1.2 SOUTH AFRICAN MEDICAL CONGRESS, 1907.pdf
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94 THE TRA BVAAL <strong>MEDICAL</strong> JOURNAL. December, 1907.<br />
It is impossible to gauge the mental attitude of a<br />
man capable of pleading prescription on an account<br />
for professional fees, or any other debt for the matter<br />
of that.<br />
The presumption is that he desires to stand well<br />
with his friends and acquaintances, and yet he runs<br />
the enormous risk of encountering contempt, disgust,<br />
and derision. It is not commonly honest; honourable<br />
it is not!<br />
<strong>SOUTH</strong> AFRICA <strong>MEDICAL</strong> CONGRESg, 1907.<br />
<strong>MEDICAL</strong> SECTION.<br />
Cerebro·Spinal Meningitis.<br />
By a. A. TURNER, M. B., D.P.JI.<br />
Cerebro-spinal Meningitis is a disease, w~ich has<br />
been recently a g1'eat deal before the medIcal profession<br />
in all parts of the world, and has been a matter<br />
of importance along the Rand for many ~ears.<br />
It may b~ fairly claimed tha~ since the d.Jscovel)'<br />
of the memngococcus by 'VelChselbaum, m 188 (,<br />
Johannesburg medical men were among the first to<br />
investigate the disease from. a scientific point of<br />
view. I am, of course, referrmg to the papers read<br />
by Drs. Brodie, Rogers, and Hamilton, on.e .in 1894.<br />
another in 1 98, which undonbtedly. antIcIpated a<br />
great deal of the work recently pubhshed.. Unfortunately<br />
these did not receive the attentIOn ~hey<br />
merited, possibly owi ng to the titles they were gIven<br />
by their authors.<br />
Within the past year or so, a very large amount of<br />
work has been done on the subject in England,<br />
Europe, America, and el e-v:h~re. . In fact, t~e<br />
amount of material, and the lImIted time at my dISposal,<br />
has rendered it impossi~le for ~e either to<br />
make myself thoroughly acquaInted wIth the most<br />
recent vie,,'s on the que tion, or to dis?uss th.e~1<br />
in this paper. I propose, therefore, to glVe a chmcal<br />
account of the disease, as it has come under my<br />
observation with a few statistics, and some deductions<br />
draWl; from personal experience, which, u.nfortunately,<br />
are not so well supported by bactenolog-ical<br />
work as I COll Id wish. ~~me of my deductions<br />
have, no doubt, been antIcIpated by 0 hers,<br />
and some may possibly: have be~n ?i.spJ:oved. .<br />
I believe cel'ebro-spmal memngI.tls IS a ~enolls<br />
menace to South Africa. It is a dIsease whICh appears<br />
at intervals in nearly every part of the wo~ld ;<br />
witness the epidemics which have ravaged Amenc~"<br />
India and Europe. It has recently appeared 10<br />
parts of Great Britain. A few years baek it c?mmitted<br />
fearful havoc on the 'Vest Coast of Afnca,<br />
and in Nigeria; two or three years ago th~re w~s<br />
an epidemic among European and natIves 10<br />
Lourenco Marques, anil the disease still exists on<br />
the East Coast, because J met case in the kraals in<br />
that district recently.·<br />
it In Livingstone's "Journeys in South ~frica," he state3, when<br />
referring to the disease among the B..kwams about th~ year 18~O,<br />
that-" One year the epidemic periocl was mar~ed by a dISease which<br />
"looked like pneumonia, but had the peculIa,: symptom trongly<br />
" developed of great pain in the seventh cervICal proce . Many<br />
"person died of it after being in a comatose state for many hours or<br />
" days before their decease." This disease mnst surely have been<br />
some form of cerebro-spinal meningitis.<br />
I t was, I believe, first recognised on the Rand<br />
about 1894, and lately there has been a recrudescence<br />
of the disea e here, which, it is to be hoped, is<br />
not the forerunner of an extensive epidemic.<br />
I personally first met with cases of cerebro-spinal<br />
meningitis on transports carrying indentured coolies<br />
from the East to the West Indies. These<br />
vessels take nearly six months on their<br />
voyage. I remember how surprised I was at the<br />
precautions the snrgeon-superintendents took to<br />
isolate these cases, and how seriously they regarded<br />
an outbreak among the emigrants.<br />
One surgeon informed me he would sooner ha:re a<br />
case of cholera on his ship than one of cerebro-spmal<br />
meningitis, and, as he had had 30 years' expe~ience<br />
in that service, his opinion was worthy of consIderation.<br />
Other slUgeons informed me of the fearful havoc<br />
the disease had at times made among the coolies.<br />
I am afraid to qllote defi nite figures, but, to the best<br />
of my recollection, I was informed that one vessel<br />
arrived in Table Bay with only half her passengers;<br />
and. as these boats usually carry about 800 emIgrants,<br />
it means there must have been a fearful<br />
mortality.<br />
Recently I have had cases under my care OCClU<br />
ring among natives arriving for work on the mines,<br />
and my account of the disease is based on these.<br />
nerebro-spinal meningitis is caused by an invasi~n<br />
of the human system by one or more of CeI'tam<br />
organisms, the seat of the disease being the membranes<br />
of the brain and spinal cord. The following<br />
organisms have, among others, been found to cause<br />
the disease :-<br />
(1). Pneumococcus.<br />
(2). Meningococcus intracellularis.<br />
(3). Streptococcus pyogenes.<br />
(4). Staphylococcus pyogenes aureus.<br />
(5). Influenza bacillus.<br />
(6). Typhoid bacillus.<br />
(7). Bacillus coli.<br />
My cases, with two exceptions, were infected<br />
with one of the first three on tIle list. -<br />
I believe that cases of mixed infection of the<br />
meninges, with the pneumococcus and meningococcus,<br />
have been recorded. one of the bacteriological<br />
examinations made for me showed this, but on<br />
one occasion the meningococcus was found in the<br />
purulent material in the pia-arachnoid of the brain,<br />
and the pneumococcus was obtained from the lungs.<br />
Tuberculous meningitis does not come under the<br />
head of cerebro-spinal meningitis. I have only<br />
had one very doubtful case among natives, which<br />
is remarkable, considering how prone the native on<br />
the Rand i to contract tuberculous disease of other<br />
organs of the body. i[oreover, I have only heard<br />
of the OC~Hrenceof'one case of tuberculolls meningitis,<br />
which wa confirmed by post-mortem examination;<br />
it was under the care of Dr. Rigby.<br />
All my patients were adult males, many of whom<br />
spoke a language understood by few Europeans in<br />
thi COllntry, a fact which may account for differences<br />
between my de cription and those of other observers,<br />
also for the apparent absence in many cases of minor
December, 1907. THE TRA SVAAL <strong>MEDICAL</strong> JOURNAL. 95<br />
premonitory symptoms, such as malaise, etc., which<br />
would not come under my personal observation.<br />
I can find no difference in the clinical signs of the<br />
disease, whether it be caused by infection with<br />
meningococcus or pneumococcus. My expe~-ience<br />
with other organisms is too limited to permIt me<br />
to express an opinion as to whether they produce<br />
variations in the symptoms.<br />
SYMPTOMS.<br />
My cases may be divided into two distinct classes<br />
according to the symptoms :-<br />
(i.) Those in which the primary symptoms are<br />
of a cerebral type.<br />
(ii.) Those in which the cerebral symptoms do<br />
not develop for some days after the onset<br />
of sickness; such cases I shall refer to as<br />
the "delayed type."<br />
Class 1. may be subdivided into :-<br />
(a) Those in which the onset of the disease IS<br />
gradual.<br />
(b) Cases in which the onset is sudden.<br />
The following is a short clinical picture of cases<br />
belonging to division (a) of Class I., in which the<br />
onset of cerebral symptoms is gradual. .<br />
The patient comes before th~ doc~or in<br />
a tottering condition, with a most tYPlC~1 ga~t. He<br />
has evidently the greatest fear of extendmg hIS legs;<br />
he takes short steps, with his feet set somewhat far<br />
apart, seeming to b~ afraid that his knees will g~ve<br />
way, and plants hIS feet flat on the ground wlth<br />
caution. The way he holds his head is characteristic;<br />
it looks as if he were trying to balance some<br />
heavy load. . .<br />
Nothing will induce him to benc~ any pOl-bon. of<br />
his spinal column. If asked to pJCk up anythmg<br />
from the ground, he lets himself down gradually by<br />
bending his knees. A closer examination w.ill show<br />
that the patient's neck is rigid, and he reslsts any<br />
attempt at flexion, and it is evident that any such<br />
movement causes him intense pain.<br />
Kernig's sign, an inability to extend the knee<br />
joint, after the thigh has been flexed, ,may be present<br />
in one or both legs.<br />
I think that in dealing with raw natives one can<br />
often judge of the presence of this sign, more by the<br />
('xnression of pain on the patient's face. when an<br />
attempt is made to extend the knee after flexion<br />
of the thigh, than by the actual feeling of resistance<br />
to the arm. The patient complains of intense headache<br />
and p!1in down the back of his neck. The temperature<br />
lS above normal; the lips and tongue may<br />
have sordes on them, and it is possibly only a matter<br />
of from a few hours to two or three days before such a<br />
case dpvelops all the symptoms of the disease in its<br />
most severe form, opisthotonos becoming extreme,<br />
and Kernig's sign being readily obtained, the<br />
patient generally losing consciousness and falling<br />
into a state of muttering delirium, often accompanied<br />
by a series of epileptiform seizures, during<br />
which he throws himself from his bed, bruising anrl<br />
cutting himself; finally death ensues, the result, I<br />
believe, of pressure, combined with toxic poisoning.<br />
Under the heading (b), in which the onset of<br />
cerebral symptoms is very rapid, the patient may<br />
fall down as if in an epileptic fit, and enquiry possibly<br />
elicits the fact that on the previous night he<br />
had complained of headache. The patient may<br />
recover from the seizure, and be subject to a simple<br />
mania for a few hours, when suddenly his temperature<br />
will run up, opisthotonos will develop, and<br />
I\:ernig's sign and other symptoms become apparent.<br />
The following is a good example of this type of<br />
the disease :-<br />
An Myambaam youth (No. 48,668), who had been returned<br />
from one of t~e mines on August 30th, 1905, convalescent<br />
from pneumoma, but who, though somewhat debilitated<br />
see~l1.ed to be. hea!thy, was standing with the other boy~<br />
waltmg for hIS raIlway pass, when he had a fit. A police<br />
boy told me that there was a boy .. plenty stiff over<br />
there.." When I saw the patient, he was apparently recovermg<br />
from an epileptic seizure, his eyes were staring,<br />
and froth was coming from his mouth; he had not completely<br />
recovered consciousness, and for the remainder of<br />
the day he was in a state of simple mania, very noisy and<br />
req,:iring constant restraint. I looked upon him as an<br />
ordlllary case of epilepsy and treated him with bromides.<br />
I was therefore surprised on the following morning to find that<br />
his temperature was 102'5° F.; his neck was rigid and<br />
retracted; Kernig's sign was present; pulse 120 per minute.<br />
These symptoms became accentuated, aud death occurred on<br />
September 6th, seven days after the seizure.<br />
Post-mortem examination confirmed the diagnosis of cerebrospinal<br />
meningitis, pus being found in the pia-arachnoid.<br />
Unfortunately no baderiological examination was<br />
made, but I have little doubt that this was a pneumococcal<br />
form of the disease. I shall refer to this<br />
case later on.<br />
Cases of this class are sometimes brought into<br />
hospital in a totally unconscious condition. Examination<br />
shows they are completely paralysed below the<br />
waist, the breathing is stertorous, the cheeks moving<br />
in and out with each inspiration and expiration,<br />
and the conjunctival reflexes absent. There is a<br />
total absence of all stiffness of the neck, and of<br />
Kernig's sign, but the temperature is high (103 to<br />
104 0 F.); the only account of any preliminary<br />
sickness, being usnally that the patient had a headache<br />
on the previolls day; in fact, except the high<br />
temperature, the patient has none of the symptomR<br />
of cerebro-spinal meningitis, but a.1l the signs of a.<br />
basal haemorrhag-e (which is not surprising, as a<br />
post-mortem examinntion shows a big clot of pm;<br />
at the base of the brain, causing the pressure symptoms).<br />
Such cases only survive a. few hours, and<br />
from the first it is evident that they must terminate<br />
fatally. .<br />
The following is a good example of this type:<br />
A ~1akll" (No. 61,969), about 32 years of age, was found<br />
unconscious, and carried into hospital; he had complete<br />
paralysis below the waist; his breathing was stertorous:<br />
his cheeks blowing in and out with each inspiration and<br />
expiration; a total absence of conjunctival reflexes; no<br />
stiffness of the neck, and Kernig's sign was absent. Temperature<br />
103; pulse 120.<br />
I at first diagnosed this case as one of basal<br />
haemorrhage, but could obtain no account of any<br />
assault or accident; the only history I could get waR<br />
that he had complai ned of severe headache the previous<br />
day. Death occurred within a few hours of<br />
admission.<br />
Post-mortem examination showed no naked eye<br />
appearance of pus in the pia mater of the cerebrum,<br />
but a heavy fibrino-purulent exudate at,<br />
the base. The fluid in the ventricles wa!l clear.
98 THE TRA fEDICAL JOUR AL. December, 1907.<br />
The lungs, liver, spleen and kidneys showed evidence<br />
of acute toxic poisoning.<br />
Bacteriological examination demonstrated the presence<br />
of meningococci in the exudate at the base.<br />
No pneumococci could be found.<br />
I must admit that, though I made the diagnosis of<br />
cerebro-spinal meningitis in this case, when I attended<br />
the post-mortem examination I did so with<br />
a certain amount of trepidation. I half expected to<br />
find a ba al haemorrhage, and no evidence of meningitis.<br />
There i one other type coming into this class, of<br />
which I have only een two or three cases. They<br />
were brought into hospital in a drow y, semi-conscious<br />
tate, from which the. could only be roused<br />
with the greate t difficulty, and then but for short<br />
intervals.<br />
They gave o:oe the impression that they wished to<br />
be left alone and allowed to go to sleep. They<br />
could not be got to answer questions. They evidently<br />
could not collect themselves sufficiently to<br />
under tand what was being said to them.<br />
They did not complain of any pain, neither did<br />
they show any evidence of it.<br />
An examination revealed nothing abnormal. Their<br />
pupils were equal and of normal size. The conjunctival<br />
reflexs were pre ent. There was no stiffness<br />
of the neck, nor could Kernig's ign be demonstrated.<br />
The first of these cases which I saw I diagnosed as<br />
one of acute alcohollsm, though I could neither smell<br />
spirits, nor get a history of the patient having obtained<br />
any.<br />
The man's temperature was only 99° F. ; he was<br />
collapsed.<br />
I was not absolutely certain of my diagnosis, but<br />
I had seen several natives, in a similar condition,<br />
as a re ult of taking a large draught of some form<br />
of illicit liquor.<br />
I pre cribed five grains of calomel, a hypodermic<br />
injection of strychnine if nece sary, and hot water<br />
bottles, etc.<br />
The following day it was found that some stiffness<br />
of the neck had developed, and that Kernig's<br />
sign could be demonstrated. Other signs of cerebrospinal<br />
menigitis then became apparent, and a correct<br />
diagnosis was made.<br />
In these cases, though, the stiffness of the neck<br />
and ICernig's sign do not come on at first. The<br />
primary symptoms are undoubtedly of a cerebral<br />
nature, and they therefore come into Class Cb).<br />
Both of the foregoing types of case are pitfalls for<br />
the police surgeon. The first would be very apt to<br />
be sent to the wards to be treated for basal fracture'.<br />
if he were brought into a, casualty hospital with a<br />
history of having been found unconscious in the<br />
street; and the second "'ould stand every chance,<br />
under similar circumstances, of being sent to the<br />
cells until sober, and fit to be charged for drunkenue<br />
s. .<br />
Clas n. is that which I have ugge ted might be referred<br />
to as the "delayed type" of the disease. nder<br />
this heading patients are admitted to hospital with<br />
a high temperature and headache. No other symptoms<br />
of any sort can be found. When dealing with<br />
such cases from tropical areas, and having examined<br />
the heart and lungs ,,,ithout any result, one is<br />
general;y, I think, justified in believing that the<br />
pati nt i suffering from some form of malarial<br />
trouble.<br />
But in these cases under consideration antimalarial<br />
treatment has no effect. The patient remains<br />
in the same state for three or four or even<br />
five days without any drop in the temperature or<br />
development of fresh symptoms. Such patients<br />
are repeatedly examined; enteric and every other<br />
form of fever is con idered, until at last one notices<br />
a slight stiffness of the spinal column, only to be<br />
elicited by flexing the neck, so as to bring the chin<br />
down on to the sternum. At first the stiffness is<br />
sliRht; perhaps Kernig's sign can be demonstrated<br />
with difficulty in one leg. These symptoms, however,<br />
soon increase in intensity; the stiffness of the<br />
neck is apparent, and Kernig's sign is noticeable in<br />
both legs, and the patient gradually enters the final<br />
stages of the disease already described.<br />
'rhe following case illustrates this type:<br />
A Makua (No. 60,947) was admitted to hospital on January<br />
28th, 1906, with a temperature of 100° F.; no other sign<br />
of disease could be found. The case was looked upon as<br />
one of malaria, for which he was treated without effect.<br />
On February 2nd it was first noticed that there was some<br />
stiffness of the neck, but Kernig's sign could not be demonstrated.<br />
This condition continued lmtil the 8th, during<br />
which time the temperature did not fall below 100°<br />
F., but on two occasions rose in the mornings to 1020 F.<br />
On February 8th Kernig's sign could just be demonstrated,<br />
but was not marked until the 15th. After that date the<br />
symptoms became much accentuated; by the 20th opisthotonos<br />
·was marked, and the patient bec....me semi-conscious.<br />
On the 23rd there was intense headache, and death<br />
occurred the following morning.<br />
This case is interesting, as showing the exceedingly<br />
gradual manner in which the symptoms ma:,<br />
develop.<br />
A post-mortem examination showed the lungs :.mu<br />
heart to be normal; the abdominal organs V\·~rc<br />
healthy, except that the calices of the kidneys were<br />
dilated, and there were bilharzia worms in the portal<br />
vessels.<br />
The vessels over the convexity of the brain were<br />
acutely congested. Under the base was a little pale<br />
yellow-coloured fibrino-purulent exudate, and the<br />
ventricles contained some fluid pus.<br />
Bacteriological examination of the pus III this<br />
case was unfortunately not recorded.<br />
Thi gives a brief clinical picture of the various<br />
tvpes of the disease. But in certain cases the<br />
. symptoms appear to abort, sometimes before Kernig's<br />
sig-n has developed, at other times afterwards.<br />
In some of these cases the patient can be discharged<br />
from ho pital in ten days, but as a rule the<br />
time necessary for complete recovery is much longer.<br />
The following case illustrates the abortive type :-<br />
A<br />
1akua (No. 60,(05), aged about 20 years, was admitted to<br />
hospital on February 2nd with a headache, temperature<br />
102, a stiff neck, and the characteristic d isi nel ination to<br />
bend the spine. Kernig's sign, if present, was so slightly<br />
. marked that it was difficult to form a definite opinion as<br />
to its presence or absence. On February 3rd there was<br />
no doubt that Kernig's sign was absent, but the neck was<br />
still stiff. By the 5th some movement of the neck had been<br />
recovered; the temperature, which had been irregular, fell<br />
to normal, and the patient said he was not sick. By the<br />
8th he had regained complete movement of his neck. The<br />
temperature during the following three weeks shewed occasional<br />
erratic rises, but the boy eventually recovered completely,<br />
and was discharged on March 3rd, 1906, after being<br />
in hospital 33 days.
