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In eight cases consent for post-mortem examination was obtained, and the
typical appearances of tuberculous meningitis were found. The identification of
tubercle bacilli in the fluid of 15 cases during life had however already definitely
established the diagnosis, and in the remaining three, in which bacilli were not found,
the diagnosis was on the whole in favour of tuberculous meningitis from the high
lymphocyte and protein content, but remained doubtful until verified by postmortem
examination.
Cerebrospinal
meningitis.
6. Cerebrospinal Meningitis.—1,5 specimens of fluid were examined from seven
patients; one aged 20 and the others aged six or under, in whom the diagnosis of
meningitis had already been made in hospital, but information as to the type of
infection could only be provided by bacteriological examination. The characters
of the fluid in the acute stage were distinctive, showing marked turbidity, heavy
deposit of polymorph cells, with the presence of gram negative diplococci in film
preparations of the cell deposit, and the meningococcus was obtained in pure culture
in three of the cases ; the remainder proving sterile.
The protein content ranged from .13 to .75 per cent. yielding an average of .32
per cent., and globulin was present in marked excess. Dextrose was usually absent;
in three cases there was a very faint reduction of Fehling's fluid—chloride estimation
in three specimens amounted to .7, .58 and .64 per cent. In the later stages of the
disease, which resulted in recovery after three months in two cases, polymorph cells
were replaced by lymphocytes, and only a very few degenerate meningococci were
visible, whilst cultures proved sterile.
In the five fatal cases, death occurred 6 days, 16 days, two months and three-four
months after first onset of symptoms. Post-mortem examination, which was allowed
only in one case, showed typical cerebro-spinal meningitis, and diagnosis of the
other cases was based on the result of examination of the cerebro-spinal fluid.
The meningococcus (diplococcus intracellularis meningitidis of Weichselbaum)
is held responsible for two types of meningeal infection. The one known as cerebrospinal
fever or meningitis or "spotted fever" may occur (1) in epidemic form, and
was notably prevalent during the early period of the war twelve years ago among
both the civil and military population; or (2) sporadically, giving rise to isolated
cases in non-epidemic times ; characterised by sudden onset and not uncommonly
the appearance of hemorrhagic spots or rash; occasionally fulminant and fatal in
24 to 48 hours, or lasting one to two or more weeks, with a high case mortality (50
to 80 per cent.) and showing at post-mortem examination extensive exudate of
purulent lymph over the membranes covering the vertex and base of the brain,
involving also those of the spinal cord. This type was present in three of the
seven cases above mentioned ; two proved fatal in six and sixteen days ; one made
good recovery and was discharged from hospital three months after the first onset of
illness.
The other type of meningitis caused by the meningococcus has long been known
as post-basic meningitis (as described by Gee and Barlow in 1878 and later by Stills
in 1898) and is non-epidemic. It attacks chiefly young children or infants under the
age of two years, afEecting the membranes at the base of the brain and giving rise
to a characteristic condition of head retraction (cervical opisthotonos). Its duration
may extend to several weeks or months resulting in eventual recovery, and if not
fatal may be followed by hydrocephalus and blindness with consequent arrest of
cerebral development. In this group the other four cases investigated are to be
classed ; one, aged 6, was discharged from hospital greatly improved three months
after the first symptoms appeared; one aged 3i and two aged 10 months, died
after two or three months' illness.
Meningitis;
other form
4. Other form of meningitis include the types of intection caused by pyogenic
and other organisms than the tubercle bacillus and meningococcus. Nine specimens
of cerebro-spinal fluid from eight cases were examined and showed marked turbidity