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Chapter IV

Communicable Diseases, Table of Contents

CHAPTER IV

CEREBROSPINAL MENINGITIS

Cerebrospinal meningitis was of serious importance in the United States Army during the World War, not because of its incidence, which was comparatively low-in fact this disease ranked seventy-sixth as a cause for admission to hospital-but because of its high case mortality. Approximately 39 per cent of the cases died, thus causing meningitis to rank sixth as a cause of death. Furthermore, its appearance in a command usually caused a definite feeling of apprehension or alarm, and as a consequence few diseases were the cause of more concern to, or were given more active attention by, medical officers.

Many sporadic outbreaks and small epidemics have been reported throughout the world since 1805, when the disease was recognized clinically by Vieusseau. However, an accurate bacteriological diagnosis was not possible before 1887 when Weichselbaum1 showed the meningococcus (Diplococcus intracellularis meningitidis) to be the specific cause of cerebrospinal meningitis.

This infection has, no doubt, occurred in our Army during all previous wars. Interesting clinical reports of outbreaks are recorded in histories of the War of 1812, the Mexican War, and Civil War; while it is evident from these reports that meningitis was present, the incidence is not known since there was considerable confusion in the nomenclature and differential diagnosis and, of course, bacteriological diagnostic methods were unknown. In spite of the fact that the meningococcus had been recognized as the specific cause of cerebrospinal meningitis for 10 years previous to the Spanish-American War, very few of the cases which occurred during that period were diagnosed by accurate laboratory methods, and clinically the disease was confused to some extent with typhoid, typhus, and other fevers. It is obviously impossible, therefore, to make a comparison of the meningitis rates of our Army for the World War with the rates for any previous war. Such a comparison not only would be worthless, but also misleading.

Since the Spanish-American War the diagnosis of cerebrospinal meningitis in the Army has been more exact, and the records have included only cases in which the clinical diagnosis was confirmed by bacteriological examination. During this time, as indicated graphically in Chart XXVI, the annual admission rate per 1,000 strength has been almost negligible, except during the mobilization of unseasoned troops; for example, the rate increased noticeably in 1907 at the time of the Cuban occupation, in 1913 during the mobilization on the Mexican border, and again in 1917 when the United States entered the World War. It is noteworthy that the concentration of Regular Army troops on the Mexican border in 1911 was not attended by any remarkable increase in the meningitis admission rate.

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General-Ed.


204

Cerebrospinal meningitis has for some time been known as a disease of soldiers, or a "barracks disease," because of its tendency to become more prevalent during the mobilization of recruits. These terms were justified by the increased incidence in the Army during the World War. The rapid mobilization of enormous numbers of untrained, unseasoned men, from all sections of the country, and their subsequent, intimate contact in large camps, provided ideal conditions for the dissemination of meningococci, and as a consequence meningitis was far more prevalent than in normal peace times.

CHART XXVI.-Admissions and deaths for cerebrospinal meningitis, United States Army, 1900 to 1920. Ratios per 1,000 strength

STATISTICAL CONSIDERATIONS

The total mean annual strength of the Army for the period April 1, 1917, to December 31, 1919, was 4,128,479. As indicated in Table 28, 4,831 cases of cerebrospinal meningitis were reported as "primary admissions" during this period, giving an annual admission rate of 1.17 per 1,000 of strength, or 117 cases among every 100,000 men. Death occurred in 1,836 cases, or 38 per cent, giving an annual mortality rate of 0.44 per 1,000, or 44 deaths in 100,000 men.


205

TABLE 28.-Cerebrospinal meningitis. Primary admissions and deaths shown by countries of occurrence for officers and enlisted men, United States Army, with ratios per 1,000 strength, April, 1917, to December 31, 1919

Period, April, 1917, to December, 1919

Total mean annual strengths


Admissions

Deaths


Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Total officers and enlisted men, including native troops

4,128,479

4,831

1.17

1,836

0.44

Total officers and enlisted American troops

4,092,457

4,826

1.18

1,833

.45

Total officers

206,382

120

.58

56

.27

Total enlisted American troops:

 

 

 

 

 

    

White

3,599,527

3,928

1.09

1,387

.39

    

Colored

286,548

526

1.84

239

.83

    

Color not stated

---

252

---

151

---

         

Total

3,886,075

4,706

1.21

1,777

.46

Total native troops (enlisted)

36,022

5

.14

3

.08

Total Army in the United States (including Alaska):

 

 

 

 

 

    

Officers

124,266

69

.56

28

.23

    

White enlisted

1,965,297

2,466

1.25

825

.42

    

Colored enlisted

145,826

343

2.35

133

.91

         

Total enlisted

2,111,123

2,809

1.33

958

.45

         

Total officers and men

2,235,389

2,878

1.29

986

.44

U.S. Army in Europe (excluding Russia):

 

 

 

 

 

    

Officers

73,728

45

.61

23

.31

    

White enlisted

1,469,656

1,384

.94

534

.36

    

Colored enlisted

122,412

169

1.38

96

.78

    

Color not stated

---

250

---

149

---

         

