1.2 SOUTH AFRICAN MEDICAL CONGRESS, 1907.pdf

94 THE TRA BVAAL MEDICAL JOURNAL. December, 1907.
It is impossible to gauge the mental attitude of a
man capable of pleading prescription on an account
for professional fees, or any other debt for the matter
of that.
The presumption is that he desires to stand well
with his friends and acquaintances, and yet he runs
the enormous risk of encountering contempt, disgust,
and derision. It is not commonly honest; honourable
it is not!
SOUTH AFRICA MEDICAL CONGRESg, 1907.
MEDICAL SECTION.
Cerebro·Spinal Meningitis.
By a. A. TURNER, M. B., D.P.JI.
Cerebro-spinal Meningitis is a disease, w~ich has
been recently a g1'eat deal before the medIcal profession
in all parts of the world, and has been a matter
of importance along the Rand for many ~ears.
It may b~ fairly claimed tha~ since the d.Jscovel)'
of the memngococcus by 'VelChselbaum, m 188 (,
Johannesburg medical men were among the first to
investigate the disease from. a scientific point of
view. I am, of course, referrmg to the papers read
by Drs. Brodie, Rogers, and Hamilton, on.e .in 1894.
another in 1 98, which undonbtedly. antIcIpated a
great deal of the work recently pubhshed.. Unfortunately
these did not receive the attentIOn ~hey
merited, possibly owi ng to the titles they were gIven
by their authors.
Within the past year or so, a very large amount of
work has been done on the subject in England,
Europe, America, and el e-v:h~re. . In fact, t~e
amount of material, and the lImIted time at my dISposal,
has rendered it impossi~le for ~e either to
make myself thoroughly acquaInted wIth the most
recent vie,,'s on the que tion, or to dis?uss th.e~1
in this paper. I propose, therefore, to glVe a chmcal
account of the disease, as it has come under my
observation with a few statistics, and some deductions
draWl; from personal experience, which, u.nfortunately,
are not so well supported by bactenolog-ical
work as I COll Id wish. ~~me of my deductions
have, no doubt, been antIcIpated by 0 hers,
and some may possibly: have be~n ?i.spJ:oved. .
I believe cel'ebro-spmal memngI.tls IS a ~enolls
menace to South Africa. It is a dIsease whICh appears
at intervals in nearly every part of the wo~ld ;
witness the epidemics which have ravaged Amenc~"
India and Europe. It has recently appeared 10
parts of Great Britain. A few years baek it c?mmitted
fearful havoc on the 'Vest Coast of Afnca,
and in Nigeria; two or three years ago th~re w~s
an epidemic among European and natIves 10
Lourenco Marques, anil the disease still exists on
the East Coast, because J met case in the kraals in
that district recently.·
it In Livingstone's "Journeys in South ~frica," he state3, when
referring to the disease among the B..kwams about th~ year 18~O,
that-" One year the epidemic periocl was mar~ed by a dISease which
"looked like pneumonia, but had the peculIa,: symptom trongly
" developed of great pain in the seventh cervICal proce . Many
"person died of it after being in a comatose state for many hours or
" days before their decease." This disease mnst surely have been
some form of cerebro-spinal meningitis.
I t was, I believe, first recognised on the Rand
about 1894, and lately there has been a recrudescence
of the disea e here, which, it is to be hoped, is
not the forerunner of an extensive epidemic.
I personally first met with cases of cerebro-spinal
meningitis on transports carrying indentured coolies
from the East to the West Indies. These
vessels take nearly six months on their
voyage. I remember how surprised I was at the
precautions the snrgeon-superintendents took to
isolate these cases, and how seriously they regarded
an outbreak among the emigrants.
One surgeon informed me he would sooner ha:re a
case of cholera on his ship than one of cerebro-spmal
meningitis, and, as he had had 30 years' expe~ience
in that service, his opinion was worthy of consIderation.
Other slUgeons informed me of the fearful havoc
the disease had at times made among the coolies.
I am afraid to qllote defi nite figures, but, to the best
of my recollection, I was informed that one vessel
arrived in Table Bay with only half her passengers;
and. as these boats usually carry about 800 emIgrants,
it means there must have been a fearful
mortality.
Recently I have had cases under my care OCClU
ring among natives arriving for work on the mines,
and my account of the disease is based on these.
nerebro-spinal meningitis is caused by an invasi~n
of the human system by one or more of CeI'tam
organisms, the seat of the disease being the membranes
of the brain and spinal cord. The following
organisms have, among others, been found to cause
the disease :-
(1). Pneumococcus.
(2). Meningococcus intracellularis.
(3). Streptococcus pyogenes.
(4). Staphylococcus pyogenes aureus.
(5). Influenza bacillus.
(6). Typhoid bacillus.
(7). Bacillus coli.
My cases, with two exceptions, were infected
with one of the first three on tIle list. -
I believe that cases of mixed infection of the
meninges, with the pneumococcus and meningococcus,
have been recorded. one of the bacteriological
examinations made for me showed this, but on
one occasion the meningococcus was found in the
purulent material in the pia-arachnoid of the brain,
and the pneumococcus was obtained from the lungs.
Tuberculous meningitis does not come under the
head of cerebro-spinal meningitis. I have only
had one very doubtful case among natives, which
is remarkable, considering how prone the native on
the Rand i to contract tuberculous disease of other
organs of the body. i[oreover, I have only heard
of the OC~Hrenceof'one case of tuberculolls meningitis,
which wa confirmed by post-mortem examination;
it was under the care of Dr. Rigby.
All my patients were adult males, many of whom
spoke a language understood by few Europeans in
thi COllntry, a fact which may account for differences
between my de cription and those of other observers,
also for the apparent absence in many cases of minor

December, 1907. THE TRA SVAAL MEDICAL JOURNAL. 95
premonitory symptoms, such as malaise, etc., which
would not come under my personal observation.
I can find no difference in the clinical signs of the
disease, whether it be caused by infection with
meningococcus or pneumococcus. My expe~-ience
with other organisms is too limited to permIt me
to express an opinion as to whether they produce
variations in the symptoms.
SYMPTOMS.
My cases may be divided into two distinct classes
according to the symptoms :-
(i.) Those in which the primary symptoms are
of a cerebral type.
(ii.) Those in which the cerebral symptoms do
not develop for some days after the onset
of sickness; such cases I shall refer to as
the "delayed type."
Class 1. may be subdivided into :-
(a) Those in which the onset of the disease IS
gradual.
(b) Cases in which the onset is sudden.
The following is a short clinical picture of cases
belonging to division (a) of Class I., in which the
onset of cerebral symptoms is gradual. .
The patient comes before th~ doc~or in
a tottering condition, with a most tYPlC~1 ga~t. He
has evidently the greatest fear of extendmg hIS legs;
he takes short steps, with his feet set somewhat far
apart, seeming to b~ afraid that his knees will g~ve
way, and plants hIS feet flat on the ground wlth
caution. The way he holds his head is characteristic;
it looks as if he were trying to balance some
heavy load. . .
Nothing will induce him to benc~ any pOl-bon. of
his spinal column. If asked to pJCk up anythmg
from the ground, he lets himself down gradually by
bending his knees. A closer examination w.ill show
that the patient's neck is rigid, and he reslsts any
attempt at flexion, and it is evident that any such
movement causes him intense pain.
Kernig's sign, an inability to extend the knee
joint, after the thigh has been flexed, ,may be present
in one or both legs.
I think that in dealing with raw natives one can
often judge of the presence of this sign, more by the
('xnression of pain on the patient's face. when an
attempt is made to extend the knee after flexion
of the thigh, than by the actual feeling of resistance
to the arm. The patient complains of intense headache
and p!1in down the back of his neck. The temperature
lS above normal; the lips and tongue may
have sordes on them, and it is possibly only a matter
of from a few hours to two or three days before such a
case dpvelops all the symptoms of the disease in its
most severe form, opisthotonos becoming extreme,
and Kernig's sign being readily obtained, the
patient generally losing consciousness and falling
into a state of muttering delirium, often accompanied
by a series of epileptiform seizures, during
which he throws himself from his bed, bruising anrl
cutting himself; finally death ensues, the result, I
believe, of pressure, combined with toxic poisoning.
Under the heading (b), in which the onset of
cerebral symptoms is very rapid, the patient may
fall down as if in an epileptic fit, and enquiry possibly
elicits the fact that on the previous night he
had complained of headache. The patient may
recover from the seizure, and be subject to a simple
mania for a few hours, when suddenly his temperature
will run up, opisthotonos will develop, and
I\:ernig's sign and other symptoms become apparent.
The following is a good example of this type of
the disease :-
An Myambaam youth (No. 48,668), who had been returned
from one of t~e mines on August 30th, 1905, convalescent
from pneumoma, but who, though somewhat debilitated
see~l1.ed to be. hea!thy, was standing with the other boy~
waltmg for hIS raIlway pass, when he had a fit. A police
boy told me that there was a boy .. plenty stiff over
there.." When I saw the patient, he was apparently recovermg
from an epileptic seizure, his eyes were staring,
and froth was coming from his mouth; he had not completely
recovered consciousness, and for the remainder of
the day he was in a state of simple mania, very noisy and
req,:iring constant restraint. I looked upon him as an
ordlllary case of epilepsy and treated him with bromides.
I was therefore surprised on the following morning to find that
his temperature was 102'5° F.; his neck was rigid and
retracted; Kernig's sign was present; pulse 120 per minute.
These symptoms became accentuated, aud death occurred on
September 6th, seven days after the seizure.
Post-mortem examination confirmed the diagnosis of cerebrospinal
meningitis, pus being found in the pia-arachnoid.
Unfortunately no baderiological examination was
made, but I have little doubt that this was a pneumococcal
form of the disease. I shall refer to this
case later on.
Cases of this class are sometimes brought into
hospital in a totally unconscious condition. Examination
shows they are completely paralysed below the
waist, the breathing is stertorous, the cheeks moving
in and out with each inspiration and expiration,
and the conjunctival reflexes absent. There is a
total absence of all stiffness of the neck, and of
Kernig's sign, but the temperature is high (103 to
104 0 F.); the only account of any preliminary
sickness, being usnally that the patient had a headache
on the previolls day; in fact, except the high
temperature, the patient has none of the symptomR
of cerebro-spinal meningitis, but a.1l the signs of a.
basal haemorrhag-e (which is not surprising, as a
post-mortem examinntion shows a big clot of pm;
at the base of the brain, causing the pressure symptoms).
Such cases only survive a. few hours, and
from the first it is evident that they must terminate
fatally. .
The following is a good example of this type:
A ~1akll" (No. 61,969), about 32 years of age, was found
unconscious, and carried into hospital; he had complete
paralysis below the waist; his breathing was stertorous:
his cheeks blowing in and out with each inspiration and
expiration; a total absence of conjunctival reflexes; no
stiffness of the neck, and Kernig's sign was absent. Temperature
103; pulse 120.
I at first diagnosed this case as one of basal
haemorrhage, but could obtain no account of any
assault or accident; the only history I could get waR
that he had complai ned of severe headache the previous
day. Death occurred within a few hours of
admission.
Post-mortem examination showed no naked eye
appearance of pus in the pia mater of the cerebrum,
but a heavy fibrino-purulent exudate at,
the base. The fluid in the ventricles wa!l clear.

98 THE TRA fEDICAL JOUR AL. December, 1907.
The lungs, liver, spleen and kidneys showed evidence
of acute toxic poisoning.
Bacteriological examination demonstrated the presence
of meningococci in the exudate at the base.
No pneumococci could be found.
I must admit that, though I made the diagnosis of
cerebro-spinal meningitis in this case, when I attended
the post-mortem examination I did so with
a certain amount of trepidation. I half expected to
find a ba al haemorrhage, and no evidence of meningitis.
There i one other type coming into this class, of
which I have only een two or three cases. They
were brought into hospital in a drow y, semi-conscious
tate, from which the. could only be roused
with the greate t difficulty, and then but for short
intervals.
They gave o:oe the impression that they wished to
be left alone and allowed to go to sleep. They
could not be got to answer questions. They evidently
could not collect themselves sufficiently to
under tand what was being said to them.
They did not complain of any pain, neither did
they show any evidence of it.
An examination revealed nothing abnormal. Their
pupils were equal and of normal size. The conjunctival
reflexs were pre ent. There was no stiffness
of the neck, nor could Kernig's ign be demonstrated.
The first of these cases which I saw I diagnosed as
one of acute alcohollsm, though I could neither smell
spirits, nor get a history of the patient having obtained
any.
The man's temperature was only 99° F. ; he was
collapsed.
I was not absolutely certain of my diagnosis, but
I had seen several natives, in a similar condition,
as a re ult of taking a large draught of some form
of illicit liquor.
I pre cribed five grains of calomel, a hypodermic
injection of strychnine if nece sary, and hot water
bottles, etc.
The following day it was found that some stiffness
of the neck had developed, and that Kernig's
sign could be demonstrated. Other signs of cerebrospinal
menigitis then became apparent, and a correct
diagnosis was made.
In these cases, though, the stiffness of the neck
and ICernig's sign do not come on at first. The
primary symptoms are undoubtedly of a cerebral
nature, and they therefore come into Class Cb).
Both of the foregoing types of case are pitfalls for
the police surgeon. The first would be very apt to
be sent to the wards to be treated for basal fracture'.
if he were brought into a, casualty hospital with a
history of having been found unconscious in the
street; and the second "'ould stand every chance,
under similar circumstances, of being sent to the
cells until sober, and fit to be charged for drunkenue
s. .
Clas n. is that which I have ugge ted might be referred
to as the "delayed type" of the disease. nder
this heading patients are admitted to hospital with
a high temperature and headache. No other symptoms
of any sort can be found. When dealing with
such cases from tropical areas, and having examined
the heart and lungs ,,,ithout any result, one is
general;y, I think, justified in believing that the
pati nt i suffering from some form of malarial
trouble.
But in these cases under consideration antimalarial
treatment has no effect. The patient remains
in the same state for three or four or even
five days without any drop in the temperature or
development of fresh symptoms. Such patients
are repeatedly examined; enteric and every other
form of fever is con idered, until at last one notices
a slight stiffness of the spinal column, only to be
elicited by flexing the neck, so as to bring the chin
down on to the sternum. At first the stiffness is
sliRht; perhaps Kernig's sign can be demonstrated
with difficulty in one leg. These symptoms, however,
soon increase in intensity; the stiffness of the
neck is apparent, and Kernig's sign is noticeable in
both legs, and the patient gradually enters the final
stages of the disease already described.
'rhe following case illustrates this type:
A Makua (No. 60,947) was admitted to hospital on January
28th, 1906, with a temperature of 100° F.; no other sign
of disease could be found. The case was looked upon as
one of malaria, for which he was treated without effect.
On February 2nd it was first noticed that there was some
stiffness of the neck, but Kernig's sign could not be demonstrated.
This condition continued lmtil the 8th, during
which time the temperature did not fall below 100°
F., but on two occasions rose in the mornings to 1020 F.
On February 8th Kernig's sign could just be demonstrated,
but was not marked until the 15th. After that date the
symptoms became much accentuated; by the 20th opisthotonos
·was marked, and the patient bec....me semi-conscious.
On the 23rd there was intense headache, and death
occurred the following morning.
This case is interesting, as showing the exceedingly
gradual manner in which the symptoms ma:,
develop.
