system and that they are seldom met with in diseases of the nervous system outside of meningitis.'

Tremor of the head and limbs on movement is usually found when the disease is advanced and eventually some rigidity of the limb appears but this may vary from day to day.

Laboratory Findings.

Urine generally normal though amount per 24 hours may be lessened and it may contain a trace of albumin or sugar.

Blood usually shows a leukocytosis of from 15,000 to 30,000 with no appreciable increase in the relative lymphocyte count. Cabot (6) found leucocytosis in 32 of 43 cases.

Tuberculin Tests. Von Pirquet and Calmette reactions are fairly constant in the early stages but negative in the later according to Holt.

Spinal Puncture. The fluid obtained from spinal puncture is the greatest single help in the diagnosis we have. Ebright (5), in an article on the subject summarizes the facts to be gained from spinal puncture as follows:

(1). High intraspinal pressure in the irritative stages should be measured by water manometer. Rous found an average pressure of 308mm of distilled water, Normal 120-180mm.

(2). Fluid usually clear. Presents a filmy coagulum on standing a few hours. This coagulum is highly characteristic.

(3) Albumin content-high may equal 7%, is usually 2%. (4). As in all meningitides Fehlings solution is not reduced.

(5). Tubercle bacilli in 30 to 50% of cases and always post mortem.

(6). Lymphocytes are usually present except in later stages when polymorphonuclears may predominate possibly on account of mixed infection but more likely because the protective function, represented by the increase in lymphocytes in tuberculosis, has been overcome and lost.

Hemenway (7) found the tubercle bacillus in all but 2 of 137 cases.

Diagnosis.

The vague history and the common symptoms, headache, vomiting, restlessness and convulsions make the diagnosis in the early stages difficult. The first conditions to rule out are

those referable to some form of gastro-intestinal catarrh and second, the exanthems and pneumonia.

Typhoid fever is probably the most important single disease to be considered, but the more regular and more characteristic fever, the roseola, the position of the patient,-lateral in meningitis, dorsal in typhoid-the presence of the agglutination test, the leucopenia and finally the findings on lumbar puncture serve to differentiate the two diseases.

From the exanthematous diseases and pneumonia a diagnosis is often impossible for the first three to five days, but by that time the characteristic eruption of the exanthem or the pulmonary signs of a pneumonia should have appeared and the pulse and temperature become more suddenly and more persistently higher than in the prodromal stage of a tuberculous meningitis.

Martin (8), calls especial attention to the liability of confusion in the diagnosis from what he calls "meningesim" occurring during the course of acute infectious diseases or intoxications where the condition simulates a meningitis but is without the pathological changes. He would rely only upon the demonstration or cultivation of the tubercle bacillus from the spinal fluid or upon the inoculation test. According to him the presence of a lymphocytosis in the spinal fluid is of less value for it may occur in other diseases. Porter (14) calls attention to this condition also and says that it is most frequently associated with typhoid, influenza, pneumonia and intestinal toxemia.

The presence of a trace of albumin in the urine combined with a partial suppression leads one to think of uremia especially inasmuch as the convulsions and coma are also found. Lumbar puncture usually helps to exclude this condition. Takemina (13) reports a case occurring during pregnancy in which uremia and eclampsia had to be excluded.

Hysteria is sometimes indistinguishable from a tubercu lous meningitis in adults, some of the mental symptoms being suppressed by douching and electrical applications as in hysteria. The incontinence of urine and faeces associated with strange behavior on the part of the patient may lead to the same diagnosis or be mistaken for the onset of mental disease. Delirium Tremens.

Otitis Media.

Thrombosis of the Cerebral Sinuses.
Cerebral Syphilis.

Cerebral Abscess.

Cerebral Tumor, especially if tuberculous, all have to be considered. The absence of the cardinal signs of tuberculous meningitis during the observation of the case and the findings on lumbar puncture being the greatest helps in the diagnosis.

Prognosis.

The prognosis in every case of tuberculous meningitis is grave although recoveries have been reported. There are several reasons for the enormous mortality in the disease according to Hatgar (9). 1. "The injury to the brain due to the pressure causes degenerative encephalitis. 2. The coexistance of a tuberculous process in some other part of the body, usually in the lungs and 3. The fact that it often occurs as a terminal infection in diseases, such as nephritis and cirrhosis of the liver", are important factors. The first of these reasons is the most important-the greatest danger being due to pressure upon the medullary centers and the gray matter for as is well known tuberculosis elsewhere has a remarkable tendency to spontaneous cure."

From a careful analysis of 797 cases occurring in seven London hospitals since 1894, Dr. A. Martin (8) concludes that only 20 can be accepted as positive recoveries. He says remissions. and recoveries do occur probably more frequently than has been believed and that in those cases either the resistanc of the individual is greater than usual and the disease is checked early in its course or the virulence of the bacilli is less than usual and the lesion in the meninges becomes localized and undergoes a fibrous change or later form a focus of fresh infection.

Dunn of Boston, Hamill of Philadelphia, and Abt of Chicago, each reported a case at the American Pediatric Society in Washington, in 1910, of recovery from tuberculous meningitis. In each of these cases the bacillus and the lymphocytosis were shown in the spinal fluid.

The duration of the generalized diseases varies from 3-63 days. The so-called primary cases, those in which tuberculous meningitis occurs in a child apparently in the best of health and in fair nutrition, averages according to Gee, 23 days. In the secondary cases, those in which the tuberculous process in the meninges supervenes upon a chronic tuberculous process, the duration is much shorter and may be no longer than three days.

Treatment.

Prophylaxis. All tuberculous lesions and all atria of in