i 3.
V
A PAPER
ON
EPIDEMIC MENINGITIS,

             BEAD before the

   MEDICAL SOCIETY OF MONTGOMERY, ALABAMA,

                IN 1848, /

            BY S. AMES, M. D,
:-.^\.*.
 
 
Some Account of an Epidemic Ccrcbro-Spinal  Meningi-
  tis, which prevailed in Montgomery, Ala., in the Winter
  and Spring of 1848.   By S. Ames, M. D.

  The name, Ccrcbro-Spinal Meningitis, is not strictly
applicable to the  epidemic I am about to describe.—
Whatever may have been the extent of the organic le-
sions, in  the milder forms, which, it will be seen, the dis-
ease frequently assumed, both  the  symptoms and the
morbid anatomy of the malignant forms showed that the
substance of the brain, if not of both the great nervous
centres, was  almost always involved.  In some parts of
France, which were visited, some years ago, by a simi-
lar epidemic, it is said, on the contrary, that the integri-
ty of the brain was the rule, and its alteration an excep-
tion, which, when it occurred, ought rather to be view-
ed as a complication than as a part of the  original or
primary  affection.*   This assertion, however, seems to
be the expression of an  opinion instead of a statement
of fact,—the opinion depending, as I conceive, more on
the peculiar  views entertained by the French patholo-
gists in regard to the post mortem evidences of pre-exis-
ting inflammation, than on just conclusions drawn from
the morbid anatomy which they observed.  Requiring,
always, for  example, the presence  of some product of
inflammation, they reject all other evidence, giving no
weight to the presence of that vascular condition which,
nevertheless, is admitted to be  essential to such  pro-
ducts.   The French physicians,f in describing the epi-
demic just spoken of, affirm the existence of hyperemia
of the brain  in, I believe, every instance  in. which the
condition of that organ is noticed, the occasional obser-
vation of one of the products, viz: softening, of inflam-

  * Compendium de Medicine Practique.  Tom. vi.
  f I refer here more particularly to M. Tourdes (Histoire de  l'cpi-
demie Meningitc Cerebro-Spinale qui a regno a Strasbourg, en 1840
et 1841); and M. Forget (Gazette Medicale, 1841.) 
2
mation, and in all the fatal cases the occurrence of symp-
toms, such as abnormal sensibility and muscular mo-
tions, delirium, coma, &c, which,  being observed in a
disease having a constant excess of fibrine in the blood,
may be considered unequivocal evidence of inflamation
of the nervous substance—at least so long as there is no
proof that simple meningitis  can produce them—proof
which would almost necessarily be  to the effect that the
meninges  are  the seat of the intellectual faculties.  If,
then, this excessive refinement or incredulity  in  the
French pathological school be set aside, the  pathology
of the two epidemics is in strict accordance with their
resemblance in symptoms, and the anatomical charac-
ters have  only this difference, that one  of the products
of inflammation was found in the brain more  frequently
in the one than in the other,—a state of facts which can
leave no doubt as to the identity of the two diseases.  I
have retained the name, therefore, which  has already
been applied to the French epidemic, as well as  to oth-
ers, in order to avoid the confusion which  might grow
out of a description of the  same disease under another
name.  If it were necessary or important,  however, to
give it a name which would approach somewhat nearer
to an expression of its true pathology, that of meningo-
cerebritis  and myelitis, would better answer the purpose.

                Morbid  Anatomy.

  The following account of the anatomical characters
of the disease is drawn  up  from notes taken  in  eleven
cases, examined at periods varying  from four to  twenty
hours after death.
   Vascularity of the Membranes  of the Brain.—The dura
mater was the seat of abnormal vascularity in two ca-
ses, in one of which there was merely a greater number
of vessels  than usual displayed on its upper and  lateral
surface, on the left side; on the other, there were  red
patches occupying parts on each side and along the en-
tire course of longitudinal sinus, and  also that portion
which covers the frontal bone just above the  orbitar
plates of this bone;  at  these places the  number  of red
patches was greatest on the right side.  The arachnoid 
3
 covering of the dura mater, showed this kind of altera-
 tion in one case only; in this there was a very delicate
 pink or carmine tint diffused over it, while its usual pol-
 ish was retained.  The pia mater showed the usual vas-
 cularity of meningeal inflammation in every case.  The
 vessels lying across  the convolutions were uniformly
 red, numerous, and large, being seen, in several instan-
 ces, many of them as much as a line, or even more, in
 diameter.  The red vessels were equally numerous, but
 in no instance  so large, on the parts at the base of the
 brain, and on the cerebellum.  They were also found
 in great numbers on the walls of all the ventricles, ac-
 companied occasionally with spots of capilliform injec-
 tion resembling ecchymosis to the naked eye.  Spots of
 red ecchymosis were observed in different subjects  on
 the lateral walls of the third ventricle, the anterior wall
 of  the fourth, and in the posterior horn of the left later-
 al ventricle ; they were also seen in several cases on the
 upper surface of the hemispheres and on the cerebellum.
   Vascularity of the Brain.—On cutting into the nerv-
 ous substance, there was found, invariably, besides the
 red points, as they are commonly   seen in congestion,
 as well as in inflammation of the brain,'an infinite number
 of  red vessels, sometimes  containing fluid, sometimes
 coagulated blood.   The  enlarged  vessels occupied dif-
 ferent parts in different subjects.  They were absent in
 the hemispheres in but one case; in this the grey mat-
 ter was a uniform pink color, and spots similarly colored
 occupied various parts of the white substance.  They
 might be seen also after the membranes were peeled off,
 ramifying on the several  parts at the base  of the brain,
 and on the parts constituting the floors and walls of all
 the ventricles, as well as on a section of any of these
 parts.   The grey and white matter had also a pink color,
 which was not dependent on the presence of vessels that
 were separately visible, and this, too, occupied different
 parts in different subjects, and was  never altogether ab-
 sent.   The medulla oblongata was dotted interiorly with
 dark ecchymosed spots in two cases.   The cerebellum
partook of these alterations to a greater or less extent
in every case. 
4
  Softening of the Membranes.—This lesion occurred  iti
circumscribed portions of the membranes in seven ca-
ses, viz : on the exterior of the brain, including the in-
ferior surface of the cerebellum, in four cases, and in the
membrane covering the floor of the lateral ventricle  in
three.
  Softening of the Brain.—This lesion was observed  in
nine cases, viz: in some part of the hemispheres, chiefly
in the  cortical, in seven cases; in  the meulla oblongata
and pos varolii, in three; in the fornix and septum luci-
dum, in five; in the walls of the third ventricle and ca-
nal leading to the fourth, and in the infundibulum, in one
case;  in the corpus callosum and outer semi-circular
rim of the  left corpus striatum, in one case; in  the op-
tic nerves  and commissure and tractus  opticus, in one
case ;  in the crus cerebri, in two cases, and in the cere-
bellum in one case.  In the latter, the softening, which
was also seen, in  the grey matter of the hemispheres in
the same case, was confined to two spots on the posterior
and superior surface of the cerebellum on either side of
the median line;  at these spots, which looked under the
membranes like ecchymosis, a part of the nervous mat-
ter was converted into a reddish  pulp,  which adhered
to the membranes so as to tear out with them, leaving
a regular  and smooth cavity, with white walls, the  lar-
gest about the size of the  first joint of the  thumb.   A
portion of the disorganized mass showed, under the  mi-
croscope,  blood, lymph, and pus globules,  the latter
largely predominating, with scarcely a trace of neunne *
   Thickening of the Membranes.—'The  arachnoid  was
thickened and opaque where it  covers the anterior sub-
 arachnoidean space in three cases, and  where it covers