A post-mortem examination showed the lungs :.mu
heart to be normal; the abdominal organs V\·~rc
healthy, except that the calices of the kidneys were
dilated, and there were bilharzia worms in the portal
vessels.
The vessels over the convexity of the brain were
acutely congested. Under the base was a little pale
yellow-coloured fibrino-purulent exudate, and the
ventricles contained some fluid pus.
Bacteriological examination of the pus III this
case was unfortunately not recorded.
Thi gives a brief clinical picture of the various
tvpes of the disease. But in certain cases the
. symptoms appear to abort, sometimes before Kernig's
sig-n has developed, at other times afterwards.
In some of these cases the patient can be discharged
from ho pital in ten days, but as a rule the
time necessary for complete recovery is much longer.
The following case illustrates the abortive type :-
A
1akua (No. 60,(05), aged about 20 years, was admitted to
hospital on February 2nd with a headache, temperature
102, a stiff neck, and the characteristic d isi nel ination to
bend the spine. Kernig's sign, if present, was so slightly
. marked that it was difficult to form a definite opinion as
to its presence or absence. On February 3rd there was
no doubt that Kernig's sign was absent, but the neck was
still stiff. By the 5th some movement of the neck had been
recovered; the temperature, which had been irregular, fell
to normal, and the patient said he was not sick. By the
8th he had regained complete movement of his neck. The
temperature during the following three weeks shewed occasional
erratic rises, but the boy eventually recovered completely,
and was discharged on March 3rd, 1906, after being
in hospital 33 days.

December, 1907. THE TR vAll MEDICAL JOUR AL. 97
These ca es which abort are important, because,
though" they may be diagno ed and treated for
cerebro-spinal meningiti , their OCCUlT nce clearly
indicates that there are probably numbers of others,
with the symptom le s sev re even than in the c~"e
quoted, which would not come under the not~ce
of a medical man; or, if seen, might very easIly
be passed over as being infiuemm, and such cases
could serve as carrier of the disease from place to
place.
It now remains to discuss the more ip1portant
individual symptoms. In doing so, I ~hall ~ndeavour
to introduce them, as far as possIble, ID the
order of their importance :-
(1.) The temperature in my cases was, with one
exception, above norlllal on admissio~ but
later in the disea e it varied exceedmgly.
Twenty-four hours before death it fell to
normal or sub-normal in many instances.
The height it reached was no indication of
the severitv of the case; some with the
highest temperatures eventually r~cove.re~.
But while any sign of fever remams, It IS
very risky to form a favomabl~ 'p~ognosi~.
(2.) Stiffness of the neck. The ngldlty.whIC.h
affects the whole length of the spille IS.
most marked in the cervical region. It
is present in a greater or less degree at
some period of the disease in every .case of
cerebra-spinal meningitis, except ID the
fulminating cases already referred t?
It mn,y vary in extent from a st.ate, m
which the movement of the neck IS only
slightly limited, to one in which th~ nec.k
is retracted to its fullest, and the patient IS
in a state of extreme opisthotonos.
(3.) Kernig's sign is probably the next most
constant symptom, except in the f?l~inating
ca es; but ~ as alre~dy ~tated, It IS frequently
late ID mal~mg It~ appeara.nce,
sometimes not appearIng until several days
after the neck has been stiff, and other
symptoms have developed; usually at first
it is present in one leg only. _ .
It is one of the earliest sympt.oms to disappear
and its disappearance is of favourable augury.
The peculiar gait is, I take it, part and parcel.of
the spinal symptoms, and therefore does not reqmre
further mention.
vVe may consider the temperature, the spinal
symptoms and Kernig's sign as the three symptoms
typical of the disease.
RASH.
Though the disease is known i~ some countries
as spotted fever, with the exceptIOn of heI'pe~, I
have only seen a rash in t\V~ cases of cerebro-splI~al
meningitis. One was a patIent ~ho had a pecuhar
mottling of the skin over the thIghs and abdomen,
which disappeared in .48 hours. I. am ~ot prepared
to state it had any connectIOn wIth the
disease. . h
The other was a Zulu. a lighter coloured boy, W 0
developed a high ternperature (104 0 F.), with a
rash something like confluent measles, but t~e spots
were more raised than is u ually the case m that
disease. This boy eventually developed cerebral
symptoms, bnt recovered.
Herpes of the lip and round the alae of th nose
was not uncommon, usually coming out about th
third or fow' h day f the di ase, but I ha e s en
it well marked on the first day.
Herp's appears to be an unfavourable sign, but
the South African .nativ· is peculin,rly prone to
it, as the slightest indisposition may cause an
eruption.
Retention of urine ,,"as common among th
patients; it should n,1\\'ays be looked for. I know
of no disease in which the use of a catheter is 0
frequently called for.
The emi-conscious state of some of the patients
probably p rmits them to endme di tend d bladder
without showing signs of di comfort.
Rhinitis, a purulent streaming di charge from n
or both no tr:ils, often commenced uddenly, as on
of the primary symptoms, n,nd milder forms of
rhinitis were suspicioLlsly frequent among contacts.
I gl:eatly regret I did not cause a systematic bacteriological
examination to be made of all nn,sal discharge
of both patients and contacts.
Epistaxis was met with in a few cas s, but on
no occasion was it severe enough to cause any
anxiety. Once it reculTed after the interval of a
few days.
In all ca es the bleeding cea ed under treatment
with calcium chloride.
ystagmus and strabismus were lloticed occasionally
in the later stagcs of the disease, but I hn,ve seen
patients admitted to hospital with well-mal'ked
nystagmus.
Conjunctivitis of a highly purulent type was a
noticeable feature in lllany cases of the disea e. I
regret that no records of this symptom were kep .
Bowels.-In some ca es the patients had acute
diarrhrea, but this ",a' not, a a rule a mark d feature
of the disease. In several cases, howev r, the cerebral
symptoms were u hered in by mild attack vf
diarrhrea, which is interesting when con'idering
Drs. McDonald and Fowler's views on the mode of
infection, to be mentioned later. \\ e must not,
however, overlook the fact that most of the patients
concerned were tropical or sub-tropical natives,
omewhat prone to inte·tinal disorders, and very
liable to commit errors in their diet.
Urine.-Albuminuria occurrcd frcquently, but
owing to the number of patient suffering from
bilharzia, the presence of albumen in the urine was
of small significance. The same r mark applies to
haematuria.
Spleen.-I note that OsIer ay the spleen as a
rule is enlarged; but in my ea es this sign was of no
moment, because the boys had all more or less enlarged
spleens, due to malaria.
\Vhile discussing the symptom', I would draw
your attention to several interesting points which
require explanation.
A. What is the eau e of Kernig'. sign? One might
ugge t that in some cases i re ulted from ~u
pre ing on certain nerve centre ; but, on refernng
to the po t-mortem examination r cords, ca es ar
met with in which all the ymptom. of cerebropinal
meningiti were pre ent during lif , including
Kernig's ign, yet on op ning the kull no pus could
b found in the pia mater, and in some of th se
there was an absence of both m ningococci and

'l'HE 1'RA S\ At M1

( December, 1907. THE TRA SVAAL MEDICAL JOUR AL. 99
hour. Po t-mortem examination reveals a large
clot of pus at the base of the brain, which one would
think could not have been formed in the short time
which has elapsed since the onset of symptoms.
It seems possible that the pressure of the fluid in
the spinal column at times changes rapidly. ]I
such is the case, should pu commence to form at a
low pres. me, it might for a time e cape re i tance,
but on the pres un~ increasing, it can be understood
that violent pressure symptoms would come on suddenly.
Dr. Geo. Turner, ledical Officer of Health for
the Transvaal, however, suggests that the sudden
onset of symptoms is due to the rapidity with which
the pus is formed, a he state a quantity of pu
slowly formed would produce little effect, becau e
the spinal fluid would be ab orbed pari passu, but a
rapid formation would give ri e to pressure symptoms,
as there would be no time for compensating
absorption of cerebro-spinal fluid.
COMPLICATION.
Regarding these, I need say little; a glance
through the records of post-mortem examinations
shows that pneumonia, pericarditis and pleurisy are
common.
Blindness.-Several of my patients have had complete
loss of vision, as a reslllt of the disease, but I
think that, with one exception, they all of them
regained their normal sight, though not till after
some months.
Deafness and dumbness, said to be frequent, particularly
when European children are attacked, is
not common with adult natives. I have only seen
it on one occasion following an attack of meningitis.
Mental Defic-iency.-On several occasions my
patients, after making an apparently good recovery,
have been found to be mentally deficient. It is
difficult to make any very definite statement on this
subject, because the border line between sanity and
insanity in the raw native is a very narrow one.
Further, unle s one can understand the native language
well, it is very difficult to say whether a native
is affected mentally unless, of course, he is in a state
of acute mania, the form of insanity most common
amongst uneducated natives.
PROGNO I .
This varies with the type of the disease which is
prevalent.
Out of 193 fatal cases, death occurred on an
average after 11'80 days of sidmess, but among the e
there were three which had very prolonged illnesses,
viz., 209, 111, and 129 days. If these are deducted,
the average period of death \Va 9'7 days.
It need only be said hat the prognosis is in all
cases serious. One can never be certain that an :tpparently
mild case may not relapse after the disappearance
of all symptoms, and then die of the most
accentuated form of the disease.
DANGER OF I
FECTIOUS JESS.
Per onally, I have never een a case of the di ease
which I could trace to direct contact with another
patient, but we must not overlo?k the fact that. mild
abortive ca e are wrongly dlagno ed at tlIll s.
Herein lies the danger of stating that the disease is
not acutely infectious.
On t\ 0 occa ions I have een patients ufT ring
\yith a high temperature (104 0 F.), and severe h adache,
which followed their occupation of
room recently u~ed by well-marked case
of cerebro- pinal meningitis, but these boys
howed no tiltlle~s of the neck n ither
did any other ymptom of the disea' e app ar
in th m, and they recovered in a few days. Thcy
were su pected to be suIT ring from the initial stages
of meningitis, and they may have had a very mild
form of it, but I do not think one would have been
justified in making a lumbar puncture under the circumstances
to verify or refute the diagnosis.
I personally do not think that ceTebro-spinal
meningitis is acutely infectious. uch a tat ment
mu t be accepted cautiou'ly, with the above facts
b fore one.
Dr. Robertson, l\Iedical Officer for Leith, in his
paper on "Outbreak of Epidemic Cerebro- pinal
Meningitis," published in the Brit-ish Medical
Journal of July 27th, 1907, enters into this question
more fully than I can do here.
PERIOD OF I C BATIO .
This from a public health point of view is a
matter of importance. I am of the opinion that it
will eventually be proved that the period of incubation
may range from a comparatively short one, to
one of several weeks' duration.
I note that in the report ofthe Congress of the Incorporated
Sanitary A sociation of cotland, h~lrl on
September 6th, 1907, it i tated that Dr. Chalmers,
the Medical Officer of Health for Glasgow, was ot
the opinion that the incubation period might be a
matter of months. The belief in this prolonged
period of incubation is justified in many ways.
In the first place, Drs. 1\Iary Goodwin and Anna
von Sholly proved that the meningococcus might
exist in the no tril of person for at lea t three
weeks without causing any symptoms.
Dr. Williams, who was on the \\ est Coast, informed
me that while he was examining blood films,
made from natives whom he believed free from the
disease, and whose blood he required as a control for
samples taken from persons undoubtedly infected,
he was surprised to find the meningococcus on
several occasions, which led him to keep these persons
under observation. He was able to prove that
all those in whose blood he had found the meningococcus,
developed the ordinary ym ptoms of cerebra-spinal
meningitis, and ome of them died.
The incubation period in these cases of Dr. Wil­
!iams, though unknown, was undoubtedly a long onc.
Again, since the meningococcus and pneumococcus
:1re closely allied, we may expect them to behave in
somewhat imilar ways, and we kno\y that tho pneumococcus
may remain in the ystem for long periods
before making itself apparent.
The following case, I think, illustrates very well
the vagaries of the pneumococcus :-
H. \V. H., a male European, aged 33 years, contracted
facial erysipelas as the reRult of a fall from
bis bicycle, in which he had abraded onc side of hi.
lace. He was admi ted to the Inf etiou Disease
Ho pital on August 12 h, 1904, with a high temperature
: he oon b came d lirious: he had a cough,
311d his lungs were cong t d at both ha es; he spat
a quantity oi brown purulent material. The con-

100 December, 1907.
dition of his lungs at the time was considered to be
t.he result of septic infection, due to erysipelas. He
rallied, made a rapid recovery, and was di charged
on Augu t 25 th, 1904. Five we ks later, he felt 3
pain in the left inguinal region, clnd three or four
day later he noticed a slight swelling there, which
increased.
His medical man. Dr. Ashe, was good enough tu
allow me to examinc him. I could obtain no history
of any injury to the foot, of exposure to tick
bite , or vermin of any kind, or any history of
venereal disease. His temperature was normal,
tongue clean, complexion good, and he did not feel
or look in any way sick.
The bubo was opened. I obtained from the pus
a pure culture of a diplococcus, which answered to all
the tests for the pneumococcu ,so far as staining and
mieroscopical appearances went.
It appears to me that this is a case in which the
pneumococcus had been in the system from the tin",
that the patient was first admitted to hospital, that
the pneumonia from which he was suffering Oll admission
was of the ordinary pneumococcal variety,
and therefore the incubation period for the glano
trouble was not less than five weeks.
The cas~ at any rate is interesting, though the
deductions are open to many fallacies, because the
investigation was not nearly so complete as one
would have liked.
To demonstrate further the time the pneumococcus
may remain concealed in the system before breaking'
out, let us consider the cases of pneumococcal meningitis
following pneumonia. In the earlier part of
this paper I quoted the case of a native, returncd
from one of the mines with debility following pnellmonia,
who Ruddenly contracted meningitis and dierl.
The incubation period for this case of menin~-iti.
must have been at least from the commencement of
the pneumonia, a matter of several weeks.
These cases and others leave no doubt in my mind
that the incubation period of pneumococcal menin·
I;itis may be very long, sometimes a question of
several weeks. Such b0ing the case, I see no reason
why the meningococcal form of meningitis should
not have an equally long incubation period.
J3esidc~ this, I have on several occasions noticed
that among::;t a body of emigrants wbo have been
under observation for severu,l weeks, four or five
cases of cerebro-spinu,l meningitis may occur sud·
denly within two or three days; the disease then
stops. no further cases occurring.
This suggests not only that the disease is noi
acutely infectious. otherwise further cases would

December, 1907. THE TRA SVAAL MEDICAL JOURNAL. 101
rasion in the mucous membrane of the no tTil ,
th.rough inflamed ton ils, or by means of biting
insects, etc.
That the diplococcus does not always travel direct
"from the mucous membrane of the nostrils to the
meninges of the brain, as described by ome authorities,
is proved by Dr. William , who found the
meningococci in blood film
had never hewn· any sign
taken from patients who
of cerebro-spinal meningitis,
and who, though at the time the film was
taken appeared perfectly well, afterwards contracted
the disease.
'l'he human system might be invaded through one
or more of the following entrances:-
(1). Alimentary tract.
(2). Lungs.
(3). ares.
(4). Tonsils.
(5). Conjunctivae.
(6). Skin. .
