Communicable Diseases, Table of Contents

CHAPTER IV

CEREBROSPINAL MENINGITIS

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

Many sporadic outbreaks and small epidemics have beenreported throughout the world since 1805, when the disease was recognizedclinically by Vieusseau. However, an accurate bacteriological diagnosis was notpossible before 1887 when Weichselbaum¹ showed themeningococcus (Diplococcusintracellularis meningitidis) to be the specific cause of cerebrospinalmeningitis.

This infection has, no doubt, occurred in our Army during allprevious wars. Interesting clinical reports of outbreaks are recorded inhistories of the War of 1812, the Mexican War, and Civil War; while it isevident from these reports that meningitis was present, the incidence is notknown since there was considerable confusion in the nomenclature anddifferential diagnosis and, of course, bacteriological diagnostic methods wereunknown. In spite of the fact that the meningococcus had been recognized as thespecific cause of cerebrospinal meningitis for 10 years previous to theSpanish-American War, very few of the cases which occurred during that periodwere diagnosed by accurate laboratory methods, and clinically the disease wasconfused to some extent with typhoid, typhus, and other fevers. It is obviouslyimpossible, therefore, to make a comparison of the meningitis rates of our Armyfor the World War with the rates for any previous war. Such a comparison notonly would be worthless, but also misleading.

Since the Spanish-American War the diagnosis of cerebrospinalmeningitis in the Army has been more exact, and the records have included onlycases in which the clinical diagnosis was confirmed by bacteriologicalexamination. During this time, as indicated graphically in Chart XXVI, theannual admission rate per 1,000 strength has been almost negligible, exceptduring the mobilization of unseasoned troops; for example, the rate increasednoticeably in 1907 at the time of the Cuban occupation, in 1913 during themobilization on the Mexican border, and again in 1917 when the United Statesentered the World War. It is noteworthy that the concentration of Regular Armytroops on the Mexican border in 1911 was not attended by any remarkable increasein the meningitis admission rate.

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

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Cerebrospinal meningitis has for some time been known as adisease of soldiers, or a "barracks disease," because of its tendencyto become more prevalent during the mobilization of recruits. These terms werejustified by the increased incidence in the Army during the World War. The rapidmobilization of enormous numbers of untrained, unseasoned men, from all sectionsof the country, and their subsequent, intimate contact in large camps, providedideal conditions for the dissemination of meningococci, and as a consequencemeningitis was far more prevalent than in normal peace times.

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

STATISTICAL CONSIDERATIONS

The total mean annual strength of the Army for the periodApril 1, 1917, to December 31, 1919, was 4,128,479. As indicated in Table 28,4,831 cases of cerebrospinal meningitis were reported as "primaryadmissions" during this period, giving an annual admission rate of 1.17 per1,000 of strength, or 117 cases among every 100,000 men. Death occurred in 1,836cases, or 38 per cent, giving an annual mortality rate of 0.44 per 1,000, or 44deaths in 100,000 men.

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TABLE 28.-Cerebrospinal meningitis. Primaryadmissions and deaths shown by countries of occurrence for officers and enlistedmen, United States Army, with ratios per 1,000 strength, April, 1917, toDecember 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 cerebrospinalmeningitis are considered in the figures given above or in the statisticaltables used in this chapter. However, during this same period 1,008 additionalcases and 443 deaths were reported as "concurrent diseases," havingbeen admitted to hospital for other conditions. Therefore the total number ofcerebrospinal meningitis cases was 5,839, an annual admission rate of 1.41 per1,000 strength; while the total number of deaths was 2,279.

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DISTRIBUTION BY GRADES

The incidence and mortality rates for enlisted men weregreater than for commissioned officers. The annual admission rate amongenlisted 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 strengthwas 206,382. The annual death rates per 1,000 were: Enlisted, 0.46; officers,0.27.

The lower incidence and mortality rates among officers wereno doubt due to several factors. As a rule the officers were older than theenlisted men and possibly less susceptible to the infection. They also hadcertain advantages, such as less crowded living quarters, less exposure tohardship and fatigue, and because of their training they were better able tounderstand and apply the principles of personal hygiene and sanitation.

RACIAL DISTRIBUTION

Meningitis was more common among colored than among whiteenlisted 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 casefatality for colored troops was 42.7 per cent and for white troops, 35.3 percent. A comparison of the rates in the United States is shown in Chart XXVII. Ithas 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 thespread of meningococci.