   * If the reader require any further evidence that this is an instance
 of inflammatory  softening, in  which Dr. Bennett (Med. Chir.  Rev.
 Vol LX., p. 460) says, the purulent, infiltration has no  existence, he
 may consult the history of the case at page —, case 11.  This  kind
 of softening in exact appearance, at least to the naked eye, occurred
 in several other instances ; in one the seat of it was the external pos-
 terior  surface of the medulla oblongata, and in another, the anterior
 surface of the tuber annulare.  In other cases, the softened parts were
 whiter than the normal brain, and in others the natural color remained
 unchanged. 
5
the posterior sub-arachnoidean, in one case.  This alter-
ation could be easily demonstrated at these places, so
as to leave no doubt as to the fact.  There  was an ap-
pearance of thickening in other places, but this was not
certainly ascertained by separating the membrane from
its connections.
  Effusion.—There was an effusion of yellowish color-
ed matter, showing under the microscope an abundance
of pus and lymph globules, on some part of the  mem-
branes covering  the exterior surfaces of the brain in ten
cases.   In the greater number, enough  of the  effused
lymph was coagulated  to give some cohesiveness to the
morbid product, but not enough to give it the appearance
of an organized  membrane.   In appearance  and con-
sistence it  resembled  a  very  loose  coagulum  of
fibrin.   It was always found uuder the arachnoid cover-
ing of the pia mater.   In some cases it was so diffused
under the membrane on the hemispheres as  to look like
a coating of cream, or, rather, as if the membrane had
a cream color; in others it was confined, on the convex
surface of the hemispheres, to the course of the  large
vessels  between the convolutions.  At the  base  of the
brain  this  lympho-purulent  deposit was  largest and
found most frequently  about the optic commissure—in-
deed, at this place, either on  the commissure  and mam-
millary bodies, or between them and the tuber annulare,
it was never absent.  In one  case, it was found only at
this place, the interstices of the convolutions  being oc-
cupied by a serous fluid containing a few  pus globules.—
In several  instances  it  projected from  the  arachnoid
membrane into the sub-arachnoidean spaces, a line  or
more in thickness; and once, the anterior cavity was
occupied and even distended  by it.  It was found, also,
on the corpora quadragemina,  the medulla oblongata,
and around the third pair of  nerves,  where they  pene-
trate the arachnoid membrane.  The exterior surface of
the cerebellum was frequently the seat of this deposit.*
  * The facts lead to the inference that this effusion was exclusively
a product of the under or inner surface of the arachnoid.  The reader
will have noticed that it was not found in any of the ventricles, where
      U 
6
    An effusion of fluid  into  the  arachnoid cavity was
  found in nine cases.  With this  effusion,  pus globules
  were mixed in uncertain proportions in every  case  in
  which they  were sought.  In two cases the effusion
  chiefly consisted of pus, mixed with blood globules.  In
  one case, that in which the arachnoid membrane had a
  pink color, a  small quantity of the effused fluid, after
  standing a short time, coagulated; this was not submitted
  to the microscope.  In  one case, the cranial portion of
  the arachnoid was the  seat of an organized false mem-
  brane.  In some places  this organized effusion was soft
  and but slightly adherent to the true membrane; but, in
  other places, and in large patches, it was quite as strong
  as the arachnoid at the base of the brain, and adhered
  with a good deal of firmness.  Its color was rather a din-
  gy pink, and from its surface everywhere pus  could be
  scraped.
   A morbid effusion was found in the lateral ventricles
  in four cases; in one it  consisted of a cream-colored
  layer, semi-fluid, on a part of the left corpus striatum; in
  another, there was about a drachm of greenish colored
  pus;  in another, there  was serum, made  turbid with
  flocculi;  and in another, there was serum, mixed with
  pus and blood.
   Fibrous Concretions.—Concrete fibrin was found in
 the  vessels of the brain  in several cases, viz:  in the in-
  ternal carotids, in two; in the basilar artery, in one, [a
 dark coagulum of blood was found in this artery in one
. case, and black fluid blood in another], and  in the longi-
tudinal sinus and veins leading to it, in another; the con-
 cretion in this case occupied  the entire length of the
 large vessel, and extended from it into the  smaller ves-
sels, from which threads of fibrin were drawn out to the
 length of several inches.
   Spine.—Several partial  examinations of the spinal
 cord were made, in which  the lesions,  it may be said
 generally, were the same as those found m  the brain in
he membrane ,? said not to extend, nor between the convolutions, and
that it was found on the inner surface of the membranous walls of the
anterior and posterior sub-arachnoidean spaces, having, in more than
one instance, no intimate connection with the pia mater 
7
the same cases.   The intense vascularity of the pia ma-
ter was always present, but the lympho-purulent deposit
and the injection of the cord proper, were less common
than in the brain. The spine was opened  in  its whole
length in one case only.   In this the dura mater had the
color of muscle, which was uniformly diffused over every
part of it, the internal surface being divested of its pol-
ish.   It was thickened, also, in its whole length, but not
equally;  its arachnoid covering was also  thickened  in
the parts which were  separately examined after macera-
tion.  The cervical portion of the cord was softened in
every part, presenting, in color, various shades of white,
yellow and red;  the filamentous portion exteriorly be-
ing reduced to a disorganized pulp, which came off with
the pia mater, and adhered  to the finger when touched;
the color of this part, without being brilliant, was a pure
and beautiful white.   This  alteration was found princi-
pally in the upper part of the cervical expansion of the
cord; nearer  the dorsal  portion, where  the  softening
was rather less, the color degenerated into a dingy yel-
low of several  shades.   The vesicular matter of this
part  of the cord was less altered  than the  fibrous—
though much softened it would  bear  division  with the
scalpel;  its color, in  some parts, was  pinkish, and in
others, a more or less dull red.  Besides this general col-
oring, a transverse section of the firmest parts showed
a number of red and dark dots and striae.   In the dor-
sal division, the grey matter was more softened than the
white, the softening becoming more decided in proceed-
ing downwards.  The pure white color was not obser-
ved in this division;  the yellow tinge predominated, in-
termingled here and there with shades of dull red.  The
deposit of lympho-purulent matter  was found chiefly
about the roots of the anterior cervical nerves, being de-
cidedly greater on the right than on the left column.*
   Abdomen.—In other parts of the body no lesions were
observed, which seemed to  be other than accidental, or
  * The reader will find the history of the  symptoms of this case at
page —, case 5th.  In connection with the post mortem appearances,
it presents some points of interest to the physiologist as well as to tho
pathologist, 
8
particularly worthy of note, except those found  in the
digestive tube, and mesenteric glands.  Here the alter-
ations were so constant as, even  in  the few cases ex-
amined,  to denote something more than a casual com-
plication.  The abdomen was opened in five cases.  In
all of them the mucous membrane of the stomach and
the ileum, to a greater  or less  extent, was reddened,
thickened and softened.  In the stomach, this alteration
was found mostly in the smaller curvature, about the
cardiac orifice; the parts immediately about the pylo-
rus were not observed to be softened in either case.  In
the ileum, the  examination was confined  to the  lower
part,  in  extent from one and  a half to four or five
feet.  In all but  one, the membrane wras  most altered
in that part nearest the  ccecum;  in  the case excepted
the membrane was equally affected throughout the por-
tion examined—about five feet; in four cases, including
the latter, there were lesions of the agminated, solitary,
and mesenteric glands, which, on account of the circum-
stances under  which they were found, became the sub-
ject of particular attention and interest, and seem to re-
quire here a somewhat detailed  notice.
   Case 1. T. H., white male, aged  14 years.  Attack
sudden.  Death on  the second day.   Ex. 6  hours after
death.  A part of the ileum next to the ccecum was ta-
ken out and washed.  The mesenteric glands near this
part of the gut, as also for some distance above it, were
enlarged and red, but not perceptibly  softened.   Its in-
ternal surface  had a deep  red color imparted  to  it by
the injection of the  sub-mucous cellular tissue, the ves-
sels forming a beautiful arborescence under, and imme-
diately around the elliptical plates, where they were lar-
gest and most numerous.   On raising portions  of the
mucous tissue its color was found to be rather a pale red.
There were three elliptical plates in the parts examined,
all of which were elevated above the adjacent surface
half a line or more; their surfaces were  covered with
prominent granules, which slightly roughened them to
the touch; and the cellular tissue beneath  was  thick-
ened, apparently to  the extent of the  elevation  of the
plates, and softened. The lower plate was more deeply 
9
 colored, and more  elevated than the one immediately
 above it, which was itself more altered in these respects
 than the third.  A  great number of the solitary glands
 were also enlarged and elevated.   For the further histo-
 ry of this case, see case 12.
   Case 2. J.  H. White male, aged 12 years.  Attack
 sudden: death on  the  fourth day.   Ex.  twenty hours
 after death.  The mesenteric glands were enlarged and
 red.  About four feet of the lower part of the ileum was
 taken out and washed. The mucous membrane was more
 or less reddened, softened and thickened, throughout this
 part.  There were found in it eight of the agminated, and
 a great number of the solitary glands, in a diseased state.
 In  all of  the former, the elevated and granular  aspect
 was very  obvious, but not equally so in all.   The differ-
 ence, however,  did not offer a regular gradation  of
 changes from below upwards; those most altered were,
 as in the preceding case, nearest the colon, but next
 to these there were others which were less altered than
 those further up.  Under the glands, the  cellular tissue
 was thickened and softened.  There were no symptoms
 of  abdominal disease in either of  these cases.  The
 further history of this may be found in case 11.
  Case 3.  Black male,  aged 3 years.  Attack sudden:
 death  on the second day.  Ex.  eighteen  hours after
 death.  In this case, in  addition to the alteration in the
 intestinal  glands, which corresponded very  nearly with
 that of case 1, a great many lumbrici were found in the
 part taken out.  The mesenteric glands were not alter-
 ed.  There was acute pain in the abdomen,  on the first
 day;  there was no vomiting, and the bowels were con-
 stipated.
  Case 4. May, black  male  aged  17 years.  Attack
 sudden: death on the fifth day.  Ex. 6 hours after death.
 The mesenteric glands, to a great extent, along the
 ileum,  were  enlarged, dark red, and  much softened.
 About five feet of the lower part of the  ileum was ta-
 ken out and washed.  Opposed to the elliptical plates,
 on the external  surface were patches of mottled pur-
ple,  corresponding  with the plates  in size.  The in-
ternal surface had a deep and rather dark  red color, ex-
    2 
10
cept immediately around and  in the ulcerated glands,
presently to be described. The deep redness was owing
to the injection of the sub-mucous cellular tissue; the
mucous  membrane when separated being less  deeply
colored than the general appearance of the mucous sur-
face indicated.
  The agminatedand solitary glands presented the fol-
lowing alternations ; The inner surface of  the gut,  in
the whole extent examined,  was thickly embossed with
nodules, elevated from  a line and a half to two  lines
above the adjacent membrane, and differing from  each
other in size and color.  These nodules represented the
solitary and agminated glands.  The glandular struct-
ure of all the elliptical plates, and of a great number of
the solitary glands, with the mucous membrane of which
they form a part, was entirely destroyed  by ulceration.
The edges of the ulcers, formed out of deep rose-color-
ed mucous membrane, were abrupt and irregular.   The
place of the glands and of the cellular tissue under them,
was occupied by  a dingy yellow substance, whose  sur-
face was a  little depressed  below the  edges of the ul-
cers,  so as to give  a well-marked prominence to the
rose colored  zone, from which it was  separated  by a
line, which I  supposed,  indicated  the beginning  of a
sloughing process.  The  consistence  of this deposit
was nearly that of crude tubercle, and, like that, it was
friable.   Its surface was smooth, or, at least, presented
no very marked irregularities any where  but in the lar-
gest gland, nearest the ccecum, where it was irregularly
grooved  or pitted.  It  rested  on  the muscular coat,
which remained unaltered—no trace of the normal cel-
lular tissue could be found in it.   The  same substance
occupied the place  of the sub-mucous  cellular tissue
under the solitary glands.  There was no apparent  dim-
nution of disease in proceeding upwards to the extremity
of the section examined—a fact which renders it proba-
ble  that the  whole, or  at least, the greater part of the
ileum was involved in it *   This patient had neither
  *AU of the post mortem examinations, that I made  or witnessed,
were  more or less incomplete, for want of time.   The usual course
was to take away the part or parts which were the objects of particu- 
11
vomiting, nausea, nor diarrhoea.  He took a dose of cas-
 tor oil on  the first day of the attack,  which  acted very
 gently;  on the  second and  third days his bowels were
 constipated; on the third day  he had pain in the  abdo-
men, with  tenderness on pressure, and some tympanitic
distension, to relieve which he took some cathartic med-
icine, which, operating in the evening of the same day,
 gave entire and permanent relief to the pain, distension
and tenderness.   With the exception of these symptons,
 lasting but a few hours on the third day, the very formi-
dable disease of the abdomen was effectually masked by
the brain disease.
  Blood.—The blood taken from the arm, and by cups
from  the back  of the neck,  presented some  physical
characters which, considering the nature of the disease,
were peculiar, and sufficiently uniform to assist in the
diagnosis of some equivocal  cases.  It coagulated with
great rapidity,  so much so, that  I was foiled in several
attempts to ascertain its density by the hydrometer, for-
ming  a large and loose coagulum in which all the cor-
puscles  were rarely  included.  The serum separated
from  it very slowly, and in  small quantity.  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 only in four.  The blood an analysis of which is
given below, was 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 of twelve  years old, while comatose,
and the two others from stout  women,  between thirty
and thirty-five.
lar interest, and inspect them afterwards, as time permitted.  In this
way the examinations of the interior of the intestines were made, so
that any questions of new  interest arising during the examination
which  would have led, if practicable, to further enquiry,  had to be
overlooked or left to conjecture. 
12
             l.
So. gr. of defibrinated
      blood,........1053,50
    «  Serum........1026
Water................767,87
Solid contents........232,13
Fibrin  ................6,40
Corpuscles  .......... 140,39
Solid residue of serum . 85,34
             2.
Sp.  gr. of defibrinated
      blood, ........1046
    "  Serum........1022
Water................813,83
Solid contents........186,17
Fibrin  ................5,28
Corpuscles............112,79
Solid residue of serum ... .68,10