Alimentary Tmct.-Dr. Fowler supports a COIItention,
originally put forward by Dr. Stewart
McDonald, that epidemic cerebro-spinal meningiis
may be related to acute abdominal infection. The
organism invading tbe nervous system through the
spinal meninges. Certainly my experience among
natives does not support this theory.
It is a question, however, I have not thoroughly
investigated. It is possible that adults may not
contract the disease in this manner; but infants, and
young children, of "'hom I have had no experience,
may do so.
Lungs and Bronchi.-" e know that the pneumococcal
variety of meningitis is frequently, but
not by any means ahvays, preceded by an attack of
pneumonia, and in these particular cases it is probable
that the organism first gained access to the
system through the lungs, though it may not have
nttackeq the meninges till weeks later.
The meningococcus may in the same way OCC'1­
s'onaIIy gain access to the system through the lungs,
hnt only under exc('ntional circumstances; as
it is improbable. if infection occurred through
the lungs, that the preliminary sympto~s of bronchitis,
etc., would not frequently mamfest themselves,
which is not the case.
On the other hand, I believe that in a large number
of cases of pure meningococcal meningitis. th('
lnogs are infected secondarily, because one cannot
help being impressed by the number of post-mortem
examinations in which red hepatisation is found at
the bases of the lungs, even when death has not
occurred for some days after the commencement of
the illness, and in which, had pneumonia been a
primary symptom, grey hepatisation would have
replaced the red.
Nares.-There seems little doubt that it i~ through
the muCous membrane of the nares that the bulk of
the meningococcal cases receive infection. I think
this supposition is justified :-
(1). By the numbers of
•
cases
.
m which
there is an acute purulent rhinitis among
the primary ymptoms.
(2). By the prevalence of cases in which the
primary symptoms are of a cerebral nature.
(3). By the re nits of the bacteriological examination
of the discharge from the nostrils
of patient and contacts made in several
parts of the world.
(4). By the results of post-mortem examinations
made by Drs. Brodie, Rogers and Hamilton,
supplemented by bacteriological examination.
The question a to how the Ql'gani m enters the
human y tern, from the mucous membran of the
no trils is a di puted one. I have little doubt
that sometimes it gains acce s through abrasions in
the mucou m mbrane of the nares; at other times,
to quote Drs. Brodie, Rogers, and Hamilton: " The
" most u ual coursL' to ·th interior of the skull is from
"the muco-perio teum of the sphenoidal sinus to
" the sheaths of the nerves imbedded in the walls
" of the cavemou.' inu, and thence, by direct ex­
" tension, to the arachnoid and pia mater.
" In other ca e nndoubtedly the Ql'gani m infect
" the meninges by extension along.the nerves or ves­
" sels traversing the (Tibriform nlate of the ethmoid.
" It has been shewn that the nasal lymphatics are in
"communication \yith the subdural and subarach­
" noid spaces by means of perineural paths. An­
" other possible route i by the Eu tachian tube to
" the middle ear and petrous bone thence by the
" seventh and eighth nerve sheaths."
Dr. Robertson, however in his paper, published
in the British lIIedical Journal of July 27th, 1907,
states inter a.lia: " Jn fact, I have the as urance of
" my re pected teacher of anatomy, Pro£. Cleland,
" of Glasgow, that it i extremely unlikely t4at-the
"meningococci can pass readily, if at all, by the
" nasal rout~that is, through bony structures."
The point is, therefore, debatable; but I think the
majority of people \\'ho have made post-mortem examinations
of cases of cerebro-spinal meningitis will
favour the views of Drs. Broclie, Rogers and Hamilton.
Tonsils.-Infection through the tonsils is probably
not uncommon, hence the frequency with which one
hears of sore throats preceding attacks of cerebrospinal
meningitis (. ee the case quoted by Dr. Cun-ie
in the Transvaal 111edical Journal), and also the remarks
by others when describing outbreaks of
meningitis in different parts of the world.
Among natives, J have not noticed cases of sore
throat. I have not looked for them especially, but
for some reason the Bantu race does not eem to be
so susceptible to pharyngeal troubles as European .
Conjunctivae.-It is possible that infection may
occur throngh the conjnnctivae. Purulent conjunctivitis
i a common featnre of the disease. The infection
of these membrane may. of conrse, be
secondary to that of the Schneiderian membranes,
with which they are in direct commnnication throngh
the nasal and lachrymal canals.
Dr. Napier con ider that the infection of the
conjunctivae is probably the result of the patient
conveying infections material from his nostrils with
his fingers to the membranes.
But. quite anart from the conjnnctivitis.lmet with
several ca es (abont a dozen) in whom choroiditis,
r ndering the patients quite blind, preceded the
cerebro- pinal meningitis.
Dr. J apier. who was good enough to examine these
cases, was of the opinion that this condition waR
the result of infection with either toe pneumococcus
or meningococcus.

102
THE TB
VAAL MEDICAL JOUR
AL.
Declmber; 1907_
Skin.-I see no reason why the disease should not
be ca,nied through the skin by biting insects, though
I know the idea, has all' ady been advanced by some
(among others, 'urgeon J. F. Anderson, D.S.A.),
and refuted by other authorities.
But on one occasion while making smears from
lice, fre hly fed on the blood of persons suffering
from cerebro-spinal meningiti, I found in the
leucocyte, contained in their bodies, cocci, which
I believed to be cliplococci. Whether they were
meningococci or not I, of cour e, cannot say. I
have not been able to make furth l' investigations,
but think the pos ibility of infection being carried
by vermin worth remembering.
Mortality.-The mortality, as with the prognosis,
varies with the type of the disease. Occasionally
one has a series of cases attacked with the most virulent
type of infection, in which probably not one
patient survives. At other times a comparatively
mild form prevails, and a, fair number of good recoveries
may be expected.
I have been able to obtain records of 279 cases
among mine ·native. Of these, 196 or 70'25 per
cent. terminated fatally. The mortality would
probably have been somewhat lower among Europeans.
The following is a brief extract of 90 post-mortem
examinations :--
Bacteriological examination of the cerebro-spinal
fluid and pus in the pia-arachnoid shewed that-
Of 90 post-mortem, 45 contained meningococci.
" 17 contained pneumococci.
" 1 contained st.reptococci.
" 1 contained gram - staining
cocci, not the pneumococcus.
"
"
6 gave negative results.
20 were not recorded.
90-
As a rule, the blood vessels of the cortex were
engorged with blood; in some cases intensely so.
In one case there was a small haemorrhage at the
base, and in another there was a number of petechiae
on the inferior surface~ of both lobes of the cerebellum.
The a.monnt of cerebral fluid was in many cases
larger than normal.
Pus.-There were mncroscopic evidences of pns
in the- pia mater of the cerebnlm in 51 cases. In
some the amount was Rmall, but in 30 cases it was
present in considerable qnantities. In six cases
it was especially plentifnl over the frontal lohes ..
Twice. small localiRed pntches of purnlent flmcl,
about the size of u shilling. wore found near the
pncchioniur. boclies. . Therp wns a fibrino-pnrnlent
deposit at the' ba. c of the brain in 69 inRtan~PR.
On only eight occaRionR, where pus was plentlful
in the pia m:1ter of the cerebrum, was it absent
at the base. .
No pus could be discovered, with the naked eye,
in the cranial cavity in five instances.
The ventricles contained pus in 32 of the cases.
In addition, in five flakes of purulent material were
floating in a nearly clear cerebral fluid.
* Details of each post-mortem examination are given in tbe appendix"
H cart.-In nine cases there were evidences of
recent acute pericarditis. In' ten, the organ was
flabby.
Hypertrophy was noted on two occasions. Onc~
there were vegetations on the aortic l:USPS, and on e
these valves were atheromatous. .
Lttngs.-The right and left lungs were normal on
Q3 occasions.
The right lung was congested 39 times.
The right lung had red hepatisation 18 "
The right lung had grey hepatisation 8 "
The right lung had tuberculous nodules 2 "
The left lung was congested 50 times.
The left lung had red hepatisation 15"
The left lung had grey hepatisation 1"
The left lung had tuberculous nodules 1 "
There \Vere evidences of pleurisy on 17 occasions.
Abdo11linal Organs.-It is sufficient to say that
~here were frequent evidences of acute toxic poison­
Illg.
Livers.-An old yphilitic lesion was met with
once.
10 livers were cirrhotic.
4 livers were fatty.
:2 livers were waxy.
2 livers were markedly anaemIC.
16 livers were very acutely congested.
Spleen.-As \yould be expected, among a class of
patients llniformly infected with mal::tria, the spleens
were usually enlarged, and on 36 occasions were
fl.cutely congested. .
[(idnells.-In one the capsnle was adherent; in
seven dilatation of the calices was noted, two were
anaemic, and acute congestion was noted on 32
occasions.
In conclusion. gentlemen, I have to express my
thanks to Dr. McCrae, Dr. May and Mr. Josephs,
of the Govern'ment Laboratories, Johannesburg, for
the bacteriological examinations of all the specimens
qnoted in this paper.
REFERE CE."l.
"Epidemic Cerehro-spinal Meningitis," by J. S. Fowler. Review
of Nenrology and Psychiatry. April, 1907.
"Acnte Specific Rhinitis," by W. H. Brodie, M.D., ana W.
G. Rogers, M.S., M.D.
Novemher, 1894.
South Africa-n Medical Joumal,
"Contribution to the Pathology of InfectJon by the Pnenmococcns,"
by W. H. Brodie, M.D., W. G. Rogers, M.D_,
M.S., E. T. E. Hamilton, B.Sc., M.D., M.S. Lancet,
1898.
"The Freqnent Occurrence of Meningococci in the Nasal Cavities
of feningitis Patients and in those in direct contact
with them," by Mary E. Goodwin and Anua I. von Sholly.
Journal of Infectious Disease, Febrnary 2nd, 1906.
Reginald Farmr'g Report to the Local Government Board
on cases of cerebro-spinal meningitis, occnrring in Irthlingborough,
August, 1905.
Memorandum by Reginald Farrar to Local Government Board
on Illness resembling Epidemic Cerebro-spinal Meningitis
in certain localities of the Ellesmere Rnral and Oswestry
Urball. Districts. Shropshire, Septemher, 1903.
"Epidemic Cerebro-spinal Meninigitis and its Relation to
other forms of Meningitis," by Drs. Councilman, Mallory
and Wright. 1898.
Report on Epidemic Cerehro-spinal MeninlPtis in India by
Capt. C..J. Robertson Milne, M.B.. I.M.S. 1906.
"Outbreak of Cerebro-spinal Meningitis," by William Robert·
son. M.D.. D.P.H., fedical Officer of Health, Leitb.
Briti!'!l Medical Journal, 1907.
Discussion on :Spotted l'ever at the Congress uf the Incor·
porated Sanitary Association of Scotland, reported in the
Aberdeen Fru Press, September 6th, 1907.

,
TABLE OF POSl MORTEM EXAMINATIONS.
I
'
!
i
Duration Couclltlon
No. L'rlbe. Alte. of of Brain. Hrart. Lungs. LiveI'. Spleen. Kidneys. Intestines. Jlact. EXllfll. l~ llemal·ks.
Sickness. Body.
I
I
I
------ ,
----
1 MYIlIll' , 20 yrs. 3 days Well nourishcd ; Vcssels on cortex con· Normal. I Both bases con- Marks of old Enlarged and Slight congestion. Normal. No bact. exam. ma.c1e.
baam Ollvc-colourrd ge,ted ; small llJIlount 0/ geRted. syphilitic congested. Marks or old sore on
fluid running gus under p.la mater; (Oilions on sur' penis.
from the mouth rain substance soft. fnco.
-- --------------------
2 ~han- - 5 days l::macla.ted; Olive All vcssels on the cortex Normal. JlIght base con· Norll'lal. Normal. Normal. Normal. Mcnlngococci were obl"logaan
coloured flulcl ongorged with blood; tCsted ; left ed In the fluid ot a IUIII'
runnlllg from pus under pia ml\tcr nsc solid. bar ~unoture made Mter
tho mouth. over the whole ot brain. deat 1.
oxtending Into cord;
ventrioles contained a
Quantity 01 bloodstained
scrum.
----------------------
8 Mozam· 20 yrs. 56 dnl's Emaciatcd. Vcsscls of convcxity con· Pericardial sao Normal. Normal. Normal. Pale. but other' Congested In No organisms tound In
blque gested ; thick deposit or containedabout wise normal. places; con· cranlnl pus; menlngo-
J1brino Rurulent exudate an ounce ot talned ankylo- cocol and pneumococci
under t 1(; base; ventricles serous fluid; stomes and specially looked tor.
werc full of thick yellow heart otherwise Ascaris Lum·
pus. normal. brlcoldes.
--------------
j ~rozam· 26 yrs. 4 days Wcllnourished. Certain amount of pus Normal. VCl'y slight con- Normal. Enlal'gcd and Normal. Ankylostomes No records kopt ot bac·
hlque. under pia mater. over gestion at both gested. prescnt. teriologlcal examlnatJon·
the convexity. und at buscs.
thc base; ventricles dry.
--._------------------- ,
5 ~fozam- 28 yrs. 4 days Well nourished; 1'us under pia inater. over Normal. Right lung nOr· Normal l ?); post Enlarged. Normal (?) : post Not examined. No records ot bacterioblque
de('.omposlt.ion the convexity. and a ma.1 : left ba8e mOl:tel1l changes mortem changes logical examination.
~et In before flbrlno purulent exudate congested. extensive. extensive.
p.m. mnde. n.t the base; muco purulent
fluid in both \·en·
tl'iclp8. fhnt in left bcing
bloon-stnincd.
--
____
----__--4-
6 Mozam- 21 yrs. 5 da.ys Emaciated. Small amounl ot pus Kormal. Right lung.patch Kormal. Slightly enlarged. Normal. Ankylostomes' Ko record. ot bacterlobiqu~
under pia. over the con- of red he~atls. pre8ent. logical examination.
vexlty ; lal'l!e flbrlno- ation at ase;
purulent exudate at the
Icft lung nor·
basc ; pus in both Veu-
mal.
tTlcles.
--------------
7 Mozam- 24 )'rs. 6 days IWell nourishcd. ,. ery marked flrbino' Deposit of lympl\ Right lung acute- :Fatty. l,nlarged and Normal. Normal. Pns at base ot brn.in
biqu p gurulent exudate at the in pericardial Iy congested; congested. showed few menlngoase.
sac on tJle heart left lung con· . cocci. but no pneumowalls.
rcsult or gested also, but cocci.
I
recent perlcar- not to the
ditls.
same degrec.
I
I
o
et>
o
et>
8 g-
,'"
;-0
"" t::J
tj
H
o
>t""
c:..;
o
d
~ ;>
t""
;-0
o
~

Po.d Mortcm Examlnatlons-~ontJnued.
• • -- Duration .• Condition. •.•. • . I
No. Tribe. Age. ot ot Brain. .- aea-it: ... Lunlls. -J.lver~ ". Sp'Jeen. Kldn~ys. Intestines. ])aot. Exam. &: Remarks.
SlcknCfls. Body.
