For example, a child two to three years of age begins to lose interest in play, becomes moody, and all the efforts of its family to please it scarcely succeed. At times it is peevish, it loses its appetite and fre quently, but by no means always, vomits.
There is usually, at an early date, disturbed, broken .sleep, lighter than in health.
As a rule in this stage physical examination discloses nothing definite: at most the tongue is somewhat coated and the temperature is slightly elevated—to 3S° C. (100° F.) or a little higher; pulse and respiration are normal or, in the presence of fever, only slightly hurried. Therefore the attack is often regarded as a digestive disturbance, an error which even the experienced observer cannot always avoid. But one should not, as often happens, because of the normal stools, speak of a gastritis., as this presents no independent symptom-eomplex. Doubt concerning the diagnosis does not as a rule persist longer than two or three days; then the failure of the prescribed treatment (laxatives, scant diet of cereal waters) indicates the serious nature of the disease. It is evident that the child grows constantly weaker, more apathetic, scared. He sits by his toys for a long time without playing. At times he lies down and would gladly go to bed also in the daytime. Ile lies there half awake or perhaps falls asleep and arises after one or several hours apparently refreshed. But the improvement does not last long; play is not very alluring. At times the child sighs, but to the question whether anything hurts, even children four to six years of age seldom say definitely that they have headache; more frequently they complain of being tired, pains in the legs (in the tibite) or abdomen.
Physical examination even at this time usually discloses an indefinite pulse anomaly, which with the advance of the disease soon becomes more evident and is numbered among the most constant symptoms of meningitis. The pulse is irregular and uneven, especially' after moving about., changing position ancl the like. The pulse rate is not altered in the same manner in all eases; it is usually normal, seldom somewhat increased (corresponding to the low fever) occasionally a little. diminished. Increased tension and pulsation of the membrane of
the fontanelle, in children with patulous fontanelles, indicate the com mencement of increased intraeranial pressure. In older children exag gerated tendon reflexes and hypertony of the muscles of the extremities appear as its symptom.
Very soon the child takes to bed, never to rise again. The clouding of the mind becomes protracted and deeper; sleep is not sound and quiet, but the child often lies half asleep, with half-close.d eyes, nearly always with ruddier cheeks than it had in the months just before the attack. Its head and brow, occasionally the whole body, arc often moist, as is the ease in a sleeping healthy chikl. This dozing is interrupted at variable intervals by monotonously repeated movements, as picking the lips or bed-spread, by peculiar sucking or chewing motions, by deep, sighing inspirations or short piercing, shrieks ("cris hydrocephaliques"). Great fright at sudden noises, sudden brilliant illumination, or touch indi cates that besides somnolence, there exists hypercesthesia of the sensory organs. From a slight stiffness of the neck at first, even at this time there succeeds firm retraction of the head, so that it bores into the pillow.
Increasing hypertony of the muscles with heightening of the tendon reflexes accompanies this feature.
The abdominal muscles are contracted causing the " boat shape" appearance. But at the outset it should be stated that this symptom, so significant in older children, is often lacking in infants; on the con trary it is often replaced by a decided distention of the abdomen. The same holds true of constipation, which in older children is almost con stant and of higher degree than can be explained by the reduced amount of food taken; in its place we much more frequently find in infants, at least in those artificially nourished, severe diarrhcea. In this advanced stage of the disease vomiting is much rarer than in the beginning.
The behavior of the temperature does not follow any fixed rule; it may be subnormal, normal or elevated; indeed it may be elevated in any stage or form of the disease.