Volume 1 — GENERAL DISEASES. (continued 20)

LEPROSY.

BY JAMES C. WHITE, M.D.

DEFINITION.—Leprosy is a constitutional disease of chronic course and fatal termination, characterized by peculiar changes in the tissues of skin, mucous membrane, nerves, and most organs of the body.

SYNONYMS.—Elephantiasis of Greek writers; Lepra of Arabian authors; Anssatz (Germany); Spedalskhed (Norway). The local names in use among the numerous races in which it prevails are too numerous to be given here.

HISTORY.—Although great confusion has existed among the most ancient as well as later medical writers with regard to the definition of this disease, it having been confounded with several other affections (elephantiasis arabum, syphilis, psoriasis, morphoea, etc.), leprosy has prevailed in certain parts of the world from the time of the earliest records. The biblical accounts show that it existed among the Jews in Egypt, although it was not accurately distinguished from other diseases resembling it in some respects. It was recognized in Greece before the Christian era, and in the early centuries after Christ it had extended widely over Europe. In the seventh and eighth centuries special leper-houses were founded in Italy, France, and Germany. The disease reached its height in Europe in the twelfth and thirteenth centuries, when 19,000 lazarettos are said to have been in existence. Its spread was greatly increased by the constant intercourse kept up between Europe and the East during the Crusades. In the fifteenth century it began to diminish, and in the course of the seventeenth it had almost wholly disappeared from the most civilized states. It has lingered, however, in other parts, and exists to-day in France and Spain and Portugal, in Norway and Sweden, and in Italy, Greece, and Southern Russia. As in ancient times, it is widely spread along the coasts of Africa and prevails largely throughout Asia. It is found in many of the islands of the Indian and Pacific Oceans, in Japan, New Zealand, Madeira, the West Indies, extensively in some of the states of Central and South America and Mexico and the Hawaiian Islands.

It may be interesting to trace its history in the United States and adjacent districts more minutely. It is not known just when leprosy was introduced into North America. According to the Louisiana historian, Gayarré, the Spaniards established leper hospitals in several of their colonies on the Gulf of Mexico during the last century. One existed in New Orleans as late as 1785. In 1776 the disease was reported as existing among the blacks in Florida. It seems to have died out, and with it all remembrance of its former existence amongst us, until within the last few years, when its occurrence in the Southern States has again attracted attention. In Louisiana the first case was discovered in 1866 in an old woman whose father came from the south of France; she died in 1870. In 1871 it appeared in one of her sons, in 1872 in two others, and in 1876 in a nephew. A sixth case developed in a young woman who was in constant attendance upon the first case. In addition to this group, other cases have been observed in several parishes, amounting to twenty-one in all, as collected by Salomon of New Orleans in 1878.¹ Two other cases, brother and sister, in Louisiana are known to the writer, one of whom has recently died under his care. In South Carolina the disease is reported by J. F. M. Geddings² to have been observed in sixteen cases since the year 1846; four were Jews, four negroes, and eight whites. In none was any hereditary taint to be traced. No new cases have developed since that report.³

¹ New Orleans Med. and Surg. Journal, March, 1878.

² Trans. Intern. Med. Congress, Philadelphia, 1876.

³ See article on "Contagiousness of Leprosy" by writer, in Amer. Journ. of Med. Sciences, Oct., 1882.

In Minnesota and other North-western States leprosy has been known to exist for a considerable time among the Norwegian immigrants who have settled in them in large numbers. Holmboe in 1863 and Prof. Boeck later made visits to these colonies while in this country, and published reports concerning them after their return.⁴ The latter found eighteen cases among his countrymen, most of which were leprous before emigration; in others the disease developed after arrival in America. It had not manifested itself in any person born in this country. The character and progress of the affection seem to have been little influenced by residence here. Since these observations other cases have been collected by the committee on statistics of the American Dermatological Association,⁵ showing the continuance of the disease in these States. In 1879 there were fifteen cases in Minnesota. Its spread in this portion of our country is slow.

⁴ British and For. Med.-Chir. Review, Jan., 1870, and Nord. Medic. Ark., Bd. iii.

⁵ See Transactions.

Since 1871, 52 cases of the disease have been inmates of the hospital for lepers in San Francisco, California. Of these, all, with one exception, were Chinese, and forty-five of them had been sent back to China. It is presumed to have shown itself after arrival in this country, as "unproductive labor would not be imported by the Six Companies."⁶ No case of the disease known to have been acquired in this country has yet been reported upon the Pacific Coast. One case has developed in San Francisco after residence in the Hawaiian Islands.

⁶ Trans. Am. Derm. Assoc., 1881.

In Oregon, too, the disease has appeared among the Chinese immigrants, steps having been recently taken to re-ship five lepers from the poor-farm at Portland to China.

Since 1815, possibly earlier, leprosy has prevailed among the poor French settlements along the Miramichi River, near the Bay of Chaleurs, New Brunswick. It was first noticed in a woman whose mother came from Normandy, and has continued mainly in her descendants since. No measures were taken to control the disease until 1844, when a hospital was erected on Sheldrake Island. In 1849 the present lazaretto at Tracadie was established. During the first five years (1844-49) there were admitted 32 patients; from 1849 to 1863, 67 additional patients were received; and from the latter date to 1879, 30 more, making a total number of 129 up to the last report. The greatest number present at any one time was 37. In 1878 there were 16 patients in the lazaretto—6 men and 10 women. The total number of deaths in the hospital has been, up to 1878, 123. A. C. Smith, who resides near Tracadie, states that at the latter date but three cases were known to exist outside the lazaretto. Residence is not compulsory, and no sufficient measures are taken to remove patients from their homes before they may have inoculated other members of the family. The disease is more restricted in locality than formerly.

Within the last two years two or three small groups of the disease have been discovered in the island of Cape Breton, which are described in the Canadian Journal of Med. Science, Sept., 1881.

These are all the places north of Mexico where the disease exists in an endemic form. A considerable number of cases have been reported within the past few years from other parts of the United States, where it has manifested itself in persons who have formerly resided in leprous countries or in those who have wandered from the above infected districts. A very few instances have been recorded in which it has appeared in those who have never visited any infected locality or have been in apparent contact with lepers. Such cases, if authentic, establish the possibility of a sporadic origin of the affection. The fact of so many foci already established, and the penetration of a race so prone to the disease as the Chinese into all parts of the country, give the study of leprosy in America a special importance.

ETIOLOGY.—The study of the etiology of leprosy is intimately connected with that of its history and geographical distribution. From the earliest times it was regarded in all parts of the world as a contagious affection, and efforts were made by the sternest laws of Church and State to control its spread by segregation, by interdiction of marriage, etc. No disease has ever been regarded with an equal degree of abhorrence by mankind; none has received greater attention from physicians of every age. Within the present century it has come to be regarded, almost without exception, by the profession as non-contagious. Peculiarities of climate, soil, and modes of life have been looked upon as predisposing, exciting, or even essential influences in its causation; but the widespread distribution of the disease, with the consequent diversity of diet and customs of living, its prevalence upon the coast and in interior regions, in high altitudes as well as at the sea-level, in Iceland as in the tropics, show that these conditions, however they may affect the course of the affection, have no direct relation to its causation. The theory of heredity, as the most plausible explanation, has received its strongest support in the investigations of Boeck and Danielssen in Norway, where the disease can be traced for several generations in families. The same conclusions readily present themselves where the disease is studied in restricted localities, as in Louisiana and New Brunswick at the present time, where, as we have seen, it manifests itself closely in families in different generations. But this is a narrow point of view from which to study the etiology of leprosy. It often fails to manifest itself in the descendants of lepers in such communities, and affects persons in whose families it has never previously existed. Moreover, in countries where it does not prevail it not infrequently attacks individuals who have at some time visited regions where it was endemic, and in the latter places may develop in immigrants from parts of the world where it has never existed.