--------......----------------1,-------1-------1------·------1·------1--- 1 _
8 II.Ccnt. 28 yrs. 17 da~'s. Emaciated. An extensive cXj,date of Flabby. but :J;leurltic adhe- Normal. Anromle, friable. Normal. Normal. Baet. Exnm. 01 pus at
Atrlcan pale colourAd nul" under otherwise nor- slon over whole and slightly base showed pneumnthe
pia nJater over the mal. ot right .lung, enlarged. cocci In 1I00l!' numbers.
whole of the convexity. land the whole no meninllococci. .'
Tbe exudnte nt tbe hns. ,Iunll in stnte of . •
wag much more fluid. grey hepatisa...
nnd 01 n palcr colour :tion; small • .•..
thnn in prevlons cases; pnteb 01 r'eur. ..
ventricles contained a ltic ndhesJOn 011
Quantity of blood· the left side.
stnined serum.
but thc lung it_
scll healthy.
....
o,.,..
__-------- I _ •
o M'yam· 10 yrs. 11 dnys EmacJated. Extensive exuda.te or l\ormal. Ren hepat.lsntlon Commencing cir· Dry and con· Normal. Patehes of con· Pus at basc showed a few
baam ftbrino Ilurulcnt mntter at both bases rhosls; portal gested. gestlonln both meningococci, but no
at basc; vcntrlcles con· 01 the lungs. vessel. con' the large and. )lIleumoooccl.
talnrd a quant.lty 01 tained bllhar. smalllntestlncs;
mUCQ·purulrnt Hnid. in zia worms. Ankylostomes
which Hnkes '01 yellow presellt.
matter were suspended.
--------'---:------1---------1------1------1·------:------1---·---1------+-- _
10 B.C'ent. /l5 yrs. 6 da~'s Well nourished. Intense rongesUon of the l'ericnrdium ad· LUllgs normal. Commencing clr' Enlarged and Normal. Normal. Pus at base contained a
African velljlel~ of thc convexity; herent to heart rhosis. congested. fell' meningococci. no
Jnrge amount or fibrino· W1l1l8. pneumocooci.
pUT-ule"t exudate nt the
basc.
.... - ..
-----:---:-·_----·--1--------1------[-----1-----1·_-----1------1------·1--------
11 Nyassa ,26 yrs. 4 dnys Well nourlshcd. Vessels Ill. eonvcxlty much Rcnrt eovcred Marks of rccent Normnl. Somewhat en· Congested; cap· Ankylostomcs Pus nt basc 8howed a fcw
congested; quantity "I with nn exten' plcurltlc adhe. largcd. sule adhercnt prescnt. meningococci, no pneu'
pus under pin mnter, slvc doposlt 01 slon"On both In plnce.. mococcl.
, e8peClaJly marked at the lymph. the re· slde8; both
ba8e. . suIt of reccnt ba8CS con. '•.,
pericarditis. gested. I,; . "'..
----------
12 Mozam· 27 yrs. D days Well nourished. V.cssels lit convexlty,'On· Normnl. CongCJjtlon lit Normal. Normal. Slightly con' Patchel showing Pus nt ba8e .hcwcd
gested: IlO nllkcd eye both baBcs. gested. pctechloo on menlnllococcl, no pneu·
blQue signs of pus under pia mucous memo mococol.
at the convexity. Ilut a
brane; numbers
thick ftbrJno· purUlent
olankylostomes
cxudate lit Ilase.
present.
• I j 1
--I----I~-- j ~ i ~
13 1I10zam· 20 yrs. 27 dal's Emaciated. Vessels 01 the oonvexlty Normal' Normal. Normal; bllha.... Normal. Caliccs dllated, Petechlooon mu·, No baeterlolOl1I.",' ."am.
congcsted: at base was "ill worms in otherwise nor· cous membrane Inatlon recordcd.
bique a Quantity ot pale yel· I)Orta.1 vessel~. mal. o.t small IlIteslow,
nAarl)' wh,t.e.Hllrino' tllle; ankylopurulent
exudate; vcn·
stomes present.
triclrs contained large •
, amount of /lu,ld P1ls.
.
----------1---------------1------,--------_'·-------1------1------1------1----;--·-----
14 Mozam· 25 yrs. 4 days Well nourishen. VCiseJs of convexity con· Normal. Both bases con. Normlll; pnrtal Friable and Congested. Normal. Pus at bj1S~ ,beWed
blQue gested : cxtenslve puru· g••1;(,'I. vesp"lp con· somewhat en' Il!eplngococc)' In .maU
lent exud"te nnder the talned bilhar.da larged. numbcTl. no pneumo'
pia mater of the whole worms. _ .cocti... ••. .• ..••.
surface of brill n ; at th"
basc a fibrlno-plIrulent
• • I 6.\':udate. /. .;.' _,}\ ' ~ 'r,,', ,.1, '.,,\1
-~~~ , ~ .
116 Mourn- 21 yrs: '32 dd'Y8 EmacIated; de- Vessels at cOllvexlty con· Normal. Red hepatisation Decomposed. Decomposed. Normal. Ankyl08tomes No bact. exam. }Iladete0n
blque I composition gested : ftbrlno-puruJellt at both bllses present. account of pOI..-mor m
commenced. exudate at. tilebaBe.' chanllcl.
• 1
~
~
~
00
~
P>
>­
~
.a::
t:;j
tj
....
(').
~..
~
0.'
'~
~
,~
t1
g
s"
i:. ....'.
....-
~
~

POlt, Mortem Examinations-continued.
No. Tribo. Ago.
Duration Condition I
of of Brllln.
Sleknell. Body.
\
I'
Heart. Lungs. Liver. Spleen. Kidneys InteltlDOI. Bact. Exam... Rllmlfks.
- ---
--'------
16 MQzlltn· 26 yrs. 6 days Well nourished. Vossels of convexity ron· Hypertrophlod ; Plouritic adhe- Normal; bllhll1" Friable. Slightly con' Normal: anky· Pul lit bue sbo~ed
blque ae.ted; pus under the old vegetlltlon sion lit the right zill worms In ge~ted. IQ!ltome. menlnlloCOCCl In small
pia mater over whole on the aortic bMe \ reerntl ; the portlll prosent. numbers. no pneumasurface
of brain, flbrino- cmps ; no sign' both hll8es con- vessels. cocci.
of recent gested.
g~~~le:ntve~~r~~I~~ co~: trouble.
, talned quantity of bl~d'
stained .erum, wi h
flakes of,vellow purulent
mllterialsuspenrlerl in it
17 l\[ozlIm· 22 yrs. 20 days Emacinted. Whole of the cerebrum Normlll. Normal. Normal; portal Dry aud con· Normal. Normal. PUI at the bue showed no
blque unrler the pia mater \'essels contain' gested. menl ngooOCOl. but a few
bathed In 0 pole coloured ed bilharzia pneumococci.
pUI 0, thick flbrlno· Worms.
guruient exudate at, ~he
08e : ventricles con· • J
tAlned 0 large amount ,
of flulrl pUI.
--
18 Mozllm· 19 yrs. 16 days .F:maciated. Ve88pll of the cortex con- Normal. Congested. Normal; blhllr- Normal. Normal. Normal. Pus at bue showed
bique gesterl ; only a 811ght zla worms In menl ngoeocol In small
exnda·t1nn of pale-colonr portal velsol8. numbers. no pneuma-
~u" lit the b/l.

Post Mortem examinations-continued.
No. Tribe. Age.
Duration: Condition
01
I
Brain.
or I Heart.
Sicknes~. Body.
Lungs. Liver.
22 M07.am- 23 yrs. 2 days Well nourishcd. Vesspl~ or the cortex much Normal. Right. yellow Normal. Enlarlled. nnro- CSytic kidney~. Petechi:r on mu- Exudate rrom surrace or
biQue eugOl'ged with blood; exudate over mic and friable. calices dilated; caus membrane brain showed neither
I
.Sp.1c~n. Kidneys. Intestines. Bact. Exam. & Remarks.
l-'
0,
m
----------
mllrked COdema o"er the whole or sure
convexity, with an exu-
ureter h)'perlace.
and lung or small inWd' pneumococci nor menin-
dation or albuminous- trophied : bladsolid
throughtine:
ankylo- gococcl.
looking fluid. streaked der walls thl ckout,
with grey
stomes present.
with yellow in places: ened.
I
heratisation :
nothlnl/ marked at base; ler slightly con-
'- ..
vcntrii'lcs f'ontninod ex· gested.
ep8S or blood - stai ned
SCrum.
23 Shnn- 34 yrs. 4 clays Well nourl~hed. Ve~sels
gaan
on eortex con- Very thick coat- Small patches 01 Normal. Enlarged. Congested. Normal. Pus at the base showed a
~~~~ed ~o~~~~gXi~~ltI~n~
Ing of yellow pleuritic adhefew
ft brlno - puru- .Ions on both .
meolnllococcl. )10
thick lal'er or pus. that lent material on sides ;
.poeumococcl.
both
.. at base bel ng orl/anised. heart walls. lungs con- --
result 01 reeent gested.
pericarditis. ,
---------- , , --------
24 Myam- 19 yrs. 14 days Emaclatcd. Vcssels at the convexity Norml11. Congestcrl at Normal. SlIghtiy enlarged. Normal. Normal. Bact. exam. or pus at base
bnnm conllcstcrl : a thick mass both bases.
01 ftbrino-purnlent exudate
at the buso : ven-
trlpJe~ rontaincr! a quantity
or liquid pus.
----------------------
showed smail numbers of
: meningococci, no pneu·
mococci.
--------
25 Shnn- 20 yrs. 4 days }'airl)' well VesElofllp; over cortpx COIl- Norma,1. 130tll
gaan 110urishrr!.
apices in Normal.
ge,ter! : larl/e a,mount, or
Enlarged aod Cystio, the
.tate
lntestlncs conof
rer!
No bacteriological exam-
pair coloured pus a'. thc
rrlable. calices dilated. talned ankylohepatisation.
inatlon recorded.
bll8e ; vontricle~ con ..
stomes and
Ascaris lum-
hrlcoide•.
tained quantity of thic~
pus.
------ , ,
-26 Nya8lla . 29 yr~. 9 cloy. Emaciated. Vessrls over the cort..,x Aortic valves Normal. Normal. Not enlar~ed. Normal. Contained ank)'· Pus at the base showed a
cOlwest.ed : ouly a small slightly athero- lostom08 and few meningococol, but
amount of pus at the matous. other- Asoarls Inmbri- no pneu mococcl.
ba se : ]ln8 i11 both ven- wise henrt nor- coidcs.
trlclos.
mal.
----------
27 Shan· 20 yrs. S days Emaciated. Traces of pus visible under Normal. Normal. Somewhat
gaan
con· Normal.
1)ln mater a t the
Normal. Mucons memo
con-
Pus at the base contaloer!
gested; portal
vo"lty: brone conl/ested
onl~· a small no menihgOcoccl. but a
vessels conamount
at the
In places: tew pneumoooccl.
base; I taioed bilharventricles
dry. Ascaris lum·
zin worms. brlcoldes present.
----------
I I
28 Myam· 20 yrs. 6 days Emaciated. Small ql~antity of pus Normal. Both' bases con- Normal. Enlarged
baam
and Normal.
uncler ]lla mater at the gested.
\ Normal. Pus at the base cootaloed
frlllble.
convexity: only a smail
rair numbers 01 meniogo·
amount or organised pU8
cocf'i. but 00 pneumo-
at tho base: ventricles
coccI.
dry.
---- ..
-29 NYfis8a 20 yrs. 3 days No record. An excessive amount of Normal. Both bases Congested and E:llarged. Normal. Smail· Intestine
yellow rus uncler pia
PU8 at the base contalne
slightly con- somewhat cn·
ma,tcr a t,he convexl ty :
contained anky· reil'
gested.
meningococcI. n
larged.
I 10sOOme•.
Iu,rge mas8 or flbrinopneumococci:
,
.' :
purulent material at the
buse: ventricles con·
.
.
tallled only a smail
,I
L""
, " . "I amount
'.
ot fluid. with
'" :
some pus.
.
..
~.
f-:3
~
~
Z
rn
~'
~ t;I:j
t;
I-"-
);l>
t:­

Post Mortem ExamlnatloDs-contlnued.
I I jDuratlon\ Condition
Spleen.
Kidne~s. Intestines. Boot. Exam.,~ !tPlllllrk,.
~: Tribe: ~~, ngJ y • 1 Brnin. 1 Heart. I I.ungs. \ ~---i, , , , _
so I Quill·:
mane
32 I Utyopl
26 yra. 110 days I Well nourished.
42 yrs.
23 yrs. I 8 days
A larlle amount 01 pale I Normal.
yellow coloured pus
under the pia mater.
eoverlng the convexl ty :
mass of tlbrlno-puru!ent
material a,t the bllse;
ventrloles oontained a
QUllntl ty of bloodstalnecl
serum Ilnd pus.
Vessels of the eonvexlty I Normal.
engorll:ed with blood;
a pale. thin. milkyeo
loured fluid under the
plo. mater.over the whole
surfaee of the brain: a
small tlbrlno - purulent
exudate Ilt the bn8e.
" Normal.
Acut.e congestion
11 t both bases ;
red hopatlsn·
tlon commnnr­
Ing.
Normlll.
Normal.
Decom posed.
"ery small.
Normal.
Friable. but not I Decomposed.
enlarged.
rr:abJr. but not I Normal.
enlarged.
SOlidi Inl,stlll"
rontlllnert
ank)'lostolllr•.
Small Intestlnrs
contained
nnkylostome,.
Bartel!ololllral exanun.·
tlon of the pi' At lIlt
'base nel/atfve.
Decomposltlon had rom·
menren : bact. exam. 0 I
PUll at thp bur .ho\\ eel
no menlnllG(orrl. a fe"
pneulJ'ocorcl and ,treptr
roool.
Pus at the b8l~ showed 8
few mpnlr'lI:ococr!. DO
pneumococol.
_J---l.I-I I ~I I I I I 1------1-------1------- _
QUill- i
SS
mane'
II
11 '
-.'~-I 3 days IWell nourished. I I I I 1--------1--------1--------,-- ----
2S yrs. I 15 da)'s 1 J'maelated.
Pia mater over the con- I Normal.
voxlty bulging with pus:
wholo brain substance
covored with thlok
flbrlno-purulcnt oxudate.
especlnlly mllrked on the
under surfaoe of the
II fronta,1 lobes; pus
1 streamed from the spinal
I canal.
_, 11 1 'I i l
I 1----__1 -, 1 1 1 _
'I I.MlIe amount of cloudy IFlabby, otherfluid
under the pia mater wise normal.
I eauRlnl!' the membrRneR
to bu iI~e when the
brain was removed. An
exresshe Quant.jt.y of
fluid came from the
spl nal oanal; no pus
could bc fn'lIld Iln)'­
",her('.
Normal.
This rasr had bern dl"ll
nO!led as onp (I entello
lever: his tem~erature
had beeD SubDormal lor
several days be/ore
d~ath; no bsrt. exam
reeorded.
----,---,--1 I I I I 1------,-------1--------1---------__
34 Quill'
mono
25 yrs. 2 da)'. Emnoilltrd. Small (,uantlt)' of whil.c. ,!-'i brino-purulent
milkl"ooloured drposit deposit on the
over tile baso ; "entrleles heart walls
contained nn exres_lve ntherwlse nor·
Quantltl' 0' (hold. with mal.
somr purnlent material.
Uljlht lunll solid.
with pneumonia
throughout;
left lung ROute·
I)' congested at
the. base
Normal.
