recommended by Victor Horsley. If the
phlebitis is accompanied by other intra-cranial infections, these are,
of course, treated at the same time.

The _superior sagittal_ or _longitudinal sinus_ is liable to be
infected from pyogenic lesions of the scalp. There are no symptoms
that are pathognomonic, but oedema of the scalp with turgescence of
its veins, epistaxis, and convulsions followed by paralysis, are those
most likely to be met with.

The _cavernous sinus_ is usually implicated by spread of the process
from other sinuses--for instance, from the petrosal or transverse
(lateral) sinuses--or from the ophthalmic veins in cases of orbital
cellulitis. Although at first unilateral, the thrombosis usually
spreads across the middle line to the sinus of the opposite side. The
special symptoms--exophthalmos, oedema of the eyelids, and paralysis
of the ocular nerves--are due to pressure on the structures entering
the orbit.

Operative interference is seldom feasible in phlebitis of the superior
sagittal (longitudinal) or cavernous sinuses.

#Intra-cranial Tuberculosis.#--_Tuberculous meningitis_ is most
frequently met with in patients below the age of twenty, and the
infection takes place by the blood stream from some focus elsewhere in
the body or from the spinal membranes. In cases of tuberculous disease
of the middle ear infection may spread to the membranes by way of the
internal auditory meatus (Macewen). The arachno-pia, especially at the
base, is studded over with miliary tubercles, and an excess of fluid
collects in the arachno-pial space and in the ventricles (_acute
hydrocephalus_).

At first the _symptoms_ of irritation of the brain predominate: severe
headache, photophobia, inequality of the pupils, stiffness of the
neck, cutaneous hyperaesthesia, vomiting and convulsions. Kernig's
sign--pain on flexing the hip while the knee is extended, and
inability to extend the knee while in the sitting posture--is present.
There is usually obstinate constipation, and the abdomen is retracted.
Later, signs of increased intra-cranial tension develop:
unconsciousness deepening into coma, paralysis of ocular muscles,
rapid pulse, Cheyne-Stokes respiration, and sometimes hyperpyrexia. An
excess of mono-nuclear lymphocytes and, sometimes, tubercle bacilli
may be discovered in the cerebro-spinal fluid withdrawn by lumbar
puncture. The absence of the diplococcus intracellularis helps to
differentiate the disease from cerebro