The same class of facts which seem to demonstrate its hereditary nature may be used in support of its infectious character. The proper field for observation in this regard would be a virgin region where its natural course could be studied independently of theories. Fortunately for science, such an opportunity is afforded in the history of the disease in the Hawaiian Islands. The exact date and mode of its introduction there are not definitely known. The islands have for years been the resort of the whaling-fleets manned by sailors coming from leprous regions. The natives also shipped as sailors, and after visiting such ports returned home. The absence of any restraint in the intercourse of crews and native women is well known. Isolated cases may have occurred as far back as 1830, but the disease made slow headway until about 1860, when it increased so rapidly that the government took stringent measures to control it, all cases discovered being sent to the leper segregation upon an island from which there is no escape. Since 1866, 2000 cases have been received there, and at last report the asylum contained 750 inmates. This by no means represents the extent of its prevalence in the islands, however. As the native population by recent census was only 44,000, it will be seen that the proportion affected is very large. This unwonted rapidity of spread cannot be accounted for on the ground of heredity. Transference from individual to individual by inoculation seems to be the only possible explanation, and all resident physicians believe that the disease is contagious in this sense. It affects almost exclusively those of native descent, and their habits of life are such as would greatly facilitate its wide dissemination in this way—viz. their great licentiousness and absence of all fear of the disease, which affords no bar to ordinary association or cohabitation; the crowding of large families in small huts and sharing the same mats and blankets; the eating of poi with the fingers from the same dish; passing a common drinking-vessel or pipe from mouth to mouth, etc.⁷ Promiscuous and compulsory vaccination with impure virus, too, has been generally practised during recent epidemics of small-pox. It is evident that abundant opportunity has in many ways been presented for the inoculation of pus or blood into the circulation from infected to healthy persons. Where immunity from contraction has followed marriage with a leper, it may be assumed that the conditions of an abraded surface and the contact with pus or blood have not been fulfilled. The wide spread of syphilis among the natives, and a consequent cachexia, have no doubt contributed to these conditions and established a national lack of resistance to the ravages of the disease. Nor can we overlook the proclivity of all endemic diseases to extraordinary manifestations of virulence in insular nations not previously protected by gradual inoculation. Many reliable cases are cited by resident physicians where the evidence of direct communication of the disease seems to be reliable. Facts of the same nature may be collected in the study of the history of the disease in New Brunswick and in Louisiana, where, as above stated, much better fields for investigating this question exist than in the Old-World regions where the affection has been rife for centuries.

⁷ Dr. G. W. Woods, U.S.N., in Hygienic and Med. Reports of Navy Department, vol. iv., 1879.

If we admit the fact of transference by inoculation in a single instance, there is no reason why we should not regard this as the principal if not the only means of extension of the disease, whether we accept or not the theory of its parasitic nature. It is not inconsistent with our knowledge of its laws and history to believe that leprosy is an affection communicated with difficulty, and after a prolonged period of incubation, from one person to another by contact with certain products of the diseased tissue; that it has in past and present time in this way spread from nation to nation; and that its progress as an endemic affection has been checked only by laws based upon this theory. All the negative facts so frequently urged against this doctrine of contagion apply as strongly to that of heredity, and may be interpreted in support of the former. The latest investigations into its pathology afford tangible evidence in its favor. It may at least be claimed that the question of contagion through inoculation must be reopened.⁸

⁸ See article on the question of contagion in leprosy in the American Journal of Med. Sciences, Oct., 1882, by the writer.

Leprosy affects both sexes in about equal degree, and may first show itself in early childhood. It is apt to produce sterility, so that marriages between lepers are rarely fruitful. This result seems to limit the extension of the disease under the law of heredity if we admit its action. There can be no doubt that cohabitation may take place for years without communication of the disease where one party alone is leprous; and such immunity may be explained by the failure of favorable conditions for sexual inoculation, just as in syphilis. The disease would naturally be most dangerous in its ulcerative tubercular form.

SYMPTOMATOLOGY.—There are two well-marked forms of leprosy—viz. the tubercular and the anæsthetic—which are characterized by certain easily recognized external manifestations, and which are accompanied by symptoms indicative of disturbances of the general economy as well as of special organs. These forms are not always sharply defined, and often occur simultaneously or in succession in individual cases. Both are generally preceded by premonitory symptoms, consisting of unaccountable languor of mind and body, tingling sensations in the skin, rise of temperature in the evening, and various disturbances of digestion, or by the occasional outbreak of single or several blebs. This prodromal stage affords no indication of the type of disease to follow, and may last for days, months, or even years, with greater or less intervals and intensity.

TUBERCULAR LEPROSY.—This form may declare itself at once by the characteristic tubercles, but frequently an earlier manifestation is the appearance of macules or dull red spots, varying in size from a pea to two or three inches in diameter. They have an indistinct margin, a glazed and smooth surface, and become paler on pressure. The patches, although not at all or but slightly elevated above the general surface, are firmer, and penetrate more or less deeply into the cutaneous tissues. They may increase in size peripherally and undergo involution in the older central portions simultaneously. During the latter process the color changes from a more or less dull red to a brown, yellow, or grayish tint, and finally may become quite white. The spots also become thinner or even slightly depressed. Their seat is principally the trunk, but also the limbs, and less frequently the face. This condition of the skin may precede any other changes in its tissues for months or years, the patches appearing and disappearing or remaining as permanent stains. At last well-defined tubercular elevations show themselves, varying in size from a small shot to a filbert, flattened or semi-globular in form, generally smooth and firm to the touch, and of a dull red or brown color. They occur upon any part of the surface, but are especially abundant upon the face, where they may cause great deformity of the features. The forehead and eyebrows may become very greatly thickened by general infiltration, or thrown out into very prominent folds and protuberances by the massing of individual tubercles. The lips thicken, the nose broadens, and the ears stand out conspicuously with their increased bulk. All these changes in form, with the great darkening in tint which is often present, give at times a most repulsive expression to the face. The tubercles are sometimes to be felt imbedded in the skin, or considerable areas are found to be uniformly thickened and scarcely at all prominent. All forms are capable of involution after an existence of months, and may leave dark-colored atrophic patches to mark their seat. They are rarely painful, and occasionally slightly sensitive. They may be transformed into ulcers, especially upon prominent positions, as the knuckles, elbows, knees, as the result of pressure or injury, which are extremely indolent, although shallow, and may heal and break down repeatedly. Occasionally they give rise to serious complications—inflammation of the lymph-vessels, suppuration of the joints with loss of the attendant members, as the fingers and toes. Tubercles appear also upon the mucous membrane of the nasal cavities, the mouth, and larynx, often in great abundance, causing a very characteristic hoarseness or loss of voice. With these changes in the cutaneous tissues, which may be accompanied in their periods of greatest activity by febrile disturbances, there are developed after months or years, with gradual failure of strength, manifestations of changes in the internal organs, the lungs, intestines, and brain, which may prove fatal at any time, or the patient may die of slowly progressive marasmus. The course of the tubercular form is on the average between eight and ten years. At any period there may supervene manifestations of the anæsthetic type, which makes the so-called mixed variety, in which either form may predominate.

