Part 124

{795}

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 {796} 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: "The great plague which visited Constantinople in 543, and which Procopius and Enagrius described, the plague of {797} 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.

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, Stoll 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. 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 {798} 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.

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 {799} 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 {800} very young persons. 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.

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, 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.

Deaths in Philadelphia from Cerebro-Spinal Meningitis from 1863-82.

| Brought over 1136 1863 49 | 1873 246 1864 384 | 1874 82 1865 192 | 1875 83 1866 92 | 1876 85 1867 109 | 1877 56 1868 55 | 1878 90 1869 37 | 1879 62 1870 36 | 1880 78 1871 49 | 1881 90 1872 133 | 1882 41 to Sept. 23d. ---- ---- 1136 Total 2049

If to these deaths are added those charged to malignant fever, 111, and to {801} congestive fever, 279, we obtain a total of 2439 deaths, nearly all of which may be set to the account of epidemic meningitis. It may also be remarked that up to the date at which this computation was made (May, 1883) hardly a week passed in which the Health Office did not register several deaths from this cause. Hence it would appear that the disease continues to linger in this locality longer than has been reported of any other place from which information has been obtained.

In the city of New York it appears to have been much more limited both in extent and duration. The first recorded death from it was in 1861; in 1866 the deaths were 18; in 1867 the deaths were 32; in 1868 they were 34; in 1869, 42; in 1870, 32; in 1871, 48. In 1872 the disease became epidemic, and "from January 6 to May 31, inclusive, 632 cases were reported to the City Sanitary Inspector, and 469 deaths to the Bureau of Records of Vital Statistics" (Clymer). After this period the disease seems to have declined very rapidly, and not to have reappeared, since no notice is taken of its recurrence by the medical journals of New York.

It was mentioned above that about 1870 some traces of the disease were observed in Asia Minor, and in 1872 several cases are said to have occurred at Jerusalem, 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.

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. 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., 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.

Of later occurrences of the disease the following may be mentioned: Several cases were reported in London in 1867, 1871, 1876, and 1878. In 1870 four cases were observed in Providence, R.I. 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.

ETIOLOGY.--Epidemic meningitis has occurred in Europe and America in every portion of the temperate zone, but its greatest prevalence and mortality have undoubtedly been in the northern rather than in the southern portions of that region. One of its most interesting features consists in its appearing simultaneously at points very remote from one another and having no connection with each other save through the atmosphere. Of this statement several illustrations have already been presented. Another {802} peculiarity of the disease consists in its occurring with hardly any relation to external natural conditions or to those of its victims. It affects localities as diverse as possible in their geological, meteorological, and sanitary states, the rich and the poor, the old and the young, and both sexes, and (as it is certainly not in a strict sense contagious) its rise and spread must necessarily be attributed to some occult cause pervading the atmosphere.

It is evident that the prevalence of the disease has some relation to meteorological agencies, for not only is it greater, on the whole, in cold than in warm climates, but it is also greater in cold than in warm seasons. Thus, if we examine the epidemics in Europe and America we shall find that they almost invariably were most severe in the winter and spring. Yet the rule presents several exceptions on both continents. In France, out of 216 local epidemics, more than one-fourth took place during the warm months of the year, and in Sweden the proportion was about the same. It is evident, therefore, that cold is not an essential cause of the disease. Among the problems that remain unsolved in regard to this disease none is more obscure than the apparent immunity of Russia from its ravages, although the climate seems adapted to favor it, and the domestic habits of no people are fitter to intensify it if individual conditions entered into the etiology of the disease; but, in truth, no such causes are related to epidemic meningitis. Localities of every sort, high and low, dry and moist, those saturated with marsh miasmata and those fanned by pure mountain-breezes, have been alike visited by this disease. It has passed by large cities reeking with all the corruptions of a soil saturated with ordure and populations begrimed with filth, as Vienna, Berlin, Paris, London, and New York, to devastate clean and salubrious villages and the families of substantial farmers inhabiting isolated spots.

By far the greatest number of the subjects of epidemic meningitis are young persons. In Sweden, according to Hirsch, of 1267 fatal cases of the disease, 889 occurred in persons under fifteen years of age, 328 between sixteen and forty years, and 50 in persons of forty years and upward. In 1866, in the Kronach district (Germany), of 115 cases, 75 occurred under the seventh year, 22 between the seventh and twelfth years, and 10 between the thirteenth and twentieth years (Schweitzer). During 1865 a local outbreak of the disease in Bavaria affected 53 persons, of whom 22 were children under ten years of age, 18 between ten and twenty years, and 11 between twenty and thirty years. Under the fifth year few were attacked (Orth). Dr. J. L. Smith found that, according to the reports of the Board of Health of the city of New York, out of 975 cases, 771 occurred in persons under fifteen years of age, the greatest number for any quiquennial period being 336 in children under five years. Of the 469 deaths occurring in this epidemic, 216 were of children under five years of age, and the next largest number for an equal period was 99, which represented the deaths between the ages of five and ten years. Of adults or persons beyond the age of twenty, the whole number was but 39. The peculiar liability to the disease of the young recruits in the French army has already been alluded to. The proportion of male victims to this affection is rather larger than that of females in the civil population, but in France especially the excess was greatly on the side of males, owing to the prevalence of the disease in the army. In other places, as {803} in Sweden and Germany, the number of deaths among females equalled, or even exceeded, that of males, and in Leipsic the garrison remained exempt while the disease prevailed among the citizens. In 1847 a fatal epidemic of it affected the second regiment of the Mississippi Rifles, and was entirely confined to that corps (Love). During the Civil War of the United States the disease affected particular corps or regiments in the South or in the North, yet it never became epidemic in the army, even when the disease prevailed among the adjacent civil population.

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." Supposing the concluding statement to be accurate, the case only shows that the cause of the disease which destroyed the mother's life infected the system of the child also. If there is one point in the history of the disease established by the concurring testimony of American and European writers, it is the extreme rarity of its attacking either the physicians and nurses in attendance upon patients affected with it, or those laboring under other diseases and occupying beds adjacent to persons ill with epidemic meningitis. That, nevertheless, there is a material morbific principle which inheres in certain localities, so that those who occupy them successively are liable to suffer from this disease, and that also this principle may be carried from place to place so as to render certain houses (barracks) infectious, seems to be demonstrated by the history of the disease in the French army. Between 1837 and 1850, when the disease prevailed in various parts of France, it did so not indiscriminately, but it usually followed the ordinary routes of communication, and especially the movements of the military in their transfers from one post to another, and the course of navigable streams. Strangely, also, it attacked soldiers much oftener than civilians. The most curious fact of all is one already referred to--viz. that although the disease prevailed in almost every part of the provinces, and although then as ever an incessant stream from them was flowing into the capital, neither its civil nor its military population was generally affected, nor, {804} indeed, at all so, until near the close of the period mentioned. Meanwhile, however, the disease extended to several countries conterminous with France or in close and frequent intercourse with it--to Italy (1839-45), Algeria (1839-47), England, Ireland, and Denmark (1845-48). These events seem to point to a certain transmissibility of the disease until we examine the negative facts that bear upon the question. They are such as these: The epidemic did not spread at all from France into two of the adjacent countries, Belgium and Switzerland, with which the first-named country maintained an incessant intercourse by travel and traffic, but, on the other hand, it broke out at an early date within the period mentioned at places very remote and absolutely independent of all influence emanating from France or any other European source--in the south-western portions of the United States. It is by numerous facts of this description that we are compelled to remove the disease from the category of endemic and even epidemic diseases, and relegate it, along with influenza, to that of pandemic affections.