December, 1907. THE TR vAll <strong>MEDICAL</strong> JOUR AL. 97<br />
These ca es which abort are important, because,<br />
though" they may be diagno ed and treated for<br />
cerebro-spinal meningiti , their OCCUlT nce clearly<br />
indicates that there are probably numbers of others,<br />
with the symptom le s sev re even than in the c~"e<br />
quoted, which would not come under the not~ce<br />
of a medical man; or, if seen, might very easIly<br />
be passed over as being infiuemm, and such cases<br />
could serve as carrier of the disease from place to<br />
place.<br />
It now remains to discuss the more ip1portant<br />
individual symptoms. In doing so, I ~hall ~ndeavour<br />
to introduce them, as far as possIble, ID the<br />
order of their importance :-<br />
(1.) The temperature in my cases was, with one<br />
exception, above norlllal on admissio~ but<br />
later in the disea e it varied exceedmgly.<br />
Twenty-four hours before death it fell to<br />
normal or sub-normal in many instances.<br />
The height it reached was no indication of<br />
the severitv of the case; some with the<br />
highest temperatures eventually r~cove.re~.<br />
But while any sign of fever remams, It IS<br />
very risky to form a favomabl~ 'p~ognosi~.<br />
(2.) Stiffness of the neck. The ngldlty.whIC.h<br />
affects the whole length of the spille IS.<br />
most marked in the cervical region. It<br />
is present in a greater or less degree at<br />
some period of the disease in every .case of<br />
cerebra-spinal meningitis, except ID the<br />
fulminating cases already referred t?<br />
It mn,y vary in extent from a st.ate, m<br />
which the movement of the neck IS only<br />
slightly limited, to one in which th~ nec.k<br />
is retracted to its fullest, and the patient IS<br />
in a state of extreme opisthotonos.<br />
(3.) Kernig's sign is probably the next most<br />
constant symptom, except in the f?l~inating<br />
ca es; but ~ as alre~dy ~tated, It IS frequently<br />
late ID mal~mg It~ appeara.nce,<br />
sometimes not appearIng until several days<br />
after the neck has been stiff, and other<br />
symptoms have developed; usually at first<br />
it is present in one leg only. _ .<br />
It is one of the earliest sympt.oms to disappear<br />
and its disappearance is of favourable augury.<br />
The peculiar gait is, I take it, part and parcel.of<br />
the spinal symptoms, and therefore does not reqmre<br />
further mention.<br />
vVe may consider the temperature, the spinal<br />
symptoms and Kernig's sign as the three symptoms<br />
typical of the disease.<br />
RASH.<br />
Though the disease is known i~ some countries<br />
as spotted fever, with the exceptIOn of heI'pe~, I<br />
have only seen a rash in t\V~ cases of cerebro-splI~al<br />
meningitis. One was a patIent ~ho had a pecuhar<br />
mottling of the skin over the thIghs and abdomen,<br />
which disappeared in .48 hours. I. am ~ot prepared<br />
to state it had any connectIOn wIth the<br />
disease. . h<br />
The other was a Zulu. a lighter coloured boy, W 0<br />
developed a high ternperature (104 0 F.), with a<br />
rash something like confluent measles, but t~e spots<br />
were more raised than is u ually the case m that<br />
disease. This boy eventually developed cerebral<br />
symptoms, bnt recovered.<br />
Herpes of the lip and round the alae of th nose<br />
was not uncommon, usually coming out about th<br />
third or fow' h day f the di ase, but I ha e s en<br />
it well marked on the first day.<br />
Herp's appears to be an unfavourable sign, but<br />
the South African .nativ· is peculin,rly prone to<br />
it, as the slightest indisposition may cause an<br />
eruption.<br />
Retention of urine ,,"as common among th<br />
patients; it should n,1\\'ays be looked for. I know<br />
of no disease in which the use of a catheter is 0<br />
frequently called for.<br />
The emi-conscious state of some of the patients<br />
probably p rmits them to endme di tend d bladder<br />
without showing signs of di comfort.<br />
Rhinitis, a purulent streaming di charge from n<br />
or both no tr:ils, often commenced uddenly, as on<br />
of the primary symptoms, n,nd milder forms of<br />
rhinitis were suspicioLlsly frequent among contacts.<br />
I gl:eatly regret I did not cause a systematic bacteriological<br />
examination to be made of all nn,sal discharge<br />
of both patients and contacts.<br />
Epistaxis was met with in a few cas s, but on<br />
no occasion was it severe enough to cause any<br />
anxiety. Once it reculTed after the interval of a<br />
few days.<br />
In all ca es the bleeding cea ed under treatment<br />
with calcium chloride.<br />
ystagmus and strabismus were lloticed occasionally<br />
in the later stagcs of the disease, but I hn,ve seen<br />
patients admitted to hospital with well-mal'ked<br />
nystagmus.<br />
Conjunctivitis of a highly purulent type was a<br />
noticeable feature in lllany cases of the disea e. I<br />
regret that no records of this symptom were kep .<br />
Bowels.-In some ca es the patients had acute<br />
diarrhrea, but this ",a' not, a a rule a mark d feature<br />
of the disease. In several cases, howev r, the cerebral<br />
symptoms were u hered in by mild attack vf<br />
diarrhrea, which is interesting when con'idering<br />
Drs. McDonald and Fowler's views on the mode of<br />
infection, to be mentioned later. \\ e must not,<br />
however, overlook the fact that most of the patients<br />
concerned were tropical or sub-tropical natives,<br />
omewhat prone to inte·tinal disorders, and very<br />
liable to commit errors in their diet.<br />
Urine.-Albuminuria occurrcd frcquently, but<br />
owing to the number of patient suffering from<br />
bilharzia, the presence of albumen in the urine was<br />
of small significance. The same r mark applies to<br />
haematuria.<br />
Spleen.-I note that OsIer ay the spleen as a<br />
rule is enlarged; but in my ea es this sign was of no<br />
moment, because the boys had all more or less enlarged<br />
spleens, due to malaria.<br />
\Vhile discussing the symptom', I would draw<br />
your attention to several interesting points which<br />
require explanation.<br />
A. What is the eau e of Kernig'. sign? One might<br />
ugge t that in some cases i re ulted from ~u<br />
pre ing on certain nerve centre ; but, on refernng<br />
to the po t-mortem examination r cords, ca es ar<br />
met with in which all the ymptom. of cerebropinal<br />
meningiti were pre ent during lif , including<br />
Kernig's ign, yet on op ning the kull no pus could<br />
b found in the pia mater, and in some of th se<br />
there was an absence of both m ningococci and
'l'HE 1'RA S\ At M1
( December, 1907. THE TRA SVAAL <strong>MEDICAL</strong> JOUR AL. 99<br />
hour. Po t-mortem examination reveals a large<br />
clot of pus at the base of the brain, which one would<br />
think could not have been formed in the short time<br />
which has elapsed since the onset of symptoms.<br />
It seems possible that the pressure of the fluid in<br />
the spinal column at times changes rapidly. ]I<br />
such is the case, should pu commence to form at a<br />
low pres. me, it might for a time e cape re i tance,<br />
but on the pres un~ increasing, it can be understood<br />
that violent pressure symptoms would come on suddenly.<br />
Dr. Geo. Turner, ledical Officer of Health for<br />
the Transvaal, however, suggests that the sudden<br />
onset of symptoms is due to the rapidity with which<br />
the pus is formed, a he state a quantity of pu<br />
slowly formed would produce little effect, becau e<br />
the spinal fluid would be ab orbed pari passu, but a<br />
rapid formation would give ri e to pressure symptoms,<br />
as there would be no time for compensating<br />
absorption of cerebro-spinal fluid.<br />
COMPLICATION.<br />
Regarding these, I need say little; a glance<br />
through the records of post-mortem examinations<br />
shows that pneumonia, pericarditis and pleurisy are<br />
common.<br />
Blindness.-Several of my patients have had complete<br />
loss of vision, as a reslllt of the disease, but I<br />
think that, with one exception, they all of them<br />
regained their normal sight, though not till after<br />
some months.<br />
Deafness and dumbness, said to be frequent, particularly<br />
when European children are attacked, is<br />
not common with adult natives. I have only seen<br />
it on one occasion following an attack of meningitis.<br />
Mental Defic-iency.-On several occasions my<br />
patients, after making an apparently good recovery,<br />
have been found to be mentally deficient. It is<br />
difficult to make any very definite statement on this<br />
subject, because the border line between sanity and<br />
insanity in the raw native is a very narrow one.<br />
Further, unle s one can understand the native language<br />
well, it is very difficult to say whether a native<br />
is affected mentally unless, of course, he is in a state<br />
of acute mania, the form of insanity most common<br />
amongst uneducated natives.<br />
PROGNO I .<br />
This varies with the type of the disease which is<br />
prevalent.<br />
Out of 193 fatal cases, death occurred on an<br />
average after 11'80 days of sidmess, but among the e<br />
there were three which had very prolonged illnesses,<br />
viz., 209, 111, and 129 days. If these are deducted,<br />
the average period of death \Va 9'7 days.<br />
It need only be said hat the prognosis is in all<br />
cases serious. One can never be certain that an :tpparently<br />
mild case may not relapse after the disappearance<br />
of all symptoms, and then die of the most<br />
accentuated form of the disease.<br />
DANGER OF I<br />
FECTIOUS JESS.<br />
Per onally, I have never een a case of the di ease<br />
which I could trace to direct contact with another<br />
patient, but we must not overlo?k the fact that. mild<br />
abortive ca e are wrongly dlagno ed at tlIll s.<br />
Herein lies the danger of stating that the disease is<br />
not acutely infectious.<br />
On t\ 0 occa ions I have een patients ufT ring<br />
\yith a high temperature (104 0 F.), and severe h adache,<br />
which followed their occupation of<br />
room recently u~ed by well-marked case<br />
of cerebro- pinal meningitis, but these boys<br />
howed no tiltlle~s of the neck n ither<br />
did any other ymptom of the disea' e app ar<br />
in th m, and they recovered in a few days. Thcy<br />
were su pected to be suIT ring from the initial stages<br />
of meningitis, and they may have had a very mild<br />
form of it, but I do not think one would have been<br />
justified in making a lumbar puncture under the circumstances<br />
to verify or refute the diagnosis.<br />
I personally do not think that ceTebro-spinal<br />
meningitis is acutely infectious. uch a tat ment<br />
mu t be accepted cautiou'ly, with the above facts<br />
b fore one.<br />
Dr. Robertson, l\Iedical Officer for Leith, in his<br />
paper on "Outbreak of Epidemic Cerebro- pinal<br />
Meningitis," published in the Brit-ish Medical<br />
Journal of July 27th, 1907, enters into this question<br />
more fully than I can do here.<br />
PERIOD OF I C BATIO .<br />
This from a public health point of view is a<br />
matter of importance. I am of the opinion that it<br />
will eventually be proved that the period of incubation<br />
may range from a comparatively short one, to<br />
one of several weeks' duration.<br />
I note that in the report ofthe Congress of the Incorporated<br />
Sanitary A sociation of cotland, h~lrl on<br />
September 6th, 1907, it i tated that Dr. Chalmers,<br />
the Medical Officer of Health for Glasgow, was ot<br />
the opinion that the incubation period might be a<br />
matter of months. The belief in this prolonged<br />
period of incubation is justified in many ways.<br />
In the first place, Drs. 1\Iary Goodwin and Anna<br />
von Sholly proved that the meningococcus might<br />
exist in the no tril of person for at lea t three<br />
weeks without causing any symptoms.<br />
Dr. Williams, who was on the \\ est Coast, informed<br />
me that while he was examining blood films,<br />
made from natives whom he believed free from the<br />
disease, and whose blood he required as a control for<br />
samples taken from persons undoubtedly infected,<br />
he was surprised to find the meningococcus on<br />
several occasions, which led him to keep these persons<br />
under observation. He was able to prove that<br />
all those in whose blood he had found the meningococcus,<br />
developed the ordinary ym ptoms of cerebra-spinal<br />
meningitis, and ome of them died.<br />
The incubation period in these cases of Dr. Wil<br />
!iams, though unknown, was undoubtedly a long onc.<br />
Again, since the meningococcus and pneumococcus<br />
:1re closely allied, we may expect them to behave in<br />
somewhat imilar ways, and we kno\y that tho pneumococcus<br />
may remain in the ystem for long periods<br />
before making itself apparent.<br />
The following case, I think, illustrates very well<br />
the vagaries of the pneumococcus :-<br />
H. \V. H., a male European, aged 33 years, contracted<br />
facial erysipelas as the reRult of a fall from<br />
bis bicycle, in which he had abraded onc side of hi.<br />
lace. He was admi ted to the Inf etiou Disease<br />
Ho pital on August 12 h, 1904, with a high temperature<br />
: he oon b came d lirious: he had a cough,<br />
311d his lungs were cong t d at both ha es; he spat<br />
a quantity oi brown purulent material. The con-
100 December, 1907.<br />
dition of his lungs at the time was considered to be<br />
t.he result of septic infection, due to erysipelas. He<br />
rallied, made a rapid recovery, and was di charged<br />
on Augu t 25 th, 1904. Five we ks later, he felt 3<br />
pain in the left inguinal region, clnd three or four<br />
day later he noticed a slight swelling there, which<br />
increased.<br />
His medical man. Dr. Ashe, was good enough tu<br />
allow me to examinc him. I could obtain no history<br />
of any injury to the foot, of exposure to tick<br />
bite , or vermin of any kind, or any history of<br />
venereal disease. His temperature was normal,<br />
tongue clean, complexion good, and he did not feel<br />
or look in any way sick.<br />
The bubo was opened. I obtained from the pus<br />
a pure culture of a diplococcus, which answered to all<br />
the tests for the pneumococcu ,so far as staining and<br />
mieroscopical appearances went.<br />
It appears to me that this is a case in which the<br />
pneumococcus had been in the system from the tin",<br />
that the patient was first admitted to hospital, that<br />
the pneumonia from which he was suffering Oll admission<br />
was of the ordinary pneumococcal variety,<br />
and therefore the incubation period for the glano<br />
trouble was not less than five weeks.<br />
The cas~ at any rate is interesting, though the<br />
