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The condition or circumstances of the patients, whether easy or otherwise, were pretty evenly balanced.
The disease prevailed most extensively during the spring months. Of three hundred and ninety-four cases in which the date of the attack is definitely stated, ten began in January, twenty-five in February, eighty-four in March, one hundred and sixteen in April, ninety in May, thirty-seven in June, ten in July, eight in August, five in September, seven in October, one in November, and two in December. The first recorded case bears date January 6th. Relapses or decided remissions are referred to only in a minority of instances. The shortest recorded duration of the disease is two hours, the longest six months. *
It would be out of place here to enter upon the question of treatment. From the evidence in hand, we feel bound to say that no line of therapeutical management can absolutely control or cut short the disease, though much can be done to comfort and relieve the patient. The mortality in the five hundred and seventeen cases adduced was a little less than fortyfour per cent. This goes to confirm the opinion expressed by many of our correspondents, that, compared with former epidemies of which we have record, the present visitation must be considered a mild one. The post-mortem records of the epidemic are few and meagre ; but the developments, so far as observed, tally with the already chronicled facts in the pathological history of the disease.
The locality is stated in four hundred and forty-six cases. It is said to have been " low and damp” in one hundred and thirty cases, " low and dry” in thirty-seven cases, "low" in eighteen cases," damp” in twenty-one cases. " high and dry” in eighty-nine cases, " high and damp” in seven cases, "high” in twenty-two cases, "dry” in sixty
It was said to be "medium” in sixty-two cases, and in seventy-one cases the nature of the locality is not stated. By this it will be seen that the low or damp element is somewhat in the ascendant.
* As a complication, or sequel, of this disease, ophthalmic affections are not unfrequently observed. So also affections of the ear, resulting in deafness, are not uncommon. We are permitted by Dr. Clarence J. Blake to refer to his private notebook for the year ending Oct. 1, 1873, from which we derive the following facts.
Has the disease prevailed among animals ? Returns from Boston, Brighton, Charlestown, Fall River, Lynn, Newton, Stockbridge, Wakefield and Worcester, all speak of the existence of the disease, to a greater or less extent, among animals. Horses and cows appear to have been most often affected; after that hens and chickens, and in some instances dogs and cats; so that the cognomen, "pandemic,” as applied to this disease by a recent medical writer, is not wholly inapt, though of somewhat questionable etymology. The following account of the disease, as it appeared to a considerable extent among horses in New Bedford, has been furnished by Dr. O. H. Flagg, a well-informed and reliable veterinary surgeon of that city. Under date of July 9th, 1873, Dr. F. writes as follows :-"Since the first of January, sixteen cases of the so-called cerebro-spinal meningitis have come under my observation and treatment. Of these, fifteen were horses and one a calf four months old. The ages of the horses varied from five to sixteen years; two only were over twelve years old; nine were males, six were females. Their symptoms were as follows :—They were attacked with violent pain, followed, in most of the cases, with a rapid swelling of the lumbar and sacral muscles, which became as rigid and hard as iron. After the subsidence of this condition the muscles became exceedingly lax and flaccid, with more or less impaired contractile power, but without entire paralysis. In one case the muscles of only one side were affected ; in others this affection showed itself more severely on one side than the other. The sensation continued intact. There was, in many cases, a
Twenty-seven cases of deaf-mutism came under his observation in the time named, the origin of which he clearly refers to cerebro-spinal meningitis. Commenting upon these cases, he writes as follows:-"The majority of the cases of deaf-mutisin resulting from cerebro-spinal meningitis, were presented for examination within four Weeks from the time of the attack. In most of them the history was the same,-the child having heard well before the illness, and the deafness being first noticed when convalescence began. In a few cases the deafness was noticed early in the disease. In the majority of cases, moreover, the external and middle ears were in a comparatively healthy condition, the exceptions being traces of slight catarrhal inflammation of the middle ear, not sufficient to account in any degree for the deafness, which was in all but two of the cases, so far as could be ascertained, total. In these two cases there was hearing for loud noises. It is probable that the sound of their own voices in speaking was heard by some of the remaining patients, but their age rendered it difficult to determine this point.” All the cases above referred to were children, the youngest being two and the oldest twelve years of age.
