pus. It does not follow
that every milky looking liquid contains pus corpuscles;
in many cases the color is derived from exuded fibrin.
These anatomical conditions would serve to prove
the essentially inflammatory nature of the process
in which this disease involves the brain; but a
more conclusive one remains to be described. This
is a fibrino-purulent easudation in the meshes of the
pia mater. Among early American physicians, the
first who attempted to illustrate the nature of the
new disease by dissection were Danielson and Mann,
who, in their essay, which was published in 1806,
give an account of two post-mortem examinations to
which reference has already been made. Of the first
they say, “the dura mater and pia mater, in several
places, adhered together, and both to the substance
of the brain;” and of the second, “between the dura
and pia mater was effused a fluid resembling pus;”
proving, therefore, that the lesions were those of men-
ingitis. In 1810, Bartlett and Wilson reported a fatal
case, in which, among other lesions, was found “an
extravasation of lymph on the surface of the brain.”
In the same year the report of Jackson and his col-
leagues contained an account of the lesions, which
leaves little to be added. After speaking of the con-
gestion and serous effusion found within the cranium
“in those who have perished within the space of
twelve hours from the first invasion,” they add, “the
82 EPIDEMIC MENINGITIS.
other appearances we are to describe are more con-
spicuous in proportion to the duration of the disease.
The tunica arachnoides and the pia mater are remark-
ably altered in appearance by the effusion of an opaque
substance between them, which may be called coagu-
lated lymph or semi-purulent lymph,” . . . and then,
speaking of the base of the brain, they remark, “an
effusion of coagulated lymph in mass has been wit-
messed in the same part.” Wilson, again, in 1813,
described a case presenting “several small depositions
of lymph on the surface of the brain.” In 1818,
Gamage found in one of his dissections, that “the
tunica arachnoides seemed to be thickened, and two
or three small portions of coagulable lymph were dis-
covered upon its external face.” After an interval of
twenty years the same lesions were found in the epi-
demic at Montgomery, Alabama. Ames describes an
abundant deposit of “lymph and pus” upon the ex-
terior of the brain “under the arachnoid covering of
the pia mater.” At the base of the brain it was most
abundant about the optic commissure, “indeed, at
this place, either on the commissure and mamillary
bodies, or between them and the tuber annulare, it
was never absent.” “It was also found on the corpora
Quadregimina, the medulla oblongata, and around the
third pair of nerves. The inferior surface of the cere-
bellum was frequently the seat of this deposit.” About
the same time, in Massachusetts, Sargent found “under
the cerebral arachnoid, over the upper surface of both
hemispheres, a whitish deposit, as of purulent matter,”
and “on both sides of the cerebellum a considerable
deposit of pus and lymph.” In 1857, Squire stated that
ANATOMICAL CHARACTERS. 83
in a case narrated by him, “beneath the arachnoid
membrane was a plentiful effusion of yellowish white
lymph,” and at the base of the brain, “a perfect pool
of sero-purulent fluid filled the foramen magnum.”
Craig found “lymph of a yellowish and greenish hue”
upon the convexity and at the base of the brain.
We have called attention to the relation between
the brain lesions and the duration of the attack before
death. It was distinctly pointed out by Jackson and
his cotemporaries; it is more elaborately presented by
Upham, in his history of the epidemic at Newbern.
When death took place within two or three days there
was commonly opalescence of the membranes, flocculi
of lymph in the subarachnoid fluid of the convexity
of the brain, and an exudation of thick yellow lymph
at the base. After a longer period the exudation was
more pus like, or more abundant and concrete. In
two cases, of which the one lasted for twenty-four
hours and the other for twenty-three days, Jewett
found that these conditions were well contrasted,
serum predominating in the one and dense lymph in
the other. Ketchum, also, refers to the stage of the
disease causing the lesions to vary between congestion
and exudation; and Githens notices the influence of
this element in determining differences in the appear-
ance of the exudation even in a class of cases all of
which might be termed inflammatory. In point of
fact there were scarcely any others in the epidemic
of which he has sketched the history. Similar grades
of the specific lesion are recognized by European
writers, as we shall presently show.
It might be inferred from the silence of Vieusseux
84 EPIDEMIC MENINGITIS.
on the subject, that in the Geneva epidemic of 1805
there were no brain lesions of a distinctly inflamma-
tory sort, just as it has been too hastily alleged that
the American epidemic of the same period was an
idiopathic fever, for no better reasons than that dis-
sections were not made at all by the first historian of
the disease, and in some other cases of rapidly fatal
course vascular engorgement of the encephalon only
was detected. But we have seen that abundant evi-
dence of meningeal inflammation in the American
epidemic existed, and the same is true of the cotem-
poraneous prevalence of the disease at Geneva; for
Mathey thus describes the lesions in one case: “the
meningeal blood-vessels were strongly injected. A
jelly-like exudation tinged with blood covered the
surface of the brain.... On the lower surface of the
brain and in the ventricles a yellowish, puriform
matter was found.” A full and particular description
of this lesion is furnished by Tourdes. Sometimes
the exudation was liquid, and sometimes concrete,
like butter spread over the surface of the brain.
Sometimes it was scanty and disposed in streaks
along the veins; sometimes it was more abundant and
formed rounded islands of various extent; generally
it remained superficial, but sometimes, also, penetrated
between the convolutions. Its consistence varied
extremely; now, it was like thin pus, and again had
the aspect and firmness of a false membrane. “It
existed about equally on the upper and lower surfaces
of the brain fourteen times; on the upper alone eight
times, and chiefly six times; at the base alone twice,
and chiefly nine times; in the ventricles twenty-six
ANATOMICAL CHARACTERS. 85
times; on the optic nerves nine times; on the pons
Varolii four times; on the medulla oblongata three
times; on the olfactory nerves twice, and on the cere-
bellum in nearly every case.” Lesions almost iden-
tical with those just described were found by Gill-
krest at Gibraltar; Ferrus and others at Petit-Bourg;
Wilks, in London; Gordon and Banks, in Dublin;
Gaskoin, in Portugal; and Niemeyer, Hirsch, Burdon-
Sanderson and others, in Germany. In some cases,
as in that of Banks, the exudation is confined to the
base of the brain, while the blood-vessels of the con-
vexity of the organ are highly congested. The solid,
semi-solid, or more fluid material constituting the
exudation is found, on microscopical examination, to
consist of cell-like bodies imbedded in a transparent
interstitial substance, or corpuscles and granules float-
ing freely. Burdon-Sanderson remarks, that “the
cell-like bodies, although in general resembling pus
corpuscles, did not present that uniformity of size
and character which is met with in normal pus. . . .
The interstitial substance was beset with granules,
some of which were albuminous, others fatty.” Upon
this point Klebs remarks that very often pus exists
where it is not visible to the naked eye, and where
even with the aid of the microscope it is necessary,
in order to recognize it, that the observer should be
familiar with its transition forms. Some of these he
describes as analogous to mucous corpuscles.
The most recent researches have fully confirmed
the judgment of Jackson, Upham and other American
writers, that the physical qualities of the exudation
depend partly upon the original type of the disease,
86 EPIDEMIC MENINGITIS.
and partly upon its duration. In malignant cases death
occurs before time has sufficed for the full development
of inflammatory lesions; in those of longer course may
be found, first of all, turbid serum, then a more or less
pasty and fibrinous deposit with some admixture of
pus, and, finally, in cases of long duration the exuda-
tion becomes tougher, more adherent, and shrivelled.
The substance of the brain is generally softened.
We have met with but one reporter (Hale), who
describes it as being firmer than natural. Daniel-
son and Mann state that “the substance of the brain
was remarkably soft, offering scarcely"any resistance
to the finger when thrust into it, and the cerebellum
was found in the same state;” and Bartlett and Wil-
son say there was “a looseness of texture or disor.
ganization through the whole substance of the brain.”
Ames found softening in nine out of eleven cases, “in
some part of the hemispheres, chiefly the cortical, in
seven cases; in the medulla oblongata and pons
varolii, in three; in the fornix and septum lucidum,
in five; in the walls of the third ventricle and canal
leading to the fourth, and in the infundibulum, in one
case,” &c. It was observed by Craig in several cases,
and in one of them after an illness of several months
duration; in another, which terminated fatally on the
thirty-fifth day, Moorman found the brain softened in
circumscribed patches; C. M. Clark describes this
alteration of a high grade in several cases; and Rus-
sell, with many others, repeats the same testimony.
As a summary of these lesions and their relation to
the period of death, the following description by
Chauffard is instructive. “When death had taken
ANATOMICAL CHARACTERS. 87
place rapidly the upper portions of the brain were
gorged with blood, the arachnoid already cloudy and
as if thickened, and a layer of pus upon the corpora
quadregimina, the optic chiasm, the pons varolii, and
the anterior portions of the base of the brain; the
ventricles contained serum, and there was local and
more or less extensive softening of the spinal cord.
When death occurred in the second week, there were
wide strips of false membrane beneath the arachnoid,
and pus in the ventricles, the walls of which were
softened; pus abounded at the base of the brain and
of the cerebellum and in the spinal canal; and the
spinal marrow itself was softened and sometimes re-
duced to a mere pulp. When the period of death
was still later, or very long delayed, the interior sur-
face of the ventricles, the fornix and septum lucidum
were reduced to a pultaceous and creamy consistence,
and in the latter case escaped into the adjoining cavi-
ties. Portions of the spinal marrow were completely
destroyed, and in their place was found only a yel-
lowish liquid, or the empty membranes fell into con-
tact when it was wanting.” It is unnecessary to
quote in greater detail the statements of European
writers upon this subject, since they do but reproduce
the observations of our own physicians. They, how-
ever, make use of arguments to show that softening
of the brain in epidemic meningitis is a true anatomical
lesion and not a cadaveric phenomenon; that in fact it
arises from a local and persistent occlematous infiltra-
tion, or from the presence of minute sanguineous
extravasations.
SPINAL MARROW.—The earlier writers whom we
88 EPIDEMIC MENINGITIS.
have quoted in the preceding pages do not afford
much information respecting the anatomical conditions
of this nervous centre. It was not until the time of
the publication of Tourdes' Essay that it was habitu-
ally examined, or that the importance of its lesions
was appreciated. It may be stated, in general terms,
that the lesions of the spinal marrow and its mem-
branes are identical with those of the encephalon.
The dura mater is often very dark; its blood-vessels
are engorged; the cavity of the arachnoid is distended,
and upon incision gives issue to serum, which may be
clear, or mixed with blood, or simply turbid, while in
advanced cases a profuse discharge of pus may take
place from the puncture. C. M. Clark mentions a
case in which two ounces of pus were collected in
this manner. The spinal pia mater presents analogous
varieties in the proportion and distribution of the
exudation to those found in the brain. They have
been described, among other native writers, by Ames,
Sargent, Squire, Upham, Woodward, Lidell, Arm-
strong, Craig, Moorman, Russell and Clark, and
among foreign authors, by Tourdes, Lionnet, Wilks,
Banks, Burdon-Sanderson, Wagner, Niemeyer and
Hirsch. The more concrete, and even the purulent
exudation is not always, nor even usually, diffused
equally over the cord; often it is limited to the ante-
rior, and more frequently to the posterior face or to
some particular region or regions of the organ, the
larger collections, in the latter case, being connected
by streaks of lymph or pus. These accumulations
are usually most abundant at the lower end of the
cord, and may be found around the roots of the nerves.
ANATOMICAL CHARACTERS. 89
Their excess in the lower and posterior portions of
the cord is attributed by Klebs to the influence of
gravity. Softening of the spinal marrow appears to
be less frequent than that of the brain. But Ames
relates a case in which the cervical portion was soft-
ened, “the filamentous portion interiorly being re-
duced to a disorganized pulp.” In a case referred to
by Hirsch, the central canal of the cord was distended
with pure pus. More complete destruction sometimes
occurs, as above described by Klebs and Chauffard.
Partial and superficial softening of the cervical por-
tion we have seen repeatedly.
THE BLOOD.—Next to the great nervous centres,
the blood presents the most important changes in
this disease; they are, however, as diverse as the
lesions affecting the meninges of the brain and spinal
marrow. But we should here distinguish between
blood drawn from a vein during life and blood found
in the body after death, and in both cases between
the adynamic or malignant and the sthenic or inflam-
matory types of the disease. Pursuing, at first, the
chronological order, we find it stated by Arnell, in
1811, that “the blood drawn in the early stage ap-
peared like that of a person in full health; there was
no unusual buffy coat, neither was the crassamentum
broken down or destroyed.” Fish, also, speaking of
the same epidemic (1809), says: “two patients were
bled: one furiously delirious, the other comatose; in
neither of these did the blood present any uncommon
appearance. There was no inflammatory buff, nor
was it dissolved. In one case, in 1807, where the
eyes were suffused, it had a slight buffy appearance;
7
90 EPIDEMIC MENINGITIS.
in another, in the following year, it was darker, and
had a larger proportion of serum than usual. The
two last-mentioned cases proved fatal in a few hours
after the patients were bled.” Andral noted a very
marked increase in the fibrin of the blood “in a case
of cerebro-spinal meningitis, in which, after death, he
found the spinal marrow surrounded, in its whole ex-
tent, by a sort of purulent sheath, the pus having in-
filtrated the pia mater.” “At the autopsy,” says
Tourdes, “the blood was remarkable for the abundance
and toughness of the fibrinous clots.” Faure-Villar
also notes the buffy coat as characteristic of the
blood. In 1864, Dr. Ketchum found that “the blood
had every appearance of blood taken from a patient
laboring under acute inflammation.” Ames states
that “the blood taken from the arm, and, by cups,
from the back of the neck,” “coagulated with great
rapidity.” “Its color was generally bright—in a few
cases nearly approaching to that of arterial blood; it
was seldom buffed: in thirty-seven cases in which its
appearance was noted it was buffed in only four.”
Analyses were made in four cases, “the blood being
taken early in the disease from the arm, and was the
first bleeding in each case. The first was from a
laboring man, thirty-five years old; the second from
a boy twelve years old, while comatose; and the two
others from stout women between thirty and thirty-
five.” I. Fibrin, 6.40; corpuscles, 140.29. II. Fibrin,
5.20; corpuscles, 112.79. III. Fibrin, 3.64; corpus-
cles, 123.45. IV. Fibrin, 4.56; corpuscles, 129.50.
Tourdes states that “blood drawn from a vein was
rarely buffed; if a buffy coat existed, it was thin, and
ANATOMICAL CHARACTERS. 91
generally a mere iridisation upon the surface of the
clot.” Analysis furnished the following results: I. Fi-
brin, 4.60; corpuscles, 134. II. Fibrin, 3.90; corpus-
cles, 155.54. III. Fibrin, 3.70; corpuscles, 143. IV.
Fibrin, 5.63; corpuscles, 137.84. Maillot gives, as the
eresult of analysis in six cases, an increase of fibrin to
six parts, and more, in a thousand. Thus, in not a
single case in which the blood was analyzed did it
contain less than three parts of fibrin in one thousand,
less, that is, than the proportion of this element in
healthy blood. On the contrary, it perfectly repre-
sented the condition of the blood in inflammatory dis-
eases. These are, we believe, the only reports which
have been published of a qualitative analysis of the
blood in epidemic meningitis, and it has been objected
to them that they were made of blood taken “at a
second or third venesection, when the proportion of
fibrin would naturally be increased” (Draper), and
that “the proportion of fibrin may rapidly increase
even during venesection” (Klebs). As to the latter
objection, it appears futile, for it would apply to the
standard analyses of the blood in other diseases; and as
to the former, it is not founded in fact, for in most of
the cases the blood was derived from a first venesec-
tion. Besides, it would not apply to the proportion
of the corpuscles, which it is well known diminishes
rapidly as blood is lost, whereas in the present in-
stance it shows a decided increase.
In regard to the condition of the blood after death,
it has already been stated that Tourdes and others
found firm fibrinous clots in the heart and large ves-
sels: but perhaps the greater number of observers
92 EPIDEMIC MENINGITIS.
have reported it to be dark and liquid. Such it was
stated to be in the report of Jackson, and also by
Lidell, Gerhard, Levick, Niemeyer, Gordon and others,
and such we found to be in the greater number of
cases which we examined at the Philadelphia Hos-
pital. But in two instances, at least, the heart con-
tained large and very firm fibrinous coagula. Several
observers have noted a shrivelled or crenated ap-
pearance of the edges of the blood disks, and an
irregular distribution of these bodies in the field of
the microscope instead of the ordinary arrangement
in rouleaua or piles. -
It is evident, therefore, that when venesection
has been practised, the blood has uniformly pre-
sented the characters indicative of inflammation,
and that in some epidemics, especially in France,
a similar condition has been observed even after
death; but that in a large number, probably in a
majority of fatal cases, the blood, after death, has
been found dark, and either liquid or else containing
only soft clots. It follows that the conditions which
occasion death in a large number of cases include a
disorganization of the blood. But it is equally true
that in many others death results from causes inde-
pendent of such a change, and, as we shall see here-
after, from a direct interference with the functions of
the nervous centres which are necessary to life. It
is probable that post-mortem fluidity of the blood
exists under two conditions; the one when the epi-
demic or zymotic cause is so intense from the com-
mencement of its action as to destroy very rapidly
the vitality of that fluid; the other when the powers
CAUSES. 93
of life are very gradually exhausted by the indirect
operation of the same influence. In the latter case
the inflammatory elements of the disease are more or
less gradually overcome by the prolonged action of
the peculiar morbid poison which is essential to the
generation of the disease. *
It is unnecessary to dwell upon the condition
of the lungs, heart, stomach, intestines, liver, kid-
neys and spleen, in fatal cases of epidemic menin-
gitis. These organs present a variety of lesions,
depending upon the patient's previous health, and
upon the complications which may arise during the
fatal attack, but none whatever which properly
belong to the pathological history of the disease.
