Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from 362 POST GRADUATE MEDICAL JOURNAL July 1948 Serous Meningitis or Aseptic Meningitis c.cm. Organisms are not present. In some cases an actual meningitis may supervene. This is the name given to the syndrome in which A lymphocytic meningitis is not an infrequent a meningeal reaction occurs as the result of an occurrence in the early stages of Weil's disease and infective focus adjacent to the meninges, e.g. an example came under my own observation mastoiditis, lateral sinus thrombosis, extradural recently. The lymphocytes were several hundreds abscess, intra-cerebral abscess, etc. The pressure per c.cm. and took two-three weeks to return to of the C.S.F. is increased, and there is an increase normal. There was no jaundice in this patient in cells, generally polymorphs, but sometimes and the diagnosis was made by finding a high lymphocytes predominate. The protein is slightly agglutination titre in the blood. but the and chlorides are normal. BIBLIOGRAPHY increased, sugar ALEXANDER, H. E., 'Treatment of Haemophilus Influenzae In- The cell count is usually in the neighbourhood of fections, and of Meningococci and Pneumococci Meningitis,' Amer. Jour. Dis. Child., Aug., 1943, lxvi, x60. 200-300, but occasionally it is as high as I,ooo per DINGLE, J. N., FINLAND, M. (1942), War Med., 2, I.

MENINGITIS: RATIONALE OF DIAGNOSIS By JOHN APLEY, M.D., M.R.C.P. Department of Child Health, Bristol University Increased power entails increased responsibility. tion of the meningeal nerves and those portions of With the advent of chemotherapy delay in the the cranial and spinal nerves which traverse the by copyright. diagnosis of purulent meningitis can no longer be theca. The mechanism is identical with that excused, for diagnosis at leisure is condonable obtaining in peritonitis, and the results are similar. only when dealing with an incurable or benign The three characteristic features of meningeal disease. Virtually all the common varieties of irritation are :--() pain, (2) hyperaesthesia, and purulent meningitis are now curable, yet even now (3) muscular rigidity. The first two of these arise many patients die, or survive only with distressing from irritation of sensory components, and the residua. Inadequacy of laboratory facilities and third through the mechanism of a meningeal- improper selection of therapeutic agents are con- motor reflex. tributory factors in the production of these The various signs, such as those of Kernig and http://pmj.bmj.com/ failures; but the most important single factor is Brudzinski, and the demonstration of neck rigidity, delay in diagnosis. which are employed in the diagnosis of meningitis, It is axiomatic in medicine that urgent diagnosis depend for their effects upon increasing the depends on leisurely preparation. The diagnos- irritability of the meninges by mechanical stretch- tician who has failed to discipline himself by re- ing. peated observation, analysis and synthesis will fail also to attain that maturity of judgment which Correlation of Symptomatology with Site permits diagnosis to be made rapidly yet without of Meningeal Irritation on September 28, 2021 by guest. Protected the sacrifice of accuracy. The study of meningitis The production of the three characteristic provides an example of the preliminary, catholic features of meningeal irritation can be clearly preparation which is essential for urgent diagnosis. illustrated by contrasting anterior poliomyelitis Though the present discussion is centred on with meningococcal meningitis. At the same time purulent meningitis the logical