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

GEOGRAPHICAL DISTRIBUTION

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

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

IN THE UNITED STATES

During the World War, meningitis occurred most frequently introops stationed in the United States. There were 2,878 primary admissions amongAmerican enlisted men in this country, an annual admission rate of 1.29 per1,000 strength; death occurred in 986, or 34.1 per cent of the cases. The annualdeath rate was 0.44 per cent 1,000 strength; 131 patients were discharged fordisability, a rate of 0.06 per 1,000. A total of 150,386 days were lost becauseof the disease. The admission and death rates for colored troops were higherthan for white, as shown in Chart XXVII.

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CHART XXVII

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TABLE 29.-Cerebrospinal meningitis. Primaryadmissions and deaths, by months, withannual ratios per 1,000 strength; white and colored enlisted men, UnitedStates 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

 

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TABLE 29.-Cerebrospinal meningitis. Primaryadmissions and deaths, by months, with annual ratios per 1,000 strength; whiteand 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

 

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Cerebrospinal meningitis, as indicated by the weekly reportsof the United States Public Health Service and the United States mortalitystatistics, had been prevalent and widely distributed throughout the civilianpopulation of the United States for several years before we entered the WorldWar. The rapid mobilization of over a million men from all sections of thecountry between April and October, 1917, naturally brought the disease intoevery cantonment, and the monthly admission rates increased to a peak of over 4per 1,000 in January, 1918. From this point the rate fell to about 0. 3 inAugust, 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 decreasedafter 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 absolutenumbers in Chart XXVIII. Evidently the incidence was affected not so much bytemperature or season as by mobilization.

Chart XXVIII

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

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TABLE 30.-Cerebrospinalmeningitis. By camps of occurrence, showing primary admissions and deaths, withannual ratios per 1,000 strength, white and colored enlisted men, United StatesArmy; also case fatality rates, April, 1917, to December, 1919

The highest primary admission rates for white and coloredenlisted 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 inthese camps were, respectively, 284, 132, and 153, or one-fifth the total numberfor the whole country. It is obvious that the increased prevalence was notdue entirely to the size of these camps, since other large camps such as CampDix, N. J., had much lower admission rates; furthermore,it can not be ascribed to climate or other similar local conditions, since therates for different camps in a single State, or for differentStates in a given section of the country, varied considerably. For example, inSouth 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

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CHART XXIX

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

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

The relatively high incidence of meningitis in certain of ourcamps was no doubt due mainly to the fact that large numbers of susceptible menfrom rural sections, under the strain and fatigue incident to intensive militarytraining, were, for the first time, brought into close contact withmeningococcus carriers and cases.

CAMP JACKSON, S. C.

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

CAMP WADSWORTH, S. C.

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

CAMP BEAUREGARD, LA.

There were 132 cases, an annual primary admission rate of6.40 per 1,000 in this camp,which drew troops mainly from Louisiana, Arkansas, and Mississippi,⁴all of which States have a large rural population.

CAMP FUNSTON, KANS.

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

IN EUROPE

Meningitis in the American Expeditionary Forces occurredsporadically rather than in extensive epidemics. A large percentage of the casesoriginated either in the base ports or on shipboard, and, as a rule, theincidence was highest in organizations from training camps with high rates inthe 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 1,000strength, or 111 cases in every 100,000 men. Of these, 802 died, a case fatalityof 43.3 per cent; the annual death rate was 0.48 per 1,000 strength. The firstcase was reported in June, 1917, and more cases occurred as the strength of theArmy 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 dueto outbreaks in organizations which had brought the infection with them fromtheir training camps in the United States.

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

ETIOLOGY

While the experience during the World War added nothingentirely new to our knowledge of the etiology of cerebrospinal meningitis, itemphasized the relative importance of certain contributing factors.

As stated above, since 1887 it has been known that thedisease is a specific infection caused by the meningococcus. In 1909 Dopter⁶differentiated two types of meningococci which hedesignated "normal" and "para." Gordon⁷ dividedmeningococci isolated from cases of meningitis, which occurred in British troopsduring 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 intheir serological reactions. The relative frequency of these types in theBritish 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 withDopter by dividing the meningococci into normal, para, and intermediate types.

In the United States Army the typing of meningococci was nota routine procedure; however, it was done in a great many instances. Theinformation obtained sometimes aided in the selection of therapeutic serum forindividual cases or in tracing the relationship between cases or carriers. Thereports from certain organizations indicate that the normal type (II)predominated; that the para type (I) was about half as frequent, and that arelatively small percentage of the intermediate types (III and IV) were found.