ANÆSTHETIC LEPROSY.—This variety is characterized by the loss of sensation in the skin over areas of varying extent, which occupy no definite positions in relation to nerve-distribution. The anæsthetic patches may appear upon the seat of old maculæ or former tubercles or of a preceding bullous efflorescence, or upon parts not previously affected in any way. They may follow a reddened and hyperæsthetic condition of the cutaneous tissues, or they may be surrounded by a serpiginous border of this character. The degree of anæsthesia in the affected parts is sometimes so complete that the skin and underlying tissues may be deeply pricked or cut or burned without the patient being aware of the injury. Such patches may possibly regain their sensibility. Their surface appears in later stages dry, wrinkled, shrunken, and of a brownish color, and atrophy, not only of the skin but of the muscles, is gradually developed, in consequence of which the expression of the face undergoes a marked change. The eyelids and lips droop, the hair falls, the hands contract, and the joints of the fingers and toes are laid bare, so that the phalanges, or even the whole hands and feet, drop off. Ulceration or gangrene of the parts may develop, and whole extremities may shrivel up. With these manifestations of local derangements of nerve-action the functions of the brain fail, the patient becoming stupid and incapable of action or motion, the temperature and pulse are lowered, and death comes slowly by marasmus or the most various complications—tetanus, disease of the lungs, pyæmia, etc. The average duration of this form is from eighteen to twenty years.

PATHOLOGICAL ANATOMY.—The structural changes which take place in the tissues of parts which are the seat of the appearances above described have received the special study of many excellent observers⁹ in recent times, and are now well understood. A section through the thickened skin or a tubercle shows the corium and underlying connective tissue infiltrated with round cells, as in lupus and syphilis; in other words, converted into "granulation tissue." This change first takes place along the course of the cutaneous vessels and glands, penetrating more deeply and forming a firmer cell new-growth in proportion to duration, the cells being enclosed in a coarse meshwork of fibrous tissue, and encroaching upon the various structures of the skin, so as to produce atrophy and finally destruction of all its characteristic tissues. This cell-infiltration may of itself undergo later changes, as fatty degeneration and softening (ulceration). The lymph-glands and corpuscles assume a special fatty metamorphosis. An examination of the tubercles upon the mucous membrane reveals the same small-celled new-growth. In the nerve-tissues also marked structural changes are found, both in the central and peripheral systems, in the anæsthetic form of the disease. In many cases the posterior segments of the gray cornua and the fibres of the commissure, as well as the nerves of the extremities, have been found altered by inflammation, which will account for the disordered sensibility and the subsequent disturbances of nutrition, muscular atrophy, etc. The nerve-trunks are often to be felt beneath the skin, thickened and sensitive on pressure. The chronic cell-infiltration affects the fibrous structure of the outer sheath, the neurilemma, and the septa between the nerve-bundles, producing fatty metamorphosis and atrophy of the nerve-bundles. Similar cell-infiltrations are found also in the connective tissue of all the internal organs of the body, which lead to destructive processes in their respective structures.

⁹ Boeck and Danielssen, Traité de la Spedalskhed, Paris, 1848; Virchow, Die Krankhaften Geschwülste; Kaposi in Hebra's Lehrbuch der Hautkrankheiten; Monasterski, Vierteljahressch. für Derm. u. Syph., 1879, p. 203; Hansen, Virchow's Archiv, Band 79, 1880; Neisser, Virchow's Archiv, Band 84, 1881; Cornil et Souchard, Annales de Derm. et de Syph., 1881, No. 4.

Within the last two years repeated observations have been made which confirm the statement published by Hansen in 1873, that a peculiar bacterium occurs in leprous tissues, which, it is claimed, establishes the parasitic nature of the affection. These examinations have been carried on with leprous material derived from many parts of the world, and the results have been uniform. Within the round cells which characterize the cutaneous neoplasms, both in the distinct tubercles and the diffused infiltrations, small agglomerations of minute rod- or staff-like bodies (bacilli) are found, arranged in parallel rows or placed end to end. Their length is one-half or three-fourths the diameter of a red blood-globule, and their breadth is one-fourth their length. With them minute granular particles are seen in the cells. They occur in greatest numbers in the cells of the upper layers of the true skin, which are considerably swollen by their presence. They never penetrate the epithelial layer, nor are they found in epithelial cells in any position. When the protoplasm of the cell is interfered with by the later tissue-changes of the disease, the bacillus perishes. They are found not only in the leprous cells, but also in those of the connective tissue running between the agglomerated masses of the former. Between the leprous cells and the filaments of connective tissue but few free bacilli are seen. The neoplasms of the mucous membrane and of many organs of the body have been found to contain them also. In the blood they have been detected by some observers. Their presence in the nerve-tissues is of importance as throwing light upon the question of the specific or inflammatory nature of the morbid processes above described as affecting them. If we regard the bacteria as pathognomonic of leprous tissue-changes, their occurrence, recognized in the cells penetrating between the fibres of the peripheral nerves, would seem to make all primary structural changes identical, and the anæsthetic as much as the tubercular form the direct result of their presence. Neisser draws the following conclusions from his investigations: "Leprosy is a real bacterial disease, caused by a special kind of bacterium. The bacilli appear in the tissues as such, or more probably as spores, and remain for a longer or shorter time in a state of incubation, according to circumstances, in dépôts, perhaps in the lymph-glands. This period, much longer than in other infective diseases, is in proportion to the physiological resistance of the human organism compared with the feeble developing power of the bacilli. It, as well as the course of the disease, is more rapid in tropical countries than in Europe. From these dépôts the disease extends throughout the body in those portions of the skin most exposed, the face, hands, elbows, knees, and into the peripheral nerves. The other organs are less freely invaded. The bacilli excite inflammation, and by a specific action transform the migrating cell into the leprous cell. Leprosy is probably an infectious disease, and its specific products are contagious—viz. the leprous cells of the tubercles, the tissue-fluids, and the pus containing bacilli or viable spores. On the other hand, the pus may not always be infectious, as the fluid contained in the bullæ is not."

It must be said that the bacterial nature of leprosy, if established in accordance with the above observations, furnishes a satisfactory basis of explanation of all facts, historical, clinical, and pathological, which have so long been awaiting solution. The inability of the parasite to penetrate the epithelial layer of the skin and mucous membrane explains why contagion is so difficult, and why the ulcerative tubercular form would be more favorable to such transference than the anæsthetic variety.

DIAGNOSIS.—Leprosy in some of its early appearances may be readily confounded with vitiligo, morphoea, pemphigus, lupus, and syphilis. In some cases its prodromal manifestations cannot be positively diagnosticated until other symptoms have developed, which by concurrence establish their true significance. Such are the pemphigus-like bullæ, the pigment-changes, and the smaller tubercular efflorescences. In regions where the disease occurs only by importation, and in the so-called sporadic cases, it is not at all strange that it should fail of recognition, even in well-advanced forms, unless the observer is acquainted with its whole symptomatology. On the other hand, there is no disease which presents more strikingly characteristic features in its advanced stages.