approach must be the discussion can be taken a stage further to through the subject of lepto-meningitis in its provide evidence on which to attempt localization wider aspects. of the site of meningeal involvement. In anterior poliomyelitis, when the' site of pre- Features of Meningeal Irritation dilection is in the lumbar region of the cord, the The essential feature common to the many manifestations of meningeal irritation appear first forms of meningitis is meningeal irritation. This in the back and the legs; from these regions they phenomenon may occur even in the absence of may spread or remain localized, according as the infection of the meninges; but, whatever the disease process spreads or is halted. In menin- cause of the irritation, the clinical features which gococcal meningitis, when, as commonly occurs, the may be observed result in all cases from stimula- site of predilection is at the base of the brain, the Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from July 1948 APLEY: Meningitis: Rationale of Diagnosis 363 results of meningeal irritation are manifest first in tend, therefore, to occur at an early stage. In the head and neck, to become widespread only as pneumococcal meningitis, on the contrary, the the infective process extends. Since the anterior yellow-green exudate may predominate at the and middle cranial fossae are supplied by the vertex of the brain. As a result, though headache trigeminal nerve, the results of irritation in these is severe, neck rigidity is minimal or absent. In areas will be manifest in the frontal, facial and influenzal and in streptococcal meningitis the dis- temporal regions; the posterior fossa is supplied tribution of the exudate is capricious, following no by the upper cervical nerve roots, so that dis- set pattern, and the symptomatology is corres- turbances originating in stimulation of these nerves pondingly unpredictable. Post-basic meningitis of will be referred to the occipital and post-nuchal infants, a chronic 'variety of meningococcal regions. In practice the three fossae are, however, meningitis, derives its unique features from the generally involved concurrently, so that clinical special conditions pertaining in infancy. Because localization of the infection to one or other of them of the comparative softness of the infantile brain is usually not possible. the sulci become closed at an early stage in the As between the different types of infective disease process, so that the exudate is confined meningitis, the variations in symptomatology may almost exclusively to the basal cisterns. be explained, at least in part, by what is known of their applied pathology. In the meningococcal Mechanisms of Production of Meningeal variety, as also in tuberculous meningitis, the in- Irritation flammatory exudate tends to be concentrated at Comprehension of the widely different mechan- the base of the brain. It fills the interpeduncular isms by which meningeal irritation may be pro- space, spreading thence with the flow of cerebro- duced is of more than academic interest; without spinal fluid down into the spinal theca, forward it differential diagnosis remains as unsatisfying as along the optic nerves, backward into the cisterns, it is superficial. The conditions which give rise to or upward along the middle and anterior cerebral meningeal irritation will be described in five arteries to the vertex. In the natural history of groups, a division which appears natural and by copyright. these diseases neck rigidity and occipital pain contributes to clarity of diagnosis (see Table i), PATHOGENESIS OF FIG. MENINGEAL REACTIONS