Normal, bilhar'
zlll worms
found In ths
portal vessels.
SI I Quillmane
Hobnailed rirrhosls;
bilhar­
"in. worms
found In the
portal vessels.
Small.
Mueh enlnrged.
friable. and
mol8t.
Normlll.
l\ormal.
Normal.
Ankylostomes
present lu small
Intestine.
Anky!ostomes Allcrosroploal examluatlon
pre8ent In sm31l showed pneumococrl to
Intestlncs. be vresent In llnod Dum
ben In the flulcl from
the brnlD.
-.---,!I--I---I : -! I I I I 1-------1-----------
S5 Mtyopl 10 yrs. 4 dill'S Fnlrly well nourished.
Vesscls on the oortex of
the brain wpre Rcute1"
oongested ; only 11 Rmail
amount of pus under
the pill of the cerebrum;
n dense flbrino-purulent
exudate at the base;
ventricles rontainert a
largn qUllntity of yellow­
Ish green purulent fluid.
Normal.
Both bases aoutely
congested. vessels oon­
Normal: portal
vorgi ng on the tained bilharzia
worms.
stage of red
hepatisation.
Enlarged: on old
olcatrlx on the
anterior surfllce
of about the 811.0
of a two shilling
pleoe.
Calioes on both
sides somewhat
dilated.
Normal.
Bact. exam. of the PIIS at
the base 8howed a very
few mp.nlnllooocd. and
no pneumoeocei.
~C':l
~
o
if
,'"'
....
~
o :--l
1-3
~
~
~
.......
tr.l
tj
H
Q
~
c:....
o
d
~
~
....
o
"-lI

Post Mortem Examinations-continued.
Duration
Condition
No. Tribe. Age. ot ot Brain. Heart. Lungs. Llvcr. Spleen. Kidneys. Intestines. Bact. Exam. & Remllrks.
Slcknes~. Body.
----------
S6 Trnsv\. 15 yrs. 7 days Emaciated. Vesae.l. over the convexity Kormal. Normal. Peculiar dark Normal. Normal. Ankl'lostomes Meningococci were present
Basuto congested: no macro· colour, other- present In small In tnir nnmbers In the r,us
scoplcal appearance of wise normal. intestines. at'the base of the bra n.
pus nnder the pia mater
covering the convexity.
but, over the base was a
pecnliar pole green purulent
deposit: ventricles
containcd an exrcss of .- .
"
fluid. with It quantity of
purulent mo,terial sus·
pendcct in it,.
----------
S7 Myam- 26 yrs. 5 days Emaciated. Vessels ot the convexity Normal. Normal. Acntely con· Slightly enlarged. Slightly con- One round worm Meningococci were prtll1cnt
baam engorged with blood: a gested. gested. present; a cyst In good numbeJ'l! In the
large deposit of thick.
of about the pus at the ,base: no
yellow pus nnder the pia
size of an orange pnenmococcl.
mater on both hemiwas
attachedto
sph~resot the cCrebrum:
the mesentery
a thIck. fibrino-purulent
ot the smoli Inexud~te
at the base;
testinc; the
ventricles contained an
crst contained
c lyle.
excess ot flUid. with
flakes ot purulent matc- ,
"
rial floating in it: thick
yellow pus exuded from .
the Int.. AUd. Meat. and
I
the optIC foramina.
----------
S8 Myom- 2S yrs. 9 days Ema~iated. Vessels of the convexity Flabby, other- Pleuriticadhesion Normal; portal Small and hard. Normo.I. Contained a num- Meningococci were present
baam engorged with blood' wise normal. on the lett side; vessels con- her ot round In fair numbers In the
pia mater over convex: both lungs were talned bllhar- worms. pus at the,.basc; no
Ity wus slightly QJdema- congested. and zia worms. pneumococci.
tous. but there were no
there was purnnaked
el'e evidences of
lent material In
pus there; there was a the bronchioles.
thick fibrlno-purulent
exudate at the base' a
deposit of pus on the
walls of the ventricles,
and pus floated in the
f1 uid of the ventricles.
-------------- ------_.
S9 Myam- 26 yrs. 4 days Emaciated. Vessels of the convexltv Normal. SmalJ patch of Normal. Large,and friable. Norm"1. ~f~ Ankylostomes Meningococci were round
baam e~gOrged with blood": red hetatlsatlon presen t in small In the pus at the bBse ;
shllht rodema under the at bot bases.' Intestines; some ot the cells congla
mater of the cere-
round worms tlllned 15 to 20 pairs ot
rum. but no naked eye present. copcl: no pneumococci.
evidence of ~"S : a th(ck I
flbrlllo·puru ent exudate
ut the base: ventricles
I
_Icon
tal neri pas.
---- ------------------
40 Myam- 27 yrs. S days Well nOllrlshed. Vesspls of the cortex en- Normal. Congested at Congested ; por- M\lch enlarged ; Normal. Normal Small numbers of menlnllbaam
gorgnd with blood; thick both bases. tal vessels con- weighed 18 ozs. cocci were founn in the
layer of yellow pus un- tained bilhar· pus from the bral n : no
rier tho pia mater ex- zla worms. pneumoooccl.
tenning over the whole
of the cerebrum. also a
..
thick :Ibrino,pllrulent
exudate at the 11MB:
ventricles contained
. - .
some pus in their flUid;
.
pus streamed from the
, I. ._. spinal canal.
.\
I
_.
......
0-
8·
~
8·
i;x:l
~~
'(J)

,
Post Mortem I!xamlnatlons-contlnued.
No. 1 Tribe. 1 Age.
&1 I }lyam·
, baam
29 yrs.
Duration
of
Sickness.
Condition
of
Body.
16 days I Emaelat~d.
Bmin.
Heart.

Po.t Mortem Examinations-continued.
No.
1
Tribe.
_i1__1
48 1~!ozam·
bique
20 yrs
6t I NYll8sa 1 28 Yrs;
f. :
i
, Duration
Condition
of
Body.
10 day~ I Emaciated.
Brain.
Heart.

Post Mortem Examinations-continued.
:lio. I Tribe.
1 Age.
-'--'--1--1 r 1 1 1 1 1 1---'---I --
53 1 Mozam-I 34 yrs.
blque
Duration
of
Slekness.
1 day
Condition
of
Body.
Fairly well nou·
rlshed.
Drain.
Heart.
Thiek layer of pale.milkyco!oul'ed
fibrino-puru­
Normal.
lent exudnte under the
pia mnter of the whole
convexlt,y: lityeI' of t.hln
fibrlno·purulent exudate
a,t the base, mOre Jlquld
than usual: fluid In the
ventricles contained pus;
pus oozed from the
spinal canal.
Lungs.
Right base In a
state of red
hepo.tisatlon ;
left base acutely
congested.
Liver.
Congested; por­
. tal vessels con·
tai ned bllhn.r·
zia worms.
Splccn.
Dark and congested;
~~mind­
Ing one of a
typhoid speci·
men.
r' I '-; t ;. ~ ~ .
Kidneys.
Slightly con'
gcsted.
-~ ... ~... -.~- ..-.~-_._-
intestines.
Normal.
Bact. Exam. et Hemark.
Pus from the bose sholVerl
. many menlngocol'cl: no
pneumOCOl·CI.
-'--'--'--' I I I 1------1------1 1-------
54 I' ]\fozom· 11 25 yrs. 2 days I Well nourished. Thick laj'cr of fibrino· Dilated and ll.ecent pleurisy Congested. Enlltrged : P.~f. decompo· Ankylostomes ~o bacteriological exa,m·
i bique
J1urulent exudate under flabby.
on the right weighed 6 ozs.; sltlon com· present. I nation reeorded.
the pia ma ter of the
side. Implicat- con%ested and menced. 1-3'
whole eonvexitj'. extend·
Ing the whole
frla le.
Ing over the whole of
right thoracic
the brain Into the spinal
cavity; a small
~
canal: It Sl}erially heavy
plttell the size ' ; ..
deposit at the base;
of a five shilling , , . 1 t :""'1
8
'ventrieles dry.
piece on the left
~
55
I
I1
-1..---1....---1-,--I 1 I 1
Mozam·1 26 yrB. "]i'ew hrs.1 WcU nouriBhed.
blque
56 1 Myam·
baam
, ,
10 yrs.
57 I Mozam-I 23 ~'rs.
blQue
1 day
3 days
WeU nourished.
Fnirty well nOli·
rishecl.
A small ,91Ialltlt.y of yel­
10wlshL' green oliveeo1onre-Cl
material under
the pia mater oyer the
convexit~';.no signs of
anv pns or orgnni.ed
clot at the base; ventricles
dry.
-'--'--1--1 I 1
Normal.
T.I'luld pns at the base.: I Normal.
b oorl·staincd I}UB ooring
fro III the spinal cunal.
--'---,---,---1 I . -I 1--------
A layer of fihrino·puru- 1 Kormal.
lent exudate unner the
pia mntcr of nearly the
whole surface of the
brain. with a very heavy
orllanised clot at the
bllse; vr-ntricles con·
talned an excess of fluid
with f1akcs of pur~lent
mnterinl 8tl~pended in it.
side; both lung .. , , .." ..... - - ... '0.' ... ........ -., ------ _... ~. .._-- >
Mutely con- Z
gested. verging
on red hepatisation.
-
Very Mutely con- Hob-nailec1 clr- Much enlarged; Congested; Round worms Meningococci found in the
gested, but not rhosls; portal weighed 3lbs. . calices dilated. present. ., fluid unrler the pia mater;
reaching the vessels con· 100zs. no pneumococci.
stage of red tnll)ed bilha rzla
~,
hepatis"tion. WOI;OlS.
, ' . tJ
.. H-
I
"
0
.- . :;.-
t:"'
-- ,
~
g-
....
I-'
I-'
I-'
I-'

Post Mortem Examinations-continued.
No. I Trlbe.
Age.
Duration
of
Sl~kness.
Condition.
of
Body.
Brain. Heart. Lungs. Liver. Spleen. Kidneys. Intestines. Bact. EXAm. & Remarks.
-'---'---'.---\ I I I 1 1 I 1--------
59 ?!fozam'j 29 yrs. IFew hrs·1 Well nourished. A thick layer or a peculiar Fatty degenera· The lungs were Fatt)' : portal IEnlarged and Normal. Ankylostomes INo bacterloloalcal exam·
blque
I
pale grcen pus 'Inder the tlon to a slight acutely congested.
and hod to.lncd bllhor- weighed 90zs.
Intestine.
vessels con- congested ;
present In small Inatlon recorded.
pia mater of the whole degree.
of the cerebrum. extenl!­
a pecnllar dark zla worms.
ing to the base. but not
co Iouration .
accumulated there more
than in othcr ports. and
not fibrlnous ; ventricles
contained some pus. and
there W08 PU8 oozi ng
from the spinal canal.
-'--I 1 r 1 I 1 I I I I 1-------
60 I. QUJ\l- 25 yrs. I: Few hrs.1 Well nourished. Pia mater over cerebrum Normal. Normal. Acutely conaested.
gested.
Inatlon recorded.
Conaested. Very acutely con·1 No notes kept. No bacterlololJlcal exam'
mane I
distended with fiuid;
between the convolution
a small amount of white
material con Id be ileen.
61 I Pondo
40 yrs. I 2 days I Well nourished.
of the Sl\,ITIO consistence as
pus; small amount of
fo~esa ~l~~e b~:~e:be~~~
had peteehloo on the
surface.
nuro mater very flrml)'
adherent to the skull:
under the pia mater of
the cerebrum was a
quantity of milk)'­
COIOU! Buld: no deposit
pus at the base;
ventric es contained a
small amount of olivecoloured
Buid; a large
amount or fluid come
from the spinal canlll.
Normal.
Congested at IA peculiar green
both bases. colour, but no
evidences of
P.M. decomposition.
Acutely congested;
of a
very dark
colour.
Neither meningococci nor
pneumococci were found
in the pus at the base.
-0--'---'--1 I 1 I I I I 1,-------
621 Basuto ,'I 29 yrs. I 3 days,1 Poorly nourished. An amount or l1'dema Normal. I,eft base acutelyI Normal. Normal. Pale, otherwise I No notes kept. Neither pneumococol nor
under the pia mater of
congested.
normal.
meningococci were found
the cerebrum: an ex·
in the pus at the base.
cesslve amount or fluid
came from the 8pi nal
cllnal. which was cloudy.
possibly the result of
pus; ventricles dry.
-,--,--1--.1 1 1 I I I I I 1------
63 I MozaID' I 26 yrs. 1 day 1Emaciated. Blood vessels on the convexity
engorged wi th
state of red he· vessels con- friable; weighed
present In small the PIIS at the base. but
Normal. Both bases In Pale; portal IEnlarged and I Conaested. Ankl'lostomes Streptococci were found In
blque
blood; an amount of
patllatlon : talned bilharzia 120zs.
Intestine. neither meningococci nor
pus under the pia mater
lungs generlllly worms.
pneumococci could be
of the cerebrum extend·
congested.
demonstrated.
Ing on to the base.
-,--,--1--1 1 I I I 1 1-----11--'-------
64 I Mozam' I 27 yrs.
blque
10 day~1 Well nourished.
> .. ~ .J, I , ,/;1,1 t' ..,_~.•"". I I ...·
A quantltl' of PU8 under Normal.
the pia ma·ter of the
cerebrum, especially
marked 011 the frontal
region; large fibrinopurulent
exudat.e at the
base.
Red hepatisation Much congested; I Congested.
at both baaes ; portal vessels
both lungs contained bil·
generally congested.
harzla worms.
Normal.
Congelted.
I Normal.
Numbers of
ankyJostomes
preaent In ,mall
IntCltine.
No menlngocooel were
found In the pus at the
bllle. but f.lr numbers
of pneumoooccl.
,....
""" ~
~
8
:d I>
r:J).

POAt Mortem Examlnatlon5-cont/nued.
No. I Tribe.
1 AlIe.
Duration
of
SlckneBB.
Condition
of
Body.
_'__1__1__1 1--------1 1 1 I I I 1-------
65 1 Mozam- 1 26 YfI.
blque
S daYB 1 Fairly well nou-­
rlBhed.
Brain.
VeBBelB of the cortex engorlled
wlth blood;
whole of cerebrum under
the pia mater bathed In
yellow PUB, eBpeclally
marked over the left
frontal relllon; bMe of
brain covered with pUB.
ventricles full of pUB.
Heart.
Hypcrtrophled ;
pericardium
adherent to
heart wall, the
result of old
perlcardltlB.
Lunlll.
LIver.
PateheB of red 1 ConlleBted.
hepatlBation at
both bMeB.
Spleen.
KldneYI.
Enlarged and I Conllelted.
friable; welllhed
Hozl.
InteBtlnes.
No notel.
Bact. Exam. & Remarks.
No menlnllococcl' were
found In the pUI at the
bue, but small numben
. of pneumococci.
_,__1__1__1 1 I 1 I I 1----
ll6 1 Shangaan
20 yn.
13 dayB 1 Emaciated.
Cerebrum WIlB quite clean.
but at the baBe waa a
thick. glory, fibrlno·
purulent maBB extending
Into the Bplnal canal;
ventricles contained an
exceBS of fiuld, but no
PUI could be Been with
l.he naked eye.
Normal.
