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a bit of a cold and cough 14 days before his attack, but ran about as usual; other children had had
whooping cough. House infested with flies. Two children (brother and sister) seen, scalps and mucous
membranes ill cared for, excoriation of the nostrils and " colds." Face of one of the children scrubbed
by the mother with her apron while I was there." This was a polishing process done in such a way
as to suggest that it was common. The following was the note on the post-mortem examination, by
the pathologist who performed it. "Lepto meningitis with much flattening of the convolutions ;
a large quantity of greyish green, in some places yellowish, mucus in the nasal passages, the catarrh
having spread upwards into the ethmoidal cells." Here is a case resembling, clinically, cases
recorded as cerebro-spinal fever, and described as of a fulminating type. There can be little
doubt but that this case would have been so recorded but for the completeness of the pathological
examination. But with the evidence as it is, is there need to go beyond what seems the obvious
reading of the case, that here was a child with a cold, whose nasal passages, not being attended to and
kept clean, became obstructed, and filled with mucopus, from which inflammation spread to the
ethmoidal cells, and thence to the membranes of the brain ?
While these cases emphasise the necessity of making a complete necropsy, a similar conclusion
on the bacteriological side, is to be drawn from the following case:—
T.N.F.D.y 11 years.—Certified to have died of posterior basal meningitis.
Clinical.
An illness of 31 days' duration,
ending fatally, showing many of
the signs of meningitis, including
Kernig's sign.
Bacter'ological.
Meningococcus not found.
Tubercle bacilli were found in
the lymphatic glands of a guinea
pig, in the neighbourhood of an
injection made into it of the
cerebrospinal fluid from the case.
Pathological.
No evidence of tubercle. Pus
at base of brain. Meningitis apparently
unassociated with any
other morbid condition.
Here again is a case almost certain to have been classed as cerebro-spinal fever, but placed in its
proper category by the completeness of the bacteriological examination. It suggests the question as
to what would be the result, if all cases of posterior basal meningitis were so tested.
Evenuatlly a striking illustration of the value of additional evidence, which may be gathered
about cases, is afforded by a reference to the Death Returns for the year 1907. In this period 25
persons are shown as having died in London from cerebrospinal fever. By the courtesy of the
Registrar-General I have been enabled to ascertain the names of the 12 persons who were reported as
having died from that disease during the second half of the year 1907. These 12 cases were among
those into which I inquired, and the final result of my inquiries was as follows. Of the 12 cases in
question, 2 I noted as having died from meningitis apparently associated with no other lesions, and as
presenting an organism considered to be indicative of cerebrospinal fever ; in 5 cases the evidence
. was conflicting ; 2 cases were considered to be tuberculous meningitis 1 and the remaining 2 not
meningitis at all.
I will now refer more particularly to the bacteriological evidence. In his report of 18th
February, 1907, to the Local Government Board, page 1, Dr. Mervyn Gordon states:
"The presence within the human body of this micro-organism has been found to constitute the surest
test whereby cases of epidemic cerebrospinal meningitis can be detected. Its identification, therefore,
becomes a matter of no little importance with reference to that early and accurate recognition of this
disease upon which a successful system of prevention of the malady must in our present state of knowledge
in great part, if not wholly, depend." And on page 3 : "At the present day, therefore, it is
generally admitted that the Diplococcus intracellular is of Weichselbaum, or as this micro-organism is
sometimes termed, Micrococcus meningitidis cerebrospinalis, or more briefly the meningococcus, is certainly
the chief, and apparently the sole, bacteriological factor in epidemic cerebrospinal meningitis."
The characters of the meningococcus, which Dr. Gordon appears to consider of special importance
in its identification, are as follow :—
1. A coccus occurring usually as a diplococcus.
2. Occurring as intra- and extra-cellular.
3. Giving a negative result with Gram's stain.
4. Growing freely at 37°C. on a medium termed "nasgar " composed of Ascites fluid
and Nutrose mixed with Peptone agar.
5. Inability to grow on nasgar between 22°C. and 25°C. Of this test he says that it
"would appear to be of very great value for the purpose of distinguishing Gram-negative
cocci of the normal throat from the meningococcus."
Dr. Gordon mentions other reactions, which are characteristic of the meningococcus, viz., its
pathogenetic, agglutinating and fermentative properties ; but these, as I understand, he does not
consider essential to the identification of the meningococcus ; on the other hand, he would not consider
the meningococcus to be identified if it did conform to character No. 5.
Other bacteriologists, upon whose identification of the meningococcus recent cases have been
diagnosed in London, do not wholly agree with the above-named criteria. Cases have been
diagnosed as cerebrospinal fever on the bacteriological examination with the following variations.
The organism in a certain case was usually Gram negative, but on one occasion was undoubtedly
Gram-positive. In some cases a fermentation test has been applied, and importance attached to
it; in others this test was regarded as of no value. By some observers the behaviour of the organism
in milk and other media is taken into account, and, with most, the appearance of the growth, and its
behaviour to drying are factors in its recognition. Not a few cases have been certified on a