FLOATING HOSPITALS FOR WEST AFRICA.

178 been vaccinated in 1897 and 1898. Furthermore he failed to state that the emolument from this "extra" which goes to the district medical officer, as he happens to be the public vaccinator. was very much below the average. One guardian remarked that "vaccination ought to be at a much less price than they are now paying for it." Probably when a new appointment is made this board will ask medical men to tender at a contract price, and will then be willing to publish the prices of the successful contractor. A borough with a population of over 63,000 is not paying in return for two years’ a large sum in disbursing ;&212 vaccinations. ___

THE COMMON

FORMS OF MENINGITIS.

Dp. CHARLES L. DAXA of New York publishes an interesting and opportune paper on this subject in the dozcrnal of Nervous and Mental Disease for December, 1899. Few subjects are more perplexing to a student than the different types of meningitis. The classification, never very simple, has undergone constant changes during the last decade. In one of the earliest and most conscientiously made classifications of meningitis, that by Huguenin (published in Ziemssen’s " " Cyclopaedia nearly 25 years ago), 14 different forms of cerebral meningitis were described. In Grasset’s masterly work published about the same time the forms described were acute, chronic, and tuberculous meningitis. The proin has on the made the two decades been shown gress past one hand by a gradual simplification of the classification, and on the other by clinical and pathological studies which have added richly to the store of knowledge and obliged us to add two

or three new names to the list. Thus, in the recent treatises of Gowers, Oppenheim, and Mills from 10 to 12 types of meningitis are recognised. The various types of the new and the old added together make a total of about "20 different forms, without using the term ’meningismus,’ or including acute cerebral cedema or acute and chronic hydrocephalus." The forms of meningitis as seen in ordinary practice are shown by an analysis of 137 cases collected by Dr. Dana from the records of Bellevue Hospital, New York, during the past 15 years. In 46 cases the records of necropsies were also available. The forms of meningitis in the 137 cases referred to include the following :—Purulent

tuberculous meningitis. Pachymeningitis is a disorder which has received an extraordinarily rich vocabulary of qualifying terms, and the distinction into external and internal types is an academic one. Extra-dural abscess would be the correct term for acute suppurations involving the outer surface of the dura. Intra-nasal, aural, and mastoid inflammations are really the morbid conditions in such cases and they call for surgical treatment. A non-surgical pachymeningitis is mostly an internal pachymeningitis. This form of disease is commonly syphiliticThe hsemorrhagic and not infrequently hsemorrhagic. form is associated with disease of the blood and bloodvessels and is found practically only in scorbutic children, in some forms of insanity, and in chronic alcoholism. Leptomeningitis both clinically and pathologically occurs in one of three forms, the epidemic cerebro-spinal, the fibrino-purulent, and the tuberculous. The first is well known, and in doubtful cases the employment of lumbar puncture enables us to settle the diagnosis if we find the diplococcus intracellulalÌs or the micrococcus lanceolatus. Most epidemics seem to be associated with the former and a few with the latter organism, but there is no way of two between the forms distinguishing except by culture. Purulent or fibrino-purulent meningitis is usually a pyogenic infection due to the streptococcus pyogenes or to the pneumococcus of Fraenkel, but may sometimes be due to almost any other pyogenic organism. Clinically it is not possible to distinguish these from one another and all have a high mortality. While tuberculous meningitis is one of the best known and most readily recognisable, the same cannot Oar knowledge of this be said of serous meningitis. To this class of brain affection is far from complete. affections should be added the so-called cases of meningismus described by Quincke (1891) and later by Boenninghaus (1897), of which about 40 have been recorded. Some of these have been traceable to the effects of alcoholism with its resultant cerebral irritation, congestion, and cedema, or been assigned to conditions rising from narcotic poisons, cerebral trauma (traumatic serous meningitis), or cerebral exhaustion and starvation. Acute cerebral oedema, usually following severe blows on the head, is associated with symptoms like those of true meningitis, lasting two or three days and then generally disappearing with rapidity. The acute serous meningitis of alcoholism and allied toxic conditions called wet brain closely simulates meningitis and lasts about 10 days. A mild delirium, with a temperature of 101° or 102° Fa and some muscular twitchings may be observed. The skin is hypersesthetic and the irritability of its vascular mechanism is shown by the tache cérébrale which can be readily evoked. There is some rigidity of the neck with contraction of the pupils, while the tongue is coated and the bowels are constipated. Eventually the patient dies or turns towards convalescence at the close of the second week. The serous meningitis of Quincke and Boenninghaus is an acute bydrocephalus occurring most often in children or in young adults. Sometimes it runs a short course ending in recovery, and sometimes it is rapidly fatal. A few cases are marked by partial remissions and subsequently by gradually developing hydrocephalus. It affects the sexes in equal proportion and pyrexia is present in about one-third of the number of The cause is some form of infective fever in about cases. half the cases. Traumatism, otitis media, and sepsis are occasional factors and bacteriological tests so far have been

