1842, appeared in the United States, but at places as remote as
possible from Transatlantic communication and hundreds of miles
distant from one another--_e.g._ in Louisville, Kentucky, in
Rutherford co., Tennessee, and in Montgomery, Alabama. In the
following year it prevailed in Arkansas, Mississippi, and Illinois. In
1848 it occurred again at Montgomery, Ala., and simultaneously, in
Beaver co., Pa.; in 1849 it existed in Massachusetts and in Cayuga
co., N.Y., and in 1850 at New Orleans.
Between 1850 and 1854 epidemic meningitis ceased to be heard of, but
in the spring of the latter year it began to appear in the southern
provinces of Sweden, whence it rapidly spread over the greater part of
the kingdom, reaching an extreme degree of fatality in 1858, and not
finally disappearing until 1861. It is said to have caused more than
four thousand deaths. It was not until the height of the Swedish
epidemic in 1858 that it invaded Norway, where it seems to have been
even more malignant and extensive. Between 1850 and 1860 local
outbreaks of the disease took place in Ireland, and isolated cases
were observed in various parts of England, but in that country it has
never prevailed as a general epidemic. This fact alone is sufficient
to defeat all the attempts that have been made to trace the origin of
the disease to any of the conditions associated with a crowded
population. In Scotland, where such conditions exist in their greatest
intensity and fulness of development, it has never occurred as an
epidemic. During the decade under consideration (in 1856 and 1857)
epidemic meningitis again appeared in the United States, and, as
before, at points very remote from one another. In the former year it
occurred for the first time in North Carolina, and in the latter year
in the central portions of New York and Massachusetts.
Hardly had the disease subsided in the Scandinavian peninsula and in
the United Kingdom when it reappeared in Holland during the winter of
1860-61. In the following year and at the same season it occupied a
large extent of Portuguese territory, including the cities of Oporto
and Lisbon, and now for the first time it spread over Germany.
Beginning slightly during the summer of 1863 in Prussia, it acquired
new vigor during the succeeding winter, and in the two following years
it devastated almost every part of Northern Germany, and in 1864-65
extended throughout Bavaria except in its southern and western
provinces. Strange to relate, the disease appears to have passed
almost wholly by Austria proper, and to have prevailed, although not
extensively nor fatally, in Hungary, and in the latter part of the
decade in Istria, Greece, Turkey, and Asia Minor.
The American counterpart of this epidemic first appeared in Livingston
co., Missouri, in the winter of 1861-62, and during the same season it
invaded Indiana and Kentucky in the West and Connecticut in the East.
From about the same date, and until 1864, it prevailed in Ohio, and
during the last-named year in Illinois. Cases occurred at Newport,
Rhode Island, in 1863, and in Vermont in 1864. In the winter and
spring of the latter year it broke out at Carbondale, Pa., and in a
population of 6000 caused the death of 400, principally among children
and {800} very young persons.[5] In the winters of 1863-64 and of
1864-65 it prevailed in the U.S. army, and in the early part of this
period in the Confederate army which at the time was stationed near
Fredericksburg, Va. In North Carolina also, from 1862 to 1864, the
disease assumed a very malignant type, and affected citizens and
soldiers equally, and the latter in the Union and Confederate armies
alike. During the winter of 1864-65 a limited but very fatal epidemic
of the disease prevailed at Little Rock, Arkansas. About the same time
it existed as an epidemic in Maryland, Alabama, and other Southern
States, and throughout the Civil War affected both whites and negroes,
but showed, as in France, an exceptional gravity among the military.
[Footnote 5: Burr, _Trans. Med. Soc. State of N. York_, 1865, p. 40.]
The first appearance of the disease in Philadelphia took place in
1863, and from that date until the present (1884) it has never failed
to appear among the causes of death in the reports of the Health
Office. A table compiled by Dr. C. F. Clark, and printed in a paper on
the subject by Dr. James C. Wilson,[6] exhibits the difficulties of
obtaining accurate statistics, even from official reports, on this
subject. The medical profession of the city, having had but little
knowledge of the disease either by reading or observation, reported
deaths from it which occurred in their practice under various
denominations. At first it was spotted fever, which continued to be
used by many for a year or two, when it was superseded almost entirely
by cerebro-spinal meningitis. There can be no doubt that both of these
terms were used to designate the same disease, and therefore no error
will be committed in merging the deaths charged to each of them, and
in estimating by their annual totals at least the relative mortality
of the disease in the successive years of the period. But in the
Health Office reports there are at least three other rubrics that
suggest doubt. One is typhus fever, which seems to have presented a
sudden and remarkable increase of mortality during the first years,
and the most fatal, of the existence of cerebro-spinal meningitis. It
should also be observed that typhus fever is applied by many German
physicians in this country, as in their native land, to typhoid fever.