Total enlisted

1,592,068

1,803

1.13

779

.49

         

Total officers and men

1,665,796

1,848

1.11

802

.48

U.S. Army in Hawaii, total enlisted

19,480

3

.15

1

.05

U.S. Army in Panama, white enlisted

19,688

5

.25

1

.05

Other countries not stated, officers

8,388

6

.72

5

.60

Other countries not stated, total enlisted

14,232

22

1.55

7

.49

Transports:

 

 

 

 

 

    

White enlisted

97,498

51

.52

22

.23

    

Colored enlisted

10,535

13

1.23

9

.85

         

Total

108,033

64

.59

31

.29

Native troops enlisted:

 

 

 

 

 

    

Philippine Scouts

18,576

1

.05

1

.05

    

Hawaiians

5,615

2

.36

---

---

    

Porto Ricans

11,831

2

.17

2

.17

Only cases admitted to hospital primarily for cerebrospinal meningitis are considered in the figures given above or in the statistical tables used in this chapter. However, during this same period 1,008 additional cases and 443 deaths were reported as "concurrent diseases," having been admitted to hospital for other conditions. Therefore the total number of cerebrospinal meningitis cases was 5,839, an annual admission rate of 1.41 per 1,000 strength; while the total number of deaths was 2,279.


206

DISTRIBUTION BY GRADES

The incidence and mortality rates for enlisted men were greater than for commissioned officers. The annual admission rate among enlisted men with a total mean annual strength of 3,886,075 was 1.21 per 1,000, compared with a rate of 0.58 for officers, whose total mean annual strength was 206,382. The annual death rates per 1,000 were: Enlisted, 0.46; officers, 0.27.

The lower incidence and mortality rates among officers were no doubt due to several factors. As a rule the officers were older than the enlisted men and possibly less susceptible to the infection. They also had certain advantages, such as less crowded living quarters, less exposure to hardship and fatigue, and because of their training they were better able to understand and apply the principles of personal hygiene and sanitation.

RACIAL DISTRIBUTION

Meningitis was more common among colored than among white enlisted men. The annual admission rates per 1,000 strength were: Colored, 1.84; white, 1.09. The mortality rates were: Colored, 0.83; white, 0.39. The case fatality for colored troops was 42.7 per cent and for white troops, 35.3 per cent. A comparison of the rates in the United States is shown in Chart XXVII. It has long been known that the incidence is usually higher among colored persons. This apparent racial susceptibility may be due mainly to insanitary habits, ignorance, and carelessness in matters of elementary personal hygiene which, together with the necessarily crowded conditions of camp life, facilitate the spread of meningococci.

One case occurred among Philippine Scouts, 2 cases in Hawaiians, and 2 in Porto Ricans.

GEOGRAPHICAL DISTRIBUTION

In order of importance the geographical incidence was: The United States, Europe, Panama, Hawaii, Porto Rico, and the Philippine Islands. The slight difference between the rates for the United States and Europe probably has no significance, though it is possible that the lower incidence in Europe was influenced by the fact that overseas troops had become more hardened and resistant to infection because of their training, and a large percentage of meningococcus carriers were eliminated before the troops left the United States.

The slight importance of meningitis in the Tropics is emphasized by these figures.

IN THE UNITED STATES

During the World War, meningitis occurred most frequently in troops stationed in the United States. There were 2,878 primary admissions among American enlisted men in this country, an annual admission rate of 1.29 per 1,000 strength; death occurred in 986, or 34.1 per cent of the cases. The annual death rate was 0.44 per cent 1,000 strength; 131 patients were discharged for disability, a rate of 0.06 per 1,000. A total of 150,386 days were lost because of the disease. The admission and death rates for colored troops were higher than for white, as shown in Chart XXVII.


207

CHART XXVII


208

TABLE 29.-Cerebrospinal meningitis. Primary admissions and deaths, by months, withannual ratios per 1,000 strength; white and colored enlisted men, United States Army in theUnited States and Europe, April, 1917, to December, 1919

Month and year

White enlisted men

United States

Europe

Mean strength

Admissions

Deaths

Mean strength

Admissions

Deaths

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

1917

 

 

 

 

 

 

 

 

 

 

April

183,758

18

1.18

9

0.59

---

---

---

---

---

May

245,454

35

1.71

20

.98

626

---

---

---

---

June

309,205

22

.85

9

.35

12,794

1

0.89

---

---

July

458,817

22

.58

8

.21

28,821

5

2.08

---

---

August

562,714

15

.32

7

.15

50,882

2

.47

---

---

September

776,466

10

.15

5

.08

70,266

4

.68

1

0.17

October

1,032,244

93

1.08

19

.22

92,139

2

.26

2

.26

November

1,061,422

273

3.09

102

1.15

123,429

14

1.36

3

.29

December

1,129,065

371

3.94

149

1.58

160,178

35

2.62

19

1.42

1918

 

 

 

 

 

 

 

 

 

 