           3.
Sp.  gr. defibrinated
     blood........1046,50
    » Serum........1024
Water................796,07
Solid contents  ........203,93
Fibrin ................3,64
Corpuscles............123,45
Residue of serum......76,84
            4.
Water................787,37
Solid contents........212,63
Fibrin ................4,56
Corpuscles............129,50
Residue of serum........78,57
                     Symptoms.
  The  analysis of  symptoms which follows is made
from notes taken in sixty-four cases; this number con-
sequently, is to be taken as the standard of comparison
where the proportion is not otherwise stated.
  Mode of Access.—Premonitory symptoms occurred in
forty-three cases.  In all of these, pain in some part of
the head was a prominent and constant symptom.  The
cephalalgia was not so acute in this stage,  as after the
attack was formed,  except in those cases of the  latter
where the premonitory symptoms  were  followed by a
comatose state, in which the sensibility was blunted by
oppression of the brain.  It was generally  continuous,
but occasionally it  was observed to be remittent  or in-
termittent,  with or  without regular  periods.  Its seat
was commonly in the forehead,  temples,  supercilliary
ridges of one or both sides, or the  occiput; sometimes
it occupied the whole head, being in such cases  most
acute under the frontal or occipital bones.   In  a  few
instances among persons who  had been  subject to at-
tacks of sick head-ache, the premonition assumed this
form, and to such cases, nausea and vomiting,  as a pre-
monitory symptom, was strictly confined.   In the great-
er number, the  head-ache was the only warning given,
but  sometimes there were added  some pain along the
course of the spinal column, particularly in the neck; 
13
soreness in the muscles or joints; facial neuralgia; and
very rarely, giddiness, with or without dimness of vision.
There was but little impairment of the strength, and but
little complaint of a general feeling of malaise; persons
seldom left  their employment, whatever that might be,
before the attack was fairly begun.  As a general rule,
the appetite was but little affected, though it was occa-
sionally lost, or a great deal diminished.  In a few cases,
the  disease was developed on a relapse from  inter-
mittent fever, showing itself in the cold stage of the
second paroxysm.   The length of  the premonitory
stage was very various, nor  did the time of its  contin-
uance afford any indication  of the  severity of the ap-
proaching  attack ; the most  malignant sometimes giv-
ing  several days' warning, and at others, making the
attack without even  a momentary precursory symptom.
The premonition lasted less than twelve hours in eleven
cases ;  twenty-four hours, in  eight; two days, in five ;
three days, in six; four days, in four; five days, in three;
six days, in  one ;  seven days, in three ; and over seven,
in two.  The hour at which the full development  of
the attack began, I find noted in twenty-seven.  Of this
number, nineteen began between 12 m.  and 12 p. m., in-
cluding the  former and excluding the latter hour.
   Mode of Attack.—The disease was ushered in by
some degree of chilliness, never amounting to rigors, in
twenty-eight, of which eighteen had had premonitory
symptons.   The chill  was generally short,  being fol-
lowed in a few minutes, but  sometimes not for half an
hour, either by a decided febrile reaction ; a state  of
stupor more or less profound, with a cool skin and fee-
ble pulse; or, this condition of the skin and pulse, with-
out stupor.   When  there was no chill, the develop-
ment was sometimes manifested by  the sudden advent
of a comatose or  apoplectic state—a degree of stupor
not  amounting to coma, accompanied by a feeling  of
excessive debility, giddiness, dimness of sight, or double
vision ; or, by a sudden aggravation of the premonitory
cephalalgia, accompanied by various  changes in the
condition of the pulse,  skin, &c; or, as in a few instan-
ces, the premonitory head-ache increased gradually day
     2b 
II
  by day, with but little change in the skin or pulse, un-
  til at last the patient was compelled to take his bed.
    State of the Skin.—This was noted  in fifty-seven ca-
  ses :  of these, the skin was dry on the first day in forty-
  two ;  of these, it had the natural temperature in fourteen,
  was below  the natural temperature in  seventeen,  and
  above it in  eleven; it was moist, on the  first day in
  fifteen ; of which the temperature was natural in lour,
  below natural in three, and above natural in eight.  The
  dryness, which it is seen was so common, even with  a
  low temperature,  sometimes predominated throughout
  the attack when it ran its course quickly.  In  these
 cases, it proved to be very unyielding to remedies,  par-
 ticularly so to losses of blood.   I have noted in several
 instances, that patients were bled  to- the verge of  syn-
 cope, and this repeated within an hour or two, without
 affecting  it.   Death  took place in more  than one in-
 stance with a dry skin in  the moribund state.  Gener-
 ally, however, in the progress of  the attack, the state
 of the skin varied a good deal in regard to dryness and
 moisture, being dry or moist at different periods on the
 same day,  or on different days,  without any regularity,
 or any apparent dependence on the action of the heart.
 The temperature was  not usually so changeable ; very
 frequently there  was no change in this respect during
 several days, and but very rarely was any observed on
 the same day ;  this kind of change, too, when it did oc-
 cur, seemed to follow certain changes in the pulse, from
 a weaker to a more active state.  There never was any
 pungent heat in the  skin; in the  greater number in
 which it was above the natural temperature, it was still
 below  ordinary febrile heat; nor  was the head ever
 warmer than the trunk, though the  extremities might be
 cool when  the head and trunk were warm, but this was
 not very common.  When, however, the skin was else-
 where  cool, it was always cooler or positively cold on
 the feet or hands.   In  some instances the skin was ab-
 normally sensitive to the touch, particularly on the ex-
 tremities ;  the  scalp  was  sore  in  one case only.   An
eruption around the mouth (herpes labialis) was obser-
ved in  three cases.  Petechial  purple spots, which did 
15
not disappear on pressure, in one case.   In some the
face was flushed and the skin clear; in others, the face
was pale and  the skin sallow; the lips were  always
deeply colored.  In  one case, the skin had a peculiar
shining or glistening appearance, at the beginning of the
attack.   These  observations concerning the color and
petechias, of course refer only to  white persons, which,
it will be seen, formed a small proportion of the whole
number.
  Pulse.—It  may be said generally, in regard to the
pulse, that it was slower, smaller  and softer on the first
day than in health; and very irregular in the force of its
beats, in the time between them, and in their number to
the minute, in the same, as well as in different subjects.
To this  general  character, however,  there were many
exceptions, appertaining to certain varieties or forms of
the disease, which will be pointed out more particularly
in  another place.  The softness  of the  pulse  was its
most constant  feature.   I find it noted corded, or hard,
in  but one case ; and those instances in which it rose
above the natural fullness were very rare.   A pulse slow-
er than that of health, was less common than either of
the preceding.  In general, it was slower on the first
day than afterwards ; in the greater number it was be-
low 70—in many below 60, in others below 50, and in
several below  40.   The same remark is applicable to
the irregularity of  the  pulse.  Its irregularity in the
number  of beats  to the minute, was remarkable and
characteristic.  It  is thus noted in  one  patient on the
first day.  10 o'clock a.  m., 76; 12 m., 96;  5 1-2 p. m.„
68 ; 9 1-2 p.  m., 96; 9 3-4 p. m., 76; and so  varying
on the second day between 120 and 150.   On  another
occasion, the  pulse on the first day, during several hours
was continually varying its number to some figure be-
tween 30 and 76.   There  was one remarkable except-
ion to this kind of irregularity, in which the pulse stood
steadily at 100 throughout the attack, which lasted three
days, having been counted frequently, and the last time
but half an  hour before death.   These characters of
the pulse—slowness, softness and irregularity, were not
confined to the more violent or  malignant varieties of 
16
 the  disease; but were  observed in some of  the very^
 mildest attacks, in which there was no other evidence of
 serious organic lesion—and on the other hand, the small-
 ness  and feebleness were but little marked in the be-
 ginning and through the progress of  some of the most
 malignant cases.
   Very few notes,  I find,  were made concerning the
 action of the heart;  so far as its sounds were observed,
 they were never less feeble  than in health, nor in other
 respects offered any peculiarity.
   Tongue and Mouth.—The tongue underwent two kinds
 of changes from its  natural state, one or the  other  of
 which, with a single exception, was always seen at the
 beginning,  and, (if there were  no considerable compli-
 cation,) through the whole  course of  the attack, even if
 greatly protracted.   They were exhibited separately, in
 one of the two principal forms of the disease, and will be
 referred to  hereafter, in describing these varieties.
   The first kind that I shall refer to, occurred most fre-
 quently in one of the more grave or malignant forms of
 the disease.  In this  kind,  the  tongue was broad and
 flabby, filling up the mouth sometimes, so as to impede
 articulation, and press against the teeth, which formed
 by the pressure indentations on  its edges laterally as
 well as anteriorly.   In one case a portion of the tongue
 by its enlargement,  was protruded  constantly beyond
 the front teeth, and in a few others the pressure produ-
 ced on the  thick edges anteriorly, a  line or raphe, re-
 sembling that on  the gums  of an infant.  A  short time
 before death, the thickening and elongation were apt  to
 increase.   The coating which was usually of a pale ash
 color, or white, but sometimes yellowish, very often cov-
 ered the whole of the free surface of the tongue, always
 the whole of the dorsum, and a part at least of the edg-
 es, being thinner  at the  tip and sides, and  thickening
 backwards and towards the  centre.  With this state  of
 the tongue, there was always an abundance of saliva,
 which being generally more viscid than in health, had
 sometimes the consistence of thick mucibge; when the
coat began to give way, its edges  became abrupt, and
the clean edges of the tongue assumed the bright pink 
17
<color belonging  to the  alteration next  to  be des*
<cribed.
  In the other kind of alteration which I shall designate
the second, the tongue was less obviously enlarged; be-
ing generally broad, however, though not often thicken-
ed nor indented by the teeth.   The coating which was
always present, had the color of the first, but it never
occupied more than three-fourths, sometimes not more
than one-half of the dorsum; beginning thin before, as
if it were  coloring matter incorporated  with  the epi-
thelium, and  generally  thickening backwards.  The
parts uncovered, particularly the end and  sides of the
anterior  two-thirds, had a bright pink  color, which was
very peculiar and  striking.  As the disease advanced
towards  a fatal termination, it  was not uncommon for
this condition to assume that of the other, in all its char-
acteristics.  In neither  of these  conditions  was the
tongue  ever dry on the first day.  It  became  dry after
the first day, in five cases, viz: on the  second, third,
fifth, sixth and seventh day.
  Cephalalgia.—This  proved  to  be a very important
diagnostic symptom.  It was absent throughout the at-
tack in but one case in which there was consciousness
enough to answer a question.   Those persons who had
been subject to spasmodic or neuralgic head-ache, uni-
formerly spoke of the pain from this disease as different
from any they had ever experienced before.  Some de-
scribed it as consisting of a continued painful roaring  ;
others as a fullness and tightness, as if a tight band were
drawn round the head ; or, as if the forehead or crown,
or sides were being crushed  inwards.  A greater num-
ber  described it,  as darting  and throbbing,  frequent
shooting or darting through the head from behind for-
wards, and from side  to side and of such violence as to
cause the patient to cry out.   It occupied in some the
temples, supercilliary ridges, and frontal  region ; in oth-
ers, the back of the head  only; but in the  larger num-
ber, it was felt in the  whole head,  being more violent
in some one of the places just mentioned, or under the
parietal bones.
  The intensity of the head-ache was by no means pro-
   3 
18
  portioned to the severity of the other symptoms ; in some
  of the worst cases the pain was but little complained of,
  being obtunded, as it were, by the cerebral oppression;
  but it was sometimes slight also, in cases of equal ma-
  lignity, when there was  no want  of intelligence and
  sensibility; and, on  the other hand, it was at times in-
  tense and almost insupportable  when the disease assu-
  med its mildest form.   It was continuous with the at-
  tack in but few instances, disappearing towards the close
  of the first, or on the second, third, or fourth day,  to re-
  turn generally after an uncertain  interval.   It was gen-
  erally aggravated by an erect or semi-erect posture,
  though in two instances, such a position  relieved it very-
  much whenever  it was assumed.   In a number of cases
  the cephalalgia  was aggravated by pressure on  some
  part of the spinal column, chiefly the cervical—a pain
 was said by the patient to dart from the point pressed
 on  through the  head to the  eyes  and  temples..  The
 pain so produced was spoken of as very  acute ;  on one
 occasion, the patient, a young lady, begged me with the
 most earnest and moving entreaty, to desist from a very
 slight pressure on the fourth cervical vertebra, and  to.
 refrain from repeating it; she complained of the intense
 agony produced  by it during some minutes—the  case
 proved fatal.
   Giddiness.-—This was rarely complained of after the
 first few hours of the attack.  It occurred in but few ca-
 ses, and was never a prominent nor an important symp-
 tom.
   State of the Senses.—The conjunctives wTere generally
 injected, and the eyes glittering and watery; in a few
 cases, principally among children, the conjunctiva had a
 pinkish tint, when there were  no distinct vessels to be
 seen.  The pupils were dilated in seven out of forty-one
 cases in which their  condition was noted;  in the  rest,
 they were either  contracted or natural;  they were in-
 sensible to light from  coma, in three cases, and insensi-
ble without  loss of consciousness  (amaurotic,) in two
cases, m both of which perfect vision was restored in  a
few hours, and both of whom died apoplectic. Double
vision occurred in six  cases; painful sensibility to lio-ht 
19
occurred also in six cases; in a number of others, there
was enough of abnormal sensibility to make the ordina-
ry light disagreeable, but in far the greater number, the
strongest light was not complained of.
  In several cases,  there was a profuse discharge from
the nostrils of thick mucous, alone or mixed with blood.
In one patient, the sense of smell was lost in one nostril.
Spontaneous deafness was noted in a few patients, in
one of whom there were three exacerbations of it on the
second day, each lasting about three hours, with inter-
missions lasting about the same time.
   State of the Mind.—Some degree of stupor, amount-
ing in most instances  to profound  coma, was present
on° the  first day, in eighteen cases ;  and there were a
few others, in which it appeared on the second or  third
day.   In the greater number this symptom passed off
within twenty-four hours, but in  others not for two or
even three days, generally to return at some subsequent
period, varying  from twelve hours  to  several days;
sometimes it did not  return at all, though the disease
were protracted to many days—there were cases again
in which it did not remit, but these were  such only as
proved speedily  fatal.  Delirium,  with or without stu-
por, occurred at some period of the attack in twenty-four
cases; unlike the stupor, it was never continuous, some-
times  lasting but three or four hours, and rarely ever
more than twenty-four.   It was wild and furious in two
cases only, and  playful in  one; in a few it was melan-
choly  and pathetic, the  voice being  subdued  and the
tone and language  touching.  The mind was generally
desponding and apprehensive, so much so that even  in
the delirium, fears were not unfrequently expressed  in
regard to  the result of the attack.  There was in all
the more violent cases, forgetfulness of the events which
transpired during the attack, not only after it was end-
ed, but frequently from day to day while it continued;
and this, whether delirium or stupor was present or not.
   State of the Muscles.—The posture  commonly  assu-
med was on the back, with the lower extremities extend-