deductions are open to many fallacies, because the<br />
investigation was not nearly so complete as one<br />
would have liked.<br />
To demonstrate further the time the pneumococcus<br />
may remain concealed in the system before breaking'<br />
out, let us consider the cases of pneumococcal meningitis<br />
following pneumonia. In the earlier part of<br />
this paper I quoted the case of a native, returncd<br />
from one of the mines with debility following pnellmonia,<br />
who Ruddenly contracted meningitis and dierl.<br />
The incubation period for this case of menin~-iti.<br />
must have been at least from the commencement of<br />
the pneumonia, a matter of several weeks.<br />
These cases and others leave no doubt in my mind<br />
that the incubation period of pneumococcal menin·<br />
I;itis may be very long, sometimes a question of<br />
several weeks. Such b0ing the case, I see no reason<br />
why the meningococcal form of meningitis should<br />
not have an equally long incubation period.<br />
J3esidc~ this, I have on several occasions noticed<br />
that among::;t a body of emigrants wbo have been<br />
under observation for severu,l weeks, four or five<br />
cases of cerebro-spinu,l meningitis may occur sud·<br />
denly within two or three days; the disease then<br />
stops. no further cases occurring.<br />
This suggests not only that the disease is noi<br />
acutely infectious. otherwise further cases would<br />
December, 1907. THE TRA SVAAL <strong>MEDICAL</strong> JOURNAL. 101<br />
rasion in the mucous membrane of the no tTil ,<br />
th.rough inflamed ton ils, or by means of biting<br />
insects, etc.<br />
That the diplococcus does not always travel direct<br />
"from the mucous membrane of the nostrils to the<br />
meninges of the brain, as described by ome authorities,<br />
is proved by Dr. William , who found the<br />
meningococci in blood film<br />
had never hewn· any sign<br />
taken from patients who<br />
of cerebro-spinal meningitis,<br />
and who, though at the time the film was<br />
taken appeared perfectly well, afterwards contracted<br />
the disease.<br />
'l'he human system might be invaded through one<br />
or more of the following entrances:-<br />
(1). Alimentary tract.<br />
(2). Lungs.<br />
(3). ares.<br />
(4). Tonsils.<br />
(5). Conjunctivae.<br />
(6). Skin. .<br />
Alimentary Tmct.-Dr. Fowler supports a COIItention,<br />
originally put forward by Dr. Stewart<br />
McDonald, that epidemic cerebro-spinal meningiis<br />
may be related to acute abdominal infection. The<br />
organism invading tbe nervous system through the<br />
spinal meninges. Certainly my experience among<br />
natives does not support this theory.<br />
It is a question, however, I have not thoroughly<br />
investigated. It is possible that adults may not<br />
contract the disease in this manner; but infants, and<br />
young children, of "'hom I have had no experience,<br />
may do so.<br />
Lungs and Bronchi.-" e know that the pneumococcal<br />
variety of meningitis is frequently, but<br />
not by any means ahvays, preceded by an attack of<br />
pneumonia, and in these particular cases it is probable<br />
that the organism first gained access to the<br />
system through the lungs, though it may not have<br />
nttackeq the meninges till weeks later.<br />
The meningococcus may in the same way OCC'1<br />
s'onaIIy gain access to the system through the lungs,<br />
hnt only under exc('ntional circumstances; as<br />
it is improbable. if infection occurred through<br />
the lungs, that the preliminary sympto~s of bronchitis,<br />
etc., would not frequently mamfest themselves,<br />
which is not the case.<br />
On the other hand, I believe that in a large number<br />
of cases of pure meningococcal meningitis. th('<br />
lnogs are infected secondarily, because one cannot<br />
help being impressed by the number of post-mortem<br />
examinations in which red hepatisation is found at<br />
the bases of the lungs, even when death has not<br />
occurred for some days after the commencement of<br />
the illness, and in which, had pneumonia been a<br />
primary symptom, grey hepatisation would have<br />
replaced the red.<br />
Nares.-There seems little doubt that it i~ through<br />
the muCous membrane of the nares that the bulk of<br />
the meningococcal cases receive infection. I think<br />
this supposition is justified :-<br />
(1). By the numbers of<br />
•<br />
cases<br />
.<br />
m which<br />
there is an acute purulent rhinitis among<br />
the primary ymptoms.<br />
(2). By the prevalence of cases in which the<br />
primary symptoms are of a cerebral nature.<br />
(3). By the re nits of the bacteriological examination<br />
of the discharge from the nostrils<br />
of patient and contacts made in several<br />
parts of the world.<br />
(4). By the results of post-mortem examinations<br />
made by Drs. Brodie, Rogers and Hamilton,<br />
supplemented by bacteriological examination.<br />
The question a to how the Ql'gani m enters the<br />
human y tern, from the mucous membran of the<br />
no trils is a di puted one. I have little doubt<br />
that sometimes it gains acce s through abrasions in<br />
the mucou m mbrane of the nares; at other times,<br />
to quote Drs. Brodie, Rogers, and Hamilton: " The<br />
" most u ual coursL' to ·th interior of the skull is from<br />
"the muco-perio teum of the sphenoidal sinus to<br />
" the sheaths of the nerves imbedded in the walls<br />
" of the cavemou.' inu, and thence, by direct ex<br />
" tension, to the arachnoid and pia mater.<br />
" In other ca e nndoubtedly the Ql'gani m infect<br />
" the meninges by extension along.the nerves or ves<br />
" sels traversing the (Tibriform nlate of the ethmoid.<br />
" It has been shewn that the nasal lymphatics are in<br />
"communication \yith the subdural and subarach<br />
" noid spaces by means of perineural paths. An<br />
" other possible route i by the Eu tachian tube to<br />
" the middle ear and petrous bone thence by the<br />
" seventh and eighth nerve sheaths."<br />
Dr. Robertson, however in his paper, published<br />
in the British lIIedical Journal of July 27th, 1907,<br />
states inter a.lia: " Jn fact, I have the as urance of<br />
" my re pected teacher of anatomy, Pro£. Cleland,<br />
" of Glasgow, that it i extremely unlikely t4at-the<br />
"meningococci can pass readily, if at all, by the<br />
" nasal rout~that is, through bony structures."<br />
The point is, therefore, debatable; but I think the<br />
majority of people \\'ho have made post-mortem examinations<br />
of cases of cerebro-spinal meningitis will<br />
favour the views of Drs. Broclie, Rogers and Hamilton.<br />
Tonsils.-Infection through the tonsils is probably<br />
not uncommon, hence the frequency with which one<br />
hears of sore throats preceding attacks of cerebrospinal<br />
meningitis (. ee the case quoted by Dr. Cun-ie<br />
in the Transvaal 111edical Journal), and also the remarks<br />
by others when describing outbreaks of<br />
meningitis in different parts of the world.<br />
Among natives, J have not noticed cases of sore<br />
throat. I have not looked for them especially, but<br />
for some reason the Bantu race does not eem to be<br />
so susceptible to pharyngeal troubles as European .<br />
Conjunctivae.-It is possible that infection may<br />
occur throngh the conjnnctivae. Purulent conjunctivitis<br />
i a common featnre of the disease. The infection<br />
of these membrane may. of conrse, be<br />
secondary to that of the Schneiderian membranes,<br />
with which they are in direct commnnication throngh<br />
the nasal and lachrymal canals.<br />
Dr. Napier con ider that the infection of the<br />
conjunctivae is probably the result of the patient<br />
conveying infections material from his nostrils with<br />
his fingers to the membranes.<br />
But. quite anart from the conjnnctivitis.lmet with<br />
several ca es (abont a dozen) in whom choroiditis,<br />
r ndering the patients quite blind, preceded the<br />
cerebro- pinal meningitis.<br />
Dr. J apier. who was good enough to examine these<br />
cases, was of the opinion that this condition waR<br />
the result of infection with either toe pneumococcus<br />
or meningococcus.
102<br />
THE TB<br />
VAAL <strong>MEDICAL</strong> JOUR<br />
AL.<br />
Declmber; 1907_<br />
Skin.-I see no reason why the disease should not<br />
be ca,nied through the skin by biting insects, though<br />
I know the idea, has all' ady been advanced by some<br />
(among others, 'urgeon J. F. Anderson, D.S.A.),<br />
and refuted by other authorities.<br />
But on one occasion while making smears from<br />
lice, fre hly fed on the blood of persons suffering<br />
from cerebro-spinal meningiti, I found in the<br />
leucocyte, contained in their bodies, cocci, which<br />
I believed to be cliplococci. Whether they were<br />
meningococci or not I, of cour e, cannot say. I<br />
have not been able to make furth l' investigations,<br />
but think the pos ibility of infection being carried<br />
by vermin worth remembering.<br />
Mortality.-The mortality, as with the prognosis,<br />
varies with the type of the disease. Occasionally<br />
one has a series of cases attacked with the most virulent<br />
type of infection, in which probably not one<br />
patient survives. At other times a comparatively<br />
mild form prevails, and a, fair number of good recoveries<br />
may be expected.<br />
I have been able to obtain records of 279 cases<br />
among mine ·native. Of these, 196 or 70'25 per<br />
cent. terminated fatally. The mortality would<br />
probably have been somewhat lower among Europeans.<br />
The following is a brief extract of 90 post-mortem<br />
examinations :--<br />
Bacteriological examination of the cerebro-spinal<br />
fluid and pus in the pia-arachnoid shewed that-<br />
Of 90 post-mortem, 45 contained meningococci.<br />
" 17 contained pneumococci.<br />
" 1 contained st.reptococci.<br />
" 1 contained gram - staining<br />
cocci, not the pneumococcus.<br />
"<br />
"<br />
6 gave negative results.<br />
20 were not recorded.<br />
90-<br />
As a rule, the blood vessels of the cortex were<br />
engorged with blood; in some cases intensely so.<br />
In one case there was a small haemorrhage at the<br />
base, and in another there was a number of petechiae<br />
on the inferior surface~ of both lobes of the cerebellum.<br />
The a.monnt of cerebral fluid was in many cases<br />
larger than normal.<br />
Pus.-There were mncroscopic evidences of pns<br />
in the- pia mater of the cerebnlm in 51 cases. In<br />
some the amount was Rmall, but in 30 cases it was<br />
present in considerable qnantities. In six cases<br />
it was especially plentifnl over the frontal lohes ..<br />
Twice. small localiRed pntches of purnlent flmcl,<br />
about the size of u shilling. wore found near the<br />
pncchioniur. boclies. . Therp wns a fibrino-pnrnlent<br />
deposit at the' ba. c of the brain in 69 inRtan~PR.<br />
On only eight occaRionR, where pus was plentlful<br />
in the pia m:1ter of the cerebrum, was it absent<br />
at the base. .<br />
No pus could be discovered, with the naked eye,<br />
in the cranial cavity in five instances.<br />
The ventricles contained pus in 32 of the cases.<br />
In addition, in five flakes of purulent material were<br />
floating in a nearly clear cerebral fluid.<br />
* Details of each post-mortem examination are given in tbe appendix"<br />
H cart.-In nine cases there were evidences of<br />
recent acute pericarditis. In' ten, the organ was<br />
flabby.<br />
Hypertrophy was noted on two occasions. Onc~<br />
there were vegetations on the aortic l:USPS, and on e<br />
these valves were atheromatous. .<br />
Lttngs.-The right and left lungs were normal on<br />
Q3 occasions.<br />
The right lung was congested 39 times.<br />
The right lung had red hepatisation 18 "<br />
The right lung had grey hepatisation 8 "<br />
The right lung had tuberculous nodules 2 "<br />
The left lung was congested 50 times.<br />
The left lung had red hepatisation 15"<br />
The left lung had grey hepatisation 1"<br />
The left lung had tuberculous nodules 1 "<br />
There \Vere evidences of pleurisy on 17 occasions.<br />
Abdo11linal Organs.-It is sufficient to say that<br />
~here were frequent evidences of acute toxic poison<br />
Illg.<br />
Livers.-An old yphilitic lesion was met with<br />
once.<br />
10 livers were cirrhotic.<br />
4 livers were fatty.<br />
:2 livers were waxy.<br />
2 livers were markedly anaemIC.<br />
16 livers were very acutely congested.<br />
Spleen.-As \yould be expected, among a class of<br />
patients llniformly infected with mal::tria, the spleens<br />
were usually enlarged, and on 36 occasions were<br />
fl.cutely congested. .<br />
[(idnells.-In one the capsnle was adherent; in<br />
seven dilatation of the calices was noted, two were<br />
anaemic, and acute congestion was noted on 32<br />
occasions.<br />
In conclusion. gentlemen, I have to express my<br />
thanks to Dr. McCrae, Dr. May and Mr. Josephs,<br />
of the Govern'ment Laboratories, Johannesburg, for<br />
the bacteriological examinations of all the specimens<br />
qnoted in this paper.<br />
REFERE CE."l.<br />
"Epidemic Cerehro-spinal Meningitis," by J. S. Fowler. Review<br />
of Nenrology and Psychiatry. April, 1907.<br />
"Acnte Specific Rhinitis," by W. H. Brodie, M.D., ana W.<br />
G. Rogers, M.S., M.D.<br />
Novemher, 1894.<br />
South Africa-n Medical Joumal,<br />
"Contribution to the Pathology of InfectJon by the Pnenmococcns,"<br />
by W. H. Brodie, M.D., W. G. Rogers, M.D_,<br />
M.S., E. T. E. Hamilton, B.Sc., M.D., M.S. Lancet,<br />
1898.<br />
"The Freqnent Occurrence of Meningococci in the Nasal Cavities<br />
of feningitis Patients and in those in direct contact<br />
with them," by Mary E. Goodwin and Anua I. von Sholly.<br />
Journal of Infectious Disease, Febrnary 2nd, 1906.<br />
Reginald Farmr'g Report to the Local Government Board<br />
on cases of cerebro-spinal meningitis, occnrring in Irthlingborough,<br />
August, 1905.<br />
Memorandum by Reginald Farrar to Local Government Board<br />
on Illness resembling Epidemic Cerebro-spinal Meningitis<br />
in certain localities of the Ellesmere Rnral and Oswestry<br />
Urball. Districts. Shropshire, Septemher, 1903.<br />
"Epidemic Cerebro-spinal Meninigitis and its Relation to<br />
other forms of Meningitis," by Drs. Councilman, Mallory<br />
and Wright. 1898.<br />
Report on Epidemic Cerehro-spinal MeninlPtis in India by<br />
Capt. C..J. Robertson Milne, M.B.. I.M.S. 1906.<br />
"Outbreak of Cerebro-spinal Meningitis," by William Robert·<br />
son. M.D.. D.P.H., fedical Officer of Health, Leitb.<br />
Briti!'!l Medical Journal, 1907.<br />
Discussion on :Spotted l'ever at the Congress uf the Incor·<br />
porated Sanitary Association of Scotland, reported in the<br />
Aberdeen Fru Press, September 6th, 1907.
