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excess of globulin and a lymphocytosis of 27 per c.mm. Alternative diagnoses of
tuberculous or other meningitis in 10 cases were also contra-indicated by negative
bacteriological results in slide and cultural examinations.
Tuberculous
meningitis.
Examination was made of 21 specimens of cerebro-spinal fluid from 19 cases.
The original clinical diagnosis of tuberculous meningitis was regarded as probable in
12, and doubtful in 7 cases, with alternative suggestions of septic or pneumococcal
meningitis in 3, cerebral tumour in 2, cerebral abscess in 1, and encephalitis in 1.
From examination of the fluid it was possible to arrive at a positive diagnosis
of tuberculous meningitis in 11 cases, or 61 per cent., by the discovery of tubercle
bacilli in slide preparations of the fine clot usually present, together with the characteristic
well marked lymphocytosis. In the other 8 cases conclusions were based
solely on the excess of lymphocytes with cell counts of 200 to 300 per c.mm..
examination of the clot having failed to show the presence of tubercle bacilli.
In addition, chemical examination of the fluids showed a range of the total
protein content from .1 to .7 per cent., more often .1 or .2, globulin in excess, and the
presence of dextrose in traces below normal, but in 2 cases there was no reduction
of Fehling's solution—results which, together with the cytological evidence, were in
accord with the diagnosis of tuberculous meningitis, supported by the clinical features
and fatal termination, further verified in 4 cases by post-mortem examination.
In 4 additional cases a tentative diagnosis of tuberculous meningitis was not supported
by examination of the cerebro-spinal fluid, which showed no departure from the
normal, borne out by recovery in 3 cases, and, in the remaining case which ended
fatallv, bv post-mortem discovery of cerebral abscess.
MeniDgitis.
Meningitis, due to other organisms than the tubercle bacillus, was diagnosed
on the examination of 14 specimens of cerebro-spinal fluid from 12 cases, as shown by
the presence of pus or a marked excess of polymorphonuclear cells, clot formation,
high protein content, usually the non-reduction of Fehling's solution, as well as by
cultural tests and the identification of the causative organisms. As might be
expected from the low incidence of cerebro-spinal fever during the past year, with
the exception of one case, the meningococcus has been conspicuously absent as the
causative organism in the cases of meningitis investigated. The following organisms
were identified either in slide preparations of the cell deposit or in culture
Streptococcus in 5 cases (in three secondary to otitis media and invasion of the
mastoid, and in one following on pneumonia—all 4 of which proved fatal), one
case, in which a streptococcus of low virulence was isolated from the cerebro-spinal
fluid, associated with rheumatism, mitral valvular disease and resulting septicaemia,
eventually recovered from the attack of meningitis.
Pneumococcus in 4 cases, associated with septicaemia or pneumonia, all proving
fatal.
B. influenzce in 1 case, which later developed measles and died after an illness
of 4 weeks.
Meningococcus in 1 case, identified in slide preparations from the cell deposit,
but not obtained in culture, the case proving fatal after 3 weeks and diagnosed
as post-basic meningitis rather than epidemic cerebro-spinal meningitis.
Staphylococcus pyogenes aureus was eventually obtained in culture from a case
which on clinical grounds and from the cytological examination of the cerebro-spinal
fluid led to the provisional diagnosis of cerebro-spinal meningitis. Death occurred
two days later and post-mortem examination showed acute endocarditis, pericarditis
and commencing cerebral abscess formation with leakage into the subarachnoid
space, inflammatory cells thus gaining access to the cerebro-spinal fluid.
Inflammation
of the middle
ear.
In 6 cases of suppuration of the middle ear with involvement of the mastoid,
examination of the cerebro-spinal fluid proved of value in deciding whether inflammation
had extended to the meninges, and in helping to exclude alternative
diagnosis of encephalitis, typhoid fever or cerebral abscess. In 3 of the 6 cases
there was found evidence of meningitis due to streptococcal infection which proved