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In cerebral concussion and congestion, with or without blood effusion, the
withdrawal of fluid by lumbar puncture invariably gives relief. Examination of
the fluid may show nothing abnormal except in the event of actual haemorrhage,
of which the presence of blood or blood serum in the fluid may be indicative, but
not invariably so.
The fluid from three cases of concussion, two of which occurred as the result
of falls on the head during epileptic seizures, showed traces of blood visible only
on centrifugation. In the third of the three cases there was doubt as to the diagnosis,
encephalitis lethargica being in question owing to the marked drowsiness and
headache. However, lumbar puncture released a considerable amount of fluid
slightly blood-stained and under raised pressure, which gave prompt relief to the
symptoms. From the subsequent rapid recovery of the patient, together with
the history of sudden giddiness resulting in a fall on the head, it was concluded that
the symptoms were attributable only to concussion.
As an example of cerebral congestion may be mentioned a case in which the
diagnosis of tuberculous meningitis was corrected as the result of examination
of the cerebro-spinal fluid. The presence of serum and blood cells, but no excess
of lymphocytes and no tubercle bacilli, indicated only cerebral congestion. This
was borne out at post-mortem examination, the condition being found due to
ulcerative endocarditis, although there was no evidence of cerebral embolism.
Other cerebral conditions or disordered mental states, simulating encephalitis or
its sequelæ, in which the fluid was found to be normal in composition, included:—
post-influenzal depression, dementia præecox, psychosis of puberty and epilepsy
(two cases). In the absence of a past history of epileptic attacks the diagnosis
of the lethargy due to the post-epileptic state may be difficult to distinguish from
the drowsiness of encephalitis. The problem is all the more puzzling when encephalitis
supervenes in a chronic epileptic, and vice versa, when, as occasionally
occurs, epilepsy develops as a post-encephalitic condition. The epileptic complication,
whether one of association with encephalitis, or directly resulting therefrom,
or requiring differentiation of two separate causes of a lethargic state, has hitherto
received scanty attention in the literature of the subject.
Cerebral degeneration or atrophy in early life calls for separate classification
and provided two examples only.
1. Cerebral diplegia in a child of five, who had suffered from loss of power of
the right side of the body for some months and epileptiform fits. There was no clear
history of encephalitis lethargica but the clinical condition in hospital suggested
either meningitis or encephalitis as accounting for the lethargic state. The cerebrospinal
fluid was quite abnormal in appearance, of a milky opacity, yielding no clot
but considerable deposit of amorphous cell debris and degenerate cells in units and
clusters and a cell count of 25 per c.m.m. Protein content -025 per cent., globulin
in slight excess. Dextrose, definite trace.
Whilst not in favour of meningitis, the changes in composition of the fluid were
regarded as not inconsistent with those occurring in some cases of encephalitis and
described as catarrhal ependymitis or inflammation of the membrane lining the
cerebral ventricles, but such changes may also be found in cerebral atrophy, to
which group the case was eventually decided to belong.
2. Chronic internal hydrocephalus.—This condition is most often attributable
to a past attack of post-basic or meningococcal meningitis in early infancy, by the
inflammatory process blocking the foramen of Majendie in the roof of the fourth
ventricle, thus creating obstruction to the outflow of fluid from the ventricles of
the brain and causing their subsequent distension. Occlusion of the foramen may
also occur as a developmental defect, causing simple congenital hydrocephalus. The
fluid withdrawn in considerable quantity from a child aged 7 months, was faintly
blood-tinged, and in addition to the blood corpuscles, film preparations from the
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