A second is malignant fever, and a third is congestive fever, neither
of which has claimed many victims in the health reports of
Philadelphia except while meningitis was epidemic. It seems probable,
therefore, that nearly all of the deaths charged under these heads
belong to the disease under consideration.
[Footnote 6: _Phila. Med. Times_, xiii. 88.]
_Deaths in Philadelphia from Cerebro-Spinal Meningitis from 1863-82._
| Brought over 1136
1863 49 | 1873 246
1864 384 | 1874 82
1865 192 | 1875 83
1866 92 | 1876 85
1867 109 | 1877 56
1868 55 | 1878 90
1869 37 | 1879 62
1870 36 | 1880 78
1871 49 | 1881 90
1872 133 | 1882 41 to Sept. 23d.
---- ----
1136 Total 2049
If to these deaths are added those charged to malignant fever, 111,
and to {801} congestive fever, 279, we obtain a total of 2439 deaths,
nearly all of which may be set to the account of epidemic meningitis.
It may also be remarked that up to the date at which this computation
was made (May, 1883) hardly a week passed in which the Health Office
did not register several deaths from this cause. Hence it would appear
that the disease continues to linger in this locality longer than has
been reported of any other place from which information has been
obtained.
In the city of New York it appears to have been much more limited both
in extent and duration. The first recorded death from it was in 1861;
in 1866 the deaths were 18; in 1867 the deaths were 32; in 1868 they
were 34; in 1869, 42; in 1870, 32; in 1871, 48. In 1872 the disease
became epidemic, and "from January 6 to May 31, inclusive, 632 cases
were reported to the City Sanitary Inspector, and 469 deaths to the
Bureau of Records of Vital Statistics" (Clymer). After this period the
disease seems to have declined very rapidly, and not to have
reappeared, since no notice is taken of its recurrence by the medical
journals of New York.
It was mentioned above that about 1870 some traces of the disease were
observed in Asia Minor, and in 1872 several cases are said to have
occurred at Jerusalem,[7] but beyond that time and place it does not
appear to have extended as an epidemic. In 1879, Cheevers said: "I am
not aware of the existence of any report of an outbreak of the disease
in India." He refers, however, to several cases occurring in Calcutta
as possibly representing this affection.[8]
[Footnote 7: _Berlin klin. Wochensch._, May, 1872.]
[Footnote 8: _Times and Gazette_, Aug., 1879, p. 121.]
In 1867-68 sporadic cases occurred at Little Rock, Ark., and in the
former year in Madison co., N.Y., thirty-three cases were reported.[9]
In Chicago, between February and April, 1872, Dr. Davis reported forty
cases observed in his own practice in seventy-two days. In the same
year the disease occurred at Elizabethtown, Ky.,[10] and at
Louisville, Ky., in December of the same year. It existed in Michigan
between 1868 and 1874, but only in the latter year epidemically, and
not to a very great extent.
[Footnote 9: _Trans. Med. Soc. State of N.Y._, 1868, p. 251.]
[Footnote 10: _Richmond and Louisville Journ._, Nov., 1872, p. 555.]
Of later occurrences of the disease the following may be mentioned:
Several cases were reported in London in 1867, 1871, 1876, and
1878.[11] In 1870 four cases were observed in Providence, R.I.[12] In
1882 cases were met with in Boston, New York, Philadelphia, Pittsburg,
Western Ohio, Indianapolis, Detroit, Louisville, Memphis, New Orleans,
Richmond, Milwaukee, St. Louis, Salt Lake City, San Francisco, etc.,
but in none of these places did the disease become epidemic.
[Footnote 11: _Times and Gazette_, July, 1867, pp. 58, 59; Nov., 1867,
p. 511; _Guy's Hospital Rep._, 3d Ser., xvii. 440; _St. Bart's
Reports_, xii. 267; _Times and Gaz._, Aug., 1878, p. 167.]