fibrino-purulent lepto-meningitis 52 cases, cerebro-spinal meningitis 15 cases, serous meningitis of traumatic, alcoholic, or infectious origin 15 cases, tuberculous meningitis 14 cases, internal pachymeningitis (hasmorrhagio and syphilitic) 12 cases, chronic lepto-meningitis three cases, external pachymeningitis from mastoid disease two cases, and unclassified forms 19 cases. Apart from these there were five cases of spinal meningitis. Leaving out the spinal cases there were, therefore, only five kinds of meningitis recognised in ordinary hospital practice. It will be seen that the purulent, tuberculous, cereb!o-spinal (epidemic and sporadic), and serous are the principal forms, while pachymeningitis is practically only a chronic syphilitic manifestation. "Acute syphilitic meningitis," says Dana, " is certainly most rare, if it ever exists, at least, using the word acute in the same way And again, posterior basic we apply it to other forms." meningitis-a phase which only denotes its topographical distribution-is probably a syphilitic or tuberculous disease or a serous meningitis. These hospital figures in Dana’s experience seem to coincide in the main with those of ordinary and general practice. Acute spinal meningitis is negative. a rare disease. Dana confesses that he has never seen a or

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very

It is well case and can find no record of one. FLOATING HOSPITALS FOR WEST AFRICA. abandon the distinction between cerebral and spinalII meningitis in ordinary clinical work, for if pus is found IN a lecture given at the Livingstone Exhibition, held at on the cerebral membranes it is almost invariably preSt. Martin’s Town Hall on Jan. 5th, Miss Mary Kingsley, sent in the spinal canal also. Similarly tubercles are in urging the claims of the Colonial Nursing Association, often found in the spinal canal if there is a cerebral said that what was wanted on the West Coast of Africa was

primary to

I

179 with a staff of nurses and medical men establishment of branch hospitals in the shore settlements. The amount of good that medical science and nursing could do in a country like that of the West Coast of Africa was great, and some such scheme should be devised both for sympathetic and Imperial reasons. There were certain disadvantages attaching to hospital ships, but even a hospital hulk in Miss Kingsley’s view was superior to coast sanatoria. There is much to be said for Miss Kingsley’s plea and we trust that the Colonial Nursing Association will not allow the matter to drop.

hospital cruiser together with the a

"CHRONIC RECURRING MEMBRANOUS PHARYNGITIS."

departments of work in which the new Medical College and Polyclinic proposes to engage is the investigation of special subjects by the agency of permanent One of the Graduates’

sub-committees. We are informed that the Committee on Tuberculosis, of which Dr. Heron has been appointed chairman, will meet for a second time on Wednesday next, Jan. 24th, and will proceed according to arrangement to discuss various questions in connexion with the external manifestations of tuberculosis, more especially those coming under the name of lupus. This meeting will be open to all members of the college. Various questions and statements have been drawn up with a view to elicit facts and opinions as to the clinical history of these maladies and their relation to other forms of tuberculosis. Copies of these questions may be obtained on application to the medical superintendent at 22, Cheniesstreet. The hour of meeting is a quarter past five. The Committee on Climate and Geographical Pathology has elected Sir William Kynsey as its chairman and Dr. A. P. Hillier as secretary, and holds its first open meeting at 5.15 P.M. on Wednesday, Feb. 7th..The region to which it first gives attention is South Africa. It is desired to collect information respecting the diseases and the climate of different regions and districts. Those possessing information on this subject are requested to communicate with Dr. A. P. Hillier and the gift of books and pamphlets will be thankfully received. The committee is a standing one and will no doubt resume the same subject on future occasions as material may accumulate.