PROGNOSIS.—Leprosy is almost uniformly a fatal affection, and its course toward this termination varies but slightly under the most diverse conditions of life. Its development and progress are naturally more rapid under circumstances of least individual resistance, where food is poor and scanty, where extremes of climate are most felt, where the constitution of the individual or nation is debilitated by previous disease, as that of the Hawaiians by syphilis, or where no proper professional care is employed. It has been believed that a change of residence from infected to non-leprous regions would retard its advance or avert its appearance in those supposed to be hereditarily disposed; but the former effect follows probably only so far as the general condition of the patient is affected by the change, as in other constitutional disorders, and the latter is necessarily a matter wholly of conjecture. No case of leprosy in the Norwegian colony in our North-western States has ceased to progress after arrival toward its fatal ending, even if this has been somewhat delayed in individual cases under more generous ways of living. If it could be known that a child born in Norway had escaped leprosy by removal to America, we should not, if we accept the bacterial origin of the disease, consider that climate or other mysterious influences had overcome its inherited tendencies, but that it had been taken away from the chance of direct inoculation. It is stated that very rarely cases cease to progress beyond certain stages even in countries where the disease is endemic. The course, as has been stated, varies according to the clinical form, the duration of the tubercular variety being on an average but one-half that of the purely anæsthetic type. Leprosy may be called the slow disease, its period of incubation, so far as this can be determined, extending from one to several years, its prodromal stage lasting often several more years, and its well-developed forms requiring at times more than twenty years to destroy the patient. Cases sometimes prove fatal, however, in a single year.

TREATMENT.—In a disease which affects so many of the races and such great numbers of mankind, which has been for centuries the object of special attention on the part of physicians, and of late years of government commissions and of eminent pathologists, it is evident that every remedy which the materia medica includes, as well as those of merely popular reputation in the widely-diverse geographical regions in which it prevails, must have been employed in its treatment. None of them exert any specific action upon it; it remains incurable. Every year some new article is employed with the usual claims of success which accompany the introduction of new remedies, but they merely swell the long list of failures in the therapeutics of the affection. Still, leprosy is influenced somewhat by medical care; life may be prolonged and made more comfortable. To this end we may employ remedies which are capable of improving and maintaining the constitutional powers of resistance to the disease, such as are found of service in other chronic wasting affections. The patient is to be put in as healthy ways of living as possible, removed from debilitating localities, and given generous diet and tonics, as iron and quinia. Several new drugs which seem to stimulate the nutrition and produce temporary improvement in the local and general symptoms have lately been widely employed, as Gurjun balsam and chaulmoogra oil, but they have wrought no cure. Digestion is to be aided, diarrhoea to be checked, and disturbances of respiration to be alleviated. Local treatment is also of service. The tubercles may sometimes be made to disappear—partly, at least—by stimulating applications, and ulcers made to heal by cauterization and other well-known methods of dressing. These ulcers and their secretions should be regarded as possible sources of infection by attendants and members of the patient's household. For the anæsthetic alterations in the tissues but little can be done locally. If the bacterial origin and causation of the disease be eventually established, its future extinction must be based upon studies directed to the nature and mode of protection against this organism. Collectively, the disease should be treated by every nation by thorough segregation, and importation should be prevented by the most rigid quarantine laws.

EPIDEMIC CEREBRO-SPINAL MENINGITIS.

BY ALFRED STILLÉ, M.D., LL.D.

DEFINITION.—A febrile, and often malignant, but non-contagious disease of unknown origin; usually occurring as a local epidemic; confined hitherto to the North American and European continents, and to the vicinity of the latter; characterized by its rapid and irregular course, and usually by a tetanic rigidity or retraction of the neck, a tendency to disorganization of the blood, and the formation of inflammatory exudates beneath the membranes of the brain and spinal cord.

SYNONYMS.—Spotted fever; petechial fever; malignant purpuric fever; malignant purpura; pestilential purpura; black death; typhus petechialis; typhus syncopalis; febris nigra; febbre soporoso-convulsivo; tifo apoplettico tetanico; fièvre cérébro-spinale; typhus cérébro-spinale; phrenitis typhodes; epidemic meningitis; epidemic cerebro-spinal meningitis; malignant meningitis; typhoid meningitis; méningite cérébro-spinale épidémique; méningite cérébro-rachidienne; Genickkrampf; Genickstarre.

The names which have been given to this disease convey more or less distinctly one or the other of two ideas: 1st, that the disease is essentially a blood-disorder; and 2d, that it is an inflammation of the cerebro-spinal meninges. Under the first head belong the following names: Malignant purpuric fever; malignant purpura; pestilential purpura; petechial fever; spotted fever; febris nigra; black death, etc. Under the second head belong epidemic cerebro-spinal meningitis; epidemic meningitis; malignant meningitis; typhoid meningitis, etc. As partaking of the qualities of both categories may be cited the names cerebro-spinal fever and fever with cerebro-spinal meningitis. In regard to all those of the first class it is sufficient to repeat the criticism made by the early American writers who described this disease after having largely studied it. One only of them need be cited, because he expresses the opinion of all. Miner, writing in 1822, said: "It is quite unfortunate that a single symptom (petechiæ), and one, too, that is wanting in a great majority of cases, should have been seized upon to give it the odious and deceptive name of spotted fever, as that name has been applied by European writers to a very different kind of fever." Among the names given to the disease, cerebro-spinal fever is perhaps the least suitable and the least in harmony with the principles of scientific nomenclature. It is one of those terms which may be pardoned when used by the laity, but which educated physicians ought not tolerate. Parallel examples may be found in such compounds as brain-fever, lung-fever, gastric-fever, and, most unfortunate of all, enteric fever. The first three of these are inflammations, pure and simple, of the brain, lung, and stomach; and, after their example, cerebro-spinal meningitis would be, what it is not, merely an inflammation of the membranes of the brain and spinal marrow. The name of the remaining disease has only to be turned into English and called intestinal fever to demonstrate its defects. It is evident that other diseases—and dysentery in particular—are equally entitled to be called enteric fever. Moreover, there are cases of enteric fever in which death takes place so early that the intestinal lesion is undeveloped, and the fatal issue must be attributed to the fever-poison in the blood or else to the changes it has wrought in that fluid. Analogous illustrations abound in the history of the eruptive fevers. The disease we are studying presents another affection in which the septic element sometimes so far overrides the inflammatory as to destroy life before the latter has developed characteristic tissue-changes. There may be no valid objection against classing it among the fevers, but there can be no excuse for denominating it cerebro-spinal fever. The very reasons that militate against its being regarded as a meningitis forbid its being considered as a meningeal fever. But if it is a meningitis, inchoate or complete, then the prefix epidemic denotes its constitutional nature and its probable blood origin, and a term is employed which is descriptive and accurate, and not misleading. Moreover, the term epidemic indicates, or at least implies, the characteristic type of the disease, which is asthenic and sometimes more or less typhoidal, just as other inflammatory diseases become so in their epidemic form—e.g. pneumonia, bronchitis (influenza), dysentery, etc.

There ought to be no doubt whether epidemic meningitis should be classed with general diseases or with inflammations. It is excluded from the latter class by the total absence of any tangible external cause from its causation, as well as by its frequent fatal termination before the characteristic signs of inflammation have had time to form, or because the peculiar type of the disease prevents their development. It belongs to the former class because it is epidemic in the largest sense, its outbreaks occurring simultaneously in remote parts of the earth and independently of all cognizable celestial or terrestrial influences. In this as in other elements of its pathology the disease stands absolutely alone. While the acute affections of the pulmonary and digestive organs, which were just now alluded to, affect large districts, and even sweep over a whole continent, epidemic meningitis breaks out in limited localities, and may for years prevail in a populous city within a hundred miles of another still more populous which during that time may altogether escape its ravages. Of this curious fact the cities of Philadelphia and New York present a striking illustration. Since, then, we are ignorant of the circumstances under which the disease arises, and since, as will more distinctly appear later on, its several forms really include quite various morbid conditions, we are compelled to consider it as occupying a peculiar and exceptional nosological position.

