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unsuspected fracture lines are then often determined. Apparently trivial cases, without immediate symptoms, disclose linear or depressed fractures, or fractures of the inner table only. If the depression is definitely localized and not extensive, a vertical incision will suffice, and the operative hemastasis will be simple, and the attachment of the temporal muscle to the parietal crest is left intact.

When it is desired to expose a large area of the brain, an osteoplastic flap, with pericranium and scalp intact, is desirable. A constant stream of warm saline solution will keep the operative field clean and washes away clots and fragments of bone, and aids in locating the source of hemorrhage. The most frequent source of hemorrhage is, of course, from the middle meningial artery, or its anterior or posterior branch. If the dura is contused the edges are excised.

The bone edges are treated in like manner; foreign bodies imbedded in brain tissue, and accessible, should be removed by direct extraction, or with the aid of a magnet, provided, of course, that this can be done without severe injury to the tissue; the tract or wound is mechanically cleansed, and is then ready for closure.

Dr. Cushing advocates the use of a rubber catheter, attached to a suction apparatus, for cleansing out a tract and removing fragments and devitalized brain tissue; and the injection of dichloramine-T where the bacteriological examination indicates.

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In the event of blood welling up into the operative field from some part which cannot be reached with a ligature, the area is packed with gauze, which may be removed within twenty-four hours; this condition is frequent in fractures which involve the vault and base. If the dura is intact and there is no pulsation, it is incised to relieve the sub-dural pressure and, if possible, to determine its cause. No drainage should be inserted in the brain, unless we are concerned with an abscess cavity.

When we have the final reports and statistics on brain injuries, and their treatment, covering the period of the world war, they will, I believe, undoubtedly impress upon us, amongst other things, the importance of early operative interference in cases of brain injuries.

EPIDEMIC CEREBROSPINAL MENINGITIS AT CAMP JACKSON, S. C.

FRED. W. BAESLACK, M.D.

DETROIT, MICH.

The first case of cerebrospinal meningitis at Camp Jackson, S. C., was diagnosed Nov. 15, 1917. The disease assumed the character of an epidemic during December, and January and February of the year following.

PREDISPOSING FACTORS.

The rapid spread of this disease through the camp was due to the following predisposing circumstances:

1. The unusual cold weather with sudden, marked temperature changes during the later fall and winter of 1917-18, to which the majority of men were not accustomed, and which caused a widespread nasopharyngeal catarrh, bronchitis, mumps .and measles.

Tables 1, 2, 3 and 4 give the weather conditions during the months of November, December, 1917, and January and February of the year following.

2. The general condition of the camp, which, was not completed until the end of the winter. The facilities for heating the buildings were especially retarded. To keep warm, the men would stay indoors, crowding the barracks, thus coming into closer contact with those suffering from nasopharyngeal inflammations.

The majority of the barracks rooms were heated by one large furnace, the size of a hot air furnace used for heating houses. Usually two such furnaces were installed in the center of the two rooms on the ground floor. As there were no pipes for the distribution of the heat throughout the building, during spells of cold weather the men would congregate around these furnaces, thus offering every advantage for the spread of respiratory infections.

3. The base hospital was not completed, and while every attempt was made to accommodate all, the problem became more involved, because white and negro patients had to be kept separate.

4. The laboratory facilities were meager. The function of the base hospital laboratory as a public health laboratory for the entire camp had not been taken into consideration in the

plans of the hospital. This was corrected during the later part of January both as regards space and equipment.

5. The transfer of troops from one can

tonment to another. By this means new foci of infection were introduced, and the problem of coping with the condition present complicated. The following cases are illustrative of this:

(a). Nov. 18, 1917. D. S., Pvt, Co. 21, 156 D. B. from Camp Pike, Little Rock, Ark., taken from train directly to hospital, diag. C. S. M.

(b). F. M., Pvt., Co. 23, 156 D. B. from Camp Pike, Little Rock, Ark., arrived at Camp Jackson Nov. 17, 1917; admitted to Base Hosp., C. S. M. No. 21, 1917.

(c) P. B., Pvt., Co. 15, 156 D. B. from Camp Gordon, Atlanta, arrived at Camp Jackson, S. C., Nov. 5, 1917. Admitted to Base Hosp. as C. S. M. Suspect. Nov. 8, 1917; diagnosis pos. C, S. M., Νον. 10, 1917.

