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 v'ew 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.

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:

- was

1. Pvt. J. M. F., aged 25, admitted Jan. 5, 1918, 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

Purulent exudate in vertex Purulent exudate in base Purulent exudate in vertex and base.. 16 Purulent exudate in parietal region 5 While diffuse purpuric spots are absent on the serous surfaces, petechiae were frequently observed on these membranes of the pericardium. and peritoneum. It may be assumed that cerebrospinal meningitis is in more instances than has been supposed a bacteremia, co-existent with or followed by the formation of metastatic foci due to the distribution of the meningococcus by the blood stream.

This assumption is based on the following considerations:

1. The demonstration of the meningococcus in blood cultures in a larger percentage of cases than heretofore.

2. The presence of a distinct premeningeal stage of the disease.

cultures; this, however, was found impracticable owing to the large number of cultures which had to be taken daily and to the time required for cleaning, refitting, and sterilizing these tubes. Our next method of taking cultures was by means of sterilized wooden applicators. A small pledget of cotton wound on the end of these applicators permitted the culturing culturing through the nose, thus reaching the posterior nasopharyngeal wall. The last method employed by us consisted of applicators made from No. 18 stove wire. The wire is cut up into 8-10 inch lengths, a loop is bent on one end, and the other end hammered flat so that cotton wound around this end will hold. Five of The applicators are placed into a heavy walled

type. The type sera used were furnished by the Army medical school.

ISOLATION.

Upon notification from the laboratory, the men found to be carriers were isolated in the carrier camp, established by orders of the Division surgeon. Here a card index was kept of the date of entry, number of cultures taken and the results of the culture. Three negative cultures obtained in succession at from 3 to 5 day intervals, were required before discharge from the carrier camp.

TREATMENT.

The treatment of the carriers consisted in

for culturing, the wire is bent on the edge of the test tube to an angle of approximately 60 degrees, one and one-half inches from the end holding the cotton. By burning off the cotton and straightening out the wire it may again be prepared for use.

The reduced expense

and saving of time, as well as the ease with which cultures can be taken recommend its use.

The culturing was done in a convenient room which had been washed and cleaned previously. A table and chair for the clerk, a pail and a chair so placed that the person to be cultured. faces the light are all the furniture necessary. One man at the time is allowed to come into the room to prevent crowding. The tongue is depressed with a wooden tongue depressor and the culture taken by introducing the wire applicator well up the posterior portion of the nasopharynx, first on one side of the uvula and then on the other.

The applicator is withdrawn without touching the oral cavity and the culture plate inoculated, and the inoculated material evenly spread with a platinum wire.

The fireless cooker keeps the plates and cultures at constant temperature until placed in the incubator.

Owing to shortage in glassware we were compelled at first to put three cultures on each plate. This number was later reduced to two, as more petri dishes were available.

The agglutinations were carried out with one. or two polyvalent-sera, diluted 1:200 and normal horse serum diluted 1:50. All strains of meningococci isolated either from the spinal fluid, blood, or nasopharynx as well as those obtained from exudates of patients were typed. All strains thus examined were of the "regular"

with Dichloramine-T. Treatment was discontinued at least 18 hours before culturing.

During the period from December 18, 1917, until March 7, 1918, 520 carriers were isolated and treated in the carrier camp. Of this number six developed cerebrospinal meningitis.

The number of cultures taken from organizations during the months indicated are as follows:

Dec., 1917... 4873 Carriers isolated 176-3.6 % Jan., 1918...11825 Carriers isolated 293-2.47% Feb., 1918... 2480 Carriers isolated 51-2.06%

In all 97 organizations were involved in this epidemic. Of this number 59 were cultured, 38 were not cultured, since in the latter, one case only of cerebrospinal meningitis appeared. In addition 22 organizations were cultured for the purpose of removing the carriers before cases could develop.

Aside from the cultures taken in organizations and the Carrier Camp, it was thought advisable to culture all patients at the time of admission to the hospital. This measure was instituted to prevent the spread of meningitis to other than meningitis wards of the hospital by isolating patients who were carriers of the meningococcus. As soon as the patient was admitted through the receiving ward, he was. if able to walk, brought to the laboratory where the culture was taken, if unable to walk, the culture was taken at the receiving ward. From 75 to 125 cultures were thus taken daily at the laboratory. This number includes also those who desired leave of absence. A statement that bearer had been cultured and found negative was required before permission to leave the camp was granted.

The spread of cerebrospinal meningitis is mainly due to the carriers, who, under certain