MENINGITIS SIMPLEX. 239 



which by their appearance often set at rest any remaining diag- 

 nostic doubts. These palsies are rarely complete hemiplegias, and 

 seldom are they so marked as when arising from local disease of the 

 brain ; but they ought not to escape the attention of any but a su- 

 perficial observer. Sometimes an arm or a leg loses its strength. 

 More commonly, however, there is a partial palsy of the face, such 

 as dilatation of the pupil with insensibility to light, squinting, or the 

 like.] The pulse also is usually, but not always, retarded. While 

 the stupor and general paralysis increase, the patient generally dies 

 of coma in a few days, more rarely not till the second or third week. 

 These stages in the clinical course, between which there is occasion- 

 ally a slight improvement, cannot be referred to any perceptible 

 change in the pathologico-anatomical course ; as if, for instance, the 

 first stage corresponded to the hypersemia of the meninges, and the 

 second to the exudation in the subarachnoid space. Nor must we 

 omit to mention that not unfrequently, especially where the menin- 

 gitis is due to caries of the petrous bone or to disease of the brain, 

 the first stage is very little marked or not at all noticed. In these 

 cases the symptoms begin with an attack of convulsions, which is 

 repeated several times, and is followed by deep coma and general 

 paralysis, usually accompanied by contraction of certain muscles. 



[Stories of recovery from acute meningitis must be accepted 

 with hesitation, error of diagnosis being a more probable event. 

 Nevertheless, limited and mild inflammations of the pia mater un- 

 doubtedly have got well, but convalescence is very slow, and various 

 derangements of the nervous apparatus persist for a long time. In 

 chronic cases, and less often in acute ones, there may be imperfect 

 recoveries, with permanent damage to the meninges and cortical 

 matter of the brain with trembling paresis, numbness of a limb, 

 squinting, or deafness ; sometimes there are epileptic fits. The pro- 

 gressive palsy of the insane appears to depend upon a creeping 

 inflammation of the meninges and upon periencephalitis, with occa- 

 sional exacerbations and rises of temperature. The periods of men- 

 tal excitement, headache, and convulsions correspond to those of 

 elevation of temperature. Many other cases of insanity, character- 

 ized by psychical depression and ending in idiocy, must also be 

 attributed to permanent injury to the cortical substance and menin- 

 ges from inflammation. 



The diagnosis of meningitis may present great difficulties. It 

 has no pathognomonic symptom, and it is only by a careful grouping 

 of the signs and a history of the case that a positive determination 

 can be made.] 



The symptoms of chronic meningitis are not accurately known, fre- 