arachnoid villi

/ / http://pmj.bmj.com/ venous blood / / // --// - MENINGEAL INFECTION /

nervous /, CEREBROSPINAL nervous C.N.S. INFECTION WITH SUBSIDIARY on September 28, 2021 by guest. Protected tissue // ) FLUID / MENINGITIS lepto- / meninges /NON-INFECTIVE MENINGEAL / / - // IRRITATION // // ASEPTIC MENINGEAL REACTION TO ///// / / EXTRA-MENINGEAL SEPSIS arterial // / / V blood / / / MENINGISM: INCREASE IN C.S.F. FROM // / / / / / / / // / BLOOD OSMOTIC DISTURBANCES ·

choroid plexus Reproduced by permission from ' The Clinical Apprentice,' by J. M. Naish and J. Apley, published by J. Wright, Bristol Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from

364 POST GRADUATE MEDICAL JOURNAL July 1948

TABLE i frequently characterized, in its early stages, by a meningeal reaction which is transient. CAUSES OF MENINGEAL IRRITATION 2. Infection of C.N.S. with subsidiary meningitis GROUP I.-Predominantly Meningeal Infections In accordance with the general statement pre- (commonly bacterial). viously made, the majority of virus infections of Cocci: meningo-, strepto-, pneumo-, staphylo-. the central nervous system fall into this group. Others : B. tuberculosis, H. influenzae, The more of these are shown in Table i. B. coli, B. proteus, Brucellosis, B. typhosus. important Virus: benign lymphocytic meningitis. Conversely, suppurative encephalitis, though of bacterial origin, is invariably preceded by GROUP 2.-C.N.S. Infection with Subsidiary meningeal inflammation. Meningitis (commonly virus). Some diseases due to organisms other than Anterior poliomyelitis, polioencephalomyelitis, viruses also fall into this group. Of these, the only encephalitis (especially in association with specific common one is syphilis. Extremely rarely Weil's fevers), infectious mononucleosis. disease, actinomycosis and some fungus and Syphilis, Weil's disease, actinomycosis and other similar diseases are concerned. fungus infections, infections with yeast-like organisms similarly (e.g. torula, coccidioides). 3. Non-infective mechanical irritation of meninges GROUP 3. Non-infective Mechanical Irritation Various non-infective causes may give rise to of Meninges. direct irritation of the meninges. Even normal Intra-thecal therapeutic agents, e.g. anaesthetics, saline produces a meningeal reaction when intro- sera, penicillin, streptomycin. duced into the theca, so that the effects of thera- Blood: Sub-arachnoid or cerebral haemorrhage. peutic agents similarly introduced can readily be Neoplasm: medulloblastoma, cholesteatoma, oligo- understood. Thus, streptomycin frequently evokes leukaemia. dendrogliosis, a well-marked pleocytosis (predominantly poly- by copyright. Chemical: lead encephalopathv. morphonuclear) which may be accompanied by Cyst fluid. clinical signs of meningeal irritation (M.R.C., GROUP 4. Aseptic Meningeal Reaction to 1948). Extra-Meningeal Sepsis. Skull sepsis, extra-dural abscess, venous sinus 4. Aseptic meningeal reaction to extra-meningeal thrombosis, brain abscess. sepsis (Otitis media, mastoiditis and sinusitis are the This reaction has been given many names, common predisposing causes.) such as ' aseptic meningitis' and ' sympathetic meningitis '; under the term ' serous meningitis ' http://pmj.bmj.com/ GROUP 5. Meningism. it is frequently confused with disease-processes which fall more naturally into groups 3 or 5. I. Infection predominatly meningeal The effects produced arise from irritation by a In this group are included those conditions in septic focus which is adjacent, but external to the which meningeal irritation is produced by infection meninges. In the production of the aseptic confined to, or predominating in the meninges. It meningeal reaction the type of organism does not has been stated that no organism evokes ex- to be of An increase in

appear importance. on September 28, 2021 by guest. Protected clusively a meningitic or an encephalitic reaction, pressure and of cells in the cerebro-spinal fluid but clinically one or the other almost invariably occurs, but the meninges continue to function as predominates. In contrast with virus infections, a barrier which prevents the passage of organisms. bacterial infections are characterized by a selective After removal or sterilization of the septic focus affinity for the lepto-meninges, and they produce the cerebro-spinal fluid reverts to normal. The their effects by direct irritation. It is unnecessary danger inherent in the situation is that, with failure to enumerate all the bacteria which give rise to to recognize and ablate the source of sepsis, the meningitis; those which have not done so on meningeal barrier may be broken down and some occasion must be rare. The bacteria most purulent meningitis result. commonly encountered are shown in Table I, and comprise the common agents of purulent 5. Meningism meningitis. The clinical distinction between meningism and Some virus infections break the general rule, meningitis was, according to Walshe, first made by in that the site of maximal infection is in the Sir William Jenner. In meningism headache meninges. Benign lymphocytic meningitis is a ceases when delirium begins; in meningitis it common example; anterior poliomyelitis is also continues. Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from