January

1,096,434

409

4.48

131

1.43

193,264

54

3.35

15

.93

February

1,095,039

222

2.43

68

.75

223,130

25

1.34

9

.48

March

1,129,223

142

1.51

39

.41

283,268

40

1.69

9

.38

April

1,168,558

122

1.25

43

.44

388,048

31

.96

11

.34

May

1,197,757

83

.83

17

.17

587,240

33

.67

7

.14

June

1,303,746

74

.68

15

.14

796,427

42

.63

7

.11

July

1,328,513

61

.55

10

.09

1,063,192

21

.24

5

.06

August

1,284,247

30

.28

7

.07

1,266,592

35

.33

18

.17

September

1,321,440

41

.37

20

.18

1,527,793

78

.61

41

.32

October

1,343,933

136

1.21

51

.46

1,635,321

197

1.45

88

.65

November

1,255,195

70

.67

22

.21

1,682,836

141

1.01

56

.40

December

941,219

63

.80

27

.34

1,591,962

180

1.36

65

.49

1919

 

 

 

 

 

 

 

 

 

 

January

672,937

45

.80

11

.20

1,488,683

122

.98

53

.43

February

471,815

26

.66

12

.31

1,310,083

108

.99

43

.39

March

406,839

17

.50

5

.15

1,115,693

81

.87

37

.40

April

339,836

21

.74

6

.21

853,425

63

.89

23

.32

May

291,810

17

.70

4

.16

569,842

23

.48

10

.21

June

246,903

9

.44

1

.05

271,633

10

.44

4

.18

July

215,104

7

.39

3

.17

111,634

10

1.07

3

.32

August

156,791

5

.38

2

.15

48,006

5

1.25

1

.25

September

149,360

2

.17

---

---

30,315

4

1.58

1

.40

October

139,877

1

.09

---

---

21,055

9

5.13

---

---

November

132,403

1

.09

1

.09

18,920

1

.63

1

.63

December

135,441

1

.09

1

.09

18,379

---

---

---

---

Month not stated

---

2

---

1

---

---

8

---

2

---

    

Total

1,965,297

2,466

1.25

825

.42

1,469,656

1,384

.94

534

.36

 


209

TABLE 29.-Cerebrospinal meningitis. Primary admissions and deaths, by months, with annual ratios per 1,000 strength; white and colored enlisted men, United States Army in the United States and Europe, April, 1917, to December, 1919-Continued

Month and year

Colored enlisted men

United States

Europe

Mean strength

Admissions

Deaths

Mean strength

Admissions

Deaths

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

1917

 

 

 

 

 

 

 

 

 

 

April

4,870

---

---

---

---

---

---

---

---

---

May

5,826

---

---

---

---

---

---

---

---

---

June

5,171

---

---

---

---

---

---

---

---

---

July

6,675

---

---

---

---

---

---

---

---

---

August

8,519

---

---

---

---

---

---

---

---

---

September

9,409

---

---

---

---

---

---

---

---

---

October

21,795

---

---

---

---

935

---

---

---

---

November

39,225

16

4.89

6

1.84

2,392

1

5.03

1

5.03

December

36,851

38

12.37

15

4.88

5,346

2

4.48

1

2.24

1918

 

 

 

 

 

 

 

 

 

 

January

50,705

30

7.10

12

2.84

8,673

5

6.92

1

1.38

February

49,955

11

2.64

3

.72

9,664

2

2.48

---

---

March

54,814

22

4.82

9

1.97

11,541

3

3.12

1

1.04

April

59,015

21

4.27

12

2.44

12,667

---

---

---

---

May

87,650

51

6.98

17

2.33

28,279

4

1.70

4

1.70

June

89,305

24

3.23

6

.81

33,208

2

.72

---

---

July

124,976

17

1.63

6

.58

47,171

2

.51

---

---

August

168,422

8

.57

6

.43

78,734

8

1.22

4

.61

September

164,846

15

1.10

3

.22

91,270

14

1.84

7

.92

October

182,705

39

2.56

10

.66

138,827

25

2.16

16

1.38

November

150,587

19

1.51

8

.64

148,697

20

1.61

13

1.05

December

104,140

10

1.15

8

.92

148,372

20

1.62

11

.90

1919

 

 

 

 

 

 

 

 

 

 

January

68,337

3

.53

1

.18

140,396

16

1.37

7

.60

February

66,104

11

2.00

7

1.27

131,219

11

1.01

6

.55

March

44,634

7

1.88

3

.81

123,152

9

.88

4

.39

April

29,824

1

.40

1

.40

119,801

10

1.00

9

.90

May

20,780

---

---

---

---

108,650

7

.77

4

.44

June

18,562

---

---

---

---

64,166

6

1.12

5

.94

July

20,058

---

---

---

---

12,508

1

.96

1

.96

August

18,013

---

---

---

---

1,741

---

---

---

---

September

11,322

---

---

---

---

1,287

---

---

---

---

October

9,084

---

---

---

---

185

---

---

---

---

November

8,792

---

---

---

---

83

---

---

---

---

December

8,935

---

---

---

---

---

---

---

---

---

Month not stated

---

---

---

---

---

---

1

---

1

---

    

Total

145,826

343

2.35

133

.91

122,412

169

1.38

96

.78

 


