THE LATE EPIDEMIC OF 
CEREBROSPINAL MENINGITIS 
IN MASSACHUSETTS. SOME ADDITIONAL REFLECTIONS UPON THE LATE 
EPIDEMIC OF CEREBRO-SPINAL MENINGITIS. 
Read before the Massachusetts Medical Society, June 2,1874. 
J. Baxter Upiiam, M.D., of Boston. 
Gentlemen,—It fell to my lot in the last year to investigate, with some 
care, the disease which forms the subject of this paper, during its 
prevalence in an epidemic form in various parts of the State. The 
purpose of my examination then was to inquire more especially into 
the circumstances attendant upon the advent of the disease, with a 
view to ascertain, if possible, its origin or supposed cause. In the 
course of this inquiry, I obtained, from personal researches and a 
somewhat extensive correspondence with the Fellows of this Society, 
a mass of facts which I have thought might perhaps be of some 
further use to the profession. Under this idea, I have selected the 
most complete of the cases comprised in the tabular returns received, 
with a view to a more careful analysis of some of their important fea- 
tures. It will be my aim not to repeat what I have so recently ad- 
vanced upon this subject, although I must, necessarily, traverse, to 
some extent, the same ground. 
And, in reviewing the labors of my honored predecessors in this field 
of research, I am struck with the superior facility for obtaining accu- 
rate statistical information which we of the present generation enjoy. 
The able and indefatigable committee, who were charged with the 
inquiry into the causes and history and modes of treatment of the first 
epidemic of this disease, of which we have record, in Massachusetts— 
that of 1810—framed with great care and conscientiousness a series of 
questions, under seventeen heads, which were sent in behalf of the 
Massachusetts Medical Society to all its Fellows and other gentlemen 
of character, in whose vicinity.the disease had prevailed. They were 
published, also, in the principal newspapers of the day, in order (as 
the report says) that any persons possessing useful information on this 
subject might be induced to communicate it. 
In reply to this circular, the committee affirm that they received 
communications from twelve persons, all Fellows of the Society; and, 
likewise, indirect communications from several gentlemen of respecta- 
bility in the State of Connecticut. And upon this somewhat meagre 
return, together with the few cases which the members of the committee 
themselves were able to inspect, was founded that most interesting 
and instructive Report on “ Spotted or Petechial Fever,” which appears 
in the second volume of the Medical Communications and Discussions 
of this Society, under date of June 21, 1810. 2 
In contrast with the above, the circular issued under the auspices 
of the Massachusetts State Board of Health, in the month of May, one 
year ago, brought replies from about two hundred physicians, repre- 
senting seventy-seven towns and cities, and containing the data, more 
or less complete, of upwards of five hundred cases of the disease. And 
I am happy to improve the opportunity, which I may not again have, 
to tender my sincere thanks to those members of this Society—many 
of whom are now before me—who have responded so fully and so 
promptly to the demands thus made upon their time and patience. 
The consciousness of duty well performed, and the satisfaction of 
aiding in the elucidation of an obscure and terrible disease, must be 
your abundant reward. 
But to my subject:—It is well known that the disease we are now 
considering has prevailed to a limited extent, within the last few years, 
in our own and several of the adjoining States. Dr. Parks, in the able 
and exhaustive report made to this Society in 1866, has given us a 
detailed account of all the cases he could collect in the eight or ten 
years preceding that date. Since 1870, it would appear that the num- 
ber of cases rapidly increased, till they culminated in the somewhat 
extensive epidemic of 1873. 
I am convinced that I have been able to get together only a minority 
of the cases that occurred in that year, and of these the data, as a 
whole, are by no means as complete as could be wished. But the re- 
turns are widely distributed over the State, and may be said to fairly 
represent the ordinary phenomena of the disease. The name which 
has, of late years, been given to this affection—that of cerebro-spinal 
meningitis—conveys the idea of its essential natui*e, as manifested in 
its prominent symptoms and revealed by post-mortem inspection; and 
it points, likewise, to the principal indications to be aimed at in its 
treatment. It was not possible, within the scope of my communication 
to the State Board of Health, to more than glance at the general char- 
acteristics of the malady in question—to give, in briefest form, an idea 
of its history, its habits and progress, and gain some hints for pro- 
phylactic management in times of its epidemic prevalence. 
