The prognosis is bad, yet a number of patients recover. Treatment. The patient should be kept free from noise and light. The continual use of the ice-cap throughout the disease is frequently of service, and should always be employed. Leeches should be applied behind the ear in robust cases, but depletion in the latter stages of the disease is not to be advised. Blisters to the occiput add to the discomfort of the patient and do no good. Calomel and magnesium sulphate should be given at the outset, in such doses as will act on the bowels and reduce the meningeal congestion. Ergot is advised during the earlier stages, to reduce congestion. Potassium iodide in 5- to 10-grain doses is employed as a routine treatment, but its use is theoretical. The restlessness and headache are to be controlled by opium, phenacetine, chloral, bromide of sodium, and sulphonal. For the tubercular form the head may be shaved and covered with iodoform ointment; for this treatment good results have been claimed. Should meningitis follow middle-ear disease or suppurative disease of the dura, localized trephining and drainage should be practised. To avoid meningitis prophylactic treatment should be directed toward the careful cleansing of the ear in suppurative otitis media, the opening and draining of abscesses of the mastoid cells, and the antiseptic treatment of suppurative processes about the cheeks and the orbit. SYPHILITIC MENINGITIS. CHRONIC MENINGITIS. Etiology and Synonym.-The disease is one of middle life, and is most commonly seen in those who have led a life of privation and exposure. It is common in tramps and in the inhabitants of almshouses. Chronic alcoholism and cerebral endarteritis seem to lead to the disease. Chronic meningitis may complicate fractures or inflammation of the cranial bones, chronic pachymeningitis, chronic Bright's disease, chronic degenerations of the brain, and slow-growing cerebral tumors. Synonym: Chronic leptomeningitis. Pathology. The pia mater is thickened, opaque, œdematous, and infiltrated with cells. There may be adhesions between the pia and the dura. The brain-cortex may be softened or sclerotic. The ventricles may be distended with clear serum, and the ependyma lining them may be thickened and rough. The meningitis may be localized at the base or the cortex of the brain. The symptoms are those of slow compression; they resemble those of chronic pachymeningitis except that hemorrhages do not occur. Prognosis. The disease is chronic in its course, extending over years, but recovery cannot be expected. Treatment.-Syphilitic meningitis should be excluded. by a conscientious trial of mercury and of potassium iodide in full doses. Otherwise the treatment is symptomatic. MENINGEAL HEMORRHAGE. Hemorrhage may occur between the dura mater and the bones of the skull, and between the dura and the pia mater. HEMORRHAGE BETWEEN THE DURA MATER AND THE BONES OF THE SKULL.-Etiology.-These hemorrhages are regularly due to violence, either by concussion separating the dura from the cranial bones and lacerating the middle meningeal artery, or by fracture of the cranial vault. The symptoms are those of shock, laceration and compression of the brain, followed by the symptoms of meningitis. Although these cases are of surgical rather than of medical interest, they are important to the physician, owing to the unpleasant results that follow an erroneous diagnosis. A man whose breath is alcoholic may be found unconscious in the street with a scalp-wound. The case is regarded as one of alcoholism, but the coma deepens, the temperature rises, and the patient dies. At the autopsy there is found a fracture of the skull with laceration of the middle cerebral artery and meningeal hemorrhage. Treatment. In suspected cases incision should be made, exposing the site of probable fracture. When the diagnosis is made, trephining and removal of the clots should at once be resorted to. HEMORRHAGE BETWEEN THE DURA MATER and the Pia MATER. Etiology. This form of meningeal hemorrhage may occur from—(1) Traumatism; (2) thrombosis of the venous sinuses; (3) in new-born children as the result of severe labor or the pressure of forceps; (4) chronic hemorrhagic pachymeningitis; (5) rupture of an aneurysm of one of the cerebral arteries; (6) after convulsions in children; (7) hemorrhagic diseases. The disease may occur at all ages, thus differing from cerebral hemorrhage. Pathology. The hemorrhage may be at the base of the brain, at the convexity, or may be more equally distributed. Small hemorrhages may ultimately be absorbed, leaving hæmatin staining. It must be remembered that in cerebral hemorrhage the blood may rupture through the cortex or may leak out by the fourth ventricle and appear between the membranes. The symptoms vary according to the size, location, and cause of the hemorrhage. 1. Large Clot over One Cortex-There is sudden coma, with stertorous breathing, slow pulse, and abolition of all reflexes. There may be hemiplegia or monoplegia, according to the size and position of the hemorrhage. Convulsive movements of muscles ultimately to be paralyzed may occur. The temperature falls to 96° or 97° F., but subsequently rises to 103° or 105° F. or even higher. The patient may die in coma within twenty-four hours, or may die in several days with the symptoms of meningitis. Recovery occurs only if the clot be small. Small hemorrhages over a convexity may give rise to the symptoms of acute meningitis without the occurrence of sudden coma. 2. Clots over both hemispheres give rise to sudden coma and general convulsions, so that the diagnosis from uræmia may be one of great difficulty. 3. Hemorrhage at the base of the brain compresses the medulla and leads to death in a few hours. A high antemortem temperature is usually observed in these cases. 4. Meningeal Hemorrhage of the New-born.-The child may be stillborn, or it may be born in asphyxia, from which it may die, or from which it may recover, only to die in coma with convulsions within a few days. In those who live, symptoms of paralysis with or without athetosis, mental defects, and epileptic seizures may develop (see Cerebral Atrophy of Children). The prognosis of meningeal hemorrhage is bad unless the clot is small and is situated over the convexity. Recovery may be complicated by permanent paralysis (with or without convulsive movements) of groups of muscles upon the side opposite to the lesion. Death from meningeal hemorrhage usually occurs earlier than from cerebral hemorrhage. 2. DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. CONGESTION. Congestion may be active or passive. Active hyperemia may be due to exposure to the sun, to the ingestion of such drugs as alcohol, amyl nitrite, and nitroglycerin, to excessive brain-work, to reflex causes, or to fever. Passive hyperemia results from (1) mechanical obstruction to the venous return of blood, as with tumors of the neck or strangulation; (2) from general venous congestion due to heart or lung disease. senses. The symptoms are neither characteristic nor constant. The active congestion causes headache, a sense of fulness and throbbing in the head, and hyperæsthesia of the special The face is flushed; the superficial arteries pulsate visibly. Passive hyperæmia gives rise to dull headache, to mental slowness, to disturbances of sleep, and to a feeling of fulness in the head. Attacks of delirium or unconsciousness may attend the severer forms of congestion. Treatment. The patient should be kept quiet, and the bowels should be freely moved. Venesection may be indicated in acute congestion of an intense type, and an icecap should be applied to the head. In passive hyperæmia the treatment should be directed toward the cause of the condition. ANEMIA. Anæmia may result from general or local causes. Localized anæmia may be due to vaso-motor constriction, endarteritis, or cerebral compression. Symptoms.-Acute anæmia, such as results from profuse hemorrhage, gives rise to confusion of ideas, marked dyspnoea amounting to "air-hunger," spots before the eyes, ringing noises in the ears, a tendency to yawn, nausea, and dilated pupils. Convulsions and syncope may occur. Sudden death in syncope may result from an intense anæmia suddenly induced. Chronic anæmia is characterized by vertical headache, disturbances of sleep, lack of mental power and concentration. 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