210

Cerebrospinal meningitis, as indicated by the weekly reports of the United States Public Health Service and the United States mortality statistics, had been prevalent and widely distributed throughout the civilian population of the United States for several years before we entered the World War. The rapid mobilization of over a million men from all sections of the country between April and October, 1917, naturally brought the disease into every cantonment, and the monthly admission rates increased to a peak of over 4 per 1,000 in January, 1918. From this point the rate fell to about 0. 3 in August, and again rose to a second peak of less than 2 per 1,000 in October, 1918. Then, instead of rising during the winter of 1918, the rates decreased after the armistice began, until a low point of .09 was reached in October, November, and December, 1919, as shown in Table 29 and graphically by absolute numbers in Chart XXVIII. Evidently the incidence was affected not so much by temperature or season as by mobilization.

Chart XXVIII

Since a majority of the men were collected in 39 large camps located in various sections of the country, the occurrence of meningitis in these camps, shown in Table 30 and Chart XXIX, is of interest.


211

TABLE 30.-Cerebrospinal meningitis. By camps of occurrence, showing primary admissions and deaths, with annual ratios per 1,000 strength, white and colored enlisted men, United States Army; also case fatality rates, April, 1917, to December, 1919

The highest primary admission rates for white and colored enlisted men combined occurred in Camps Jackson, S. C. (6.76 per 1,000), Beauregard, La. (6.40), and Funston, Kans. (2.72); and the numbers of cases in these camps were, respectively, 284, 132, and 153, or one-fifth the total number for the whole country. It is obvious that the increased prevalence was not due entirely to the size of these camps, since other large camps such as Camp Dix, N. J., had much lower admission rates; furthermore, it can not be ascribed to climate or other similar local conditions, since the rates for different camps in a single State, or for different States in a given section of the country, varied considerably. For example, in South Carolina the primary admission rates per 1,000 were 6.76 for Camp Jackson, 2.45 for Camp Sevier, and only 0.63 for Camp


212

CHART XXIX


213

Wadsworth. A study of the mobilization charts indicates that the disease was most common in the camps which were made up mainly of men from the rural sections of the Southeastern States and from Kansas and Missouri, and that it was relatively infrequent in camps composed of troops drawn from States which had large urban populations.

Sporadic cases occurred in all of the other camps except Camp Forrest in Georgia, and Camp Syracuse in New York, which were relatively small camps, organized late in 1918.

The relatively high incidence of meningitis in certain of our camps was no doubt due mainly to the fact that large numbers of susceptible men from rural sections, under the strain and fatigue incident to intensive military training, were, for the first time, brought into close contact with meningococcus carriers and cases.

CAMP JACKSON, S. C.

This National Army cantonment which had 284 cases of meningitis and an admission rate of 6.76 per 1,000, drew a large percentage of its men from the rural sections of North Carolina, South Carolina, and Florida.2 Meningitis occurred in practically epidemic form during November and December, 1917, and was prevalent from that time on.

CAMP WADSWORTH, S. C.

Although located in South Carolina, only 20 cases occurred in this camp, and the admission rate was 0.63 per 1,000 strength. However, Camp Wadsworth was made up largely of troops from New York City and other thickly populated localities.3

CAMP BEAUREGARD, LA.

There were 132 cases, an annual primary admission rate of 6.40 per 1,000 in this camp, which drew troops mainly from Louisiana, Arkansas, and Mississippi,4 all of which States have a large rural population.

CAMP FUNSTON, KANS.

Including all troops in the State, 153 cases, or an admission rate of 2.72 per 1,000, were reported for Camp Funston. The men in this camp came mainly from Missouri and Kansas.5

IN EUROPE

Meningitis in the American Expeditionary Forces occurred sporadically rather than in extensive epidemics. A large percentage of the cases originated either in the base ports or on shipboard, and, as a rule, the incidence was highest in organizations from training camps with high rates in the United States.

There were 1,848 primary admissions reported between June 1, 1917, and December 31, 1919, an annual admission rate of 1.11 per 1,000 strength, or 111 cases in every 100,000 men. Of these, 802 died, a case fatality of 43.3 per cent; the annual death rate was 0.48 per 1,000 strength. The first case was reported in June, 1917, and more cases occurred as the strength of the Army increased during the following months, until a peak was reached in January, 1918, with 59 cases and a rate of over 4 per 1,000. These cases were mainly due to outbreaks in organizations which had brought the infection with them from their training camps in the United States.


214

In October, 1918, when the strength was over a million and a half men, 222 cases occurred, or a rate of less than 2 per 1,000. This increase occurred just after the highest incidence of influenza, which possibly contributed, along with hardships, fatigue, and overcrowding of troops, to lowering the resistance of soldiers to meningitis. During demobilization the monthly number of cases decreased rapidly until there were only 9 in October, 1 in November, and none in December, 1919. The high admission rate of 5 per 1,000 in October, 1919, is not considered significant, as it is based on only 9 cases.

ETIOLOGY

While the experience during the World War added nothing entirely new to our knowledge of the etiology of cerebrospinal meningitis, it emphasized the relative importance of certain contributing factors.