A thin layer of pUB under 1 Flabby.
the pia mater of the
whole Burface of the
brain. not particularly
marked at thc baBe;
ventrlcleB contained a
Bmall quantity of blood-
Btalncd fiuid.
SignB of recent
pleuriBY on both
BldeB. more extensive
on the
rlllht; both
baBeB acutely
cOlIgested.
":"ormal.
CongcBted ; portal
veBBelB contained
bilharzia
worms.
CongeBted
friable.
Acutely congealed.
Fine eirrhosiB; IConlleBted
portal veBBels friable.
contained bilharzia
WormB.
and I Normal.
Round wormB
preBent.
Round WormB
present.
Few menlnllococci were
found In the pUB at the
bMe, no pneumococci.
No meningococci were
found In the PUB at the
bMe, but large numben
of pncumococci.
-,--,--,--1 I I I 1 I I I 1------
VeBsels of the convexity I Normal.
congcstcd; pus under
the pi a mater of the
cercbrum; thick fibrinopurulent
deposit under
the base; ventricleB
contained quantity of
purulcnt fiuld.
Right lung con- I Normal.
geBted; baBe
soU d ; left lung
congestcd.
and 1 Normal.
-,--i--I--I 1---------1 I I I I 1-------
671 Myambaam
at the baBe was a slllall welghcd 15 oz. ly congeBted,
and eonlleBted ;
found In the pUB at the
25 yn. 1 day I Poorly nourlBhed. Cerebrum WaB clean, but Hypertrophied; Both baseB acute­
Normal. Much cDJarlled 1 CongeBted. No noteB. No meningococci were
glary exudate. with ri
verging on a
welllhed 1 lb.
bale, but a few pneumococci.
whltiBh noduln.r maBB
Btate of rcd
50ZB.
about Blze of a lentil, In
hcpatisation.
Bome way reBembling a
tuburculouB nodule.
_,__,__,__1 1 1 1 I 1 1 1 1-------
68
69 I Myambaam
31 YfI.
8 dayB I Emaciated.
30 yrs. 1 4 daYB 1 Fairly well nourlBhcd.
CongeBted.
Normal.
l\{enlngococci werC present
In fair numben In the
PUB from the brain ; the
pneumOCOCCUB waB not
found.
_,__1__'1__1 1 I 1 I I- 1 I 1-------
70 1 Myambaam
25 yrs. ' 1 5 dILYB Fairly well nou'
riBhed.
VeBBelB of the convexity I NormlLl.
congeBted; pUB under
the pia mater of cerebrum;
thick fibrinopurulent
ex,udate under
the baBe; ventricles full
of pUB.
Both lungs con- ICongeBted; bB- I Congested.
gCBted. harziIL worms
in the portal
veBBelB.
ConlleBted. Normal. lIfenlngococci were preBent
In fair numben In the
PUB from the brain; the
pneumococcus waB not
found.
-,--,--1 I : I I 1 1 I I 1
71 Mozambique
20 yn. 4 daYB Well developed. VeBBels congeBted; pus
under pia mater of cerebrum
; thi n layer of pus
under the cerebellum
and pons; ventricles
filled with purulent fluid.
Normal. Right Dormal;
left acutely con·
geBted, verging
on red hepatlsaatlon
iu partB.
ClrrhoslB corn­
. meDclog; bllharzlIL
wormB
preBent.
Enlarged and
congested.
Congested; two
Bmall CYBts in
the right kidney
Normal; anky­
10BtomeB
preBent.
A few meningococci were
preBent in the smeILrB
from thiB braIn; the
pneumococcuB was not
found. The pneumococ­
CUB WM found In the lung
In this case.
~'
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Post Mortem Examinations-continued.
.... .....
~
No. I TrIbe.
Age.
Duration
of
Sickness.
ConditIon
of
Body.
Brain. Heart. Lungs. Liver. Rpleen. Kidneys. Intestines. I J3act. Exaui.
rn
~
~
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....
;g
~

Post Mortem Examinations-continued.
No. I Tribe.
DurlV­
pneumococci. but neither
011 ve·colonr~d\lellttl nO'JS
Itv was about
the men! nJ:!ococel nor
ml>terlal : under the bl>SC
two pints of
other bll. Pneumococci were present.
mane
jaundiced. congosted: sm,,1I amount
tilor",,; right
1 lb.
cystl c degeneration;
lelt
but the meningococcus
nus under the nia mltter.
of pnrlllent e"lldat~
lung. lower and
under the base.
middle lobes In
normal.
was not found.
.tate of grey
hepatisation;
".
left lung. ba.e
congested.
otherWise nor·
:'
mal.
--,--,--1 I I I I I I I
82 Shangaan
gested; thick deposit of
left \ ery a.cnte­ cap'ule t··,irk­
gested.
lostomes and mat.er showed IIood num­
20 yrs. 2 days Emaciated. Vessels of the cortex con- I Normal. night normal; Finely cirrhotic; Much congested. I Acutely con- Normal; anky· Pus from under the pia
pus In the flssure. under
I~' cc>nge.ted at ened : bllhlp.nt
hemispheres of the cerebrum
: no exudltte
patls.tlon. vessel•.
ollng Welchselbaum's
under the base: ventricles
contained blood·
upon blood-agar.
organism was obtained
stained and purulent fluid.
tj
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..
Post Mortem Examinations-continued.
~
~
0:>
No. I Tribe.
Ago.
Duratl"n
of
Slckncs•.
Conelltlon
of
Body.
Rraln. Heart. Lungs. Liver. Splcen, Kidneys. Jutestlnes. Bl\Ct. F.:tam. It' Rrmark•.
83
84
Vessels on cortex acut.ely
conllested; no nnked
e~'e nppearnnce of pus
under the pin mat.er:
ventricles contn' ned
blood-stained serum.
Normal.
Norma.!.
Extensive recent
pleurisy over
the whole of
bot.h sides of
the thornx:
right lung solid
nt the base between
the red
and the grey
stage of hepa.­
tisntlon: left
lunll, whole lung
solid nenrly into
the grey st.age.
more advanced
thnn the right
base.
Extensve pleurisy
on both
sleles ; right
lung, whole
orllan, except
for a sma 11 part
the size. of an
orgnnge at the
apex ,solid with
grey hepntisatlon
; left lung,
Rmnll patch of
very acute congestion
at the
base.
Normal; bilha.rzla
worms In
the portal vesscl•.
Normal: bilharzin.
worms in
the portal vesscls.
Thl. bo)' had stllfness of
the ncck, with Kernlll's
sllln,anel vomltlnll elmlnll
life, as well as the nhyslcnl
-illDS of cOlIsollelntlon
of both bases, yet
po-t mortem examlnntlon
showed no slllns of
meningitis.
Pneumococci werc present
in fair nllmbcrs In the
cerebral fluid, but the
meningococci were not
found: this patient dur­
Ing life hn.d Kcrnlg's sign
well marked, bu t there
was no stiffness of the
neck.
-'--,--1--1 I I I I i 'I 1------
85
Shangaan
Quillmane
Fal rly well nourished.
25 yr•.
27 yrs':
ltJozam-I 24 yrs.
blque
6 days
6 days
4 days
Poorly
rished.
Wcll
nou-
nourished.
Brnln Bubsta,nce normnl :
no na.ked rye evidence
of meningitis.
VesRels on cortex engorgedI Norma·l.
with blood; whole of
both hemispheres of
cereb4'um under pia
matfr bathed In pus; a
thick. almost whitecoloured
ftbrlno-purulent
exudate unrler the base;
vcnt.ricle. contained a
ounntity of purulent
ftuld.
Right, patch of
dark red hepatisation
n,t the
base; Icft normal.
Normal: bilharzia
WormR In
the portal vessels.
Normal.
Acutely
gested.
Normal.
con-
Conllested.
-,--,--,--1 I ! I : I I I I
Congested.
Congested.
Normal.
Congested
patches.
In
Normal:
ankylostomes
present.
Menlngocoecl wero present
In good numbcrs In the
pus under the pia mnter.
but the pneumococcus
was not found.
-,-----!--I 1 I I I I 1-----
86 Mozambiqur
25 yrs. 13 days I Well nourished. Drniu anEl'mie: Rurface I Normal.
of bOUl hemisphere9 of
e.erebrum uniformly
covered with a thin layer
or pllle. almo.t. white PUg
uneler the pin mater; no
evldencf or allY exudate
under the bllse: ventrlole.
contained n small
Quantity of blood-sta.ined
"crltm.
Right lower lobe
solid wit.h grey
hepntisation ;
upper and midd
le lobes congested:
left
lung congested
at the base.
verging on red
t'epatlsatlon.
Kormal ; bilharzia
worms in
the porta.] ve'ssels.
Normal.
Acutely
gested:
con-
Normal:
ankylostomes
present.
Pneumococci were present
In good numbers in the
pus under the pia mater,
but the meningococcus
was not found.
a
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Post Mortem Examlnatlons......:ci)ntinued.
Durllt!oo
CondJtlon
No. rrlbe. Age. of 01 Brain. Heart. Lung8. Liver. Spleen. KldneY8. Inte8tlnes Bact. Exam. & Remark8.
Sickness. Body.
-- -'"'---------------------------------------
87 ~lozam- 29 yr8. 20 daY8 Poorly nou- Normal; no evidebces of Normal. Small patcrl of Normal. Anremic. Pale, otberwlse Normal; Absence of purulent ma·
blquc rished. meningiti8. recent pleuri8Y normal. ankylostome8 terlal under the pia mutpr
"
at both base8 ; present. rendered bacteriological
right lung,ba8e
examination unnercssary.
solid with grey . bnt thl8 1'IItipnt hnd
, hepatisation, Kernig's sign dllrlng life :
and the sub· death resulted from pul·
stance riddled
monary tuberculosi8 of a
wi th tuberoular
very ncute form.
nodule8 about
the size of a
split pea; left :
lung, whole substance
occupied
hy number or
small, very recent
tubercular
nodules,In80me
cases commenc·
Ing to caseate;
.. nn ab8cess
about the si zo
01 a naartje at
Ing lIuid.
---------------------- ----------------
88 Mozam- 24 yrs. 5 c!I\Y8 Poorly nou- Whole brain anremic: Normal. Exten8"e pleur- Normnl. Norml\l. Normal. Normal; Pneumococci pre8ent In
blque rl8hed. under the pia mater 01 18Y on the right ankylo8tome8 fair numbcrs In the pU8
both hemlsphere8 01 the 81c!e; right lung prescnt. uncler the pin mater;
cerebrum was a thin thick c1eposl t 01 the meningococcuR was
layer of .white pus, lymph on thc not found; thl8 patent
especlal1y marked In the posterior Bur- 8howed no symptom8 0 f
fls8ures; no deposit at Ince, and the meningitis during life.
the base; \'Ontricles base solid with
_.
showed naked eye a,p- hcpatlsl\tion 01
pearunce 01 pus. a dirty grey
colour. bet,vcen
the red and
grcy stage; lclt
tho posterior
and npper sur-
Il\ce 0 tM lower
lobe, filled with
l\ Cluantlty or
grumous·look-
luug, base acutcly congcsted.
not con·
I
solidated.
I
---------------------- --------
89 Quli- 29 yrs. 7 days Emaciated. Vessels 01 the cor~ex con- Normal. Right, upper and Normal. Fibrous. INormal. Normal. Menlnllorocrl were ~resent
mane gested ; small amount middle lobes In the pus under he pia
01 ])lIle yellow ])UB in the congested, mater: the poeumofissures
01 both hemi- lower lobe in a coccus WII' not found.
spheres 01 the cerebrum; state of grel'
11 thick flbrlno-purulent he~atlsation ;
exudate under the base.
lef , on surface
principally confined to of base were
the medulla; lateral ven- several darktricles
contained fluid colourcd .acutemixed
with purulent Iy congested
material. looking spots,
, which section
. .
showed theY
."
were caused by
localised
patehes of very
, acute red hepat1sntlon.
I
I
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118 THE TRANSVAAL MEDICAL JoUR AL. December, ISO".
sourH AFRICAN J~EOICAL CONORESS, 1907.
SPEI,;IAL SUBJECTS SECTIO'4.
....
III
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By N. A.
Death by Lightning-Stroke.
SPENCER, L.R.C P. (Lond.\ M.R.C.S. (Eng.),
District Surgeon, Mlddelburg, Transvaal.
In a country vi ited during six months of every
year by violent thunderstorms, sometimes tropical
in their intensity, it would be extraordinary if cases
of lightning-stroke did not occur at times, and
almost every medical mn,n in the Transvaal mll;;l
have seen such cases. Yet, owing to most of the
records of these cases having been derived from
laymen and not from trained observers of detail, as
arc medical men, we still await a clear and ..;att:­
gorical de cription, let alone an explanation, of the
injuries caused to man by atmospheric electricity.
In searching through medical works at disposal,
one is struck by the absence of mention of anyone
condition as characteristic of these injuries; onc
wades through a maze of "reported" conditions
without meeting with a single peg on which to hang
anything definite. There can be no doubt that,
from a medico-legal point of view, these injuries are
still contradictory, equivocal and shrouded in
mystery to such a degree as to produce confusion of
thought, when something definite is sought, rather
than orderliness of mind; far too many" facts which
have not been sustained" are included in these
descriptions, one author stating that" there are no
n,bsolute and constant indications of death by electricity.".
.
It needs no excuse, therefore, to give prominence
to a subject requiring so much elucidation, and to
discuss it even in detail in the light of some of the
cases met with during the last seven years. It has
fallen to my lot during this time to see a good many
cases of death or injury from lightning, all of which
have shewn such very definite evidences of what I
now consider to be characteristic of the condition
that, were I requested to examine a. body lying dead
upon the veld in summer-time, I should look for
these signs at once, and first, and were they present
I should have no hesitation in swearing to death
being due to this cause. The forms taken by
lightning when it comes to earth-the well-known
flash and the most extraordinary" fireball "-with
their varied effects upon the material struck, form
an absorbing study, often at variance with what we
have learnt of the movements of electricitv. and not
always capable of ready explanation. in reading
some scores of instances of the effects of lightning
upon edifices, human beings and animals in abookt
recently lent me by the Director of the Transva::d
Meteorological Department, the vagaries of atmospheric
electricity, and variety of effect. filled me with
amazement. It is generally accepted that what we
know as lightning is ~enerated both from the earth
and the thunder cloud. The earth being electrified
-it is suggested by the fTiction of its mtation in the
atmo pbere, its internal heat, etc.-that electricity
will be split up into its positive and negative elements
* Cantell's Post Mortem Pathology, p. 413.
t .. Thunder and Lightning," by Camille F1ammarion, translated by
Waiter Mostyn and published by Chatto and Windus, 1905.

December, 1907. THE 'rRA SVAAL MEDlCAL JOUR Al.. 119
by the near approach to the earth's surface of one of
the elements opposite to it; that thunder clouds
being also electnfied-by their motion, the heat,
the friction of wind currents, etc.-form close to the
earth's sudace, and as they move above it, attract
the opposite electricity of the earth, \,:hich follows
it below, only awaiting an opportumty of neal:
approach to unite with a flash and a crash of
thunder. \Ve can imagine, for instance, a thunder
cloud moving above and clo e to the eart~'s sUl'~ace,
charged in that part nearest the earth with positive
electricity and the negative electricity, attracted by
it, following the cloud upon the eartl~'s surface; thiS
negative element meets with a kop]e, a steeple, .a
tree or even a man standing upright, runs up it
towards the opposite element in the cloud and the
circuit is complete, lightning leaps from the cloud
and is conducted to earth by the medium. With
the cause of the noise which accompanies this connection
and discharge, known as thunder, we are not
here concerned, .but we know that the course of the
electric fluid becomes visible to us by reason of the
air through which it passes being raised to the point
of incandescence.
