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(4) Pneumococcal meningitis.—The pneumococcus was obtained in film
preparation and pure culture from the fluid of two cases, both fatal, one due to
pneumococcal septicaemia, the other to extension from disease of the middle ear.
It is worthy of note that out of a total of 32 investigated cases of all forms of
generalised meningitis, the meningococcus organism was held responsible for five,
or 15 per cent.; the other forms being tuberculous in 66 per cent., streptococcal,
pneumococcal, influenzal in 6 per cent. each.
Diseases of the middle ear and accessory nasal sinuses.—Of the 11 cases of meningitis
under the previous heading, nine may be regarded as attributable to a blood
infection by the particular organism concerned ; the other two, occurred as secondary
extensions from the middle ear, one being due to streptococcus, the other to the
pneumococcus. Valuable information as to the involvement of the meninges in
conditions requiring urgent operative measures, may, therefore, be provided by
examination of the cerebro-spinal fluid, e.g., middle-ear disease and inflammatory
conditions of the accessory nasal sinuses.
Besides the two cases just mentioned, fluid was also examined from four others ;
in two cases of middle-ear disease, involving the mastoid bone, the fluid was found
normal showing no evidence of meningitis, one made recovery after operation, the
other proved fatal from operative shock, and post-mortem examination of the brain
showed no evidence of meningitis. In one case the fluid gave definite evidence of
meningitis, by the excess of protein present and heavy deposit of inflammatory
cells. Death occurred, meningitis being found post-mortem, due to extension of
inflammation from the sphenoidal sinus. On the other hand a localised meningitis,
as in a case which proved fatal from extension of inflammation from the frontal
sinus, may show little change in the cerebro-spinal fluid, owing to the restricted area
infected becoming shut off from the rest of the cranial cavity.
Grross cerebral lesions.—(1) Cerebral Abscess—(Four cases). The cerebro-spinal
fluid may show little or no change in composition, but the following case of abscess
secondary to inflammation of the frontal sinus proved an exception. The fluid on
lumbar puncture yielded a heavy deposit of pus showing a few gram-positive cocci
in film preparations but yielding no growth in cultivation. Purulent meningitis was,
therefore, diagnosed. Post-mortem examination, however, showed that an abscess
in the frontal lobe had ruptured into the lateral ventricle, thus accounting for the
presence of pus in the cerebro-spinal fluid.
In a second case, diagnosed clinically as tuberculous meningitis, the excess of
polymorphonuclear cells, low protein content, and absence of tubercle bacilli were
not suggestive of meningitis, but taken in conjunction with the clinical features,
headache, vomiting and optic neuritis, were more in favour of cerebral tumour or
abscess. Post-mortem showed multiple cerebral abscesses secondary to pulmonary
bronchiectasis.
In two other cases the composition of the fluid was found to be within the normal
limits and gave no clue to their diagnosis. Post-mortem examinations revealed, in
one, a cerebellar abscess secondary to chronic middle ear disease, in the other, abscess
of the temporo-sphenoidal lobe attributable to puerperal infection.
(2) Cerebral tumour.—Three cases, in which the alternative diagnosis of tuberculous
meningitis was clearly contra-indicated by the negative characters of the fluid
in each case. In two, the absence of any change in the fluid, taken in conjunction
with the clinical features, suggested the possibility of encephalitis lethargica, but
post-mortem examination showed in each case a gliomatous tumour involving the
occipital lobe. In the third case, a normal cell content but excess of protein were
regarded as in favour of cerebral tumour, taken together with a history of persistent
headache and disordered vision. Post-mortem proved this amended diagnosis to
be correct, deposits of cerebral growth secondary to carcinoma of the bronchus
being found.
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