HISTORY.—Previous to the present century the existence of this disease can hardly be demonstrated. And yet Dr. B. W. Richardson believed that some faint traces of it could be discovered, as in the following statement:¹ "The great plague which visited Constantinople in 543, and which Procopius and Enagrius described, the plague of hallucination, drowsiness, slumbering, distraction, and ardent fever, with eruption on the skin of black pimples the size of a lentil,—this plague, which usually killed in five days, and left many who recovered with withered limbs, wasted tongues, stammering speech or such utterance of sound that their words could not be distinguished,—this plague, which had passed into mythical learning under the name of cerebro-spinal meningitis, has also in our time reappeared." The concluding statement in regard to the name of the plague is quite erroneous, and there is nothing in the description which distinctively applies to the disease we are examining. On the other hand, we know that Procopius wrote a history of the Oriental plague, which invaded Europe for the first time at the very date above given. It had as a distinctive symptom the well-known inguinal bubo, and there is no mention whatever, in the descriptions of it that have survived, of the tetanoid symptoms belonging to epidemic meningitis. In 1802 an epidemic occurred at Roetlingen in Franconia which had a certain resemblance to the subject of this article, for it was characterized by lacerating pains in the back of the neck. According to Hecker, this was the sweating sickness which had ravaged various parts of Europe during the Middle Ages, and of which limited outbreaks still recur. In 1880 such a one took place at l'Ile d'Oléron in France, and many of the patients were affected with tonic or clonic spasms, both general and local, but not, apparently, opisthotonic.²

¹ Diseases of Modern Life, p. 16.

² Pineau, Archives gén. de méd., tom. i., 1882, pp. 25, 169.

If epidemic meningitis occurred before the nineteenth century, it must have been confounded with other affections, but when we consider its characteristic symptoms such an error seems improbable. The comparatively rare resort at that time to post-mortem examinations, particularly of the cranial and spinal cavities, may in part account for such a confusion of ideas; and even when dissections were made, the skill to interpret the discovered lesions was possessed by few. It has been thought that in the latter part of the last century some cases of this disease were seen and described, although their nosological value was unrecognized. Thus, Stoll³ speaks of a young soldier who was seized with a pain in the back of the head and neck, and who was affected with opisthotonos before he died. On examination pus was found between the arachnoid and the pia mater. The first clear and unquestionable description of epidemic meningitis was published in 1805, first by Vieusseux and directly afterward by Mathey.⁴ The disease appeared at Geneva in the spring of the year, in a family composed of a woman and three children, of whom two of the latter died within twenty-four hours. A fortnight later four children in a neighboring family died of it after fourteen or fifteen hours' illness, and a young man in an adjoining house, being attacked, died the same night, with his whole body of a violet color. The disease ceased during the spring, after having destroyed thirty-three lives. Its distinctive features were an abrupt attack during the night, bilious vomiting, excruciating headache, rigidity of the spine, difficult deglutition, convulsions, nocturnal paroxysms, petechiæ, and death in from twelve hours to five days. Vieusseux calls it "a malignant non-contagious fever," and Mathey gives as the lesions revealed by dissection a gelatinous exudation covering the convex surface of the brain, and a yellow puriform matter upon its posterior aspect, upon the optic commissure, the inferior surface of the cerebellum, and the medulla oblongata.

³ Quoted by Boudin, Hist. du typhus cérébro-spinal, p. 5.

⁴ Journ. de Méd., Chirurg. et Pharm., etc., an. xiv., tom. xi, pp. 163, 243.

After its first appearance at Geneva the disease does not seem to have extended in any direction from that place as a centre, but we next hear of it at two points remote from it and from one another—Germany and the United States. From the former it extended to the conterminous countries, Bavaria, Holland, and the east of France, where, however, it prevailed neither extensively nor fatally, and soon died out; while in America it first appeared at Medfield, Mass., in 1806. The European epidemic was faintly felt in England the following year, and between that time and 1816 it prevailed at several places in the east of France, and slightly at Paris, while during the corresponding period it had extended through New England into Canada, New York, Pennsylvania, and several Western and South-western States. It is a noteworthy fact that on both sides of the Atlantic it ceased in the same year (1816). During the six following years we can discover no trace of its existence, but in 1822-23 it reappeared at Vesoul in France, and at Middletown, Connecticut, and does not seem to have extended beyond those places. Again, after an interval of five years, in 1828 it was heard of in Trumbull co., Ohio, two years later at Sunderland in England, and three years afterward (in 1833) at Naples.

After four years of quiescence the disease entered upon a wider and more destructive career than ever before, which was almost uninterrupted from 1837 to 1850. During the first two years of its recurrence in Europe it was confined almost wholly to France. It began in the southern departments, with Bayonne as a centre, and extended gradually westward and northward, in some places attacking only military garrisons and in others only civilians. Elsewhere the predilection was reversed, or, again, civilians and soldiers were equally affected. As Boudin has pointed out, "it located itself in certain districts; in garrison-towns it seemed to affect certain barracks only, and in them only certain rooms. In one place it broke out in a prison and spared the soldiers; in another its victims were among the soldiers and the citizens, while the prisoners were untouched." Thus the disease spread over the whole of France, and was more fatal almost everywhere else than in Paris itself. Almost at the gates of the capital, at Versailles, and among the garrison, it was very destructive in 1839, causing a mortality among those attacked of from 50 to 75 per cent. About the same time it occasioned a great mortality at other military posts, especially at Rochefort and Metz, and in 1840-41 at Strasbourg. In 1843 the disease had almost ceased to prevail in France, but in 1846 it reappeared at Lyons, and in the following years, and until 1849, affected the garrisons of Orléans, Cambrai, Saint-Étienne, Metz again, Lunéville, Dijon, Bourges, and Toulon. In some of these places the military experienced five, and even seven, successive epidemics. Meanwhile, the disease spread to Algeria (1839-47), and to Italy in the former year—not, however, on the confines of France, but at Naples and in the Romagna, whence it extended to Sicily and Gibraltar, and did not cease there until 1845. In 1839 it first showed itself in Denmark, and remained for about three years, while in 1846 it "appeared in the majority of the workhouses of Ireland," and in the spring of the same year it occurred in England, at Liverpool and Rochester.

While the disease was thus spreading throughout Europe, it again, in 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 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.

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.

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 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

⁷ Berlin klin. Wochensch., May, 1872.

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.

⁹ Trans. Med. Soc. State of N.Y., 1868, p. 251.

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.

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.

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 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. Smith¹³ 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 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.

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, 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.

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

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, 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 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.

¹⁶ Richmond Med. Jour., ii. 1.

Dr. Purcell of Cork¹⁷ furnished a classification which is one of the best for practical and clinical purposes—viz. 1, the rapid variety, attended with purple blotches, embarrassed respiration and circulation, followed by sopor, insensibility, and coma; 2, the cerebro-spinal form, with retraction of the head, pain and cramps of the muscles, hyperæsthesia of the skin, delirium, etc., accompanied by fever, herpetic eruptions, etc. These two forms are apt to be more or less associated in the same case.

¹⁷ Dublin Quarterly Jour., Aug., 1870, p. 243.

