Chronic cerebral meningitis, unconnected with a tuberculous condition, is not of fre quent occurrence, lthough not so rare as the acute form. In most instances it is a sub-acute affection front the commencement, and is very insidious in its character, the symptoms being such as not to strongly attract attention. There is pain in the head, but not usually violent, and the febrile symptoms are unitnportant. Vomiting is common, but as all these symptoms accompany other diseases, it is difficult to inake the distinc, lion. There is often a degree of stupidity or apathy, accompanied by irritability when aroused, and which, taken in connection with all the other sy-raptonis and the circum stances attending the inception of the disease, furnish to the ex-perienced practitioner data for forming in most cases a correct judgment. 3. Tuberculous meningitis. The recognition of this form of meningitis is due to Guersaut in 1823, and Gerhard and Rufz in 1833. Post-mortem examination reveals usually at the base of the brain beneath the arachnoid a fibrinous exudation, covering the pons-varolii, optic commissuros and cere. belltnn; but the most prominent feature is the presence of numerous minute granula tions having the appearance of gray tubercles, such as are found in the lungs and spleen in tuberculosis. These miliary tubercles, as they are called, are in the tract of the cere bral vessels, and according to Bastian and others within sheaths which are peculiar to the blood-vessels of the brain, and called perivascular sheaths, because surrounding the lalood-ve,ssels. (These perivascular sheaths are also found in the liver, q. v.). The symp toms are somewhat intermediate between those of acute and chronic simple meningitis, but the affection is frequently preceded by signs of tubercles in the lungs. It generally attacks children between 2 and 7 years of age, rarely appearing during the first year, but it is not confined to childhood. It usually commences with pain in the head, gener ally in the forehead. Vomiting is a frequent and early symptom, and there is more. fever than in simple clironic meningitis, Remissions usually take place daily, with increased symptoms during the night, Sometimes the headache is very severe, attended by a short, sharp cry which has been called the " cephalic cry." There is great sensibil ity to light and sound. The pupils, in this the first stage, are contracted, and the con junctiva suffused. A. p.rominent symptom is the flushed face which comes on itt paroxysms, often precedmg convulsions. In the second stage there is drowsiness and less headache, although lancinating pains often occur. The pulse becomes less frequent, sometimes falling below the natural standard, and is often fluctuating and irregular The respiration also becomes irregular. The pupils are dilated, and not infrequently unequal in size. Strabismus and oscillation of the eyeballs sometimes occur, and the patient often lies with the lids partially or widely open. There is Often paralysis of one side of the face, and sometimes, more or less, of one side of the body. The muscles of the back °Mlle neck often have tonic contractions, and there are sometimes contractions of the muscles of the limbs. There is almost always obstinate constipation in conse quence of the sluggish and deranged condition of the nervous system, and there is generally retention of urine. The duration varies from 1 to 3 weeks and is almost invariably, some say invariably, fatal. 4. Spinal meningitis. This disease, like cerebralt meningitis, may be acute or chronic, and it is also rare; excluding cases arising from. injury, even more rare than the cerebral affection. The pathological conditions aresimi lar to those in cerebral meningitis, but the symptoms are somewhat different, owing to. effects manifested through the spinal nerves. Pain is felt in the spine, passing to the extremities, and it is increased by movements of the body more than by pressure over the spinal column, and there is great increase of sensibility of the surface of the body. The pain is referable to the posterior roots of the cord. Muscular contractions are, referable to excitation by the disease of the anterior roots, sometimes causing the bend ing of the body backwards. producing the condition known as opisthotonos (q.v.). Sometimes the thoracic muscles are the subject of tonic spasm, causing great difficulty of breathing (dyspncea). These are the early- symptoms; subsequently paralysis and other symptoms follow, constituting the second stag,e. Acute spinal meningitis is rapid in its course, generally, terminating fatally within 8 or 10 days. Asphyxia is the usual mode of (loath, in consequence of spasni of the respiratory muscles, or, more frequently perhaps, from paralysis of the respiratory nerves.
