MENINGITIS. 317 MENINGITIS. Ing and convulsions, followed by nnisculnr weak- ness and paralysis. The disease affects the dur.a of both brain and cord, but the symptoms refer- able to the latter are often overshadowed by the cerebral effects. The diagnosis is very diflicult and the termination almost invariably fatal. The case may be treated as one of apoplexy (q.v. ), but nothing materially alters the course of the affection. A chronic hypertrophic form of internal pachymeningitis occurs in the spinal dura, producing an extensive thickening of the membrane. This in turn causes severe compres- sion of the cord and spinal nerve-roots. After a tirst stage of shooting pains along the course of the nerves affected, with muscular twitchings and spasms, there gradually supervene ana-s- thesia, paralysis, and atrophy. As the compres- sion increases, paraplegia, secondary degenera- tion, and rigidity of the pai-alyzed parts appear. This form of pachymeningitis is due to syphilis, alcoholism, or injury, and is thought by some writers to follow- the hemorrhagic form. Treat- ment consists of counterirritation over the spine, with remedies for the pain and spasms. When the trouble is syphilitic great improvement may be derived from mercurials and potassium iodide. C'EREBEAL JIexingitls. Acutc inllammation of the pia mater of the brain occurs chiefly in two forms — tubercular, and simple or punilent. The arachnoid takes part, to a greater or less extent, in the inflammatory process. Tuhercular ineninffitis occurs at all ages, but is more common in children than in adults. The disease is caused bythe ?/oci7/H.? tiibrrciiJosisiind is usually secondary to a tuberculous process in some other portion of the body, for example, pul- monary phthisis, hip-joint disease, or caries of the spine. Primarv cases are said to occur, but it is usually found after death that caseous tubercular glands, or other latent or previously imrecognized forms of tubercular infection, are present. The characteristic lesions of the dis- ease are found in the pia mater at the base of the brain, or over the optic chiasm, crura, or pons. Tubercles are deposited along the vessels of the pia. which becomes thickened, opaque, and studded with grayish white granules. There is an exuda- tion of lymph, gray or grayish yellow, biit rare- ly purulent, into the meshes of the membrane in the same portions in which the tubercles exist and extending along the fissure of Sylvius and the middle cerebral artery. The upper surface of the hemispheres is only slightly affected, so that the disease is sometimes called basilar meningitis. The ventricles are generally distended with fluid (whence the old name, acute hydrocephalus), clear, milky, or even bloody. The symptoms of tuliercular meningitis are very comiilcx, and a case fully developed presents a painful clinical picture, particularly in children. The onset of the disease is often preceded by a period of gen- eral ill health. The child is peevish, irritable. and experiences a complete change of disposition, together with loss of appetite and constipation. The first or irritative stage then sets in sud- denly, with a convulsion, or more commonly with vomiting, headache, and fever. The headache is severe and continuous, and the child moans and occasionally utters a sharp cry — the so-called Tiydrocepbalic cry.' Sometimes the patient screams until utterly exhausted and has to be kept under the influence of powerful sedatives all the time. There is moderate fever and exces- sive sensitiveness to light and sound. In the second period of the disease, the stage of de- pression, the irritative s^ymptom.s subside. The child no longer complains of headache, but is dull and apathetic, drowsy or slightlj' delirious. Pulse and respiration are irregular, and fever continues. The head is retracted and the neck stiff. If the finger-nail is drawn across the skin of the forehead or abdomen a broad red streak appears, the tdchc cerebrate, which may last for five minutes. In the last or paralj-tie stage, all these symptoms are intensified; the drowsiness increases to coma ; paralysis of various parts of the body occurs, and death takes place in from ten days to three weeks after the onset of i)ronounced symjitoms. Few ca.ses recover. Treatment is entirely symptomatic and palliative. An ice cap is put upon the head, and sedatives are given in- ternally. Simple acute meninrfitis is as a rule purulent or suppurative. It may be caused bj' inflamma- tion of neighboring tissues, e.g. otitis, suppura- tive phlebitis, or abscess of the brain; or may occur as a complication of pyemia, septicoemia, malignant endocarditis, or the specific fevers, par- ticularly smallpox, typhoid, and scarlatina. The pia mater and arachnoid become infiltrated with purulent material, and the brain beneath them is commonly softened. The symptoms resemble in a. general way those of the tubercular form just de- scribed, but the onset and course of the malady are much more rapid. When simple meningitis occurs in the course of other acute illnesses, its features may be ma.sked to a certain extent, but in other cases the s_vmptoms begin acutely with a chill, severe pain in the head, and vomiting, and the ease passes on to convulsions, paralysis, coma, and death, as in the tuliercular form. A fatal termination is the rule, but some recoveries occur after a long period of convalescence. Spixal Meningitis. The membranes of the spinal cord may be affected separately, but it is common for inflammation to spread from one to the others. Inflammation of the dura, pachy- meningitis, has already been described. Acute leptomeningitis, or acute spinal meningitis as it is called, involving the pia, is often of obscure origin, but is known to lie due to exposure to cold, sunstroke, and injuries to the spine ; and it sometimes complicates pneumonia, scarlatina, typhoid fever, and septic;T?niia. Not infrequently a tubercular inflammation accompanies a like process in the cerebral pia mater. The attack begins with the usual symptoms of meningeal inflammation, namely, vomiting, chill, fever, and pain. The pain is in the back; it may be local or general, and it is increased by movement or pressure. There are also shooting paro.xysmal pains radiating along the course of the nerves arising in the affected area, and extreme sensi- tiveness of the skin and muscles to which those nerves are distributed. Irritation of the anterior nerve-roots leads to spasms of the muscles, pro- diicing rigidity of the spine with sometimes ex- treme arching (opisthotonos). In addition there is the usual accompaniment of fever. After a few days the symptoms of irrital ion give way to paralysis and insensibility, and the disease either proves fatal from exhaustion and failure of the respiratory muscles or lapses into a chronic condition with wasting and shortening of the muscles. Some patients recover after several months, while others ultimately die from bed-