When lightning meets the body of a man, i~ is
usually conducted by his skin to the earth., teanng
off his clothes and even his boots by rendmg them
open immediately over .its course down his body
and flinging them to a distance. Appa!ently w~en
a man is struck indirectly, by the lightmng glancmg
off a tree to his body "for instance, he may be hurl~d
away some yards, he in one direction, his clothes.m
another; but when struck directly he usually mamtains
his position, and may continue to stand even,
for some moments, before he falls.
It seems to be in cases of a direct stroke that the
very severe injuries sometimes described are seen.
A case is recorded* of a man who was struck on the
head and a large lacerated wound ~n th~ scalp produced,
without fracture. The lightnmg passed
down between the tissues and the bone as far as the
root of the neck on each side and then came to the
surface. In all such cases when the lightning gains
admission to the body it comes to the surface quickly,
doing much damage previously., and it is evident that
the tissues offer very great resista1?ce to the. c.onduction
of the electric fluid. Ranks, m determmmg the
relative conducting power of living. muscle in ref~rence
to electricity concluded that it was three million
times less tha~ mercury and fifteen million times
less than copper. .
There is little doubt that the skm of the body
offers the most suitable medium for conduction ~f
the electricity, and I think that those parts of it
usually moist with perspiration conduct I?ost
readily, e.g., the inner surface of the arms, thighs
and legs, the middle lines of the back and th~rax
in front, the sides of the thorax and the vanous
natural folds and flexures of the body. The track
of the electric fluid over the body can easily be
traced, presenting such an extraordinary appear~n~e
that once seen it will never be forgotten; and it is
this track of the lightning, wherever.it. tou.ches the
skin which I consider absolutely distmctive and
char~cteristic of this form of injury. It. consists. of
an arborescent branching and re-branchmg reddish
.. Taylor's Medical Jurisprudence, Vol. 2, 4th edition, pp. 131 and 132'
streak which become finer as it descends the body;
as broad as a finger or a lead pencil above, it thins
off to the finest thr ad. The branching is often
wonderful, and reminds one of the distnbution of
the superficial blood ve sels of the skin, thrown into
view by an injection of them. 1\ly own opinion is
that this is the case; that the superficial blood vesel
of the skin in ·tantly dilate to their utmo t, the
blood conducting the electric fluid; tha,t the
haemoglobin of the corpuscles is set free and tain
the skin in the track of the .lightning. rl~is is
exactly the appearance produced in the arbore cent
streak and in all its branches, rather than, as is
u ualIy described, " an appearance of burning." It
is this peculiar distribution of the streak upon thc
skin which has gi\"en rise to so many records of the
likeness of neighbouring trees, foliage, ferns, etc.,
having been " reproduced" or "accurately
delineated" upon tho e struck by lightning. Yet
when seen it would really require but little imagination
to conceive this a fact. The first time I saw
this red arborescent streak it i'eminded me of the
injected vessels of a subject in the dissecting room,
and I notice amongst the cases of lightning-stroke
described by Flammarion that, in connection with
the skin appearances, mention is made of this similarity
by others, which lends some weight to the
opinion set forth above as to the cause of these
markings.
In those 'Yho survive li.ghtning- troke these stre~ks
fade away m a re", day , leavlllg no mark; whiCh
would not be the case if they "ere due to a burn.
\Vhen seen after death these ·streaks are brown, and
in the skin of the native are usually some tints
darker than the contiguou skin.
As already mentioned, these red streaks are
generally referred to as "burns," but against this
is the constantly recorded fact that tbe clothes of
the person struck, though rent from the body, are
neither burnt nor singed, whilst in those cases wh re
burning is recorded it is invariably mentioned to
have occurred in connection with some metallic substance,
worn or carried in a pocket. Thus-the
half of a man's head had the hair singed off beneath
the buckle of his hat, the hat burnt immediately
around it and the buckle fused; a man wearing a
belt with a buckle to it " was severely burnt on the
abdomen, over a space the size of a hand " immediately
beneath the buckle, and his shirt over this
area was also burnt; others have been burnt beneath
watches carried in the wai tcoat pocket and money
in he trouser pocket, whilst still others have been
burnt beneath metal buttons on their clothes. In
all cases the clothes contiguous were burnt, and the
metal substance responsible for the burning partially
or completely fused. I hink, therefore, that we
may say that licrhtning only burns the human body
when it meets in its cour e some metallic object. It
may be tha upon further investigation of this
matter, thatched roof , hay ricks and other objects
burnt as the result of lightning-stroke will be found
to owe their ignition to he presence of metallic substane
s, though re istance to conduction may play
an important part.
A " smell of burning" is often referred to in connection
with the lightning-stroke, although no
evidences of burning or singeing exists uEon the

120 i'ltE 'rRANSVAA1.. ME.blCAL JOURNAl.. December, 1907.
clothes of the person struck; also in connection with
\\oodwork which was struck and \ hich was" split
and splint red in every direction without a sign of
buming upon it." This is no doubt due to the
ozone generated in the air by the fla h, and also to
the various substances rendered incandescent in the
air; this smell is, however, characteristic and
invariably present for some time after the flash, and
is often referred to by those in its immediate
vicinity as " the smell of an explosion." The rent
made in the clothes of those struck by lightning also
bas its characteristics. As stated, it occurs immediately
over and corre ponds with the red streaks on
the body. vVhen examined, it has the appearance
of having been caused by a blunt edged in trument,
to have been violently burst open from within, the
cdg s as a rule showing no singeing.
In the Royal College of Surgeons' :Museum,
London, is to be seen a hat, dothes, shirt, stockings,
garters and boots of a man struck by lightning whilst
sheltering beneath a tree. The rents are characteristic
and shew no singeing of the finest threads;
the boots, of thick leather, burst open down the
back as with great violence by a blunt-edged instrument.
The history records that he was flung out
of his clothes some yards away; and as far as I
remember, though badly "bmnt," i.e., marked,
and unconscious for some time, he ultimately
recovered.
Amongst the more severe injmies described as
caused by lightning strokes are :-¥(1) "Lacerated
and punctured wounds, as though with a blunt
dagger," of entrance and exit, in the head-generally
without singeing. of the hair at their edges. Fracture
of the cranial bones with conversion of the brain
"into pulp" and into "a liquid mass"; a large
wound of the thigh exposing the femoral artery;
haematomata at the point of impact severe contusions
and extravasations, rupture of blood vessels
even to "splitting of the body into two parts."
(2) These injmies might give rise to great difficulty
in inferring the cause of death, but I think that were
such cases carefully examined by a medical man
acquainted with the subject, the red streaks would
be found in evidence somewhere, as the electric fluid
travels so short a distance in the tissues and comes
to the smface really at the first opportunity, to continue
its course to earth by means of the skin surface;
but, never having seen such a case, I am only
able to draw attention to their recorded existence
·ometimes. The results of lightning-stroke upon
the interior of the body requires much elucidating
and recording of cases. Some say that the blood
does not coagulate in these cases, also that" rigormortis
is absent in them," but these are amongst
" the facts not as yet substantiated." A condition
which I have generally found, and which may be
i1istinctive in this form of death, is an empty :).(Jl1
firmly contracted heart, especially the left ventricl~.
with a congestion of the lungs, as though c3:11sed
by a spasmodic contraction of the heart at the
moment of being struck, forcing its contents into
the pulmonary and other vessels and not being followed
by a relaxation of this organ.
* (1) Flammarion'e 11 Tbunder and Li~btning" and Taylor'e
,. Jurisprudence."
t (2) FIammarion.
In those who sUTvive, a condition of profound concussion
is produced, minor conditions of confusion
of mind, tingling of the extremities and temporary
paralysis, or weakness only of the limbs. But
death from lightning-stroke is instantaneous, and is
due to shock to the brain and nervous system.
The first experience I ever had of the effects upon
man of lightning-stroke occUlTed in September, 1900,
near the Valsch River Bridge, in the a.R.c. Two
other civil surgeons and myself were under canvas
about 100 yards away from the camp of the Highland
Brigade. The sky had been overcast for an bour
or more, ,vith dark thunder clouds, and a heavj'
thunderstorm was momentarily expected, the first
of the season. Hearing a few heavy rain-drops fall
upon the canvas, I knelt up to the tent wall to iet
down the flies, and was so occupied, facing toward;~
the camp, when a sudden fl3..,h of lightning can'f~
to earth a little distance away and straight in front
of me. It was so vivid that I could see, though
indistinctly, through the thick canvas in front of
me, as though it had been of gauze; saw the flash
fall amongst a group of soldiers on the outskirts of
the camp, and the men falling and scattering, as if
they had been hurled away.' It was but a momentary
glimpse dispelled, almost on the instant, by u.
terrific crash of thunder. Running up to the spot,
I found a sergeant of one of the Highland regiments
struck dead and lying upon the ground·; near him
lay a private, motionless and apparently dead;
whilst, rolling about on the ground, groaning as
though in great pain, or sitting up on the ground
rubbing various parts of their bodies and limbs, were
nearly a score of men, all more or less affect~d hy'
that one flash. Hastily examining the sergeant, ]
found, only some three minutes since he was struck,
not the faintest flicker at the heart, nor any respiratory
movement. To describe his injuries :-First, I
found the hair singed off the left side of his head;
his soft felt hat, which lay some six yards away,
was rent and scorched on the left side of the crown,
around a metal badge which had been pinned thtlre,
but which had fallen out. The hat smelt strongly
of singed hair, and I should have remal'ked that the
neighbomhood smelt of " lightning," at one moment
reminding one of exploded gunpowder, at another of
a smith's forge. From the left side of the head a
red arborescent streak, as broad as a finger, ran down
to the shoulder, and, dividing there, proceeded
obliquely across the chest in front to the right side,
down the inside of that thigh to the inner side of
the leg, and so to the ground; whilst on the back it
ran down the middle line, by the gluteal fold, to the
scrotum and inner side of the left thigh and leg to
the ground. The remnants of the man's uniform,
stockings and boots, were scattered arouhd a few
yards away, and had been rent in lines corresponding
~ith the tracks of the electric fl uid upon his body.
There was no wound or contusion visible anywhere.
o po t-mortem of the body was made, and it was
buried a few hours later. The private, who was
apparently dead on my arrival, ha:d ~omm~nced .to
!!Toan by the time that I reached hlS sIde, hIS pupils
~ere widely dilated but insensible to touch or light,
and his breathing very slow and shallow; he was
removed at once to the Field Hospital, where he
recovered consciousness in a few hours, had a head-

December, 1907. THE TRA VAAL MEDICAL JOURNAL. 121
ache next day, and was on duty on the fOUl'th day.
'l'he r maining men had all experienced a shock
more or I ss severe, some were still dazed and stup ­
lied, others felt" smarting" or " tingling" sensations
about their bodies and limbs, which they soon
"rubbed out of them"; all these completely
recovered in an hoUl' or so. When the sergeant was
struck, he was standing leaning upon his rifle, the
bayonet being fixed, ith his head and shoulders
bent, talking to a man sitting in a blanket bivouac
at his feet. The man to whom he was talking told
me that it seemed as though he and his rifle were
enveloped in lightmng for an instant, that he uttered
no sound, and fell after standing rigid for an appreciable
time after being struck; he described "the
rush" of the lightning, and it was he who drew my
attention to the smell of it. The rifle was flung
from the sergeant's hands and fell against the
bivouac. I greatly regret that I did not think of
asking for and examining it. The man in the
bivouac, who was sitting on blankets, seemed to be
the only one for some distance around who felt not
the slightest touch of the electricity.
'
In 1901, during the summer months, in one of the
tents of the Burgher Camp, Middelburg, a man,
occupying a tent by himself (he was an epileptic),
was found dead one morning, the clothes ripped off
him, and lying beneath his body. A rent at the
point of the tent showed where the lightning hacl
penetrated to reach the pole, from which it had probably
glanced off on to the left shoulder of the man.
An arborescent streak, starting here, ran down the
left arm to the finger tips, down, from the axilia,
the left side of the thorax, the inner (per the gluteal
fold) and outer side of the thigh, and uniting again
in the popliteal space down the back of the leg and ­
heel to the ground. The boot of that foot was
burst open behind, and had evidently been fhmg
off the foot. The clothes showed the characteristic
rending, corresponding to the tracks of the lightning.
There was no singeing of the hair upon the man's
body, nor of the clothes. nor were the edges of the
hole in the top of the tent in the least singed.
In the following year in the same camp, a tent, in
\ hich 16 men and women were gathered at a prayermeeting,
was struck by lightning, as before, through
the canvas at its point. Rain had not fallell for
some months, but had been threatening for some
hours, a time, well known to the inmates of the tent,
specially fraught with danger from lightning. The
man who was praying held the ten pole with his
right hand, the elbow being flexed, and against his
elbow a woman leant her chest. All the occnpants
were more or less in contact with each other and
the canvas of the tent. A flash of lightning strnck
the point of the tent, rent a hole in the canvas and
ran down the pole; it ran along the man's arm, who
held the pole, to his elbow, and was so conducted
to the breast of the woman leaning against him; she
was stnlck dead. The man's coat sleeve was stripped
to the elbow, and his arm showed a broad red streak
so far, but nowhere else on his body. The woman
had her clothes rent from her body over the red
streak, whieh lit rally starred her chest and ran
clown each side of her body and legs to the feet. t
her neck was a burn about 2in. x 3in., where a
brooch with a metal back had been worn. Everyone
in the tent was more or le aff cted, and 1 think no
le han live howed the characteristics of having
b en touched by the lightning. It wa reported to
me that most of them were " undre sed " by the
lightmng. Most of these cases were well in a few
days. 0 post-mor em examination was held upon
the woman killed. The hole through the top of the
tent showed no singeing or burning-in fact, in the
Burgher Camp in l\1iddelburg, which at olle time
tl:umbered 8,000 people, tents were on many oeca-
~ons struc~ by lightning, though, with the exceptIOns
mentIOned, they were empty; and in one's
round through the camp day by day it was no
unusual thing to ee tent with characteristic holes
at the point caused by lightning, but never was a
tent set on lire, nor did 1 ever observe singeing of
the edges of the tent. I regret that my time did
not admit, in tho e days of careful notes being made
of these cases of lightning- troke. A detailed
description of the damage done would have been
better than merely the memory of them.
In September, 1903, a native employee of the local
~epatria~ion Depot wa ba hing and wa hing clothes
10 the nver about 300 yards from his compound.
From the accounts of those with him, they were
overtaken by a very heavy thunderstorm, and
" Titus" seems to have dropped behind the rest
in racing back to the compound; but he was seen to
be running back naked except for a cloth round his
waist, when he was s ruck dead by a flash of
lightning. He had been struck upon the right side
of the head, and the streak ran down the side of the
body upon which the rain was beating in a most
marked manner. 0 peculiarly dis ributed was this
arborescent streak that I took one of the boys who
had reached the compound in time back to the spot,
and got him to show me the position of the boy
killed and the dir ction of the beating storm. It
was then easy to sce that the side to\\n.rd the rain
had conducted the electric fluid to the ground, and
it had avoided the inn r and protected ides of he
body and limbs. My notes upon the post-mortem
examination state that the lungs were "engorged
n.nd congested," the heart being empty of blood and
the left ventricle "firmly contracted," and that
"death wa attributed to shock resulting from
lightning stroke." There were no other external
or internal injuries or disease with the exception of
those described. nfortunately the cranium was
not examined.