(d). W. F. F., Pvt., Co. 21, 156 D. B. from Camp Pike, Little Rock, Ark., arrived at Camp Jackson, S. C., Dec. 1, 1917; diagnosis C. S. M.

BACTERIOLOGY.

While it is highly probable that local inflammation of the nasopharynx may be caused by the meningococcus before its invasion becomes general, its exact etiologic significance in relation to the inflammation of the respiratory passages is still doubtful, for its presence on the inflamed naso-pharyngeal membrane may be accidental. The absence of marked inflammation of the naso-pharyngeal membranes in some cases of meningitis throughout the entire course of the disease further support this view. The assumption that the meningococcus reaches the meninges from the nasopharynx by way of the cribriform plate of the ethmoid is also questionable in view of the findings of Westenhoffer, Von Lingelsheim and Meyer, which indicate that if direct extension does occur, its course is through the sphenoid bones, the sinuses of which were found inflamed in 34 per cent. of cases examined.

That the meningococcus produces a local inflammation before invading the general system may be assumed until further data are available. From the nasopharynx the organism invades the blood current, either directly, causing a meningococcus bacteremia with secondary localization in the meninges, or by a direct infection through the lymphatics, as pointed out by Westenhoffer, who observed the constant enlargement of the cervical lymph glands.

That this disease may at times be a generalized infection has been shown by Solomon, Moller, Bettencourt, Franc, and Elsner, who have in isolated instances succeeded in culturing the meningococcus from the blood. Elsner succeeded in isolating the organism in 25 per cent.

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While generally cerebrospinal meningitis is diagnosed from the symptoms resulting from meningeal irritation, there is observable in many cases a premeningeal stage of the disease which varies in time from several days to a few hours, and is characterized by general septic symptoms, as chills, fever, malaise, lack of appetite, indefinite pains in the joints and muscles. The headache observed in this stage is probably due to increased amounts of cerebrospinal fluid which on lumbar puncture is found clear, containing no organisms or only a few free meningococci which may be explained by the general sepsis. The cytology of the fluid may be negative or may show a slight increase in lymphocytes. The Globulin test may be negative or faintly positive. Fehling's solution is reduced. The essential impression gained from the examination of the fluid during this stage of the disease is not that of meningitis, but rather that due to a general toxemia.

STAGES OF INVOLVEMENT. ́

The stage of meningeal involvement has been variously subdivided according to severity of the disease, its symptom complex and probable prognosis.

This general bacteremia leads to widely scattered foci of infection in the body, of which that of the meninges is the most commonly observed. The following cases are illustrative of the metastatic involvement of other regions of the body than the meninges:

-1. Pvt. J. M. F., aged 25, admitted Jan. 5, 1918, was in poor condition; there were marked tremor, and cyanosis of the lips and finger tips. The provisional diagnosis was bronchitis following measles, Jan. 11; broncho-pneumonia developed. The patient died Jan. 15. Cultures of pus found at necropsy, in the sphenoid sinus, gave a gram-negative diplococcus, which was identified as a meningococcus of the regular type.

2. S. R., Pvt., aged 23, admitted Nov. 15, 1918, complained of cold and pain in chest, and pain in the eyes and back. The provisional diagnosis was measles. Nov. 24, bronchitis developed in the left side. Nov. 28, there was pleurisy on the left side. Next day the diagnosis of bronchopneumonia was made. Jan. 15, 1918, an intercostal incision for left emphyema was made and a large amount of slightly cloudy serous fluid removed. A meningococcus of the regular type was isolated from it.

3. Chas., Pvt., 156 D. B., Co. 19, was admitted as meningitis suspect. One lumbar puncture made, examination of spinal fluid negative. Patient developed mumps, and was transferred from wards for meningitis cases to that for mumps. To determine whether patient had had meningococcic infection, sample of blood was obtained.

The serum from this blood agglutinated a strain of meningococcus of the regular type up to 1:320 dilution.

4. Miss M., Nurse, reported on sick list, diagnosis articular rheumatism, which did not yield to usual treatment. On suggestion of the Chief of the Laboratory, a blood culture was taken,. disclosing a gram-negative diplococcus, which was identified as a meningococcus of the regular type. Patient was put on antimeningococcic serum treatment, receiving it intravenously, and recovered promptly.

