many of these sporadic cases the pneumococcus, staphylococcus and streptococcus play a not inconsiderate rôle. Spinal puncture has given us invaluable aid of late years in determining the nature of the infecting agent. In consequence many cases have been reported singly and in groups during the past few years emphasizing Weichselbaum's well founded assertion, that the diplococcus intracellularis meningitidis was not the sole cause of acute cerebrospinal meningitis.

Elsner, in speaking of sporadic cases occurring in the State of New York, finds that the pneumococcus is occasionally the cause. The infection is usually of a malignant nature and early death is the rule. Willson reports four cases due to the pneumococcus. He lays especial stress on the similarity of symptoms to the fulminant type in the epidemic form.

Cupler observed three cases of "primary cryptogenic pneumococcus meningitis." One case was chronic while two were malignant.

Councilman, in fifty-eight autopsies, discovered primary pneumococcic meningitis in but one instance. He reports, four cases since 1898 in which the spinal fluid showed the pneumococcus. Each case was rapidly fatal. "All my experience," he says, "leads me to the belief that with rare exceptions cases of primary meningitis are due to the diplococcus intracellularis meningitidis."

In England, where epidemic cerebrospinal meningitis is uncommon, the infecting agents are varied. A smaller proportion of the cases are therefore classed under the group caused by the diplococcus intracellularis. Barras speaks of the rarity of primary pneumococcic infections. He reports the case of a boy of five years-perfectly well on one day— who developed, the following morning, intense headache and incessant vomiting. The headache and spasms which followed were replaced by coma within forty hours. Death occurred on the fifth day.

These few examples are cited to show that sporadic cases are frequently caused by the pneumococcus primarily, that the form due to the meningoocccus, as Willson and others point out, is of the epidemic variety. Consequently it is of the utmost importance that a diagnosis be made between the varieties of acute primary cases so that both proper therapeutic and preventive measures be instituted by the physician in charge.

It is in this connection that I desire to report to you a case of more than usual interest. A young unmarried woman, aged twenty-one, had come from New York City to Ann Arbor on June 15, 1906, for a visit. Her occupation was that of teacher in the New York slums where she was constantly in contact with Italians. According to her mother's statement no disease other than measles had existed in that neighborhood for some time. (This is contrary to the New York health report which shows meningitis to have been very prevalent in that district in the spring of 1906.) The patient had always enjoyed moderately good health. She had had measles in girlhood. From early childhood she had suffered from "catarrh" which became "offensive"

later on. Her nasal condition was under constant treatment for many years with but transient periods of improvement. Those in attendance said that the condition was incurable for the "disease was lodged in the bone of the head." She left New York on June 15 feeling well except for a slight cold which passed away the following day. About noon of the 17th her right ear pained slightly and felt "full." She called on a local physician in whose office she fainted without any examination or treatment of the ear having been attempted. The following day she called again when local irrigation and cleansing relieved her considerably. Until Wednesday, the 20th, the young woman was not discomfited in any way, her time being spent out of doors and with friends. On that day she vomited three times, but felt well otherwise. During the following night she complained of a violent headache and slept little. She continued to complain of the headache until noon of the 22nd, when she fell asleep. A physician was called at noon, but not caring to awaken her returned later in the day. When he arrived the patient was in an unconscious state. He immediately sent her to the Otolaryngologic Clinic of the University Hospital, thinking that some process beginning in the ear had extended into the brain cavity.

The patient was first seen in the Medical Clinic as a case referred by Doctor Canfield. Her condition was as follows at 8:30 P. M.: Patient was lying on her right side, head retracted, shoulders thrown back, lower part of trunk curved forward, legs flexed on thighs and thighs drawn up to the abdomen. Her forearms, too, were flexed and resisted attempts to straighten them. Her color was good, cheeks but moderately flushed and face expressionless. She did not respond to questions but resisted any forcible attempts to move her from her fixed position. Temperature by axilla, 103.6°; pulse, 102 and regular; respiration, 22, and quiet.