ed.  There was never any  disposition to assume the
foetal position, or a near approach to it. In two patients 
20
 both comatose, a position was taken on the right side,
 and maintained with great pertinacity; in another, in
 which  there was continued  opisthotonos, the position
 taken and kept during the greater part of several days,
 was on the chest and abdomen, the head being kept el-
 evated, or  if resting on the  arm  or  pillow, was  still
 thrown considerably backwards; in other cases when
 the head was thus drawn back, the decubitus was on the
 side.  Tonic contractions  of the extensors of the back
 occurred in three other  cases, in each of which a simi-
 lar action in the extensors of the head was also  obser-
 ved ; but the latter was observed also in a number of pa-
 tients, in whom the extensors of the back were not af-
 fected.  Besides these  cases  of tetanic contraction  of
 the muscles of the neck, the  latter were  affected with
 stiffness and soreness in thirty-five cases.   In a few of
 them, the affection was  confined to the sterno-mastoid
 muscles of one or both sides; but  in the others the  ex-
 tensors were principally concerned ; the head in these
 cases, instead of being drawn back, as in the more  ac-
 tive  contractions, was steadily kept in the  natural posi-
 tion  (of the head) when the body is erect, either  in-
 voluntarily or voluntarily as the easiest position.
   Quivering of the muscles of the face, tremors of  the
 hands, and embarrassment in the movements of the arms;
 tonic contraction of the flexors of the fore-arm, and of
 the recti muscles of the abdomen were, one or more  of
 them, observed  in  several  cases; subsultus tendinum,
 picking at the bed clothes, and reaching after imaginary
 objects, with other typhoid  symptoms, occurred in three
protracted cases.  Strabismus occurred in nine cases;
convulsions coming on towards the close of the  attack,
in three cases;  and at the  beginning  of the attack  in
one case.*
  *Dr. Abercrombie (Path, and Practical researches, &c.)  seems to
consider that meningitis most commonly attacks  by general convul-
sions.  Dr. Watson reiterates this opinion.  Both, however, were
treating of sporadic meningitis.  The  observations of others, of the
trench physicians particularly, are more in accordance with  the fact
stated in the  text.  For example, in Andrei's cases, if I remember
aright, convulsions are not mentioned among the symptoms at all. Dr,
Abercrombie  s cases are themselves far from satisfactory in proof of 
21
   An incomplete paralysis of the right eye-lid occurred
in one case,  and of one entire side of the body, in an-
other—one of the mildest kind, in which the  symptoms
previously indicated that there  was no serious affection
of the brain or spinal cord.   In a few cases, there was a
general soreness of the  muscles,  which gave rise to a
great deal of pain in moving.
   Spine.—Pain in the cervical division of the spinal cord
occurred in twenty-three -cases ; in the dorsal, in elev-
en ;  and in the lumbar, in six.   In all but two, the pain
was slight,  many  making no mention  of  it, until they
were questioned, and others  complaining of it less than
patients  generally  do in remittent  fever.   A more re-
markable feature in the symptoms of the spinal disease
I have already had occasion to refer to, viz: the effect
of pressure on the cervical and dorsal vertebras.  This,
when applied to  the cervical part of  the column, pro-
duced pain in the head, frequently darting from the spot
pressed on to the forehead, eyes and temples, in twenty
cases.  In two, during the existence of deep  coma, press-
ure on the upper dorsal vertebrae occasioned great rest-
lestnness  and apparent distress.  Pressure on the cer-
vical vertebras produced, also, pain at the top of the ster-
num—on the dorsal, pain in the middle of the sternum,
at the epigastrium, or about the umbilicus, as it was
made higher or lower.  Sometimes pain was not expe-
rienced in the part  pressed on at all, but only at some
one of the places mentioned above.   The pain so pro-
duced was often violent, and not always transient, con-
tinuing  sometimes  for  several  minutes.   In one case,
the  patient, a  black woman,  cried out from a slight
pressure  on one of the upper  dorsal vertebras,  saying
" you hurt me all over," and she recurred to  the circum-
stance more than once afterwards, with much bitterness
of complaint.
the general conclusion, for I find that the ages of his patients, in whom
this symptom occurred, were, with one exception—a girl of fourteen—
under twelve years, and a great majority of them under eight; proving
if anything,  only that the fact may be  true in regard to children, al-
though my experience, neither in the sporadic disease, any more than
in this epidemic, tends at all to confirm even the latter conclusion.
      3c 
22
   Stomach and Bowels.—Vomiting  occurred in fifteen
 cases-^at the beginning of the attack in two—at a later
 period on the first day, in eight;  not till the second day
 in three, and not till the third day in two.   There was
 nausea,  without vomiting, in three cases; one  on the
 first, and the two others on the third and fourth days.
   The bowels were either natural or constipated in ev-
 ery case but one, in which  diarrhoea occurred  on the
 sixth day, probably from the use  of tartar emetie for a
 pneumonic complication.  There was acute pain in the
 abdomen in three cases, and tympanitic distension, with
 tenderness on pressure, in one, occurring on the third
 day.
   Appetite—Thirst.—A desire for food, more or less ur-
 gent, was expressed in eight cases, at such times as ob-
 viously pointed it out as a symptom of disease, and not
 as a sign of  convalescence, or  of its near approach.
 The desire was evinced in some  on the first or second
 day; in others, protracted cases, on the eighth or ninth.
 It was rather  urgent  in two or three patients,  and in
 one continued to be so for several days.
   /Respiration.—This I find noticed in twenty-five cases.
 The  most remarkable feature concerning it, was the
 absence of stertor, which occurred in only two;  anoth-
 er feature worthy of notice, was the number of respira-
 tions  to the minute—in five only it  was below twenty-
 one, in two of these it was  twenty, and in one fell as low
 as eight; in five, it was between twenty-six and thirty ;
 in eight, between thirty and forty ; in five, between for-
 ty and fifty; and in four, from fifty-two  to fifty-six, all
 of them being  counted on the first or second days, and
 before the breathing  had become affected by the ap-
 proach  of  death—generally the breathing was regular.
 I noticed it as suspirous in one instance.
  Physiognomy.—The  expression  of the countenance
 was exceedingly various, and variable, affording little or
nothing  which was available in diagnosis, or prognosis.
It was frequently natural even under the influence of the
most fatal symptoms; in not  more than  two instances,
and in these after the disease had been long protracted,
was there anything of idiocy in the expression ?  When 
23
it was neither natural nor idiotic, the various shades pre-
sented may be expressed by the words, wild, anxious, or
distressed, melancholy, heavy, and lastly as was rarely
the case, however, brilliant and-pleasing; and several of
these varieties of expression were observed in the same
patient at different periods during the attack, and occa-
sionally at different times  on the same day.
  Emaciation.—Extreme emaciation occurred in but a
small proportion of even the protracted cases.   In far
the greater part of the whole number  there was none
perceptible.  In one, however, it took place suddenly,
in a manner which could  not be accounted for  by  the
extent of the evacuations,  for they were  inconsiderable,
on the accession of an acute and very formidable gastro-
enteritis,—induced probably, by tartar  emetic—which
appeared on the sixth day.
  Duration.—This disease seemed but little disposed to
observe the usual critical  days of the endemic diseases
of this locality, which are  the fifth,  seventh, and ninth—
particularly the ninth.  The extremes of duration were
fifteen hours, and fifty days.  Between these periods in-
clusively, there were three which terminated on the fifth
day, none on the seventh,  and three on  the ninth, while
there were sixteen which  terminated on the second  and
third, and nineteen on the fourth.   Besides these there
were two which proved fatal within the first twenty-four
hours, and two which lasted over forty days; one  ter-
minated on the fourteenth,  and nine between the four-
teenth and thirtieth—making fifty-five cases to which the
notes have reference.
                       Forms.
   The disease assumed a great  variety  in its aspect,
and a  distinctness in the  varieties, which was very re-
markable.   I do  not refer merely to  shades  of vio-
lence,  nor to modifications occasioned by serious com-
plications, in which the disease might still preserve its
identity by  the symptoms alone; but to more palpable
differences seemingly dependent on other  causes, con-
nected perhaps essentially, with the epidemic constitu-
tion of the atmosphere ; and of such  kinds,  as to very
much embarrass the diagnosis for some time after the 
24
  epidemic first  made its appearance.  Various  as  the
  forms were, however,  their distinctness of outline ren-
  ders them capable of being  easily arranged under two
  principal heads,  each of which will admit of being ad-
  vantageously sub-divided; an arrangement which appears
  to me to be of practical importance, and necessary  in-
  deed, in order to present this part of the  subject in a
  tolerably clear light.
   Taking the character of the symptoms alone  for the
  foundation of the principal division, one is  naturally led
  to apply the term congestive, to one class  of cases, and
  that of inflammatory to another; under which the wThole
 number  may be included,—the former comprising a lit-
 tle more than one half.   The  distinguishing features of
 these classes, if I may so call them, which  are very ac-
 curately represented by their names, were  always well
 marked  at the beginning, and generally also through the
 course of the attack, even when most protracted.  The
 exceptions  to this latter remark  were  found in but a
 small number, in some  of which, for  example, the dis-
 ease, inflammatory in its aspect at the  beginning, assu-
 med, after a first remission, a stage of congestion more
 or less decided in its symptoms ; or, as in others, the first
 stage of congestion, after an uncertain time, gave way
 before a reaction,  which might continue to  characterize
 the attack in its further progress ; or, might be succeed-
 ed after another uncertain  interval, by  a  more or less
 obvious return to the congestive state.   The latter, how-
 ever, can hardly be called exceptions with  strict propri-
 ety, for the stage of reaction  in them,  no matter how
 violent it might prove  to be  afterwards, was at first a
 state of improvement—a remission in fact differing from
 other remissions presently to be noticed, only when the
 secondary state proved to be permanent.  With these
 few exceptions then, the stamp put upon the character
 of the attack, as concerns these classes, was neither ef-
 faced, nor indeed  hardly obscured  in its progress or
 march.
   It is next to be observed that among the individuals of
 each class there were many well defined shades of dif-
ference which require to be fully set forth in a true pic- 
25
ture of the epidemic, and which will afford the founda-
tion for  the  further division or sub-division  spoken of.
These  differences were of two kinds :  The first de-
pending chiefly on different degrees of violence, may be
represented in three groups, the general features of which
may be properly expressed by the terms malignant, grave
and mild; the middle term being  applicable to  the in-
flammatory  class  only.  The second  kind  occurring
among cases of equal violence, cannot be expressed in
general  terms,  but may be represented to some extent
in a selection of cases from the several groups.  It will
be found that this sub-division is, in point of fact, much
less arbitrary than the terms would generally imply.—
The several varieties were not disposed to run into  each
other by imperceptible  shades, so as  ever  to leave a
doubt as to the place to which certain cases might be-
long,—on the contrary, they preserved a distinctness
and0uniformity of outline, which could not have been an-
ticipated from different shades of violence merely, in the
same epidemic disease; nor were the individuals of one
group disposed to change abruptly to that of another.—
I have not been able to find, neither among my  own
notes, nor among those furnished me by  other  physi-
cians, more than a single instance  in which an individu-
al of one of the sub-divisions, viz : the grave, assumed,
in its progress, the symptoms of another,  viz: the  ma-
lignant.   Thus, the first impress of the power of the dis-
ease o-iving rise to this sub-division, was not less a  last-
ing one, than was  that on which the higher division was
founded;  and whatever deviations from  it might  have
been observed, were comprised within limits which fair-
ly justify, as an expression of uniform and stable differ-
ences, the application of the comparative terms I  have
employed to designate them.
   I now proceed to consider the two classes and  their
sub-varieties separately.
   1st. Of the congestive class.—As I have  already  inti-
mated,  there were but two divisions  of this  class,  viz:
the malignant, and the mild.  Their affinity to each oth-
er was manifested by such symptoms as  distinguished
this from the inflammatory class, viz : the constant  pres-
      4 
26
ence of a cool skin, a small and feeble pulse, and a char-
acteristic tongue, which corresponded,  in  appearance,
with that first described at page —.  The traits which
distinguished them from each other were not less obvi-
ous and uniform.
  2d. The malignant was distinguished by the frequent
occurrence of chilliness in the forming  stage;  a  great
diminution or prostration of strength;  the  invariable
occurrence,  at some period of the attack, for the most
part on the first day, of coma, or at least a great degree
of stupor, which was more common than delirium ;—of
delirium, or of both;  embarrassment in the movements
of other muscles than those of the neck, and the strong-
er contraction of some  of the former, drawing the occi-
put downwards; a wider range in the frequency of the
pulse, and its  more changeable character otherwise;
the  greater quantity and viscidity of the  saliva, and
thicker coating of the  tongue; and by an occasional
tendency to assume the symptoms of the inflammatory.
  Case 1. Moody, white, aged 20, Printer, was taken
with a slight chill on the 13th of March, 1848, at 5^ P.
M.r and had some fever during the night, and rested bad-
ly.   On the next day, at 11 A. M., he was  seen by Dr.
Sims. He then had the  following symptoms: comatose;
skin cool and dry all over; face pale; hands and feet cold;
pulse 76 to 80, small, very feeble  and irregular; resp.
32; pupils natural, and move readily to the light;  con-
junctivas injected;  lies with his mouth open when  quiet,
but is  very restless;  flexure of the hand  on  the fore
arm, and of the latter on the  arm; great  sensitiveness
of the skin of the arms  to the touch or pressure; press-
ure on the cervical vertebras caused great "distress, and
increased restlessness, during which he made strenuous
efforts to get out of bed, turning his eyes wildly;  it was
now ascertained that he was amaurotic; does not speak.
He  remained pretty much in this condition during the
day, his pulse continuing feeble, but variable, ranging
from 62 to 96.   Towards evening his  skin had nearly
the normal temperature, and  had become  moist, but
again become cool, and his feet very cold before 9 P. M.,
about which time he had a large evacuation of  urine.— 
27
On the 17th, his bowels had been opened freely by Cro-
ton Oil, and a blister which had been applied to the spine
had filled well; his pulse  had become very  frequent,
138 to the minute, with rather more feebleness and di-
minution of volume;  the  amaurosis had disappeared
with the  tonic contraction  of the muscles of  the  arm;
during the day he was restless, and disposed to get out
of bed, which he did frequently ; then he would go to the
fire and sit awhile, then to  the pail and drink water, re-
turn to bed, respread the covering with some  care, and
lie down; while this was going on he carried his  head
bent  backwards w ith the chin elevated;  did not speak,
but groaned a-great deal in a way that indicated a general
uneasiness and distress, rather than pain.  At night  it
was evident that he was failing fast,  he continued rest-
less, but  now kept his bed; his eyes had  become  more
injected  ; his pulse still quicker and more feeble; and
the expression of  his  countenance,  which had before
been rather stupid, was wild; when importuned to  speak
he merely ejaculated,  " Oh  Lord!"  He died  without
convulsions about 9, A. M.
   Case 2.  Black, age 22, called at the office of Dr. Jones
early on the morning of the 8th of March.  He had
been treated during the past summer for  a quotidian in-
termittent cephalalgia, which proved to  be very obsti-
