"Pharyngitis, pneumonia and other febrile diseases have, in almost every instance, taken on cerebro-spinal symptoms; and it is common for the patient to say, if his head is raised for any purpose,-'you hurt my neck!'so that it is difficult to tell which is the disease,-the pneumonia, etc., or the cerebro-spinal meningitis. This general observation has struck me forcibly in connection with disease in this locality."

Palmer.-Dr. Holbrook had a single case about which he says, and drainage good; no traceable cause of the disease."

"Water

Peabody.-Three cases are reported. In one-"the location is a level area of ground, nearly circular and surrounded by hills and farms,—a sort of amphitheatre, as it were, perhaps three-fourths of a mile in diameter: the soil, dry. Not far from the house a field is used for the purpose of drying gluestock, and from this the smell is sometimes very offensive. The drains of the house were in a slovenly condition, discharging within fifteen feet of the well." In the second, the house stands "on low made land; a tannery on one side and a morocco manufactory on the other. The smell is offensive, and the air must be very impure." The third was in a healthy locality. The patient (a young woman) "had been at work at Lynn for some time, at a shoe establishment, using a sewing-machine and confining herself very closely, working, at times, sixteen hours a day; she had been for years subject to bilious attacks."

Quincy Point.-A single case. The house of the patient "stands on a low, porous soil, and within an eighth of a mile of tide-water. His sleepingroom is large and well ventilated; cellar, dry; sink empties into the privy, which is about a foot from the house. Half a dozen other persons live there, and are all in good health.”

Rorbury Highlands.-Dr. Flint gives a report of two cases, of which he says: "I cannot think either case referable to bad drainage or impure water. The first was in St. James Street; drainage, good; water, Cochituate. The second was at the Simmons estate, Highland Street, with which locality Dr. Derby is probably familiar. The water, I presume, is well-water. I made no inquiries in regard to drainage." Dr. Streeter also reports two cases which he could not trace to any special cause. He had also "seen many cases accompanied with cephalalgia and rachialgia, requiring a few days' release from business; no special treatment; others did not give up business or occupation. Evidently a strong epidemic influence prevailed throughout the winter and spring."

Salem.-Dr. Johnson writes: "We have not seen much of cerebro-spinal meningitis in Salem. There have come under my own observation several cases of intense and uncontrollable headache, affecting chiefly the back of the head, with muscular pains and slight stiffness of the neck, suggesting for several days the commencement of an attack of cerebro-spinal meningitis. But, without further development of symptoms, the pains would slowly decline and cease. These cases seemed to me peculiar, and in conversation with Dr. Kemble, I found he had met with several cases in which there seemed to be but little lacking to constitute the initial symptoms of the disease. The quiet departure of the symptoms suggested to me an abortive cerebro-spinal meningitis; yet, the cases were too ill-defined to be satisfactorily classified. Of the few genuine cases which have occurred, the locali

ties have not been peculiarly damp, some of these cases occurring in the drier portions of our city."

In a letter of later date, Dr. J. gives an account of a large number of typhoid fever cases, which occurred during the summer and autumn, and sketches the localities in which this disease especially prevailed. Bad air and water, insufficient drainage and unsanitary surroundings made up, as usual, the prevailing elements attendant upon the advent of the fever. But cerebro-spinal meningitis did not, as we have seen, particularly flourish in these localities, although the predisposing cause was imminent during the earlier part of the year.

Sandwich.-One case reported: "Can give no cause; the locality is at least thirty feet in altitude above sea-level; plenty of air and light; no miasm."

Somerville. Of six cases reported, the locality in five was found to be "low and damp." Dr. Knight gave the details of two cases only, though he “had seen many more.” “Locality," he says, seems to have had no marked influence. In none of my cases can I refer to any origin or cause."

Springfield. Twelve cases are reported. The locality was "low," or "low and damp," in nine cases, "damp" in one, "high" in two.

Stoughton.-Dr. Tucker reports seven cases, and says, "I could not discover that locality, whether high or low, damp or dry, had any influence."

Swampscott.-Dr. Chase says of a case reported by him: "He was as healthy a young man as we have in town, of good habits, etc. I know of no cause why he was attacked with this disease."

Tyngsborough.-Dr. Dutton had two cases, "five miles apart." Of one of them he says, "Her earliest symptoms date sharply from exposure in a damp night, with wet feet."

Ware.-Dr. Miner says: "I have neither seen nor heard of any cases of cerebro-spinal meningitis in this region. We have had a few cases in which there were complaints of pain in the neck and back, but not sufficiently severe for treatment, or to warrant us in calling it the genuine disease, though there was evidently a tendency that way."

Watertown.—Dr. Hosmer relates the following somewhat curious circumstance in regard to three cases of the disease which came under his observation, the patients being two brothers and a sister: "Their home was in the village of Watertown, in the second story of a house with fair surroundings. The eldest (a boy), fifteen years of age, was living on a farm two miles away, visiting his family every Sunday. He was seized with the disease, while away from home, at the same time that his brother and sister were ill with it at his father's house."

He says:

Webster.-Dr. Brown gives five cases. "I am unable to state any specific cause for the occurrence of the cases aside from the supposed epidemic influences, as the circumstances of these patients, with the exception of two which occurred in same family, were very unlike in almost every particular; and I saw no especial reason for the attack."

West Rorbury.-In three cases reported by Dr. Maynard, he finds " parent cause."

no ap

Weymouth. Dr. Forsaith reports a single case, which, he says, occurred in the vicinity of other families and among a healthy population.

