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post-mortem, trustworthy as far as it goes ; and the bacteriological apparently infallible. No wonder
then that the bacteriological evidence is felt to be the sheet anchor in diagnosis.
I will now proceed to compare the evidence in certain recent London cases. No difficulty is
experienced when it all points in the same direction—when the bedside signs are confirmed by the
bacteriological, and both by the post-mortem. But what of those cases in which the evidence is contradictory,
and the bacteriological and post-mortem evidence is in conflict ? Which are we then to
believe ? I have notes of 14 cases which were originally believed to be either epidemic cerebrospinal
or posterior basal meningitis, and all but one were so certified. The clinical evidence of that disease
was well marked, but the post-mortem examination excluded it. In 8 of these 14 the meningococcus
was absent, but in the other 6 cases the meningococcus was found, or an organism resembling it so
closely as to identify the disease ; and the conflict of evidence in 5 of these cases is so remarkable
that I will quote them in detail. For the notes of the patients I am indebted to the courtesy of
the respective physicians in whose care they were.
I.R., aged 2 months.—Certified as epidemic cerebrospinal meningitis.
Clinical.
Had an acute illness with many
of the signs of meningitis including
Kernig's sign, terminating
fatally at end of three days.
Otorrhœa noted during life.
Bacteriological.
Small diplococcus resembling
Weichselbaum's organism. It
was seen in large numbers contained
within the leucocytes. It
lost the stain by Gram's method.
No growth obtained : it was tried
on agar and blood.
Pathological.
Post-mortem examination
showed pus of a thick creamy
character . . . scattered over the
entire brain . . . and down
spinal cord. Both middle ears
contained pus and also the R.
nasal fossa. There was no caries
of the bone in these situations
and nothing to suggest that
infection started from the ears or
nose.
The final diagnosis by the certifying physician, was epidemic cerebrospinal meningitis, and the
case was so recorded. It was considered that the inflammation in the ears was secondary to that of the
brain; but it is not easy to see why suppuration should have spread from the meninges to the ears
rather than from the ears to the meninges. The mother stated to me that the child had had a running
of the ears before he was taken ill, and that she had syringed the ears for that reason.
I.V., aged 8 months.—Certified as epidemic cerebrospinal meningitis.
Clinical.
Died after 50 days' illness which
showed clinically many of the
signs of meningitis including
Kernig's sign.
Bacteriological.
Diplococcus intracellularis meningitidis
of Weichselbaum recovered
from the cerebrospinal
fluid.
Pathological.
Post-mortem general tuberculosis.
T.O.V., aged 6 months.—Certified as epidemic cerebrospinal meningitis.
Clinical.
An acute illness lasting 3 days,
terminating fatally, presenting
clinically many of the signs of meningitis,
including Kernig's sign.
The mother stated that she attended
a hospital with the child
when he was 6 weeks old, for a
running from the ear and that
she used to syringe the ear.
Bacteriological.
Intracellular and extracellular
Gram-negative diplococci in fluid
from lumbar puncture during life.
Pathological.
Thin sheet of pus over vertex
(of brain), 3 drachms of creamy
pus in pericardium.
Mucopus in both ears.
T.T.N.B., aged 7 months.—Certified at death as posterior basal meningitis.
Clinical.
An illness lasting 52 days, terminating
fatally, presenting signs
of meningitis, but not Kernig's
sign.
Bacteriological.
Intracellular and extracellular
Gram—negative diplococcus recovered
from cerebrospinal fluid
during life. Culture sterile.
Pathological.
Creamy purulent exudate at
posterior base of brain. . . .
Lateral sinuses and fourth ventricle
contained pyolymph and
were dilated. . . . Pus in left
ear, mucopus in right ear.
T.M.N.B., aged 20 months.—Certified at death as cerebrospinal meningitis ; considered to be posterior
basal meningitis.
Clinical.
An illness, lasting 22 days,
terminating fatally, showing signs
of meningitis, but not Kernig's
sign.
Bacteriological.
In cerebrospinal fluid taken
during life was found the diplococcus
meningitidis intracellularis.
Pathological.
Post-mortem examination
Purulent meningitis. Double
otitis media.
On the relationship between otitis media and cerebrospinal fever, the following is a quotation
from " A System of Medicine " (Osier and McCrae, Ed. 1907, p. 513).
Dr. Koplik writes :
"Otitis in its various forms is a very frequent complication. In fact, in certain forms of the
affection, especially in young children, English observers have advised early puncture of the drum
even with slight symptoms of myringitis as a possible measire of relief. The otitis may be catarrhal