nate, but yielded, at last, to a salivation.   He now com-
plained of a similar intermittent pain which came on
early in the morning, increased in severity until 12, M.,
and then gradually declined until night,  when  it went
off.  The paroxysm for which he consulted Dr. J. was
the third,—along  with it he  had tenderness of the cer-
vical vertebras.  He was directed to have a blister put
on  the  spine over the cervical and upper dorsal verte-
 bras, and to take half a grain of valerinate of zinc, with
extract of hyoscyamus, every four  hours.  On the 9th
 I saw him, in the absence of Dr. Jones,  at 8, A. M.;  he
was  then very stupid, but could be roused  to answer
 questiens in monosyllables without much difficulty ;  he
 was  lying on his right side, and would not keep any oth-
 er position; his skin was moist and cool on the head
 and body, and cold and dry on his feet and hands; coun- 
28
tenance dull, as if from  sleepiness  rather than  coma ;
pulse 84, small, feeble,  and irregular; conjunctiva  not
injected ; pupils natural; when questioned said  he had
pain in his head.  At 9, A. M., Dr. Jones took charge of
him, and from him  I have obtained the following addi-
tional history.   At this time his pulse  had increased in
frequency, without any other change in it, and he had
become more stupid.  He took  a  cathartic, and had
mustard cataplasms to his extremities.  At 12, M.,  his
bowels had been acted on twice;  his skin was becoming
dry, without getting warmer, and the  pulse was even
more feeble.  At 4, P. M., his pulse had risen to 112, and
having a little increased fullness, he was  bled  from the
arm to thirty-two ounces, after which the pulse became
again exceedingly weak, and rose in number to 125.  He
was then directed to have six grains of ferrocyanide of
quinine with Sp. lavend. comp. every four hours.   At 9,
A. M., his pulse was  160, his skin moist, and the coma
profound.
  On the 10th, at 8,  A. M., he had  taken twenty-four
grains of quinine; pulse 132, other symptoms not at all
improved.  At 11, A. M., he was taken with convulsions
in paroxysms which lasted about a minute, and recurred
at intervals of about  ten minutes—these continuing, he
died about 3, P. M.
  Case 3. Dennis, black, aged about 30, Ferryman, was
taken with a bad cold and cough on the 21st of  Febru-
ary ; along with the cough he had also a  sore  throat,
and some stiffness and soreness on motion in his neck ;
he continued at his work until  the  24th,  at 4 o'clock,
when he took a chill and  came  home to bed; rested
badly during the night;  had great thirst, and complain-
ed of slight pain in the head, and severe pain in all his
joints.   On the 26th, at 10, A. M., he was in  the  fol-
lowing condition—the history of the case from this time
being taken from the  notes of Dr. McLester:—Free from
delirium and coma, eyes injected; pupils, skin, and res-
piration natural; tongue covered  with a thick  whitish
coat; nausea, and occassional vomiting  of a greenish
water; bowels open;  pulse 62,  small  and irregular;
urine highly colored; has severe pain in the  region of 
29
 the frontal sinuses, which is increased by light pressure
 over them; pain,  also, in the occiput, and back of the
 neck, but not violent;  some  increase of pain on press-
 ing the cervical spine; soreness in the  muscles of the
 neck; movements of the head and arms embarrassed ;
 discharges from his nose, with difficulty, a thick bloody
 muco-purulent  matter.  He was  ordered  to  take sul-
 phate of quinine,  morphine,  and ext. of  hyoscyamus,
 every four hours, and to have a sinapism  to  the neck,
 which, at 8, P.  M., had relieved the pain in the head and
 neck, to a great degree.  On the 27th, at  8, A. M., the
 pain  in the head, which was relieved during the night,
 had returned; the movements of the head were more em-
 barrassed ;  and those of the arms were tremulous;  in
 other respects the symptoms were the same.  In the eve-
 ning  he had some difficulty in deglutition, and in getting
 rid of the matter in his nose ;  in the  course of the night
 he became delirious, for the first time,  and continued rest-
 less until the morning of the 28th, when he had become
 perfectly rational, and was almost free from pain in the
 head, the little remaining being in the region of the fron-
 tal sinuses.  From this time  his condition changed but
 little until late in the afternoon of the 29th—he was kept,
 during this time, quiet, with an occasional  dose of mor-
 phine0 and had  colomel, in doses of five grains, given  to
 produce ptyalism ; in the afternoon of the  29th, he was
 evidently  sinking, and at 7, P. M., he died  quietly, hav-
 ing had no delirium, and conversing  sensibly of his ap-
 proaching death, almost to the last moment.
   Case 4.  Rose,  black, female,  aged 20,  having com-
 plained for a short time of pain in the  head, neck, and
 shoulders, was  observed to totter, and show an inclina-
 tion to fall backwards while at work in the field on the
 18th  of April.  Soon afterwards she got separated from
 the other  hands, and was found lying on the ground in-
 sensible ;—this  was about 12, M.  At 5, P. M., when
 she was seen by Dr. Holt, she was in a profound coma,
pulse72, small, and very compressible;  skin cool, gen-
erally, and cold on the extremities ;  eyes natural; mus-
cles of the extremities cataleptic.   She was directed to
take a drachm of calomel, and to have  a blister on the
      4d 
30
 spine, to cover the whole of the cervical and dorsal ver-
 tebras.  On the 19th, at 9, A. M., the symptoms had not
 changed, in any respect; two scruples of calomel were
 given  at this time.  At 5, P. M., the stupor had subsi-
 ded, and she then complained of pain in the head,  and
 soreness and stiffness of the neck.  She was directed to
 have an enema, and take ten  grains  of  calomel every
 three hours.  On the 20th, she had  become salivated,
 her skin warm, and pulse fuller, 110.  From this time
 she continued to improve,  and was discharged on the
 23d, the salivation having become very profuse.
   Case 5, (from Dr.  Berney's notes.) Cornelius, black-
 smith, 30 years old, of sound  constitution  and  regular
 habits, complained for the  first time on the morning of
 the 17th of March, of head-ache over the entire frontal
 region, which caused him to quit work.  The pain not
 having diminished at 7 o'clock, P. M., I (Dr. B.)  was
 requested to visit him.  He  now  complains,  as during
 the day, of pain in the forehead, but is free from pain or
 uneasiness in every part of the spine ; his  skin  cool;
 tongue clean; pulse natural in frequency,  but  feeble;
 pupils  natural;  no thirst; bowels constipated.
   12th, 11, A. M..  He was moved this morning, early,
 at his own  urgent request, to  his  master's,  four miles
 from town.  Temperature of the surface rather  below
 natural; hands and feet cooler than the rest of the body;
 pulse 96, small, feeble, and very  compressible;  deliri-
 um ; excessive pain in the  head  and lumbar region;
 strong contraction of the flexor muscles of the left fore-
 arm ;  extreme restlessness,  rolling and tossing in bed,
 exclaiming, " I shall die;" pupils natural; tongue clean ^
 (this is a single exception to a rule which was otherwise
uniform)  no thirst;  sensibility unembarrassed, as, also,,
muscular motion,  except in the left  arm:   R. V. S. to
thirty-eight  ounces,  blisters to neck, arms, thighs, and
legs, hot  turpentine rubbed  on extremities,  calomel gr.
xl.  At 4, P. M., he was bled again to ten ounces,  and
again to the same extent during the night.
  13th. The blood drawn on yesterday exhibits a  soft
coagulum, not buffed, and but little  serum; pulse 94,
still small and  feeble; some  tendency to  stupor; the 
31
contraction of the arm having ceased entirely, there is
now no embarrassment in  the  functions of any of the
motor or sensitive nerves—R.  Cal. and ext. colocynth
comp., each five grains, to  be  given every  two  hours;
blisters over Ossa Parietalia.
  14th. Tranquil, head free from pain; slight pain in
the back; pulse 112, feeble and small; skin natural in
temperature; herpetic eruption  on the lips; asks for
food, and says he is hungry ; ptyalism suspected.
  15th. Ptyalism evident;  has been restless during the
night from strangury, which is  still very  troublesome;
is very loquacious.  In the afternoon he was observed
to pick at the bed clothes;  pulse 112, a little fuller and
stronger.
  21st. But little change since the 15th,  until  to-day.
He has been troubled a great deal with strangury, and
has had, along with it, rigid contraction of the recti mus-
cles of the abdomen.   He has been free from delirium,
and nearly so from pain, the pulse varying from 100  to
120;  to-day he is stupid, and greatly prostrated—these
increasing, he died on the 22d, without convulsions.
  The two following may be called mixed cases, as per-
taining to both of the malignant groups, having,  at the
beginning, those  pertaining to the congestive.
   Case 6. Miss B., a  young  lady, just returned  from
boarding school, in excellent health, aged about 16, of a
lymphatic temperament, had some degree of chilliness,
about midnight, on the 16th March, which was follow-
ed  by fever, and pain in the head.  On the morning of
the 17th, the fever and pain continued; at 4, P. M., she
had some feverish heat about  the  skin ; her  eyes were
somewhat injected; her tongue  was coated all over the
dorsum; and her pulse 118 beats to  the  minute, and
nearly natural in fullness and force;  she had  no pain in
the head when still, but complained  of pain in the fore-
head when it was raised from  the pillow;  in about half
an hour she vomited once, but made  no  complaint of
sick stomach afterwards;  at 9,  P. M., she had a  return
of  head-ache, and was somewhat restless  until  11',  P.
M  , when she expressed a wish to get up, in doing which
she was assisted by her father;  but she had  no sooner 
32
gained a sitting posture than she began to  talk  rapidly
and incoherently ;  her articulation becoming indistinct,
she very soon fell into a comatose state, and had a large
involuntary evacuation from her bowels, in bed.  I saw
her in half an hour afterwards, at which time she  was
comatose,  but  restless  and moaning; her skin  pale,
cool, and dry ;  pulse about 70 beats to the minute, was
small, soft, and irregular in the  time and  force  of its
beats.   In a very short time the coma became profound
and the breathing slow, and a little stertorous.  She was
now still, and insensible to any  kind of stimulant; the
right pupil was  steadfastly dilated, so as to leave but a
very narrow rim of the iris visible ; the left pupil was di-
lated, but moved spontaneously, both being insensible
to light.  She was bled from the arm to twenty ounces;
the blood was not  buffed; before it had ceased running
the left pupil moved to the light of a candle, to a limited
extent; at the same time a free sweat broke out, which
was particularly cold on her forehead;  she got restless,
and her pulse quickened.   After these symptoms  had
subsided, 'which required half an hour or more, six oun-
ces more of blood  were taken from the back part of the
neck by cups, and, sometime afterwards, eight  ounces
more from  the arm, each of the last bleedings producing
a recurrence of the symptoms which followed  the first;
after the last one her pulse rose to 104 ; in the meantime,
mustard had been  applied to her extremities ; hot appli-
cations had been made to various parts of her body, and
her head had been shaved, and a blister had been  ap-
plied, so as to cover a part of the frontal, and nearly the
whole of the parietial  bones.   For several hours after-
wards  the left pupil became more and more  moveable,
and the rioht contracted gradually, being still insensible
to lio-ht.   At 10, A. M., on the 18th, both pupils, though
dilafed, responded to the light,  but not perfectly,  and
their motion was not consentaneous ;  when asleep both
pupils   were contracted,  but  not equally,  and  when
awake thev were unequally dilated, and  the  dilatation
wax invariably  increased when  she made  any muscular
effort    Vt this time the skin on the head  and body had
become warm, while her feet and hands were still cool, 
33
and her face very pale ;  her pulse was 108,  small and
soft; she was more sensible,  spoke when  importuned,
and articulated well; drank water when it was put  to
her lips, and pressed the glass towards her mouth; it was
now ascertained that the  right eye lid was partially
paralytic.  At  7, P. M., she  had recovered entirely
from the  coma;  her skin had become  warm all over,
and she was free from pain of any kind.  On  the 19th,
at 6, A. M., I was told that she had  passed a very rest-
less night, had vomited several times, and had had a fre-
quent desire to evacuate her bowels  ; her pulse was now
76, small, soft  and laboring; she  complained  of her
head, and had a cool and dry s kin.  One hour afterwards,
without any medicine having been given, all these symp-
toms had changed; her pulse was full, strong, firm, and
130 to the minute; her face flushed, and  skin  warm;
had no pain ; spoke cheerfully, and jested with a young-
er sister  when she came to the bedside.  This state of
improvement  continued  throughout the day, her pulse
falling, in the evening, to  104.  At 124, A. M., of the
20th, I was called to see her, and found that half an hour
before she had been taken, suddenly, with  a  very acute
throbbing, and  lancinating pain, which occupied,  at
times, the whole of her head; her pulse was  120, full,
steady, and firm ; face flushed ;  lips deeply  colored; fre-
quent desire to go to stool; nausea, and, at times, vom-
iting ;  no delirium, nor coma; about five ounces of blood
having been taken from her neck, by cups, she complain-
ed of feeling faint, and asked for colonge ;  at the same
time her face and lips turned pale, and her pulse became
very feeble.  Her head not being at all relieved,  two
cups more were applied, drawing not more than an oz.
and a half of blood, when the symptoms of approaching
syncope  appeared again, without the slightest relief, but
rather an aggravation of the cephalalgia.   As the morn-
ino-  advanced  the pain  increased in violence,  so that
she frequently cried out with it.  She became  a little
delirious towards 5 o'clock,  A. M., asking   irrelevant
questions, and  replying to imaginary ones.   She now
took one fourth of a grain of morphine, and at 8, A. M.,
was sleeping quietly; pulse 80, full, irregular and hard;
      5 
34
face flushed; skin hot and moist; no pain in the head;
and though she talks when asleep, is free from delirium
when awake ;  she asked for ice, which was allowed her.
At 3, P. M., I received a note from her father to the ef-
fect that she  had become very talkative and restless,
and that her face had become more  flushed ;  at  34, P.
M., I found her comatose, breathing slowly and sterto-
rously ; pulse 70, full, and irregular ; tongue  much en-
larged, and protruding from  between  the  teeth; the
mouth overflowing with saliva ; face red; lips purple ;
she could be roused with some difficulty, and gave short
answers, correctly, though her articulation was greatlv
impeded; she complained of  being  numb, all over.—
Blood was again drawn, but  without effect;  the coma
deepening rapidly, she died, asphyxiated, at 54, P. M ,
her heart having continued to beat nearly two minutes
after she had ceased to breathe.
   Case 7. B. P., black, male, aged 46, went  to bed as
well as usual on the night of the 1st of March, and was
found, at day-light, lying with  his feet on the door-sill,
and his head and  body on the ground, snoring and in-
sensible.  Half an hour later he had the following symp-
toms : feet and hands  cold; body  and head cool;  pulse
small and soft, and varying from 30 to 60 beats  in the
minute; eye-lids  closed;  respiration slow,  irregular,
suspirous, and from 10 to 15 in  the minute ; occasional
tetanic rigidity of the muscles of the back and extremi-
ties, very slight, and lasting but a few seconds  at a time;
skin absolutely insensible  to  any ordinary stimulant;
eye lids motionless, when touched with a straw, and al-
so  when the conjunctiva was irritated;  pupils  not
affected by light;  contracted, but  moving spontaneous-
ly ; deglutition difficult; occasional  attempts  to vomit;
succeeded twice in throwing up some yellow fluid.  At
14 o'clock, P. M., he had a strong convulsion, his  pulse
having previously risen to 96, and  became full and firm
while his skin had  attained more than the normal heat
all over, and the reflex sensibility  had been restored to
the eyelids and conjunctiva.  The  convulsions recurring
at short intervals,  he died at 64 o'clock, P. M.
   Second. The mild congestive form was distinguished 
35
  from the former by the preservation of a good degree of
  strength, no matter how protracted the attack; the con-
  tinued slowness of the pulse, which never  fell  below
  forty-six, nor rose above ninety, and its greater regular-
  ity in other respects;  by the greater violence of the ce-
  phalalgia, and more frequent tenderness of the cervical
  vertebras; and negatively, by the  uniform  absence of
  any  cold stage, of coma,  of delirium,  of  any nausea
  or vomiting, and of any embarrassment in the movements
  of other muscles than those of the neck.
    Case 8. C. G., mulatto, male, aged 26, Carpenter, had
  had head-ache for several days, with an occasional ces-