[Footnote 12: _Boston M. and S. Jour._, Oct., 1870, p. 261.]
ETIOLOGY.--Epidemic meningitis has occurred in Europe and America in
every portion of the temperate zone, but its greatest prevalence and
mortality have undoubtedly been in the northern rather than in the
southern portions of that region. One of its most interesting features
consists in its appearing simultaneously at points very remote from
one another and having no connection with each other save through the
atmosphere. Of this statement several illustrations have already been
presented. Another {802} peculiarity of the disease consists in its
occurring with hardly any relation to external natural conditions or
to those of its victims. It affects localities as diverse as possible
in their geological, meteorological, and sanitary states, the rich and
the poor, the old and the young, and both sexes, and (as it is
certainly not in a strict sense contagious) its rise and spread must
necessarily be attributed to some occult cause pervading the
atmosphere.
It is evident that the prevalence of the disease has some relation to
meteorological agencies, for not only is it greater, on the whole, in
_cold_ than in warm climates, but it is also greater in cold than in
warm seasons. Thus, if we examine the epidemics in Europe and America
we shall find that they almost invariably were most severe in the
winter and spring. Yet the rule presents several exceptions on both
continents. In France, out of 216 local epidemics, more than
one-fourth took place during the warm months of the year, and in
Sweden the proportion was about the same. It is evident, therefore,
that cold is not an essential cause of the disease. Among the problems
that remain unsolved in regard to this disease none is more obscure
than the apparent immunity of Russia from its ravages, although the
climate seems adapted to favor it, and the domestic habits of no
people are fitter to intensify it if individual conditions entered
into the etiology of the disease; but, in truth, no such causes are
related to epidemic meningitis. Localities of every sort, high and
low, dry and moist, those saturated with marsh miasmata and those
fanned by pure mountain-breezes, have been alike visited by this
disease. It has passed by large cities reeking with all the
corruptions of a soil saturated with ordure and populations begrimed
with filth, as Vienna, Berlin, Paris, London, and New York, to
devastate clean and salubrious villages and the families of
substantial farmers inhabiting isolated spots.
By far the greatest number of the subjects of epidemic meningitis are
young persons. In Sweden, according to Hirsch, of 1267 fatal cases of
the disease, 889 occurred in persons under fifteen years of age, 328
between sixteen and forty years, and 50 in persons of forty years and
upward. In 1866, in the Kronach district (Germany), of 115 cases, 75
occurred under the seventh year, 22 between the seventh and twelfth
years, and 10 between the thirteenth and twentieth years (Schweitzer).
During 1865 a local outbreak of the disease in Bavaria affected 53
persons, of whom 22 were children under ten years of age, 18 between
ten and twenty years, and 11 between twenty and thirty years. Under
the fifth year few were attacked (Orth). Dr. J. L. Smith[13] found
that, according to the reports of the Board of Health of the city of
New York, out of 975 cases, 771 occurred in persons under fifteen
years of age, the greatest number for any quiquennial period being 336
in children under five years. Of the 469 deaths occurring in this
epidemic, 216 were of children under five years of age, and the next
largest number for an equal period was 99, which represented the
deaths between the ages of five and ten years. Of adults or persons
beyond the age of twenty, the whole number was but 39. The peculiar
liability to the disease of the young recruits in the French army has
already been alluded to. The proportion of male victims to this
affection is rather larger than that of females in the civil
population, but in France especially the excess was greatly on the
side of males, owing to the prevalence of the disease in the army. In
other places, as {803} in Sweden and Germany, the number of deaths
among females equalled, or even exceeded, that of males, and in
Leipsic the garrison remained exempt while the disease prevailed among
the citizens. In 1847 a fatal epidemic of it affected the second
regiment of the Mississippi Rifles, and was entirely confined to that
corps (Love). During the Civil War of the United States the disease
affected particular corps or regiments in the South or in the North,
yet it never became epidemic in the army, even when the disease
prevailed among the adjacent civil population.
[Footnote 13: _Amer. Jour. of Med. Sci._, Oct., 1873, p. 320.]
Various depressing or debilitating causes, such as lowness of spirits,
home-sickness, mental or bodily strain, over-eating, drinking alcohol,
the action of excessive cold or heat, checking perspiration, etc.,
have been enumerated as causes of this disease. It is unnecessary to
dwell upon such gratuitous assumptions. All of these influences are
constant, but epidemic meningitis is the rarest of epidemic diseases,
and the agencies referred to have no further operation than to lessen
the resistance of the body to morbid influences of every description.