It will be my object at this time more especially to present a con- 
densed view of the symptoms and pathological manifestations of the 
disease, based upon the series of cases I have selected, and to consider 
a few of the many modes of treatment adopted. The number of these 
selected cases is 315, of which 173 recovered and 139 died,* the ratio of 
mortality being 44per cent. This percentage is almost precisely the 
same as that of the 517 cases comprised in my recent report to the 
State Board of Health, and it is interesting as containing, so far as it 
goes, the statement, already published, that the recent epidemic was a 
mild one in comparison with many others on record. 
In the tabular statements to which I have alluded, the symptoms are 
grouped under two heads, according to the time of their appearance, 
whether in the earlier or later stages of the disease. In this way, I 
believe we are more likely to obtain, from a multitude of observers, 
such minuteness and particularity of record as will conduce to a more 
reliable analysis of this important chapter in the history of any epi- 
demic disease. And in regard to these symptoms, as I have elsewhere 
said, they exhibit great diversity of manifestation ; it cannot be ex- 
pected in any given case that a majority, even of those which legiti- 
* Three cases were incomplete. 3 
mately belong to the disease, will be present. This has, no doubt, 
tended greatly to obscure its diagnosis, on the part of those especially 
who are not familiar with the affection, who have learned its habits 
from books mainly. Hence it is important to find out, if we can, the 
most constant and prominent of the signs and symptoms which per- 
tain to the affection. 
The relative frequency of these symptoms, as applicable to the list 
I have in hand, may be seen by the following tables :— 
Table showing the Relative Frequency of some of the more Marked Symptoms 
in the Early Stages of 315 cases of Cerebro-spinal Meningitis indicated in 
the foregoing series. 
Noted in how 
many Cases. 
Eakly Symptoms. 
61 
Chills. 
223 
Headache. 
44 
Nausea. 
147 
Vomiting. 
102 
Pain in nape of neck. 
86 
Delirium. 
64 
Irregularity of the pulse. 
57 
Pain along the spine. 
50 
Stiffness of muscles (of neck especially). 
49 
Retraction of head. 
40 
Spasms or convulsions. 
39 
Stupor or drowsiness. 
37 
Anomalous pains. 
30 
Opisthotonos. 
29 
Restlessness. 
27 
Tenderness over spine. 
24 
Hypersesthesia. 
19 
Prostration. 
18 
Muscular twitchings. 
Table showing the Relative Frequency of the more Prominent among the Ad- 
vanced Symptoms in 315 cases recorded in the preceding series. 
Noted in how 
many Cases. 
Advanced Symptoms. 
74 
Headache. 
84 
Delirium. 
75 
Retraction of head. 
62 
Opisthotonos. 
56 
Spasms or convulsions. 
54 
Coma. 
54 
Prostration. 
46 
Irregularity of the pulse. 
39 
Stupor. 
36 
Pain in nape of neck. 
34 
Rigidity of muscles (of neck especially). 
34 
Dilated pupils. 
34 
Anomalous pains. 
32 
Paralysis. 
31 
Hyperesthesia. 
31 
Pain in spine. 
55 
Petechial spots. 
26 
Restlessness. 
20 
Strabismus. 
15 
Herpes. 
15 
Deafness. 4 
It must be remembered that I am only attempting to show, by this 
analysis, the comparative frequency of such symptoms as are suffi- 
ciently marked to attract the attention of observers in the series of 
cases I have adduced. Unfortunately, we are, for the most part, with- 
out the negative evidence which, if obtained, would have added greatly 
to the interest and value of the tables. We can only take them as we 
find them. 
It appears from these tables that chills, headache, nausea, vomiting, 
pains at the nape of the neck, delirium, irregularity of the pulse, stiff- 
ness of the muscles (of the face or neck more particularly), retraction 
of the head, spasms or convulsions, stupor or drowsiness, and anoma- 
lous pains were among the most constant of the early symptoms, being 
noted respectively in 61, 223, 44, 147, 102, 86, 64, 57, 50, 49, 40, 39 
and 37 cases ; and, in the later stages, the symptoms and phenomena 
more frequently observed were headache, delirium, retraction of the 
head, opisthotonos, spasms or convulsions, coma, irregularity of the 
pulse, stupor, pain in nape of neck, rigidity of muscles, dilated pupils, 
anomalous pains, paralysis, hyperaesthesia, &c., these symptoms being 
noted in 74, 84, 75, 62, 56, 54, 54, 46, 39, 36, 34, 34, 34, 32 and 31 
cases, respectively. 