uly 1 948 APLEY: Meningitis: Rationale of Diagnosis 365 The syndrome of meningism has in the past In its later stages, after the stage of meningeal been attributed to many causes, all equally irritation, with the natural progress of meningeal nebulous, of which the most popular was infection certain mechanical factors may come into 'toxaemia.' It now appears clear (Fremont operation. As the exudate increases and extends Smith, et al., I928-29) that meningism is pro- widespread irritative phenomena may occur. duced, for the major part at least, by disturbances Later, organization takes place; obstruction to in equilibrium between the blood and the cerebro- the flow of the cerebro-spinal fluid may arise, spinal fluid. The characteristic changes in the either inside or outside the ventricular system; cerebro-spinal fluid may occur at the onset of any and the final picture is that of increased intra- febrile illness, though only in childhood do signs cranial tension, with depression and failure of and symptoms commonly result. When they do function. occur they are those typical of meningeal irrita- The stages through which a typical meningeal tion, presumably as a direct effect of mechanical infection passes are most easily distinguishable in stretching of the meninges. tuberculous meningitis. With purulent meningitis It is important to appreciate the mechanism of the stages are less clearly demarcated; the production of meningism. It is analogous with sequence may be modified or distorted according the experimental injection of hypotonic solutions to many factors-the characteristics of the into the veins, whereby the osmotic pressure of causative agent, the rapidity of development of the serum is reduced, with a resultant increase in the disease process, the extent and site of maximal the rate of formation of the cerebro-spinal fluid and infection, the resistance of the subject, and the a rise in its pressure. With the onset of an acute effects of treatment. The natural history of febrile illness the osmotic pressure of the blood purulent meningitis, despite these limitations, may falls, and the serum becomes temporarily hypo- however be usefully described according to three tonic compared with the cerebro-spinal fluid. As stages : a result, there is an increased flow the (I) The stage of invasion. through by copyright. choroid plexus, and the cerebro-spinal pressure (2) The stage of meningeal irritation. rises accordingly. The symptomatology is pro- (3) The stage of raised intra-cranial tension. duced by the increase in amount and pressure of the cerebro-spinal fluid; when equilibrium is I. Stage of invasion restored the signs and symptoms disappear. Changes in mentality are often the first to be The common causes of meningism are the observed; they may be extremely pronounced or common febrile illnesses which have an abrupt so trifling as to escape notice. The sudden oc- onset. It may occur as a transient phenomenon currence of delirium accompanied by a rise in at the commencement of diseases, but is temperature is not uncommonly the first mani-

many http://pmj.bmj.com/ most marked, and therefore most frequently festation. Irritability alternating with drowsiness recognized, in pneumonia, tonsillitis and pyelitis. is not infrequent. Malaise, discomfort and languor may precede the onset of more definite Natural History of Purulent Meningitis symptoms by a variable period. Headache, fever The different mechanisms by which meningeal and a rise in pulse rate are the rule. Petechial irritation may be produced, whether in the eruptions in the skin are characteristically present presence or absence of meningeal infection, have so in the early stage of meningococcal infection.

far been discussed. The complete syndrome ofmenin- The occurrence of vomiting at this early stage is on September 28, 2021 by guest. Protected geal infection comprises additional components, difficult to explain, but it is a common event in which can be deduced from general principles. pyogenic and, more especially, in tuberculous Purulent meningitis, like tuberculous meningitis, meningitis. is commonly secondary to infection elsewhere in the body. Before the local effects of infection of 2. Stage of meningeal irritation the meninges become appreciable the causative The three cardinal features already described agent may produce other disturbances. Usually are almost always evident. The site at which they they are generalized and predominate only at the appear depends on factors which have been dis- outset, but this predominance may persist, as not cussed; but it may be repeated that these mani- infrequently occurs in infants. They may even festations tend to be localized in the early stages, prove fatal before meningeal irritation is recog- and to become widespread as the infection extends. nized; an example is the Waterhouse-Friederich- Pain is usually described as headache, though sen syndrome, in which the septicaemic stage of there may also be pain down the spine. The fulminating meningococcal infection may cause headache previously attributable to toxaemia is death through acute adrenal failure before replaced by one which is more intense. It is meningitis becomes clinically manifest. described as continous, though fluctuations in Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from