  sation of an  hour or so, but kept at work until  the 22d
  of March, when he was obliged to quit on  account of
  general weakness,  with giddiness and dimness of vision.
  At 34, P. M., he presented the following symptoms :—
  surface of body and head moist, and hands and feet cold ;
  pupils natural;  countenance dull; tongue moist, large,
  and indented by the teeth, coated with  a thick pasty
  looking ash colored coat on the  posterior three-fourths
  of its surface, and having an epithelium-like termination
  anteriorly; some pain in the back of the head,  and gid-
  diness when sitting up, and sometimes, also, when lying
  down; pulse 56, soft, and small;  resp. 26.   With these
  symptoms, which, it is perceived, differ from the ma-
  lignant cases, of this  variety, in  little else than the ab-
  sence of coma and delirium, and abnormal muscular con-
  tractions ; the patient retained a good deal of strength,
  so as  to be able to sit while being bled.  He  was bled
  to xxiv oz., after which his pulse rose to 60, but was not
  otherwise changed. He then had  a blister  applied to
,. his neck and back, and took a cathartic.  On the next
  day his pulse was nearly in the same state, but his skin
  had become warm  and dry;  his head free  from pain
  and giddiness, and  he  was discharged on the 24th with-
  out further treatment.                     ^
    Case 9. Henry, mulatto, male, aged 33 years,  Barber,
  having had head-ache, the day before which remitted in
  the night, complained, on the 17th of March, of a gen-
  eral feeling of heaviness in his head, and  of fixed pain
  in the occiput, and also in the back of the neck, where 
36
there was some stiffoess and  soreness  on motion ;  his
countenance, at this time, was anxious, and he express-
ed apprehensions in regard to his condition; he was sit-
ting up in his shop when  I visited him, and had but  re-
cently been at his work.  At this time his pulse was 70,
small and very feeble;  his skin, dry and cool elsewher^,
was positively cold on his feet and hands ; his tongue
was broad, white and flabby, moist, and indented by the
teeth.  There was tenderness of all  the cervical  and
two-thirds of the dorsal vertebras; pressure on the lat-
ter  produced a sharp  pain, darting forward from the part
pressed on to the sternum.  He had a blister to his neck
and back, and took an active cathartic.  On the next
day he was greatly better, and was discharged on  the
19th.
  II. Of the Inflammatory class.—In this class  there  is
an intermediate  group, viz:—the grave, between  the
malignant and the mild.   The affinity  to each other of
the individuals of these three groups  was manifested by
the symptoms which distinguish this  from  the conges-
tive class, viz: the uniform presence  of a  temperature
of the skin above that of health; a full, and generally a
firm pulse, and a characteristic tongue, which corres-
ponded with the  second kind described at page —.  The
traits by which they were distinguished from each other
are placed under the several heads, as follows :
  First. The Malignant, was marked by the early oc-
currence of delirium,  or of coma, the former being the
more common; a great irregularity of the  pulse; the
abnormal contraction of other large muscles than those
of the neck, either tonic or convulsive; strabismus ; and
the occasional occurrence of  amaurosis; a tendency  to
nausea and vomiting, and  a tendency  to  a speedy and
fatal termination.
  Case 10. (From Dr. Pollard's notes.) F.K.M., white
male, ag^d 23, Printer, had a paroxysm of acute pain  in
the lower part of the  back, on the  evening of the  18th
of March, and another of very great severity, twenty-
four hours  afterwards; was pretty well  on the 20th,
until near night,  when he had a distinct chill, accom-
panied with pain in the region of the  lower dorsal and 
37
lumbar vertebras, extending into the groin, lancinating,
and of great severity, but without pain in the head.  Af-
ter some reaction had taken place, he was  bled nearly
to syncope, with only slight relief.  On the  21st, at 7,
A. M., his skin was hot  and dry;  pulse  104,  full  and
tense; tongue moist, thickly coated  on the posterior
two-thirds, and red on the tip and  edges ; pain in  the
back only on motion; general soreness of the muscles ;
face flushed; eyes brilliant, pupils dilated.  He remain-
ed in  this condition, without delirium or pain in the head,
until 114 o'clock, P. M., when he was found much worse;
he had become wildly delirious, was complaining of great
pain in the head, tossing about the bed,  pulling at  his
hair, and, at times, retching violently, bringing up only
a little white  froth; pulse 84.  After losing  fourteen
ounces of blood, he became quiet, and continued so du-
ring the night, being rather comatose.  On the 22d the
coma had increased; when roused he was delirious ; in
the course of this day his tongue became dry,  and the
coating was coming off.  At 34,  P. M., he  was  again
bled,  to fourteen ounces, immediately after which  his
pulse, which, just before, was 104, rose to 120, and be-
came smaller; the coma was not at  all diminished by
the bleeding;  sometime after it he  passed urine involun-
tarily.  On the 23d, it was found  that he had spent a
quiet night, sleeping well, was free from coma, and near-
ly so  from delirium;  said his head felt better, (he had
not complained of it for  twenty-four hours,) but gave
him some pain; pulse  100, full and soft;  his tongue,
however,  was red and dry, and black sordes  were gath-
ering on his teeth, and he complained of great soreness
all over.  On the 25th,  having been  freed from pain in
the head and delirium since the 23d,  he complained of
pain in his head again, the skin of which was hot;  and
he was inclined to wander in his speech, and his tongue
continued to be dry and red.  A pitcher full of cold wa-
ter having been poured on his head, the pain and delir-
ium disappeared, and his pulse fell from 84  to  76,  and
became softer.  After remaining in this improved con-
dition, but without improving for several days, he began
to get better, but so slowly that he was not discharged
for several weeks.
      5e 
38
   Case 11.  (From Dr. Holt's notes.)  J. H., while male,
aged 12 years, was attacked without premonition, on
the morning of the 21st of  April, with chilliness  and
pain in the forehead.  In the course of two hours after,
the chilliness had subsided;  the pain in his head  was
violent, of a throbbing kind; his skin was hot and dry ;
face flushed and frowning; tongue coated white on the
posterior two-thirds, and the tip  and edges of a bright
pink color;  pupils natural;  pulse 108, lull, soft and ir-
regular.  On the next day (22d,) 1 learned that he had
had delirium through the night, and was restless,  and
moaned a good deal.  At 8 o'clock, A. M., the delirium
had subsided, but had left him entirely blind, so that he
could not discover the sun light, which shone on his eyes
through the window.  At the  same time  he was  tree
from stupor, and answered  questions  even cheerfully;
his pulse 120, full and soft;  the pupils were dilated gen-
erally, but contracted, at times, spontaneously.  About
12, M., he fell into a semi-comatose state, his pulse fell
to 80, and was  very irregular in force, and  in the time
between the beats;  he had, also, strabismus, and spas-
modic flexure of the fore-arms and hands.  He com-
plained, now, bitterly, when  pressure was made on any
part of the cervical vertebras, or on the three or four first
dorsal, saying that the former produced pain in his head
and neck, and the latter in the belly.  He was bled from
the arm, which  took the flush out of his face and quick-
ened his  pulse to 120; the blood was not buffed.   At
4, P. M., all these bad symptoms had subsided, including
the amaurosis, and he remained tranquil and rational
through the niglit.   On the 23d,  the  febrile  symptoms
again increased, threatening  a return of coma ;  he  was
again bled;  the blood  not buffed or cupped, after which
his pulse, which, previously,  was  120, rose very soon to
150.  Little or no change occurred during the day ; in the
night he became wild with delirium, which subsided to-
wards morning, to a milder state, but accompanied, still,
with great restlessness.  At  8, A. M., on the 24th, this
state continued; the pupils were  dilated; the vision im-
perfect, and the strabismus had returned;  pulse 138.—
After eight ounces  of blood were drawn from the tern- 
39
poral artery, the strabismus went off, but his pulse rose
to 160.   From this time he gradually sunk, without co-
ma or convulsions, and with but little delirium, until 7,
P. M., when he died.
   Case 12. J. H., white male, aged 14 years, was taken
sick some time towards morning, on the night of the 18th
of April, complaining of pain in the head. On the 19th,
at 9, A. M., he was seen by Dr. Holt.  He had, then, vi-
olent pain in  the head, neck, back, and legs; skin hot
and dry; face flushed;  eyes red ; pupils natural;  coun-
tenance anxious ; tongue coated white, on the posterior
two-thirds, an^dbright pink on the edges and tip; pulse
100, full and  firm, but not hard; no delirium, nor  coma;
lies on  his left  side chiefly; bowels constipated.  He
was directed  to have a blister along the  spinal column,
from the head nearly to the lumbar vertebras; hot pedi-
luvium and sinapisms to his legs, and  to take twenty
grains of calomel, which  was immediately thrown up
with the contents of the stomach, but was repeated and
retained.   At 5, P. M., he had become  delirious,  and
very restless, with jactitation; he  now took another
scruple of calomel, and was directed to have ten  grains
every three hours, until half a drachm was given.  On
the 20th, at 9, A. M., the delirium, which had continued
through the night, was increased; his  extremities had
become cool, while his body and head continued hot and
dry.  During the night he had several large green evac-
uations, from the operation of the calomel, which had
ceased to operate for some hours.  At 5, P. M.,  he was
furiously delirious.   After this he soon took convulsions,
and died in the night.               #
   Secondly.  The grave was distinguished from the for-
mer by the regularity of the pulse, which was never be-
low one hundred in the minute,  except during a  remis-
sion •  by the morbid contraction of the muscles being
confined to those of the neck, and  sometimes  to the
sterno-mastoid of one, or both sides, alone;  by the oc-
casional occurrence of a painful  sensibility of the  skin
to the touch, and of the retina to light;  the occurrence
of regular remissions, and the absence, uniformly, ol co-
ma, and of delirium. 
40
  Case 13. J. T., black male, aged 12 years, having had
head-ache, with red and suffused eyes, from early in the
morning of the 25th of March, was taken  with a  chill,
at 4 o'clock, in the afternoon, which was soon followed
by fever.  He was seen, soon after the febrile excerba-
tion begun, by Dr. McLester, who bled him from the
arm to ten ounces, when he got sick at the stomach and
vomited, and hi3 pulse, which had been 120, fell to 104.
His pulse, at this time, was full  and firm;  his skin hot
and dry; his tongue was coated  with a brownish fur,
red on the tip and edges, and rather sharp; his head-
ache was not relieved by the bleeding.  At  3,  A. M.,
on  the 26th, he had become lethargic, rather than stu-
pid ; when awake, he complained of his head aching all
over, but particularly in the frontal  region;  the pupils
were somewhat dilated, and the  conjunctiva injected;
the skin  hot and dry, and the pulse firm and regular. He
was bled to 14 oz., but without any perceptible relief to
the head-ache, though his  pulse was reduced in force.—
At 8, A. M., the  febrile symptoms had, in a great meas-
ure, subsided, and along with them, the head-ache, which
was only felt when he raised his head from the pillow;
then it throbbed painfully;  he was ordered to take qui-
nine, in doses of five grains, made into pills with mass.
hydrg., every two hours.   At 1, P. M., he had a return
of fever without any chill having preceded  from  it, and
with it the cephalalgia returned with increased violence,
being  throbbing and lancinating; pulse 124, full, and
strong; skin dry and hot;  resp.  28; slight  strabismus
when looking  intently ; sleeping when not complaining
of his  head.  Bled  to  16  ounces, after which his pulse
became softer, and fell to  118.  10, P. M., remission of
fever; pulse smaller and softer, 110; no pain nor drow-
siness ; talks freely;  has no recollection of having seen
me to-day, nor last night, nor of  being  bled.  At 7, A.
M., next day, he was free from pain ; pulse 104.  At 5,
P. M., he was  found with fever again; pulse  128;  dart-
ding pain in the right eye,  cheeks, and gums ; free dis-
charge of saliva; discharge of thick mucus from the
nose; sense of smell confined to one nostril; no  head-
ache, nor drowsiness.  This paroxysm declined early in 
41
the night, and, on the 28th, he was nearly free from fe-
ver, and had some appetite.   On the next day  he had
continued to improve, and was discharged convalescent.
  Case 14.  G. O., female, aged 9 years, clear white skin,
large light blue eyes, and light curling hair, delicately
formed and nurtured, who had complained, occasionally,
for several days, of pain  in the back and soreness in her
legs, when playing, was taken with a slight chilliness,
which was followed by fever, at 1, A. M., on the night of   .
the 20th March.   At 9, A.  M., has fever;  pulse 120,   *
sharp and jerking, but not hard; skin hot and dry ; eyes
pinkish and watery ;  tongue coated brown on the poste-
rior two-thirds, and pink at the  tip and  edges;  intense
pain  in  the forehead and eyes, alternately; pain fre-
quently  lancinating; excessive intolerance  of light;
soreness and stiffness in the  sterno-mastoid muscle, on
both sides, and soreness in the muscles of the arms and
legs.  This state continued until the next morning (21st)
when there  was a considerable  remission of all  of the
symptoms, except the pain in the head, and the  intoler-
ance of light, neither of which were much mitigated.—
On the 22d, she was still improving, and continued com-
fortable until 10 o'clock, P. M., when the febrile symp-
toms returned, as I was told, with an aggravation of pain,
&c.  On the 23d, at 8, A. M., her pulse was 124, full
and sharp ;  intolerance of light, and intense head-ache;
painful sensibility of the skin, so much so that, at times,
she could not bear to be touched; when her head was
raised she complained very much ;  on one occasion she
said, " you are dragging my head to pieces."  She was
now directed to take carb. potass, in solution, four grains
every two hours, and to have a blister to the neck.  At
12, M., all these bad symptoms had disappeared—the
pulse had fallen to 84, the skin cool and moist; the face,
which had all along been flushed, was now pale ; she had
neither pain in the head, nor soreness in the skin or mus-
cles, and was cheerful.   The carb. of potass was now
suspended, and two grains of quinine ordered in its place,
every  two  hours.  On the 24th, at 9, A. M., I learned
that the fever had come on early in the night, and had
continued,  without  any remission; her cheeks  were
6 
42
 again flushed, and the pain in  the head,  intolerence of
 light, and sensibility of the surface had returned.  The
 quinine was now suspended, and the carb. potass order-
 ed to be given as before.   At  J, P. M., the symptoms of
 head disease had again disappeared, and there  was  a
 very great remission of fever, and this state of improve-
 ment continued, with but  little  interruption, until  the
 27th, when  she was discharged convalescent.
   Thirdly.  Mild Inflammatory. The individuals  of this
 group were distinguished from either of  the preceding,
 by the lower grade of the febrile excitement; the pres-
 servation of a good degree of strength, no matter how
 long the attack might be  continued; a tendency  to take
 on a chronic form: and,  negatively, by the absence  of
 coma, drowsiness, delirium, and of a cold sta^e.
   Case 15.  Nat,  black male, aged  18 years,  drayman,
 had had head-ache for a week, when he came to  my of-
 fice on the 21st of March, having continued at work un-
 til the 20th.  He has now fullnes and pain  all over his
 head, but particularly in the occipital regions; his skin
 has a feverish heat and dryness; his pulse is 80,  and
 full; his tongue has a white coat on it,  and red  cd«-es,
 not enlarged.  He was bled, sitting, to xxxii oz., when
 he became  faint,  and his pulse  got small and  quick,
 while his skin remained dry.  After lying down  a  few
 minutes he got up, and again hecame very faint, and his
 pulse slow and soft;  the dryness of the skin persisting ;
 blood not buffed; the coagulum very large, and  firmer
 than usual in this disease.   He had a blister to his neck,
 and took a cathartic dose of calomel and rhubarb, was
 directed to take some quinine, and return next day.  On
 the 22d, he was wiihout head-ache, but had a very  troub-
 lesome sense of fullness in the  head, and shrunk from a
 very slight pressure at the junction of the occiput with
 the spine; pulse full and firmer, 104. He was ordered
 to take a pill composed of five grains of mass, hydrg.,
 and one fourth of a grain  of tart. ant. every  four  hours!
 On the 23d his gums became sore, and on the 24th he
 was discharged.