It may be interesting to append here a tabular statement, showing, 
in condensed form, the relative frequency of these more prominent 
symptoms as noted at some period of the disease in all the recorded 
cases, as follows :— 
Table showing the Relative Frequency of the Prominent Symptoms noted at 
some Period of the Disease in the cases recorded in the preceding series. 
Noted in how 
many Cases. 
Prominent Symptoms. 
61 
Chills. 
238 
Headache. 
147 
Vomiting. 
132 
Delirium. 
102 
Pain in nape of neck. 
102 
Retraction of head. 
92 
Irregular pulse. 
90 
Pain in spine. 
79 
Opisthotonos. 
70 
Rigidity of muscles. 
68 
Spasms or convulsions. 
66 
Stupor or drowsiness. 
61 
Anomalous pains. 
58 
Coma. 
57 
Prostration. 
55 
Petechial spots. 
51 
Restlessness. 
46 
Nausea. 
44 
Dilated pupils. 
41 
Tenderness of spine. 
35 
Paralysis. 
34 
Hypersesthesia. 
27 
Muscular twitchings. 
22 
Herpes. 
22 
Irregular breathing. 
21 
Deafness. 
20 
Strabismus. 
13 
Contracted pupils. 
12 
Intolerance of light. 5 
As I have before said, it is not to be supposed that even in a majority 
of the cases from which these tables are deduced all the important symp- 
toms of the disease have been set forth. I do not claim, therefore, for these 
numerical statements anything more than a comparative exhibition of 
the facts and phenomena that more particularly arrested the attention 
of the physician in his earlier and later visits. Nor can we attach any 
very great value to such chronological statistics in a disease of so un- 
certain duration. Its onset is for the most part sudden and unheralded, 
and, as will appear from an inspection of the returns, the physician’s 
services are generally demanded at once. His first visit dates, usually, 
within a few hours from the time of the attack. I have classed the 
early symptoms, therefore, among those which appear in the first three 
or four days of its course. With this explanation, the summary I 
have given will, I hope, afford some aid in the prompt diagnosis of 
this oftentimes obscure affection. 
Before leaving this part of my subject, I will dwell somewhat upon 
a few of the symptoms above enumerated. It will be seen that the 
disease is not uniformly ushered in by chills or rigors, as is commonly 
the case with purely febrile affections ; and my own experience has 
been that when such symptom is present it is rather a sense of chilli- 
ness than a well-defined chill. Headache is an early and an almost 
constant accompaniment, and it is generally of the severest kind. It 
is variously denominated in the preceding returns as “ intense,” “ very 
severe,” “excruciating,” “tearing,” “horrible,” &c. &c. The de- 
lirium may be severe, but it is oftener than otherwise of a kind which, 
for want of a better term, I will call superficial—by which I mean that 
the patient can usually be roused so as to answer questions logically, 
even in the worst cases. There are, of course, exceptions to this rule. 
Vomiting is an early and pretty constant symptom, with children 
especially. Pain in or about the nape of the neck, it will be seen, is 
noted as among the most frequent of the early symptoms. This is 
oftentimes accompanied with a peculiar sense of stiffness and of ten- 
derness to the touch, and with that other characteristic, oftentimes pa- 
thognomonic, sign, retraction of the head. Conjoined with these last, 
may usually be found the rigidity of muscles referred to in the tables. 
Irregularity of the pulse is a marked symptom. It indicates, of course, 
the erratic action of the heart, which has many times sadly confused 
the diagnosis. So closely, indeed, does this latter symptom simulate 
valvular disease of the heart as to deceive the most wary. A labored, 
panting respiration is very naturally joined with the symptoms just 
mentioned. And I cannot help thinking that it must have existed in 
more instances than the preceding tables would indicate. Under the 
head of anomalous pains may be classed the painful sensations alluded 
to by various writers on this disease, which come on, for the most 
part, suddenly and unexpectedly, and affect the arms, legs, feet, hands, 
the stomach or bowels, the joints, &c. &c., without seeming connec- 
tion or cause. We might speak, also, of anomalous motions as per- 
taining to this disease. One patient is spoken of as indulging in 
“ small, convulsive movements, such as no Christian ever made.” 