Of the various forms admitted by different authors, and of which we have seen examples, we would class together—(a.) The abortive, in which the characteristic phenomena are often faintly defined, and yet to the practised eye distinctive. (b.) The malignant, in which the symptoms, of whatever kind, are exaggerated, the attack sudden, the course short, and the issue fatal. (c.) The nervous, including 1, the Ataxic—viz.—1, the delirious; 2, the cephalalgic; 3, the neuralgic; 4, the convulsive; 5, the paralytic; and 6, the adynamic (comatose and typhoid). (d.) The inflammatory. (e.) The intermittent. Of these the abortive and intermittent call for a brief explanation. Abortive meningitis is observed only during the prevalence of the disease in a more characteristic form. Thus, the mother of a boy who had died of the fully-developed disease "complained of the head and back and limbs, and of chilliness, and presented a petechial eruption. After active purgative and counter-irritant treatment she was about her work on the second day."¹⁸ The late Dr. Burns of Frankford, Philadelphia, while attending patients affected with the disease suffered from headache, severe pains along the spine and in every joint of the body, and a general languid feeling.¹⁹ Kempf during the decline of an epidemic observed "a great number of individuals, especially adults, who complained of headache, malaise, neuralgic pains in various parts of the body, and pain in the nape of the neck or other parts of the spine."²⁰ In a case observed by the writer (June, 1867) most of the characteristic symptoms were present in a mitigated form, and the pulse was at 60. Within five days restoration was complete.²¹ The intermittent and remittent types are apt to be quotidian or tertian, and in fatal cases the former has been taken for malignant intermittent fever, which it resembles by a periodical febrile movement, with pains, cramps, delirium, etc. This type sometimes first manifests itself during the decline of an attack.

¹⁸ Sargent, Amer. Jour. of Med. Sci., July, 1849, p. 35.

¹⁹ Amer. Jour. of Med. Sci., April, 1865, p. 339.

²⁰ Ibid., July, 1866, p. 55.

²¹ Epidemic Meningitis, p. 42.

SUMMARY OF THE SYMPTOMS.—Like other fatal epidemic diseases, meningitis is sometimes sudden and sometimes gradual in its development. In the former case the patient, who has gone to bed apparently in perfect health, awakes suddenly from a sound sleep about the small hours of the night to find himself in a severe chill. In the case of young children a convulsion attends the awakening. Or the patient, while pursuing his ordinary avocations, may be seized with a chill, prostration, vomiting, and headache, of which symptoms the last is often intensely distressing. In this, as in other epidemic diseases, such violent seizures are most common during the earlier periods of its prevalence, but later in its course premonitory symptoms are more frequently observed. They may last for an hour or two, or may extend to several days; and, in general, it may be stated that the longer their duration the milder will be the subsequent attack. But the symptoms in either case are essentially the same—prostration, chilliness, feverishness, and sometimes vomiting and sharp pains in the head, back, and limbs. The character of the vomiting, as well as the absence of all gastric lesions in fatal cases, proves that it is occasioned by an irritation of the central nervous system.

In the cases which are regularly developed these phenomena more or less gradually assume a graver aspect or usher in a heavy chill, which in its turn is followed by alarming symptoms, and especially by an excruciating pain in the head, a livid or pale and sunken countenance, and extreme restlessness. The pulse is as often slow as frequent, and the skin is rarely hot, and, indeed, is generally but little, if at all, warmer than natural. The vague pains that began with the attack are now concentrated, and seem to dart in every direction from the spine, which is also, at its upper part, the seat of severe aching; and in some cases hyperæsthesia of the skin is very marked. In a large proportion of cases the spinal muscles become more or less rigidly contracted, so that the head is drawn backward or the whole trunk is arched as in tetanus. Trismus is not uncommon, and clonic spasms frequently affect the limbs. Even general convulsions are occasionally observed. As these phenomena grow more decided delirium of various degrees is often manifested, from mere wanderings and hallucinations during the sleepless watches of the night to violent maniacal ravings or incoherent mutterings, or the stertor of coma. Frey and others have noted a remission of the symptoms occurring on or about the third day in cases of a regular type. The rigidity of the cervical muscles becomes relaxed, the headache subsides, and the mental condition improves. But this amelioration lasts but a short time, and then the normal course of the symptoms is resumed.

As the attack advances the pulse gradually or rapidly rises above the normal rate, and sometimes becomes very frequent, and the skin, although it grows warmer, does not often acquire the temperature observed in idiopathic fevers or sustain it as they do. In many cases eruptions appear upon the skin. During some epidemics the only one observed is herpes labialis; in others the eruption resembles roseola, measles, or the mulberry rash of typhus, or from the first it consists of petechiæ, vibices, or extensive ecchymoses. The tongue presents the characters which belong generally to the typhoid state. At first moist and coated with a whitish fur or a mucous secretion, it afterward, if life is prolonged, grows red and shining or brown and fuliginous. There is usually a complete loss of appetite, and the thirst is not commonly urgent. One or two liquid stools at the commencement are generally followed by constipation, which continues throughout the attack, although in very grave and protracted cases diarrhoea may persist, and even become colliquative. When the attack tends to a fatal issue the patient generally, but by no means always, sinks into a soporose condition, in which muscular relaxation, debility, and tremulousness, such as are common in the typhoid state of fevers, are associated with paralysis of the sphincters and of other muscles. But we have seen rigid opisthotonos continue until within a few hours of death in a case of more than the average duration.

In cases that tend toward recovery the typhoid condition is rarely so grave, but patients have often survived very severe nervous symptoms. It is true that the return to health may be tedious and uncertain, and not unusually a perfect restoration of all the functions is very long delayed, or, it may be, is never attained.

INDIVIDUAL SYMPTOMS.—Pain in the head is one of the most characteristic symptoms of epidemic meningitis. It is always present, except in those malignant cases in which the morbid poison seems to spend its fatal power upon the blood. In some, however, of a less rapid but still malignant type, in which after death no exudation is found, but only an extreme venous congestion of the membranes, or it may be an effusion of blood beneath them, this symptom may be more or less marked. It is generally an excruciating pain, sometimes darting apparently through the head from the nuchæ to the forehead, extorting cries and groans, and is variously described by the sufferers as throbbing, boring, lancinating, sharp, or crushing, "as if the head were in a vice or nails or screws were being forced into the brain." Its paroxysms arouse the patient from his apathetic stupor or his coma, and cause him to become restless or violent or to shriek with agony. Even when this evidence of anguish is wanting the patient often attests his suffering by contortions or cries, or by frequently carrying his hands to his head. That it depends upon mechanical pressure upon the sensitive ganglia within the cranium and upper part of the spine is shown by the relief which revulsive and counter-irritant measures afford when applied to the occipital region and the back of the neck. Identical in cause and quality with this pain is the spinal pain proper. No better description of it has been given than that of Fiske in 1810. It is in these words: "Its bold and prominent features defy comparison.... In some a pain resembling the sensation felt from the stinging of a bee seizes the extremity of a finger or toe; from thence it darts to the foot or hand or some other part of the limbs, sometimes in the joints and sometimes in the muscles, carrying a numbness or prickling sensation in its progress. After traversing the extremities, generally of one side only, it seizes the head, and flies with the rapidity and sensation of electricity over the whole body, occasioning blindness, faintings, sickness at the stomach, with indescribable distress about the præcordia—a numbness or partial loss of motion in one or both limbs on one side, with great prostration of strength. The horrible sensation of this process no language can describe."²² These spinal pains are always aggravated by pressure made on either side of the spinous processes of the vertebræ, and, like the cephalic pains, are more or less mitigated by revulsive applications. Accompanying the pains is a hyperæsthesia or morbid sensibility of the skin, rendering it painfully sensitive to the slightest touch; in the advanced stages of the disease, when the spinal phenomena predominate, the irritation of the nerves by the pressure of the exudation on their roots is exchanged for numbness or absolute insensibility, due to the increase and continuance of that pressure. Moving the limbs or separating the closed eyelids will sometimes provoke resistance, and even extort cries; and especially is this true of attempts to straighten the rigidly bent spine or the flexed extremities. Lewis states that such outcries were so often excited by slowly introducing the thermometer into the rectum that he was forced to believe that the anal and perhaps the rectal surface was hypersensitive.

