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Second. That isolation should be insisted upon, together with disinfection of all excreta and of the sick room and its contents after they are no longer needed by the patient.

Third. That all cases should be promptly reported to the health department, that proper means may be taken to enforce isolation and disinfection.

Fourth. That unsanitary conditions contribute largely to the spread of the disease, and should be corrected wherever possible.

Fifth. That there is probably an abortive form, though at present it is not possible to prove it scientifically, in the absence of lumbar puncture.

Sixth. That the pneumococcus or diplococcus lanceolatus is not the cause of the epidemic type of the disease in question. Respectfully submitted.

WM. B. FRENCH, M. D.,
Special Medical Sanitary Inspector,
Health Department, District of Columbia.

The HEALTH OFFICER DISTRICT OF COLUMBIA.

Table showing case number, age, color, sex, duration, and termination.

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Table showing case number, age, color, sex, duration, and termination-Cont'd.

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List of physicians who have reported one or more cases.

Acker, George N.
Appleby, James F. R.
Bailey, Grafton D. P.
Baldus, William T.
Ball, Charles A.
Barber, James M.
Barker, Howard H.
Bogan, S. W.
Boyd, G. W.
Brooks, Philip B.
Brown, Charles W.
Burton, G. C.
Carr, William P.
Chappell, J. W.
Children's Hospital.
Childs, C. W.
Choate, Rufus.
Clark, George C.
Crook, Harrison.
Crosson, H. J.
Crusor, C. B.
Devereux, J. Ryan.

Douglas, J. F.

Eliot, Johnson.
Eliot, Llewellyn.

Emergency Hospital.
Emmons, Charles M.
Evans. Warwick.
Fisher, William N.
Freedmen's Hospital.
Fry, Henry D.
Gibbs, B. F.
Gill, William T.
Gillette, Hubbard.
Glazebrook, Larkin W.
Graham, Neil F.
Harding, H. T.
Hazen, D. H.
Hazen, W. P. C.
Holden, R. T.
Kolopinski, L.
Krogstadt, H.
Mazzei, F. A.
Medford, H. S.
Miller, Thomas.
Moran, John F.
Mudd, T. D.

Mundell, John H.
Ober, George C.

Pierre, S. M.

Price, John F.
Pyles, R. A.
Richardson, E. E.

Rixey, P. M.
Sellhausen, E. A.
Sewell, C. Á.
Shaw, John W.
Slattery, J. J.

Sprigg, William M.
Stafford, John J.
Stearns, J. S.
Stewart, C. C.
Stuart, A. Rhett.
Stuart, James.
Thompson, M. F.
Tucker, William P.
Walter, William F.
Washington Asylum Hos-
pital.

Watson, James A.
Wilder, J. R.
Winter, E. C. C.
Winter, John T.

CASE 1.-Age, 12 years. F. W.

HISTORY-CASES.

Family of a nervous temperament. Hygiene very poor. Vaccinated four or five years ago. First sick December 25, 1898; chill; moderate temperature; fast pulse; vomiting; severe headache; semiconscious; herpes labialis; muscular tremor, especially of arms when disturbed; marked rigidity of neck, and head drawn well back; general hyperæsthesia; decided photophobia; condition of pupils not recollected. These symptoms lasted, with varying intensity, for nearly six weeks, when gradual improvement began, and patient finally recovered perfect health.

CASE 2.-Age, 15 years. M. W.

Family history good. Hygienic conditions fair. No recent vaccination. First sick January 20, 1899. In this case the temperature ranged from 105 on second day, to normal several times during the disease, being quite irregular. Pulse full and rapid in beginning, and then slow, increasing in frequency toward the end. Respiration fast at first, then slower, and markedly slow at last. Herpes of lips and nose. No eruption. Muscular contractions, tremors, and convulsions present at times during disease. Hyperæsthesia during first and middle stages, followed by anaesthesia. Pupils contracted first few days, then diluted until death. Lids remained open for long intervals, giving, with the diluted pupils, a fixed, expressionless stare. Strabismus at first, later none. Opisthotonos well marked after first week. Marked deafness, increasing with duration of disease. Consciousness during first week, then partial for several weeks, followed by coma for last ten days. Urine negative. No complications. Died March 7, after forty-four days' sickness.

CASE 3.-Age, 12 years. M. C.

Parents in good health. Only child. Hygiene bad. Never vaccinated. No direct exposure, though there was a case of the disease in question within three doors. First sick February 15, 1899, with chill, fever, some vomiting, severe occipital and abdominal pain. Slow pulse. Marked retraction of head, and muscles of neck rigid. Legs draw up. Pupils dilated at times, and intense photophobia. One eye became inflamed and swollen, which condition disappeared later. Early delirium was followed by profound coma. Obstinate constipation, but when bowels were emptied their contents were passed involuntarily. Urine passed involuntarily. Patient remained in the above state for four or five weeks, when symptoms gradually improved and recovery became complete.

CASE 4.-Age, 13 years. M. W.