Another is represented as striking and spitting at his father. Others 
are described as “clutching,” “kicking,” “ gyrating,” &c.” The 
petechial spots, which are reported as having been present in a limited 
number of cases, are generally of a hsemic character, and resemble 6 
those seen in the worst cases of typhus. Restlessness and jactitation, 
with hyperassthesia, do not assume that prominence in the foregoing 
tables which my own experience has given to them ; and it is quite 
likely that, in the greater prominence of more important symptoms, 
these may have passed unnoticed. There is oftentimes great nervous 
agitation, and a dread of being moved or even touched. The bowels 
are usually torpid ; indeed, constipation is very generally alluded to 
as the ruling condition in the preceding tables. The temperature is 
not given as often as could be wished, and when indicated, the period 
of the day or the stage of the disease has not been particularized. In 
several cases, however, a very high temperature has been noted, as 
high as 108t by Dr. Wm, Read, and in one instance (that of a boy 
eight years of age), by Dr. Ira Russell, as high as 110°. 
We come now to the anatomical characteristics of the disease, 
which, as might be inferred from the symptoms above detailed, belong 
mostly to the brain and spinal cord. In fifteen cases only were post- 
mortem examinations obtained. But, so far as they go, they tend to 
confirm the generally received pathology of this affection. In twelve 
cases, there was either purulent effusion or a deposit of lymph on 
some part of the surface of the brain, most often at its base—in one 
instance, “ like fibrine ” in substance. In seven cases, there was 
an increased quantity of fluid in the ventricle, or beneath the arachnoid. 
In seven cases, there was congestion of the membranes to a greater 
or less extent. There was a deposit of lymph upon the spinal cord in 
six cases. In three cases, there was apparent suppuration of the cord. 
Opalescence of the arachnoid was manifest in three cases ; and in one 
case the membranes at the base of the brain and spinal cord were 
thickened and adherent. It is much to be regretted that so few au- 
topsies could be obtained. But such as we have will afford a fair 
opportunity to judge of the average character of the anatomical lesions. 
And they tally, in the main, with my own observations in other and 
more limited epidemics of the same kind. According to my former 
experience, however, it sometimes happens that the most undoubted 
manifestations during life leave no perceptible trace after death ; more 
especially is this to be anticipated in cases sudden and violent in their 
accession, and of brief duration. 
In reviewing the tabular statements of the list of cases to which I 
have called attention, I have studied with much care the record of 
treatment. And I am struck with the manifold and various plans of 
therapeutic management which have been adopted, and the evident 
earnestness and faith with which, sometimes, very opposite methods 
are advocated. Indeed, almost every known mode of treatment, in its 
every kind and degree, seems to have found its representative here. 
Thus: one physician, of high standing and influence, gives morphia, 
Dover’s powder, tartrate of antimony and aconite, with calomel and 
opium, but “ no stimulantsand brings his patient through in about 
two weeks with a good recovery ; another equally eminent practition- 
er, in the same town and in the same space of time, reports a perfect 
recovery upon beef-tea and milk, quinine, carbonate of ammonia and 
brandy. In the practice of a Boston physician, two cases having the 
same symptoms, were treated with ergot and the bromides early ; 
later, with opium, quinine and wine, conjoined with milk diet and 
occasionally a warm bath. The result was, in the one case recovery, 7 
in the other death, in about the same period of time. Seven out of 
nine patients died in the hands of another physician, who assiduously 
and conscientiously administered opiates and the iodides, together 
with tonics and stimulants, and counter-irritation to the parts particu- 
larly affected. An eminent country practitioner, who had several 
cases under his charge, reports that he faithfully administered 
belladonna, ergot, quinine, brandy, wine and iron throughout the 
course of the disease and found them in every instance to disa- 
gree. Another, in speaking of a three months’ case which was 
still pending, tells us that after the bromide of potassium and 
the application of cold to the head and neck, and irritants to the 
spine, added to abundant nourishment with milk and eggs, beef-tea, 
&c. &c., for the last month his patient had “ taken no drug,” for no 
treatment, he adds, seemed to be of any avail; and, on the next page, 
he continues, in grim despondency, “ result, probably fatal” 
Another adopted a thoroughly rational, expectant treatment; the 
bowels were kept open by mild laxatives, pain and restlessness were 
relieved by bromides and opium ; irritation was applied to the nuchas 
and upper portion of the spine, and, in later stages, quinine, iron, stimu- 
lants, with nourishing diet, were given, secundum artem. The result 
in a majority of his cases was death. Another sums up his treatment 
in the one word, “ stimulants,” and his next record reads as follows : 
“ No autopsy was permitted.” Still another puts under the head of 
treatment the designation “ homoeopathic ;” the inevitable result was 
“ death.” 