²² North, on Spotted Fever, p. 176.

The physical causes that give rise to the pains which have just been described likewise occasion the spasmodic and tetanoid phenomena that are so peculiar to this disease. In general terms, they are most marked in cases attended with inflammatory exudation, and least so when, instead of this lesion, there is only vascular congestion of the meninges of the spinal cord. But the rule is, of course, not absolute, for individuals are so differently constituted that one will remain impassive under an irritation that will throw another into convulsions. There is no doubt that spinal rigidity may be produced by mere congestion of the cord, and, on the other hand, that it may be absent even when plastic exudation is abundant. This symptom is, however, more than any other one, characteristic of the disease. It existed in the original epidemic at Geneva, attracted the attention of the earliest American observers of the disease, and elsewhere has marked a greater or a smaller proportion of the cases in every epidemic. It was described by such terms as these: "a drawing-back of the head;" "a corpse-like rigidity of the limbs;" "the form of tetanus called opisthotonos;" "spastic rigidity of the muscles of the lower jaw and the posterior muscles of the neck;" "rigidity of the posterior cervical muscles, retracting the head considerably backward." The historians of the disease in Europe are, if possible, still more emphatic in their elaborate descriptions of this phenomenon, and, on the Continent at least, it seems to have been more uniformly present than it was in Ireland or in this country. Tourdes, in describing the epidemic of 1842 at Strasburg, said: "The decubitus of the sick was distinguished by a backward flexion of the head and spine; most frequently the neck alone was affected, but sometimes the whole trunk was arched." And again: "The contraction often involved all of the extensor muscles of the spine, and the trunk formed an arch opening backward and resting upon the occiput and sacrum." In Ireland, Gordon says of a patient, "Her spine presented a most wonderful uniform curve concave backward; her head was also curved backward on the spine of the neck." During an epidemic at Birmingham in 1875 in one case "the retraction was so marked that a slough formed from the occiput pressing between the scapulæ."²³ In some cases rigid flexion of the body forward or laterally has been noticed. The rigidity persists, as a rule, until death, but sometimes ceases a short time before that event. If recovery takes place, this symptom gradually subsides, and disappears within a few days; but, on the other hand, more or less stiffness of the spine may last for several weeks. In one case it continued for more than two months, and in another until death on the forty-ninth day.

²³ Hart, St. Bart's Rep., iv. 141.

The same physical cause that occasions rigidity, when acting less intensely or when a special susceptibility of the nervous system exists, also excites clonic convulsions. They are oftenest observed in patients of the age especially liable to spasmodic affections—in children before the completion of the first dentition. They vary in degree from twitching or subsultus affecting particular muscles, as of the eyes, the face, a limb, etc., to general epileptiform convulsions with loss of consciousness. They may be associated with paralysis, as where the two halves of the body are, the one convulsed and the other paralyzed. A case occurred in Dublin which "presented the very striking phenomenon of continued and violent convulsions during the whole of the brief course of the illness."²⁴ These convulsions, like others occurring at the commencement of acute diseases, are by no means always fatal, even when they are general. In the case of a robust adult convulsions occurred repeatedly during the first two days, and less frequently during the two following days, but the patient ultimately recovered.²⁵

²⁴ Dublin Quart. Jour., xlvi. 187.

²⁵ Boston Med. and Surg. Jour., Feb., 1884, p. 121.

Paralysis, it may be inferred from the statements already made, is an incident of this disease, for an excess of the action causing tonic or clonic spasm must induce paralysis. Paralysis of an arm or leg or of the muscles of deglutition was long ago noticed among even the initial symptoms of the attack. In Dublin (1865) it was said of a patient, "All his members seemed to be paralyzed; he could move neither arms nor legs." Wunderlich describes the case of a man who "on the second day of the disease lost both sensibility and motility in the lower limbs and over the greater part of the trunk, while his left arm also was partially paralyzed." In another case complete paralysis of the right side occurred on the third day, the left side being rigid.²⁶ Baxa relates the case of a soldier in whom paralysis of the left side persisted after recovery from the disease,²⁷ and that of a woman in whom paralysis of the left lower limb continued along with right ciliary paralysis. Ptosis, strabismus, paralysis of the bladder and rectum, of the muscles of deglutition, and even general paralysis, have been observed. Aphasia also has been recorded by Hirsch and by Hayden.²⁸

²⁶ Dublin Quart. Jour., 1867, p. 431.

²⁷ Wiener med. Presse, No. 29, p. 715.

²⁸ Dublin Quart. Jour., xlvi. 187.

The condition of the eyes and of vision in this disease is directly due to pressure of the exudation at the base of the brain upon the nerves and blood-vessels that supply these organs. One of the most striking peculiarities of the countenance of a patient at the beginning of an attack is the diffused and uniform redness of the conjunctivæ. In children it has a light tint, but a darker one in adults, and in some cases the eye becomes suffused with an extravasation of blood. The conditions of the pupil are also very peculiar. Very long ago it was observed to undergo sudden changes from contraction to dilatation, or the reverse. Dilatation is, however, its ordinary condition, especially in the fully-formed attack. Very often the pupils of the two eyes are in opposite states. In cases of long duration, with great exhaustion, they are almost invariably dilated. Photophobia is not uncommon, and oscillation of the pupils and spasmodic movements of the eyeball have frequently been observed. Strabismus is a symptom of very ordinary occurrence, particularly when other paralytic or spasmodic phenomena exist. It may be convergent or divergent, but most commonly is the former, and may be either a transient or a permanent symptom. Like other individual symptoms, it may be present rarely or frequently in a particular epidemic.

Blindness has been repeatedly observed. At first it seemed to be noticed as a transient symptom only. Fish (1809) states that it was sometimes the first deviation from health, and then was followed by paralytic spinal symptoms. He also observed that sight was sometimes restored in a few hours, and in no case did he know it to be permanently lost. American as well as European physicians, however, have met with many cases in which the sight was seriously and permanently impaired or altogether destroyed. In 1873 the changes affecting the eye were more fully and accurately described, especially those which tend to the structural injury of the organ. The abnormal appearances included cloudiness of the media, discoloration of the iris, irregularity of the pupils, and their obstruction with exudate. In exceptional cases the cornea ulcerated, and the globe collapsed after losing its contents. Ordinarily, however, says Lewis, "no ulceration occurs, and as the patient convalesces the oedema of the lids, the hyperæmia of the conjunctiva, the cloudiness of the cornea and of the humors gradually abate, and the exudation in the pupils is absorbed. The iris bulges forward, and the deep tissues of the eye, viewed through the vitreous humor, which had a dusky color from hyperæmia, now present a dull white color. The lens itself, at first transparent, after a while becomes cataractous, and sight is lost totally and for ever."