Parents in good health. A brother died of meningitis ten years ago. Hygiene fair. A year before present attack this boy fell on back of head on concrete pavement, but no bad results followed. On February 16, 1899, he was struck with a piece of ice on back of head, or fell on the ice, striking his occiput, and was rendered unconscious. After two or three days he seemed well and remained so for two weeks, when he complained of headache, pain in left shoulder and right hip, and at

night had chill, fever, and vomiting, and became unconscious on following day for an hour or more. For ten days subsequent to this time he was delirious, but would evince pain if moved. Muscles of neck stiff, and painful on moving. The attending physicians were changed several times in this case, and a connected history could not be secured. From April 17 to 23 the temperature ranged from 100 to 97.8, and pulse 88 to 118. With this date gradual improvement began, nourishment was taken, vomiting ceased, consciousness returned, and there seemed to be a promise of recov ery; but a few days before the 23d of May rapid failure of the patient occurred, and thirty-six hours before death on that date he had bronchorrhea, which appeared to be the immediate cause of the fatal termination. An earnest effort to secure an autopsy in this case failed.

CASE 5.-Age, 4 years. M. C.

Mother and four children in good health; father probably tuberculous. Hygiene poor. Child well until the summer of 1898, when he had chills, fever, and sweats, accompanied by epileptiform seizures; gradually recovered. About February 10, 1899, had chill, headache, abdominal pain, vomiting and purging, and was drowsy; respirations hurried, temperature high, delirious at night. Admitted to Children's Hospital February 17, 1899. Very irritable, dislikes to be disturbed; respirations 30, very slight dullness right apex posteriorly, roughened breathing, and numerous coarse and fine râles throughout both lungs. Pulse, 130, temperature, 103°; urine, negative. Sleeps well but perspires freely; irritable. February 19, coughs fre, quently; temperature irregular, with evening rise; 21st, increasing dullness at apicesmoist and liquid râles; 23d to 25th, about the same, though coughs less; is somnolen; and stupid; 27th restless during night; slight muscular twitchings. March 1 to 3, seems better. March 5, rigidity of muscles of shoulders and neck; head retracted to left. March 7, increased rigidity of neck; pulse slow; temperature from normal to 104.60; did not recognize his mother. March 9 to 11, takes nourishment poorly; continued rigidity of muscles of neck; head still retracted, and abdomen markedly retracted; constipated; temperature irregular. March 13, the same. March 15, general conditions about the same, though stupor is increasing; pupils irregular, at times contracted, at others dilated; respond to light. March 17 to 19, pulse weaker; muttering delirium for past twelve hours. March 21 to 23, stupor; crying out in sleep; pulse weak; temperature falling; sweats profusely, especially about head at night. March 25, objects to having right arm or leg moved; legs and arms flexed. March 29, has vomited several times in last twenty-four hours. March 31, vomiting continues; screams out if moved or touched; stupor absolute; swallows mechanically. April 2, tenderness marked over body, and especially over spine; constipated. April 3 and 4, general hyperæsthesia continues. April 6, temperature rauging higher; other symptoms the same. April 8 to 12, muscular twitchings of face; less retraction of head; temperature irregular. April 14, lumbar puncture yielded about 4 c. c. clear fluid, with nearly transparent floating masses in it. Cultures on old blood serum were not successful. April 16, general improvement. April 18 to 30, improvement continues. May 1, bright and talkative at times, at others cross and fretful.

During May has been comparatively comfortable, except occasional abdominal pains and pain on being handled. Temperature has ranged from 97° to 99.8; pulse 76 to 104. June 1 to 9, complained considerably of abdominal pain at intervals; cries out in sleep; grits teeth. June 11, discharge from left ear; temperature and pulse ranging higher. June 17, lies in mild stupor; neck seems stiff; vomited. June 20, sleeping badly; screaming at night; cries as if in pain during day. June 22, 8.30 p. m., on changing position, child became very rigid; head retracted; eyes rolled up and to the right, and knees flexed. June 23, another seizure of the same kind on changing position. June 25, sleeping with eyelids open; semiconscious. June 29, slight convulsion at 9 p. m.; head retracted; body rigid; eyes staring; vomited during night. June 30 to July 7, sleeping alternately well and poorly; temperature 98.8° to 105; pulse 92 to 150. July 9 to 13, conditions growing worse; pulse weaker and irregular; temperature 102 to 1050; respirations 30 to 46. Died 3 a. m 14th, temperature 104, pulse 160 to 170. Could not obtain consent to autopsy.

CASE 6.-Age, 6 years. F. W.

Family history good, except grandmother, who died February 24, 1899, of cerebrospinal meningitis, after six day's sickness, in same house with child. Hygiene very poor. Never vaccinated. Had epidemic influenza in January, 1899. Child first sick February 18, 1899, and sent to Children's Hospital on April 1. During the time between those two dates was attended by two physicians; the first one for a week, the second for the remainder of the time. In hospital temperature ranged from 98° to 104°, except a terminal rise to 109.50; pulse very fast and irregular. Hyperæsthesia of right side, parethesia of left; retraction of head to left; muscular contractions of feet; and last twenty-four hours of life waves of muscular contractions extending from head to feet occurring about every twenty minutes, and lasting three or four minutes. Paralysis of left side and right leg; incontinence of urine; pupils varying, but equal; rolling up of eyes; deafness; localized pain on pressure along spine and over scapula; marked pain, and some swelling in left knee and

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left elbow; difficulty in swallowing; screaming out in sleep; marked perspiration day and night. Cheynes-Stokes respiration. Bowels loose on entry, later constipated; no eruption; not unconscious until four hours before death, and during that time gave evidence of pain if head were moved. Died midnight of April 8th.