When the joints have been swollen and painful during
life, pus has been found in them by Levy, Klebs,
Ottman and others. The lesions which have been
met with in cases of deafness do not always suffice to
explain this symptom. It might be supposed that
the existence of so large a deposit of lymph upon the
root of the seventh nerve, as is generally found, would
be habitually attended with more or less impairment
of hearing. But such is not the case; and where
the symptom exists, it must probably be ascribed
to an alteration of structure in the brain or medulla
oblongata, or to what has in some instances been de-
monstrated (Klebs), suppuration of the internal ear.
CAUSES.
It may be said, in general terms, that epidemic
meningitis has occurred in all portions of the tem-
|
94 EPIDEMIC MENINGITIS.
perate zone inhabited by European races and their
descendants; in all sorts of localities, among all ranks
and conditions of society, at all ages, and in both
sexes, and that it is therefore in the strongest sense
of the word a pandemic disease. And when the
statement is added that the disease is not dissemi-
mated by contagion, it evidently falls into the category
of the diseases referred to, of whose occurrence no
other explanation is at present possible than that they
are directly produced by a specific atmospheric poison.
Yet there are some peculiarities in the circumstances
which have attended many of its outbreaks, which, if
they do not bring the case under the laws which are
known to regulate the occurrence of other epidemics,
may at least serve as materials for an induction which
shall hereafter lead to the law under which this dis-
ease, also, is generated. The very first particular
which, in the natural order of causes, we must inquire
into, illustrates this statement. -
SEASON.—In the United States epidemics of men-
ingitis have taken place with great uniformity in the
winter and spring, as we learn from North, Daniel-
son, Mann, Fitch, Woodward, Fish, Warren, Gallup
and Hale, respecting the early occurrences of the dis-
ease; from Ames, respecting the epidemic of 1848–9,
and from Squire, Parks, Upham, Ketchum, Arm-
strong and many others, respecting the last epidemic.
Indeed we are acquainted with but one exception to
the rule: the epidemics at Middletown, Connecticut,
are stated by Miner to have prevailed between the
last of March and the last of December, 1823, and
in the summer of 1825. We should have regarded
CAUSES. 95
the rule as equally absolute for Europe; but it appears
to be less so, although the proportion of epidemics in
summer is comparatively small. In Germany the
rule has been nearly the same as in the United States;
but in France, out of 216 local epidemics, 166 occurred
between December 1 and May 30, while in the other
six months of the year there were 50. So in Sweden,
out of 417 local epidemics, 311 took place in the
former period and 106 in the latter.
WEATHER.—It is evident from the above statement
that cold and heat have neither of them an absolute
influence in the causation of this disease, although its
development is clearly favored by cold. The mode of
action of this agent may, perhaps, be considered here-
after.
LOCALITIES, of every sort, high and low, dry and
moist, those saturated with marsh miasmata, and
those favored by the pure breezes of mountain dis-
tricts have been alike invaded by epidemic meningitis;
it has passed by large cities reeking with all the cor-
ruptions of a soil saturated with ordure, and a popu-
lace grimed with filth, to devastate clean and airy
villages, and the families of substantial farmers in-
habiting isolated spots.
SEx, AGE AND OCCUPATION.—Instead of destroying
females and old and infirm people, its victims are
chosen, in far greater numbers, from among persons
in the very bloom of youth and early manhood than
from any other class. It has in many places been
noticed that the proportion of males attacked is much
greater than of females, and such is probably the
general rule. Thus, in Massachusetts, where the
96 EPIDEMIC MENINGITIS.
female population is greatly in excess, there was a
preponderance of nearly sixty per cent. of male over
female patients. In France this difference was all
the more striking, because the first epidemics of men-
ingitis were so exclusively among males, and especi-
ally among young military recruits in garrison, that
its cause was sought in some peculiarity of the sol-
dier's life, or in some supposed unhealthy condition
of the military barracks. Yet there are other places,
as Sweden, and certain towns in Germany, where the
proportion of deaths among females equalled or even
exceeded that among males: and in Leipsic, the gar-
rison remained entirely exempt while the disease
prevailed among the citizens. In this country there
were instances which suggested that the conditions
of military life are peculiarly favorable to the develop-
ment of the disease. Such was the fatal epidemic in
1847 in the second regiment of Mississippi Rifles,
which originated in and was confined to that body,
during and after great hardships and exposure to in-
clement weather (Love). During the late civil war,
while there was at least one military post, Newbern,
North Carolina, at which the disease raged violently,
and while it occurred among the soldiers at Gallop's
Island, in Boston harbor, it never became epidemic
in the army, although nearly every possible predis-
posing cause of disease existed within its limits, and
although this very disease prevailed at the time
among the civil population. Without going further
into particulars, it may perhaps be sufficient to state
that everything proves conclusively the inadequacy
of the causes which have been considered to deter-
CAUSES. 97
mine the development of epidemic meningitis, inde-
pendently of the concurrence of an unknown specific
C8,UIS6.
DEBILITY--It has been a favorite theory that what-
ever causes weaken the system predispose to and
even excite this disease. Thus we find the following
passage in North's treatise. “The exciting causes
are better understood. They are such as immediately
debilitate the system, as too much fatigue, fear, grief,
nursing, abuse of stimuli, wetness, cold, and other
diseases preceding, as the measles and influenza, and
chincough. Among these, as far as I have observed,
cold is the most frequent eaciting cause.” The same
statement is repeated, substantially, by Fish and by
Jackson, who subjoins that it is not made “in con-
formity with general principles,” but is “founded on
the observations of correspondents.” Some have
attributed the recent epidemic to the depressing in-
fluence of war, forgetting that the disease prevailed
for several years before war was even so much as ap-
prehended. A vast array of facts exists to demon-
strate the virulence of the disease in places crowded
with a poor and filthy population; but these facts pos-
sess no special value. They merely illustrate the
general and familiar proposition that all diseases, and
especially all epidemic diseases, occasion a greater
mortality among the hungry, filthy, and vicious, and
among the feeble and fearful inmates of public estab-
lishments for the poor, than among the independent,
industrious, and relatively virtuous classes of society.
Alongside of such instances, moreover, are hundreds
of others, like the rural districts and large towns of
ſ
98 EPIDEMIC MENINGITIS.
our own country, and like the garrisons in France,
where the victims of the epidemic were remarkable
for their excellent physical condition and their free-
dom from mental anxiety. What was true of the
first epidemic, in Geneva, has everywhere been found
true. “The disease,” says Vieusseux, “attacked
people of all ranks at once, poor and rich, in every
district of the city, in narrow, dirty and crowded
rooms, and in great houses where clean and well aired
chambers had but a single occupant.” Chauffard,
speaking of the epidemic at Avignon, in 1840, says:
“it selected for its attacks only men of from twenty
to thirty years old, fresh and vigorous young men,
wholly exempt from morbid proclivity, and who died,
almost all of them, in full flesh.” The morbid agen-
cies which have been referred to are permanent in
all large cities; and, if they were really efficient, they
should always determine the occurrence of the dis-
ease, but they notoriously do not. There are three
cities, at least, in which all of these causes have
attained an intensity of virulence unparalleled else-
where; and yet neither in London, Liverpool nor
New York has meningitis become epidemic. The
soil is, indeed, there in which all morbid germs what-
ever which are adapted to the climate must flourish;
but the specific germs of this disease have not yet
been sown in it under conditions appropriate for their
development. In other words, while we know that a
certain material poison will generate typhus, and a cer-
tain other typhoid fever, we are not acquainted with
the conditions which are essential to the production
of epidemic meningitis. We may know that some
CAUSES. 99
external influences appear to favor, but we know of
none that are essential to, its generation.
CONTAGION.—The contagiousness or non-contagious-
ness of epidemic diseases is a question which has
always given rise to differences of opinion, and some-
times to acrimonious disputes, as the history of yellow
fever, typhoid fever, cholera, &c. abundantly exhibits.
If, therefore, a new disease arises, and those who
have observed it independently of one another agree
in representing it to be communicable, or non-com-
municable, by the sick to the well, their judgment
may be regarded as conclusive. In the present in-
stance it may be affirmed that epidemic meningitis
has been pronounced non-contagious by almost the
unanimous verdict of competent judges. The few
dissentients only prove the rule. Let us, as hereto-
fore, examine the witnesses in chronological order.
Among American writers who described what they
saw, the following may be referred to. North de-
clares categorically, “it is not a contagious disease,”
and again he repeats that such is the opinion of “all
those physicians who have witnessed its ravages.”
So Haskell, Spooner and Holmes declare, “we cannot
discover a single instance in which it clearly appears
that the disease has been communicated from one to
another by contagion;” and Fiske writes as follows:
“this I can affirm, that in all the cases of the spotted
fever which I have seen, not one could fairly be traced
to this source.” Fish, while asserting that “there
are facts which go to prove that it is infectious.”
(contagious), admits that “it is not more infectious
(contagious) than the common typhus (typhoid feygr)
|
100 EPIDEMIC MENINGITIS.
or autumnal fevers of our country,” which last state-
ment is an admission that it is not contagious at all.
And this is the conclusion which the committee of
the Massachusetts Medical Society tell us, “it is very
generally agreed” to adopt. Hale furnishes negative
as well as positive evidence of its non-transmission
from the sick to the well. Coming down to the recent
epidemic, we find that among the cases that occurred
in Stanton Hospital, “no relation by contact could be
traced” (Lidell). In Vermont, Ketchum was led by
experience “to conclude that the disease was not
contagious;” and Holbrook reached the same conclu-
sion. In Massachusetts, “out of 268 cases” in which
the question was answered in reference to their origin
through contagion, “the answers were negative as to
252.” In the epidemic which we observed in the
Philadelphia Hospital, no evidence whatever of con-
tagion was afforded. Not a few historians of the
disease omit, in their reports, all notice of this ques-
tion, as if it was one that had not been suggested by
their experience. Neither Ames nor Upham nor
Squire refers to it.
In Europe, the first authentic history, by Vieus-
seux, says “the disease did not extend in the neigh-
borhood of the sick;" and again, the disease appears
to depend “upon peculiar atmospheric conditions, and
not on a contagion communicated from man to man;"
and, once more, the author proposes to call the dis-
ease “malignant non-contagious cerebral fever.” In
* In an excellent paper upon this disease, (New York Medical
Times, September, 1864, p. 113,) Vieusseux is credited with saying,
“we do not doubt that this was a malignant contagious fever.” This
• *
e e
• * . • * : • *e º e
g º • * * ~
& º * º
º º *
CAUSES. 101
the epidemic of Strasburg, “a study of the facts re-
sulted adversely to the idea of its spread by contagion”
(Tourdes); the same conclusion was reached by Ferrus,
at Petit-Bourg; Wunderlich found “not the slightest
indication of contagiousness” in the disease at Leipsic;
nor Burdon-Sanderson, in Dantzic; nor Mannkopf, in
Berlin. Indeed, the only writer of authority who has
contended for the contagiousness of epidemic menin-
gitis is Boudin, who refers to cases in which the dis-
ease affected certain garrisons without extending to
the surrounding civil population, or the soldiers of
certain barracks while it spared the prisoners confined
separately within their limits, or vice versa; and other
cases in which it seems to have accompanied a regi-
ment to new and healthy quarters, and then attacked
the recruits there incorporated into the affected regi-
ment, or the civilians in communication with its mem-
bers; and again others in which certain barracks were
occupied by different regiments in succession, and in
like order were attacked; and finally, cases in which
the disease spread to physicians, nurses, and other
attendants upon the sick. The last statement is in
direct opposition to universal experience; and the
preceding ones, supposing them to be accurately re-
ported, only show the existence of some local cause
capable of determining the development of the dis-
ease in all who came within its influence; a cause
susceptible of being transported by healthy men, or
mis-statement is probably due to Boudin, of whose exceptional notions
we may have occasion to speak. Mathey, observing the same epidemic
with Vieusseux, says, “the idea of contagion, which had alarmed
many persons, had to be abandoned.”
102 EPIDEMIC MENINGITIS.
by their camp equipage, from one place where the
disease existed to another where it had not previously
occurred. The views of Boudin have failed to satisfy
and convince all judges who have examined them.
They fail most where most they need strength, in
the proof that the disease is ever communicated from
man to man; and, without that proof, there is no evi-
dence of contagion. If there is one point in its his-
tory which is established by the concurrent testimony
of American and European writers, it is the extreme
rarity of its attacking the physicians and the nurses
in attendance upon the sick, and those patients affected
with other diseases, who occupy the adjoining beds
in hospital wards.
PROGNOSIS.
It will have been observed in the paragraph refer-
ing to the mortality of this disease that, its issue, in
general, is extremely uncertain, since the death rate
varies between widely remote extremes. It was
there mentioned that the general percentage of mor-
tality caused by epidemic meningitis had, on the
whole, been annually declining since the beginning of
its last appearance. Yet while writing this statement
we learn that the mortality at the Hardwicke Hos-
pital, Dublin, in 1866, was not less that eighty per
cent. In like manner, when it is affirmed that the
disease occasions a less mortality in the spring than
in the winter, the proposition should be accepted in
reference only to the epidemics which having begun
in midwinter decline in the spring months, and not
PROGNOSIS. 103
to those which commence at the latter season. It
has frequently been observed that the severest cases
occur in persons previously in good health. The dis-
ease certainly exhibits no peculiar tendency to attack
the delicate and feeble. In the late epidemic at the |
Philadelphia Hospital, nearly all of the patients were
“of a vigorous and hardy appearance,” and those
whom we saw at the St. Joseph's Hospital and in
private practice were most severely attacked in pro-
portion as they were of the same condition. The
age of the patients is also an important element in
prognosis. The mortality is greater in childhood
than during adult life, and after the age of thirty or
thirty-five it increases rapidly. The disease is nearly
always rapid in its development; but suddenness of
attack or a very short premonitory stage is generally
an unfavorable sign. This is especially the case when
the early symptoms are comatose. But of whatever
nature, violence in these symptoms portends imme-
diate danger. Thus Niemeyer states that life is most
endangered during the first four days of the attack.
Out of thirty-eight deaths, twenty-three took place
within that period. The conclusions drawn by Parks
from his careful analysis, are, “first, the prognosis,
during the first few days, at least, is grave; secondly,
after four or five days have elapsed, if fatal symptoms
be not present, the prospect becomes more hopeful;
thirdly, the patient is not safe, even in convalescence,
since there have been instances of fatal relapse.” It
is remarked by Mannkopff, what, indeed, is true of
many, if not of most other diseases, that a prognosis
cannot safely be grounded upon individual symptoms,
I04 EPIDEMIC MENINGITIS.
since the attack may pursue a course diametrically
opposed to theirs. It is this author's opinion that, on
the whole, the cerebral are of graver importance than
the spinal phenomena. In this he is opposed to
Tourdes, who says that prominent spinal phenomena
are of grave significance, while cerebral without spinal
symptoms are favorable. Everything, we should
judge from our own experience, would depend upon
the quality of the cerebral disturbance. The greater
number of rapidly fatal cases present but few and ill-
defined spinal symptoms. That delirium, even when
violent, is less dangerous than persistent and deep
coma cannot be doubted. The latter is, however, by
no means constant even in fatal cases; nay, not even in
such as terminate fatally within a few hours. Its
absence therefore is not unequivocally favorable. A
symptom of much more evil augury is a want of per-
ception of the gravity of the situation, or unconcern
about its issue. A preternaturally slow pulse is dan-
gerous, especially if it be compressible, giving a delu-
sive sensation of fullness and force. Among the
most unfavorable nervous symptoms are “lively jacti-
tation, rigid retraction of the head, spasms of other
than the spinal muscles, general convulsions, exten-
sive hyperaesthesia, dilatation and insensibility of the
pupil, retention or incontinence of urine, and all cere-
bral paralyses” (Mannkopf), to which may be added
deep coma, paralysis of the muscles of deglutition,
and a rapid change of the pupil from a dilated to a
contracted condition. Coolness of the surface is very
significant of danger, especially when the skin grows
purplish by the diffusion of blood beneath it, or even
PROGNOSIS. 105
by venous stasis. An eruption of petechiae has every-
where been regarded unfavorably, but less so than
the condition just named, while the other numerous
and light colored eruptions incident to the disease are
rather favorable than otherwise. The more rapidly
the dark discoloration or eruption is developed the
more significant it is of peril. Profuse sweats during
a Soporose state; bullae and gangrenous spots; bron-
chial obstruction with serum or mucus; pneumonia
and pericarditis, these are all signs of danger. The
unfavorable signs drawn from the digestive organs
are chiefly these: a dry, fissured, or shrivelled and
pale tongue (Fish), a fuliginous condition of the
mouth; swelling of the parotids (of minor import-
ance); obstinate vomiting; profuse diarrhoea, especi-
ally at an advanced stage of the disease, and persist-
ent albuminuria. On the other hand, the general
mildness of the symptoms, a slight loss of strength, a
moderate degree of pain and muscular stiffness, the
absence of petechiae or vibices, (although in many
grave epidemics they are of rare occurrence); a desire
for food and the ability to digest it, these, it need
scarcely be said, are favorable indications. It will
be found imprudent too confidently to predict the
issue of any grave case of the disease. Patients have
recovered when all hope seemed forbidden, and others
have died on the sudden accession of nervous symp-
toms, cerebral or spinal, when the hour of danger
seemed to have passed away. In other cases, again,
death has come to the patient's relief after months of
helpless misery.
8
106 EPIDEMIC MENINGITIS.
DIAGNOSIS.