Impairment or loss of hearing has been occasionally observed during the successive epidemics of this disease, even from the beginning of its history, and it was early noticed that the symptom was often quite independent of any cognizable lesion of the ear itself. It was also observed that the sense of smell sometimes became impaired or was lost at the same time with that of hearing. More recently, Collins reported a case in which the patient lost the sight of one eye and became permanently deaf in both ears. Knapp states that in all of thirty-one cases examined by him the deafness was bilateral, and, with two exceptions of faint perception of sound, complete. Among twenty-nine cases of total deafness only one seemed to give some evidence of hearing afterward.²⁹ This surgeon holds that the deafness results from a purulent inflammation of the labyrinth, and his judgment has been confirmed by Keller and Lucas. When the impairment of hearing occurs simultaneously, or nearly so, in both ears, it is probable that the chief cause of the deafness is the pressure of the plastic exudation in which the auditory nerve is imbedded. Such deafness is rarely permanent. When the loss of hearing, whether complete or partial, does not improve, there is reason to believe that the internal ear has suffered great and incurable changes of structure. Sometimes this follows a distinct attack of suppurative inflammation of the middle ear; but as complete and permanent deafness sometimes occurs without being preceded by any such affection, it must be inferred that atrophic changes have taken place in some portion of the nervous apparatus of hearing. It is stated by Moos that of sixty-four cases of recovery from cerebro-spinal meningitis, which showed disturbance of hearing as a sequel, one-half manifested in addition a more less disordered equilibrium. Of these twenty-nine were totally deaf on both sides, two totally deaf on one and hard of hearing on the other side, and one case had merely impaired hearing in both ears. The disturbance of locomotion had existed for periods varying from three weeks to five years from the inception of the disease, and was chiefly characterized by a staggering or waddling gait.³⁰ In the deaf-mute institutions at Bamberg and Nürnberg it is said that out of 91 pupils, 80 owed their infirmity to this disease (Ziemssen). Salamo states that some awake out of sleep totally deaf, and remain so for a long time, or, it may be, permanently (Moos).

²⁹ Smith, loc. cit.

³⁰ Mening. Cerebro-spinal epid., p. 11.

The expression of countenance in this disease is peculiar. When the pain in the head is severe and paroxysmal the features are apt to be violently distorted; when it is more persistent the face assumes a fixed or rigid expression, or is at the same time dull, particularly after a long continuance of the pain. In the apoplectic form the expression may be set and stupid, but the features have neither the dark, dull, swollen, and duskily-flushed aspect of typhus, nor the languid, sleepy expression, and circumscribed flush on the cheek which are so characteristic of typhoid fever. Except during absolute insensibility in rapidly fatal cases there is a look of greater intelligence than belongs to either of the diseases mentioned. Indeed, in the beginning of the attack in regular cases the distinctive facies presents pale and sunken features, with paleness of the skin over the whole body.

Delirium in this disease exhibits a great many degrees and varieties. It may occur among the earliest symptoms in certain rapid cases not of the congestive type, but is more apt to arise on the second or third day in those more typically developed. It may be mild, reasoning, hysterical, or maniacal, or it may change from one to another of these forms during the same attack. Fish states that it is apt to be violent if it comes on at the commencement of the illness, but that when it begins at a later period it is milder, and sometimes playful, the patient being sociable and humorous. All good observers have furnished similar descriptions of this symptom; some have added that the mental condition is often desponding and apprehensive, and others that certain patients remain sombre and silent; and it sometimes happens that the delirium comes on abruptly, as when a patient "woke suddenly in the middle of the night and began to hum tunes, to fancy that people were conversing with him," etc. (Gordon).

Coma is met with sooner or later in nearly all fatal cases, but rarely in a marked degree until the approach of death. If anything is surprising in epidemic meningitis, it is the absence of that deep and prolonged stupor that characterizes the typhoid state, notwithstanding the pressure of the exudation upon the brain in most cases, and in others such a profound alteration of the blood that it exudes through the tissues as water passes through a porous body. Another striking phenomenon of the disease is that the patient after recovery has generally a complete oblivion of all that happened to him between the beginning of the attack and convalescence. This is true even of cases in which the brain symptoms are far from being conspicuous.

Another symptom closely related to the local lesion and the blood-change in this disease is vertigo. As originally described by Miner in 1823, it occurred from the very commencement of the attack, and was even then regarded as denoting a deficient supply of the blood to the brain, so that when the patient rose to an erect posture it was felt along with uneasiness in the stomach, acceleration of the pulse, dimness of sight, nausea, and fainting. Tourdes, speaking of it as it occurred in the Strasburg epidemic, says that it confused the mind and rendered walking impossible. In two cases patients were seized with a giddiness which compelled them to whirl around, when they fell and did not rise again. According to Moos (1881) unilateral affections of the labyrinth give rise to vertigo, and bilateral lesions to a staggering gait. Bilateral hemorrhage or acute suppuration of the ampullar terminations of the auditory nerve occasions paralysis and staggering. Children, and those who at the same time have the sight impaired, are apt to remain affected for a long time. Otherwise, prolonged and systematic muscular exercise may remove the tottering walk.

To the same causes must doubtless be attributed the debility which is so early and so conspicuous a symptom in this disease, and which gave it one of the names, typhus syncopalis, by which it was first known in this country. It was manifested by the vertigo already noticed, by a sense of sinking in the epigastrium, by a quick, frequent, feeble, and irregular pulse, and by a sudden and extreme loss of muscular power, so that the patient found himself unable to raise his hand before he was sensible of being ill. This state of asthenia is conspicuous throughout the whole of the disease, and is the immediate cause of the slow and irregular convalescence which is characteristic of it.

Of the symptoms peculiar to the digestive apparatus hardly any belong to it directly. They are nearly all the effect of reflex influences. The condition of the tongue is for the most part quite unlike that which belongs to the typhoid state. The fuliginous condition of the tongue, gums, cheeks, and lips which characterizes that state is seldom met with in epidemic meningitis. The older writers agreed that even when the tongue does grow dry and brown the condition is not of long continuance, and later observers have confirmed their statements. Thus, J. L. Smith (1872) says, "Occasionally, in cases attended with great prostration, the fur of the tongue is dry and brown, but only for a few days, when the moist whitish fur succeeds." We have generally found it moist, whitish in the centre and at the tip and edges.

Nausea and vomiting are very constant among the initial symptoms of the disease, and, as already pointed out, are due to irritation of the cerebro-spinal ganglia. Very often the vomiting is not preceded by nausea, and is brought on by the patient's raising himself, etc. The stomach itself undergoes no change. Both symptoms are usually accompanied by faintness or giddiness, and are more decided in the initial than in the later stages of the attack. The matters vomited, varying with the contents of the stomach and the urgency and duration of the symptom, consist of ingesta, mucus, serum, or bile, and in some grave cases of a dark grumous matter taken to be altered blood. In some epidemics, apparently, more than in others, this symptom is very distressing, as it was at Birmingham in 1875.³¹ The inability of the stomach to retain food necessarily leads to a rapid wasting of the flesh, which is aggravated by the patient's suffering, restlessness, and want of sleep. Nevertheless, no sooner is the vomiting appeased than a desire for food is felt, and when it is retained it generally undergoes digestion. Indeed, in no other disease is the return of a good appetite and digestion so prompt and complete. It is true that the recovery of flesh and strength is not always in proportion to the appetite. As might be expected in a disease in which fever plays so subordinate a part, there is seldom urgent thirst. But epidemics differ in this as in so many other respects. In that which we witnessed in the Philadelphia Hospital in 1866-67 the patients were clamorous for liquids. Constipation is the rule among patients with this disease, as, indeed, might naturally be expected, for no lesion affects the bowels and little or no food is retained by the stomach. Yet in a few cases diarrhoea accompanies persistent vomiting.