As stated above, since 1887 it has been known that the disease is a specific infection caused by the meningococcus. In 1909 Dopter6 differentiated two types of meningococci which he designated "normal" and "para." Gordon7 divided meningococci isolated from cases of meningitis, which occurred in British troops during the World War, into four serological types, which he called I, II, III, and IV. His types I and II corresponded with Dopter's "para" and "normal" types, while III and IV were irregular or intermediate in their serological reactions. The relative frequency of these types in the British Army is indicated by the following table:8


Type

I

II

III

IV

Specimens

195

218

69

36

Percentage

37.66

44.05

11.38

6.94

In 1917, Flexner9 investigated the subject and agreed with Dopter by dividing the meningococci into normal, para, and intermediate types.

In the United States Army the typing of meningococci was not a routine procedure; however, it was done in a great many instances. The information obtained sometimes aided in the selection of therapeutic serum for individual cases or in tracing the relationship between cases or carriers. The reports from certain organizations indicate that the normal type (II) predominated; that the para type (I) was about half as frequent, and that a relatively small percentage of the intermediate types (III and IV) were found.

It is now generally believed that the normal habitat of the meningococcus is the posterior nasopharynx of man. In susceptible individuals the organism may invade the body and produce meningitis, while in resistant or immune persons infection does not occur. These latter, apparently normal "carriers," may harbor meningococci in their throats for long periods of time and spread them to their associates. While it has been estimated that about 1 to 3 per cent of the population are carriers, fortunately relatively few persons are susceptible to the infection. Conditions which increase the contact between carriers and susceptible individuals favor the spread of meningitis. The tendency of the disease to greater prevalence in the winter and early spring is, no doubt, due to the fact that people live indoors and are therefore closer together


215

during the cold months. The higher incidence among recruits, especially those from rural localities, in mobilization camps points to the importance of contact between these relatively susceptible persons and carriers. Other infections, fatigue, and hardship may also help to lower the resistance of soldiers.

DIAGNOSIS

The specific diagnosis of cerebrospinal meningitis depends upon the isolation and identification of the meningococcus from the cerebrospinal fluid. During the World War, spinal punctures usually were performed on all patients with symptoms of meningeal irritation or inflammation; and the diagnosis was based entirely on the bacteriological examination of the spinal fluid. Wegeforth and Latham,10 however, warned against the indiscriminate use of spinal puncture as a diagnostic procedure in human septicemia, stating that the release of spinal fluid was an important factor in the development of meningitis. This observation was preceded by the investigations of Weed, Wegeforth, Ayer, and Felton,11 who showed that in animals suffering with an experimentally produced bacteriemia, spinal puncture was invariably followed by meningitis. It was therefore recommended that careful consideration be given to the bacteriological study of the blood before attempting puncture of the spinal canal. However, in spite of the fact that cases were observed in which the spinal fluid obtained at the first puncture was sterile and from later punctures infected, this was usually considered only an indication of the normal progress of the infection; and it was quite generally believed that diagnostic spinal puncture in meningitis was not attended by any serious results.

The observations of previous workers that meningococci may invade the blood stream were confirmed during the World War by Herrick.12 He reported that in a comparatively large percentage of the cases at Camp Jackson, S. C., the organism was isolated in cultures made of the blood before the appearance of meningeal symptoms; and, as a consequence, he advocated the more general use of blood cultures as an aid to early diagnosis, and proposed that the term "meningococcus sepsis" be used.

In most cases it is possible to isolate the meningococcus from the upper respiratory tract, and nasopharyngeal cultures may be helpful, when meningococci in a turbid spinal fluid escape detection. During the World War nasopharyngeal cultures were used mainly in the detection of carriers, but occasionally as an aid in the diagnosis of cases.

The symptomatology of cerebrospinal meningitis observed during the World War did not differ materially from that already recognized as characteristic of the disease. Naturally, differences occurred in the percentage of severe and mild cases in the various camps, resulting in variations in the predominant clinical signs and symptoms.

TREATMENT

Polyvalent antimeningococcic serum was used routinely for treatment. The gross case fatality for primary admissions in the whole Army was about 38 per cent. In the American Expeditionary Forces about 43 per cent of the cases died, while in the United States the percentage was about 34. Also the


216

case fatality in different camps in this country varied from 8 to 43.9 per cent, as shown in Table 30. These differences no doubt were influenced to some extent by differences in the severity of the disease in various localities, but the most important factor was probably the duration of the disease before serum therapy was begun.

According to Flexner9 and others, specific serum treatment reduced the mortality due to meningitis from a percentage of 60 to 90 to a gross case mortality of 23 to 50 per cent, and even to a much smaller percentage when the serum was administered in the first three days of the disease.

