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49
was clear and colourless with a cell count of 7 or 8 per c.m.m. and centrifugation
yielded scanty number of blood corpuscles and lymphocytes and a very few polymorph
cells. Total protein of .04 per cent., globulin not in excess. Dextrose
slightly in excess of the normal.
Clinical diagnosis suggested either encephalitis lethargica or tuberculous
meningitis. The latter was clearly contra-indicated by the practically normal
cerebrospinal fluid, except for a slight increase in protein. Unfortunately tests
were not applied for the Wassermann or colloidal benzoin reactions, but the fact
that there was no increase of globulin makes it probable that the reactions would
have proved negative. Moreover, the Wassermann reaction in the blood had been
found negative.
The conclusions arrived at as the result of the examination of the fluid were,
therefore, in favour of encephalitis as the more probable of the two suggested
diagnoses, but with the added alternative of cerebral tumour, which post-mortem
examination subsequently proved to be as nearly correct as was possible. However,
as ophthalmoscopic examination revealed no abnormal changes in the fundus oculi
pointing to cerebral tumour, the case was decided to be one of encephalitis lethargica
and notified as such. Following lumbar puncture there was considerable improvement
in mental alertness, with disappearance of headache and vomiting for over a
month, when a relapse occurred; drowsiness again supervened with gradual loss
of consciousness and death took place 6 weeks after admission. The post-mortem
discovery of meningitis and gummatous tumours in the right frontal lobe was quite
unexpected, but the syphilitic nature of the tumours was verified by microscopic
examination.
Meningismus, a term applied to conditions simulating meningitis, in which
the fluid is found to be normal in composition, occurring in infancy or early childhood,
the symptoms being due to reflex disturbance attributable to the toxic effect
of an acute febrile attack, e.g., in pneumonia; also associated with teething or
gastric disorder. Examples were provided by five cases of broncho-pneumonia,
acetonæmia, vomiting and diarrhoea, constipation and teething, in children aged
six months to 5 years, in whom the original diagnosis of meningitis was disproved
by the completely normal fluid and by the subsequent course of events.
Other cases in which lumbar puncture was performed for diagnostic purposes and
yielded normal fluid were five cases in which the cerebral conditions suspected were
cerebral abscess, meningitis, uraemia, cerebral haemorrhage, and cerebral tumour or
meningitis; the final diagnoses reached in these five cases were nephritis, enteric
fever, nephritis, carcinoma of stomach and chronic nephritis respectively.
Special investigations.
In addition to the routine laboratory examinations, certain special investigations
were conducted:—
(1) A bacteriological examination was made by Dr. Forbes of samples of the
pulverised material from the refuse dump at Ebury Bridge, a reference to which
appears on page 75.
(2) Dr. Nairn Dobbie also carried out a series of tests on the dust-allaying
properties of a special oil used on the surface of school flooring. His observations
were directed to ascertaining by bacteriological methods, as an approximate index
of the relative number of dust particles, the number of organisms deposited when
agar and gelatin culture plates were exposed to the air for certain periods in rooms
where floors had been treated or not with the oil preparation. The plates were
then incubated and counts made of the resulting colonies which had grown. In
two selected schools six experiments were carried out, comprising 24 separate tests,
12 being in a treated room, 12 in a non-treated, and under such varying atmospheric