,<br />
TABLE OF POSl MORTEM EXAMINATIONS.<br />
I<br />
'<br />
!<br />
i<br />
Duration Couclltlon<br />
No. L'rlbe. Alte. of of Brain. Hrart. Lungs. LiveI'. Spleen. Kidneys. Intestines. Jlact. EXllfll. l~ llemal·ks.<br />
Sickness. Body.<br />
I<br />
I<br />
I<br />
------ ,<br />
----<br />
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.<br />
baam Ollvc-colourrd ge,ted ; small llJIlount 0/ geRted. syphilitic congested. Marks or old sore on<br />
fluid running gus under p.la mater; (Oilions on sur' penis.<br />
from the mouth rain substance soft. fnco.<br />
-- --------------------<br />
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<br />
coloured flulcl ongorged with blood; tCsted ; left ed In the fluid ot a IUIII'<br />
runnlllg from pus under pia ml\tcr nsc solid. bar ~unoture made Mter<br />
tho mouth. over the whole ot brain. deat 1.<br />
oxtending Into cord;<br />
ventrioles contained a<br />
Quantity 01 bloodstained<br />
scrum.<br />
----------------------<br />
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<br />
blque gested ; thick deposit or containedabout wise normal. places; con· cranlnl pus; menlngo-<br />
J1brino Rurulent exudate an ounce ot talned ankylo- cocol and pneumococci<br />
under t 1(; base; ventricles serous fluid; stomes and specially looked tor.<br />
werc full of thick yellow heart otherwise Ascaris Lum·<br />
pus. normal. brlcoldes.<br />
--------------<br />
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·<br />
hlque. under pia mater. over gestion at both gested. prescnt. teriologlcal examlnatJon·<br />
the convexity. und at buscs.<br />
thc base; ventricles dry.<br />
--._------------------- ,<br />
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<br />
de('.omposlt.ion the convexity. and a ma.1 : left ba8e mOl:tel1l changes mortem changes logical examination.<br />
~et In before flbrlno purulent exudate congested. extensive. extensive.<br />
p.m. mnde. n.t the base; muco purulent<br />
fluid in both \·en·<br />
tl'iclp8. fhnt in left bcing<br />
bloon-stnincd.<br />
--<br />
____<br />
----__--4-<br />
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~<br />
under pia. over the con- of red he~atls. pre8ent. logical examination.<br />
vexlty ; lal'l!e flbrlno- ation at ase;<br />
purulent exudate at the<br />
Icft lung nor·<br />
basc ; pus in both Veu-<br />
mal.<br />
tTlcles.<br />
--------------<br />
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<br />
biqu p gurulent exudate at the in pericardial Iy congested; congested. showed few menlngoase.<br />
sac on tJle heart left lung con· . cocci. but no pneumowalls.<br />
rcsult or gested also, but cocci.<br />
I<br />
recent perlcar- not to the<br />
ditls.<br />
same degrec.<br />
I<br />
I<br />
o<br />
et><br />
o<br />
et><br />
8 g-<br />
,'"<br />
;-0<br />
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c:..;<br />
o<br />
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~
Po.d Mortcm Examlnatlons-~ontJnued.<br />
• • -- Duration .• Condition. •.•. • . I<br />
No. Tribe. Age. ot ot Brain. .- aea-it: ... Lunlls. -J.lver~ ". Sp'Jeen. Kldn~ys. Intestines. ])aot. Exam. &: Remarks.<br />
SlcknCfls. Body.<br />
--------......----------------1,-------1-------1------·------1·------1--- 1 _<br />
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<br />
Atrlcan pale colourAd nul" under otherwise nor- slon over whole and slightly base showed pneumnthe<br />
pia nJater over the mal. ot right .lung, enlarged. cocci In 1I00l!' numbers.<br />
whole of the convexity. land the whole no meninllococci. .'<br />
Tbe exudnte nt tbe hns. ,Iunll in stnte of . •<br />
wag much more fluid. grey hepatisa...<br />
nnd 01 n palcr colour :tion; small • .•..<br />
thnn in prevlons cases; pnteb 01 r'eur. ..<br />
ventricles contained a ltic ndhesJOn 011<br />
Quantity of blood· the left side.<br />
stnined serum.<br />
but thc lung it_<br />
scll healthy.<br />
....<br />
o,.,..<br />
__-------- I _ •<br />
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<br />
baam ftbrino Ilurulcnt mntter at both bases rhosls; portal gested. gestlonln both meningococci, but no<br />
at basc; vcntrlcles con· 01 the lungs. vessel. con' the large and. )lIleumoooccl.<br />
talnrd a quant.lty 01 tained bllhar. smalllntestlncs;<br />
mUCQ·purulrnt Hnid. in zia worms. Ankylostomes<br />
which Hnkes '01 yellow presellt.<br />
matter were suspended.<br />
--------'---:------1---------1------1------1·------:------1---·---1------+-- _<br />
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<br />
African velljlel~ of thc convexity; herent to heart rhosis. congested. fell' meningococci. no<br />
Jnrge amount or fibrino· W1l1l8. pneumocooci.<br />
pUT-ule"t exudate nt the<br />
basc.<br />
.... - ..<br />
-----:---:-·_----·--1--------1------[-----1-----1·_-----1------1------·1--------<br />
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<br />
congested; quantity "I with nn exten' plcurltlc adhe. largcd. sule adhercnt prescnt. meningococci, no pneu'<br />
pus under pin mnter, slvc doposlt 01 slon"On both In plnce.. mococcl.<br />
, e8peClaJly marked at the lymph. the re· slde8; both<br />
ba8e. . suIt of reccnt ba8CS con. '•.,<br />
pericarditis. gested. I,; . "'..<br />
----------<br />
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<br />
gested: IlO nllkcd eye both baBcs. gested. pctechloo on menlnllococcl, no pneu·<br />
blQue signs of pus under pia mucous memo mococol.<br />
at the convexity. Ilut a<br />
brane; numbers<br />
thick ftbrJno· purUlent<br />
olankylostomes<br />
cxudate lit Ilase.<br />
present.<br />
• I j 1<br />
--I----I~-- j ~ i ~<br />
13 1I10zam· 20 yrs. 27 dal's Emaciated. Vessels 01 the oonvexlty Normal' Normal. Normal; bllha.... Normal. Caliccs dllated, Petechlooon mu·, No baeterlolOl1I.",' ."am.<br />
congcsted: at base was "ill worms in otherwise nor· cous membrane Inatlon recordcd.<br />
bique a Quantity ot pale yel· I)Orta.1 vessel~. mal. o.t small IlIteslow,<br />
nAarl)' wh,t.e.Hllrino' tllle; ankylopurulent<br />
exudate; vcn·<br />
stomes present.<br />
triclrs contained large •<br />
, amount of /lu,ld P1ls.<br />
.<br />
----------1---------------1------,--------_'·-------1------1------1------1----;--·-----<br />
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<br />
blQue gested : cxtenslve puru· g••1;(,'I. vesp"lp con· somewhat en' Il!eplngococc)' In .maU<br />
lent exud"te nnder the talned bilhar.da larged. numbcTl. no pneumo'<br />
pia mater of the whole worms. _ .cocti... ••. .• ..••.<br />
surface of brill n ; at th"<br />
basc a fibrlno-plIrulent<br />
• • I 6.\':udate. /. .;.' _,}\ ' ~ 'r,,', ,.1, '.,,\1<br />
-~~~ , ~ .<br />
116 Mourn- 21 yrs: '32 dd'Y8 EmacIated; de- Vessels at cOllvexlty con· Normal. Red hepatisation Decomposed. Decomposed. Normal. Ankyl08tomes No bact. exam. }Iladete0n<br />
blque I composition gested : ftbrlno-puruJellt at both bllses present. account of pOI..-mor m<br />
commenced. exudate at. tilebaBe.' chanllcl.<br />
• 1<br />
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~<br />
,~<br />
t1<br />
g<br />
s"<br />
i:. ....'.<br />
....-<br />
~<br />
~
POlt, Mortem Examinations-continued.<br />
No. Tribo. Ago.<br />
Duration Condition I<br />
of of Brllln.<br />
Sleknell. Body.<br />
\<br />
I'<br />
Heart. Lungs. Liver. Spleen. Kidneys InteltlDOI. Bact. Exam... Rllmlfks.<br />
- ---<br />
--'------<br />
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<br />
blque ae.ted; pus under the old vegetlltlon sion lit the right zill worms In ge~ted. IQ!ltome. menlnlloCOCCl In small<br />
pia mater over whole on the aortic bMe \ reerntl ; the portlll prosent. numbers. no pneumasurface<br />
of brain, flbrino- cmps ; no sign' both hll8es con- vessels. cocci.<br />
of recent gested.<br />
g~~~le:ntve~~r~~I~~ co~: trouble.<br />
, talned quantity of bl~d'<br />
stained .erum, wi h<br />
flakes of,vellow purulent<br />
mllterialsuspenrlerl in it<br />
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<br />
blque unrler the pia mater \'essels contain' gested. menl ngooOCOl. but a few<br />
bathed In 0 pole coloured ed bilharzia pneumococci.<br />
pUI 0, thick flbrlno· Worms.<br />
guruient exudate at, ~he<br />
08e : ventricles con· • J<br />
tAlned 0 large amount ,<br />
of flulrl pUI.<br />
--<br />
18 Mozllm· 19 yrs. 16 days .F:maciated. Ve88pll of the cortex con- Normal. Congested. Normal; blhllr- Normal. Normal. Normal. Pus at bue showed<br />
bique gesterl ; only a 811ght zla worms In menl ngoeocol In small<br />
exnda·t1nn of pale-colonr portal velsol8. numbers. no pneuma-<br />
~u" lit the b/l.
Post Mortem examinations-continued.<br />
No. Tribe. Age.<br />
Duration: Condition<br />
01<br />
I<br />
Brain.<br />
or I Heart.<br />
Sicknes~. Body.<br />
Lungs. Liver.<br />
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<br />
biQue eugOl'ged with blood; exudate over mic and friable. calices dilated; caus membrane brain showed neither<br />
I<br />
.Sp.1c~n. Kidneys. Intestines. Bact. Exam. & Remarks.<br />
l-'<br />
0,<br />
m<br />
----------<br />
mllrked COdema o"er the whole or sure<br />
convexity, with an exu-<br />
ureter h)'perlace.<br />
and lung or small inWd' pneumococci nor menin-<br />
dation or albuminous- trophied : bladsolid<br />
throughtine:<br />
ankylo- gococcl.<br />
looking fluid. streaked der walls thl ckout,<br />
with grey<br />
stomes present.<br />
with yellow in places: ened.<br />
I<br />
heratisation :<br />
nothlnl/ marked at base; ler slightly con-<br />
'- ..<br />
vcntrii'lcs f'ontninod ex· gested.<br />
ep8S or blood - stai ned<br />
SCrum.<br />
23 Shnn- 34 yrs. 4 clays Well nourl~hed. Ve~sels<br />
gaan<br />
on eortex con- Very thick coat- Small patches 01 Normal. Enlarged. Congested. Normal. Pus at the base showed a<br />
~~~~ed ~o~~~~gXi~~ltI~n~<br />
Ing of yellow pleuritic adhefew<br />
ft brlno - puru- .Ions on both .<br />
meolnllococcl. )10<br />
thick lal'er or pus. that lent material on sides ;<br />
.poeumococcl.<br />
both<br />
.. at base bel ng orl/anised. heart walls. lungs con- --<br />
result 01 reeent gested.<br />
pericarditis. ,<br />
---------- , , --------<br />
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<br />
bnnm conllcstcrl : a thick mass both bases.<br />
01 ftbrino-purnlent exudate<br />
at the buso : ven-<br />
trlpJe~ rontaincr! a quantity<br />
or liquid pus.<br />
----------------------<br />
showed smail numbers of<br />
: meningococci, no pneu·<br />
mococci.<br />
--------<br />
25 Shnn- 20 yrs. 4 days }'airl)' well VesElofllp; over cortpx COIl- Norma,1. 130tll<br />
gaan 110urishrr!.<br />
apices in Normal.<br />
ge,ter! : larl/e a,mount, or<br />
Enlarged aod Cystio, the<br />
.tate<br />
lntestlncs conof<br />
rer!<br />
No bacteriological exam-<br />
pair coloured pus a'. thc<br />
rrlable. calices dilated. talned ankylohepatisation.<br />
inatlon recorded.<br />
bll8e ; vontricle~ con ..<br />
stomes and<br />
Ascaris lum-<br />
hrlcoide•.<br />
tained quantity of thic~<br />
pus.<br />
------ , ,<br />
-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<br />
cOlwest.ed : ouly a small slightly athero- lostom08 and few meningococol, but<br />
amount of pus at the matous. other- Asoarls Inmbri- no pneu mococcl.<br />
ba se : ]ln8 i11 both ven- wise henrt nor- coidcs.<br />
trlclos.<br />
mal.<br />
----------<br />
27 Shan· 20 yrs. S days Emaciated. Traces of pus visible under Normal. Normal. Somewhat<br />
gaan<br />
con· Normal.<br />
1)ln mater a t the<br />
Normal. Mucons memo<br />
con-<br />
Pus at the base contaloer!<br />
gested; portal<br />
vo"lty: brone conl/ested<br />
onl~· a small no menihgOcoccl. but a<br />
vessels conamount<br />
at the<br />
In places: tew pneumoooccl.<br />
base; I taioed bilharventricles<br />
dry. Ascaris lum·<br />
zin worms. brlcoldes present.<br />
----------<br />
I I<br />
28 Myam· 20 yrs. 6 days Emaciated. Small ql~antity of pus Normal. Both' bases con- Normal. Enlarged<br />
baam<br />
and Normal.<br />
uncler ]lla mater at the gested.<br />
\ Normal. Pus at the base cootaloed<br />
frlllble.<br />
convexity: only a smail<br />
rair numbers 01 meniogo·<br />
amount or organised pU8<br />
cocf'i. but 00 pneumo-<br />
at tho base: ventricles<br />
coccI.<br />
dry.<br />
---- ..<br />
-29 NYfis8a 20 yrs. 3 days No record. An excessive amount of Normal. Both bases Congested and E:llarged. Normal. Smail· Intestine<br />
yellow rus uncler pia<br />
PU8 at the base contalne<br />
slightly con- somewhat cn·<br />
ma,tcr a t,he convexl ty :<br />
contained anky· reil'<br />
gested.<br />
meningococcI. n<br />
larged.<br />
I 10sOOme•.<br />
Iu,rge mas8 or flbrinopneumococci:<br />
,<br />
.' :<br />
purulent material at the<br />
buse: ventricles con·<br />
.<br />
.<br />
tallled only a smail<br />
,I<br />
L""<br />
, " . "I amount<br />
'.<br />
ot fluid. with<br />
'" :<br />
some pus.<br />
.<br />
..<br />
~.<br />
f-:3<br />
~<br />
~<br />
Z<br />
rn<br />
~'<br />
~ t;I:j<br />
t;<br />
I-"-<br />
);l><br />
t:<br />
Post Mortem ExamlnatloDs-contlnued.<br />
I I jDuratlon\ Condition<br />
Spleen.<br />
Kidne~s. Intestines. Boot. Exam.,~ !tPlllllrk,.<br />
~: Tribe: ~~, ngJ y • 1 Brnin. 1 Heart. I I.ungs. \ ~---i, , , , _<br />
so I Quill·:<br />
mane<br />
32 I Utyopl<br />
26 yra. 110 days I Well nourished.<br />
42 yrs.<br />
23 yrs. I 8 days<br />
A larlle amount 01 pale I Normal.<br />
yellow coloured pus<br />
under the pia mater.<br />
eoverlng the convexl ty :<br />
mass of tlbrlno-puru!ent<br />
material a,t the bllse;<br />
ventrloles oontained a<br />
QUllntl ty of bloodstalnecl<br />
serum Ilnd pus.<br />
Vessels of the eonvexlty I Normal.<br />
engorll:ed with blood;<br />
a pale. thin. milkyeo<br />
loured fluid under the<br />
plo. mater.over the whole<br />
surfaee of the brain: a<br />
small tlbrlno - purulent<br />
exudate Ilt the bn8e.<br />
" Normal.<br />
Acut.e congestion<br />
11 t both bases ;<br />
red hopatlsn·<br />
tlon commnnr<br />
Ing.<br />
Normlll.<br />
Normal.<br />
Decom posed.<br />
"ery small.<br />
Normal.<br />
Friable. but not I Decomposed.<br />
enlarged.<br />
rr:abJr. but not I Normal.<br />
enlarged.<br />
SOlidi Inl,stlll"<br />
rontlllnert<br />
ank)'lostolllr•.<br />
Small Intestlnrs<br />
contained<br />
nnkylostome,.<br />
Bartel!ololllral exanun.·<br />
tlon of the pi' At lIlt<br />
'base nel/atfve.<br />
Decomposltlon had rom·<br />
menren : bact. exam. 0 I<br />
PUll at thp bur .ho\\ eel<br />
no menlnllG(orrl. a fe"<br />
pneulJ'ocorcl and ,treptr<br />
roool.<br />
Pus at the b8l~ showed 8<br />
few mpnlr'lI:ococr!. DO<br />
pneumococol.<br />
_J---l.I-I I ~I I I I I 1------1-------1------- _<br />
QUill- i<br />
SS<br />
mane'<br />
II<br />
11 '<br />
-.'~-I 3 days IWell nourished. I I I I 1--------1--------1--------,-- ----<br />
2S yrs. I 15 da)'s 1 J'maelated.<br />
Pia mater over the con- I Normal.<br />
voxlty bulging with pus:<br />
wholo brain substance<br />
covored with thlok<br />
flbrlno-purulcnt oxudate.<br />
especlnlly mllrked on the<br />
under surfaoe of the<br />
II fronta,1 lobes; pus<br />
1 streamed from the spinal<br />
I canal.<br />
_, 11 1 'I i l<br />
I 1----__1 -, 1 1 1 _<br />
'I I.MlIe amount of cloudy IFlabby, otherfluid<br />
under the pia mater wise normal.<br />
I eauRlnl!' the membrRneR<br />
to bu iI~e when the<br />
brain was removed. An<br />
exresshe Quant.jt.y of<br />
fluid came from the<br />
spl nal oanal; no pus<br />
could bc fn'lIld Iln)'<br />
",her('.<br />
Normal.<br />
This rasr had bern dl"ll<br />
nO!led as onp (I entello<br />
lever: his tem~erature<br />
had beeD SubDormal lor<br />