When patient was placed in dorsal position she groaned occasionally. Her eyes were sensitive to light; the pupils reacted very slightly. Slight divergent strabismus was present. There were no skin lesions present. No tâche could be elicited. Kernig's sign was absent. Her neck was symmetrical, thick in lower part due to slightly enlarged thryoid. No thrill nor murmur over gland. Lungs were normal. Heart was not enlarged, both sounds at apex and those at base being clear and strong. The abdomen was on the level of the ribs. Abdominal muscles were slightly rigid. Spleen was felt at edge of ribs. No spinal tenderness existed.

With the history of ear involvement Doctor Canfield decided to do a paracentesis on the right tympanum. Bloody serum discharged, but no pus was seen. Cultures were made of this, which developed diplococci.

Ice caps were applied to head and spine.

The following day found her much the same. Early in the morning, twitching of the extremities was noticed for a short while. Partial consciousness returned at times. She was resting quietly towards

noon, but took no nourishment. Her bowels and urine were voided involuntary, nor were enemata of any kind retained.

The ear was clean and very little serum discharged. At 1:30 P. M. she had a profuse nosebleed requiring plugging of nares. There was also a dark brownish-red vaginal discharge. Towards evening the right sclera became markedly injected. Her eyes were partly open most of the time and the pupils were becoming gradually more dilated. The eye grounds were examined at this time by Doctor Slocum, who found the vessels tortuous and congested with some edema in the right fundus.

The patient's pulse and respiration gradually rose all day while the temperature remained persistently high. Her muscles were becoming more flaccid. Doctor Canfield performed a lumbar puncture at this time recovering forty cubic centimeters of slightly turbid fluid which ran out under pressure. In the small sediment numerous intra- and extracellular organisms were found. They were diplocococci of varying size and shape with a distinct capsule. There were no lanceolate forms. Cultures made on blood serum showed watery looking colonies which on staining proved to be diplococci. Soon after the first lumbar puncture I made a blood culture of five cubic centimeters of blood in seventy-five cubic centimeters of bouillon and incubated thirty-five hours. The media became turbid. Stains of the growth showed a diplococcus of equal length and breadth. A rabbit inoculated with a few drops of the culture medium died in forty-eight hours, a typical pneumococcus being recovered from all the organs and blood.

Following the drainage of the spinal canal, the patient was more comfortable. The rigidity was less marked and she became somewhat conscious on the following morning. Her blood pressure at this time was 130 maximum systolic. Her temperature was little lower. The pulse, however, was steadily increasing and became of less force and volume.

At 9 P. M. on the 23d she laid in passive dorsal position, eyes half closed, mouth open with slight rigidity of back and leg muscles. Mucus was collecting in her throat and the breathing was decidedly labored, a prolonged groan accompanying each expiration. Her extremeties were warn and of good color. On auscultation of thorax, the heart sounds which were distinct and rapid were obscured by mucous râles heard all over the chest. There were no skin lesions and no tâche cerebrale. The paralysis of all muscles was becoming marked. The pupils dilated to light, while the corneæ were steamy. Lumbar puncture brought away thirty-two cubic centimeters of very slightly cloudy fluid at this time. The symptoms were not relieved.

The temperature was gradually falling while pulse was growing steadily weaker and more rapid along with the respiration, which two hours before death reached forty-four per minute.

Death came about 4 A. M. about four days after the first marked symptom complained of.

An autopsy was obtained and the brain and cord were examined by Doctor Albert M. Barrett, to whom I am indebted for the following notes:

EXAMINATION OF THE HEAD.

Eyes. The pupils were four millimeters in diameter. The scalp was not notable. The diplo laterally and posteriorly were slightly congested.

Brain. The dura mater was rather tense. Its inner surface was smooth. The longitudinal and lateral sinuses were filled with a red and yellow postmortem clot.

The cerebrospinal fluid was turbid and considerably increased in quantity.

The convolutions were flattened and closely approximated to each other.