The diagnosis of epidemic meningitis may be either
direct or differential. The former includes the cha-
racteristic symptoms of the disease. These have
been already pointed out, but it is proper in this
place to recall them. They depend partly upon a
special abnormal blood crasis, and partly upon inflam-
mation of the cerebro-spinal meminges. The various
proportions in which these elements are commingled
determine the physiognomy of the disease in individual
cases. Although not absolutely characteristic, and
therefore not decisive in an individual case, yet sudden-
ness of attack and rapidity of development, when they
have occurred in many cases, suffice to determine the
character of an epidemic of the disease. The most dis-
tinctive phenomena are these: acute pain in the head,
neck, spine and limbs, faintness, vomiting, stiffness
or spasm of the cervical or spinal muscles, hyperaes-
thesia of the skin, delirium alternating with intelli-
gence, and merging afterwards into dullness, or coma;
occasionally convulsive spasms; paralysis of the face
or of one side of the body. The evidences of blood
poisoning are, the epidemic prevalence of the disease,
various eruptions upon the skin (herpes, roseola, pe-
techiae, &c.), ecchymoses, debility out of proportion to
the evidences of local disease, redness of the eyes,
foulness of the tongue and mouth, and more or less
of the other conditions which characterize the typhoid
state. To these features must be added the rate of
mortality, which is greater in most epidemics of men-
ingitis than that of any disease with which it is liable
DIAGNOSIS. 107
to be confounded. Some writers draw a distinction
between epidemic and sporadie meningitis; but if by
the latter term is intended an idiopathic disease, we
are obliged to confess our ignorance of its character-
istics. Meningitis may occur as an effect of traumatic
causes, and of sunstroke, which is, in fact, a traumatic/
cause, and may be excited by tubercle and othe
morbid deposits in the brain or its membranes, and by
various other mechanical irritants; but of its occur-
rence as a primary idiopathic disease no conclusive
evidence exists. We have never met with an example
of it; neither has Hirsch, who, while admitting that some
such cases have been (erroneously) reported, states as a
proposition, which no one, we imagine, can gainsay, that
the whole of medical literature does not contain a single
case of sporadic idiopathic cerebro-spinal meningitis
with the characteristic sudden onset of the epidemic dis-
ease. Niemeyer asserts that cases of sporadic men-
ingitis are almost without exception symptomatic of
some primary disease or injury; and Klebs, that they
are extremely rare. Köhler's exhaustive treatise on
Meningitis Spinalis presents an array of spinal com-
plications in various diseases which must amaze the
ordinary observer; for he exhibits them in dentition,
sunstroke, rheumatism, suppression of habitual dis-
charges, and suppression and metastasis of eruptions, in
scrofula, tuberculosis, syphilis, gout, cholera, yellow,
intermittent and typhoid fevers, in uraemia, cholaemia,
hydrophobia, and poisonings of various kinds,-yet
it does not seem to have entered his mind that epi-
demic meningitis could be regarded as a complica-
tion or epiphenomenon of any other disease; on the
108 EPIDEMIC MENINGITIS.
contrary, he declares expressly that he had no per-
sonal knowledge whatever of that affection. It is
but just, however, to say that he admits the occa-
sional occurrence of sporadic idiopathic cerebro-spinal
meningitis, and he cites one case out of three or four
which he himself met with. This case is given
in detail, and, except in the absence of an eruption,
is characteristically well defined. But it occurred
at Halle, in 1857, while a severe epidemic of the dis-
ease was prevailing in Sweden. Gordon speaks of
the possibility of confounding epidemic meningitis
with hysteria. He refers to a few cases which ad-
vanced treacherously, with slight malaise and vomit-
ing, lassitude, and occasional pain in the back and
limbs, rendered very acute by pressure. These
symptoms, occurring in delicate females, were occa-
sionally regarded and treated as hysterical. Such
an error seems hardly excusable. The symptoms
enumerated would rather suggest neuralgia or rheu-
matism than hysteria. Fassett states that he saw
many cases of nervous disorder mistaken for the epi-
demic disease: “the community were greatly excited
and alarmed, and every catarrhal or ephemeral fever
was magnified by their fears into something terrible.
Every hysterical girl was at once set to cramping,
with her head bent backwards, if from any cause she
had an attack of headache; nor were these actions
limited to girls, but many nervous ones of the sterner
sex had similar fearful attacks.”
Typhoid fever has only that degree of resemblance
to epidemic meningitis which is common to all diseases
of which the typhoid state is an incident. The con-
DIAGNOSIS. 109
trast was noted by more than one of the earlier
American historians. It is to be remarked that the
term typhus employed by them always indicated what
is now called typhoid fever; for they were acquainted
with no other form of continued fever. The same is
true of most German authors, even at the present
time. Many French writers fail to make the dis-
tinction, also; and English treatises until recently,
confounded typhus, typhoid, and relapsing fever and
epidemic meningitis under the common designation
Fever. In New England, where, as in France, the
endemic fever is typhoid fever, the last error was not
generally committed. Hale says, “it has been cus-
tomary to give the name of typhus to all fevers in
which prostration and exhaustion are prominent
symptoms, however variable their character in other
respects. . . . But if typhus is to be considered as a
peculiar disease, the fever under consideration was
not a typhus; for it did not exhibit the characteristic
symptoms which belong to that disease. It had not
the regular approach, nor the uniformity of appear-
ance of typhus. Its progress was more rapid, its
features more variable, its changes more abrupt, and
its termination more sudden.” No better summary
of the symptomatic distinctions between typhoid
fever and epidemic meningitis has been offered, so
far as relates to the general course of the two dis-
eases. Fish pointed out the distinctive characters
of the two diseases in these terms: “in typhus we
have an increase of arterial action, a foul tongue,
bitter taste in the mouth, and loss of appetite, clearly
indicating a disordered stomach. The intestines also
110 EPIDEMIC MENINGITIS.
ſ
are deranged; the excretions are altered in quality
or quantity; the temperature is increased, and the
skin hot and dry; in short, between almost every
symptom of the two diseases, when they are carefully
compared, there will be found a material difference.”
Tº e impression made on Vieusseux by the epidemic
of Geneva is expressed in these words: “its symp-
toms differed from those of every form of fever with
which the physicians of Geneva were acquainted.”
And let it be remarked, that in that epidemic all
the elements of the disease were present in full
force; the signs of blood changes and those of
cerebro-spinal inflammation were equally distinct.
Tourdes refers to the slow approach of typhoid fever
and the rapid onset of epidemic meningitis; the ex-
quisite pain in the head, the neuralgic pains, spinal
and other, the opisthotonos, convulsions, alternate de-
lirium or coma and clearness of mind in meningitis con-
trasting with the hebetude, stupor, or muttering deli-
rium, and the complete muscular relaxation in typhoid
fever. The sordes on the tongue, the diarrhoea, the
meteorism, the intestinal hemorrhage of the latter, in-
stead of the moist or simply dry tongue and the transient
vomiting and torpid bowels of the former; high fever
on the one hand, slight on the other; diffluence of the
blood and increase in the proportion of fibrin; sup-
puration within the cranium and lesions of the intes-
timal follicles; these as well as the extremely different
duration of the two affections and the circumstances
under which they occur, draw a line of distinction so
broad that none but the blind can fail to see it. Such
seems, also, to be Niemeyer's opinion, when he says
DIAGNOSIS. 111
that the contrast is so clearly defined that it is unne-
cessary to present parallel pictures of the symptoms
and course of the two diseases.
Typhus fever.—Before contrasting typhus fever
with epidemic meningitis, it is necessary to say a
word respecting the term “spotted fever,” which was
the ordinary designation of the latter disease in the
infancy of American medical literature. In this his-
tory we have constantly made use of the documents
relating to epidemics of “spotted fever,” as if they
had been more appropriately entitled, and no one
familiar with the subject will call in question the cor-
rectness of the method. We have elsewhere shown
that the epidemic which prevailed in this country from
1806 to 1815, and was described by Strong, North,
Hale and others, was in reality a meningitis; and
Parks has demonstrated the same truth by a detailed
tabular comparison of the symptoms and lesions in that
epidemic and the present one. It may also be men-
tioned that Dr. J. L. Chandler, of St. Albans, Ver-
mont, who witnessed the first epidemic of meningitis
in that neighborhood, and the recent occurrence of
the disease in New England, recognizes the two affec-
tions as identical. (Boston Med. and Surg. Journal,
lxx, 287.) We should have thought it of less conse-
quence to rectify the error to which we now refer,
had it not been committed by so eminent a physician
as Hirsch, who, in his Monograph on Epidemic Men-
*ngitis, states that “spotted fever” “has nothing in
common with epidemic meningitis,” and refers to a
chapter in his great work on Epidemics for the proof.
In that place is to be found a faithful description of
112 FPIDEMIC MENINGITIS.
the symptoms of the disease, by Miner, Strong, Fish
and Kirtland, from which it is inferred by the author
that the affection was so peculiar that none analogous
to it could be found in the whole range of epidemiologi-
cal literature. “Unfortunately,” he remarks, “the
reporters have not furnished an account of a single
post-mortem examination, so that we are reduced to
conjectures in forming a judgment concerning its
nature.” It is very much to be regretted that the
distinguished author of this opinion had not been ac-
quainted with the dissections made from 1806 onward,
by Danielson and Mann, Bartlett and Wilson, Jack-
son and others, which we have described elsewhere,
and which demonstrate conclusively that the “spotted
fever” of that period was an epidemic meningitis.”
Considering, now, more particularly, the diagnosis
between typhus and epidemic meningitis, it may be
remarked, that by most of the historians of the latter
disease the distinction is insisted upon in strong terms,
while others, as Hirsch, do not even notice it. Several,
however, maintain the identity of the two diseases,
as will be pointed out hereafter. Among American
writers upon the subject who recognized the latter
as a separate and distinct affection, the following may
be cited. “The malignant fever,” says North, mean-
ing typhus, “is dissimilar to this disease in the fol-
lowing respects: the petechiae do not generally appear
in so early a stage of that fever as in this; that fever
makes a more regular course in its progress, like other
* Corson, in his report on the epidemic witnessed by him, says:
“the disease, as described by Dr. North, though no reference is made
to its pathology, was clearly a cerebro-spinal meningitis.”
DIAGNOSIS. 113
fevers, than this; death does not happen so suddenly
in that fever as in this; death happens in that fever
in seven, fourteen or twenty days; in this, it com-
monly happens within forty-eight hours from the
attack; that fever is said to be contagious; this is
not.” Miner says, “we occasionally see the typhus
petechialis of nosologists, but it differs essentially
from the spotted fever of New England;” and again,
“in common language, this epidemic has been gene-
rally called typhus, though it varies essentially from
all the fevers which have received that appellation by
foreign authors.” And once more: “this epidemic,
very obviously was not common typhus, as that term
is intended to include the nervous and putrid fevers
of the older authors.” Fenner at first mistook the
disease for typhus, but in a short time he became
convinced that it was cerebro-spinal meningitis. Dr.
Gerhard was the first person in Philadelphia to call
attention to the present epidemic. If any one was
competent to distinguish another disease from typhus,
it certainly was he who first established upon a firm
foundation the diagnosis of the latter disease from
typhoid fever. It is true that in some points his
conclusions were erroneous; but he pointed out the
rapid and irregular course of cerebro-spinal meningitis,
the absence of calor mordax and the odor peculiar to
typhus; the great difference in the mortality of the
two affections; and the contagiousness of the one, and
the absence of that quality in the other. In Lidell's
excellent paper, it is said of the two affections, “both
of them are blood diseases, and both of them are apt
to be associated with cutaneous ecchymoses. But
114 EPIDEMIC MENINGITIS.
|+I
here the resemblance ends. If we examine their
clinical history with a critical eye, we find that they
differ from each other as widely as typhoid fever and
measles.” He then alludes to the chief points of dif-
ference. Epidemic meningitis often runs its course
in a few hours; typhus requires at least several days.
In the one disease convulsive movements occur, in the
other not; in one the eruption frequently appears upon
the first day, in the other not until the end of a week
or more : “the two diseases are not identical, but
entirely distinct from each other.” So J. S. Jewell
concludes from a tabular analysis of the phenomena
of the two diseases, that “they are not identical, but
really present wide differences;” cerebro-spinal men-
ingitis is “a disease sui generis, and not a mere form
of typhus as it has been assumed to be.” Woodward,
also, points out, in detail, the differences between the
two affections.
Tourdes, referring to the spinal symptoms said by
some writers to be present in typhus, remarks that
epidemic meningitis has more than once been con-
founded with that disease, and he explains the error
by a reference to the extremely varied physiog-
nomy of the former affection. Levy arrives at the
same conclusion. Lebert objects to those who con-
found the disease with typhus, that it differs from
that affection in its anatomical characters, its particular
symptoms and its general course, and its mortality.
Niemeyer declares that he is utterly unable to 'com-
prehend how certain authors should have mistaken epi-
demic meningitis for a form of typhus, or have even
DIAGNOSIS. 115
supposed it to be a nearly allied affection. It may
be objected, perhaps, that the continental physicians
who expressed these opinions were not familiar with
typhus fever, and were, therefore, incompetent judges
of the disputed question. Without attaching much
importance to this objection, we are quite content to
rest the decision of the question upon the evidence of
those who were familiar with both diseases, as, for
instance, the physicians of Ireland. It is true that
they at first (1849) confounded the new affection
with other diseases comprised under the vicious de-
nomination, “fever,” while they agreed that they
never before had met with a similar “fever,” and
they soon learned to term it cerebro-spinal arachnitis
or meningitis. Quite recently (1867), Stokes found
that it differed from typhus in the rapidity of its
course, in the character, mode of appearance, and
duration of the eruption, and in its cerebro-spinal
symptoms. Gordon has, also, stated his opinion that
the marks which distinguish the two diseases have
been so well laid down by certain American authors
that it is difficult to confound them. He adds,
“Murchison, I conceive, has utterly failed in his
attempt to connect them.” In England, also, the
conclusions of this gentleman have not been accepted,
and the British Medical Journal maintains that “it is
impossible even to place the two diseases next each
other in the nosology, much less to admit their iden-
tity. . . . So complete is the contrast between them,
that it is scarcely possible to mention a single charac-
teristic of the former which is also possessed by the
116 EPIDEMIC MENINGITIS.
latter.” Hirsch goes farther still, and, after comparing
epidemic meningitis with various diseases, including
typhus and typhoid fever, in which the typhoid state
exists, remarks: “the analogies which bind typhoid
affections together in a single group are extremely
loose, and hence it becomes all the more difficult to
include epidemic meningitis within it, particularly
when it is remembered, that apart from its very
obscure pathological essence, there is hardly anything
in its symptoms or lesions which bring it within that
comprehensive and elastic title typhus.” For our
own part, having, as already stated, had ample oppor-
tunities of studying both diseases, and especially
having witnessed in a large hospital, and during two
successive winters, an epidemic of each disease, we
fully adopt the language just quoted as faithfully re-
presenting what we conceive to be the truth. It is
very true that without an accurate analysis of the
symptoms, the diagnosis may sometimes be attended
with difficulty; but equally true it is that the noso-
logical table is filled with examples of superficial re-
semblances between diseases which are radically dif-
ferent. It is not long since the two great fevers, so
unlike one another in their causes, phenomena and
lesions, were regarded as merely casual varieties of
the same disease. Indeed, epidemic meningitis itself,
was, as we shall presently see, comprehended, with
still other affections, in the same nosological group,
which, with a sublime contempt for the teachings of
early English and continental physicians, was labelled
with the vague and inexpressive term Fever.
DIAGNOSIS.
117
TABULAR SUMMARY.
EPIDEMIC MENINGITIS.
A pandemic disease. Occurs in places
remote from one another, and without
intercommunication.
Attacks all classes of society. Is
never primarily developed by squalor
and deficient ventilation.
Is not contagious.
More males than females attacked.
More young persons than adults.
Generally occurs in winter.
Eruptions are wanting in at least
half of the cases; they occur within
the first day or two.
The eruptions are very various, in-
cluding erythema, roseola, urticaria,
herpes, &c. Ecchymoses are common.
Headache acute, agonizing, tensive.
Delirium often absent; often hys-
terical, sometimes vivacious, sometimes
maniacal. Generally begins on the
first or second day.
Pulse very often not above the natu-
ral standard; often preternaturally fre-
quent or infrequent. Is subject to
sudden and great variations.
“The temperature is lower than that
recorded in any other typhoid or in-
flammatory disease.” It is also very
fluctuating.
The body has no peculiar smell.
The tongue is generally moist and
soft; sordes of the teeth, &c. is rare.
Vomiting, generally of bilious mat-
ter, is an almost constant and urgent
symptom, especially in the first stage.
Pains in the spine and limbs of a
sharp and lancinating character are
usual, and evidently neuralgic.
Tetanic spasms in a very large pro-
portion of cases and within the first
two or three days. They are due to
an inflammatory exudation within the
spinal canal.
TY PHUS FEW ER.
Essentially an endemic disease. Al-
ways due to local causes. Spreads by
intercommunication only.
Attacks primarily the poor, filthy,
and crowded, alone.
Contagious in a high degree.
The two sexes equally affected.
More adults than young persons.
Epidemics are irrespective of season.
The eruption is rarely absent, and
appears between the fourth and the
seventh day.
The eruption is uniformly roseolous
and then petechial.
T8...I’e,
Headache dull and heavy.
Rarely absent; usually muttering.
Rarely begins before the end of the
first week.
Ecchymoses are
A slow pulse exceedingly rare. Its
rate is pretty constantly between 90
and 120.
The temperature is always more or
less elevated, and it does not fall until
the close of the disease. “The skin is
hot, burning, and pungent to the feel.”
The mouse-like odor of typhus is
characteristic.
The tongue is generally dry, hard,
and brown; and the teeth and gums
fuliginous.
Vomiting is rare, and not urgent.
Pains are dull, heavy, and appa-
rently muscular. -
Tetanic spasms are unknown in ty-
phus. Convulsions sometimes occur,
due to “pyaemia.”
118
EPIDEMIC MENINGITIS.
EPIDEMIC MENINGITIS.
Cutaneous hyperaesthesia is a pro-
minent symptom.
Strabismus common.
The eye, if injected, has a light red
or pinkish color.
The pupils are often unequal.
Deafness often complete and perma-
ment.
Duration very indefinite; but gene-
rally from four to seven days.
Relapses are common.
TYPHUS FEVER.
The sensibility of the skin is gene-
rally blunted.
Rare.
The blood in the conjunctival vessels
has a dark hue.
Always equal.
Hardly ever permanent, or attended
with signs of disorganization of the
€8.F.
Duration from twelve to fourteen
days.