several days be/ore<br />
d~ath; no bsrt. exam<br />
reeorded.<br />
----,---,--1 I I I I 1------,-------1--------1---------__<br />
34 Quill'<br />
mono<br />
25 yrs. 2 da)'. Emnoilltrd. Small (,uantlt)' of whil.c. ,!-'i brino-purulent<br />
milkl"ooloured drposit deposit on the<br />
over tile baso ; "entrleles heart walls<br />
contained nn exres_lve ntherwlse nor·<br />
Quantltl' 0' (hold. with mal.<br />
somr purnlent material.<br />
Uljlht lunll solid.<br />
with pneumonia<br />
throughout;<br />
left lung ROute·<br />
I)' congested at<br />
the. base<br />
Normal.<br />
Normal, bilhar'<br />
zlll worms<br />
found In ths<br />
portal vessels.<br />
SI I Quillmane<br />
Hobnailed rirrhosls;<br />
bilhar<br />
"in. worms<br />
found In the<br />
portal vessels.<br />
Small.<br />
Mueh enlnrged.<br />
friable. and<br />
mol8t.<br />
Normlll.<br />
l\ormal.<br />
Normal.<br />
Ankylostomes<br />
present lu small<br />
Intestine.<br />
Anky!ostomes Allcrosroploal examluatlon<br />
pre8ent In sm31l showed pneumococrl to<br />
Intestlncs. be vresent In llnod Dum<br />
ben In the flulcl from<br />
the brnlD.<br />
-.---,!I--I---I : -! I I I I 1-------1-----------<br />
S5 Mtyopl 10 yrs. 4 dill'S Fnlrly well nourished.<br />
Vesscls on the oortex of<br />
the brain wpre Rcute1"<br />
oongested ; only 11 Rmail<br />
amount of pus under<br />
the pill of the cerebrum;<br />
n dense flbrino-purulent<br />
exudate at the base;<br />
ventricles rontainert a<br />
largn qUllntity of yellow<br />
Ish green purulent fluid.<br />
Normal.<br />
Both bases aoutely<br />
congested. vessels oon<br />
Normal: portal<br />
vorgi ng on the tained bilharzia<br />
worms.<br />
stage of red<br />
hepatisation.<br />
Enlarged: on old<br />
olcatrlx on the<br />
anterior surfllce<br />
of about the 811.0<br />
of a two shilling<br />
pleoe.<br />
Calioes on both<br />
sides somewhat<br />
dilated.<br />
Normal.<br />
Bact. exam. of the PIIS at<br />
the base 8howed a very<br />
few mp.nlnllooocd. and<br />
no pneumoeocei.<br />
~C':l<br />
~<br />
o<br />
if<br />
,'"'<br />
....<br />
~<br />
o :--l<br />
1-3<br />
~<br />
~<br />
~<br />
.......<br />
tr.l<br />
tj<br />
H<br />
Q<br />
~<br />
c:....<br />
o<br />
d<br />
~<br />
~<br />
....<br />
o<br />
"-lI
Post Mortem Examinations-continued.<br />
Duration<br />
Condition<br />
No. Tribe. Age. ot ot Brain. Heart. Lungs. Llvcr. Spleen. Kidneys. Intestines. Bact. Exam. & Remllrks.<br />
Slcknes~. Body.<br />
----------<br />
S6 Trnsv\. 15 yrs. 7 days Emaciated. Vesae.l. over the convexity Kormal. Normal. Peculiar dark Normal. Normal. Ankl'lostomes Meningococci were present<br />
Basuto congested: no macro· colour, other- present In small In tnir nnmbers In the r,us<br />
scoplcal appearance of wise normal. intestines. at'the base of the bra n.<br />
pus nnder the pia mater<br />
covering the convexity.<br />
but, over the base was a<br />
pecnliar pole green purulent<br />
deposit: ventricles<br />
containcd an exrcss of .- .<br />
"<br />
fluid. with It quantity of<br />
purulent mo,terial sus·<br />
pendcct in it,.<br />
----------<br />
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<br />
baam engorged with blood: a gested. gested. present; a cyst In good numbeJ'l! In the<br />
large deposit of thick.<br />
of about the pus at the ,base: no<br />
yellow pus nnder the pia<br />
size of an orange pnenmococcl.<br />
mater on both hemiwas<br />
attachedto<br />
sph~resot the cCrebrum:<br />
the mesentery<br />
a thIck. fibrino-purulent<br />
ot the smoli Inexud~te<br />
at the base;<br />
testinc; the<br />
ventricles contained an<br />
crst contained<br />
c lyle.<br />
excess ot flUid. with<br />
flakes ot purulent matc- ,<br />
"<br />
rial floating in it: thick<br />
yellow pus exuded from .<br />
the Int.. AUd. Meat. and<br />
I<br />
the optIC foramina.<br />
----------<br />
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<br />
baam engorged with blood' wise normal. on the lett side; vessels con- her ot round In fair numbers In the<br />
pia mater over convex: both lungs were talned bllhar- worms. pus at the,.basc; no<br />
Ity wus slightly QJdema- congested. and zia worms. pneumococci.<br />
tous. but there were no<br />
there was purnnaked<br />
el'e evidences of<br />
lent material In<br />
pus there; there was a the bronchioles.<br />
thick fibrlno-purulent<br />
exudate at the base' a<br />
deposit of pus on the<br />
walls of the ventricles,<br />
and pus floated in the<br />
f1 uid of the ventricles.<br />
-------------- ------_.<br />
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<br />
baam e~gOrged with blood": red hetatlsatlon presen t in small In the pus at the bBse ;<br />
shllht rodema under the at bot bases.' Intestines; some ot the cells congla<br />
mater of the cere-<br />
round worms tlllned 15 to 20 pairs ot<br />
rum. but no naked eye present. copcl: no pneumococci.<br />
evidence of ~"S : a th(ck I<br />
flbrlllo·puru ent exudate<br />
ut the base: ventricles<br />
I<br />
_Icon<br />
tal neri pas.<br />
---- ------------------<br />
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<br />
gorgnd with blood; thick both bases. tal vessels con- weighed 18 ozs. cocci were founn in the<br />
layer of yellow pus un- tained bilhar· pus from the bral n : no<br />
rier tho pia mater ex- zla worms. pneumoooccl.<br />
tenning over the whole<br />
of the cerebrum. also a<br />
..<br />
thick :Ibrino,pllrulent<br />
exudate at the 11MB:<br />
ventricles contained<br />
. - .<br />
some pus in their flUid;<br />
.<br />
pus streamed from the<br />
, I. ._. spinal canal.<br />
.\<br />
I<br />
_.<br />
......<br />
0-<br />
8·<br />
~<br />
8·<br />
i;x:l<br />
~~<br />
'(J)<br />
,<br />
Post Mortem I!xamlnatlons-contlnued.<br />
No. 1 Tribe. 1 Age.<br />
&1 I }lyam·<br />
, baam<br />
29 yrs.<br />
Duration<br />
of<br />
Sickness.<br />
Condition<br />
of<br />
Body.<br />
16 days I Emaelat~d.<br />
Bmin.<br />
Heart.<br />
Po.t Mortem Examinations-continued.<br />
No.<br />
1<br />
Tribe.<br />
_i1__1<br />
48 1~!ozam·<br />
bique<br />
20 yrs<br />
6t I NYll8sa 1 28 Yrs;<br />
f. :<br />
i<br />
, Duration<br />
Condition<br />
of<br />
Body.<br />
10 day~ I Emaciated.<br />
Brain.<br />
Heart.<br />
Post Mortem Examinations-continued.<br />
:lio. I Tribe.<br />
1 Age.<br />
-'--'--1--1 r 1 1 1 1 1 1---'---I --<br />
53 1 Mozam-I 34 yrs.<br />
blque<br />
Duration<br />
of<br />
Slekness.<br />
1 day<br />
Condition<br />
of<br />
Body.<br />
Fairly well nou·<br />
rlshed.<br />
Drain.<br />
Heart.<br />
Thiek layer of pale.milkyco!oul'ed<br />
fibrino-puru<br />
Normal.<br />
lent exudnte under the<br />
pia mnter of the whole<br />
convexlt,y: lityeI' of t.hln<br />
fibrlno·purulent exudate<br />
a,t the base, mOre Jlquld<br />
than usual: fluid In the<br />
ventricles contained pus;<br />
pus oozed from the<br />
spinal canal.<br />
Lungs.<br />
Right base In a<br />
state of red<br />
hepo.tisatlon ;<br />
left base acutely<br />
congested.<br />
Liver.<br />
Congested; por<br />
. tal vessels con·<br />
tai ned bllhn.r·<br />
zia worms.<br />
Splccn.<br />
Dark and congested;<br />
~~mind<br />
Ing one of a<br />
typhoid speci·<br />
men.<br />
r' I '-; t ;. ~ ~ .<br />
Kidneys.<br />
Slightly con'<br />
gcsted.<br />
-~ ... ~... -.~- ..-.~-_._-<br />
intestines.<br />
Normal.<br />
Bact. Exam. et Hemark.<br />
Pus from the bose sholVerl<br />
. many menlngocol'cl: no<br />
pneumOCOl·CI.<br />
-'--'--'--' I I I 1------1------1 1-------<br />
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·<br />
i bique<br />
J1urulent exudate under flabby.<br />
on the right weighed 6 ozs.; sltlon com· present. I nation reeorded.<br />
the pia ma ter of the<br />
side. Implicat- con%ested and menced. 1-3'<br />
whole eonvexitj'. extend·<br />
Ing the whole<br />
frla le.<br />
Ing over the whole of<br />
right thoracic<br />
the brain Into the spinal<br />
cavity; a small<br />
~<br />
canal: It Sl}erially heavy<br />
plttell the size ' ; ..<br />
deposit at the base;<br />
of a five shilling , , . 1 t :""'1<br />
8<br />
'ventrieles dry.<br />
piece on the left<br />
~<br />
55<br />
I<br />
I1<br />
-1..---1....---1-,--I 1 I 1<br />
Mozam·1 26 yrB. "]i'ew hrs.1 WcU nouriBhed.<br />
blque<br />
56 1 Myam·<br />
baam<br />
, ,<br />
10 yrs.<br />
57 I Mozam-I 23 ~'rs.<br />
blQue<br />
1 day<br />
3 days<br />
WeU nourished.<br />
Fnirty well nOli·<br />
rishecl.<br />
A small ,91Ialltlt.y of yel<br />
10wlshL' green oliveeo1onre-Cl<br />
material under<br />
the pia mater oyer the<br />
convexit~';.no signs of<br />
anv pns or orgnni.ed<br />
clot at the base; ventricles<br />
dry.<br />
-'--'--1--1 I 1<br />
Normal.<br />
T.I'luld pns at the base.: I Normal.<br />
b oorl·staincd I}UB ooring<br />
fro III the spinal cunal.<br />
--'---,---,---1 I . -I 1--------<br />
A layer of fihrino·puru- 1 Kormal.<br />
lent exudate unner the<br />
pia mntcr of nearly the<br />
whole surface of the<br />
brain. with a very heavy<br />
orllanised clot at the<br />
bllse; vr-ntricles con·<br />
talned an excess of fluid<br />
with f1akcs of pur~lent<br />
mnterinl 8tl~pended in it.<br />
side; both lung .. , , .." ..... - - ... '0.' ... ........ -., ------ _... ~. .._-- ><br />
Mutely con- Z<br />
gested. verging<br />
on red hepatisation.<br />
-<br />
Very Mutely con- Hob-nailec1 clr- Much enlarged; Congested; Round worms Meningococci found in the<br />
gested, but not rhosls; portal weighed 3lbs. . calices dilated. present. ., fluid unrler the pia mater;<br />
reaching the vessels con· 100zs. no pneumococci.<br />
stage of red tnll)ed bilha rzla<br />
~,<br />
hepatis"tion. WOI;OlS.<br />
, ' . tJ<br />
.. H-<br />
I<br />
"<br />
0<br />
.- . :;.-<br />
t:"'<br />
-- ,<br />
<br />
~<br />
g-<br />
....<br />
I-'<br />
<br />
I-'<br />
I-'<br />
I-'
Post Mortem Examinations-continued.<br />
No. I Trlbe.<br />
Age.<br />
Duration<br />
of<br />
Sl~kness.<br />
Condition.<br />
of<br />
Body.<br />
Brain. Heart. Lungs. Liver. Spleen. Kidneys. Intestines. Bact. EXAm. & Remarks.<br />
-'---'---'.---\ I I I 1 1 I 1--------<br />
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·<br />
blque<br />
I<br />
pale grcen pus 'Inder the tlon to a slight acutely congested.<br />
and hod to.lncd bllhor- weighed 90zs.<br />
Intestine.<br />
vessels con- congested ;<br />
present In small Inatlon recorded.<br />
pia mater of the whole degree.<br />
of the cerebrum. extenl!<br />
a pecnllar dark zla worms.<br />
ing to the base. but not<br />
co Iouration .<br />
accumulated there more<br />
than in othcr ports. and<br />
not fibrlnous ; ventricles<br />
contained some pus. and<br />
there W08 PU8 oozi ng<br />
from the spinal canal.<br />
-'--I 1 r 1 I 1 I I I I 1-------<br />
60 I. QUJ\l- 25 yrs. I: Few hrs.1 Well nourished. Pia mater over cerebrum Normal. Normal. Acutely conaested.<br />
gested.<br />
Inatlon recorded.<br />
Conaested. Very acutely con·1 No notes kept. No bacterlololJlcal exam'<br />
mane I<br />
distended with fiuid;<br />
between the convolution<br />
a small amount of white<br />
material con Id be ileen.<br />
61 I Pondo<br />
40 yrs. I 2 days I Well nourished.<br />
of the Sl\,ITIO consistence as<br />
pus; small amount of<br />
fo~esa ~l~~e b~:~e:be~~~<br />
had peteehloo on the<br />
surface.<br />
nuro mater very flrml)'<br />
adherent to the skull:<br />
under the pia mater of<br />
the cerebrum was a<br />
quantity of milk)'<br />
COIOU! Buld: no deposit<br />
pus at the base;<br />
ventric es contained a<br />
small amount of olivecoloured<br />
Buid; a large<br />
amount or fluid come<br />
from the spinal canlll.<br />
Normal.<br />
Congested at IA peculiar green<br />
both bases. colour, but no<br />
evidences of<br />
P.M. decomposition.<br />
Acutely congested;<br />
of a<br />
very dark<br />
colour.<br />
Neither meningococci nor<br />
pneumococci were found<br />
in the pus at the base.<br />
-0--'---'--1 I 1 I I I I 1,-------<br />
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<br />
under the pia mater of<br />
congested.<br />
normal.<br />
meningococci were found<br />
the cerebrum: an ex·<br />
in the pus at the base.<br />
cesslve amount or fluid<br />
came from the 8pi nal<br />
cllnal. which was cloudy.<br />
possibly the result of<br />
pus; ventricles dry.<br />
-,--,--1--.1 1 1 I I I I I 1------<br />
63 I MozaID' I 26 yrs. 1 day 1Emaciated. Blood vessels on the convexity<br />
engorged wi th<br />
state of red he· vessels con- friable; weighed<br />
present In small the PIIS at the base. but<br />
Normal. Both bases In Pale; portal IEnlarged and I Conaested. Ankl'lostomes Streptococci were found In<br />
blque<br />
blood; an amount of<br />
patllatlon : talned bilharzia 120zs.<br />
Intestine. neither meningococci nor<br />
pus under the pia mater<br />
lungs generlllly worms.<br />
pneumococci could be<br />
of the cerebrum extend·<br />
congested.<br />
demonstrated.<br />
Ing on to the base.<br />
-,--,--1--1 1 I I I 1 1-----11--'-------<br />
64 I Mozam' I 27 yrs.<br />
blque<br />
10 day~1 Well nourished.<br />
> .. ~ .J, I , ,/;1,1 t' ..,_~.•"". I I ...·<br />
A quantltl' of PU8 under Normal.<br />
the pia ma·ter of the<br />
cerebrum, especially<br />
marked 011 the frontal<br />
region; large fibrinopurulent<br />
exudat.e at the<br />
base.<br />
Red hepatisation Much congested; I Congested.<br />
at both baaes ; portal vessels<br />
both lungs contained bil·<br />
generally congested.<br />
harzla worms.<br />
Normal.<br />
Congelted.<br />
I Normal.<br />
Numbers of<br />
ankyJostomes<br />
preaent In ,mall<br />
IntCltine.<br />
No menlngocooel were<br />
found In the pus at the<br />
bllle. but f.lr numbers<br />
of pneumoooccl.<br />
,....<br />
""" ~<br />
~<br />
8<br />
:d I><br />
r:J).<br />
POAt Mortem Examlnatlon5-cont/nued.<br />
No. I Tribe.<br />
1 AlIe.<br />
Duration<br />
of<br />
SlckneBB.<br />
Condition<br />
of<br />
Body.<br />
_'__1__1__1 1--------1 1 1 I I I 1-------<br />
65 1 Mozam- 1 26 YfI.<br />
blque<br />
S daYB 1 Fairly well nou-<br />
rlBhed.<br />
Brain.<br />
VeBBelB of the cortex engorlled<br />
wlth blood;<br />
whole of cerebrum under<br />
the pia mater bathed In<br />
yellow PUB, eBpeclally<br />
marked over the left<br />
frontal relllon; bMe of<br />
brain covered with pUB.<br />
ventricles full of pUB.<br />
Heart.<br />
Hypcrtrophled ;<br />
pericardium<br />
adherent to<br />
heart wall, the<br />
result of old<br />
perlcardltlB.<br />
Lunlll.<br />
LIver.<br />
PateheB of red 1 ConlleBted.<br />
hepatlBation at<br />
both bMeB.<br />
Spleen.<br />
KldneYI.<br />
Enlarged and I Conllelted.<br />
friable; welllhed<br />
Hozl.<br />
InteBtlnes.<br />
No notel.<br />
Bact. Exam. & Remarks.<br />
No menlnllococcl' were<br />
found In the pUI at the<br />
bue, but small numben<br />
. of pneumococci.<br />
_,__1__1__1 1 I 1 I I 1----<br />
ll6 1 Shangaan<br />
20 yn.<br />
13 dayB 1 Emaciated.<br />
Cerebrum WIlB quite clean.<br />
but at the baBe waa a<br />
thick. glory, fibrlno·<br />
purulent maBB extending<br />
Into the Bplnal canal;<br />
ventricles contained an<br />
exceBS of fiuld, but no<br />
PUI could be Been with<br />
l.he naked eye.<br />
Normal.<br />
A thin layer of pUB under 1 Flabby.<br />
the pia mater of the<br />
whole Burface of the<br />
brain. not particularly<br />
marked at thc baBe;<br />
ventrlcleB contained a<br />
Bmall quantity of blood-<br />
Btalncd fiuid.<br />
SignB of recent<br />
pleuriBY on both<br />
BldeB. more extensive<br />
on the<br />
rlllht; both<br />
baBeB acutely<br />
cOlIgested.<br />
":"ormal.<br />
CongcBted ; portal<br />
