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The Diagnosis and Management of Tuberculous Meningitis
  1. Guy E Thwaites
  1. Oxford/Wellcome Trust Clinical Research Unit, 190 Ben Ham Tu, Ho Chi Minh City, Vietnam; E-mail: gthwaites{at}



The postmortem observations of Green, published in the Lancet in 1836, were the first to describe the distinct pathological features of tuberculous meningitis and set it apart from the other recognised causes of ‘acute hydrocephalus’ (Green 1836). The challenge for the physician then lay in distinguishing the disease before death, and delivering the grave prognosis. Thomas Mann captures the full horror of this process in Dr Faustus as the helpless Dr Kurbis presides over the agonizing death of a small child from tuberculous meningitis:

The whole thing lasted scarcely two weeks, including the earliest signs that all was not quite well with the child; from the beginnings no one – I believe no one at all – even dreamed of the horror to come … Kurbis tested the child’s eyes, the pupils of which were tiny and showed a tendency to squint. The pulse raced. Muscular contractions developed, and an incipient

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