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traces in 5. With the exception of two all yielded the characteristic fine clot or
threads of fibrin.
Cytology.—Cell counts were made in 4, yielding an average of 87 per c.m.m.
and ranging from 68 to 130. In the remainder a marked or definite lymphocytosis
was present.
Bacteriology.—Tubercle bacilli were found in films from the teased clot or cell
deposit in twelve, were regarded as doubtful in two and not found in 9 specimens.
Chemistry.—The total protein content showed a range of .025 to .7 per cent.,
with an average of .22 per cent. Globulin was present in marked excess in 21,
slight excess in 1, and not in excess in 1. Dextrose was found present in slight
traces in 16, and absent in 7 specimens.
As a result of examination of the fluid the clinical diagnosis of tuberculous
meningitis was supported with certainty in twelve, and strong probability in six
cases, to be subsequently confirmed by post-mortem examination in the 18 cases.
In eight cases the clinical diagnosis was given alternatively, as encephalitis in six,
cerebral tumour in one and cerebral syphilis in one. But in six of the eight, including
the two last-mentioned diagnoses, after examination of the fluid, it was possible to
eliminate the suggested alternatives in favour of tuberculous meningitis, postmortem
later affording confirmatory proof.
Examples of difficulties in diagnosis.—In two cases the presence of a lymphocytosis
and increased protein content and the failure to find tubercle bacilli, were
regarded as supporting the possibility of encephalitis, but this was not confirmed
post-mortem, for both proved to be cases of tuberculous meningitis.
On the other hand in two other cases, not included in the above category, the
primary diagnosis of tuberculous meningitis, in spite of the failure to find tubercle
bacilli in the fluid, seemed justified by the increase in lymphocytes and protein
content. Yet subsequent events showed this to be incorrect, the patient recovering
in one case, and post-mortem examination in the other revealed a non-tuberculous
post-basal meningitis.
In a further case, also suggested as tuberculous meningitis, the diagnosis was
definitely contraindicated by the practically normal fluid and the clinical features
in favour of cerebral tumour or abscess, later confirmed by the autopsy showing
multiple cerebral abscesses secondary to bronchiectasis.
Meningitis other than tuberculous.—Fourteen specimens of fluid from 11 cases
of meningitis due to other organisms than the tubercle bacillus were examined.
The characters of the fluid in each case were distinctive of a form of meningitis,
which to the naked eye, from the marked turbidity, was obviously not tuberculous,
and which on further examination showed a heavier protein content, 1 to 9 per
cent., marked excess of globulin, absence of dextrose and heavy cell deposits, either
in the form of pus, or polymorphonuclear excess with dense coagulum.
Bacteriologically the cases fell into the following groups:—
(1) Meningococcal=(cerebro-spinal, post-basic) meningitis.—Five cases in
which the meningococcus was recognised in film preparation from the cell deposit,
but owing to the rapidity with which it dies on exposure to cold, the organism
was successfully cultivated only in one case. Two cases recovered, three
proved fatal.
(2) Influenzal meningitis.—Two cases, both fatal. B. influenzae (Pfeiffer)
was obtained in pure culture on blood agar and identified in film preparations
from the cell deposit in each case.
(3) Streptococcal meningitis.—A hemolytic streptococcus was grown in
pure culture, and found in films from the cell deposit of two cases—both fatal,
one occurring as an uncommon sequela five weeks after scarlet fever, the other
following middle-ear disease.