366 POST GRADUATE MEDICAL JOURNAL uly I948 severity occur; it may be deep-seated or referred mains patent, and in the absence of dehydration, to the surface, usually to the back of the neck and palpation reveals an increase of pressure in the occipital area; it is aggravated by any movement fontanelle. This important sign may precede the or manoeuvre which stretches the meninges or in- onset even of neck rigidity by several days. In creases the intra-cranial pressure. The shrill older children, in whom the fontanelle is no ' meningitic cry' may be explained teleologically longer patent, there may be no clinical evidence of by a combination of some of these factors; severe meningitis beyond fever, failure to thrive, drowsi- headache compels the patient to cry out, but the ness alternating with irritability, and in some cases cry is restrained in an attempt to limit muscular a' meningitic cry.' movement and the consequent rise in intra- cranial tension which would aggravate the pain. The Cerebro-Spinal Fluid Local and general hyperaesthesia may be evident Examination of the cerebro-spinal fluid plays early. Muscle rigidity is nearly always demon- an essential part in the diagnosis of meningitis; strable. In the early stages it may be localized it completes, and is complementary to, clinical and, since meningitis is commonly maximal at the examination, but cannot be substituted for it. base of the brain, neck rigidity is an early mani- Clinical examination may occasionally afford a festation, frequently demonstrable when Kernig's, complete diagnosis, as in the case of meningococcal Brudzinski's and other signs are equivocal. Later, meningitis in the presence of meningeal irritation the whole back may become rigid, the head re- and a petechial rash. As a rule, however, it is con- tracted, and the thighs flexed on to the abdomen. cerned in the main with detecting the evidence of meningeal irritation, perhaps among a host of 3. Stage of raised intra-cranial tension other and confusing data, and with the elimination At this stage the classical signs of raised intra- or disclosure of antecedent conditions. Examina- cranial tension, whatever its origin, may be mani- tion of the cerebro-spinal fluid provides informa- fest. Often occur in an form, tion the nature of any meningeal re- they exaggerated regarding by copyright. because of the rapidity with which the tension is action, and may in some instances furnish an increasing; some, however, may be lacking be- immediate diagnosis. Since the clinical manifesta- cause of the time factor or for other natural tions of purulent meningitis are, as a rule, non- reasons. Headache, for example, may not be specific, a specific diagnosis, on which appropriate registered because the patient is stuporose. treatment should be based, must await examination Vomiting commonly occurs. Papilloedema is rare of the fluid. except in the late stages of tuberculous meningitis. In the cerebro-spinal fluid the changes as- Drowsiness develops into stupor. The pulse and sociated with meningitis fall into three groups, may become slow and are commonly on alteration of function in the meninges respiration depending http://pmj.bmj.com/ irregular. and in the vessels of the choroid plexus. With the spread of the inflammatory process irritative phenomena, such as fits and myoclonic i. Changes in pressure or choreiform movements, may appear, to be The primary increase in pressure, resulting from succeeded by paralyses. These motor signs tend increased formation of fluid, may be accentuated to develop with involvement of the cerebral later in the disease process by obstruction at those vertex. With basal lesions the cranial nerves are sites from which absorption normally takes place. the more liable to disturbance; there may be strabis- With obstruction at any point within on September 28, 2021 by guest. Protected mus, pupillary inequality, ptosis, trismus and cerebro-spinal system, on the contrary, an ap- teeth-grinding. parent diminution in pressure may sometimes The terminal phase is one of depression of result at points distal to the obstruction. In early function leading inexorably to death. childhood and in infancy, in particular, obstruc- tion at the base of the brain may result in fluid Meningitis in Infancy being obtained under low pressure by the common The manifestations of meningitis, producing method of lumbar puncture. In more extreme together so clear-cut a picture in children and cases it may prove difficult or impossible to obtain adults, are greatly modified in infancy. They may any fluid by this route, though cisternal or in early life be so atypical as to be misleading ventricular puncture will reveal that the pressure unless the great differences are borne in mind. above the site of obstruction is, in fact, con- The symptomatology of adult meningitis occurs in siderably raised. infants only at an advanced stage of the disease. As an aid to diagnosis, changes in pressure must Again, the analogy with peritonitis, as contrasted be considered in the light of these findings, and in adults and infants, may be drawn. provided always that an adequate technique is In infants in whom the anterior fontanelle re- adopted for its estimation. On the whole, changes Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from