scanty secretion or complete suppression of urine ; in others very high-colored urine, and great difficulty in evacuating the bladder. In eight of these cases opisthotonos was well marked; in three the muscles of the neck and fore extremities became swollen like those of the lumbar region before described. There was partial coma in two cases, i. e., the calf and one horse. They could, however, be easily roused at any time. I saw no evidence of active delirium. In one case there was paralysis of the optic nerve of the left eye, commencing two days before death. My treatment consisted of fomentation of the affected parts with blankets dipped in hot water, which were covered with dry cloths to prevent evaporation ; alternating with this the parts were bathed freely with ammonia and camphor-lotion, repeating the process until the pain subsided. Internally cathartics and diuretics were administered, followed, as improvement advanced, by nervous stimulants and tonics, along with good diet. Three of these animals died, and one other will probably succumb to the disease; the other twelve are convalescent. The duration of the disease was from five to fifteen days. The condition and situation of these animals, as to place of abode, general care, usage, etc., were decidedly varied. The post-mortem appearances were a general congestion of the psoas and iliac muscles, and also of the external lumbar and sacral muscles. The meninges of the posterior part of the spinal cord were inflamed, with a quantity of colored fluid in the canal, the amount of which I was unable to measure. The vessels of the arachnoid were full to distention, and, in spots, this condition seemed to dip down into the cord itself. There were petechial spots extending over the dorsal portion of the cord. The kidneys were inflamed (or, perhaps more properly, congested) and enlarged.”
It remains to see if, from all the evidence we have adduced, any reasonable deductions can be drawn which shall throw some light upon the vexed question of the etiology or cause of this affection. It is well known that during the autumn months of the preceding year a remarkable and wide-spread disease, of the influenza type, prevailed among horses. This State suffered among others, though not, as I am aware, with exceptional severity. It was a common prediction with some
of our most intelligent medical observers that an epidemic among human kind would probably follow. In this State such prediction was certainly verified. With the advent of cold weather came an unparalleled visitation of small-pox, the like of which, for its wide extent,-for virulence and fatality,-had not been known since the times of Jenner. This epidemic ran its course, and subsided with the disappearance of the extreme cold weather of midwinter. Co-incident with this subsidence arose the epidemic with which we have now to deal, and which has prevailed, as we have seen, to a greater extent than ever before in this State. These are curious facts, -perhaps nothing more.
We have long been familiar with what is called, for want of more definite knowledge, a prevailing epidemic influence, -a certain something which pervades the air, and rests like a baleful shadow on the land. Its very mystery adds to its force, and tends to excite terror and dread among the people. This, in medical parlance, is called a remote or general cause of disease. It prevails in certain years, or at certain seasons of the year, and threatens all alike. But there are immediate or exciting causes which, at such times, determine the individual attacks. In some diseases these proximate causes are well known-e. g., in small-pox it is direct contagion ; in typhoid fever it is bad drainage or impurity of the air, or water, or food, or all together; in typhus, it is contagion and insanitary influences combined.
But in the affection under consideration its origin or immediate cause is not so clear. We have seen that the condition in life and the nature of the locality do not seem to have exerted any positive controlling influence in the production of the disease; neither extreme cold nor heat seems especially to favor its propagation ; nor do we find any just grounds for relief in contagion as a specific cause.
The relation of insanitary conditions in and around the abode of the patient to its origin or supposed cause, demands the most careful consideration. In weighing the evidence contained in the returns, I find the scale to be pretty evenly balanced in this particular. The cases are distributed among all classes and grades of society,—the high and the low, the rich- and the poor, locations unexceptionable for situation,
open to abundant light and air, and the pent-up hovels of the lowly and wretched, have all contributed to the material of the epidemic. We believe, therefore, that the primal origin of the disease is atmospheric, and, for the present, beyond our ken.
It would seem, however, from the multitude of facts that have hitherto been collected, that, in times of epidemic influence, in this as in other diseases of a kindred nature, any defect of known hygienic and sanitary conditions in and about the patients' residence may, if his system be otherwise made ready or predisposed, through want, deprivation, mental or physical exhaustion, anxiety, or other depressing cause, tend to precipitate an attack, while under other circumstances he might be able to withstand the general epidemic tendency and ward off the disease. We need only refer to the mass of evidence contained in the communications of our correspondents, added to our own personal investigations, as detailed in the preceding pages of this report, for confirmation of this view.
Our conclusions, therefore, while they must be, in the main, negative as to the existence of any definite exciting cause which, under all circumstances, will produce the disease, lead us to say with confidence that those communities, towns or cities whose sanitary regulations are strictest and best observed will be most likely to escape.
Nor does it follow from the evidence adduced that any system of general municipal surveillance merely will suffice. It must be carried into the houses and daily resorts of the people. It rests equally upon the citizen as upon the city, to provide himself with all the means of safety in his power; to be vigilant to foresee and bar the approach of danger in the shape of houshold nuisances and impurities of every kind; to keep himself and his family from unnecessary exposure and excesses, and to govern wisely the walk and conduct of his daily life. While, therefore, we do not agree with some recent writers upon this subject, who boldly attribute the origin of the affection to these insanitary conditions themselves, we cannot resist the conviction that they are more than mere concomitants and accidents of the disease, and we must find in the lesson of the present epidemic the injunction of a stricter regard for the known requirements of hygiene in our habitations and our homes.