Relapses are rare.
The blood is often highly fibrinous. The blood is never fibrinous.
The lesions, unless in the most rapid
cases, consist of a fibrinous or purulent
exudation in the meshes of the cerebro-
spinal pia mater.
Mortality from 20 to 75 per cent.
There are no inflammatory lesions
whatever.
Mortality from 8 to 40 per cent.
Finally, and to sum up the elements of this contrast,
we cannot do better than to quote the following pass-
age from Dr. Murchison's admirable treatise, in which
he sets forth the diagnosis of typhus fever from
“Meningitis.” “At the commencement of this cen-
tury, the symptoms of typhus were referred to cere-
bral inflammation; and at the present day, typhus is
not uncommonly designated “Brain Fever.’ The chief
points of distinction between typhus and inflammation
of the brain are the following: in inflammation, the
headache is much more intense, and of a throbbing,
darting, bursting, or constricting character; in typhus,
the patient rarely describes it by such terms. The
delirium of inflammation is more violent and acute
than that of typhus, and accompanies or alternates
with the headache; whereas the headache has almost
always ceased in typhus before the delirium com-
mences; the loud cries and screams observed in the
DIAGNOSIS. 119
delirium of meningitis do not occur in typhus. In
inflammation there is great intolerance of light and
sound; but in typhus the senses are obtuse, and deaf-
ness is more common. In both diseases the face is
flushed, and the conjunctivae are injected; but in
typhus the flush is more dusky, and the blood in the
conjunctival vessels of a darker tint than in inflam-
mation. In both diseases there may be general convul-
sions, followed by coma, but typhus never commences
in this way, as meningitis sometimes does. Strabismus
and partial palsy are far more common in inflamma-
tion than in typhus. The physiognomy of meningitis
is anxious and expressive of pain, or wild and defiant;
in typhus it is oftener blank and stupid. In typhus
there is much more muscular prostration from the
first than in inflammation. The pulse in inflammation
is usually firm; in typhus it is soft and compressible.
Nausea and urgent vomiting are common in inflam-
mation; rare, in typhus. Lastly, in typhus, there is
a peculiar eruption appearing about the fourth or fifth
day.”
In this description the following points, alone, are
inapplicable to epidemic meningitis, so far as relates
to its cerebral phenomena. In that disease there is
not usually “intolerance of light or sound,” nor “less
muscular prostration from the first” than in typhus;
nor is the pulse “usually firm,” because there is asso-
ciated with the inflammatory element another one
which is, in different cases, “asthenic” or “adynamic.”
But the reader will probably admit that in every
other respect the description tallies accurately with
the picture we have composed from so many portraits
120 EPIDEMIC MENINGITIS.
of the disease by different hands. Yet its author
had not at all in view epidemic meningitis, which he
had never seen, but either the tubercular, the trau-
matic, or some other secondary form of meningitis;
for as a primary idiopathic disease, meningitis, whether
cerebro or spinal, has not, as we have already stated,
been proved to exist. Now, it is very singular that,
after having furnished so definite and detailed a diag-
nosis between meningitis and typhus, and after having
shown, moreover, by the testimony of Reid, Peacock,
Jenner, Jacquot, Baraillier and Moering, that the
lesions of typhus are quite independent of inflam-
matory action, Dr. Murchison should, when at last
he encountered a few cases of the former disease,
have regarded them as examples of typhus fever with
cerebro-spinal symptoms. Such an error can perhaps
be explained by supposing that these particular cases
were examples of typhus complicated with epidemic
meningitis such as have more recently occurred in Dub-
lin, or that they were simply examples of epidemic
meningitis, of which numerous cases occurred in Lon-
don in 1865, '66 and '67. But it is evident that Dr.
Murchison did not thoroughly appreciate the character-
istic conditions and phenomena of the two diseases.
For example; when he asserts, as he has done, that epi-
demics of meningitis “occur under precisely the same
circumstances as those in which typhus appears,” he
is in opposition to universal experience. As we have
shown elsewhere, crowding, filth, hunger, &c. may
possibly favor the development of this disease, as
they will that of any epidemic whatever. But these
causes generate typhus de novo, which is a very differ-
DIAGNOSIS. 121
ent thing. Again: the author says, “like typhus it
has been propagated by contagion,” a statement in
direct conflict with the testimony of every one who
has witnessed an epidemic of the disease, except
Boudin, whose opinions upon this and other matters
concerning meningitis have been repudiated by all
instructed judges. The spastic muscular rigidity of
epidemic meningitis broadly distinguishes that disease
from typhus; and Dr. Murchison, in his history of
the latter disease does not even suggest the possibility
of such a complication. If, then, as he now informs
us, “during the last three years” he has “in several
instances noted strabismus, tetanic contractions of the
muscles of the limbs, and even opisthotonos,” is it not
probable that they were in reality cases of the epi-
demic meningitis which then existed in London, or
of typhus complicated with the latter disease? Dr.
Murchison also finds that “many American physicians
admit the close relation of cerebro-spinal meningitis
to typhus, while some maintain the identity of the
two diseases.” We believe, on the contrary, that
among American physicians who have had an oppor-
tunity of studying the two diseases, not one has con-
founded them. The error has been committed by
several who did not enjoy this advantage. Dr. Mur-
chison also adopts the judgment of Dr. Upham, that
the disease “partakes of the nature of typhus” with
“a special direction to the meninges of the brain and
spinal cord.” Now, is it the typhous condition to
which the meningeal inflammation is superadded, or
is the meningitis the primary affection? Is it an in-
flammatory typhous affection, or a typhoid inflamma-
9
122 EPIDEMIC MENINGITIS.
tion? To this question but one answer seems admis-
sible. An inflammatory typhus fever would assuredly
be a new thing under the sun; but a typhoid inflam-
mation is one of the most familiar types of disease.
A typhus fever with a special direction to the cerebro-
spinal meninges, appears to us a very pathological
monstrosity. The meningeal inflammation is evidently
due to quite another element than that which originates
the typhous symptoms. The one is specific, peculiar,
and characteristic of this disease alone: the others are
incidental, non-essential, and common to this disease
and many other diseases. That which distinguishes
epidemic meningitis is the concentration of the mor-
bid action of the disease upon the membranes of the
nervous centres, and the tendency of that morbid
action to purulent or plastic exudation. If those who
die of it in the first stage do not always exhibit in-
flammatory exudation, it is simply because death
arrests the inchoate process in its earliest steps. If
the patient survive for several days and then perishes,
the characteristic lesions are revealed. But it is not
so in typhus. No stage, grade, or usual complication
of that disease was ever attended by cerebro-spinal
exudation. In the one, exudative matter is detected
by the microscope first, and then, in due course, by
the naked eye; in the other, such matter is discover-
able at no stage and by no method whatever of ex-
amination. “When the rash of typhus is present,”
says Murchison, “it may always be concluded that
there is no cerebral inflammation.” But there are
writers upon “typhus”, who describe inflammatory
products beneath the cerebral membranes. Thus,
DIAGNOSIS. 123
Roupell states that “in all the cases an affection of
the membranes of the brain was found, either turges-
cence of vessels, increased vascularity, effusion of
serum or pus, or the deposition of lymph, varying
from the thickness of a line to a quantity only suffi-
cient to render the arachnoid opaque.” And South-
wood Smith says, the arachnoid “is seldom or º
in a healthy condition. It is always either more
vascular than natural, or when in this respect un-
changed, it is altered in structure, being thick, opaque,
and milky; when in this latter state a gelatinous fluid
is usually effused beneath it.” This author also fur-
nished a series of cases in which such lesions were
discovered. Now either Dr. Murchison and all other
writers who have described typhus fever since its
diagnosis was established, have fallen into a gross
error in denying the presence of any such lesions in
that disease, or the authors from whom we have |
Quoted, and others who might be cited to the same
effect, erred in their diagnosis, and mistook epidemic |
meningitis for typhus fever, or, it is possible, observed
cases in which the two diseases were associated. Of
the correctness of the latter alternative there is every
probability, as well upon the general grounds already
stated, as upon this, that Smith's Treatise was pub-
lished in 1829, and in the preceding and following
years we know that the disease existed in this coun-
try, and at Sunderland, in England; and that Roupell
wrote in 1839, when it is certain that epidemic men-
ingitis prevailed in France, and may have also existed
in London sporadically. For these reasons, which
may be summarily stated as follows: 1. That the
124 EPIDEMIC MENINGITIS.
causes, symptoms, course, termination and lesions
are radically unlike in the two affections; and 2. That
all physicians who have witnessed epidemics of both
affections, agree in pronouncing them to be different;
we conclude that typhus fever and epidemic menin-
gitis are distinct diseases, having, indeed, nothing in
common but the typhoid state.
NATURE.
The preceding considerations, it is believed, will be
thought sufficient to demonstrate that epidemic menin-
gitis is not typhus fever, and it therefore only remains
to show what is its real nature. Upon this question
we have already several times expressed our opinion,
which is sustained by the judgment of nearly all who
have thoroughly investigated the subject. Before
offering the proof of this statement, it may be amus-
ing, if not profitable, to cite the theory of one of the
earliest, if not one of the most instructive, among
early American writers upon this disease, Dr. Job
Wilson. This ingenious author discovered that “spot-
ted fever” is an “influenzal’’ These are his words:
“the similarity of the influenza to spotted fever is so
striking, that had it not been for the accidental ap-
pearance of spots in some cases, the probability is,
that the present epidemic would still have continued
to be called by that name.” This author presents a
tabular abridgment of the symptoms common to the
two diseases, and concludes that they correspond in
all the most important particulars, and that he “can
discern no utility in considering and treating the
NATURE. 125
spotted fever and influenza as distinct diseases!” In
comparison with this the error of confounding typhus
fever and epidemic meningitis is trivial, indeed, and
venial. It is remarkable that the only point of real
analogy between the two affections should have
escaped an author so possessed by his peculiar and
original idea. Both diseases are, in the strictest
sense, pandemic. Produced by no local agencies
whatever and by no ascertained conditions of the
atmosphere; arising spontaneously and simultaneously
at remote points, and being incommunicable by the
sick to the well, it is impossible to refer them to any
other than specific atmospheric causes. But here the
analogy ceases; the characteristic phenomena of the
two diseases are as different as smallpox and diph-
theria. It may, perhaps, be truly asserted not only
that these two affections are, in a true sense pan-
demic, but that they are the only ones possessing
that character. All other epidemics are propagated
more or less, and either directly or indirectly by
contagion, however much atmospheric conditions may
favor their diffusion. But epidemic meningitis and
influenza appear to proceed, primarily and alone, from
some unknown constituents or conditions of the atmo-
sphere, or some conjunction of terrestrial causes, the
nature of which at present eludes our comprehension
altogether, and about which it is an idle waste of
words to speculate.
But to return. We shall show that while, as the
reader has already seen, some few physicians have
confounded epidemic meningitis with typhus, ignor-
ing altogether its essential and characteristic local
126 EPIDEMIC MENINGITIS.
lesions, and while a small number also regard the dis-
ease as an inflammation merely, the great majority
of those whose sagacity enabled them to perceive,
and whose experience entitled them to judge, agree
perfectly in assigning to it a compound nature de-
rived on the one hand from its specific cause, and on
the other from its local lesions, and proving it to be
at once a blood disease and a meningeal inflammation.
Dr. Strong's inferences from the symptoms of the dis-
ease show that he divined its morbid anatomy: “it is
evident,” he remarks, “from the symptoms, that the
principal seat of the disease is in the brain and nerves.
This, we think, appears from the delirium and coma,
which almost always attend; from the dilatation and
contraction of the pupils; the dimness and loss of
sight; the deprivation of taste; the frequent nausea
and puking, while the contents of the stomach do not
appear to be morbidly affected; from the severe pains
in the head; from the numbness which creeps over
the surface, and the torpid insensibility which per-
vades the whole system. It is likewise evident that
debility and great prostration of vital energy are the
enemies with which we have to contend.” Jackson
and his colleagues, in their report, arrive at this con-
clusion: “the disease is fever combined with internal
inflammation.” Fish says, “spotted fever is seated
in the brain and nerves.” Gallup concludes that it
is “an ataxic fever with a special tendency to inflam-
mation of the membranes of the brain.” Drake is of
the opinion that it is not a mere fever symptomatic
of inflammation of the brain; that “there is a lesion
of innervation made, we know not where, which is
NATURE. 127
followed by another of circulation, giving us simul-
taneously both fever and inflammation.” Davis says,
“I regard the disease as an asthenic inflammation of
the cerebro-spinal nervous centres with their invest-
ing membrane, accompanied by a highly septic con-
dition of the blood.” According to Moorman, the
disease “is essentially an inflammation of the pos-
terior and basilar portion of the brain and spinal cord,
and their meninges.” These judgments at different
periods since the first advent of the disease in this
country, it will be seen, substantially agree. European
testimony upon this subject is to the same effect, but
is generally given in a more detailed and precise form.
Like American authorities, foreign writers give pro-
minence to the septic or to the inflammatory element
in their definitions according to the peculiar type of
the epidemic which they have had to study. Tourdes
remarks, “although pathological anatomy demonstrates
an inflammatory element in the disease, it is certain
that there is something besides; it is a specific inflam-
mation, a poisoning, a cerebral typhus, produced by
a specific miasm which has an elective affinity for the
membranes of the nervous centres.” C. Broussais
adopts the less comprehensive view, and recognizes
but one element in the disease. He says: “it is an
ordinary but violent inflammation which differs from
other acute and fatal phlegmasiae, only in its seat.”
In like manner Levy remarks, “its most constant and
striking characteristic is the tendency to suppura-
tion . . . and it is not a typhus, whatever analogies
with that disease it may present.”
The physicians of Dublin during the recent epi-
128 EPIDEMIC MENINGITIS.
demic agreed that it was a very different disease
from typhus, while some laid more stress upon its
inflammatory and others upon its septic element.
Among others, Dr. Law, who had had peculiarly
favorable opportunities for observation, “looked upon
it, no matter how modified, as cerebro-spinal arach-
mitis;” Dr. Kennedy held it to be both a blood dis-
ease and an inflammation, the latter being less essen-
tial than the former; Dr. Hayden recognized the same
elements in the disease, but maintained, on the con-
trary, that the cerebro-spinal inflammation is at least
as original and primary as the disorder of the blood;
Dr. Moore “thought physiology and pathology must
lead us to view this disease as essentially of a cerebro-
spinal character;” Dr. Banks “believed the disease
was a blood disease, and that the greater number of
cases were cerebro-spinal arachnitis.” The same
opinions, substantially, were expressed by Dr. Stokes.
It is, says Wunderlich, “a disease, sui generis, and is
not to be regarded merely as the expression and re-
presentative of internal local lesions.” The symptoms,
he further remarks, are not in exact proportion to the
lesions, nor are they all explicable by them. Hence
it is necessary to admit a constitutional as well as a
local element of the disease, which often, indeed, be-
comes the predominant one, just as in eruptive and
typhoid fevers, in diphtheria, dysentery, erysipelas,
&c. the most fatal cases are those precisely in which
death occurs at so early a stage, through the violence
of the constitutional element, that the local lesion re-
mains incomplete or is entirely undeveloped. Hence,
too, in the disease under consideration, its physiog-
NATURE. 129
nomy varies with the predominance of the blood
changes on the one hand, or of the meningeal lesions
upon the other; and there is every probability that
in this, as in most other epidemic diseases, the mor-
bid cause exerts its primary action upon the blood.
Hirsch concludes that the disease is sui generis, dif-
ferent from all others etiologically and pathologically.
It has no local origin nor geographical limits, is due
to no local causes, nor any appreciable conditions
whatever, and therefore it can only be due to a
specific cause. It differs from many other epidemic
diseases by the concentration of its poison upon a
single organ, while many phenomena distinctly indi-
cate its operation throughout the whole economy,
especially the petechial and other eruptions, but most
of all those rapid cases which terminate fatally within
a few hours. This is also, substantially, the judgment
of Niemeyer and Mannkopf. Klebs illustrates his
opinion by suggesting the analogy of epidemic men-
ingitis and of typhoid pneumonia, in which also, there
is a predominant typhoid type and a local inflamma-
tion. The same may be said of epidemic dysentery.
Rlebs remarks further, that it may be questioned
whether the general disorder of the system proceeds
from the local affection, or whether both are not direct
effects of the unknown epidemic cause. Having ascer-
tained that even when inflammatory lesions are invi-
sible to the naked eye, they may nevertheless be de-
tected by the microscope, he concludes that these
lesions are essential to the disease and are direct and
primary effects of the action of the morbid cause.
Apart from this we should still so regard them, inas-
130 EPIDEMIC MENINGITIS.
much as they are uniformly, and even visibly, present
if death has not intervened to prevent their develop-
ment. So constant a lesion cannot be accidental, and
must be essential. The inflammatory element and
the septic element are both necessary to constitute
the disease; either may be in excess and overshadow
the other. According to the relative predominance
of one or the other, the disease assumes more of a
typhoid or more of an inflammatory type, and it is
this diversity in its physiognomy which has led to
such opposite doctrines in regard to its nature and its
mosological affinities.
NAME OF THE DISEASE.
Gallup commences the chapter “On Spotted Fever,”
in his work on Epidemics, with these words: “Having
little anxiety what name is attached to any particular
habit of disease, provided that the name does not in-
fluence the treatment, we shall not dispute about this,
and shall be as willing to continue it as any other;
and more so at this time, as everybody knows what
is meant by it.” Here are two bad reasons, at least,
for an erroneous conclusion. Words are things; and
few indeed are the physicians independent enough to
treat a disease by one method, when its accepted
name clearly indicates the decision of the profession
that an opposite method is alone appropriate. If
everybody knew what is meant by “spotted fever,”
many papers, including Dr. Gallup's and the present
one, might have remained unwritten, and the learned
physicians of Dublin, in college assembled, would not
NAME OF THE DISEASE. 131
have proposed at least eight different names for the
existing epidemic.” It is well known that the disease
is popularly called “spotted fever,” and that a great
many physicians have, perhaps thoughtlessly, adopted
the popular name. It is not so well known, or recol-
lected, that the epithet petechial was early used by
physicians in this country, although the term was
really less accurate than the vulgar one, inasmuch as
purpurous spots were more frequent than petechiae.
