CEREBRO-SPINAL MENINGITIS IN MASSACHUSETTS.

The disease now denominated cerebro-spinal meningitis has long been known to the medical profession in the various countries of the civilized world. It has existed as an epidemic, at stated times, in Russia, Holland, France, Germany, Spain, Portugal, Sweden and Great Britain. It has occurred also, from time to time, under various names and divers forms and phases of development, in many parts of our own land. During the war of the rebellion it was seen in marked and fatal form in some of the important military posts both West and South. It was the fortune of the writer to observe the disease in its epidemic character as it occurred in the camps in and about the town of Newbern, in North Carolina, in the winter and spring of 1862-63. This was one of the first among its recent visitations as an epidemic in the United States. So long, indeed, had the affection been dropped from the catalogue of our prevailing discases that, at first, the whole medical force in that Department were at a loss to know with what they had to deal. Coming, as it did, suddenly and without warning, it early arrested attention by the abruptness and intensity of the attack, the peculiarity of its symptoms, its protean developments, its oftentimes rapid course and fearfully fatal results. By some it was taken to be a new and unusual phase of intermittent fever; by others a severe malarial fever of the bilious remittent type; by others still, a malignant typhus, identical in its essential elements with the endemic fever of Great Britain, and which, under the various titles of hospital, jail or camp fever, putrid malignant fever, petechial fever, maculated typhus or ship fever, and other ill-favored names, "is known to lurk in the track of armies, and is familiar in the hovels and ill-drained and ill-ventilated houses of the poor and wretched”—with cach and all which affections it seemed to present many symptoms

in common. It was not, indeed, till repeated post-mortem investigations revealed the unmistakable and striking lesions which belong to the disease in question, that its true character was recognized and established.

To give, in briefest form, a portraiture of the disease as it is now understood by the medical profession, I quote the following definition from a recent admirable monograph on this subject by Dr. Meredith Clymer,* as follows, viz.: “An acute specific disorder, commonly happening in an epidemic, general or limited, and, rarely, sporadically,-caused by some unknown external influence,—of sudden onset, rapid course and very fatal; its chief symptoms, referable to the cerebro-spinal axis, are great prostration of the vital powers, severe pain in the head and along the spinal column, delirium, tetanic and, occasionally, clonic spasms and cutaneous hyperæsthesia, with, in some cases, stupor, coma and motor paralysis, attended frequently with cutaneous hæmic spots; the morbid anatomical characters being congestion and inflammation of the membranes of the brain and spinal cord, particularly the pia mater, although there is reason to believe that the evidence of these changes may be wanting, even in cases of long duration."

To this succinct and comprehensive, but purely technical, definition, it may not be out of place to add here some account of the essential characteristics of the disease, its habits, symptoms, progress and pathology, as seen in its epidemic and most prevalent form in this country. In its mode of attack it is commonly sudden and without premonition, the patient, for the most part, continuing about his ordinary duties and making no complaint till the very day of his seizure. The subjects of the disease, in most cases, among adults, and males especially, are those who have previously been in the enjoyment of sound and robust health, and have endured hardship and exposure with impunity. The symptoms at the first are headache, referred mostly to the back part of the head, of a severe, oftentimes excruciating, character; conjoined with this, or soon following, are violent pains in the nape of the

* EPIDEMIC CEREBRO-SPINAL MENINGITIS, with an Appendix on some points on the Causes of the Disease, as shown by the History of the recent Epidemic in the city of New York. By MEREDITH CLYMER, M.D. (Univ. Penn.), etc., etc. Philadelphia Lindsay & Blakiston. 1872.

:

neck, extending down the spine, accompanied with a peculiar sense of stiffness in the muscles of the neck and lower part of the face. There is chilliness rather than a well-defined chill. Nausea and vomiting, in children especially, is an early symptom. There is generally soreness and tenderness at the back of the neck and along the spine. Sudden and acute pains in the joints is a not infrequent concomitant. As the disease advances there is great exhaustion; the breathing becomes irregular and labored. Delirium is frequently present, often of a violent kind, but differing from the delirium of typhoid and typhus fever in that the patient can easily be aroused so as to answer questions intelligently. There may be, at some stage of the affection, an eruption of a dark-red or purplish hue, of a hæmic character, not raised but apparently imbedded in the substance of the skin. This eruption is by no means a constant phenomenon, nor is it confined to any particular portion of the body. There is usually much nervous agitation, manifested by a constant restlessness and jactitation. The muscles of the neck become rigid and contracted, drawing the head backward to almost a right angle with the thorax; this, although not a constant symptom, is mostly seen, or at least a tendency to this condition is noticed, at some period of the disease. There may be also tetanic and clonic spasms. The action of the heart is irregular and tumultuous, so as often to simulate valvular disease of that organ. An inflammatory condition of the iris, or of the synovial membrane of the larger joints is often an accompaniment. Such are among the more prominent and constant symptoms. But there is a considerable diversity in these manifestations during the progress of the disease, whether towards a favorable or fatal result; in no individual case can it be expected that all, or even a majority, of those above enumerated will be present.