July 1948 APLEY : Meningitis: Rationale of Diagnosis 367

TABIE 2 C.S.F. IN MENINGEAL IRRITATION I. Pressure 2. Cells 3. Chemistry (Pressure may be raised in all groups) Predominant Cell Chemistry GROUP Poly- IDENTIFICATION morpho- Mono- Sugar and nuclear nuclear Chlorides Protein I. Bacterial: Mild .. Increased Normal Increased Culture. Severe .. Increased Decreased Increased Gram stain. Direct typing. Tuberculous .. Increased Decreased Increased Acid-fast film, culture, guinea-pig inoculation. 2. Virus . .... Increased Normal Increased Complement fixation. Inoculation in animals. 3. Non-infective Irritation.. (e.g. haemorrhage) Increased Normal Increased 4. Aseptic Reaction .. Increased Normal Increased Negative culture. 5. Meningism .... Normal Normal Normal to Normal or Primary cause found. low decreased

in pressure are comparatively valueless in the are functioning normally; or it may result from by copyright. diagnosis of meningitis. Their occurrence is non- the altered permeability of meninges which are specific, and the highest pressures are frequently functionally impaired. recorded in such conditions as meningism or, Meningism provides an example of the former fallaciously, through faulty positioning or tech- group. In this condition the cerebro-spinal fluid nique in obtaining the specimen of fluid. chlorides are diminished because of the ante- cedent fall in blood chlorides. The protein in 2. Changes in cells the fluid obtained by lumbar puncture may, how- In meningism the cells tend to be diminished in ever, also be reduced. This reduction results number by the process of dilution; in all other from the enhanced circulation of the cerebro- http://pmj.bmj.com/ types of meningeal irritation a reactionary increase spinal fluid, because with an increased rate of flow in cells occurs. the protein in the fluid obtained by lumbar The type and number of cells which constitute a puncture approaches the lower level which is pleocytosis depend not so much on the under- normally to be found only in the ventricles. lying cause as on the speed of onset. Thus, the Examples of the second group are provided acute purulent meningitides are almost invariably by any infective meningitis. In inflammatory characterized and most in acute by polymorphonuclear leucocytosis, meningitis, markedly infections, on September 28, 2021 by guest. Protected while the chronic forms may show a preponderance because of the increased permeability of the of lymphocytes. On the other hand, though the blood-cerebro-spinal fluid barrier, the chemical usual chronic form of tuberculous meningitis composition of the cerebro-spinal fluid tends to typically shows a lymphocytosis, in its occasional approximate to that of the blood plasma (Cohen, acute form polymorphonuclear cells may pre- 1927). Those substances normally present in dominate. In anterior poliomyelitis a brisk relatively greater quantity in the cerebro-spinal meningeal reaction in the initial stages coincides fluid than in the plasma (e.g. chlorides) become with a polymorphonuclear leucocytosis; when the reduced in amount; those substances normally speed of advance of the disease process slackens a present in relatively smaller quantity in the lymphocytic reaction occurs. cerebro-spinal fluid (e.g. protein, glucose) become increased. Glucose provides an apparent ex- 3. Chemical changes ception; in meningitis its level in the cerebro- Alteration of the normal chemical composition spinal fluid may gradually fall, but only because it of the cerebro-spinal fluid may derive from one of is utilized in the inflammatory process. two main groups of causes. It may reflect changes Diagnosis should not rest exclusively on changes in the blood chemistry, even when the meninges in chemical composition, since these changes may Postgrad Med J: first published as 10.1136/pgmj.24.273.362 on 1 July 1948. Downloaded from