North himself, in 1809, designated the disease as
“typhus petechialis, or the malignant spotted fever.”
But in 1811, he writes, “this symptom (petechiae)
does not occur so often as the name which this dis-
ease has obtained would lead one to expect.” Per-
haps, also, he discovered that the name had been
already appropriated to quite another affection by
Huxham and Hoffmann, and many others after them,
viz. petechial typhus with which Irish emigration,
and some local epidemics, have made the physicians
of our Atlantic seaports familiar. Strong had the
same experience as North, and guided by it made a
similar statement. “So frequent, indeed,” he re-
marks, “was this species of hemorrhage (petechial)
during the first season in which the disease prevailed,
that it was considered one of its most striking cha-
racteristics, and gave rise to the name PETECHIAL, or
SPOTTED FEVER, which has been very generally though
* The following are the names referred to. “Malignant purpuric
fever” (Stokes); “Cerebro-spinal fever,” and “Fever with cerebro-
spinal meningitis” (Gordon); “Febris migra” (Lyons); “Malignant
purpura” (McSwinney); “Pestilential purpura.” (Banks); “Black
death” (A. Smith); and “Cerebro-spinal meningitis” (Hughes, Law,
Banks, Hayden, Moore, Bennett, and others). -
*
fºr-
I 32 EPIDEMIC MENINGITIS.
very improperly applied to the disease.” In 1808,
W. Foot wrote, “some have given it (but improperly)
the name of spotted fever.” In 1810, the committee
of the Massachusetts Medical Society remarked that
“the name of spotted or petechial fever has been con-
sidered improper by most medical men who have had
occasion to remark upon the subject.” In 1812, a
writer in the New England Journal, referring to the
same subject, remarks: the disease “being only occa-
sionally accompanied with spots, it seems somewhat
out of rule to name it by a character which is so little
constant.” In the following year, and in the same
journal, another writer calls attention to the rare
occurrence of petechiae, and remarks that “the em-
ployment of this appearance to designate the disease,
must, therefore, be considered very unfortunate.” In
the same journal, also, of 1814, we find that “well
informed practitioners of all descriptions are dissatis-
fied with the name;” and again: “the discontinuance
of the name “spotted fever’ is not merely desirable
for the sake of correctness of speech, spots being
neither peculiar to, nor constant in this complaint; but
where this name prevails, the frequent absence of
spots leads to doubts as to the existence of the dis-
ease.” So Fish, in 1815, remarked, “the name by
which the disease is known is incorrect; because,
strictly speaking, it is not a fever, and it is rarely
attended with petechiae or spots.” In 1822, Miner
expressed himself strongly upon the subject, in these
words: “it is quite unfortunate that a single symp-
tom (petechiae), and one, too, which is wanting in a
great majority of the cases, should have been seized
NAME OF THE DISEASE. 133
upon, to give the odious and deceptive name of spotted
fever, as that name has been applied by European
writers to a very different kind of fever. Indeed,
petechiae may appear in diseases of a very different
character; and often in purpura hemorrhagica, sea-
Scurvy, and other chronic complaints which are unat-
tended with fever.” Finally, in 1849, when Sargent
published an account of cerebro-spinal meningitis, as
it occurred in Millbury, Massachusetts, he referred
to the history of the epidemic of 1812, and to the
name it received in these words: “they gave the
name (spotted fever) to the epidemic only because
its lesion was not known, and the name was pic-
turesque.”
When American medical writers of the present
day designate epidemic meningitis as “petechial” or
“spotted” fever, although these terms were con-
demned by the first historians of the disease in this
country as inappropriate, and although later experi-
ence and the revelations of morbid anatomy have
alike demonstrated them to be incorrect, we are un-
willingly led to conclude that either they are unac-
quainted with the history of the disease, or that they
have not attentively studied its phenomena, or tho-
roughly investigated the evidences of its nature. In
Europe this error has rarely been committed. With
few exceptions, all who have written upon the sub-
ject, whether English, Irish, German or French
authors, are substantially agreed that the proper title
of the disease is epidemic meningitis, or cerebro-Spinal
meningitis. Even among the physicians of Dublin,
those only who were least familiar with its phenomena
º º
º
de &
134 EPIDEMIC MENINGITIS.
indulged in that luxury of nomenclature to which
allusion has already been made. In those of the
foregoing pages which relate to the general history
and description of the disease, as well as in those
more particularly devoted to determining its nature
and its proper name, it is hoped that the reader will
find satisfactory reasons for giving it the only title
which usage, authority and sound logic approve.
TREATMENT.
The difficulties involved in the questions which
have hitherto been discussed in this essay, and which
refer exclusively to the history, phenomena and
nature of epidemic meningitis, are trifling in compari-
son with those that relate to the cure of the disease.
These are partly inherent in the general subject of
therapeutics, in which no problem whatever is sus-
ceptible of a categorical and permanent solution.
They depend still more upon the epidemic nature of
the disease in question; for this nature gives to dis-
eases a much greater diversity of type and tendency
than they ever assume in their sporadic condition.
These difficulties are further multiplied by occurring
in a disease which stands alone in all other respects;
whose causes, phenomena and lesions, in a word,
whose laws are specific, and whose varieties of type
are as infinite as can be formed by the combination,
in constantly varying proportion, of a special disease
of the blood deranging the molecular actions of the
economy, and an inflammation of the cerebro-spinal
meninges, and even of the substance itself of the great
* > ** tº Q
• * * *
TREATMENT. 135
nervous centres. These reasons are sufficient to
account for the divergent, and often opposite methods
of treatment which have been adopted and recom-
mended by physicians of equal sagacity, at different
times and places. By some a most actively stimu-
lating and tonic method has been pursued, because
the disease, in their experience, was one of utter
prostration from the commencement, a “sinking
typhus” as they expressively termed it. To others
active inflammation of the brain and spinal marrow,
denoted by excruciating pain and tetanoid phenomena,
appeared to call for the use of vigorous antiphlogistic
measures, or the constitutional operation of mercury.
Others, still, discerned an imperative indication for
the administration of large doses of opium to coun-
teract the spasmodic phenomena and the severity of
the neuralgic and cerebral pain which are so distinc-
tive of the complaint, without particular regard to the
physical causes of the pain itself. These are the
most prominent and characteristically different methods
used in the treatment of epidemic meningitis; and
while it seems probable that each may have been
successful, and therefore right, as a general method
applicable to one or another of the several types
assumed by the disease, it is equally certain that a
uniform, or even a general success can be claimed for
neither of them. We are too apt to think, or at least
to speak as if we thought that all cases of an acute
disease are curable, and that the rate of its mortality
is also a measure of our own ignorance or inefficiency.
In this we greatly err. Our art is as little respon-
sible for the enormous mortality of epidemic menin-
136 EPIDEMIC MENINGITIS.
gitis as it is for that of cancer or tuberculosis, or for
the rapidly fatal issue of certain wounds and other
injuries. In epidemic meningitis, as in other acute,
and especially epidemic diseases, many cases are fatal
from the outset; the first symptoms of the attack are
the first phenomena of death. On the other hand,
many are so slight as scarcely to require medicinal
interference for their cure. But the event of many
others is determined by the appropriateness and the
opportuneness of the treatment, of which we shall
now attempt to furnish the elements; but their suc-
cessful application depends upon the sagacity of the
physician.
ANTIPHLOGISTIC METHOD–EMETICS.—All whose ex-
perience entitles their judgment to respect insist upon
the necessity of the early application of remedies.
The forming stage of diseases is a precious and a
fleeting opportunity for their cure. The organic ele-
ments which are then crystallizing, or, if the figure
seem more apt, germinating, and assuming a determi-
nate and permanent form, may at that stage some-
times be dispersed by a judiciously vigorous treat-
ment. Hence it is that emetics have always, until
the present dainty epoch of therapeutics, been held
to be useful, if not indispensable, remedies in the first
stage of nearly all diseases. It was so during the
epidemic of Geneva. Vieusseux attributes the mor-
tality which then occurred, in great part to the neglect
of evacuants used to combat the earliest symptoms of
the attack. “The first, the principal, and often the
only remedy” which he found necessary, was tartar
emetic, in the dose of half a grain every ten minutes,
TREATMENT.-ANTIPHLOGISTIC METHOD, 137
or sufficient to produce full and free vomiting. This
dose was repeated five or six times, or oftener, accord-
ing to its effects. Sometimes it arrested the vomiting,
the fever, and the pain in the head immediately, and
was generally sufficient for the cure. It is to be re-
marked that this treatment was applied to an epidemic
which presented in a marked degree those purpurous
spots which suggested the vulgar name of “spotted
fever.” Yet, if we are not mistaken, Vieusseux is
the only writer by whom it is recommended. Strong
and North condemn all evacuations until the energy
of the system has been in some degree restored.
Gallup admits that emetics have been used sometimes
successfully, but that, after all, their good effects are
doubtful. Hale, at the commencement, employed
this method, but was disappointed in its effects, and
Soon omitted it. But where the stomach was mani-
festly deranged “previous to the attack of fever,”
it sometimes arrested the progress of the disease.
Tartar emetic and ipecacuanha together were pre-
scribed by Hale. Miner condemned emetics as liable
to produce uncontrollable vomiting, and therefore
dangerous exhaustion. In Europe this method has,
with the exception stated, been but little employed,
and is generally disapproved. Yet Tourdes prescribed
full doses of tartar emetic to twelve patients among
those most dangerously ill, and near the commence-
ment of the attack. Four of them recovered, and
two seemed to owe their improvement to the medi-
cine. We need not, therefore, absolutely shrink from
using tartar emetic or ipecacuanha, or warm bitter
infusions during the primary period of the disease,
*
10
138 EPIDEMIC MEN1 NGITIS.
according to the strength of the patient, hoping thereby
to scatter the congestion which tends to produce exu-
dative inflammation of the cerebro-spinal membranes,
and to aid in eliminating the morbid material of the
disease.
PURGATIVES.—Of these medicines little need be
said. Experience has nothing in their favor to pre-
sent, and there is no indication founded on analogy
which is of sufficient weight to be regarded. As
Miner remarks, “it is as safe to leave a wounded
artery to nature, as in this disease to administer a
cathartic, without directing its free operation to be
instantly checked by opium. . . . One patient was seen,
that sunk irretrievably, by a single operation of an
enema.” Except upon the dangerous ground that a
remedy must be directly addressed to every symp-
tom, there is no room for cathartics in this disease.
The constipation, if any exists, yields usually without
purgative medicine, and is, in fact, and as far as it
goes, a sign of health rather than of disease.
DEPLETION.—If a judgment were now, for the first
time, to be pronounced upon the value of depletion
in this disease, it would certainly be unfavorable;
but a suspicion might fairly be entertained that it had
been biased by the doctrines, or prejudices, whichever
they may be, of the present day. But when we look
at the history of epidemic meningitis, which includes
a period when blood-letting was a cardinal point of
doctrine in the orthodox creed, we still find that the
weight of authority was opposed to its use. During
the first epidemic in this country, Strong informs us,
some persons had recourse to the lancet, hoping to
TREATMENT.-DEPLETION. 139
relieve the patients from the depression supposed to
depend upon congestion; but upon finding that “the
pulse, instead of rising, sunk still lower after a mode-
rate bleeding, they laid aside their lancets.” Foot,
North, Hale, Jackson and Miner, among the early
American authorities, agree in condemning it; Gallup,
alone, advocated depletion on the ground of its reliev-
ing internal congestion, allowing the heart to act more
freely, and favoring diaphoresis. He insisted that it
was “often necessary and sometimes indispensable.”
The “grounds” just stated can only afford a founda-
tion for practice, in so far as the practice is justified
by experience; in that case they are superfluous, or
are merely useful in enabling us to generalize them
as facts along with other similar facts. The testimony .
of Ames upon this question is so circumstantial and
decided that we transcribe it almost entire, only re-
minding the reader that the epidemic to which it
relates was one in which neither ecchymoses nor
other evidences of blood dyscrasia were prominent,
but in which, on the contrary, cerebro-spinal inflam-
matory lesions attained their fullest development.
Blood-letting “was employed, with few exceptions,
only near the beginning of the attack. It was used
frequently, and boldly, without regard to the state of
the circulation, that is, as readily and freely in the
congestive as in the inflammatory forms. The quan-
tity taken at one bleeding, or at several in quick suc-
cession, was sometimes very great—on one occasion
the quantity ascertained to have been taken at a
single bleeding was forty-eight, and on another forty-
four and a half ounces. In many other instances
140 FPIDEMIC MENINGITIS.
bleedings equally large, or larger than these were
had, but the precise quantities were not ascertained.
In one case which I visited in consultation, eighty
ounces were taken at several bleedings within twenty-
four hours. In a case treated by Dr. Boling, a female,
fifteen years old, with the notes of which I have been
furnished, there was taken by cups from the neck and
occiput forty-eight ounces, and from the arm twenty-
six ounces, all within eighteen hours. These are
extreme quantities; in the greater number—the quan-
tity taken altogether from adults in one day, varied
from fourteen to forty ounces—in twenty-six cases,
the average was found to be thirty ounces. The
effects of blood-letting were not so satisfactory as
might have been expected. Within, my own obser-
vation they were never promptly decisive for much
good or evil; the pulse in congestive cases rarely ever
filled up, or became regular from it; in some instances
it became quicker and more feeble during, or soon
after rather a small bleeding taken on the first day of
the attack. In the inflammatory form, also, the same
thing was occasionally observed, though in this form
an improved state of the pulse was more frequently
the immediate consequence of the loss of blood. The
most common sensible effect, however, was relief to
the cephalagia, but even this advantage was not always
gained. In the case referred to above, of the loss of
forty-four and a half ounces at one bleeding, the pain
which was distressing to the last degree, was hardly
at all relieved, although the pulse was enfeebled by
it, and the face made pale at the time, and for several
days afterwards. In another instance in which the
TREATMENT.—DEPLETION. 141
symptoms, besides the cephalalgia, seemed urgently
to call for this remedy, no relief whatever was ob-
tained from it, notwithstanding that both the pulse
and skin were greatly affected by it, as in the other
case just mentioned, and a tendency to syncope was
much complained of during and for some time after
the abstraction of blood. Nevertheless, prompt and
free bleeding in the early stages, and the earlier it
seemed the better, must, I think, have been of con-
siderable advantage in this epidemic in both the con-
gestive and inflammatory forms. Though the benefit
was neither immediate nor decisive, yet I cannot doubt
in surveying the whole ground, that time at least was
gained by it for other remedies more obviously bene-
ficial to produce their effects. It is certainly true,
however, that the impression of the physicians gene-
rally here in regard to bleeding, even in the bold, and
I may be allowed to add, the judicious manner in
which it was applied, was one of disappointment.”
In Europe, among others who adopt the same
views, may be mentioned De Renzi, who says, “we
have little reason to be pleased with its effects. Em-
ployed the first day of the disease with great modera-
tion, and in young and robust patients, it to some
extent moderated the severity of the symptoms, but
not to a very gratifying degree.” Tourdes tested to
the fullest extent the treatment of this disease by
depletion; his testimony, in an abridged form, we
subjoin. “From one to four times each patient was
bled to the extent of from eight to sixteen ounces;
from fifty to two hundred leeches were applied to the
temples, the mastoid processes, &c.” Now, “what
t
142 EPIDEMIC MENINGITIS.
was the influence of this antiphlogistic treatment? the
statistical results furnish a peremptory reply: the
mortality nearly reached the proportion of two-thirds.
Assuredly such a result leaves no doubt whatever in
regard to the general uselessness of the depletory
method.” This is certainly a very mild judicial sen-
tence. It follows from the reports of different French
physicians, whose testimony is collected by Boudin,
that nearly all formed an unfavorable opinion of the
curative power of depletion. Mottet asserts that de-
pletion, whether general or local, is always mischiev-
ous. Lefèvre, Faure, Besseron, Corbin, Maillot and
Laveran, pronounce it to be either useless or injurious.
Faure Villars lost 42 patients out of 101 treated by
the antiphlogistic method. About four pints of blood
were taken from each. Rollet claims to have cured
by an equally sanguinary practice all of fourteen
cases, in which he judged the membranes only of the
cerebro-spinal axis were inflamed, and six out of ten
cases in which he diagnosticated a simultaneous in-
flammation of the nervous centres. Forget, Mouchet,
Magail and others, equalled, if they did not exceed
these physicians in the lavish expenditure of blood,
which, fortunately for them, was not their own.
It is not easy to distinguish between the relative
values assigned by experience to general and to local
depletion, for in the greater number of reports both
measures were conjoined. Yet the impression seems
to have been that the latter is less open to objection
than the former. In the epidemic at Rastatt, Nie-
meyer found local depletion so efficient in relieving
pain, provided that it was early resorted to, that he
TREATMENT.—COLD TO THE HEAD AND SPINE. 143
attributes to it the most useful influence. But others
have made the observation, which we are able to
confirm, that in young persons, and especially in chil-
dren, the least abstraction of blood may be followed
by dangerous exhaustion. Our own observation
would lead us to conclude that in the more sthenic
cases, scarified cups applied to the nape of the neck
and along the cervical vertebrae are of essential ser-
vice in mitigating, and generally, indeed, in wholly
removing the neuralgic pains which form so promi-
ment and so severe a symptom in many cases of the
disease. When any abstraction of blood appears to
be contraindicated by the patient's debility, dry cups
afford him signal relief, and render the effects of vesi.
cation more prompt and complete.
CoLD TO THE HEAD AND SPINE would almost instinct-
ively be employed by any physician acquainted with
the pathological changes going on in the nervous cen-
tres in this disease, or even by any one who witnessed
the patients’ complaints of pain in these parts. In the
Massachusetts Society Report of 1810, we read, “cold
water, snow and ice have been applied to the head.