It is now generally believed that the normal habitat of themeningococcus is the posterior nasopharynx of man. In susceptible individualsthe organism may invade the body and produce meningitis, while in resistant orimmune persons infection does not occur. These latter, apparently normal"carriers," may harbor meningococci in their throats for long periodsof time and spread them to their associates. While it has been estimated thatabout 1 to 3 per cent of the population are carriers, fortunately relatively fewpersons are susceptible to the infection. Conditions which increase the contactbetween carriers and susceptible individuals favor the spread of meningitis. Thetendency 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 closertogether

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

DIAGNOSIS

The specific diagnosis of cerebrospinal meningitis dependsupon the isolation and identification of the meningococcus from thecerebrospinal fluid. During the World War, spinal punctures usually wereperformed on all patients with symptoms of meningeal irritation orinflammation; and the diagnosis was based entirely on the bacteriologicalexamination of the spinal fluid. Wegeforth and Latham,¹⁰ however, warnedagainst the indiscriminate use of spinal puncture as a diagnostic procedure inhuman septicemia, stating that the release of spinal fluid was an importantfactor in the development of meningitis. This observation was preceded by theinvestigations of Weed, Wegeforth, Ayer, and Felton,¹¹ who showed that inanimals suffering with an experimentally produced bacteriemia, spinal puncturewas invariably followed by meningitis. It was therefore recommended that carefulconsideration be given to the bacteriological study of the blood beforeattempting puncture of the spinal canal. However, in spite of the fact thatcases were observed in which the spinal fluid obtained at the first puncture wassterile and from later punctures infected, this was usually considered only anindication of the normal progress of the infection; and it was quite generallybelieved that diagnostic spinal puncture in meningitis was not attended by anyserious results.

The observations of previous workers that meningococci mayinvade the blood stream were confirmed during the World War by Herrick.¹² Hereported 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 theappearance of meningeal symptoms; and, as a consequence, he advocated the moregeneral use of blood cultures as an aid to early diagnosis, and proposed thatthe term "meningococcus sepsis" be used.

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

The symptomatology of cerebrospinal meningitis observedduring the World War did not differ materially from that already recognized ascharacteristic of the disease. Naturally, differences occurred in the percentageof severe and mild cases in the various camps, resulting in variations in thepredominant clinical signs and symptoms.

TREATMENT

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

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case fatality in different camps in this country varied from8 to 43.9 per cent, as shown in Table 30. These differences no doubt wereinfluenced to some extent by differences in the severity of the disease invarious localities, but the most important factor was probably the duration ofthe disease before serum therapy was begun.

According to Flexner⁹ and others, specific serum treatmentreduced the mortality due to meningitis from a percentage of 60 to 90 to a grosscase mortality of 23 to 50 per cent, and even to a much smaller percentage whenthe 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 suppliedprincipally by the Rockefeller Institute, the New York City Board of Health, andthree commercial laboratories.¹³ As a rule, from 30 to 80 strainsof meningococci, representing different proportions of the various types, wereemployed in its preparation. In France, additional serum was obtained from thePasteur Institute.¹⁴

In individual cases, considerable differences were observedin the therapeutic results obtained with different sera, and occasionally caseswhich were not improved by one serum were promptly benefited by another. In someof these instances the first serum used may have been generally lacking inantibody content, but usually the therapeutic failure occurred because the serumhad been prepared with a large proportion of meningococcus strains which weredifferent from the type causing the disease. In the treatment of 13 cases atCamp MacArthur, Tex., by Medalia¹⁵ itwas concluded from the therapeutic results andagglutination tests that one serum which they used wasmore effective than another because it contained specific antibodies for theparticular strains of meningococci causing their infections. Robison andGerstley¹⁶ reported that they foundan American serum to be practically useless in the treatment of meningitis inCoblenz, Germany, while almost 100 per cent of the cases treated with Frenchserum recovered. They thought that possibly the American serum failed becausestrains of meningococci, similar to those encountered in Germany, were not usedin its manufacture. Because of these differences, sera from several sources wereusually kept available for use in the large hospitals.

Since the value of serum is greatest when given early in thedisease, every effort was made to avoid delay in its administration. Usuallydoses of from 30 to 60 c. c. were injected intraspinally immediately followingdiagnostic lumbar puncture and drainage of the spinal fluid. If bacteriologicalexamination 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 severecases, usually 6 to 10 injections were given. The therapeutic results obtainedby

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

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

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 43.9per cent, Landry and Hamley¹⁷ reportedthat whereas the mortality was 54.2 per cent in 86 cases given only intraspinalinjections, and was 55.5 per cent in 9 cases given intraspinal injectionsfollowed late in the disease by intravenous injections, in 34 cases treated onadmission by the combined method the mortality was 32.3 per cent. Again, themortality among 191 Camp Funston cases, treated intraspinally, was 28.8 percent; Stone and Truitt¹⁸ reporteda mortality of 28.1 per cent in 32 cases treated by the combined intraspinal andintravenous method. Bigelow¹⁹ reportedthat 70 per cent of 10 cases treated intraspinally at a hospital center inFrance died; while the mortality was 62.5 per cent in 8 casesgiven the combined treatment. The usual nonspecific symptomatic treatment was used,of course, in all cases.