veBBelB contained<br />
bilharzia<br />
worms.<br />
CongeBted<br />
friable.<br />
Acutely congealed.<br />
Fine eirrhosiB; IConlleBted<br />
portal veBBels friable.<br />
contained bilharzia<br />
WormB.<br />
and I Normal.<br />
Round wormB<br />
preBent.<br />
Round WormB<br />
present.<br />
Few menlnllococci were<br />
found In the pUB at the<br />
bMe, no pneumococci.<br />
No meningococci were<br />
found In the PUB at the<br />
bMe, but large numben<br />
of pncumococci.<br />
-,--,--,--1 I I I 1 I I I 1------<br />
VeBsels of the convexity I Normal.<br />
congcstcd; pus under<br />
the pi a mater of the<br />
cercbrum; thick fibrinopurulent<br />
deposit under<br />
the base; ventricleB<br />
contained quantity of<br />
purulcnt fiuld.<br />
Right lung con- I Normal.<br />
geBted; baBe<br />
soU d ; left lung<br />
congestcd.<br />
and 1 Normal.<br />
-,--i--I--I 1---------1 I I I I 1-------<br />
671 Myambaam<br />
at the baBe was a slllall welghcd 15 oz. ly congeBted,<br />
and eonlleBted ;<br />
found In the pUB at the<br />
25 yn. 1 day I Poorly nourlBhed. Cerebrum WaB clean, but Hypertrophied; Both baseB acute<br />
Normal. Much cDJarlled 1 CongeBted. No noteB. No meningococci were<br />
glary exudate. with ri<br />
verging on a<br />
welllhed 1 lb.<br />
bale, but a few pneumococci.<br />
whltiBh noduln.r maBB<br />
Btate of rcd<br />
50ZB.<br />
about Blze of a lentil, In<br />
hcpatisation.<br />
Bome way reBembling a<br />
tuburculouB nodule.<br />
_,__,__,__1 1 1 1 I 1 1 1 1-------<br />
68<br />
69 I Myambaam<br />
31 YfI.<br />
8 dayB I Emaciated.<br />
30 yrs. 1 4 daYB 1 Fairly well nourlBhcd.<br />
CongeBted.<br />
Normal.<br />
l\{enlngococci werC present<br />
In fair numben In the<br />
PUB from the brain ; the<br />
pneumOCOCCUB waB not<br />
found.<br />
_,__1__'1__1 1 I 1 I I- 1 I 1-------<br />
70 1 Myambaam<br />
25 yrs. ' 1 5 dILYB Fairly well nou'<br />
riBhed.<br />
VeBBelB of the convexity I NormlLl.<br />
congeBted; pUB under<br />
the pia mater of cerebrum;<br />
thick fibrinopurulent<br />
ex,udate under<br />
the baBe; ventricles full<br />
of pUB.<br />
Both lungs con- ICongeBted; bB- I Congested.<br />
gCBted. harziIL worms<br />
in the portal<br />
veBBelB.<br />
ConlleBted. Normal. lIfenlngococci were preBent<br />
In fair numben In the<br />
PUB from the brain; the<br />
pneumococcus waB not<br />
found.<br />
-,--,--1 I : I I 1 1 I I 1<br />
71 Mozambique<br />
20 yn. 4 daYB Well developed. VeBBels congeBted; pus<br />
under pia mater of cerebrum<br />
; thi n layer of pus<br />
under the cerebellum<br />
and pons; ventricles<br />
filled with purulent fluid.<br />
Normal. Right Dormal;<br />
left acutely con·<br />
geBted, verging<br />
on red hepatlsaatlon<br />
iu partB.<br />
ClrrhoslB corn<br />
. meDclog; bllharzlIL<br />
wormB<br />
preBent.<br />
Enlarged and<br />
congested.<br />
Congested; two<br />
Bmall CYBts in<br />
the right kidney<br />
Normal; anky<br />
10BtomeB<br />
preBent.<br />
A few meningococci were<br />
preBent in the smeILrB<br />
from thiB braIn; the<br />
pneumococcuB was not<br />
found. The pneumococ<br />
CUB WM found In the lung<br />
In this case.<br />
~'<br />
(')<br />
et><br />
8<br />
g'<br />
.'"1<br />
,...<br />
q;j<br />
o .<br />
:--'<br />
~'<br />
~<br />
;><br />
,...<br />
Cl'
Post Mortem Examinations-continued.<br />
.... .....<br />
~<br />
No. I TrIbe.<br />
Age.<br />
Duration<br />
of<br />
Sickness.<br />
ConditIon<br />
of<br />
Body.<br />
Brain. Heart. Lungs. Liver. Rpleen. Kidneys. Intestines. I J3act. Exaui. <br />
rn<br />
~<br />
~<br />
t:'l<br />
I;:)<br />
Cl><br />
a<br />
CD<br />
S g"<br />
,....<br />
....<br />
;g<br />
~
Post Mortem Examinations-continued.<br />
No. I Tribe.<br />
DurlV<br />
pneumococci. but neither<br />
011 ve·colonr~d\lellttl nO'JS<br />
Itv was about<br />
the men! nJ:!ococel nor<br />
ml>terlal : under the bl>SC<br />
two pints of<br />
other bll. Pneumococci were present.<br />
mane<br />
jaundiced. congosted: sm,,1I amount<br />
tilor",,; right<br />
1 lb.<br />
cystl c degeneration;<br />
lelt<br />
but the meningococcus<br />
nus under the nia mltter.<br />
of pnrlllent e"lldat~<br />
lung. lower and<br />
under the base.<br />
middle lobes In<br />
normal.<br />
was not found.<br />
.tate of grey<br />
hepatisation;<br />
".<br />
left lung. ba.e<br />
congested.<br />
otherWise nor·<br />
:'<br />
mal.<br />
--,--,--1 I I I I I I I<br />
82 Shangaan<br />
gested; thick deposit of<br />
left \ ery a.cnte cap'ule t··,irk<br />
gested.<br />
lostomes and mat.er showed IIood num<br />
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<br />
pus In the flssure. under<br />
I~' cc>nge.ted at ened : bllhlp.nt<br />
hemispheres of the cerebrum<br />
: no exudltte<br />
patls.tlon. vessel•.<br />
ollng Welchselbaum's<br />
under the base: ventricles<br />
contained blood·<br />
upon blood-agar.<br />
organism was obtained<br />
stained and purulent fluid.<br />
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Post Mortem Examinations-continued.<br />
~<br />
~<br />
0:><br />
No. I Tribe.<br />
Ago.<br />
Duratl"n<br />
of<br />
Slckncs•.<br />
Conelltlon<br />
of<br />
Body.<br />
Rraln. Heart. Lungs. Liver. Splcen, Kidneys. Jutestlnes. Bl\Ct. F.:tam. It' Rrmark•.<br />
83<br />
84<br />
Vessels on cortex acut.ely<br />
conllested; no nnked<br />
e~'e nppearnnce of pus<br />
under the pin mat.er:<br />
ventricles contn' ned<br />
blood-stained serum.<br />
Normal.<br />
Norma.!.<br />
Extensive recent<br />
pleurisy over<br />
the whole of<br />
bot.h sides of<br />
the thornx:<br />
right lung solid<br />
nt the base between<br />
the red<br />
and the grey<br />
stage of hepa.<br />
tisntlon: left<br />
lunll, whole lung<br />
solid nenrly into<br />
the grey st.age.<br />
more advanced<br />
thnn the right<br />
base.<br />
Extensve pleurisy<br />
on both<br />
sleles ; right<br />
lung, whole<br />
orllan, except<br />
for a sma 11 part<br />
the size. of an<br />
orgnnge at the<br />
apex ,solid with<br />
grey hepntisatlon<br />
; left lung,<br />
Rmnll patch of<br />
very acute congestion<br />
at the<br />
base.<br />
Normal; bilha.rzla<br />
worms In<br />
the portal vesscl•.<br />
Normal: bilharzin.<br />
worms in<br />
the portal vesscls.<br />
Thl. bo)' had stllfness of<br />
the ncck, with Kernlll's<br />
sllln,anel vomltlnll elmlnll<br />
life, as well as the nhyslcnl<br />
-illDS of cOlIsollelntlon<br />
of both bases, yet<br />
po-t mortem examlnntlon<br />
showed no slllns of<br />
meningitis.<br />
Pneumococci werc present<br />
in fair nllmbcrs In the<br />
cerebral fluid, but the<br />
meningococci were not<br />
found: this patient dur<br />
Ing life hn.d Kcrnlg's sign<br />
well marked, bu t there<br />
was no stiffness of the<br />
neck.<br />
-'--,--1--1 I I I I i 'I 1------<br />
85<br />
Shangaan<br />
Quillmane<br />
Fal rly well nourished.<br />
25 yr•.<br />
27 yrs':<br />
ltJozam-I 24 yrs.<br />
blque<br />
6 days<br />
6 days<br />
4 days<br />
Poorly<br />
rished.<br />
Wcll<br />
nou-<br />
nourished.<br />
Brnln Bubsta,nce normnl :<br />
no na.ked rye evidence<br />
of meningitis.<br />
VesRels on cortex engorgedI Norma·l.<br />
with blood; whole of<br />
both hemispheres of<br />
cereb4'um under pia<br />
matfr bathed In pus; a<br />
thick. almost whitecoloured<br />
ftbrlno-purulent<br />
exudate unrler the base;<br />
vcnt.ricle. contained a<br />
ounntity of purulent<br />
ftuld.<br />
Right, patch of<br />
dark red hepatisation<br />
n,t the<br />
base; Icft normal.<br />
Normal: bilharzia<br />
WormR In<br />
the portal vessels.<br />
Normal.<br />
Acutely<br />
gested.<br />
Normal.<br />
con-<br />
Conllested.<br />
-,--,--,--1 I ! I : I I I I<br />
Congested.<br />
Congested.<br />
Normal.<br />
Congested<br />
patches.<br />
In<br />
Normal:<br />
ankylostomes<br />
present.<br />
Menlngocoecl wero present<br />
In good numbcrs In the<br />
pus under the pia mnter.<br />
but the pneumococcus<br />
was not found.<br />
-,-----!--I 1 I I I I 1-----<br />
86 Mozambiqur<br />
25 yrs. 13 days I Well nourished. Drniu anEl'mie: Rurface I Normal.<br />
of bOUl hemisphere9 of<br />
e.erebrum uniformly<br />
covered with a thin layer<br />
or pllle. almo.t. white PUg<br />
uneler the pin mater; no<br />
evldencf or allY exudate<br />
under the bllse: ventrlole.<br />
contained n small<br />
Quantity of blood-sta.ined<br />
"crltm.<br />
Right lower lobe<br />
solid wit.h grey<br />
hepntisation ;<br />
upper and midd<br />
le lobes congested:<br />
left<br />
lung congested<br />
at the base.<br />
verging on red<br />
t'epatlsatlon.<br />
Kormal ; bilharzia<br />
worms in<br />
the porta.] ve'ssels.<br />
Normal.<br />
Acutely<br />
gested:<br />
con-<br />
Normal:<br />
ankylostomes<br />
present.<br />
Pneumococci were present<br />
In good numbers in the<br />
pus under the pia mater,<br />
but the meningococcus<br />
was not found.<br />
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Post Mortem Examlnatlons......:ci)ntinued.<br />
Durllt!oo<br />
CondJtlon<br />
No. rrlbe. Age. of 01 Brain. Heart. Lung8. Liver. Spleen. KldneY8. Inte8tlnes Bact. Exam. & Remark8.<br />
Sickness. Body.<br />
-- -'"'---------------------------------------<br />
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·<br />
blquc rished. meningiti8. recent pleuri8Y normal. ankylostome8 terlal under the pia mutpr<br />
"<br />
at both base8 ; present. rendered bacteriological<br />
right lung,ba8e<br />
examination unnercssary.<br />
solid with grey . bnt thl8 1'IItipnt hnd<br />
, hepatisation, Kernig's sign dllrlng life :<br />
and the sub· death resulted from pul·<br />
stance riddled<br />
monary tuberculosi8 of a<br />
wi th tuberoular<br />
very ncute form.<br />
nodule8 about<br />
the size of a<br />
split pea; left :<br />
lung, whole substance<br />
occupied<br />
hy number or<br />
small, very recent<br />
tubercular<br />
nodules,In80me<br />
cases commenc·<br />
Ing to caseate;<br />
.. nn ab8cess<br />
about the si zo<br />
01 a naartje at<br />
Ing lIuid.<br />
---------------------- ----------------<br />
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<br />
blque rl8hed. under the pia mater 01 18Y on the right ankylo8tome8 fair numbcrs In the pU8<br />
both hemlsphere8 01 the 81c!e; right lung prescnt. uncler the pin mater;<br />
cerebrum was a thin thick c1eposl t 01 the meningococcuR was<br />
layer of .white pus, lymph on thc not found; thl8 patent<br />
especlal1y marked In the posterior Bur- 8howed no symptom8 0 f<br />
fls8ures; no deposit at Ince, and the meningitis during life.<br />
the base; \'Ontricles base solid with<br />
_.<br />
showed naked eye a,p- hcpatlsl\tion 01<br />
pearunce 01 pus. a dirty grey<br />
colour. bet,vcen<br />
the red and<br />
grcy stage; lclt<br />
tho posterior<br />
and npper sur-<br />
Il\ce 0 tM lower<br />
lobe, filled with<br />
l\ Cluantlty or<br />
grumous·look-<br />
luug, base acutcly congcsted.<br />
not con·<br />
I<br />
solidated.<br />
I<br />
---------------------- --------<br />
89 Quli- 29 yrs. 7 days Emaciated. Vessels 01 the cor~ex con- Normal. Right, upper and Normal. Fibrous. INormal. Normal. Menlnllorocrl were ~resent<br />
mane gested ; small amount middle lobes In the pus under he pia<br />
01 ])lIle yellow ])UB in the congested, mater: the poeumofissures<br />
01 both hemi- lower lobe in a coccus WII' not found.<br />
spheres 01 the cerebrum; state of grel'<br />
11 thick flbrlno-purulent he~atlsation ;<br />
exudate under the base.<br />
lef , on surface<br />
principally confined to of base were<br />
the medulla; lateral ven- several darktricles<br />
contained fluid colourcd .acutemixed<br />
with purulent Iy congested<br />
material. looking spots,<br />
, which section<br />
. .<br />
showed theY<br />
."<br />
were caused by<br />
localised<br />
patehes of very<br />
, acute red hepat1sntlon.<br />
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118 THE TRANSVAAL <strong>MEDICAL</strong> JoUR AL. December, ISO".<br />
sourH <strong>AFRICAN</strong> J~EOICAL CONORESS, 1907.<br />
SPEI,;IAL SUBJECTS SECTIO'4.<br />
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By N. A.<br />
Death by Lightning-Stroke.<br />
SPENCER, L.R.C P. (Lond.\ M.R.C.S. (Eng.),<br />
District Surgeon, Mlddelburg, Transvaal.<br />
In a country vi ited during six months of every<br />
year by violent thunderstorms, sometimes tropical<br />
in their intensity, it would be extraordinary if cases<br />
of lightning-stroke did not occur at times, and<br />
almost every medical mn,n in the Transvaal mll;;l<br />
have seen such cases. Yet, owing to most of the<br />
records of these cases having been derived from<br />
laymen and not from trained observers of detail, as<br />
arc medical men, we still await a clear and ..;att:<br />
gorical de cription, let alone an explanation, of the<br />
injuries caused to man by atmospheric electricity.<br />
In searching through medical works at disposal,<br />
one is struck by the absence of mention of anyone<br />
condition as characteristic of these injuries; onc<br />
wades through a maze of "reported" conditions<br />
without meeting with a single peg on which to hang<br />
anything definite. There can be no doubt that,<br />
from a medico-legal point of view, these injuries are<br />
still contradictory, equivocal and shrouded in<br />
mystery to such a degree as to produce confusion of<br />
thought, when something definite is sought, rather<br />
than orderliness of mind; far too many" facts which<br />
have not been sustained" are included in these<br />
descriptions, one author stating that" there are no<br />
n,bsolute and constant indications of death by electricity.".<br />
.<br />
It needs no excuse, therefore, to give prominence<br />
to a subject requiring so much elucidation, and to<br />
discuss it even in detail in the light of some of the<br />
cases met with during the last seven years. It has<br />
fallen to my lot during this time to see a good many<br />
cases of death or injury from lightning, all of which<br />
have shewn such very definite evidences of what I<br />
now consider to be characteristic of the condition<br />
that, were I requested to examine a. body lying dead<br />
upon the veld in summer-time, I should look for<br />
these signs at once, and first, and were they present<br />
I should have no hesitation in swearing to death<br />
being due to this cause. The forms taken by<br />
lightning when it comes to earth-the well-known<br />
flash and the most extraordinary" fireball "-with<br />
their varied effects upon the material struck, form<br />
an absorbing study, often at variance with what we<br />
have learnt of the movements of electricitv. and not<br />
always capable of ready explanation. in reading<br />
some scores of instances of the effects of lightning<br />
upon edifices, human beings and animals in abookt<br />
recently lent me by the Director of the Transva::d<br />
Meteorological Department, the vagaries of atmospheric<br />
electricity, and variety of effect. filled me with<br />
amazement. It is generally accepted that what we<br />
know as lightning is ~enerated both from the earth<br />
and the thunder cloud. The earth being electrified<br />
-it is suggested by the fTiction of its mtation in the<br />
atmo pbere, its internal heat, etc.-that electricity<br />
will be split up into its positive and negative elements<br />
* Cantell's Post Mortem Pathology, p. 413.<br />
t .. Thunder and Lightning," by Camille F1ammarion, translated by<br />
Waiter Mostyn and published by Chatto and Windus, 1905.