These applications have been made when there was
violent pain in that part with heat and flushed face,
and when there was violent delirium. The cold ap-
plications have in these cases afforded great comfort
to the patient, and have mitigated or removed those
very important symptoms. Sulphuric ether dropped
on the head and allowed to evaporate has produced
similar good effects.” Rollet recommends that when-
ever the head is warm or there is a tendency to drow-
siness a bladder containing pounded ice with bran
144 EPIDEMIC MENINGITIS.
should be applied. Niemeyer thinks highly of such
applications in the first stage, and especially of cold
effusions upon the head while the patient is in a warm
bath. Sanderson saw beneficial effects arising from
ice to the head and to the spine during the forming
stage. Mannkopf strongly recommends cold applica-
tions to the head; and Hirsch pronounces them the
best of all the antiphlogistic remedies employed in
this disease. To these judgments we substantially
subscribe; but we believe that the value of the remedy
is almost entirely restricted to the forming stage of
the attack, and while the pain in the head is most in-
tense. Its soothing influence is then very marked.
Heat of head is not an essential indication; for even
in the most violent cases its degree is rarely extreme,
and it is often entirely wanting. Pain calls more dis-
tinctly for the remedy, but, when this symptom has
subsided, the application is more annoying than grate-
ful to the patient. The best method of applying cold
is that already mentioned, i. e. a bladder containing
pounded ice mixed with bran. But cold affusions are
also very valuable, especially in children, whose thin
skulls permit the prompt and full operation of the
remedy. A long rubber bag filled with iced water
is sometimes fastened round the head. Its shape,
color and projecting brass screws give it a revolting
aspect, and its weight renders it oppressive.
ExTERNAL STIMULANTS.–Blisters, it will readily be
supposed, have been employed whenever the evidences
of active inflammation within the cranium and spine
were believed to exist; but they were also prescribed
originally to relieve pain in these parts. Perhaps
|
TREATMENT.-EXTERNAL STIMULANTS. 145
they have been esteemed more valuable by American
than by European physicians. Strong found that
they checked vomiting and relieved coma, and stimu-
lated the whole system; but that in the more violent
cases the skin was not vesicated by them. In the
comatose variety, North says, “I have thought a
blister applied to the nape of the neck a very useful
remedy,” and he also advises it to relieve pain in the
head. Gallup says that “blistering ought to follow
as soon as the patient has had warmth applied in the
first instance.” He prescribes the application of blis-
ters to various parts of the body as general stimulants,
as well as to the scalp and neck for their revulsive
operation. Jackson states that vesication “has been
followed by the most important good effects;” and
Hale, while confirming all of these statements, quali-
fies them with the remark that he found blisters to
exhibit so much less power of relieving coma in this
than in other febrile affections, that he at last ceased
to prescribe them for that symptom. The substantial
lesions (exudation, softening) in the one case, and the
simple congestion in the other, suffice to explain this
perfectly correct statement, and they also demonstrate
the necessity of resorting as early as possible to these
remedies, in order to obtain from them their full ad-
vantage. Yet we think that Hale underestimated the
epispastic treatment. Miner appreciated it more
highly when he urged the necessity of stimulating
the whole system by heat, &c. and the skin by rube-
facients, before attempting to blister; then, he re-
marks, “the freest application and repetition of
them was attended with the most obvious beneficial
146 EPIDEMIC MENINGITIS.
effects.” ... “In every case” he adds, (“the very
mildest are not with safety excepted), the forehead,
and in the severe, the vertex should be immediately
| blistered. Shaving the head and blistering it early,
is more serviceable than any other external applica-
tion.”... “So sensible were those patients who had
their reason, of the beneficial effects of blisters, that
they frequently begged to have them repeated.”
Ames furnishes equally positive testimony; he says,
“blisters were found to be very valuable applied to
the upper part of the vertebral column; in mild and
grave cases they seldom failed to remove or greatly
relieve the cephalalgia. In the malignant varieties,
also, the relief afforded by them was frequently very
great.” Hirsch remarks, that while this treatment
may not exert a substantial influence upon the course
or issue of the disease, it no doubt, in some cases,
produces a diminution of the phenomena denoting de-
pression; while Tourdes asserts that blistering the
scalp, the spine, or other parts, increased the pain
without mitigating a single symptom. It is evident
from all of these statements taken together, that the
utility of blisters in this disease is far from being uni-
formly evident. It seems probable that in different
epidemics they differed in their operation according
to the presence or absence of unknown conditions;
for the testimony, inconsistent as it is, cannot be re-
jected. Were we to judge according to our own
experience alone, we should assign to blisters, applied
to the occiput and nuchae, a very high place among
the remedies for certain forms of this disease; for we
know that they relieve or remove pain, diminish de-
TREATMENT.—EXTERNAL STIMULANTS. 147
lirium, spasm and coma, and therefore contribute as
directly as any other remedies, if not much more so,
to the favorable issue of the attack. But to accom-
plish these salutary effects of their use, they must not
be employed when the disease assumes a malignant
type, nor in any case after its constitution has become
definitely fixed. Rollet is the only writer upon this
subject, we believe, who recommends still more ener-
getically revulsive agents. When the skin was not
irritated by blisters, he employed the actual cautery
on either side of the spinous recesses of the vertebrae,
and from the head to the loins. Such “barbarous
experiments,” as Hirsch appropriately calls them,
require no especial comment, particularly as no one
has yet been bold enough to repeat them.
In the early history of epidemic meningitis in this
country we find much greater stress laid upon vari-
ous means adapted to warm the patient's body than
is to be observed in recent publications upon the sub-
ject either in Europe or America. “The body MUST
be got warm, the skin moist, and the energy of the
pulse restored, or THE LIFE OF THE PATIENT IS GONE,” are
the emphatic words of Strong. “The unanimity pre-
dominant is sufficient to establish the fact respecting
the utility of heating and sweating remedies,” says
North. According to Jackson, “the patient is first
put into a warm bath (others insist that it shall be
hot) or his feet bathed in warm water; then being
well rubbed, he is to be laid in bed between blankets,
and bedclothes added in proportion to his sensations
or to his actual temperature when his sensibility is
very much diminished. Around him are to be placed
148 EPIDEMIC MENINGITIS.
bottles of hot water or billets of wood heated in boil-
ing water and wrapped in flannel, or he is to be
wrapped in flannel wrung out of boiling water; sinap-
isms are applied to the feet, and he is to swallow
frequently some warm liquid,” . . . “as hot infusions
of the leaves of mint, pennyroyal and other similar
plants, wine whey, wine and water, wine, brandy and
other ardent spirits more or less diluted, camphor,
sulphuric ether and opium. It is not generally
thought useful to excite profuse sweating, but im-
portant to maintain it from twenty to forty hours,
and even longer in some instances. Soup and cor-
dials are at the same time administered. Under this
treatment most commonly the violent symptoms, and
not very rarely all the appearances of disease have
subsided.” It is difficult to explain why a method
which has in its favor the testimony of sound experi-
ence, and the strongest possible reasons based upon
analogy and the well established principles of therapeu-
tics, should have fallen into such disuse as almost to
have been forgotten. It cannot be because the type
of disease requiring it is no longer met with, for,
during the recent epidemic, physicians have become
familiar with all its types and grades from the malig-
nant to the inflammatory. One exception to the
statement just made is furnished by Gordon, who
says, “what I have seen most useful in the stage of
collapse is external warmth applied to the entire sur-
face by means of flannel bags containing roasted salt,
applied along the spine, along the chest, inside the
arms, and to the feet and legs, and between them.”
INTERNAL STIMULANTs.—Except typhus fever, there
TREATMENT.-INTERNAL STIMULANTS. 149
is no disease in which the due administration of stimu-
lants, and especially of alcohol, may become more
essential to its successful treatment. But as the type
of the disease varies from time to time between malig-
nant and inflammatory extremes, the need of stimu-
lants may be very slight or quite imperative. In
point of fact, we find that while in the early history
of epidemic meningitis in this country alcoholic and
other stimuli were sometimes lavishly used, they
formed but a subordinate and generally quite an in-
significant part of the method usually adopted in
Europe. How far the former course was pursued
by our professional predecessors in imitation of the
British treatment of typhus, or how far the latter
plan was preferred by the French physicians of 1836,
and subsequently, because they had been educated
in the sanguinary school of which Broussais and
Bouillaud were chief teachers; or how far, finally,
the method of treatment in each case was determined
by the predominant genius of each particular epi-
demic, it may not be possible to determine; but,
probably, each of these influences had its share in
the result. Indeed, it seems quite certain that the
earlier American physicians who did not know, or
who only knew imperfectly, that one element of the
disease was inflammatory, and who were naturally
influenced by those of its phenomena which led some
among them to call it “sinking typhus,”—it seems
quite certain, we say, that they should at first incline
to the free use of stimulants; just as it is natural in
Europe, where its first epidemic visitations fell within
the period when inflammation dominated in pathology,
150 EPIDEMIC MENINGITIS.
and its inflammatory element was immediately dis-
cerned, that the tendency should have been to coun-
teract the disease by the most powerful weapons of
the antiphlogistic armament. But time, which, in all
things blunts the extreme edge and point of mischiev-
ous error, has modified and, as we believe, improved
the therapeutics of this disease by demonstrating the
dangers to which the sick are exposed, alike from an
excessively stimulating and an extremely antiphlo-
gistic method of treatment.
The predominant view among American physicians
of the first epoch with which we are concerned is well
illustrated by the language and precepts of Strong,
who says: “the first, the great, I had almost said the
only indication of cure” is “to support the vital energy,
to raise the patient from his depressed state, and to
hold him up till the disease passes off.” He then
adds that this purpose is to be carried out “by a
proper use of nutritious diet, and of tonic, cordial and
stimulating medicines.” This “proper use,” he clearly
explains, will depend upon the condition of the patient;
some cases will require only hot aromatic infusions,
others wine, and others, again, brandy, either simple
or spiced. He relates the case of a delicate female
who took more than a quart of brandy in the course
of eight hours, and a grain of opium every two hours;
and when the brandy could not otherwise be retained
it was administered saturated with loaf sugar. This
treatment roused her from a comatose, cold, and
almost pulseless state, with constant hiccough besides,
and saved her life. So North lays down the general
precept, that “the tonic and stimulating method of
TREATMENT.—INTERNAL STIMULANTS. 151
cure, as opposed to the debilitating plan, is the correct
one,” while he admits that the degree of its use must
be regulated by the physician's sagacity. In regard
to the form of stimulus, he remarks, “fermented
liquors of every kind may be used: of these claret,
port and Madeira wine are preferred. Those who
supposed distilled spirits are equally suitable, as
general remedies, are much mistaken; though these
may have their use as sudden stimulants.” Again,
he lays down the valuable rule that wine is often
beneficial even where it is not necessary. Woodward
observed that very large quantities of wine or ardent
spirits may be given without doing any injury. Arnell
says: “in some cases I have given a quart of brandy
in six or eight hours with the happiest effect.” Has-
kell and his associates maintain that “the bold and
liberal use of diffusible stimuli is the only safe and
efficacious mode of treatment.” Fiske, however,
denied the necessity of this method in ordinary prac-
tice, using stimulants only as auxiliaries in cases of
extreme debility. Fish takes nearly the same view;
but insists upon the liberal employment of alcohol by
enema as well as by the mouth, and in conjunction
with opium, spices, and external stimulants when re-
action was difficult to obtain, or the vomiting obsti-
nate. Other writers present, however, a very modified
estimate of the treatment by stimulants and cordials.
The committee of the Massachusetts Medical Society
distinctly state that a division of opinion among phy-
sicians existed respecting the utility of such articles,
while there was a popular bias in their favor. They
condemned their liberal and indiscriminate adminis-
152 EPIDEMIC MENINGITIS.
tration, and stated their conviction that a considerable
proportion of the most judicious practitioners, and
even of those who formerly employed that method,
had learned by experience to regard it as highly in-
jurious. At the same time they admitted the neces-
sity of such medicines where the patients' faintness
and debility gave the indication. Gallup adopted
this judgment as his own, and Hale advocated the
Same discriminating use of these remedies. He also
condemned their habitual employment at the begin-
ning of the attack, while admitting their utility, and
even necessity, where the prostration of strength and
the apparent depression of the vital powers were ex-
treme. A few teaspoonfuls of hot brandy he found
often successful in arresting vomiting. “Alcohol,”
according to Miner, “was highly beneficial in some
cases, and required to be employed freely in many;
but it seemed not to be equally adapted to all, and
on the whole, was of much less importance than
opium.”
Nearly all of the more recent observers of epidemic
meningitis assign a very subordinate position to alco-
holic stimulants in the catalogue of remedies, and
some, as Ames, Tourdes, Niemeyer, Hirsch, Mann-
kopf, &c., make no mention of them whatever. In
the late Irish epidemic they were, however, regarded
as important. For our own part, while we consider
these agents as altogether indispensable in the con-
ditions of the system described by Miner, Hale and
others, we are satisfied that their too free exhibition
entails the gravest peril, by intoxicating the patients,
and oppressing, where they are intended to rouse the
TREATMENT.-OPIUM. 153
vital energies. On taking charge of the medical wards
at the Philadelphia Hospital, we found that the patients
were using as large quantities of alcohol as in typhus,
fever; but a very short period of observation rendered
it so apparent that an excess in their administration
was indulged in, that the dose of the medicine was
first diminished, and finally it was omitted alto-
gether, unless such special indications arose as have
already been pointed out. This change was followed
by a manifest improvement in the general aspect of
the sick, and the subsidence of symptoms which, it
then became evident, were attributable to a lavish
use of stimulants rather than to the gravity of the
disease. On the whole, we regard alcohol as a medi-
cine which ought not to be included in the ordinary
and systematic treatment of epidemic meningitis, but
as a cordial to be held in reserve against those signs
of failure in the power of the nervous system, which
call for its administration in diseases of whatever
name. In this, as in so many other respects, epidemic
meningitis presents a striking contrast to typhus fever.
OPIUM.–A very distinguished physician writing
upon this disease, remarks: “even opium has upon
the Continent enjoyed the reputation of curing this
malady, but upon what principle it is difficult to imagine.”
Cinchona, mercury and arsenic, have the reputation
of curing, respectively, malarial diseases, syphilis and
squamae, and although it is difficult to imagine upon
what principle they do so, we apprehend that no one
will contest their efficacy. A volume of speculations
upon the nature of epidemic meningitis and on the
action of opium are valueless in comparison with the
11
154 EPIDEMIC MENINGITIS.
direct and accumulated proofs of the curative power
of the medicine in this disease with which the litera-
ture of our profession abounds. It interests us also,
and in an especial manner, because it is an American
remedy, and was not, as Hirsch and others state, first
proposed by Forget or by Chauffard. By whom it
was first employed may not be easy to determine,
but that, in this country, it was in common use from
the year 1808, the publications of that year and of im-
mediately succeeding years abundantly demonstrate.
Strong is the first who alludes to its use to relieve
coma, and he urges that if the medicine is rejected
from the stomach it should be administered by the
rectum. “Opium,” he remarks, “either pure, or in
the form of laudanum, was found a most excellent
stimulant in every stage of this disease. The best
manner of exhibiting it appeared to be in small doses
often repeated, so that the system should be constantly
under a gentle influence from it. It tended to relieve
pain, increase the excitement, and remove delirium
and stupor. The necessary dose varied according to
the mildness or violence of the symptoms, from ten
drops of laudanum every hour to thirty drops every
two hours. In those cases of the disease especially,
which commenced with sudden and violent delirium,
this medicine exceeded all others in its beneficial
effects. In such cases, however, the dose required
was often large, but when exhibited with great free-
dom, it produced the happiest and most striking
effects.” A case is then related in which excruciating
agony in the head and maniacal delirium were pre-
dominant symptoms. Sixty drops of laudanum were
TREATMENT.-OPIUM. 155
administered every hour until 480 drops, or half a
fluidounce had been taken in the course of eight
hours. The whole of it was retained, and it subdued
the excitement and allayed the pain, but produced
no sleepiness nor any other apparent effect of opium.
In a like heroic manner Haskell employed this remedy.
He speaks of a young woman who recovered, but who
during her illness took more than a quart of brandy
and not less than twenty grains of good Turkey opium,
and that without any evidence of intoxication. “In-
deed,” he adds, “we have been obliged frequently to
exhibit ten grains of opium for a dose in some of the
violent cases attended with strong spasms, and have
never known it to produce stupor in a single instance.”
So Miner states that “a few cases imperiously re-
Quired half an ounce of the tincture in an hour, or
half a drachm in substance, in the course of twelve
hours, before the urgent symptoms could be con-
trolled, and even some cases required a drachm in
the same time. All these patients recovered.” This
sagacious observer and judicious thinker further says:
“opium was the most important remedy in the severe
form of this disease, ... The whole of those patients
whose symptoms were promptly met with opium in-
variably recovered.” Among the symptoms which it
was particularly intended to relieve was one which
is usually thought to be increased by narcotics, viz.,
coma. This object is particularly mentioned by
Strong; Hale, also, who advised tincture of opium
with oil of peppermint or lavender, frequently re-
peated, to relieve coma, remarked: “whatever may
be the explanation of its mode of action, it is certain
156 EPIDEMIC MENINGITIS.
that this was a powerful agent in removing the deepest
comas which were not absolutely irrecoverable.” Such,
indeed, is substantially the testimony of Woodward,
Bestor, Arnell and others, of that period, who em-
ployed opium for pain, vomiting, diarrhoea, and sleep-
lessness. Among the writers of the first period of
the prevalence of the disease in this country, Gallup
is the only one who passes an unfavorable judgment
upon this drug. He employed it only in cases at-
tended with cholera morbus. Otherwise he discarded
it altogether. “Observing the bad effects of opium,”
he remarks, “in certain cases not in my control, I had
determined to see if the disease could not be managed
without it;” and he then states that of eighty-one de-
cided cases committed wholly to his care, and treated
without opium, one case only proved fatal. It is evi-
dent that such a low rate of mortality could not have
been furnished by cases of this disease requiring any
active treatment at all.
