and the remnants of nerve-cells and fibres. Any of the pathogenic bacteria mentioned under acute focal suppura tive encephalitis may he present. The bacillus communis coli has also been observed by FIoward.
The infection followed a suppurating rectal wound, the child presenting very interesting congenital malformations of the heart, with imperforate rectum. The post-mortem lesions in this ease were acute purulent ependymitis and encepha litis (the ventricles being. distended with pus), with basic and cortical meningitis. The pus was creamy, yellow green in color, and a micrococeus was present in it as well as the bacillus communis coli. Howard (Johns Hopkins Hosp. Bull., vol. iii, p. 59, '92).
In some of the cases running a chronic course the brain-destruction may be very great, and an entire hemisphere or even more of the brain be destroyed, and present at the autopsy a semifluid and purulent mass.
Diagnosis.—The diagnosis is made by a study of the cause producing the con dition, the very grave nature and the decidedly septic character of the cerebral and general symptoms, the irregularity of its course, and the irregular and wide spread impairment of motor, sensory, or special-sense functions, according to the region affected. When in conjunction with purulent meningitis, the condition affecting the brain-substance can only be suspected by the intensity of the symptoms present, and their mode of onset, the grave set of paralytic symp toms with mental confusion or deep stupor, often succeeding the most acute manifestations of the meningeal inflam mation.
In some cases in which post-mortem examination reveals a large region of the brain converted into pus, and especially' in those cases where the clinical history was one of gradual loss of motor or sen sory functions, with loss of memory, con fusion of mind, without any period of active inflammatory symptoms being traceable, the condition has been called "cold abscess of the brain." It is more probable that such cases should be placed in a distinct class and that the fact be recognized, as pointed out by Gowers and others, that there is this form of softening which depends essentially upon a slow chronic form of encephalitis.
These cases, however, are quite rare, and are more often encountered, probably in hospitals for the insane than in civil practice. It is apt to occur in advanced life, at least after the age of forty.
Prognosis.—The disease always ter minates fatally, although some cases last several weeks.
Treatment. —Little need he said of treatment, which must usually be ex pectant and symptomatic. Cases pre senting signs of superficial pus-condi tions should have the benefit of trephin ing. Trephining with drainage of the ventricles may also be practiced in cases where the ventricles are distended with pus and signs of compression are great. Some cases of this kind have been re ported, in which free collections of pus in the cerebral fissures have been evacu ated and drained with success, so that in all cases in which a, diagnosis can be made the operation should be performed.
Chronic Encephaliti3.
The term "chronic encephalitis" has an indefinite and vague meaning, be cause it has been applied by different writers to a number of pathological states. As a clinical type, rare cases exist which present, post-mortem, a dif fused general sclerosis of evident inflam matory causation. These cases are rare, and the symptoms observed during life are very variable and their significance is rarely apparent during life. Sole rosis is., according to some authorities, alway-s primarily an inflammatory proc ess. If this be assumed, then the pa thology of almost all chronic brain dis eases would have chronic encephalitis as their prime causative factor. Consider able doubt, however, exists as to the essential nature of ordinary cerebral sclerosis, and positive proof is lacking. In gouty patients, according to Gowers, a chronic focal inflammation of the cor tex may exist and simulate brain-tumor, and optic neuritis may be present in addition to focal symptoms. Hughlings Jackson and others also have reported cases of seemingly primary chronic en cephalitis; but the cases are too few to need a separate classification. In some of these cases hypertrophy of the cortex has been noticed.