Autopsy (by Dr. William B. French, sixteen hours after death).-Body much emaciated, moderate rigor mortis; feet and hands strongly flexed; no eruption; abdominal and thoracic contents normal, except hypostatic congestion of lower lobe left lung. Vessels of dura and surface of brain engorged; fibrino-lymph covering structures of base as far forward as olfactory bulbs, and posteriorly beneath medullas in fissure between loves of cerebellum and a fourth inch on either side of fissure; laterally, lymph extended along middle cerebral arteries 2 inches on left side and three-fourths of an inch on right side; excess of clear cerebro-spinal fluid at base. Brain not dissected. Cord removed from upper cervical region to first lumbar vertebra. Space between pia and dura of cord posteriorly filled with thin layer of fibrinolymph; dirty brownish fibrino-purulent exudate between dura and bodies of vertebra. Hemorrhages into spinal canal. Cultures on blood serum, from fluid at base, showed typical specimens diplococcus intracellularis.

CASE 7.-Age, 11 months. M. W.

Parents in good health, and sister living. Hygiene bad. On the 20th of February, 1899, child was seized with convulsion, vomiting, muscular tremor, and fever. Temperature at first, 99 to 100; then higher, 103 to 104°; pulse fast. No herpes of lips. Body covered with measles-like eruption. On fifth day right hand seemed paralyzed. Extreme opisthotonus for three weeks, and unconscious last two weeks of life. Hyperæsthesia. Deafness. Pupils dilated. Died March 21. No autopsy. F. W. CASE 8.-Age, 1 year.

Parents in good health. Hygiene good. Never vaccinated. History of gross carelessness in diet (hominy fried in lard), followed by vomiting on February 24, 1899. Better next day, and not so well on 26th; temperature 103, and rapid pulse. On 27th, temperature 105. On 28th, pupils somewhat sluggish, but otherwise normal; slight retraction of head, and muscles of neck stiff; very irritable, with screaming spells and rapid breathing. Arms flexed and resisted extension. Child could be tilted up in bed by occiput without bending neck. Symptoms increased from day to day until death in coma on March 3. A few hours before the end temperature was 108°.

CASE 9.-Age, 26 years. F. C.

Family history negative. Patient never very strong nor well. Was asthmatic and hysterical. Had malaria six months and grippe a year prior to present sickness. Hygienic conditions fair. Vaccinated eight years ago. At beginning of sickness, February 24, 1899, temperature was 105, and dropped to normal at end of forty-eight hours, with no subsequent rise. Pulse was high and fell with temperature. No herpes. Eruption distinctly papular and evanescent all over body, but especially plentiful on thighs, hands, feet, face, and around margin of hair, and resembled varioloid, lasting throughout disease. Would fade and reappear. Persistent headache after first day, with delirium; pain in back and over sacrum, and Died on intense pain in abdomen. Pupils irregular toward last. Strabismus convergent just before death. Retention of urine after second day and catheter used. fifth day. No autopsy.

CASE 10.-Age, 16 months. F. W.

Mother and mother's family tuberculous. Father in good health. Hygienic conditions fair only. No recent vaccination, if any. Child has had cough for nearly a year, and on February 24, 1899, began a very severe pneumonia, with two convulsions, and has been more or less debilitated since. On June 8, 1899, patient had chill, temperature 105°, vomiting, rapid pulse, and became unconscious. Pupils equal, but sluggish; later irregular. After second day some rigidity of left arm and less of left leg; right arm in constant motion. Distinct convulsive seizures from six to ten times a day, and convulsive movements present throughout. UnconSister dead of tuberculosis buried from same house on day child scious until death.

was taken sick.

CASE 11.-Age, 34 years. F. C. Not Family history unknown. Brought to the Emergency Hospital by police on February 25, 1899. Was found wandering in streets in south Washington. vaccinated. Temperature ranged from 100 to 105.8, with remissions; pulse from 88 to 150. Herpes of lips, forehead, and eyelids. Vesicular eruption on forehead and inner sides of thighs. Spasmodic contraction of left arm and to a lesser degree of Left straleft leg. Head drawn to left side. Comatose on entry. Pupils at first contracted, then dilated and unequal. On third day ulcerations of each cornea. bismus. Albumin, 25 per cent by bulk. Unable to swallow during last two or three days and fed by nasal tube. Died March 1.

Autopsy (by Dr. J. J. Kinyoun).-Vessels of dura and surface of brain engorged. Pus between arachnoid and pia, over whole of cortex and base, into fourth ventricle.

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