Iw the Journal of the American Medical Association of Dec. 2nd, 1899, Dr. J. O. McReynolds has described a case of this very rare disease. Sir Morell Mackenzie seems to have previously described it under the name of chronic diphtheria, but in consequence of its pathological and clinical differences from diphtheria, the above designation, as Dr. McReynolds suggests, is the best until a more accurate knowledge of the subject is attained. A girl, aged 19 years, in fair health, was under his observation for 14 months. When uninfluenced by treatment the membrane recurred twice or three times a week, persisting on each occasion for one or two days, and then becoming spontaneously exfoliated, leaving the throat apparently healthy. If forcibly and prematurely removed a raw surface covered by glairy material was left, which easily bled on manipulation. The area affected varied, the soft palate was always covered, and the PRECAUTIONS AGAINST THE IMPORTATION entire pharynx was sometimes involved. Repeated examinaOF PLAGUE. tions never revealed the diphtheria bacillus, although several THE Local Government Board for Scotland, in a circular years previously the patient had an attack of genuine diphtheria. Streptococci and staphylococci were found in large letter dated Jan. 15th, 1900, again calls the attention of numbers, but there was no evidence as to their causal local sanitary authorities to the presence of plague in relation. The patient was able to follow her vocation with Portugal and the necessity for carrying out " with especial only slight interruptions and the constitutional symptoms care"the measures in force in these islands for preventing were mild. The daily ingestion of raw onions or the local the importation of infection. Their notice is specially of nitrate of silver prevented the formation of directed to a General Order issued by the Commissioners of application the membrane for a period of two weeks. After trying Customs on Oct. 31st of last year. The object of that Order was 11 to make certain that in carrying out the regulaa multitude of remedies the writer was convinced that tions of the board the medical officer of health shall receive a cure but that the would nothing produce permanent the greatest possible assistance from officers of Customs," disease would in time spontaneously subside. and it is pointed out that, on one occasion at least, such assistance was actually declined by an inspector of Customs. MEDICAL GRADUATES’ COLLEGE AND POLYThe mechanism adopted for joint action by the medical CLINIC. THIS institution enters this month upon its second year, and officer of health and Customs officials for dealing with arrivals from infected ports is briefly as follows. The officers of we understand that the number of subscribers and members has steadily increased, that the practical classes have been Customs look to the medical officer of health to inform them filled, and that the consultations have been well attended. from time to time of any particular ports or countries During the coming three months special clinical lectures the vessels arriving from which he would desire to In this connexion it is pointed out in the visit. are to be given on alternate Wednesdays, at 5 P.M., by of the Board that " the earliest information which letter the President. Sir William H. Broadbent, Bart., Dr. G. H. would usually be available to this end is that which would Savage, Professor McCall Anderson, Dr. Patrick Manson, be obtained Dr. Saundby, and Mr. Jonathan Hutchinson. A museum by a regular examination of the news telefrom abroad for the purposes of the daily press." is in course of erection, the builders having undertaken graphed On the other hand, the officers of Customs will, in their to finish it by March, and it is hoped that when comthe medical officer of health any information pleted this will be an additional source of attraction and turn, give which interest to the subscribers and members. A new departure they may possess respecting the arrival or impending arrival of any ships from the ports or countries in queshas been made asregards the college journal the Polyterm medical officer of health," it may be The first tion. The clinic. number of the second volume has just been issued. The journal for the future is to be noted, includes any duly qualified medical practitioner published monthly instead of quarterly, and will furnish appointed or employed by a local authority to act in a complete record of the clinical work of the college. the execution of the orders relating to plague. Attention is It is to be edited by Mr. Jonathan Hutchinson. The also dri wn to the possibility of the infection of plague being the and dark laboratories, class-rooms, rooms, carried by some of the lower animals, and especially by Roentgen-ray have been equipped in the most thorough manner, and "rats, mice, and, by natural sequence, cats," and the the medical superintendent is at all times glad to welcomE necessity for inquiring into the evidences of disease in these visitors to the college and to afford them an oppor. animals and taking measures for destroying them if occasion tunity of becoming personally acquainted with the advan should arise. That rats can and do suffer from plague and are tages and facilities which it offersfor post-graduate work an important means of diffusing infection appears no longer -