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basal meningitis. The report of the Committee, which the President appointed for this purpose, seems
to be so far from generally known that I will quote it in full. It is dated May 28th, 1907 :—
(1) We find, clinically, that although, as regards symptomatology and duration
there are some differences which might separate the most marked cases of cerebro-spinal
fever (epidemic cerebrospinal meningitis) and posterior basal meningitis from one another,
nevertheless intermediate cases occur in which such differentiation is impracticable.
(2) It cannot (at present) be maintained by experts, with absolute certainty that
there is any demonstrable difference in the bacteriology of the two diseases. The organism
which is commonly associated with each disease is microscopically the same (meningococcus,
micrococcus intracellularis, diplococcus intracellularis meningitidis), such variations as may
be met with being dependent on minor differences in cultural characters.
(3) It is noteworthy that, so far as has been ascertained at present, both diseases
tend to occur during the earlier months of the year, and that, although the occurrence of
the disease in both instances is epidemic, in neither has it the characteristics of a spreading
malady.
"The Committee recommend :—
(a) That, inasmuch as the season in which the disease is liable to be prevalent will not
recur for 7 to 9 months, the order of notification at present issued should continue in force
for a period of two years—in order to cover two possible epidemic periods.
"(b) That in the order of notification distributed to practitioners it should be stated
that for notification purposes the disease at present known as posterior basal meningitis is
included under the term cerebro-spinal fever.
"(c) That after notification further details of the cases should be obtained (i.) in hospitals
through the courtesy of the medical officers in charge ; (ii.) in private by a special officer
available to investigate the cases bacteriologically or otherwise, if desired, in association
with the practitioner in charge."
The means which exist for classification of the various cases as they arise, may be conveniently
placed in the three groups of (1) Clinical, (2) Bacteriological, and (3) Post-mortem evidence. The
case-notes which I have obtained have been arranged under these three heads and then compared.
In other words, an attempt has been made in certain cases of illness which conformed clinically to
cerebro-spinal fever, to ascertain how they showed bacteriologically, and on the post-mortem table.
The value to be attached to clinical evidence is indicated by Professor Osier in his
Principles and Practice of Medicine, Ed. 1905, p. 163 : "One has constantly to bear in mind that
certain cases of typhoid fever and of pneumonia closely simulate cerebro-spinal meningitis. Long
ago Stokes made the wise observation that4 there is no single nervous symptom which may not and does
not occur independently of any appreciable lesion of the brain, nerves, or spinal cord.' " And again,
on p. 926, he says : "I have already, on several occasions, called attention to the fact that cortical
meningitis is not to be recognised by any symptom or set of symptoms from a condition which may
be produced by the poison of many of the specific fevers. In the cases of so-called cerebral pneumonia,
unless the base is involved and the nerves affected, the disease is unrecognizable, since identical symptoms
may be produced by intense engorgement of the meninges. In typhoid fever, in which meningitis is
very rare, the twitchings, spasms, and retractions of the neck are almost invariably associated with
cerebro-spinal congestion, not with meningitis. Actual meningitis does, however, occur in typhoid
fever, and, as Ohlmachers cases show, the typhoid bacilli may be present in the exudate."
It would be unnecessary to dwell on the weakness of clinical evidence, when taken by itself,
were it not for the fact that it is sometimes claimed that that class of evidence alone is sufficient
for an accurate and final diagnosis to be made. The following cases form an illustration of the
result of relying solely on clinical evidence:—T.N.N., aged 26 years, was certified to be suffering
from epidemic cerebro-spinal meningitis, the diagnosis being made after observation for about a week.
Death occurred before I could see the patient, but the account of the case was not such as to raise
doubt as to the accuracy of the diagnosis, except on the general grounds of the unreliability of
clinical evidence. Another case, T.N.F., age 29, was also under observation for about a week, and
epidemic cerebro-spinal meningitis was confidently assigned as the cause of illness and certified as such.
I saw this case in consultation, and, although it presented features which did not exactly harmonise with
the diagnosis of meningitis, it was not possible to exclude that disease or even to deny its probability.
Necropsies, however, were obtained in both cases, and revealed in the one case, general septicaemia,
and in the other, cerebral hoemorrhage. Had no post-mortem examinations been made, both cases
would have remained on record as cerebro-spinal fever.
Referring now to a clinical sign which has been considered to be of special value in the diagnosis of
cerebro-spinal fever, viz., Kernig's sign, it seems to me that there has been sometimes a tendency to
exaggerate its importance ; in point of fact it has been held to indicate not the presence of cerebrospinal
fever, but merely of meningitis from any cause. Professor Osier, in an article in the
Encyclopaedia Medica," Ed. 1901 (Vol. VII., p. 499), on " Epidemic Cerebro-spinal meningitis,"
writes: Within the past three years we have found this (sign) of the greatest possible
assistance, and I may say that it has been present in all cases of meningitis in which it has been looked
for, and it has not been found in any case in which meningitis was not present."
In the recent cases in London, however, the amount of assistance given by this sign has been
somewhat disappointing. Of the 14 cases, for instance, alluded to below, and verified post-mortem
to be meningitis, the sign was present in 9, absent in 2, and in 3 no record on the point was available.
Opinion indeed appears to have changed somewhat during the last few years, for Dr. Koplik contributes
the following description to "A System o£ Medicine " (Osier and McCrae), Ed. 1907, p. 509 :—