Williamstown.—Dr. Smith writes, in regard to his experience in this disease, as follows: "I have not been able to discover the cause; I once attributed it to the water; and my conviction now is, that to that source, combined with local causes, as previously set forth, is to be ascribed the disease."

Winchendon.-Dr. Ira Russell states that six cases of cerebro-spinal meningitis had come under his observation and treatment during the past summer. He also states that he had been familiar with the disease in the winter of 1863-64, during his army life. He says the disease was "almost invariably ushered in by a chill, great prostration, nausea, vomiting, severe pain in the head, neck and back, delirium, sometimes wild, but more commonly moderate, the patient being easily roused to answer questions, but immediately relapsing into his former condition, with contraction of the muscles of the neck and back, rigidity of the extremities and great restlessness. Deglutition was commonly difficult, often impossible. The patient would commonly remain in this condition from twelve to thirty-six hours, when re-action would come on, followed by fever, usually of a typhoid type, lasting from one to six weeks, sometimes ending in recovery, oftener in death.” In regard to causation, he believes the disease to be undoubtedly due to an epidemic influence, "an influence more nearly allied to that which produces influenza, peritonitis and pneumonia rather than to the idiopathic fevers, like typhus .and typhoid."

Winchester.—Dr. Winsor could find "no assignable cause" for the few cases which came under his observation.

Woburn.-Dr. Cutter reports four cases. In two the locality was "unfavorable"; in two it was "fair." Dr. C. says: "It is my opinion that cases of cerebro-spinal meningitis occur in Massachusetts, which, from their mildness, are sometimes overlooked and mistaken. There is a mild form of the disease which may be thought rheumatic."

Worcester.-Twelve cases are reported. Of these Dr. Clark reports seven, and says that three cases occurred in one family and two in another. Of the former group he says: "The house is in a generally healthy location; it stands, however, upon a bank, sloping towards the street, so that the land in the rear is considerably higher than the front. Two families occupy the honse. The sink-drains open at the side of the L part, and the drainage flows in a superficial gutter, by its side, to the front, and from thence, under the sidewalk, into the street sewer. The well is outside and a little below where the sink-spout debouches." Of the latter group he remarks: "The location of the street is high, upon a hill sloping to the north; soil wet, with hard-pan beneath; hygienic surroundings very unfavorable." Dr. Clark states that there were fifteen cases in that city, and one in Millbury, in the seven months from December, 1871, to July, 1872, inclusive."

Having thus quoted largely from the correspondence of medical gentlemen, in various parts of the State, as to the locality and other circumstances connected with the origin of

the disease, I will add the results of my own personal investigation in several towns and cities where the epidemic has more extensively prevailed.

Charlestown. In company with Dr. Forster, I personally inspected the following localities:

Case I. A child, 24 Henley Place.-One in a row of tenement-houses, each floor of which is usually occupied by two families. The living-rooms were, in this case, on the second story, back, and consisted of a kitchen and sleeping-room, the latter about 7× 10 feet in dimensions, opening out from the kitchen, and having one small window looking into the back yard. These houses were on made land. Cellar in fair condition.

Case II. Adult male, 108 Water St.-Old house, near the navy-yard gate. Kitchen opens out upon the back yard. Sleeping-room of the patient 12 x 14 feet, without windows. Back yard filthy; privy-vault full and overflowing. Tidewater flows at times into cellar. No drainage.

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Case III. A child, 12 Thorndike St.-A few rods from mill-pond, the receptacle of Miller's River; land low; no drainage; privy in back yard. Water flows into the cellar. Contents of two sinks empty upon the ground cellar-floor. Family recently from Devonshire, England, and much disgusted with their present home. Much complaint of the bad air coming up the stairway from cellar.

Case IV. Adult female, 41 Chestnut Street.-A cheerful and pleasant street; high and dry; sanitary conditions apparently all right; cellar said to be dry and drainage good. I learned that this patient, the day before her attack, attended a funeral, went down into the vault, where she remained some minutes, that the tomb was cold and damp, and she felt chilly while there.

Case V. A child, 39 Henley Street.-On low ground; floor of cellar covered with boards, partially decayed; house drain said to be connected with the street sewer.

Case VI. Adult female, 44 Henley Street.-Tenementhouse; surroundings poor, but not of the worst; livingrooms a kitchen and bedroom adjoining, on ground floor, back; bedroom small, immediately over cellar, which is not wet, but in a slipshod state generally; bad smells complained

of.

Case VII. Adult male, Allston Street.-A pleasant, cheerful-looking street; locality high and dry. This man worked in a furniture factory on "the point," so called, close to the

water.

Case VIII. Adult male, Mount Vernon Street.-Locality apparently dry and pleasant. This man was a rigger, and employed much about ships and docks.

In addition to the above localities, which were personally visited, the exact position of a great many other cases which occurred in this city was obtained by our medical correspondent and marked down upon a map. They were in the main low and damp, were mostly upon made land and near the water, with marked exceptions, however, as in the list above given. On consulting this map, I find the locality of 49 cases thus designated.

Chelsea. The following places in which the disease had occurred were visited in company with Dr. Wheeler :

Case I. A child, Williams Street.-A double house. The locality of the street itself is good. The foundation of the house, however, is four feet below the level of the street, with kitchen and cellar on the same level, i. e., a basement kitchen, where the family principally live. Drains connected with the main sewer, but were without traps. This house has been complained of to the authorities for its unsanitary condition. Dr. W. says he never knew a family to live there six months without cases of illness or death. Since the occurrence of the present disease the drains have been repaired and a trap affixed.