December, 1907. THE 'rRA SVAAL MEDlCAL JOUR Al.. 119<br />
by the near approach to the earth's surface of one of<br />
the elements opposite to it; that thunder clouds<br />
being also electnfied-by their motion, the heat,<br />
the friction of wind currents, etc.-form close to the<br />
earth's sudace, and as they move above it, attract<br />
the opposite electricity of the earth, \,:hich follows<br />
it below, only awaiting an opportumty of neal:<br />
approach to unite with a flash and a crash of<br />
thunder. \Ve can imagine, for instance, a thunder<br />
cloud moving above and clo e to the eart~'s sUl'~ace,<br />
charged in that part nearest the earth with positive<br />
electricity and the negative electricity, attracted by<br />
it, following the cloud upon the eartl~'s surface; thiS<br />
negative element meets with a kop]e, a steeple, .a<br />
tree or even a man standing upright, runs up it<br />
towards the opposite element in the cloud and the<br />
circuit is complete, lightning leaps from the cloud<br />
and is conducted to earth by the medium. With<br />
the cause of the noise which accompanies this connection<br />
and discharge, known as thunder, we are not<br />
here concerned, .but we know that the course of the<br />
electric fluid becomes visible to us by reason of the<br />
air through which it passes being raised to the point<br />
of incandescence.<br />
When lightning meets the body of a man, i~ is<br />
usually conducted by his skin to the earth., teanng<br />
off his clothes and even his boots by rendmg them<br />
open immediately over .its course down his body<br />
and flinging them to a distance. Appa!ently w~en<br />
a man is struck indirectly, by the lightmng glancmg<br />
off a tree to his body "for instance, he may be hurl~d<br />
away some yards, he in one direction, his clothes.m<br />
another; but when struck directly he usually mamtains<br />
his position, and may continue to stand even,<br />
for some moments, before he falls.<br />
It seems to be in cases of a direct stroke that the<br />
very severe injuries sometimes described are seen.<br />
A case is recorded* of a man who was struck on the<br />
head and a large lacerated wound ~n th~ scalp produced,<br />
without fracture. The lightnmg passed<br />
down between the tissues and the bone as far as the<br />
root of the neck on each side and then came to the<br />
surface. In all such cases when the lightning gains<br />
admission to the body it comes to the surface quickly,<br />
doing much damage previously., and it is evident that<br />
the tissues offer very great resista1?ce to the. c.onduction<br />
of the electric fluid. Ranks, m determmmg the<br />
relative conducting power of living. muscle in ref~rence<br />
to electricity concluded that it was three million<br />
times less tha~ mercury and fifteen million times<br />
less than copper. .<br />
There is little doubt that the skm of the body<br />
offers the most suitable medium for conduction ~f<br />
the electricity, and I think that those parts of it<br />
usually moist with perspiration conduct I?ost<br />
readily, e.g., the inner surface of the arms, thighs<br />
and legs, the middle lines of the back and th~rax<br />
in front, the sides of the thorax and the vanous<br />
natural folds and flexures of the body. The track<br />
of the electric fluid over the body can easily be<br />
traced, presenting such an extraordinary appear~n~e<br />
that once seen it will never be forgotten; and it is<br />
this track of the lightning, wherever.it. tou.ches the<br />
skin which I consider absolutely distmctive and<br />
char~cteristic of this form of injury. It. consists. of<br />
an arborescent branching and re-branchmg reddish<br />
.. Taylor's Medical Jurisprudence, Vol. 2, 4th edition, pp. 131 and 132'<br />
streak which become finer as it descends the body;<br />
as broad as a finger or a lead pencil above, it thins<br />
off to the finest thr ad. The branching is often<br />
wonderful, and reminds one of the distnbution of<br />
the superficial blood ve sels of the skin, thrown into<br />
view by an injection of them. 1\ly own opinion is<br />
that this is the case; that the superficial blood vesel<br />
of the skin in ·tantly dilate to their utmo t, the<br />
blood conducting the electric fluid; tha,t the<br />
haemoglobin of the corpuscles is set free and tain<br />
the skin in the track of the .lightning. rl~is is<br />
exactly the appearance produced in the arbore cent<br />
streak and in all its branches, rather than, as is<br />
u ualIy described, " an appearance of burning." It<br />
is this peculiar distribution of the streak upon thc<br />
skin which has gi\"en rise to so many records of the<br />
likeness of neighbouring trees, foliage, ferns, etc.,<br />
having been " reproduced" or "accurately<br />
delineated" upon tho e struck by lightning. Yet<br />
when seen it would really require but little imagination<br />
to conceive this a fact. The first time I saw<br />
this red arborescent streak it i'eminded me of the<br />
injected vessels of a subject in the dissecting room,<br />
and I notice amongst the cases of lightning-stroke<br />
described by Flammarion that, in connection with<br />
the skin appearances, mention is made of this similarity<br />
by others, which lends some weight to the<br />
opinion set forth above as to the cause of these<br />
markings.<br />
In those 'Yho survive li.ghtning- troke these stre~ks<br />
fade away m a re", day , leavlllg no mark; whiCh<br />
would not be the case if they "ere due to a burn.<br />
\Vhen seen after death these ·streaks are brown, and<br />
in the skin of the native are usually some tints<br />
darker than the contiguou skin.<br />
As already mentioned, these red streaks are<br />
generally referred to as "burns," but against this<br />
is the constantly recorded fact that tbe clothes of<br />
the person struck, though rent from the body, are<br />
neither burnt nor singed, whilst in those cases wh re<br />
burning is recorded it is invariably mentioned to<br />
have occurred in connection with some metallic substance,<br />
worn or carried in a pocket. Thus-the<br />
half of a man's head had the hair singed off beneath<br />
the buckle of his hat, the hat burnt immediately<br />
around it and the buckle fused; a man wearing a<br />
belt with a buckle to it " was severely burnt on the<br />
abdomen, over a space the size of a hand " immediately<br />
beneath the buckle, and his shirt over this<br />
area was also burnt; others have been burnt beneath<br />
watches carried in the wai tcoat pocket and money<br />
in he trouser pocket, whilst still others have been<br />
burnt beneath metal buttons on their clothes. In<br />
all cases the clothes contiguous were burnt, and the<br />
metal substance responsible for the burning partially<br />
or completely fused. I hink, therefore, that we<br />
may say that licrhtning only burns the human body<br />
when it meets in its cour e some metallic object. It<br />
may be tha upon further investigation of this<br />
matter, thatched roof , hay ricks and other objects<br />
burnt as the result of lightning-stroke will be found<br />
to owe their ignition to he presence of metallic substane<br />
s, though re istance to conduction may play<br />
an important part.<br />
A " smell of burning" is often referred to in connection<br />
with the lightning-stroke, although no<br />
evidences of burning or singeing exists uEon the
120 i'ltE 'rRANSVAA1.. ME.blCAL JOURNAl.. December, 1907.<br />
clothes of the person struck; also in connection with<br />
\\oodwork which was struck and \ hich was" split<br />
and splint red in every direction without a sign of<br />
buming upon it." This is no doubt due to the<br />
ozone generated in the air by the fla h, and also to<br />
the various substances rendered incandescent in the<br />
air; this smell is, however, characteristic and<br />
invariably present for some time after the flash, and<br />
is often referred to by those in its immediate<br />
vicinity as " the smell of an explosion." The rent<br />
made in the clothes of those struck by lightning also<br />
bas its characteristics. As stated, it occurs immediately<br />
over and corre ponds with the red streaks on<br />
the body. vVhen examined, it has the appearance<br />
of having been caused by a blunt edged in trument,<br />
to have been violently burst open from within, the<br />
cdg s as a rule showing no singeing.<br />
In the Royal College of Surgeons' :Museum,<br />
London, is to be seen a hat, dothes, shirt, stockings,<br />
garters and boots of a man struck by lightning whilst<br />
sheltering beneath a tree. The rents are characteristic<br />
and shew no singeing of the finest threads;<br />
the boots, of thick leather, burst open down the<br />
back as with great violence by a blunt-edged instrument.<br />
The history records that he was flung out<br />
of his clothes some yards away; and as far as I<br />
remember, though badly "bmnt," i.e., marked,<br />
and unconscious for some time, he ultimately<br />
recovered.<br />
Amongst the more severe injmies described as<br />
caused by lightning strokes are :-¥(1) "Lacerated<br />
and punctured wounds, as though with a blunt<br />
dagger," of entrance and exit, in the head-generally<br />
without singeing. of the hair at their edges. Fracture<br />
of the cranial bones with conversion of the brain<br />
"into pulp" and into "a liquid mass"; a large<br />
wound of the thigh exposing the femoral artery;<br />
haematomata at the point of impact severe contusions<br />
and extravasations, rupture of blood vessels<br />
even to "splitting of the body into two parts."<br />
(2) These injmies might give rise to great difficulty<br />
in inferring the cause of death, but I think that were<br />
such cases carefully examined by a medical man<br />
acquainted with the subject, the red streaks would<br />
be found in evidence somewhere, as the electric fluid<br />
travels so short a distance in the tissues and comes<br />
to the smface really at the first opportunity, to continue<br />
its course to earth by means of the skin surface;<br />
but, never having seen such a case, I am only<br />
able to draw attention to their recorded existence<br />
·ometimes. The results of lightning-stroke upon<br />
the interior of the body requires much elucidating<br />
and recording of cases. Some say that the blood<br />
does not coagulate in these cases, also that" rigormortis<br />
is absent in them," but these are amongst<br />
" the facts not as yet substantiated." A condition<br />
which I have generally found, and which may be<br />
i1istinctive in this form of death, is an empty :).(Jl1<br />
firmly contracted heart, especially the left ventricl~.<br />
with a congestion of the lungs, as though c3:11sed<br />
by a spasmodic contraction of the heart at the<br />
moment of being struck, forcing its contents into<br />
the pulmonary and other vessels and not being followed<br />
by a relaxation of this organ.<br />
* (1) Flammarion'e 11 Tbunder and Li~btning" and Taylor'e<br />
,. Jurisprudence."<br />
t (2) FIammarion.<br />
In those who sUTvive, a condition of profound concussion<br />
is produced, minor conditions of confusion<br />
of mind, tingling of the extremities and temporary<br />
paralysis, or weakness only of the limbs. But<br />
death from lightning-stroke is instantaneous, and is<br />
due to shock to the brain and nervous system.<br />
The first experience I ever had of the effects upon<br />
man of lightning-stroke occUlTed in September, 1900,<br />
near the Valsch River Bridge, in the a.R.c. Two<br />
other civil surgeons and myself were under canvas<br />
about 100 yards away from the camp of the Highland<br />
Brigade. The sky had been overcast for an bour<br />
or more, ,vith dark thunder clouds, and a heavj'<br />
thunderstorm was momentarily expected, the first<br />
of the season. Hearing a few heavy rain-drops fall<br />
upon the canvas, I knelt up to the tent wall to iet<br />
down the flies, and was so occupied, facing toward;~<br />
the camp, when a sudden fl3..,h of lightning can'f~<br />
to earth a little distance away and straight in front<br />
of me. It was so vivid that I could see, though<br />
indistinctly, through the thick canvas in front of<br />
me, as though it had been of gauze; saw the flash<br />
fall amongst a group of soldiers on the outskirts of<br />
the camp, and the men falling and scattering, as if<br />
they had been hurled away.' It was but a momentary<br />
glimpse dispelled, almost on the instant, by u.<br />
terrific crash of thunder. Running up to the spot,<br />
I found a sergeant of one of the Highland regiments<br />
struck dead and lying upon the ground·; near him<br />
lay a private, motionless and apparently dead;<br />
whilst, rolling about on the ground, groaning as<br />
though in great pain, or sitting up on the ground<br />
rubbing various parts of their bodies and limbs, were<br />
nearly a score of men, all more or less affect~d hy'<br />
that one flash. Hastily examining the sergeant, ]<br />
found, only some three minutes since he was struck,<br />
not the faintest flicker at the heart, nor any respiratory<br />
movement. To describe his injuries :-First, I<br />
found the hair singed off the left side of his head;<br />
his soft felt hat, which lay some six yards away,<br />
was rent and scorched on the left side of the crown,<br />
around a metal badge which had been pinned thtlre,<br />
but which had fallen out. The hat smelt strongly<br />
of singed hair, and I should have remal'ked that the<br />
neighbomhood smelt of " lightning," at one moment<br />
reminding one of exploded gunpowder, at another of<br />
a smith's forge. From the left side of the head a<br />
red arborescent streak, as broad as a finger, ran down<br />
to the shoulder, and, dividing there, proceeded<br />
obliquely across the chest in front to the right side,<br />
down the inside of that thigh to the inner side of<br />
the leg, and so to the ground; whilst on the back it<br />
ran down the middle line, by the gluteal fold, to the<br />
scrotum and inner side of the left thigh and leg to<br />
the ground. The remnants of the man's uniform,<br />
stockings and boots, were scattered arouhd a few<br />
yards away, and had been rent in lines corresponding<br />
~ith the tracks of the electric fl uid upon his body.<br />
There was no wound or contusion visible anywhere.<br />
o po t-mortem of the body was made, and it was<br />
buried a few hours later. The private, who was<br />
apparently dead on my arrival, ha:d ~omm~nced .to<br />
!!Toan by the time that I reached hlS sIde, hIS pupils<br />
~ere widely dilated but insensible to touch or light,<br />
and his breathing very slow and shallow; he was<br />
removed at once to the Field Hospital, where he<br />
recovered consciousness in a few hours, had a head-
December, 1907. THE TRA VAAL <strong>MEDICAL</strong> JOURNAL. 121<br />
ache next day, and was on duty on the fOUl'th day.<br />
'l'he r maining men had all experienced a shock<br />
more or I ss severe, some were still dazed and stup <br />
lied, others felt" smarting" or " tingling" sensations<br />
about their bodies and limbs, which they soon<br />
"rubbed out of them"; all these completely<br />
recovered in an hoUl' or so. When the sergeant was<br />
struck, he was standing leaning upon his rifle, the<br />
bayonet being fixed, ith his head and shoulders<br />
bent, talking to a man sitting in a blanket bivouac<br />
at his feet. The man to whom he was talking told<br />
me that it seemed as though he and his rifle were<br />
enveloped in lightmng for an instant, that he uttered<br />
no sound, and fell after standing rigid for an appreciable<br />
time after being struck; he described "the<br />
rush" of the lightning, and it was he who drew my<br />
attention to the smell of it. The rifle was flung<br />
from the sergeant's hands and fell against the<br />
bivouac. I greatly regret that I did not think of<br />
asking for and examining it. The man in the<br />
bivouac, who was sitting on blankets, seemed to be<br />
the only one for some distance around who felt not<br />
the slightest touch of the electricity.<br />
'<br />
In 1901, during the summer months, in one of the<br />
tents of the Burgher Camp, Middelburg, a man,<br />
occupying a tent by himself (he was an epileptic),<br />
was found dead one morning, the clothes ripped off<br />
him, and lying beneath his body. A rent at the<br />
point of the tent showed where the lightning hacl<br />
penetrated to reach the pole, from which it had probably<br />
glanced off on to the left shoulder of the man.<br />
An arborescent streak, starting here, ran down the<br />
left arm to the finger tips, down, from the axilia,<br />
the left side of the thorax, the inner (per the gluteal<br />
fold) and outer side of the thigh, and uniting again<br />
in the popliteal space down the back of the leg and <br />
heel to the ground. The boot of that foot was<br />
burst open behind, and had evidently been fhmg<br />
off the foot. The clothes showed the characteristic<br />
rending, corresponding to the tracks of the lightning.<br />
There was no singeing of the hair upon the man's<br />
body, nor of the clothes. nor were the edges of the<br />
hole in the top of the tent in the least singed.<br />
In the following year in the same camp, a tent, in<br />
\ hich 16 men and women were gathered at a prayermeeting,<br />
was struck by lightning, as before, through<br />
the canvas at its point. Rain had not fallell for<br />
some months, but had been threatening for some<br />
hours, a time, well known to the inmates of the tent,<br />
specially fraught with danger from lightning. The<br />
man who was praying held the ten pole with his<br />
right hand, the elbow being flexed, and against his<br />
elbow a woman leant her chest. All the occnpants<br />
were more or less in contact with each other and<br />
the canvas of the tent. A flash of lightning strnck<br />
the point of the tent, rent a hole in the canvas and<br />
ran down the pole; it ran along the man's arm, who<br />
held the pole, to his elbow, and was so conducted<br />
to the breast of the woman leaning against him; she<br />
was stnlck dead. The man's coat sleeve was stripped<br />
to the elbow, and his arm showed a broad red streak<br />
so far, but nowhere else on his body. The woman<br />
had her clothes rent from her body over the red<br />
streak, whieh lit rally starred her chest and ran<br />
clown each side of her body and legs to the feet. t<br />
her neck was a burn about 2in. x 3in., where a<br />
brooch with a metal back had been worn. Everyone<br />
in the tent was more or le aff cted, and 1 think no<br />
le han live howed the characteristics of having<br />
b en touched by the lightning. It wa reported to<br />
me that most of them were " undre sed " by the<br />
lightmng. Most of these cases were well in a few<br />
days. 0 post-mor em examination was held upon<br />
the woman killed. The hole through the top of the<br />
tent showed no singeing or burning-in fact, in the<br />
Burgher Camp in l\1iddelburg, which at olle time<br />
tl:umbered 8,000 people, tents were on many oeca-<br />
~ons struc~ by lightning, though, with the exceptIOns<br />
mentIOned, they were empty; and in one's<br />
round through the camp day by day it was no<br />
unusual thing to ee tent with characteristic holes<br />
at the point caused by lightning, but never was a<br />
tent set on lire, nor did 1 ever observe singeing of<br />
the edges of the tent. I regret that my time did<br />
not admit, in tho e days of careful notes being made<br />
of these cases of lightning- troke. A detailed<br />
description of the damage done would have been<br />
better than merely the memory of them.<br />
In September, 1903, a native employee of the local<br />
~epatria~ion Depot wa ba hing and wa hing clothes<br />
10 the nver about 300 yards from his compound.<br />
From the accounts of those with him, they were<br />
overtaken by a very heavy thunderstorm, and<br />
" Titus" seems to have dropped behind the rest<br />
in racing back to the compound; but he was seen to<br />
be running back naked except for a cloth round his<br />
waist, when he was s ruck dead by a flash of<br />
lightning. He had been struck upon the right side<br />