Of more recent American observers the judgment
is not uniform upon this subject. Ames does not
appear to have tested the opium treatment, for his
whole opinion in regard to it is contained in these
lines: “from what I saw of it I can scarcely say that
it was generally safe to give opium in the inflamma-
tory malignant variety, or that it was of any use in
the congestive malignant form. In the other varie-
ties it was a safe remedy, and very valuable as an
anodyne merely.” Upham only notices opium as a
means of procuring sleep at night. Russell employed
it to control delirium; and Woodward prescribed it
if the skin was moist, but thought that it aggravated
TREATMENT.-OPIUM. 157
the head distress. But, on the other hand, Jewell
affirms that “opium stands not only at the head of
the list of stimulants, but also at the head of remedial
agencies in this disease;” and Kendall says, “ano-
dynes, even in large doses, in the early stage, seemed
to increase the watchfulness; but after the first period
had passed, and an evacuation from the bowels had
been procured, they often quelled the intense rest-
lessness like a charm.”
The greater number of European physicians who
made use of this remedy, prescribed it in doses quite
too small to serve any good purpose, except as a pal-
liative. This statement is true of the practice pursued
by Forget, Tourdes, Gaskoin, Sanderson and others.
Some, also, like Bricheteau, adopted, as an argument
against its use, the vicious question, how could it do
good? But others, like Chauffard, who administered
it in doses of from three to fifteen grains pronounce
it to be incomparably the most efficacious remedy. Its
most earnest advocate was Boudin. He increased the
dose of the drug in proportion to the severity of the
symptoms, and frequently administered from seven
to fifteen grains in a single dose at the commencement
of the attack, and subsequently one or two grains
every half hour. This method was steadily pursued
until the patient began to be sleepy, or his symptoms
abated, and then the use of the medicine was still
persevered in, although its dose was diminished.
During the active stage of the disease a remarkable
tolerance of the drug was observed. It never pro-
duced constipation, or at least did not increase that
which already existed. Our own observations cor-
158 EPIDEMIC MENINGITIS.
roborate these results fully. We were in the habit
of giving one grain of opium every hour, in very
severe, and every two hours in moderately severe
cases, and in no instance was produced either nar-
Cotism or even an approach to that condition. Under
the influence of the medicine the pain and spasm sub-
sided, the skin grew warmer and the pulse fuller, and
the entire condition of the patient more hopeful. It
seemed probable, however, that the full benefit of the
opium treatment could be received by those only who
were subjected to it in the early stages of the attack.
Direct experience is here in perfect accord with the
expectation which a knowledge of the pathological
processes involved in the disease would naturally
suggest.
CINCHONA AND QUINIA—It has been very customary
for those who had to treat epidemic meningitis during
its late prevalence to associate large doses of sulphate
of quinia with the opium which they administered.
A careful examination of the evidence does not prove
either the necessity or the utility of this association.
In the early American epidemics, before quinia was
discovered, physicians made use of Peruvian bark in
powder, tincture, decoction, &c. But two observations
were speedily made; the one was that the stomach
would not tolerate doses of the bark large enough to
display antiperiodic virtues, and the other was that
smaller doses were perfectly unavailing against the
proper elements of the disease. The medicine then
was made use of as a mere tonic during the decline
of the attack and during convalescence. Such is the
testimony of Strong, North, Fish, Jackson, Hale, &c.
TREATMENT.-CINCHONA AND QUINIA. 159
After the introduction of the alkaloids of cinchona
into medical practice, the sulphate of quinia was
largely employed for the cure of the disease we are
studying. But its effects were not generally regarded
as salutary. Love tells us that when, owing to the
apparently periodical character of the symptoms, large
doses of quinia seemed to be indispensable, they were
injurious and not beneficial. Ames had “but little
to say in favor of this medicine.”... “When the dis-
ease was attended with a fever which was regularly
remittent, the meningitis appearing as an appendage,
or as if engrafted on a remittent ſever, quinine did
occasionally arrest the paroxysms, but more slowly
and with greater difficulty than in other fevers. As
a remedy in other varieties it cannot be recommend-
ed; its use here, if not hazardous, never affording
much encouragement to repeat it.” Boling “saw it
succeed in two intermittent cases which were not
very violent, while it failed in others of a graver
character.” Upham states that quinia, in some in-
stances to the extent of sixty or even eighty grains
was given within twelve hours from the first attack,
but without effect; and Jewell found it useful only
as a tonic. In Europe all of the most reliable ob-
servers of this disease formed the same estimate of
quinia in its treatment as physicians had formed in
the United States; and this statement refers particu-
larly to Tourdes, Faure Villars, Barrilleau and Bros-
sard, Sanderson, Mannkopf and Hirsch. C. Brous-
sais, indeed, presents as a case of cerebro-spinal
meningitis cured by sulphate of quinia, one of com-
pletely intermittent paroxysms with spasms of the
160 EPIDEMIC MENINGITIS.
flexors of the forearms! Evidently an error of diag-
nosis was committed. Chauffard also relates, as a
case in point, one which recovered after five grains
of opium and fifteen of sulphate of quinia had been
administered. But the share of the opium in this
and similar instances must not be overlooked. On
the whole, it is evident that opium alone, in large
doses, will control the disease in many instances, and
that quinia in large doses will remove the complication,
when it exists, occasioned by miasmatic poisoning;
but there is no evidence sufficient to show that epi-
demic meningitis has ever been cured by sulphate of
Quinia alone. In accordance with general belief in
the efficacy of this medicine we have usually associ-
ated it with full doses of opium; but should the occa-
sion again be presented, we shall feel constrained to
discard sulphate of quinia except as a tonic during
the decline of the attack.
ALTERATIVES-MERCURIALs. – It is very certain
that mercury has entered more generally into the
treatment of epidemic meningitis than any other
medicine; and, were this fact alone considered, the
propriety of continuing to prescribe it could scarcely
be called in question. When, moreover, it is remem-
bered that of all medicines for the cure of other forms
of meningitis, this one has the greatest weight of
testimony in its favor, there would seem to be a de-
cided preponderance of motives- for its employment
against the epidemic under discussion. We leave
out of consideration here the emphatic judgment of
many recent therapeutists against it as a remedy for
any form of inflammation, believing that the grounds
TREATMENT.-ALTERATIVES : MERCURIALS. 161
of their conclusions are less extensive than they are
claimed to be, if, indeed, they are not altogether un-
Sound. But in this, as in all similar cases, the proof
by analogy is one that requires to be very cautiously
and narrowly scrutinized. It wery seldom affords a
Substantial basis for practice. At the best, it can
only be regarded as a suggestion for the trial of a
medicine, whose real utility must afterwards be de-
termined by direct observation and experiment. To
those who regard epidemic meningitis as a purely
Zymotic or blood disease, and the meningeal lesion as
a subordinate or accidental morbid element, or who
consider the affection a form of typhus fever, the ap-
plication of mercury to its cure must appear an ex-
tremely irrational and highly imprudent measure;
while those who view it as prečminently and primarily
an inflammation, may urge in support of the use of
mercurials in its cure, that it is justified by established
doctrine in regard to the therapeutical operation of
these medicines. But if we look upon the disease as
one in which a zymotic and an inflammatory element
are combined in varying proportions, it would seem
to follow that while mercury might benefit one class
of cases, it would seriously injure the other. And if,
once more, we turn to the only true source of light
in resolving such questions, we shall perhaps find
that experience, as final arbiter, pronounces an equivo-
cal judgment, and leaves the problem virtually unre-
solved. We shall perhaps learn that while this medi-
cine has been more generally employed than any
other, the proofs of its salutary operation, as distin-
162 EPIDEMIC MENINGITIS.
guished from vague impressions, are far from being
precise or clear.
Looking, now, to historical testimony for light upon
this question, we learn that neither North nor Strong
nor Miner nor Gallup employed mercury in the treat-
ment of epidemic meningitis. Miner, referring to it
as a purgative, says of this class of medicines, “juvant
per casum, nocent per se;” and he adds, “in a few bad
cases, in which a slight mercurial action was excited,
it was of no sort of service.” In Europe we find the
following testimony given by Tourdes: “frictions with
mercurial ointment upon the scalp, the thighs, in the
armpits and along the spine were employed, while
calomel was administered internally. In three cases,
one of which was fatal, salivation occurred. In spite
of the large doses and the steady application of this
medicine, it was generally unavailing.” Hirsch, also,
regards mercurial purgatives as of slight value, and
mercury as an antiplastic medicine of very question-
able value. He adds that, even apart from its mis-
chievous effects in certain cases, the observations of
Tourdes, Guepratte, Chauffard, Falot, Corbin, Lind-
ström, Wunderlich and others, do not lead us to repose
much confidence in its efficacy. On the other hand,
Bestor writes: “within three or four hours from the
attack, I usually gave from eight to ten grains of
calomel, not with a view to purge on the first day,
but to act as a stimulus to the system, and to prepare
the bowels to be moved by injections on the following
day;” and Arnell, Fish and Woodward advise the
same method, which, it need scarcely be remarked,
is justified neither by theory nor experience. Others,
TREATMENT.-ALTERATIVES : MERCURIALS. 163
more rationally, sought to produce the constitutional
effects of the medicine. “If,” says Fiske, “we were
bold and liberal in the use of anything, it was calo-
mel” until a slight affection of the glands was obtained;
and Danielson and Mann gave to a child one hundred
grains of calomel in doses of three grains each, when
the patient died,—as was most natural that it should do,
although the authors style this method “a stimulating
process.” According to Jackson, the success of the
mercurial practice “was not exceeded by that of any
other.” But this judgment is afterwards qualified by
the remark that although in cases where life is imme-
diately threatened the remedy cannot be relied on to
avert the danger, yet that it is of great value where
the most urgent symptoms are removed by other
remedies. This conclusion is less favorable, perhaps,
than the authors appear to have regarded it. Ames
employed mercury almost exclusively to produce
its constitutional effects, and regarded its beneficial
influence as more prompt and permanent than that
of blood-letting. It was, he believed, always safe if
not always effectual. Upon this testimony Drake
remarks that “it cannot be regarded as decisive.”
Rendall found “calomel in large doses” the best
remedy in the first stage of the disease; Dickson
purged with calomel and rhubarb followed by croton
oil; Iredell regarded it “of the utmost importance to
push the mercury to the extent of producing its con-
stitutional effects;” and Upham reports small doses
of calomel with ipecacuanha to have had a good effect
in several instances. Renzi attributes to blue mass,
among other effects, the resolution of the abdominal(?)
16ſ EPIDEMIC MENINGITIS.
inflammation, and asserts that a cure followed the pro-
duction of mercurial sore mouth. He was under an
impression that it directly neutralized the poison and
expelled it from the system. According to Mayne,
the chief reliance is to be placed on the internal and
external use of mercury; and Gordon recommends
small doses during the stage of reaction.
It cannot be doubted that these witnesses are far
from agreeing with one another. Between those who
absolutely neglect, or positively condemn the use of
mercurials in epidemic meningitis, and those who
eulogize them as the best of all remedies, an impass-
able gulf is fixed quite as wide as that which separates
those who found in mercury a “stimulus to the sys-
tem” or an “alterative of the minima vascula” (Jack-
son), and those who attributed to it an antidotal action
upon the poison itself. The mode of its curative action
would be of interest, certainly, to determine, but it is
of a very remote and subordinate interest when com-
pared with the primary and capital problem, is the
medicine curative at all? But upon this question we
have no satisfactory data; no comparison of cases
treated with and without mercury; no enumeration of
the special symptoms which it favorably influences;
no statement of the mortality occurring under its use.
Its virtues, according to some, depend upon its pur-
gative operation, while others regard its salivant
action as alone efficient. Are the former right when
experience demonstrates that all other purgation in
this disease is mischievous; or are the latter right,
when Tourdes, who carried the method furthest, un-
equivocally condemns it? It cannot be alleged that
TREATMENT.-ALTERATIVES : MERCURIALS. 165
the epidemic which Tourdes witnessed was one ill
adapted for the mercurial treatment. To do so would
be not only to admit that for some types of the dis-
ease such medicines are unsuited, it would also be
to make an erroneous statement; for the epidemic
at Strasburg was the one, above all others, which de-
monstrated that the anatomical character of the disease
consists in an exudative inflammation of the cerebro-
spinal meninges. Shall it then be denied that mercury
is a suitable agent in the cure of this disease? By no
means, unless the proposition is made a general one,
including all of the multiform types which epidemi
meningitis presents. Its malignant and typhoid form
must, of course, be regarded as unsuited for any treat-
ment by mercury. A very large proportion of other
cases tend to cure rather than to death, and do not
demand, even if they do not absolutely forbid, the
employment of so debilitating a remedy as the one in
Question. But there remains another group of cases
whose general expression is sthenic; in which the
pulse is comparatively strong, the skin warm if not
hot, the pains in the head, spine and limbs severe,
and the tetanic phenomena marked;—in these, if in
any, the use of mercury would seem to be justified
by analogy, and perhaps, though of this the evidence
is not conclusive, by direct observation. We have
never employed the medicine in such cases, nor, in-
deed, in any others, for the remedies before considered
appeared to be sufficient for the cure; but had we an-
other epidemic to encounter, we should certainly put
to the test whatever virtues mercury might possess
166 EPIDEMIC MENINGITIS.
for mitigating the severity of the disease, and hasten-
ing its cure.
There remain to be noticed several other medicines,
concerning which at different times favorable opinions
have been expressed. One of these, and the earliest,
in point of time, is the solution of arsenite of potassa.
It was originally exhibited in this disease by Daniel-
son and Mann. What first suggested to them the
idea of using it does not appear; but they resorted to
it after the failure of evacuants and of bark and wine,
giving to a child three years old “two drops in a
tablespoonful of wine.” The influence of the wine
in this prescription was certainly not either negative
or trifling. A further trial of it by other physicians
led to the judgment expressed by Strong several years
later, that “although it has not been sufficient in all
cases, still it has appeared to be a safe and very use-
ful medicine, and in many cases the most happy
effects have evidently been produced by it.” It was
regarded as a direct stimulant of the most powerful
description. “It tends,” says Strong, “to increase
the excitement, often in the course of a few minutes
producing a very pleasant sensation of warmth through
the whole system; and tends more than any other
medicine to remove the cold and singular sensation
at the stomach, which has been mentioned as being
so peculiarly distressing.” Fish ascribed similar effects
to the medicine, and took the same view of its ope-
ration. But the Massachusetts committee, from the
survey of a wide field of experience, expressed no posi-
tive judgment as to its value; and in 1825, Miner
wrote, “arsenic was highly serviceable when the head
TREATMENT.—IODIDE OF POTASSIUM, ETC. 167
was much affected, and the stomach at the same time
torpid. In some irritable cases it answered well, but
it was necessary to adjust the dose very accurately,
in order to have its full effect on the one hand, and
not offend the stomach on the other.” The medicine
was also used by Hale, Gallup and other physicians
of the day, either for the purposes just indicated, or
as a tonic during convalescence. In the history of
later epidemics, whether in this country or in Europe,
we have met with no reference to the use of arsenic,
nor have we employed it in our own practice; but if
the statements which have been quoted are correct,
the omission of this medicine in the treatment of epi-
demic meningitis is a grave fault. &
Jodide of potassium has been used during the de-
cline of the disease for the purpose of exciting the
absorption of the lymph effused beneath the meninges.
There is a theoretical probability of its usefulness.
Several physicians, disregarding the conclusions of
universal experience in favor of opium, and preferring
to follow the a priori road which always leads to dis-
appointment or error, concluded that since belladonna
and ergot had been shown to diminish vascular action
in the cerebro-spinal axis, they necessarily become
specific remedies for cerebro-spinal meningitis. In-
deed, one writer so far forgets the rules of medical
logic as to conclude that because, in his opinion, the
views of Brown-Séquard on the action of belladonna
and ergot are correct, therefore opium and alcohol
“are decidedly contraindicated in the treatment of the
disease under consideration.” Upham states that in
1863 Haddock recommended ergot, upon the grounds
168 EPIDEMIC MENINGITIS.
just referred to, during the epidemic at Newbern,
North Carolina, and that “several of the cases thus
treated recovered.” Under the impression which
thus originated as to its efficacy ergot was prescribed
by Borland in three cases, which also recovered. In
California, Peake advised its use on theoretical grounds,
but made no statements of its success in his hands.
Woodward appears to have allayed pain in the head
in this disease by the use of belladonna; and Gordon,
in Dublin, prescribed two grains of sulphate of quinia
and one grain of extract of belladonna every three
hours in a case marked by collapse, dark eruption,
extreme pain in the head and neck, and strabismus.
When it is known that the head was at the same
time shaved and blistered, the influence of the bella-
donna in promoting the cure may be regarded as more
than equivocal. The same writer used belladonna
with advantage, externally, to relieve dysphagia, and
around the eyes in cases of ulcerated cornea, &c.
DIET.-The remarks which have been made in re-
gard to the appropriateness of diffusible stimulants in
those cases of epidemic meningitis which are charac-
terized by exhaustion, imply the necessity of employ-
ing a nutritious diet under similar circumstances. But
such a diet is hardly less applicable in ordinary cases
of the disease which do not require the exhibition of
alcohol in any form. In European epidemics this im-
portant matter has too often been either overlooked, or
a degree of abstinence from food enjoined which we
cannot but regard as inappropriate if not injurious.
It would seem incredible to any one acquainted with
the disease that an honorable and skillful physician
TREATMENT.—DIET. 169
had advised absolute diet and emollient drinks in its
treatment (Rollet), if other heroic measures of an op-
posite nature and which no one has had the courage
to imitate, had not also been recommended by him as
the most efficient means of cure. Hirsch, also, after
stating that in the commencement of the attack there
is generally complete anorexia, declares that even
after some appetite has been felt, the strictest rules
of diet should be observed, and only the blandest
articles of food allowed. Such are not the conclusions
to which experience really points, nor are they justi-
fied by a thorough study of the genius of the disease.