 

Flexner

Netter

Dopter

Christomanos


Levy

Flack

    

Number of cases

1,294

100

402

186

165

43

Treatment begun-


Per cent

Per cent

Per cent

Per cent

Per cent

Per cent

    

Before third day

18.1

7.1

8.2

13.0

13.2

9.09

    

From fourth to seventh day

27.2

11.1

14.4

25.9

20.4

---

    

After seventh day

36.5

23.5

24.1

47.0

28.6

50

The polyvalent immune serum used in the Army was supplied principally by the Rockefeller Institute, the New York City Board of Health, and three commercial laboratories.13 As a rule, from 30 to 80 strains of meningococci, representing different proportions of the various types, were employed in its preparation. In France, additional serum was obtained from the Pasteur Institute.14

In individual cases, considerable differences were observed in the therapeutic results obtained with different sera, and occasionally cases which were not improved by one serum were promptly benefited by another. In some of these instances the first serum used may have been generally lacking in antibody content, but usually the therapeutic failure occurred because the serum had been prepared with a large proportion of meningococcus strains which were different from the type causing the disease. In the treatment of 13 cases at Camp MacArthur, Tex., by Medalia15 it was concluded from the therapeutic results and agglutination tests that one serum which they used was more effective than another because it contained specific antibodies for the particular strains of meningococci causing their infections. Robison and Gerstley16 reported that they found an American serum to be practically useless in the treatment of meningitis in Coblenz, Germany, while almost 100 per cent of the cases treated with French serum recovered. They thought that possibly the American serum failed because strains of meningococci, similar to those encountered in Germany, were not used in its manufacture. Because of these differences, sera from several sources were usually kept available for use in the large hospitals.

Since the value of serum is greatest when given early in the disease, every effort was made to avoid delay in its administration. Usually doses of from 30 to 60 c. c. were injected intraspinally immediately following diagnostic lumbar puncture and drainage of the spinal fluid. If bacteriological examination showed meningococci in the fluid, the dose was repeated in 12 hours, and then daily, depending upon the condition of the patient. In the more severe cases, usually 6 to 10 injections were given. The therapeutic results obtained by


217

this method in different camps varied considerably, as is indicated by the case-fatality percentages. This was no doubt due to a number of factors; such as differences in the severity of infections, differences in the types of infecting meningococci, and variations in the time and methods of treatment.

While as a general rule serum was administered by the intraspinal route alone, in certain camps, including Camp Jackson, Camp Funston, and Camp Beauregard, intravenous injections were used in addition to the intraspinal therapy in a number of the cases. A comparison of the results obtained by the intraspinal method and the combined intraspinal and intravenous method of treatment at Camp Jackson was reported by Herrick,12 as follows:

Number of cases

Entire epidemic


Cases treated by intraspinal route

Cases treated by intraspinal and intravenous routes

265


137

128

Number

Per centa


Number

Per centa

Number

Per centa

Deaths

66

24.8

47

34.3

19

14.8

Mild cases

97

3.0

---

---

---

---

    

Early diagnosis

59

3.3

41

2.4

18

5.5

    

Late diagnosis

38

2.5

26

---

12

8.3

Severe cases

168

37.4

---

---

---

---

    

Early diagnosis

46

34.7

20

70

26

7.6

     Late diagnosis

122

38.5

50

64

72

20.8

aPercentages are mortality rates.

At Camp Beauregard, where the gross case mortality was 43.9 per cent, Landry and Hamley17 reported that whereas the mortality was 54.2 per cent in 86 cases given only intraspinal injections, and was 55.5 per cent in 9 cases given intraspinal injections followed late in the disease by intravenous injections, in 34 cases treated on admission by the combined method the mortality was 32.3 per cent. Again, the mortality among 191 Camp Funston cases, treated intraspinally, was 28.8 per cent; Stone and Truitt18 reported a mortality of 28.1 per cent in 32 cases treated by the combined intraspinal and intravenous method. Bigelow19 reported that 70 per cent of 10 cases treated intraspinally at a hospital center in France died; while the mortality was 62.5 per cent in 8 cases given the combined treatment. The usual nonspecific symptomatic treatment was used, of course, in all cases.

Cases of recurrent meningitis were treated, as a rule, in the same way as were primary infections.

Serum sickness occasionally followed the serum treatment in meningitis, but no cases of anaphylaxis occurred.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

Complications or sequelæ of various kinds occurred in more than one-third of the 4,831 cases admitted to hospital primarily for cerebrospinal meningitis; however, the case fatality was only 32.3 per cent among these complicated cases, while the fatality among the uncomplicated cases was 41.1 per cent.


218

Some of the more important complications and sequelæ which were reported are shown in the following table:

Disease

Cases

Deaths

Case mortality


Disease

Cases

Deaths

Case mortality

 

 

 


Per cent

 

 

 

Per cent

Arthritis

79

6

7.6

Mastoiditis

39

27

69.2

Ankylosis

7

0

0

Nephritis:

 

 

 

Apoplexy

5

2

40

    

Acute

14

7

50

Bronchitis

62

27

43.5

    

Chronic

14

5

35.7

Cardiac dilatation

3

3

100

Neuritis

28

0

0

Cystitis

8

4

50

Neuralgia

4

0

0

Conjunctivitis

6

0

0

Otitis media

100

42

42

Choroiditis

4

1

25

Pericarditis

13

4

30.7

Endocarditis, acute

13

5

38.4

Pleurisy:

 

 

 

Erysipelas

17

7

41.1

    

Suppurative

12

8

66.6

Epididymitis (nonvenereal)

9

0

0

    

Serofibrinous

6

5

83.3

Neuroses, functional

27

1

37

Paralysis:

 

 

 

Hemorrhage

1

1

100

    

Facial

4

0

0

Hearing, defective

29

0

0

    

No cause stated

50

2

4

Iritis

3

0

0

Paraplegia

6

0

0

Laryngitis

2

2

100

Pneumonia:

 

 

 

Myocardial insufficiency

15

3

20

    

Lobar

120

92

76.6

 

 

 

 

    

Bronchial

144

117

81.2

It will be noted that the mortality of meningitis, complicated by pneumonia, was especially high.

The records of the Surgeon General's Office show that in the Army during the World War the following concurrent diseases occurred in cases of cerebrospinal meningitis:

Disease

Cases

Deaths


Case mortality

Diseases

Cases

Deaths

Case mortality

 

 

 


Per cent

 

 

 

Per cent

Acute articular rheumatism

12

5

41.6

Measles

32

17

53.1

Diphtheria

9

1

11.1

Mumps

68

7

10.2

Influenza

67

24

35.8

Scarlet fever

8

1

12.5

The same records show also the occurrence of cerebrospinal meningitis as a concurrent disease in patients already suffering with the following diseases:

Disease

Cases

Deaths


Case mortality

Diseases

Cases

Deaths

Case mortality

 

 

 


Per cent

 

 

 

Per cent

Measles

93

37

39.7

Bronchitis

24

4

16.6

Influenza

542

256

47.2

Pneumonia:

 

 

 

Mumps

35

10

28.5

    

Lobar

60

44

73.3

Otitis media

23

14

60.8

    

Bronchial

65

31

47.6

PREVENTION

The measures employed to prevent meningitis in the Army during the World War can not be considered as altogether successful. In spite of the great care exercised in the isolation of cases, wholesale examinations made to detect and eliminate carriers of meningococci, and the various other methods employed to limit the spread of the disease, the incidence of meningitis in troops was much greater than in the civilian population. These experiences, however, were of value, as they helped to crystallize scientific opinion concerning the relative practical value of the different preventive methods tried.


219

Since the meningococcus, a delicate organism which dies quickly outside the body, is probably disseminated only by human cases or carriers, most of the methods used for controlling meningitis aimed at the prevention of contact between persons harboring the organism and normal individuals.

All meningitis patients were given specific and general treatment and were carefully isolated until disposed of, or until their secretions became free of meningococci, thus minimizing the danger of secondary contact infections during the course of the disease and eliminating the menace of "convalescent carriers." The special precautions observed varied; in some instances patients were isolated in separate rooms, but usually they were kept in isolation wards in which the beds were separated by sheets arranged to form cubicles. As a rule gowns were worn by the attendants and often gauze face masks were used by attendants, patients, or both. Antiseptic solutions of various kinds were used extensively for the disinfection of the hands and the upper respiratory secretions, and occasionally were employed as gargles or nasal sprays by attendants and patients.

The experience in the Army and in civil communities indicates that healthy individuals rarely contracted meningitis from patients having the disease. Usually, it was very difficult to trace the infection from any patient to a preceding one. This was no doubt largely due to the great care with which patients were isolated during treatment.

Whenever a case of meningitis occurred, all persons who had been closely associated with the patient were isolated, and nasopharyngeal cultures were made and examined for meningococci. Usually several individuals known as "contact carriers" were found who, although they showed no evidence of meningitis, harbored meningococci in the mucous membranes of the nose or throat. The percentage of carriers among contacts was greater than among noncontacts, and in the former group the percentage was highest among those most intimately associated with the patient.

Contact carriers were isolated until their nasopharyngeal cultures indicated that they were free from meningococci. Various antiseptics and antimeningococcus sera were used locally, and vaccines were administered subcutaneously in attempts to eradicate meningococci from the upper respiratory tract. The results of such treatment were not of obvious value, but fortunately the carrier state in contacts was usually temporary and even without treatment over two-thirds of them cleared up in a short time. Many observers thought that, except in carriers with diseased tonsils, sinuses, or pharynx where surgical removal of the focus was indicated, it was best to rely chiefly on exercise, fresh air, and sunlight for treatment of the carrier state.

Incubationary carriers or persons in the incubation stage of meningitis were rarely identified by nasopharyngeal cultures before clinical signs of the disease became manifest. When detected, they were isolated, of course, and given the usual specific and general treatment.

Extensive carrier surveys made in many of the camps showed that from 1 to 3 per cent of apparently normal individuals, who presumably had not been associated with meningitis cases, harbored meningococci in the upper respiratory tract. These persons were called "casual" or "noncontact carriers."