If there be one peculiarity about this disease which is more
surprising and inexplicable than another, it is that its peculiar
victims are not the feeble and delicate, but the vigorous and
active--not the old and decaying, but the young and stalwart.
No one of authority has claimed that this disease can be propagated by
_contagion_. All of its early American historians are of the same
opinion upon this question, and nearly all European authorities are in
perfect accord with them. The apparent exceptions to this all but
universal judgment are so insignificant in number and weight as not in
the least to diminish its validity. A case has been published in which
a pregnant woman at full term died of the disease after giving birth
to an apparently healthy child. "Two hours later the infant presented
symptoms of meningitis, followed rapidly by death."[14] Supposing the
concluding statement to be accurate, the case only shows that the
cause of the disease which destroyed the mother's life infected the
system of the child also. If there is one point in the history of the
disease established by the concurring testimony of American and
European writers, it is the extreme rarity of its attacking either the
physicians and nurses in attendance upon patients affected with it, or
those laboring under other diseases and occupying beds adjacent to
persons ill with epidemic meningitis. That, nevertheless, there is a
material morbific principle which inheres in certain localities, so
that those who occupy them successively are liable to suffer from this
disease, and that also this principle may be carried from place to
place so as to render certain houses (barracks) infectious, seems to
be demonstrated by the history of the disease in the French army.
Between 1837 and 1850, when the disease prevailed in various parts of
France, it did so not indiscriminately, but it usually followed the
ordinary routes of communication, and especially the movements of the
military in their transfers from one post to another, and the course
of navigable streams. Strangely, also, it attacked soldiers much
oftener than civilians. The most curious fact of all is one already
referred to--viz. that although the disease prevailed in almost every
part of the provinces, and although then as ever an incessant stream
from them was flowing into the capital, neither its civil nor its
military population was generally affected, nor, {804} indeed, at all
so, until near the close of the period mentioned. Meanwhile, however,
the disease extended to several countries conterminous with France or
in close and frequent intercourse with it--to Italy (1839-45), Algeria
(1839-47), England, Ireland, and Denmark (1845-48). These events seem
to point to a certain transmissibility of the disease until we examine
the negative facts that bear upon the question. They are such as
these: The epidemic did not spread at all from France into two of the
adjacent countries, Belgium and Switzerland, with which the
first-named country maintained an incessant intercourse by travel and
traffic, but, on the other hand, it broke out at an early date within
the period mentioned at places very remote and absolutely independent
of all influence emanating from France or any other European
source--in the south-western portions of the United States. It is by
numerous facts of this description that we are compelled to remove the
disease from the category of endemic and even epidemic diseases, and
relegate it, along with influenza, to that of pandemic affections.
[Footnote 14: _Med. Record_, xxii. 547.]
There seems to be some reason for thinking that the epidemic cause of
this disease may affect the lower animals as well as man. It was
stated by Gallup in 1811 that during the epidemic of meningitis in
Vermont "even the foxes seemed to be affected, so that they were
killed in numbers near the dwellings of the inhabitants;" and of the
epidemic in 1871 in New York, Dr. Smith relates that "it was common
and fatal in the large stables of the city car and stage lines, while
among the people the epidemic did not properly commence until January,
1872." It would be desirable to learn more precisely the characters of
these vulpine and equine epidemics before associating them with the
disease we are studying, the more so that we have been unable to
discover a similar relation between any epizoötic and other epidemics
of meningitis. In this connection may be recalled the statement of Dr.
Law of Dublin, that while he was attending a lady suffering from
cerebro-spinal meningitis "nine rabbits, out of eleven which her son
had, died, all in the same way: their limbs seemed to fail them, they
fell on their side, and then worked in convulsions, and died." On
examination of the bodies of several of them congestion of the vessels
of the base of the brain was found, and also "vascularity of the
membranes of the spinal marrow, indicating inflammation."[15]
[Footnote 15: _Dublin Quarterly Journ._, May, 1866, p. 298.]