If its history has been correctly written in these
pages, it presents few cases of a purely sthenic nature;
its predominant tendency is towards a typhoid state,
or one of pure asthenia. Now, nothing can be con-
sidered more firmly established than the precept that
the treatment of a disease should be governed by its
type rather than by the local morbid process which
accompanies it. It appears, therefore, that even upon
general grounds a strict diet is not indicated. Again,
if it be true that opium and stimulating and tonic
remedies are more appropriate for the cure than the
antiphlogistic and evacuant methods, it cannot at the
same time be true that a rigid abstinence from food
should be enjoined. Once more, those who accept the
doctrine that all disease, even sthenic inflammations,
and a fortiori asthenic and typhoid conditions, are only
proofs of a struggle between the natural and the
morbific powers in which the former are to be sup-
ported by every expedient, must, of course, admit
that in this case there is a loud and emphatic call for
12
170 EPIDEMIC MENINGITIS.
supporting measures, including nutritious food. Our
own practice has, in general, been to prescribe such
food as it is customary to employ in typhus fever,
having been led thereto by the debility of the patients,
the uncertain and often compressible pulse, the cool
extremities, the eruptions upon the skin, the absence
of alvine disturbance in the greater number of cases,
and the evident dependence of the gastric derange-
ment upon irritation of the brain. In this, it ap-
pears, we did but follow the example of early Ameri-
can physicians, who were guided by the prevalent
symptoms to direct a nutritious diet, as they were
also led to prescribe a liberal use of opium. Strong
insists firmly and repeatedly upon this plan, advising
“soup made from chicken, veal, mutton and beef,
richly seasoned with pepper and savory herbs,” and
adds, “this is a very important part of the process
and ought by no means to be neglected.” These
articles were advised to be given during the height
of the disease; and afterwards, it is added, “the
stomach soon begins to crave something more solid
than soup; oysters, beefsteak, cold ham, or meats'
tongue are received with peculiar relish. Often have
I seen convalescents when they had hardly strength
enough to raise themselves in bed, make a hearty meal
of the above-mentioned articles, which were received
with great satisfaction, sat well upon the stomach,
and were well digested and assimilated.” The same
advice, substantially, is given by Hale, who recom-
mends soups at first and then solid food, for the latter
of which he observes that the patients early have an
appetite; and by Jackson and his colleagues, who
TREATMENT.-REGIMEN. 171
direct the most nutritious food that can be digested,
and add, that it is not very important to abstain from
it even during the first stage of the disease. These
precepts are the same, substantially, which are fur-
nished by all American writers whose experience
entitles them to weight in the decision of this ques-
tion, which we hold to be of capital importance in
the management of epidemic meningitis.
The general regimen to be observed consists in the
use of the ordinary measures which are adapted to
promote the repose of the patients in low forms of
fever; but an additional suggestion, to which the great-
est importance was attached by the writers just re-
ferred to, is that great care should be taken to prevent
the patient from making any unnecessary exertion,
and especially from assuming the erect or even the
sitting posture before convalescence is fully estab-
lished. The necessity of these precautions arises
from the singular debility which characterizes so
many cases of the disease, and which, as was before
pointed out, suggested the title of typhus syncopalis,
which was conferred upon it.
BIBLIOGRAPHY.”
ADAMS, J. F. A., Boston Med. and Surg. Jour., Aug. 1866,
p. 66.
Ames, S., N. Orleans Med. and Surg. Jour., Nov. 1848.
Anderson, W., Trans. Med. Soc. of Penna. 1864, p. 438.
Andral, G., An Essay on the Blood in Disease. Am. ed., p. 73.
Anonymous, N. England Jour. of Med. and Surg., i. 151; ii. 228,
241; iii. 166; iv. 238.
British Med. Jour., July 8, 1865.
– Lancet, April, 1865, p. 436; May, 1865, p. 549.
Armstrong, W. G., Am. Jour. of Med. Sci., July, 1866, p. 279.
Arnell, D. R., American Medical and Philosophical Register, vol.
i. p. 12, and p. 176.
Atlee, W. F., Amer. Jour. of Med. Séi., July, 1864, p. 94.
BALDw1N, W. O., Amer. Jour. of Med. Sci., Oct. 1866, p. 321.
Baltzell, W. H., Am. Jour. of Med. Sci., Oct. 1865, p. 368.
Banks, Dr., Dublin Quart. Jour., May, 1866, p. 448; and Feb.
1867, p. 98; Dublin Med. Press, June, 1867, p. 580.
Barrilleau et Brossard, Bulletin de l’Acad. Royale de Méd., 1844,
ix. 894. -
Bartholow, R., Cincinnati Lancet and Observer, 1864, p. 392.
Bartlett and Wilson, Med. Repository, 1812, p. 40.
Bestor, J., In North, 1810.
Black, J. R., Am. Jour. of Med. Sci., April, 1865, p. 345.
Boling, W. M., N. Orleans Med. and Surg. Jour., May, 1847, p.
732.
Borland, J. N., Boston Med. and Surg. Jour., May, 1865, p. 309.
* This list includes only the original monographs, reports, &c., referred to
in the body of the Essay. A more general and complete Bibliography of
European treatises is furnished by HIRscH and also by MANNKoPF.
BIBLIOGRAPHY. 173
Boudin, C. M., Histoire du Typhus Cérébro-Spinal. Paris, 1854.
Traité de Géographie et de Statistique Médicales. Paris, 1857.
Bull. de l'Acad. de Méd., xiv. 600; xv. 20.
Brossard, vide Barrilleau.
Burdon-Sanderson, J. Report of the results of an inquiry into
the epidemics of cerebro-spinal meningitis prevailing about the
Lower Vistula. London, 1865.
Burns, R., Am. Jour. of Med. Sci., April, 1865, p. 339.
Butler, L. C., Trans. of Vermont Med. Soc., 1864, p. 32.
CATLIN, B. H., Trans of Amer. Med. Assoc., xvi. 471.
Cayol, Revue Méd., lxxxvi. 237.
Chandler, J. L., Boston Med. and Surg. Jour., April, 1864.
Chauffard, Revue Méd., 1842, lxxxvi. 190.
Cheever, D. W., Boston Med. and Surg. Jour., April, 1866, p.
242. -
Chester, C., N. Orleans Med. and Surg. Jour., Nov. 1847, p. 314.
Clark, C. M., Chicago Med. Jour., Jan. 1867, p. 1.
Claubry, Memoires de l'Acad. Nat. de Méd., xiv. 155; xvi. 15.
Cogan, Dublin Med. Press and Circular, May, 1867, p. 506.
Comstock, J., Boston Med. and Surg. Jour., Oct. 1865, p. 237.
Condie, D. F., Trans. Med. Soc. of Penna., 1864, p. 497.
Corson, W., Trans. Med. Soc. of Penna., 1863, p. 232.
Corson, H., Trans. Med. Soc. of Penna., 1865, p. 95.
Craig, J. W., Buffalo Med. Jour., July, 1858.
Croly, H. G., Dublin Med. Press and Circular, May, 1867, p. 526.
DANIELson & MANN, Medical and Agricultural Register. Also,
in North. 1806.
Day, Henry, Clinical Histories. London, 1866, p. 1.
Dickson, J. H., Trans, of Amer. Med. Assoc., xiii. 307.
Drake, D., Principal Diseases of the Valley of North America.
Philadelphia, 1854.
Draper, W. H., Amer. Med. Times, Aug. 1864, p. 98.
Dunbar, Med. Repository, 1813, p. 357.
EDEs, R. T., Am. Jour. of Med. Sci., July, 1864, p. 274.
Ellis, C., Boston Med. and Surg. Jour., June, 1864.
I 74 EPIDEMIC MENINGITIS.
FASSETT, O. F., Trans. of Vermont Med. Soc., 1864, p. 43.
Faure-Villar, Bulletin de l'Acad. Royale de Méd., 1841, vi.
589.
Fenner, E. D., Southern Medical Reports, ii. 17.
Fish, H., Remarks on the Spotted Fever as it prevailed in Hart-
ford, Conn., in 1809. In Trans. of the Physico-Medical Society
of New York. New York, 1817.
Fiske, O., In North. 1810.
Foot, W., Philadelphia Medical Museum, 1808, v. 248.
Frentzel, Med. Times and Gazette, April 22, 1865.
Frothingham, W., Amer. Med. Times, April, 1864, p. 207.
GAMAGE, W., Some account of the Fever, &c. of 1817 and 1818.
Boston, 1818.
Gervis, H., Med.-Chir. Trans. (1811), ii. 234.
Gilbert, D., Am. Jour. of Med. Sci., July, 1864, p. 140; July,
1865, p. 93.
Gillkrest, J., London Med. Gazette, July, 1844, p. 455.
Githens, W. H. H., Notes of 98 cases. Amer. Jour. of Med. Sci.,
July, 1867, p. 17.
Green, T., Trans. Med. Soc. of Penna., 1864, p. 472.
Gallup, J. A., Sketches of Epidemic Diseases in the State of Wer-
mont. Boston, 1815.
Gauné, Archives Générales de Méd., Janv. 1858, p. 1.
Gerhard, W. W., Amer. Jour. of Med. Sci., July, 1863, p. 105.
Gordon, S., Dublin Quart. Jour., May, 1867; Dublin Med. Press
and Circular, May, 1867, pp. 508, 551.
Greene, J. S., Boston Med. and Surg. Jour., Nov. 1865, p. 256.
HALE, E., History and Description of an Epidemic Fever, com-
monly called Spotted Fever. Boston, 1818.
Hartshorne, H., Amer. Jour. of Med. Sci., July, 1864, p. 93.
Haskell, A., Spooner, M., and Holmes, F., In North. 1810.
Haverty, Dublin Med. Press and Circular, May, 1867, p. 525.
Hayden, Dublin Med. Press and Circular, May, 1867, pp. 580,
579. &
Hicks, B. J. and Taylor, B. F., New Orleans Med. and Surg.
Jour., July, 1847, p. 49.
BIBLIOGRAPHY. 175
Hirsch, A., Handbuch der Historisch-Geographischen Pathologie,
i. 163; Die Meningitis Cerebro-Spinalis Epidemica. Berlin,
1866.
Holbrook, Boston Med. and Surg. Jour., June, 1865, p. 369.
Hughes, J., Dublin Med. Press and Circular, May, 1867, p. 510.
Hutchinson, J. H., Am. Jour. of Med. Sci., July, 1866, p. 125.
JACKson, vide Welsh.
Jenks, E. W., Buffalo Med and Surg. Jour., Oct. 1863, p. 81.
Jewell, J. S., Cerebro-Spinal Meningitis; a report made to the
Illinois State Med. Society. Chicago, 1866.
Jewell, W., Am. Jour. of Med. Sci., July, 1864, p. 129.
KAY, ISAAC, Boston Med. and Surg. Jour., June, 1864.
Kempf, M., Amer. Jour. of Med. Sci., July, 1866, p. 55.
Kendall, J. W., Trans. of Med. Soc. of the State of New York,
1858, p. 96.
Kennedy, H., Dublin Med. Press, June, 1867, p. 551.
Ketchum, B. T., Trans. of the Vermont Medical Society, 1865.
Kirtland, J. P., American Med. Recorder, xiv. 441.
Klebs, Virchow's Archiv, xxxiv., 327.
Köhler, H., Monographie der Meningitis Spinalis. 1861.
LAW, R., Dublin Quart. Jour., Nov. 1849, p. 317; May, 1866,
p. 288. Med. Press and Circular, June, 1867, p. 548.
Lebert, H., Anatomie Pathologique, vol. ii. p 22. Paris, 1858.
Leedom, E. C., Trans. Med. Soc. of Penna., 1864, p. 445.
Lefèvre, M., Récherches Historiques sur la Maladie qui a regné
au bagne de Rochefort en 1839. Paris, 1840.
Lente, F. D., Am. Med Times, July, 1864, p. 14.
Levick, J. J., Trans. of Amer. Med. Association, xvii. 311. Am.
Jour. of Med. Sci., July, 1864, p. 135; July, 1865, p. 277.
Levy, M., Bull. de l'Acad. Emp. de Med., xiv. 765; xv. 20.
Lidell, J. A., Am. Jour. of Med. Sci., Jan. 1865, p. 17.
Lionet et Petit, Bull. de l'Acad. Imp. de Méd., xiv. 952.
Love, T. N., N. Orleans Med. and Surg, Jour., July, 1848.
Lyman, E., In North. 1808.
Lyons, Dublin Med. Press and Circular, May, 1867, p. 509.
176 EPIDEMIC MENINGITIS.
MANN, J., Medical Sketches of the Campaigns of 1812, "13 and
’14, p. 19, and p. 306; vide Danielson.
Mannkopf, Ueber Meningitis Cerebro-Spinalis Epidemica. Braun-
schweig, 1866.
Martin, E., An Essay on the Epidemics of the Winters of 1813
and 1814, p. 74. Baltimore, 1815.
Marques, J. A., Brit. and For. Med.-Chir. Rev., April, 1863, p.
389.
Mathey, Journal de Méd. Chirurg. and Pharm., &c. An. xiv.,
xi. 243.
Mayne, R., Dublin Quart. Jour., Aug. 1846, p. 95.
McDowell, London Jour. of Med., iii. 850.
Millar, J., Epidemic in St. Petersburg. Edinb. Journ., xi. 225.
Miner, T. and Tully, W., Essays on Fevers, &c., p. 114. Mid-
dletown, 1823. -
Miner, Thomas, Typhus Syncophalis, Sinking Typhus, or the
Spotted Fever of New England. Middletown, 1825.
Minot, F., Boston Med. and Surg. Jour., March, 1864.
Moore, Dublin Med. Press, June, 1867, p. 579.
Moorman, J. W., Am. Jour. of Med. Sci., Oct., 1866, p. 386.
Murchison, C., Lancet, April, 1865, p. 417.
NIEMEYER, F., Die Epidemische Cerebro-Spinal Meningitis.
Berlin, 1865.
North, E., A Treatise on a Malignant Epidemic, commonly called
Spotted Fever. New York, 1811.
OLIVER, J. L., Trans. Med. Soc. of Pennsylvania, 1864, p. 429.
PAGE, CALVIN G., Boston Med. and Surg. Jour., Sept. 1865, p.
109. -
Parks, Jr., L., Boston Med. and Surg. Jour., March, 1864; Pub-
lications of the Massachusetts Med. Society. Boston, 1867.
Peake, H., San Francisco Med. Press, Jan. 1865.
Pearce, T. J., Cincinnati Lancet and Observer, May, 1865.
Petit, vide Lionnet.
Poley, F. B., Trans. Med. Soc. of Penna., 1863, p. 237.
Prewitt, T. F., St. Louis Med; and Surg. Jour., 1865, p. 205.
BIBLIOGRAPHY. 177
REID, J. K., Trans. Med. Soc. of Penna., 1863, p. 232.
Rºs de, Storia del Morbo Petecchiale Nosocomiale. Napoli,
Rollet, M., Memoires de l'Academie Royale de Médecine, 1843,
x. 291.
Roupell, G. L., A short Treatise on Typhus Fever. Amer. ed.,
1840, pp. 119, 120, 121.
Russell, J., Boston Med. and Surg. Jour., May, 1864.
- SARGENT, J., Am. Jour. of Med. Sci., July, 1849, p. 35.
Saunders, A. L., Trans. of the Med. Society of the State of New
York, 1859, p. 153.
Sherrill, H., An Essay on Epidemics, &c., p. 29. New York,
1832.
Simon, Lancet, May, 1865, p. 481.
_Smith, Southwood, A Treatise on Fever. Amer. ed., 1888, p. 155.
Spooner, vide Haskell.
Squire, T. H., Trans. of Med. Society of the State of New York,
1858, p. 155.
Stillé, A., Amer. Jour. of Medical Sci., July, 1864, p. 133; Jan.
1865, p. 121; July, 1866, p. 156. -
Stokes, Dublin Med. Press, June, 1867, p. 580.
Strong, N., Med. and Philosophical Register. Philadelphia. New
Series, i. 12, 1811.
Stuart, J. B., Med. Repository, 1812, p. 23.
TAYLOR, vide Hicks.
Thomas, D. G., Trans. of Med. Soc. of the State of New York,
1858, p. 89.
Tourdes, G., Histoire de l'Epidemie de Méningite Cérébro-Spinale
observée à Strasbourg en 1840 et 1841. Paris, 1842.
Tully, vide Miner.
Tweedie, A., Clinical Illustrations of Fever. Amer. ed., Boston,
1831, p. 355, &c. Lancet, May, 1865, pp. 518, 571.
UPHAM, J. B., Boston Med. and Surg. Jour., April, 1863, p. 191.
WIEUSSEUx, Journal de Med., Chirurg., Pharmacie, &c. An
XIV., xi. 163. -
13
178 EPIDEMIC MENINGITIS.
WAIT, R., Med. Repository, 1810, p. 391.
Warren, vide Welsh.
Watson, A. T., Amer. Med. Times, May, 1864, p. 222.
Webber, S. G., Prize Essay. Boston Med. and Surg. Journal,
Aug. 1866, p. 29.
Welsh, T., Jackson, J., Warren, J. C., A Report on Spotted or
Petechial Fever. 1810. In Med. Communications, &c. of
Massachusetts Med. Society. Vol. ii., 1813.
Wilks, S., Lancet, April, 1865, p. 388.
Williamson, G., Philadelphia Med. Museum, 1808.
Wilson, J., Med. Repository, 1813, p. 351; wide Bartlett.
Wilson, Job, An inquiry into the nature and treatment of the
prevailing epidemic called Spotted Fever. In three parts.
Boston, 1815.
Woodward, S., In North. 1808.
Woodward, A. T., Amer. Med. Times, May, 1864, p. 232; Trans.
of the Vermont Med. Soc., 1864, p. 23.
Wunderlich, C. A., Archiv der Heilkunde, 1864, p. 417; 1865,
pp. 268 and 417.
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