In March, 190~, I was regue t d by the R.M.
to examine the body of a Zulu woman, who was
reported to have been struck by lightning the da
before and killcd, just out ide the town. She had
been standing upright in a square thatched hut,
when the lightning struck through the thatch just
above her and killed h l' in tantly. The thatch was
s t alight and the hut burnt down by the flash.
My notes upon the case say :-A brown arborescent
streak (darker than the woman's skin and easily
traced), nearly an inch broad where i began on the
right side of the head, desc nd d over the sid of th
face, across the side of the neck. to the IlPP r border
of th sternum; it then descend d the mirldlc line to
the left of the umbilicu. , acro. the middle of POIlpart'!'!
ligament to the inner sid of the left thigh,
behind th knee and down the inner surface of the

122 THE TRA SVA L MEDICAL JOUR AL. December, 1907.
leg to the instep of the foot. Where the streak
pas ed between the breasts, which were prominent,
a streak ran outwards to the tip of each nipple and
no further, making a perfect cro s on her body. 1
should add that the woman was nursing a child only
a few weeks old, but had put the child away in a bed
near by shortly before the torm fell. The breasts
were evidently full of milk at the time, and would
have large ves els cour ing over them. he was a
robll t woman of about 28 or 30 years of age.
Rigor mortis was pr ent, but "not marked,"
i.e., 24 hours after death. Internally all the organs
were normal, but "the lungs were congested and
the heart empty of blood and firmly contmcted."
'I he brain was deeply congested, but showed no
injury or haemorrhages. Death due' to shock, the
re ult of lightning-stroke. This woman was said
to have \\"Orn " a dress" at the time she was struck,
but when removed from the hut was naked. Asked
if she wore no bangles or anklets, her husband said
that she wore nothing of the kind but a horsehair
necklace (without bead ) " to keep her from getting
sick". He supposed the dress to have been burnt
off by the lightning, a no fragments of it were
found.
The next ca e, which I unfortunately did not see,
but i described to illu rate the vagaries of a flash of
lightning, occurred about 10 miles from town. A
man and his wife were lying upon the bed one sultry
summer afternoon, the ky out ide dark, with
a threatening thunder torm. The room was
mall, with one window about 2 feet by 18
inche in size situated just above the lower
eud of the bed, which was close to the wall.
A flash of lightning struck obliquely through the
open window, across the legs of the woman, who lay
on the inside, and striking the man apparently in
the lower part of the abdomen, " ripped the clothes
open" on the upper part of the body and killed him
instantly. The widow informed me that he neither
moved nor uttered a SOll nd, so that for a moment she
thought he had escaped, but that when she had
recovered sufficiently to turn round " she found she
was lying beside a dead man."
nfortunately no inquest was considered necessary,
the body being buried by permit i sued upon
the report of a neighbour; but nearly three months
afterwards I attended the "idow for continued weakness
of the legs, of which she had lost the use at the
time of the occurrence. Some" branching streaks .. ,
upon her legs, up to the knees, were described to
me, but beyond some" mottling " of the body of the
husband she could give me no further information as
to his condition after being struck. No signs of
burning, however, were noted, though the room
" smelt as though an explosion had occurred."
In connection with this case, it is well known that
hot air providf's a track of lessened resistance, of
which lightning often avails itself, e.g., in striking
down chimneys and down the flnes of grc~n-ho.nse~;
and as a precaution against damage by IJghtmilg lt
has been recommended by meteorologist that windows
should always be kept closed when a thunderstorm
is in the neighbourhood. This case seemed
to emphasize this necessity.
Durina the summer of 1905 a native man was
reported'"'lying dead on the hill-side just outside the
town, and J was requested to make the necessary
examination and report upon the cause of death. He
lay beside a well-frequented footpath, naked, some
passer-by having covered the body with his very
tattered coat and trousers. On removing them, I
notlCed that a sleeve and the back of the coat had
been ripped down, and on looking again at the body
saw on the neck, disappearing down the back, the
characteristic brown streak of lightning-stroke. Returning
to the clothes, I falmd the legs of the
trousers similarly ripped. The brown and markedly
arborescent streak started on the left side of the neck,
and running backwards and downwards to the back,
down the spinal funow, between the gluteal prominences,
found its W:LV to earth down the inner
surface of the left thigh and leg. At the left
shoulder a branch of this streak struck across the
back to the right side, and windiug round to the
front across Pompart's ligament, divided into two,
running down each side of the thigh and leg. His
skin \-vas of the lighter variety, and the streak
shewed well, being but little disconnected; it gave
me the impression of his having been splashed with
electric fluid from the left-hand side across the body.
Internally, the lungs were "congested and engorged,"
and "the heart firmly con racted," the
left ventricle being empty of blood or clots, the right
containing a very little dark clot. 0 other injuries
were found, and the remaining organs were normal,
the brain not being examined. Later in the day a
pair of boots found amongst some rocks near the
body of this man were brought to me; they shewed
the distinctive bursting outward of the leather corresponding
to the track of the lightning on his feet.
I feel sure, however, that the distance they were'
found from the body was a measure of the disappointment
of the one who first found them and not
of the extraordinary action exerted by lightning in
throwing off the boots of those struck, sometimes a
distance of some yard. I n the pocket of the coat
of this man was found evidence of his discharge from
the local gaol the morning of the day on which he
was killed. He had started to walk to his home
with" a bnndle," probably a blanket, but as nothing
else was found near him, it was probably uninjured
and considered too useful to leave by some passer-by.
The last case of this nature which I saw during
this last summer presented characteristics which, J
consider, illustrate the statement made in the early
part of this paper, to the effec that burns upon the
body will be fonnd invariably to be in connection
with metals. As it occurred some 40 miles from
here, it was the third day after the man's death
before I arrived and made my examination, the body
being by then well advanced in decomposition. An
old native, his wife and child of abont 10 years of age.
had occupied the usnal circular Kaffir hut, with a
thatched conical roof supported by a central post.
During the night a flash of lightning struck the roof.
setting. it alight, and travelling down the central
post, killed the old man, who was lying in contact
with it. close to a fire. The woman was sleeping
" near the centre of the hut" with her feet to the
fire; both legs shewed severe burns of the second
degree and streaks up as far as the knees. which \"ere
probably bent. These burns took place on each
leg immediately beneath 20 brass rings worn above
the ankles, and which on my arrival had been removed.
I learnt that the rings themselves" had

December, 1907. THE TR SVAAL MEDICAL JOUR AL. 123
been burnt," probably partially fused, but I could
Hot get them brought to me for inspection. 'he
had been unable to move her legs for a day or two
after being struck, and had been dragged forth from
the burning hut by the child of 10! V'hen 1 saw
her, movement was returning, but she could not as
yet stand. The small boy had been sleeping somewhere
to the side of the hut, and apparently had
been untouched. 'The post-mortem examination of
the old man was unsatisfactory owing to his having
been left in the burning hut, .. as he was known to
be dead," and his body much burnt and charred by
the falling-in upon him of the burning roof. 1
was, however, able to trace upon his neck a
dark, characteristic branching streak disa~pearing
into charred tissue down the back. Internally, the
heart was firmly contracted and empty; the luugs,
too decomposed to show anything reliable. I had
no difficulty therefore in stating as my opinion that
he had died of shock resulting from lightningstroke,
having been burnt afterwards.
In conclusion, I advance the following conditions
as definitely characteristic of death from lightningstroke
:-
The peculiar .. rent .. condition of the clothes
and boots, suggestive of being the result uf
great violence from within outwards, the
edges of the rent shewing no burning or singeing.
The presence of a peculiar arborescent. red streak,
becoming brown after death, upon the skin,
traceable wherever the electTic fluid touched
the body, and often demonstratwg its direction,
the rent in the clothing corresponding
with the position of this streak upon the body.
And whilst awaiting further experience of the
deeper injuries upon the body described as sometimes
resulting from'lightning-stroke. I offer the foll

124 THE TR NSVAAL MEDICAL JOURNAL. December, 1907.
This opinion being submitted to the Law Department
was confirmed by them, and in addition they stated
that no action for damages could be brought against
any medical man for giving, upon a sick report, the
nature of a patient's illness, in the case of Government
employees.
Transvaal Medical Council Election.
The Association have asked all medical men resident
outside the Witwatersrand and Pretoria districts to cooperate
with its members in forwarding the candidature
of two medical men to represent the country districts
upon the Medical Council.
l"orms were sent out calling for the nominations, with
the understanding that the two candidates to be selected
would be those obtaining the largest number of nomin_ations.
As notified by circular, the candidates selected were
VI's. ixon, Heidelberg, and R. T. Jupp, Klerksdorp,
who obtained a large majority of the nominations.
Changes in Membership,
Dr. McKnight, of Schweizer Reineke, has resigned hig
district surgeoncy and left the Transvaal. Dr. Huntley
Pelly, of Bloemhof has been appointed in his place, and
at present the Government does not intend. making any
further appointment at Bloemhof.
An Uncommon Cause of Sudden Death.
VI'. Sanders, Pretoria, has reported the following
case:-Upon opening the skull of a young native woman
who had died suddenly, and in whom I could find no
disease elsewhere, a gush of clear fluid came away,
carrying a cysticercus about !-inch in diameter. The
brain appeared quite normal except that the lateral
ventJ,'icles were somewhat enlarged.
A Note upon the Examination of the Accused in Cases
of Alleged Rape.
(By Dr. A. J. Nixon, District Surgeon, Heidelberg.)
In cases of supposed rape the importance of examining
the person accused is fully borne out by the following
case:-
A native girl was sent down to me by the Resident
Magistrate on July 6 last, with instructions to examine
for evidences of rape. The girl's demeanour was modest,
and she appeared to be eager to be examined. The
examination proved negative in every way. All one
could swear to at the preliminary examination was that
the girl was not a virgin, and that the hymen must have
been ruptured at least a month or two before. Nothing
more was heard of the matter until October, when a
native boy came under my care in the local gaol, suffering
from complete phimosis, due to a chancre at the
point of the prepuce and warty growth (exposed after
circumcision) around the corona and upon the glands.
This boy was the boy supposed to have committed the
rape in July. He had become lost, but· was found in
gaol in our next adjacent district, where I subsequently
learnt he had been admitted into hospital on August
19, and discharged on September 25, suffering from
syphilis. On recovering from the operation for phimosis,
which was somewhat delayed owing to infection. a~ the
points of incision, the boy was had up for prehmmar:y
examination. Both in the Court and to myself as his
daily attendant, he stoutly maintained his innocence,
averring that the the time of the suggested crime he
was suffering with syphilis, and th!l't it ~ccordingly was
not possible for him to have had COItus WIth any woman.
And, further, that if he had had intercourse, for:ced or
voluntary, with the girl, then she should show SIgns of
infection. ow, I examined the girl again three months
after the supposed crime was committed, and found her
still perfectly clean with no evidences, moreover, of past
infection.
The question, therefore, arose: Had the boy active
syphilis in July, or, in other words, ha;d he a ~ard
chancre. If so, and granted that penetratIOn had taken
place did it absolutely follow that the woman would
have' become infected. The evidence was incontrovertible
that he had come suddenly upon the girl, that
he had driven away by threats two other girls who were
with her and who had heard the girl scream. If, then,
it could 'be proved that the woman showed signs of infection,
conviction must follow. But there was no
evidence of infection.
R.M.A" BORDER BRA ·CH.
The inaugural meeting of the above branch was held
on ovember 12, 1907. Present: Drs. Tannock, Roulson,
Anderson, Alexander, Ward, Ganteaume, Mac­
Uregor, Rubidge, Grey, Brooks and Hill-Aitken.
ominations for office bearers for 190 were called for.
President, Dr. Tannock; president-elect. Dr. Roulston;
hon. sec. and treasurer, Dr. Hill-Aitken. No other
nominations being handed in these gentlemen were
elected for 1908.
Branch Council.-Df the following, twelve will be
elected by ballot at the January meeting: Drs. Conry,
Wall, Batchelor, Alexander, Ma{lGreg()r, Grey, Rubidge,
uanteaume, Nangle, Lounds, Ward, Robertson,
Querney, Randall, Shanks and Chute.
Reciprocity.-A resolution was unanimously passed by
the branch giving support to the Medical Council in
their fight for reciprocity. The secretary was instructed
to forward the resolution to the Council, and, at the
same time, to ask Dr. Darley-Hartley to impress on the
medical profession through the columns of his paper,
the advisability of their bringing the question before
candidates for Parliament.
South African Medical Congress.-Dr. Anderson proposed,
and Dr. Alexander seconded, that Drs. Tannock,
Rubidge, Ganteaume, Roulston and the hon. secretary
be a committee to approach various bodies and
pel'fons with a view to holding the Congress here in 1908.
Dr. Tannock proposed the branch be known as the
Border Branch. This was carried.
CORRESPONDENCE.
(We 110 not necessm'ily identify ourselves with the opinions
eXl'res ed under this heading.)
To the Editor at the Trallsvaal1l1edirol Journal.
Sir,-I have been requested, in the interests of the
medical profession in the Transvaal, to bring to your
notice the facts in the case of Murray v. Shawe, recently
decided by the First Civil Magistrate at Johannesburg,
as it appears that many practitioners suffer financially
to a great extent solely through their good nature and
reluctance to press their claiJlis in the Courts.
In the case mentioned the plaintiff, a medical practitioner,
sued the defendant on an account for professional
services rendered during a period extending
from 1892 to 1898. Defendant pleaded prescription, but
admitted in his evidence that in 1904 he had told the
plaintiff that he was in poor circumstances. Plaintiff
declared in eviqence, that he had had several conversations
with the defendant about the account, and that
defendant had always promised to pay when he was
able to do so, but he (plaintiff) could not swear to any
definite dates.
On this evidence the Magistrate had no other alternative
than to uphold the plea of prescription and dismiss
the case.
ow, the Supreme Court of the Transvaal has recently
held that a verbal acknowledgment of, or promise
to pay, a debt breaks or interrupts prescription,
but the point to be observed is that the practitioner to
whom a debtor admits an account should immediately
make a note in his diary of such admission, as nearly
as possible in the words used, and also of the time and
place, with a view to future reference, and, maybe,
evidence.
It is not usual for anybody in the presence of third
parties, to discuss his financial position, or to ask for
time in which to pay, and if practitioners mak~ it a
habit to record such conversations in the manner suggested,
it would go far to support their evidence, a.s
against that of the defendant, in cases where prescription
was pleaded and the admission of the debt denied.
All medical men in Johannesburg will know of their
own experience that there are many persons in that
town who are only too eager to avail themselves of the
plea of prescription, and they should, therefore, be
careful to protect their own interests as far as possible.
Of course, if the debtor acknowledges the debt in
writing, the ordinary period of prescription of two
years is extended to ten.-Yours faithfully,
C. N. KNOX-DAVIES.
Johannesburg, November 28, 1907.