220

In some of the camps where meningitis was especially prevalent meningococcus carriers were reported as follows: At Camp Funston, Shorer20 found 3.22 per cent in 102,179 nasopharyngeal cultures; while Stone and Truitt18 reported 2.1 per cent in 196,000 cultures; and according to Baeslock,21 2.6 per cent carriers were identified in 19,178 cultures at Camp Jackson. An unusually large proportion of carriers, 9.1 per cent, was reported by Robey22 in 10,076 cultures at Camp McClellan, where meningitis occurred relatively infrequently. Lamb23 found 1.28 per cent in 20,208 cultures at Camp Cody, while at Camp Lewis 1.4 per cent carriers were reported in 18,998 cultures.

The isolation and treatment of these large numbers of meningococcus carriers proved to be a very difficult problem. They were kept in special wards, hospitals, or in segregation camps. Many antiseptics, including dichloromine-T, tincture of iodine, silver nitrate solution, and others were used locally in the nose and throat. The injection of meningococcus vaccines or local applications of serum apparently had no specific effect upon meningococci in the respiratory passages. Although some observers claimed that certain antiseptics were effective, it can be stated that no generally satisfactory specific cure for the carrier state was found. Apparently, outdoor exercise and exposure to sunshine was about as effective as the use of drugs in the treatment of meningococcus carriers.

The results of attempts to immunize normal individuals against meningococcus infections by means of specific vaccines were inconclusive.

Theoretically, it should be possible to prevent the occurrence of meningitis by the isolation of all cases and carriers, but the experience of the World War demonstrated the futility of such a course in large, active military organizations. As a result, during the latter part of the war it was considered advisable to limit isolation and treatment to actual cases of meningitis and contact carriers and to attempt to keep down infection by paying particular attention to the improvement of the general living conditions.

REFERENCES

(1) Weichselbaum, A.: Ueber die Aetiologie der akuten Meningitis cerebro-spinalis. Fortschritte der Medicin. Berlin, 1887, v, No. 18, 573; Ibid., No. 19, 620.

(2) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. I, 350.

(3) Ibid., 592.

(4) Ibid., 127.

(5) Ibid., 264.

(6) Dopter, Ch.: Étude de quelques germes isolés du rhino-pharynx, voisins du méningocoque (paraméningocoques). Comptes Rendus Hebdomadaires des Séances et Mémoires de la Société de Biologie. Paris, 1909, lxvii, Tome ii, 74.

(7) Gordon, M. H.: Cerebrospinal Fever. Special Report Series No. 50. British Medical Research Council, His Majesty's Stationery Office, London, 1920, 17.

(8) Official History of the War (British). Medical Services, Diseases of the War. His Majesty's Stationery Office, London, Vol. I, 147.

(9) Flexner, Simon: Control of Meningitis. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 8, 638.

(10) Wegeforth, Paul, and Latham, Joseph R.: Lumber Puncture as a Factor in the Causation of Meningitis. The American Journal of the Medical Sciences. Philadelphia, 1919, clviii, No. 2, 183.


221

(11) Weed, L. H.,; Wegeforth, Paul; Ayer, J. B.; and Felton, L. D.: The Production of Meningitis by Release of Cerebrospinal Fluid. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 3. 190.

(12) Herrick, W. W.: Early Diagnosis and the Intravenous Serum Treatment of Epidemic Cerebrospinal Meningitis. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 8, 612.

(13) Biological Files, S. G. O. (Old Supply Files).

(14) Overseas finance and supply records. On File, S. G. O. (Old Supply Files).

(15) Medalia, Leon S.: Epidemic Meningitis Situation at Camp MacArthur. The Military Surgeon, Washington, 1919, xliv, No. 3, 258.

(16) Robison, J. S., and Gerstley, J. R.: An Experience with Epidemic Meningitis. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 15, 1134.

(17) Landry, Adrian A., and Hamley, Wm. H.: Epidemic Cerebrospinal Meningitis at Camp Beauregard, La. The American Journal of the Medical Sciences, Philadelphia, 1919, clvii, No. 2, 210.

(18) Stone, Willard J., and Truitt, Ralph C. P.: A Clinical Study of Meningitis Based on Two Hundred Fifteen Cases. Archives of Internal Medicine, Chicago, 1919, xxiii, No. 3, 282.

(19) Bigelow, Geo. H.: Nonepidemic "Epidemic" Meningitis. Archives of Internal Medicine, Chicago, 1919, xxiii, No. 6, 723.

(20) Schorer, E. H.: Epidemic Meningitis and Detection of Meningococcus Carriers. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 9, 645.

(21) Baeslack, Fred W.: Epidemic Cerebrospinal Meningitis at Camp Jackson, S. C. The Journal of the Michigan State Medical Society, Grand Rapids, 1919, xviii, No. 11, 561.

(22) Robey, Wm. H., jr.; Saylor, H. L.; Meleney, H. E.; Ray, H.; and Landmann, G. A.: Clinical and Epidemiological Studies on Epidemic Meningitis. The Journal of Infectious Diseases, Chicago, 1918, xxiii, July 26, 317.

(23) Lamb, Frederick H.: Epidemic Cerebrospinal Meningitis at Camp Cody. The Journal of Laboratory and Clinical Medicine, St. Louis, 1919, iv, No. 7, 387.