368 POST GRADUATE MEDICAL JOURNAL July 1948 be considerably delayed. Thus, a normal chloride necessary, immunological methods. In the large level is not incompatible with the diagnosis of majority of cases an immediate result can be tuberculous meningitis, for the level may become obtained by staining, either of a direct smear or of appreciably reduced only at an advanced stage in one made after rapid centrifuging of the cerebro- the disease process. spinal fluid. With skilled technique and ex- Table 2 summarizes the important changes in perience the culture of organisms from the fluid in the cerebro-spinal fluid. It will be seen that purulent meningitis is more frequently con- variations between the cellular and chemical firmatory than diagnostic. The severity of the in- responses are of great value in diagnosis, though fection can rapidly be gauged by a simple quantita- for ultimate identification additional investigations tive test for glucose concentration. usually prove necessary. The differences in The identification of haemophilus influenzae by cellular and chemical responses also serve to em- the above methods is less frequently successful, phasize the classification of the causes of meningeal since its morphological features are unpredictably irritation pr-vio,usly advanced on an aetiological variable. In difficult cases the capsular swelling basis. phenomenon may be employed.

Differentiation of Purulent Meningitides BIBLIOGRAPHY The treatment of optimal purulent meningitis COHEN, H. (1927), Brain, L., 6o0. depends on precise identification of the causal or- FREMONT-SMITH, F., DAILEY, M. E., and THOMAS, The and can be determined G. W. (I928-29), J. Clin. Invest., 6, 9. ganism. species type M. R. C. (1948), Streptomycin in Tuberculosis Trials Committee, only by accurate bacteriological and, where Lancet, April 17. by copyright. INFANTILE DIARRHOEA AND VOMITING By IAN M. ANDERSON, M.D. (Glasgow), M.R.C.P. (London) Assistant Paediatrician, Westminster Hospital

Infantile diarrhoea is a disease of infancy important factors contributing to the seasonal http://pmj.bmj.com/ characterized by vomiting, frequent watery incidence. With improvement in the milk supply, motions, rapid dehydration, loss of weight and a including the use of pasteurized and dried milks high mortality rate. and improvement in sanitation associated with the Diarrhoea and vomiting has always been a disappearance of the horse, the extermination of major problem to those physicians who have had flies and the establishment of Welfare Centres to deal with diseases of children. Epidemics have where infant hygiene could be taught to the been reported since early times. In England as mothers, there was no longer the same seasonal long ago as the mid I7th century epidemics of incidence nor mortality. It is probable that a on September 28, 2021 by guest. Protected such magnitude occurred as to lead to the death certain amount of infantile diarrhoea and vomiting of 2,000 babies during the hot summer weather of has always occurred throughout the year and that I669-71 (Garrison).' Carter2 in I893 drew when the incidence of summer diarrhoea fell below attention to the infective nature of the disease and the level of the all-season diarrhoea between 910o noted its relationship to impure milk; he and 1930 this latter attracted attention. Marriott4 suggested the use of subcutaneous saline. Wilson3 considered that otitis media and mastoiditis com- (1927) discussed the bacteriology and pointed out monly caused infantile diarrhoea and vomiting that the disease could be caused by many and following on his papers several others ap- organisms. deared claiming success in treatment by mas- Until the second quarter of the present century toidectomy. Findlay5 (I932) discussed the re- infantile diarrhoea and vomiting was synonymous lationship of otitis media to infantile diarrhoea and with cholera infantum and the main incidence of vomiting and mentioned the social and seasonal the disease was in the summer months. Eventually incidence. Craig6 (I935) drew attention to the however, investigations showed that contaminated disease as it occurred in the newborn and apart milk and poor hygienic conditions were the most from summer diarrhoea and Dick,7 Barenberg8 and