  Case 16. Solomon, aged 32, black, stout arid healthv,
had pain in the head and loss of appetite on the 23rd of 
43
March, which continued  through  the  night.  He went
to work on the 24th, but the pain  becoming aggravated
he desisted and went home, where he was visited by Dr.
McLester, at 12| o'clock, P. M.   He had, then, acute
pain in the frontal and occipital regions, and in the neck
and back, which was aggravated by pressure on all the
cervical, and on the dorsal vertebras as far  down as the
sixth ;  eyes injected; tongue covered with a thin white
coat; some nausea ; bowels constipated ; pulse 90, reg-
ular  and tolerably full and strong; skin warm and dry;
he was bled to xxxii oz., and had a blister along the up-
per half of the spinal column, and took a dose of calo-
mel, with tartar  emetic ;  he became very faint from the
bleeding, and vomited.   At 2$, P. M., the head not hav-
ing been at all relieved, he was bled  from the  arm to
xvl oz. more, which brought on syncope, with vomiting,
cramp in the fingers, and temporary delirium.  At 6, P.
M., he still had pain in his head,  when raising  himself
in the bed, and also in the back.  On the 25th, at 8, A.
M., it was found that he had rested very well during the
night; was free  from  pain  and fever;  pulse 65, and
stmno.   On the 26th he  was convalescent, but had for-
gotten nearly all that had passed during his sickness, and
had no conception of the length of time  since  he was
taken.
   In other cases of the mild varieties the  disease was
more protracted, lasting sometimes, ten  days,  or two,
or even three weeks, the patients  all the time being able
to sit up and walk about a little.  In one instance, a
man came to mv office,  having had pain in his head
stiffness in the muscles of his neck, double vision  and
dimness of sight  for several days-symptoms which re-
quired laro-e bleedings and a salivation to remove.
   Sometime the effects of the mild cases,  when appar-
 ent recovery took place within two or three days, were
 experienced for weeks, in the form of confusion of the
 mind;  a  feeling of tightness  across the  forehead, or
 about the base of the brain, from one temporal  b -ne to
 the other ;  or pain in the occiput, c;r neck, upon any un-
 usual mental occupation.  Upon  one occasion, a very
 mild attack, in a man about thirty years old, who was 
44
dismissed as cured on the second or third day, was fol-
lowed by great imbecility of mind and weakness of body,
which continued for some weeks.  It was remarkable,
as I have before said, that no matter  how  long continu-
ed these mild cases  might be, if they  began with the
cool skin, and feeble and slow pulse of the congestive
form, so they continued to the end, or until convalescence
was begun; and so, also, of those which  assumed the
inflammatory form.
  Remissions.—-I have selected the preceding cases, for
the purpose of illustrating the general  features of the
several groups into which I have gathered the innumer-
able varieties which the disease assumed, without refer-
ence to an important feature which,  though frequently
unobserved, occurred in  a  great number of cases be-
longing to each division, viz : a tendency to remission,
which was manifested very irregularly at some period of
the attack,  varying  from a few hours to several days
from its onset; but occurring most frequently on the se-
cond and third days—days  on which, also, the  greater
proportion of deaths occurred.  These  remissions were
sometimes very great, approaching very nearly to in-
termissions ;  at others  they  were  obscure, and there
were various degrees of amelioration  of the  symptoms
between these extremes.  They were irregular, also, in
other respects—sometimes  they were quotidian  or ter-
tian, and accompanied by remissions of fever, so as to
make it appear as if the meningitis were engrafted, as it
were, on an ordinary endemic fever.   In other cases, a
remission of the cerebral symptoms took place without
any very obvious change in the febrile state; and in oth-
ers, again, the febrile symptoms remitted,  or, it might
be, intermitted, leaving those of the  head disease un-
mitigated.  In all these  cases, though the hours of their
return might be uncertain, the changes were so evident-
ly remissions merely, that there was  but little difficulty
in identifying them as such, so that future changes could,
to a great extent, be anticipated; but there were others
which, from their great obscurity in  this  respect,  and
from their more frequent connection with the malignant
forms of the disease, were much more  important, in a 
45
practical point of view, as they were apt to lead  to  a
premature suspension of treatment.  In such cases as I
now refer to, after an uncertain time,  it might  be not
more than twelve hours, or it might be four or five days,
or any intermediate period, but commonly on the second
or third day, there would take place a change, sometimes
so decidedly favorable as to lead to the belief that con-
valescence was established, or, at least, about to become
so; the pulse and skin might approach very nearly  to
the condition of health, though some irregularity or ab-
normal sharpness or frequency might always be detected
in the former  (a fact of great  importance) ; the  mind
sound, and even cheerful;  the head free from pain, and
the muscles from abnormal contractions, and this  state
of things might end in a  rapid recovery.  It was very
seldom, however, that the promise was so kept, if the
preceding stage had lasted more than twenty-four hours;
such remissions, or pauses, in the march of the disease,
being generally followed  after an interval, the length  of
which could never be foreseen, but which might  be a
few hours, or days, by an exacerbation of equal severi-
ty as the first.   A t other times, these remissions  were
less decided, but still sufficiently so to feed the hopes of
the patient, and frequently to delude the judgment of the
physician.  In a few cases, the remissions were some-
what peculiar, consisting in a change of form  from the
congestive to the inflammatory  type; as, for example,
w hen a state of stupor, or coma,  attended with a  cool
skin and feeble  pulse, was  changed to a state  of reac-
tion, in which the stupor, or coma, went off, and the skin
became warm and  the pulse full and strong; the  latter
state always presenting features less alarming than the
former.
   It  was in the inflammatory forms, particularly the
grave  varieties, that the  remissions were most  regular,
and in which there was,  consequently, the least difficul-
ty in recognizing them as such.
   Complication.—Inflammation of the fauces  was ob-
served in seven patients, five of whom bad lately recov-
ered  from roseola, which was also prevailing epidemic-
ally, and two  had  roseola with the meningitis.  The
      6f 
46
 latter was also complicated, with bronchitis in three^ca-
 ses, and with pneumonia in two.
   The  affection of the mucous surface of the intestinal
 canal, and of the mesenteric elands, may be placed un-
 der this head, although the existence of the former in
 every case in which the parts were  examined, and of the
 latter, in four-fifths, might  justify the inference that a
 tendency to disease in these organs, constituted an essen-
 tial feature in this epidemic.  This  point  would have
 been  more satisfactorily determined if the abdomen  had
 been  opened in all  the post mortem examinations made,
 and I regret very much that this was not done.  My at-
 tention, however,  was not drawn  to this subject until
 the mortality had begun to abate,  and  the  opportunity
 for more extended  observations had gone by.
   A typhoid  state  was assumed at a  late period, in the
 progress of the attack, in three cases.   The occurrence
 of this state, in other  epidemics, has,  I observe,  been
 usually  recognized as one  of its forms,  but, as  it never
 occurred here, near the beginning  of an attack, the ear-
 liest appearance of typhoid symptoms having  been  no-
 ticed  about the tenth day, I have not been  willing, not-
 withstanding  the remarkable lesions  of the agminated
 and meseneric glands in other  cases,  to consider  it as
 designating a form of this  disease in any way connected
 with its essential pathology.  Whether the same intes-
tinal  alterations existed in these cases, I had no means
 of ascertaining, as  they all recovered.
  Diagnosis.—The perusal of the  several  groups  into
which I have  gathered the more constant phases in which
 the epidemic  presented itself, will serve to show but par-
 tially, the exceeding obscurity and  difficulty of the diag-
nosis, before it was suspected that an epidemic meningi-
tis was  prevailing.   The  individuals of each  of  these
groups presented other varieties than those which I have
given  examples of, and, it unfortunately so happened,
that those most widely separated were  the first that ap-
peared,  and this successively.   The consequence of this
want of  uniformity  was, that the opinion  of the  physi-
cian had to be made  up by the study of each case, al-
most unaided by any analogy with the symptoms of a 
47
preceding one, and, besides this, so great was the diver-
sity  that even  the post mortem examinations, which
were made in every  one of the first lew fatal cases,
threw but little light beyond the particular case exam-
ined.  The first cases were, nearly all of  them, of the
congestive form, which, although they might present un-
equivocal evidences of an affection of the brain or its
meninges,  and even this  they did not always  do,  the
symptoms  indicated,  if at  all,  but very obscurely, its
true seat and  nature.  To all this it must be added, that
there was only that general resemblance  to  sporadic
meningo-cerebritis as  might occur in diseases  differing
in their nature, and, not unfrequently, even this general
resemblance was wanting.  Simulating, then, as the ep-
idemic did, in the malignant varieties, in one attack, an
endemic cerebro-congestive fever; in another, idiopath-
ic apoplexy;  another, abcess of the frontal sinuses, and
in another, hysteria, it will be readily seen, that but lit-
tle akUn the diagnosis could be obtained, either from the
similarity of  one of these cases to another,  or to the
sporadic disease in its common aspect.  The symptoms
of spinal inflammation, too, as may have been observed,
were always obscure,  without excepting those cases in
which there was tenderness on pressure of the vertebral
processes,  for this is not held to be, ordinarily,  at least,
a sign of inflammation.*
   I  need hardly add, nor can it  be a matter of surprise,
that, in several instances, at the breaking out of the ep-
idemic,  the diagnosis was  either erroneously made, or
remained doubtful, until a post mortem examination, or
a more extended observation,  satisfactorily determined
it.   It is to be remarked, however, that such  errors or
doubts could  only occur at  the beginning of the epidem-
ic.  After  several post mortem  examinations,  and a free
interchange of opinion among the members of the Med-
ical Society were had, and it was thus ascertained that
  ♦These varieties were not accompanied with any corresponding vari-
eties in the anatomical lesions which were apparent; and I was con-
tinually disappointed in searching for peculiarities in the latter to cor-
respond with certain lesions of the intellect, of sensibility, and of the
motor apparatus. 
48
these varieties of fatal disease  represented an epidemic
meningitis, the difficulties were at onee either fully dis-
sipated, or sufficiently so to secure a  prompt and pro-
per treatment when  a doubt  existed.   But  even  with
this qualification, such errors or doubts as did occur, were
of a magnitude proportionate to  the fatality  of the dis-
ease, for any treatment to be efficient, as was abundant-
ly proved, had to be entered on with the  utmost  vigor,
on the first day, and thus an error in the diagnosis was
calculated, and no doubt did so occasionally, so  far  to
modify the treatment as to suffer the precious moments
to escape, when a  more active medication would  have
been successful.
  The preceding observations  are chiefly intended to be
applied to the  malignant  varieties.  In the mild and
grave varieties, the errors, if made, were  of but  little
consequence, as none of the cases belonging to them
proved fatal, and many  were not attended with even the
appearance   of danger.  Nevertheless, difficulties did
occur, in the diagnosis of these cases, which, if they were
of but little  comparative  consequence  to the patient,
were troublesome and embarrassing to the physician.—
There was,  necessarily, a good deal of doubt, at first,  as
to the  nature of the cases, being comparatively so mild,
whether they were, in fact, but the insidious precursors
of a more malignant aspect, or were  the  disease  in  a
mild form, fully developed—a  difficulty, in fact, in prog-
nosis as well as diagnosis.   Whilst such doubts existed,
they were frequently treated  with unnecessary  vigor,
were watched with the  utmost vigilance, and were the
source of incessant anxiety.  They were embarrassing
in this, that  on the one hand the indications in the mild-
est varieties, which were the most numerous, nor in the
less violent of the grave, did not warrant, without better
proof of present or prospective danger than any at hand,
the active depletion and urgent efforts to bring  about a
speedy mercurialization which was thought  indispensa-
ble in the malignant varieties; and, on the other, it was
feared that to neglect these remedies might compromise
the safety of the patient.  It was not till after the epi-
demic  had made considerable progress, that  this source 
49
of trouble was obviated by  the steadiness with which
each variety of the several groups run its course,  with-
out intermingliug with another.
  The symptoms by which  the meningitis was distin-
guished, after some familiarity with the symptoms was
obtained, were the following, viz : The cephalalgia, its
seat, particularly when in the back of the head, and oth-
er peculiarities connected with  the nature of the pain
as  differing from other head-aches.   The state of the
tongue, particularly its enlargement, indentation, and
gummy or pasty coating, and the bright pink of its edges.
The physical characters of the blood—the pain in the
neck, and stiffness and soreness in the muscles—musu-
lar tremors, and other embarrassment of motion; and
traction of the occiput  downwards—the state of the
pulse, which was valuable as a diagnostic  sign  in  both
varieties of the congestive type, but only  in  the malig-
nant varieties of the inflammatory type—delirium; rig-
idity of the large extensors of the spine;  coma—the
state of the pupil, and the  injection  of the  conjuncti-
vas, which last, though not  so important as the other,
was more constant.
   Age, sex, color.—Among eighty-five cases, sixty-four
of w hich were taken from the register of Dr. McLester
and myself, and twenty-one  from all the notes furnished
me by other physicians, there were, of whites, five years
old and under, one,—over five and not exceeding ten,
two,—over ten and not exceeding twenty, eight,-—over
twenty and^not exceeding thirty, three,—over thirty and
not exceeding forty, three,—over forty and  not exceed-
ing fifty,  two,—over  fifty, three.  Of these ten  were
males and twelve females. Of blacks under five years, one,
—over five and not  exceeding ten, six,--over  ten and
not exceeeding twenty, fifteen,—over twenty and not
exceeding thirty, twenty-four,—over thirty and not ex-
ceeding forty, ten,—over forty and not exceeding fifty,
five?__over fifty, two.  Of these  thirty-six were males
and twenty-seven females.
   Mortality—-The mortality was confined to the malig-
nant varieties.   Among these, the ratio,  from  the best
information I can get, was about sixty per cent
       7 
50
   Locality.—The little city of Montgomery is situated
 on the left bank of the Alabama river,  at  the extreme
 southern convexity of a horse-shoe shaped curvature, or
 bend of the river.  The bend  nearly  encloses  several
 thousand acres of alluvial land which is subjected to an
 annual overflow.   The geological  formation  on which
 the town is built, following Mr. Lyell's  division, is the
 eocene tertiary.  At distances varying from fourteen to
 thirty miles north and east, the tertiary forms an abrupt
junction wriih the primary, consisting, at various  points,
 of mica slate, gneiss, and granite.   A belt  of the creta-
 ceous formation, (prairie) running  east and  west,  and
 varying in width from eight to fifteen miles, approaches
 within a mile of the southern and south eastern  border
 of the town.  Beyond the prairie, towards the south, the
 eocene tertiary is again found.  On the  western  limit of
 the town, a range of hills takes its  rise  rather abruptly,
 and running first south, then east, and then  north, forms
 an amphitheatre, which rises, in some places,  one  hun-
 dred and fifty feet above the river  bank, looking,  from
its northern aspect, on the river and the alluvial  ground
beyond it, and is crowned with a narrow strip of table
land,  beyond which,  except on the eastern  side, the
ground again descends, for several miles, to a large creek
which empties itself into the river, several miles  belowr,
 or west ol the town.  A basin is thus formed with the
hills on  three sides, nearly, and the river on  the other,
having a sufficient inclination towards the latter to car-
ry off the water which gathers during a rain, in rapid
currents, and thus  to secure, whenever a hard rain  falls,
a thorough cleansing of every part of the town.   It is
within the  limits just described, and on  the hills above,
that the town is built;  the  greater  part of the popula-
tion residing below the range  of hills.  The  residents
on the sides of the hills, and on the level above,  hardly
comprise one-third ot the whole population, which num-
bers,  in  all, about  four thousand souls, a large part of
which, the proportion  not being known, are blacks.—
The dwellings are built with ample space around them ;
there  is no crowding, nor are the residents crowded with-
in them; nor are there any accumulations of filth any 
51
where to be found, at any season;  for, besides the fre-
quent washings in wet seasons, from rain, the yards and
streets are subjected to frequent inspection by a com-
mission which always includes  at least one physician;
neither  is there found, within the city, any of the desti-
tution of extreme poverty, all the inhabitants being sup-
plied, if not by their own  exertions,  by  the charity of
others, with a sufficient supply of food and comfortable
clothing—but  objects of such  charity are  very  seldom
seen.  The residents on the sides and top  of the hills
have no advantage, in any of these respects, over those
occupying the less elevated parts of the town.
  It was within the limits just described, bounded by the
base of the hills on nearly three sides, and  by the river
on the other, that the epidemic was  chiefly confined.—
Whilst a large proportion of the residents below were
attacked with the disease, there were but few cases found
among  the residents on the  sides of the hills, and still
fewer on  the table land above.  The  statistics  of Dr.
McLester and myself give three cases  on the hills for
sixty-four below them, which is larger than  a general
average.  From  the best information I can get, there
were not less than two hundred and fifty cases within the
town limits, of which not more than ten occurred above
the  base of the hills.   As, however, but few of the phy-
sicians register their cases, the former number is, in some
measure, conjectural;  I am certain,  nevertheless, that
the proportion given is not too large.
   The  surrounding country, which is thickly populated,
was remarkably exempt, at this time, not only from the
epidemic, but from all other diseases, contrasting forci-
bly, in both respects, with the city.  After the epidemic
influence had exhausted its virulence here,  and  had in
a great measure subsided, the  disease  made its appear-
ance on a large prairie plantation, belonging to Mr. Wm.
Knox, lying eight miles south-cast  of the  city,  where,
according to a report kindly furnished  me by Dr. Holt,
nineteen  cases occurred, a majority of which were of
the malignant congestive type.   About the same time it
fell upon& another plantation  (prairie)  some three miles
south of the former, stepping over an  intervening one, 
52
and leaving the latter, as, also, the other adjoining ones,
as free from sickness, as at  the same season in other
years.   After it had disappeared from these localities, it
again made its appearance on the plantation  of N. Har-
ris, Esq., situated three miles west of that of  Mr. Knox,
where four cases occurred, all of which were of the grave
inflammatory variety; and here the epidemic influence
terminated. In regard to the causes which determined
the attack on these plantations, to the exclusion of oth-
ers, I can give no information, any more than why it fell
on a part of the town of Montgomery, almost to the ex-
clusion of another part.  In regard to those of Mr. Knox
and Mr. Harris, I can affirm, from personal observation,
that there was nothing more apparent than in the city,
which might be supposed to  invite the visitation  of any
disease of an  epidemic kind.   The negro  houses  on
both, are unusually comfortable and cleanly, and the ne-
groes are well fed, and well clothed, and  are not over-
worked,  nor otherwise harshly treated.
   General influence of the constitution of the atmosphere.
—The meningitis made its appearance early  in Februa-
ry, was most prevalent in March, and  disappeared, as
an epidemic, in the latter part of April.   Three cases
occurred after the first of May, but were divided from
each other by intervals  of some weeks.  An epidemic
roseola preceded and accompanied the former as long as
it lasted, and disappeared along with it, and this was the
case on the plantations  referred to above, as well as in
the city.  Along  with these epidemic  diseases,  others
which  are common to this climate and locality prevail-
ed, somS of them  to a very unusual extent  for the sea-
son.  These were  dysenterv, diarrhoea,  intermittent,
and remittent  fever, various forms  of neuralgia, spas-
modic cephelalgia, catarrhal fever and bronchitis.
   The  following  table of Meteorological observations
was made by Mr. Swan, of this city, from his own  re-
cords.   It shows  an unusually high temperature for Jan-
uary and February, and a very low one for March. The
almost total absence of rain in January is also remark-
able: 
TABLE OF METEOROLOGICAL  OBSERVATIONS,  REDUCED TO THE  WEEKLY MEAN OF BAROMETER
  AND THERMOMETER, FROM  DECEMBER 23d, 1847,  TWENTY-EIGHT OBSERVATIONS PER_ WEEK, TILL
  MARCH 16th, 1848.  TWENTY-ONE PER WEEK AFTERWARDS.
 Dec. 23rd to 30th
Dec. 30th to Jan. 6
      Jan. 6 to 13
     Jan. 13 to 20
     Jan. 20 to 27
Jan.  27 to Feb. 3
     Feb. 3 to 10
     Feb. 10 to 17
     Feb. 17 to 24
Feb. 24 to March 2
     March 2 to 9
     March 9 to 16
    March 16 to 23
    March 23 to 30
March 30 to Apr. 6
     April 6 to 13
    April 13 to 20
    April 20 to 27
April 27 to May 4
Bar.	Th'r 40o	N.	s.	E.	w.	NE.	SE.	NW 3	SW.	Cl'r.	C'dy	Rain
29.97		4	3	1	0	7	4		6	17	10	1
29.99	51	1	5	0	2	2	2	10	6	15	13	0
29.94	48	1	0	0	3	1	4	10	9	13	15	9
30.03	59	5	4	3	0	1	1	3	11	11	17	0
29.94	54	7	8	5	1	1	2	1	3	13	10	5
29.80	53	1	3	4	2	1	4	8	5	14	10	4
29.88	50	0	0	2	7	5	0	13	2	20	8	0
30.00	60	0	7	1	6	0	0	6	8	11	16	1
29.81	63	0	5	1	3	3	4	5	7	6	15	7
29.89	59	0	4	3	0	2	0	4	15	16	1 !	0
29.86	49	2	3	1	5	1	3	7	6	15	10	3
29.98	54	1	4	0	0	4	1	6	5	18	3	t)
29.83	68	2	0	0	3	0	0	0	16	4	15	2
29.85	70	2	2	0	0	0	0	1	16	14	4	3
29.93	67	1	11	0	3	0	6	0	0	8	11	2
29.81	68	0	0	5	0	0	3	0	13	13	7	1
29.93	65	6	7	2	0	1	2	2	1	13	8	0
20.91	72	2	3	1	6	1	2	4	2	10	8	3
29.87	79	0	3	1	0	0	6	0	11	9	9	3
		35	72	30	41	30	44	83	142	240	201	35
Quantity rain fallen.			Bar.	Th'r
	in. 100s			
24th & 25th	.46			
				