TYPES.--No disease presents a greater variety--and, indeed,
dissimilarity--of symptoms than epidemic meningitis. Some of its
epidemics are sthenic and even inflammatory in their type, while
others have the malignant aspect of rapid blood-poisoning. These
contrasts have been exhibited on a large scale, for while upon the
continent of Europe the disease for the most part has presented
sthenic phenomena, it has been more generally asthenic and adynamic in
Ireland. One might be inclined to attribute the latter peculiarity to
the permanent prevalence of typhus fever in the latter country, or
rather to the special causes producing typhus, were it not that in the
United States both types of the disease have been observed at
different times and in different places. Such contrasts of type are,
however, not unusual in other diseases that occur as epidemics,
including not only the eruptive fevers, but inflammations, or
affections involving inflammation, such as pneumonia, dysentery, {805}
diphtheria, etc. Hence it is evident that certain epidemics, and
certain cases in each epidemic, may exhibit on the one hand a
predominance of inflammatory, or on the other of adynamic or ataxic,
symptoms, and each of them in every conceivable degree and
combination. It is this variation of type that has led to such
different conceptions of the nature of epidemic meningitis, many
physicians regarding it as a fever, and many others as an
inflammation, while, as we believe, it is both the one and the other,
and acquires from either element, according to its ascendency, the
typical character of the particular epidemic under observation.
As illustrative of these statements we may mention in this place the
several _forms_ of the disease as they have been seen and interpreted
by different observers. Forget classified them as follows: (_A_)
CEREBRO-SPINAL; 1, _Explosive_ (_foudroyante_); 2,
_Comatose-convulsive_; 3, _Inflammatory_; 4, _Typhoid_; 5,
_Neuralgic_; 6, _Hectic_; 7, _Paralytic_. (_B_) CEREBRAL: 1,
_Cephalalgic_; 2, _Cephalalgic-delirious_; 3, _Delirious_; 4,
_Comatose_. In the first of these divisions three-sevenths belong to
the first and fourth varieties. But "there were slight and severe
cases; violent and hectic forms; cerebral symptoms predominant in some
and spinal in others, etc."
In his excellent paper on the epidemic of 1848 in New Orleans, Ames
arranged his cases in two categories--the _Congestive_ and the
_Inflammatory_, subdividing the former into the _Malignant_ and the
_Mild_. Malignant congestive cases were distinguished by prostration,
coma or delirium, or both; opisthotonos; and a pulse varying extremely
in its degree of frequency. In _mild congestive_ cases a good degree
of strength was preserved; the pulse was below 90; there were marked
pain in the head and tenderness of the spine, but no coma, delirium,
or stiffness of any muscles besides those of the neck. The purely
_inflammatory_ cases were, in general, distinguished by a temperature
of the skin above that of health and a full, firm pulse, but the
_malignant inflammatory_ were marked by the early occurrence of
delirium or coma, great irregularity of pulse, opisthotonos,
convulsive spasm, strabismus, and occasional amaurosis, with vomiting
and a rapid and fatal course; the _grave_, by a slighter development
of the same symptoms, except coma and delirium; and the _mild_, by a
lower grade of febrile excitement, the preservation of a good degree
of strength, a tendency to become chronic, and by the absence of coma,
drowsiness, delirium, and a cold stage.
Wunderlich adopted the simple plan of arranging the cases in three
categories: 1, the _gravest_ and most rapidly fatal cases; 2, the
_less grave_; and 3, the _lightest_. The arrangement of Hirsch had
more significance, as well as a clinical foundation--viz. 1, the
_abortive_; 2, the _explosive_ (_m. siderans_, the same as _m.
foudroyante_ of Tourdes); 3, the _intermittent_; 4, the _typhoid_.
Dr. Bedford Brown,[16] who observed the epidemics in North Carolina
from 1862 to 1864, arranged the cases under the following heads: 1,
the _inflammatory_ form, in which the fever is high, the pain very
acute, and the delirium furious, but which is exceedingly rare; 2, the
_neuralgic_ form, which is stated to be the most frequent and
protracted, with moderate fever and a pulse but slightly accelerated,
and giving a favorable prognosis; 3, the _ataxic_ form, in which great
nervous depression is {806} associated with a low and busy delirium,
and the temperature "is generally much reduced below the natural
standard.... This is always a dangerous form;" 4, the _paralytic_
form, in which stupor and insensibility are early and prominent
features, with a very slow and feeble pulse, blanched skin, and death
by syncope.