Seriously, gentlemen, I am puzzled, in the abundant experience 
which the late epidemic has given us, to discover what course of treat- 
ment promises the best. At the Massachusetts General Hospital, the 
iodide and bromide of potassium, ergot, quinine, with milk and beef- 
tea, formed the staple management. The same general plan, with the 
addition of ice to the head and croton oil to the nuchee, with belladon- 
na and ergotine, constituted the treatment at the Boston City Hospi- 
tal. A well-known physician of this city puts great reliance upon the 
exhibition of ergotine and the extract of belladonna, in the proportion 
of a grain of the former to one tenth of a grain of the latter, for adults, 
administered every four hours during the acute stage. This combination, 
in connection with tonics and stimulants, a good diet and the applica- 
tion of cold to the head and occasional irritants to the nape of the 
neck, was followed by r<&overy in a large majority of his cases. One 
gentleman reports a highly favorable result in a series of ten cases 
treated by the application of hot water to the head, blisters to the 
nuchse, a sinapism to the spine and hot fomentations to the feet, fol- 
lowed, at a later stage, by the administration of bromide of potash, 
the fluid extract of ergot, aconite, stimulants and nourishing diet. 
Another, who had a considerable experience in the disease, resorted to 
the old-fashioned application of the “hemlock sweat,” as it was ad- 
ministered by our fathers a half century ago, and, as he thinks, with 
positive advantage. Several observers have thought they saw a mark- 
ed improvement consequent upon the application of irritants, as above 
described, to the nuchse and spine. 
It would appear, from the foregoing summary, that no positive plan 
of therapeutic management has been developed by the recent epidemic. 
This coincides with my own previously expressed views as derived 8 
from a personal experience of the disease in military camps and hos- 
pitals, and confirmed by study and observation elsewhere. Yet, after 
all, I believe that something can be accomplished in the way of treat- 
ment. Bearing in mind the essential element of the disease, a morbid 
poison acting primarily upon the vital fluid and affecting secondarily 
and rapidly the meninges of the brain and spinal cord more especially, 
giving rise to symptoms and phenomena which simulate, while they 
are not identical with, inflammatory action in these parts, the conse- 
quent exhaustion of the vital powers and great perversion of the nerve 
force, as manifested in the irregular action of the heart, the labored 
breathing, the restlessness and jactitation and extreme sensitiveness 
of the surface ; remembering, also, the material lesions which are so 
generally revealed on post-mortem inspection, the indications for a ra- 
tional treatment would seem to be these:— 
1. To husband the strength. 
2. To combat the tendency to congestion of the brain and spinal 
cord. 
3. To mitigate the intense pain. 
4. To calm the nervous excitement. 
5. To nourish and support the system till the exuded morbid pro- 
ducts can be removed by the kindly offices of nature, and to minister, 
in the meanwhile, by all the ways at hand, to the comfort and relief of 
the patient. The choice of means for the fulfilment of these manifest 
indications I leave to the judgment and good sense of those who 
hear me. 
I am aware, gentlemen, that much more might be said upon the sub- 
ject of this epidemic, and that the analysis of the tabular returns might 
be pursued to advantage in other directions than those I have attempt- 
ed ; but I have already reached the limit set forth in my paper at the 
outset, and I will trespass no further upon your patience. 
Reprinted from the Boston Medical and Surgical Journal, September 3,1874.