				
				
25th & 26th 27th to 2d	.56 3.24			
				
				
	.13 4.32			
				
			30.16	
	1-76	Mar 6* " 8 " 9		32o
				70°
	2.13 1.02			
				
				
	2.10			
				
22nd 29th to 1st	.22 1.11			
				
				
* Mornings of March 6th and 7th there was frost. 
54
                     Treatment.
   In what I have to say under this  head, I shall refer
 chiefly to the grave and malignant varieties, premising,
 however, that the same remedies were employed in the
 treatment  of the mild varieties, but, of course, with less
 activity and perseverance.
  Blood-letting.—This remedy was employed, with a 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 succes-
 sion, 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,  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 bleed-
 ings, 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 quantity taken altogether from adults,  in one  day,
 varied from fourteen to forty ounces—in twenty-six ca-
 ses the average was found to be thirty ounces.  The ef-
 fects of blood-letting were not so satisfactory as might
 have been expected.  Within my own observation they
 were never promptly  discisive 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 occa-
 sionally observed, though in this form, an improved state
of the pulse was more frequently the  immediate conse-
quence of the loss of blood.  The most common  sensi-
ble effect,  however, was  relief to the cephalalgia, but 
55
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 symptoms, besides the cephalalgia,
seemed urgently to call for this remedv, no relief what-
ever was obtained from it, notwithstanding that both the
pulse and skin were greatly affected by it, as in the oth-
er 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 considerable ad-
vantage in this  epidemic, in both the congestive and in-
flammatory forms.   Though the benefit was neither im-
mediate nor decisive,  yet I cannot doubt,  in  surveying
the whole ground, that time, at least, was gained by it,
for other remedies more obviously beneficial to produce
their effect.  It is  certainly true, however, that the im-
pression of the  physicians generally, here, in regard to
bleeding, even  in the bold, and, I may be allowed to add,
in reference to  others, the judicious manner in which it
was applied, was one  of disappointment.
   Mercury.—This remedy was employed almost exclu-
sively for the purpose of producing its constitutional ef-
fects, and so used proved to be a more efficient one  than
blood-letting, both in  the promptness and permanency
of its beneficial influence.   Asa general rule, this object
could be speedily obtained, more  so, I think, than is
common in the phlegmasia; there being no tendency to
diarrhoea, the medicine never appeared to irritate the
bowels, nor did I ever observe that any unfavorable in-
fluence of any kind was exerted by it.   If not always ef-
fectual, it was always  safe ; and the good obtained  by it
was more apparent and quite as permanent, as that from
all other remedies.  It is to be remarked, however, in
modification of this general commendation, that in a few
instances a salivation having been induced early in the
attack, and kept up for several days, failed altogether 
r
                             56
in producing any perceptible influence; that in some ca-
ses tisne was not afforded to effect salivation, and that
occasionally, though very rarely, when time  was  had,
the specific influence of mercury could not be obtained,
neither by  inunction, which  was a  common  mode  of
using it, nor by the internal administration of any of the
pharmaceutical preparations in common use.
   Rubefacients.—Among this class of remedies, 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 ce-
phalalgia, even when bleeding  had failed to do so.   In
the malignant  varieties, also, the relief afforded by them
was frequently very great.   In the congestive forms heat
applied  to the skin generally, in various ways, mustard!
plasters, and frictions with oil of turpentine,  were fre-
quently  beneficial.
   Potasses.—This is a new remedy in cerebral affections,
and, as such, I am  unwilling to speak of its curative
q  ••Jitius, in the disease  under consideration,  with the
confidence I really feel in  it.  My experience in its use
is  yet too limited to determine, positively,  its value, but
I have seen enough to induce me to continue my obser-
vations, and to recommend it to the attention of the pro-
fession.   I have prescribed it, for several years, in acute
hydrocephalus, seemingly with great advantage—I say
seemingly, for  its effects were never marked by any sud-
den change  for  the better, and  its claim to  merit,  in
these cases, consequently, must rest merely on the rather
equivocal fact, that a very large  proportion of those I
have treated here by it, have recovered.   It was at the
suggestion of my friend, Dr. Geo. O. Jarvis, who was de-
tained here by sickness, to whom I  communicated my
experience of its supposed influence  in hydrocephalus,
that i was induced to administer it in the still more acute
msningo-cerebritis of this epidemic.
   The additional evidence which I have thus acquired
is  more  direct, and, consequently, is entitled to more
weight, but is  yet,  as  the reader will observe, by  no
means such as to establish its remedial powers.
   In the cerebral affections of children I have prescribed
• 
57
the carbonate in doses of from half a grain to a grain,
repeated every four or six hours.  In the epidemic  dis-
ease, the dose for childien was from three to five grains,
and for adults, from ten  to fifteen grains, repeated every
two hours.  No case proved fatal, in my practice, nor,
so far as I can learn, in either of my professional breth-
ren who used it, in which it was freely and continuously
employed.  But, it is to be  observed, that, under any
treatment, the  mortality was confined to the malignant
forms of the disease ;  that the remedy was  given in but
few cases of this kind;  and that other remedies of tho
most energetic kind were also administered along with
it; so that it cannot be said to have had its powers fair-
ly tested in any one of  them; nor  can I say, with any
confidence, that all would not have got well without its
aid, for I have not  sufficient fact on  which to express
such an opinion ; the powers of the remedy were exhib-
ited in a much less equivocal manner, in the grave and
mild varieties.  In many cases in which there were no
 febrile symptoms, properly so  called, present, the ce-
 phalalgia was speedily and permanently relieved; and,
 in others, its administration was followed by a prompt
 reduction of arterial excitement, and the removal of in-
 tense  cephalalgia and other symptoms  of head disease,
 and this in such a manner, and under such  circumstan-
 ces, as to leave no doubt on my mind in regard  to  the
 beneficial agency of the medicine.   In one chronic case,
 of the grave variety, in which the patient was fast sink-
 ing into a state of dementia,  convalescence began on
 the day that the medicine was first administered.  This
 man  had been bled,  salivated and blistered  without
 benefit.
    Quinine.—I have but little to say, here, in favor of
 this medicine.   Having been taught, by experience, ma-
 ny years ago, that quinine was inadmissible in cerebral
 inflammation, both in children and in adults, I expected
 to gain but little from its use, and was not disappointed.
 I employed it frequently, in the grave variety, to which
  it seemed most applicable, and sometimes with partial
  success  When the disease was attended with a  teyer
  which was regularly remittent, the meningitis appearing 
58
as an appendage, or as if engrafted on a remittent fever,
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.
  Emetics and Cathartics.—Emetics were but little used.
Cathartics were frequently employed as adjuncts, and to
effect particular indications, but were  not  relied  on as
curative remedies.  In two  instances a free catharsis
induced by drastic medicine was evidently prejudicial
  JVarcotics.—Opium was the only remedy of this class
which I used.  From what I saw of it I can hardly say
that it was generally safe to give it in  the inflammatory
malignant variety, or that it was of any use in the con-
gestive malignant form.   In the other varieties it was a
safe remedy, and very valuable as an anodyne merely.
          PRINTED AT THE

JOB OFFICE OF THE DAILY JOURNAL,
       MONTGOMERY, ALABAMA.