Furunculosis or erysipelas of the scalp leads to purulent men ingitis by direct extension along the lymphatics rarely- and only in eacheetic children.
Infections of a septic nature (typhoid, influenza, etc.) or those localized in a distant part of the body, and which implicate the meninges by metastasis, differ from those mentioned, directly extending infections. The source of infection ean very often be only surmised,—tonsillitis, osteomyelitis, etc. Purulent meningitis originating metastatically pre sents no anatomical peculiarities differing from eases caused by direet extension.
Comparatively frequently meningitis develops with or as the result of pneumonia or pleurisy.
It is quite certain that often in such eases the eirculation carries the pathogenic germs, still the remarkably extensive participation of the spinal meninges, which we have often observed in purulent pleuritis, argues that the microbes travel by way of the lymphatics through the intervertebral foramina. The fact that. at the autopsy purulent otitis media. is almost invariably found assoeiated with empyema and purulent meningitis, had led to the assumption that it. furnishes the primary focus for both the other affections, a doctrine from whieh we must dissent for the reasons stated above.
pathology of diffuse purulent meningitis calls for little discussion. Usually, besides the external meninges, the chorioid plexus and the ependyma ventrieuli are diseased; indeed the purulent inflammation of the ependyma may preponderate to such an extent that the entire process might fittingly be denominated "ependymitis." It is evident that the cortex suffers circulatory and nutritive disturbances and round cell infiltration, exactly, as in tuberculous meningitis, and constitutes the source of at least some of the symptoms, while some are induced by cerebral pressure.
if we now proceed to portray the clinical picture of diffuse purulent meningitis it should at the outset be emphasized that its aspect is decid edly modified by the consideration svhether the disease apparently attacks an hitherto healthy child, primarily, or a child severely ill, terminally. In the latter instance, as for example with severe pneumonia:or empyema the meningitis sometimes completely escapes notice, because the pros tration clue to the basic disease obscures the cerebral symptoms. At
most the appearance of complete somnolence may call attention to the complication, but it is noteworthy that consciousness may be preserved until a few hours before death. However under these circumstances the tense, pulseless fontanelle in infants indicates cerebral involvement; in older children the startling discovery is first made at the autopsy, an experience which we have had repeatedly in cases we had watched According to our experience the onset of purulent meningitis does not have the same influence in lowering previously existing high fever, to which we called attention as a not infrequent occurrence in the tuber culous form.
Symptoms.—The disease, in children previously not very sick, usually begins suddenly. With decided elevation of temperature and acceleration of pulse the child becomes restless; although there is increased inclination to sleep—during the day—the normal, sound sleep of childhood is wanting; anorexia, coated tongue and vomiting, independent of the ingestion of food are among the early symptoms. Older children complain of distressing headache and violent delirium occurs; younger children by whimpering and crying when the head is touched evince the same discomfort. Cervical rigidity is rarer than in tuberculous and meningococcus meningitis; but epihmtiform and elonic tonic convulsions in single limbs or groups of muscles, occur in the boginniug as well as in the later stages of these much more frequently than in those forms. The abductors of the hand and the flexors of the fingers seem to us to be affected by preference. There occur small, short, slowly repeated contractions, often with associated trismus and grinding of the teeth. The convulsions recur, especially in infants, at intervals of a few minutes; sometimes tonic convulsions can be excited by striking a particular part of the body (hydreneephalic reflex convul sions). However convulsions are not an absolutely essential symptom in these forms of meningitis The sensorium appears clouded from the inception, often only slightly, usually however rapidly advancing to deep lethargy. The symptomatology and later course, apart from their greater rapidity of succession, resemble so closely those of tuberculous meningitis that we refer to its presentation and here we will select only some more important matters.