_ Cerebro-spina/ Meningitis. This disease usually occurs as an epidemic, idiopathic caiSftling very rare. The epidemic form is a consequence of blood poisoning, and is a very dant, -,,,ons affection which has sometimes extensively- prevailed in different parts of the United States and Europe. It has sometimes received the name of spotted fever in consequence of the appearanee of certain spots upon the skin in the course of the attack,. bra the spots are not constant accompanhnents. The latter name was applied to an epi 'demic which prevailed in New England between the yeam 1807 and 1816, from the sy-mp toms of which, as described, there is scarcely any doubt it was what is now called cere bro-spinal meningitis. This disease has been considered by some as a variety of typhus fever, but its greater suddenness and the absence of the characteristic mulberry rash of typhus prevent the general adoption of this view. The disease is usually ushered in teith. a chill followed by violent headache, vertigo, vomiting, and muscular rigidity, passing into tetanus. There is here also, as in the other acute meningeal affections, increased sensi tiveness of the skin; the face is pale, the pupils contracted, and the conjunctiva red. There is delirium, and usually as early ds the second day in the more severe cases the. extensor muscles of the neck and back are strongly contracted. The delinum soon. passes into coma. According to Wunderlich there are three forms. In the first, the. most rapidly fatal, the temperature rises at the approach of death to 108° F. and con tinues to rise for some hours after death. In the second form the fever has an Jrcegular course and short duration. The third form is protracted and with great variations ut temperature. In the commencement of an attack of cerebro-spinal meningitis. the pulse is often slower than in health, hut sometimes is more frequent. It increases with the .dis ease, but generally does not exceed 100 beats per minute till towards the fatal tennina tion, when it became very frequent. Headache is oue of the most prominent sy-mptoms. It was wanting in only one of 64 cases analyzed by Aines. The pain is intense, lanemat ing, and may be seated in the forehead, occiput, or the whole head. It is inciyased noise, light, and the motions of the bodv, and is persistent. There is usually pain also in the spine, but not always throughout its whole length, and the probability is that the pain corresponds in location with the seats of the inflammation. In the less severe cases the delirium is rather slower in being developed, and varies much in intensity. A. t. first the patient appears stupid, and sometimes remains so, but often becomes.wildly delinous, and struggles with his attendants. As a rule there is obstinate constipation in consequence.of the semi-paralyzed or deranged condition of the nervous system. The tongue vane& in appearance, sometimes being. large and flabby, and showing marks made by the teeth_ As the disease progresses it becomes dry and dark. Petechial spots are frequently .obesrved, but they are not constant, and accompanying some epidemics more than others. They vary in size from a pin'd head to a quarter of an inch or more, and are regarded as being due to an extravasation of hematine. They are of the nature of the ecchymoses -which occur in scorbutus, purpura, and some cases of continued fever, and do not consti tute a specific eruption. According to Tourdes, however, a rose-colored papular erup tion, resembling that of typhoid fever, sometimes appears. The duration of the disease -varies. Of fatal cases observed by Tourdes the shortest duration was 20 hours. Ames :states the shortest duration to be 15 hours. The longest duration of fatal cases is stated by Tourdes to be 100 days. Of 160 eases,analyzed by Dr. S. B. Hunt 12 died within the first 24 hours; 92 died before the end of the fifth day: 14 before the end of the teuth; 4 before the end of the fifteenth, and 18 survived for shorter or longer periods. Some writers Tegard the disease as belonging to the class of fevers instead of primarily to the nervous :system, and this is probably the correct view. Boudin, in lt349, proposed to call it cerebro-spinal typhus. It attacks all ages, but the larger number of cases occur between 20 and 30 years and the liability is rather small before 7 years. Males are more fre. quently the subjects than female,s, but the difference is not great. It prevails more in the winter and spring than during the summer. It is stated to be a disease of confined quarters, such as barracks and prisons. From 1837 to 1842 it prevailed in, most of the crowded barracks of France, and has been a frequent visitor of the galley slaves at 71roulon.