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

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

COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES

Complications or sequel? of various kinds occurred in morethan one-third of the 4,831 cases admitted to hospitalprimarily for cerebrospinal meningitis; however, thecase fatality was only 32.3 per cent among these complicated cases, while the fatalityamong the uncomplicated cases was 41.1 per cent.

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Some of the more important complications and sequel? which were reportedare 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 followingconcurrentdiseases 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 cerebrospinalmeningitis as a concurrent disease in patients already suffering with thefollowing 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 preventmeningitis in the Army during the World Warcan not be considered as altogether successful. Inspite of the great care exercised in the isolation of cases, wholesaleexaminations made to detect and eliminate carriers of meningococci, and thevarious other methods employed to limit the spread of the disease, the incidenceof meningitis in troops was much greater than in the civilian population. Theseexperiences, however, were of value, as they helped to crystallize scientificopinion concerning the relative practical value of the different preventive methods tried.

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Since the meningococcus, a delicate organism which diesquickly outside the body, isprobably disseminated only by human cases or carriers,most of the methods used for controlling meningitis aimedat the prevention of contact between persons harboring theorganism and normal individuals.

All meningitis patients were given specific and generaltreatment and were carefully isolated until disposed of, or until theirsecretions became free of meningococci,thus minimizing the danger of secondary contact infections duringthe course of the disease and eliminating the menace of"convalescent carriers." The special precautions observed varied; insome instances patients were isolated in separate rooms, but usually they werekept in isolation wards in which the beds were separated by sheets arranged toform cubicles. As a rule gowns were worn by the attendantsand often gauze face masks were used by attendants,patients, or both. Antiseptic solutions of various kinds were used extensivelyfor the disinfection of the hands and the upper respiratory secretions, andoccasionally were employed as gargles or nasal sprays by attendants andpatients.

The experience in the Army andin civil communities indicates that healthy individuals rarely contractedmeningitis from patients having the disease. Usually, it was very difficult totrace the infection from any patient to a preceding one. This was no doubtlargely due to the great care with which patients were isolated duringtreatment.

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

Contact carriers were isolated until their nasopharyngealcultures indicated that they were free from meningococci.Various antiseptics and antimeningococcus sera were usedlocally, and vaccines were administered subcutaneously in attempts to eradicatemeningococci from the upper respiratory tract. The resultsof such treatment were not of obvious value, but fortunately the carrier statein contacts was usually temporary and even without treatment over two-thirdsof them cleared up in a short time. Many observers thoughtthat, except in carriers with diseased tonsils, sinuses, or pharynx wheresurgical removal of the focus was indicated, it was best torely chiefly on exercise, fresh air, and sunlight fortreatment of the carrier state.

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

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

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In some of the camps where meningitis was especiallyprevalent meningococcus carriers were reported as follows: At Camp Funston,Shorer²⁰ found 3.22 per cent in 102,179 nasopharyngeal cultures;while Stone and Truitt¹⁸ reported2.1 per cent in 196,000 cultures; and according to Baeslock,²¹ 2.6per cent carriers were identified in 19,178 cultures at Camp Jackson. Anunusually large proportion of carriers, 9.1 per cent, was reported by Robey²²in 10,076 cultures at Camp McClellan, where meningitis occurred relativelyinfrequently. Lamb²³ found 1.28 per cent in 20,208 cultures at CampCody, while at Camp Lewis 1.4 per cent carriers were reported in 18,998cultures.

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

The results of attempts to immunize normal individualsagainst meningococcus infections by means of specific vaccines wereinconclusive.

Theoretically, it should be possible to prevent theoccurrence of meningitis by the isolation of all cases and carriers, but theexperience 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 itwas considered advisable to limit isolation and treatment to actual cases ofmeningitis and contact carriers and to attempt to keep down infection by payingparticular 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.: ?tude de quelques germes isol?s du rhino-pharynx, voisins du m?ningocoque (param?ningocoques). Comptes Rendus Hebdomadaires des S?ances et M?moires de la Soci?t? 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.

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(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.; andLandmann, G. A.: Clinical and Epidemiological Studies on Epidemic Meningitis. TheJournal of Infectious Diseases, Chicago, 1918, xxiii, July 26, 317.

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