The duration of the disease is very uncertain. It may last less than twelve hours, or it may extend, with its complications and sequelæ, to as many weeks, or, perhaps months; the greater number of fatal cases terminate on or before the seventh day. Cases are on record in which death has occurred within two or three hours from the time of seizure.

No age is exempt; nor would there seem to be any preference of sex. Children are, perhaps, more commonly subjects of

the disease.

Statistics show that more cases occur under than

over the age of ten years.

The mortality is very great, averaging in many well-marked epidemics of which we have record fully 67 per cent. In the visitation at Newbern, before alluded to, the mortality of all the recorded cases was 73 per cent.; in the city of New York, in 1872, it was 75 per cent.; in the epidemic that occurred in this State, in 1866, it was 61 per cent.

The prognosis must be regarded as doubtful from the first; of no disease is it more hazardous to base upon existing favorable or unfavorable symptoms a positive prediction as to the result. Convalescence is usually slow and relapses not infrequent.

As to the season of the year when epidemics of this affection are most apt to prevail, not much that is satisfactory can be learned. Dr. Simon has stated that, of 182 European epidemics, 24 were in October and November, 46 in December and January, 48 in February and March, 30 in April and May, 24 in June and July, and 10 in August and September. Dr. Clymer, who has collected the statistics of many epidemics, says that, in Sweden, of 417 local outbreaks, 311 were in winter and 106 in summer; that, of epidemics in Europe and the United States, noted by Hirsch, 33 prevailed in winter, 24 in winter and spring, 11 in spring, one in spring and summer, two in summer, one in summer and autumn, one in autumn, one in autumn and winter, three in autumn, winter and spring, and six throughout the whole year. Pleiffer says "it prefers winter, soldiers and children."

It would be out of place here to enter largely into the consideration of the nature and pathology of the disease. Suffice it to say that the weight of evidence is in favor of placing it in the category of those diseases which are engendered by the existence of a morbid poison acting primarily upon the vital fluid, and secondarily affecting more especially the meninges of the base of the brain and spinal cord, where, upon dissection, its material lesions can most often be found.

The etiology, or cause of the disease, is still involved in doubt. It will be our aim to consider, with minuteness and impartiality, the mass of evidence collected from the many

intelligent observers of the present epidemic, and to deduce, if we can, something that may prove of use in the prevention or management of future visitations of a like nature.

Before entering upon a discussion of the existing epidemic, let us glance at the past history of the affection within the limits of our own State. The first reliable record of it, as seen in the epidemic form in Massachusetts, dates back to 1806, when it appeared in the town of Medfield. Nine cases occurred in that town, all of which proved fatal. This was in the month of March. From that time until 1816 it appeared, at intervals, at various points within the State, and was more or less epidemic in its character. It prevailed quite extensively in 1810. In that year a most interesting report upon this then mysterious and obscure affection was drawn up and published by Drs. James Jackson and John C. Warren. It first appeared, as stated in that report, in the town of Dana, about the beginning of the year, "but not in any considerable number of instances until the cold weather of the middle of January." In the latter part of February it was heard of at Petersham, and at Barre, Oakham, Rutland, Paxton, Hardwick, New Braintree, Brookfield, Spencer, Sturbridge, Winchendon, Athol, Gerry, Leicester and Worcester, in the course of the month of March, "mostly about the third week in that month." It will be seen that all the abovenamed towns are in the county of Worcester. It was seen at Cambridgeport in the latter part of March, and at Lancaster in April. In the course of April and May a few cases occurred at Boston, and again in the counties of Worcester and Middlesex. During May it presented itself in Springfield, and had not subsided in the second week in June.* We hear little or nothing more of the disease till 1849, when Dr. Joseph Sargent, of Worcester, called the attention of the profession to its existence in the towns of Millbury and Sutton during the month of March of that year. Not many cases were seen, however, and if the disease could then be called epidemic at all, it was limited both in quantity and extent. Dr. S., in this memoir, first suggested the analogy of the

* See Report of the Committee of the Mass. Med. Soc'y, May, 1866, Luther Parks, M.D., Chairman.