MENINGITIS SIMPLEX. 237 



appears as one symptom of constitutional syphilis ; and in the Greifs- 

 walder clinic I have seen a case of this kind, which has been fully de 

 scribed by Professor Ziemssen, at that time my assistant. 



ANATOMICAL APPEARANCES. Meningitis, with puro-fibrinous exu- 

 dation, occurs chiefly on the convexity of the cerebrum. In the acute 

 form we there find the small vessels of the pia mater more or less dis- 

 tinctly injected, and in the subarachnoid space, especially between 

 the convolutions and around the large vessels, we find a yellowish, 

 generally firm exudation, consisting of pus-corpuscles and fine granular 

 fibrin. In milder grades of the disease the exudation is chiefly in the 

 perivascular spaces. Occasionally the arachnoid is at the same time 

 covered with a more fibrinous or more purulent coating. The cortical 

 substance of the brain is sometimes of normal consistence, sometimes 

 it is softened by inflammation. The ventricles which, in tubercular 

 basilar meningitis, are almost always filled with fluid, are generally 

 found empty in purulent meningitis of the convexity. In chronic me- 

 ningitis we usually find the arachnoid adherent to the dura mater 

 either by a few points or throughout a considerable extent; the pia 

 mater is thickened and cloudy, the subarachnoid spaces filled with 

 turbid fluid ; or else we find the pia mater also transformed to a firm, 

 decidedly thickened membrane, which cannot be removed from the 

 brain without tearing. 



SYMPTOMS AND COURSE. Acute inflammation of the pia mater is 

 accompanied by symptoms of severe fever, particularly by a very fre- 

 quent pulse, and, like acute and extensive inflammation of other or- 

 gans, occasionally begins with a chill. Fever of similar character and 

 equal severity occurs in scarcely any other disease of the brain, and 

 consequently is very important in the diagnosis of meningitis. If the 

 frequency of the pulse disappear after the disease has lasted some 

 time, if it fall from 120-140 beats per minute to 60-80 beats, while 

 the other symptoms of fever and the functional disturbance of the 

 brain increase, the evidence is still more in favor of meningitis. The 

 other symptoms of the disease are headache and the repeatedly-men- 

 tioned functional disturbance of the brain, partly with the character 

 of irritation, partly of depression or complete paralysis. In acute me- 

 ningitis, the headache becomes very severe ; patients not only com- 

 plain of it while they retain consciousness, but even when this is im- 

 paired they frequently grasp the head and moan slightly, so that we 

 may suppose they still feel pain. In almost all cases there are psychi- 

 cal disturbances even at the outset of the disease, probably from the 

 vicinity of the cortical substance ; the patients are very excited and 

 restless, usually quite sleepless, and soon become delirious. In the 

 sensory functions also there is more irritability, so that the patient 