These instances clearly show that the meningococcus is distributed by the blood stream, giving rise to lesions wherever conditions are favorable, without necessarily involving the meninges. To the same mechanism of distribution may be credited the complications and sequellae incident to this disease, as involvement of the joints, pleurisy, pericarditis, ophthalmitis, etc.

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3. The occurrence of lesions due to the meningococcus in parts other than the meninges. 4. The autopsy findings, with special reference to the occurrence of petechiae and purpuric spots. Based on these observations the intravenous serum therapy in large doses was recommended by us to Major W. W. Herrick the Chief of the Medical Service. The agglutinating titer of most antimeningococcic sera lies between 1:800 to 1:1000. It will be seen that fairly large quantities of serum must be administered intravenously to have the therapeutic agent in sufficient concentration to act upon the meningococci present in the blood stream.

STATISTICS.

Two hundred and fourteen meningitis patients from 97 organizations were admitted to the base hospital. Out of this number 65 died, 88 were returned to duty shortly after dismissal from the hospital, 57 requiring additional time for complete recuperation; 4 were discharged; 2 cases recurred.

Twenty-eight of the patients were city residents before entry into the National Army, 159 were rural, the residence of 27 could not be determined.

PROPHYLAXIS.

The prophylactic measures instituted consisted of:

(a) The isolation of those complaining of symptoms observed in the premeningeal stage of the disease.

(b) The placing of the organization in quarantine.

of the respiratory tract, made possible the prompt treatment of meningitis patients, while still in the early stages of the disease.

The extent of the quarantine was determined by the number of men the suspected case had come into contact with, just previous to his illness. Depending on this a single squad room, or barrack or the entire organization would be placed under the quarantine.

The infecting organism of cerebrospinal meningitis gains access to the respiratory passages by the inhalation of the fine spray droplets produced in the act of sneezing and coughing. The large number of men suffering from coryza, pharyngitis and bronchitis would aid materially in spreading the meningococcus infection in crowded rooms, provided contacts and carriers were among them. Hence the men were kept out of doors as much as possible, and the seating in the Mess rooms was so arranged that the men occupied alternate seats. Crowding the barracks wherever it occurred was relieved, and the cots so arranged that no twomen slept side by side with the heads in the same direction, but alternating.

BACTERIAL DIAGNOSIS.

As soon as diagnosis was established by the laboratory, name, rank and organization were reported to the office of the Division Surgeon. All contacts were quarantined and arrangements made for the taking of cultures. A list of those quarantined, made in triplicate, was furnished the culturing team, consisting of three physicians detailed to this duty by the Division

(c) Preventing the men from congregating Surgeon. in the barracks.

(d) Alternating the position of the cots. (e) Culturing the quarantined personnel 3 or more times at 5 day intervals, or until no more carriers could be found.

(f) Culturing all patients on admission to the hospital and segregating those found to be carriers in the hospital.

(g) The culturing of all applying for leave of absence from the camp.

(h) The isolation and treatment of the carriers in the carrier camp.

The vigilance exercised by the regimental surgeons in isolating those complaining of headache, malaise, chill, indefinite pains in muscles and joints combined with inflammation

2. For a discussion of the intravenous serum treatment of cerebrospinal meningitis and the results obtained, the reader is referred to the article by W. W. Herrick, Major, M. R. C. The intravenous serum treatment of Epidemic Cerebrospinal Meningitis. Arch. Int. Med. Vol. XXI, 1918, p. 541.

This team would obtain the necessary number of blood-agar plates, pack them into a fireless cooker and visit the organization for culturing. The plates were numbered and the corresponding number entered next to the name on the rosters prepared. The cultures and rosters were delivered at the laboratory. and on conclusion of the examination those found to be carriers were entered as positive on the lists, one of which was forwarded to the office of the Division Surgeon, one to the organization, the third being retained at the office of the laboratorv for record.

The cultures were incubated for 18-24 hours, examined and transplants of suspicious colonies made by three members of the Laboratory staff. Agglutination tests were made on all suspicious cultures. The media used consisted of laked blood, 1 per cent. glucose-agar.

At first the West tube was used for taking

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