of the head, and the streak ran down the side of the<br />
body upon which the rain was beating in a most<br />
marked manner. 0 peculiarly dis ributed was this<br />
arborescent streak that I took one of the boys who<br />
had reached the compound in time back to the spot,<br />
and got him to show me the position of the boy<br />
killed and the dir ction of the beating storm. It<br />
was then easy to sce that the side to\\n.rd the rain<br />
had conducted the electric fluid to the ground, and<br />
it had avoided the inn r and protected ides of he<br />
body and limbs. My notes upon the post-mortem<br />
examination state that the lungs were "engorged<br />
n.nd congested," the heart being empty of blood and<br />
the left ventricle "firmly contracted," and that<br />
"death wa attributed to shock resulting from<br />
lightning stroke." There were no other external<br />
or internal injuries or disease with the exception of<br />
those described. nfortunately the cranium was<br />
not examined.<br />
In March, 190~, I was regue t d by the R.M.<br />
to examine the body of a Zulu woman, who was<br />
reported to have been struck by lightning the da<br />
before and killcd, just out ide the town. She had<br />
been standing upright in a square thatched hut,<br />
when the lightning struck through the thatch just<br />
above her and killed h l' in tantly. The thatch was<br />
s t alight and the hut burnt down by the flash.<br />
My notes upon the case say :-A brown arborescent<br />
streak (darker than the woman's skin and easily<br />
traced), nearly an inch broad where i began on the<br />
right side of the head, desc nd d over the sid of th<br />
face, across the side of the neck. to the IlPP r border<br />
of th sternum; it then descend d the mirldlc line to<br />
the left of the umbilicu. , acro. the middle of POIlpart'!'!<br />
ligament to the inner sid of the left thigh,<br />
behind th knee and down the inner surface of the
122 THE TRA SVA L <strong>MEDICAL</strong> JOUR AL. December, 1907.<br />
leg to the instep of the foot. Where the streak<br />
pas ed between the breasts, which were prominent,<br />
a streak ran outwards to the tip of each nipple and<br />
no further, making a perfect cro s on her body. 1<br />
should add that the woman was nursing a child only<br />
a few weeks old, but had put the child away in a bed<br />
near by shortly before the torm fell. The breasts<br />
were evidently full of milk at the time, and would<br />
have large ves els cour ing over them. he was a<br />
robll t woman of about 28 or 30 years of age.<br />
Rigor mortis was pr ent, but "not marked,"<br />
i.e., 24 hours after death. Internally all the organs<br />
were normal, but "the lungs were congested and<br />
the heart empty of blood and firmly contmcted."<br />
'I he brain was deeply congested, but showed no<br />
injury or haemorrhages. Death due' to shock, the<br />
re ult of lightning-stroke. This woman was said<br />
to have \\"Orn " a dress" at the time she was struck,<br />
but when removed from the hut was naked. Asked<br />
if she wore no bangles or anklets, her husband said<br />
that she wore nothing of the kind but a horsehair<br />
necklace (without bead ) " to keep her from getting<br />
sick". He supposed the dress to have been burnt<br />
off by the lightning, a no fragments of it were<br />
found.<br />
The next ca e, which I unfortunately did not see,<br />
but i described to illu rate the vagaries of a flash of<br />
lightning, occurred about 10 miles from town. A<br />
man and his wife were lying upon the bed one sultry<br />
summer afternoon, the ky out ide dark, with<br />
a threatening thunder torm. The room was<br />
mall, with one window about 2 feet by 18<br />
inche in size situated just above the lower<br />
eud of the bed, which was close to the wall.<br />
A flash of lightning struck obliquely through the<br />
open window, across the legs of the woman, who lay<br />
on the inside, and striking the man apparently in<br />
the lower part of the abdomen, " ripped the clothes<br />
open" on the upper part of the body and killed him<br />
instantly. The widow informed me that he neither<br />
moved nor uttered a SOll nd, so that for a moment she<br />
thought he had escaped, but that when she had<br />
recovered sufficiently to turn round " she found she<br />
was lying beside a dead man."<br />
nfortunately no inquest was considered necessary,<br />
the body being buried by permit i sued upon<br />
the report of a neighbour; but nearly three months<br />
afterwards I attended the "idow for continued weakness<br />
of the legs, of which she had lost the use at the<br />
time of the occurrence. Some" branching streaks .. ,<br />
upon her legs, up to the knees, were described to<br />
me, but beyond some" mottling " of the body of the<br />
husband she could give me no further information as<br />
to his condition after being struck. No signs of<br />
burning, however, were noted, though the room<br />
" smelt as though an explosion had occurred."<br />
In connection with this case, it is well known that<br />
hot air providf's a track of lessened resistance, of<br />
which lightning often avails itself, e.g., in striking<br />
down chimneys and down the flnes of grc~n-ho.nse~;<br />
and as a precaution against damage by IJghtmilg lt<br />
has been recommended by meteorologist that windows<br />
should always be kept closed when a thunderstorm<br />
is in the neighbourhood. This case seemed<br />
to emphasize this necessity.<br />
Durina the summer of 1905 a native man was<br />
reported'"'lying dead on the hill-side just outside the<br />
town, and J was requested to make the necessary<br />
examination and report upon the cause of death. He<br />
lay beside a well-frequented footpath, naked, some<br />
passer-by having covered the body with his very<br />
tattered coat and trousers. On removing them, I<br />
notlCed that a sleeve and the back of the coat had<br />
been ripped down, and on looking again at the body<br />
saw on the neck, disappearing down the back, the<br />
characteristic brown streak of lightning-stroke. Returning<br />
to the clothes, I falmd the legs of the<br />
trousers similarly ripped. The brown and markedly<br />
arborescent streak started on the left side of the neck,<br />
and running backwards and downwards to the back,<br />
down the spinal funow, between the gluteal prominences,<br />
found its W:LV to earth down the inner<br />
surface of the left thigh and leg. At the left<br />
shoulder a branch of this streak struck across the<br />
back to the right side, and windiug round to the<br />
front across Pompart's ligament, divided into two,<br />
running down each side of the thigh and leg. His<br />
skin \-vas of the lighter variety, and the streak<br />
shewed well, being but little disconnected; it gave<br />
me the impression of his having been splashed with<br />
electric fluid from the left-hand side across the body.<br />
Internally, the lungs were "congested and engorged,"<br />
and "the heart firmly con racted," the<br />
left ventricle being empty of blood or clots, the right<br />
containing a very little dark clot. 0 other injuries<br />
were found, and the remaining organs were normal,<br />
the brain not being examined. Later in the day a<br />
pair of boots found amongst some rocks near the<br />
body of this man were brought to me; they shewed<br />
the distinctive bursting outward of the leather corresponding<br />
to the track of the lightning on his feet.<br />
I feel sure, however, that the distance they were'<br />
found from the body was a measure of the disappointment<br />
of the one who first found them and not<br />
of the extraordinary action exerted by lightning in<br />
throwing off the boots of those struck, sometimes a<br />
distance of some yard. I n the pocket of the coat<br />
of this man was found evidence of his discharge from<br />
the local gaol the morning of the day on which he<br />
was killed. He had started to walk to his home<br />
with" a bnndle," probably a blanket, but as nothing<br />
else was found near him, it was probably uninjured<br />
and considered too useful to leave by some passer-by.<br />
The last case of this nature which I saw during<br />
this last summer presented characteristics which, J<br />
consider, illustrate the statement made in the early<br />
part of this paper, to the effec that burns upon the<br />
body will be fonnd invariably to be in connection<br />
with metals. As it occurred some 40 miles from<br />
here, it was the third day after the man's death<br />
before I arrived and made my examination, the body<br />
being by then well advanced in decomposition. An<br />
old native, his wife and child of abont 10 years of age.<br />
had occupied the usnal circular Kaffir hut, with a<br />
thatched conical roof supported by a central post.<br />
During the night a flash of lightning struck the roof.<br />
setting. it alight, and travelling down the central<br />
post, killed the old man, who was lying in contact<br />
with it. close to a fire. The woman was sleeping<br />
" near the centre of the hut" with her feet to the<br />
fire; both legs shewed severe burns of the second<br />
degree and streaks up as far as the knees. which \"ere<br />
probably bent. These burns took place on each<br />
leg immediately beneath 20 brass rings worn above<br />
the ankles, and which on my arrival had been removed.<br />
I learnt that the rings themselves" had
December, 1907. THE TR SVAAL <strong>MEDICAL</strong> JOUR AL. 123<br />
been burnt," probably partially fused, but I could<br />
Hot get them brought to me for inspection. 'he<br />
had been unable to move her legs for a day or two<br />
after being struck, and had been dragged forth from<br />
the burning hut by the child of 10! V'hen 1 saw<br />
her, movement was returning, but she could not as<br />
yet stand. The small boy had been sleeping somewhere<br />
to the side of the hut, and apparently had<br />
been untouched. 'The post-mortem examination of<br />
the old man was unsatisfactory owing to his having<br />
been left in the burning hut, .. as he was known to<br />
be dead," and his body much burnt and charred by<br />
the falling-in upon him of the burning roof. 1<br />
was, however, able to trace upon his neck a<br />
dark, characteristic branching streak disa~pearing<br />
into charred tissue down the back. Internally, the<br />
heart was firmly contracted and empty; the luugs,<br />
too decomposed to show anything reliable. I had<br />
no difficulty therefore in stating as my opinion that<br />
he had died of shock resulting from lightningstroke,<br />
having been burnt afterwards.<br />
In conclusion, I advance the following conditions<br />
as definitely characteristic of death from lightningstroke<br />
:-<br />
The peculiar .. rent .. condition of the clothes<br />
and boots, suggestive of being the result uf<br />
great violence from within outwards, the<br />
edges of the rent shewing no burning or singeing.<br />
The presence of a peculiar arborescent. red streak,<br />
becoming brown after death, upon the skin,<br />
traceable wherever the electTic fluid touched<br />
the body, and often demonstratwg its direction,<br />
the rent in the clothing corresponding<br />
with the position of this streak upon the body.<br />
And whilst awaiting further experience of the<br />
deeper injuries upon the body described as sometimes<br />
resulting from'lightning-stroke. I offer the foll
124 THE TR NSVAAL <strong>MEDICAL</strong> JOURNAL. December, 1907.<br />
This opinion being submitted to the Law Department<br />
was confirmed by them, and in addition they stated<br />
that no action for damages could be brought against<br />
any medical man for giving, upon a sick report, the<br />
nature of a patient's illness, in the case of Government<br />
employees.<br />
Transvaal Medical Council Election.<br />
The Association have asked all medical men resident<br />
outside the Witwatersrand and Pretoria districts to cooperate<br />
with its members in forwarding the candidature<br />
of two medical men to represent the country districts<br />
upon the Medical Council.<br />
l"orms were sent out calling for the nominations, with<br />
the understanding that the two candidates to be selected<br />
would be those obtaining the largest number of nomin_ations.<br />
As notified by circular, the candidates selected were<br />
VI's. ixon, Heidelberg, and R. T. Jupp, Klerksdorp,<br />
who obtained a large majority of the nominations.<br />
Changes in Membership,<br />
Dr. McKnight, of Schweizer Reineke, has resigned hig<br />
district surgeoncy and left the Transvaal. Dr. Huntley<br />
Pelly, of Bloemhof has been appointed in his place, and<br />
at present the Government does not intend. making any<br />
further appointment at Bloemhof.<br />
An Uncommon Cause of Sudden Death.<br />
VI'. Sanders, Pretoria, has reported the following<br />
case:-Upon opening the skull of a young native woman<br />
who had died suddenly, and in whom I could find no<br />
disease elsewhere, a gush of clear fluid came away,<br />
carrying a cysticercus about !-inch in diameter. The<br />
brain appeared quite normal except that the lateral<br />
ventJ,'icles were somewhat enlarged.<br />
A Note upon the Examination of the Accused in Cases<br />
of Alleged Rape.<br />
(By Dr. A. J. Nixon, District Surgeon, Heidelberg.)<br />
In cases of supposed rape the importance of examining<br />
the person accused is fully borne out by the following<br />
case:-<br />
A native girl was sent down to me by the Resident<br />
Magistrate on July 6 last, with instructions to examine<br />
for evidences of rape. The girl's demeanour was modest,<br />
and she appeared to be eager to be examined. The<br />
examination proved negative in every way. All one<br />
could swear to at the preliminary examination was that<br />
the girl was not a virgin, and that the hymen must have<br />
been ruptured at least a month or two before. Nothing<br />
more was heard of the matter until October, when a<br />
native boy came under my care in the local gaol, suffering<br />
from complete phimosis, due to a chancre at the<br />
point of the prepuce and warty growth (exposed after<br />
circumcision) around the corona and upon the glands.<br />
This boy was the boy supposed to have committed the<br />
rape in July. He had become lost, but· was found in<br />
gaol in our next adjacent district, where I subsequently<br />
learnt he had been admitted into hospital on August<br />
19, and discharged on September 25, suffering from<br />
syphilis. On recovering from the operation for phimosis,<br />
which was somewhat delayed owing to infection. a~ the<br />
points of incision, the boy was had up for prehmmar:y<br />
examination. Both in the Court and to myself as his<br />
daily attendant, he stoutly maintained his innocence,<br />
averring that the the time of the suggested crime he<br />
was suffering with syphilis, and th!l't it ~ccordingly was<br />
not possible for him to have had COItus WIth any woman.<br />
And, further, that if he had had intercourse, for:ced or<br />
voluntary, with the girl, then she should show SIgns of<br />
infection. ow, I examined the girl again three months<br />
after the supposed crime was committed, and found her<br />
still perfectly clean with no evidences, moreover, of past<br />
infection.<br />
The question, therefore, arose: Had the boy active<br />
syphilis in July, or, in other words, ha;d he a ~ard<br />
chancre. If so, and granted that penetratIOn had taken<br />
place did it absolutely follow that the woman would<br />
have' become infected. The evidence was incontrovertible<br />
that he had come suddenly upon the girl, that<br />
he had driven away by threats two other girls who were<br />
with her and who had heard the girl scream. If, then,<br />
it could 'be proved that the woman showed signs of infection,<br />
conviction must follow. But there was no<br />
evidence of infection.<br />
R.M.A" BORDER BRA ·CH.<br />
The inaugural meeting of the above branch was held<br />
on ovember 12, 1907. Present: Drs. Tannock, Roulson,<br />
Anderson, Alexander, Ward, Ganteaume, Mac<br />
Uregor, Rubidge, Grey, Brooks and Hill-Aitken.<br />
ominations for office bearers for 190 were called for.<br />
President, Dr. Tannock; president-elect. Dr. Roulston;<br />
hon. sec. and treasurer, Dr. Hill-Aitken. No other<br />
nominations being handed in these gentlemen were<br />
elected for 1908.<br />
Branch Council.-Df the following, twelve will be<br />
elected by ballot at the January meeting: Drs. Conry,<br />
Wall, Batchelor, Alexander, Ma{lGreg()r, Grey, Rubidge,<br />
uanteaume, Nangle, Lounds, Ward, Robertson,<br />
Querney, Randall, Shanks and Chute.<br />
Reciprocity.-A resolution was unanimously passed by<br />
the branch giving support to the Medical Council in<br />
their fight for reciprocity. The secretary was instructed<br />
to forward the resolution to the Council, and, at the<br />
same time, to ask Dr. Darley-Hartley to impress on the<br />
medical profession through the columns of his paper,<br />
the advisability of their bringing the question before<br />
candidates for Parliament.<br />
South African Medical Congress.-Dr. Anderson proposed,<br />
and Dr. Alexander seconded, that Drs. Tannock,<br />
Rubidge, Ganteaume, Roulston and the hon. secretary<br />
be a committee to approach various bodies and<br />
pel'fons with a view to holding the Congress here in 1908.<br />
Dr. Tannock proposed the branch be known as the<br />
Border Branch. This was carried.<br />
CORRESPONDENCE.<br />
(We 110 not necessm'ily identify ourselves with the opinions<br />
eXl'res ed under this heading.)<br />
To the Editor at the Trallsvaal1l1edirol Journal.<br />
Sir,-I have been requested, in the interests of the<br />
medical profession in the Transvaal, to bring to your<br />
notice the facts in the case of Murray v. Shawe, recently<br />
decided by the First Civil Magistrate at Johannesburg,<br />
as it appears that many practitioners suffer financially<br />
to a great extent solely through their good nature and<br />
reluctance to press their claiJlis in the Courts.<br />
In the case mentioned the plaintiff, a medical practitioner,<br />
sued the defendant on an account for professional<br />
services rendered during a period extending<br />
from 1892 to 1898. Defendant pleaded prescription, but<br />
admitted in his evidence that in 1904 he had told the<br />
plaintiff that he was in poor circumstances. Plaintiff<br />
declared in eviqence, that he had had several conversations<br />
with the defendant about the account, and that<br />
defendant had always promised to pay when he was<br />
able to do so, but he (plaintiff) could not swear to any<br />
definite dates.<br />
On this evidence the Magistrate had no other alternative<br />
than to uphold the plea of prescription and dismiss<br />
the case.<br />
ow, the Supreme Court of the Transvaal has recently<br />
held that a verbal acknowledgment of, or promise<br />
to pay, a debt breaks or interrupts prescription,<br />
but the point to be observed is that the practitioner to<br />
whom a debtor admits an account should immediately<br />
make a note in his diary of such admission, as nearly<br />
as possible in the words used, and also of the time and<br />
place, with a view to future reference, and, maybe,<br />
evidence.<br />
It is not usual for anybody in the presence of third<br />
parties, to discuss his financial position, or to ask for<br />
time in which to pay, and if practitioners mak~ it a<br />
habit to record such conversations in the manner suggested,<br />
it would go far to support their evidence, a.s<br />
against that of the defendant, in cases where prescription<br />
was pleaded and the admission of the debt denied.<br />
All medical men in Johannesburg will know of their<br />
own experience that there are many persons in that<br />
town who are only too eager to avail themselves of the<br />
plea of prescription, and they should, therefore, be<br />
careful to protect their own interests as far as possible.<br />
Of course, if the debtor acknowledges the debt in<br />
writing, the ordinary period of prescription of two<br />
years is extended to ten.-Yours faithfully,<br />
C. N. KNOX-DAVIES.<br />
Johannesburg, November 28, 1907.