The pia mater over the entire convexity was clouded, its larger vessels were deeply engorged with blood and the smaller vessels over the surfaces of the convolutions were injected. Along the larger vessels there were long yellowish streaks and in places, especially over the frontal lobes, there were fibrinopurulent deposits. The pia mater over the base in the region cisterna was thickened and covered with exudate which obscured the nerve roots and the circle of Willis. The pia beneath the pons and medulla was moderately clouded. Over the cerebellum, especially in the region of the vermis, the pia showed considerable exudate.

On cutting into the brain, the cortex showed a pinkish hue and prominent vessel markings.

The subdural space of the spinal canal contained an increased quantity of turbid fluid. The vessels of the pia mater were intensely injected and the pia was infiltrated with exudate. In scattered patches there occurred small deposits of yellow fibrinopurulent material.

Sinuses. The ethmoidal sinuses contained considerable thick yellow puriform material. The right tympanum was perforated and the cavity of the middle ear contained turbid reddish fluid.

MICROSCOPICALLY, the exudate was more abundant in some place. than in others. The larger amounts usually lay about the vessels, especially over the sulci. In some places, as above the summit of the convolutions, the only changes noticed were a slight swelling of the fibers of the pia and an occasional large mononuclear cell with the nucleus deeply stained and of irregular outline. All degrees of transition were present between these cells and forms which were undoubtedly epithelioid cells with pale irregular nuclei and often containing inclusions of red blood cells or small deeply stained particles. Around the vessels there were numerous polynuclear leucocytes. Fibrin threads were abundant, especially near the vessels and where the exudate was thickest there were many shadow forms of disintegraded leucocytes and epithelioid cells. There were only a few red blood cells present in the exudate.

Small, deeply stained bodies resembling cocci were irregularly distributed, in some places quite numerous and in others a few or none at all.

The glia cells of the subpial layer of the cortex were generally swollen and showed well developed processes. Even in the deeper layers, among the nerve cells, the glia nuclei showed progressive changes.

The nerve cells of the cortex presented a variety of pathological forms. Some were swollen and had no Nissl granules, but the greater number were in various reactive conditions, which did not conform to any special type of alteration.

In sections from the spinal cord, the pia mater showed an abundant exudate, resembling that occurring over the brain. Throughout the entire length of the cord there were scattered small recent hemorrhages among the fibres in the peripheral part of the cord. This must have been quite recent as there were no reactive changes. In the fixed tissues there was a slight distortion and swelling.

PATHOLOGICAL DIAGNOSIS.

Acute fibrinopurulent leptomeningitis.

Acute reactive changes in the nerve cells and neuroglia of the cortex. Multiple hemorrhages into the spinal cord.

Purulent inflammation of nasopharynx, and of right middle ear.

Smears of the pus from the meninges of both the brain and cord gave numerous diplococci both in and out of the polynuclear cells. Each organism was small and spherical in shape. By Welch's method a distinct capsule could be demonstrated. The pus from the sphenoid sinus and from the right middle ear showed like organisms in considerable numbers.

The examination of the remainder of the body was conducted by Doctor Elmore E. Butterfield. Other than terminal and postmortem changes nothing pathological was found.

That this was a malignant case from the outstart was certain. The rapidity with which the symptoms developed and the character of the infecting agent left no hope for a favorable outcome. The name apoplectic given to these rapidly fatal types of meningitis is truly a deserving one. Perfectly well in the morning, stricken at night with an unendurable headache which grows more intense each minute, tremors and clonic spasms developing soon to be replaced by tonic contractions, coma coming on before twenty-four hours are past, paralysis gradually developing as the centers become exhausted,-this is the picture that prevails in the majority of the cases of pneumococcic origin.

Knowing the source of the case the possible dangers of contagion were ominous in the beginning. Especially the fact that the districts. in which the patient had taught suffered most severely from the scourge, added to the likelihood of this being a meningococcus infection (Billings). Hence every precaution indicated in such a

was