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or purulent and with or without mastoid complication, the latter being infrequent. Otitis is always
secondary in cerebrospinal meningitis and there is no authentic case on record in which the infection
began in the ear and from this spread to the meninges. The contrary is always true—the ear
infection seems to be in direct extension from the brain, or an independent infection from the
nose and throat. In quite a number of patients, at the very outset or in the course deafness
supervenes without any lesion of the middle ear. In those there seems to be an affection of the
auditory nerve apparatus. Some of these may improve in time, others remain permanently deaf."
But does this explain the occurrence of such cases as I.R. and T.O.V. It is difficult to understand
how, in them, the otitis was secondary to the meningitis. They both presented pre-existing
otorrhoea; after an interval, a sudden onset of an acute illness, rapidly fatal; post-mortem, pus or
muco-pus in both ears, and pus over the vertex of the brain. Neither in these particulars, nor in any other,
so far as I am aware, did these two cases vary from suppurative meningitis, secondary to middle ear
disease; and there can be little doubt but that, say 20 years ago, before Weichselbaum's diplococcus
was generally known, they would have been so classed and no more thought about them. But an
organism was recovered from each, solely on the strength of which they were classed as cases of a specific
infectious disease, viz., cerebrospinal fever—very severe, if not fulminant cases of that disease—with
a fatal termination in three days: cases essentially identical with those that go to make up
epidemics. But is this classification reasonable ? Is it possible to resist what seems the obvious
reading that they were, in fact, secondary suppurative meningitis with an organism occurring
incidentally ?
Turning now to the association of tuberculous and of epidemic cerebrospinal meningitis, the
following passage will be read with interest. Professor Netter writes, in his article on cerebrospinal
meningitis in "Twentieth Century Practice," Ed. 1899, p. 174: "Finally the difficulty (of diagnosis) is
greatly increased by the fact that in certain epidemics of cerebrospinal meningitis the cases of tuberculous
meningitis are very numerous, and in such cases the cerebrospinal fluid may contain the agents
of cerebrospinal meningitis. Holdheim was the first to report a case of tuberculous meningitis in
which the fluid withdrawn contained the meningococcus, but he attributed the finding to an accidental
impurity. Heubner, Lenharz and Netter have, however, observed similar cases in which there could
be no question of contamination. This fact of the possiblity of mixed cerebrospinal meningitis is
a most important one, and teaches us that in spite of apparently the best founded presumption we cannot
always absolutely deny the tuberculous nature of any case of meningitis, and that the early hopes of
the positive value of lumbar puncture are not fully justified."
The case I.V. is an illustration ; another case which I have not at present been able to trace
is that of a patient who appeared to have cerebrospinal fever, and presented not only the diplococcus,
but a petechial rash. Post-mortem, acute miliary tuberculosis was revealed.
Consideration of such cases as these raises very important questions. The issue, of course, is
this. Were these patients suffering from a dreaded epidemic disease, or from some other form of
meningitis, in which an organism has been found so closely resembling Weichselbaum's diplococcus
as to be indistinguishable from it ? But if they are placed in the second of these classes, what becomes of
Weichselbaum's diplococcus as a pathognomon of cerebrospinal fever ? If this organism be found
in meningitis of other forms, it loses its distinctive importance ; and if the special criterion, as it is now
generally considered, of cerebrospinal fever be common to other diseases, the foundations of the
existence of that disease are assailed. These are questions which, it seems to me, cannot be lightly
or summarily answered. They require to be fairly faced and thoroughly examined. It is not pretended
that the data quoted are anything but entirely insufficient. Further observations are
greatly needed.
I should like now to quote a few cases which further illustrate the complexity of the diagnosis
of this disease ; and also show the desirableness of a complete examination in every case.
I.M.A., aged 15 months, had an acute illness lasting three weeks, ending fatally, and
showing signs of meningitis. No bacteriological examination was made. The diagnosis rested
between cerebro-spinal fever and tuberculous meningitis. Opinion inclined to the latter disorder.
There was no ear discharge, and on examination during life the ears appeared healthy. A postmortem
was held. Purulent inflammation of the membranes of the brain was marked ; there was
no indication of tuberculosis. Up to this point a review of the available evidence was consistent
with the diagnosis of cerebro-spinal fever. Then, however, the petrous bones were opened, and
the internal ears examined ; the left ear was seen to be healthy, but the right contained cheesy
pus. This may be regarded as the starting point of a secondary meningitis. Of course, it will
be said that such a collection of pus in the ears of young children is common, and is frequently
noted to lead to no bad result; and I believe that the records of some of the Childrens'
hospitals, though I have not the exact figures, show that such a condition occurs in the ears of upwards
of 60 per cent, of infants dying from all causes. But because the condition is one which, in the majority
of cases, leads to no bad result, can it therefore be contended that it never does ? May not some of
the apparently primary cases of meningitis in very young children be due to this cause ? What is the
proportion of cases of meningitis associated with this condition ? And what is the result of the bacteriological
examination of the contents of such ears ? So far as I know, without further observations,
no complete answers can be given to these questions.
I will quote another case illustrating the desirableness of a complete examination of a case.
T.T.S., aged five years, certified as epidemic cerebro-spinal meningitis. Clinically, there was
an acute illness lasting 24 hours, terminating fatally, and showing many of the signs of the illness
certified. My rough note, made at the patient's house, from the mother's statement, runs: "Patient had
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