Rigidity may be noticed in the affected parts. If the paralysis be per manent, rigidity and contraction may eventually ensue. Rigidity, how ever, is often a merely temporary phenomenon which affects various joints and comes and goes irregularly. This is often seen in cases of tubercular meningitis. Other forms of rigidity of the joints are seen in children. Tonic contractions may occur in the extremities from reflex disturbance of the nervous system (see page 274) ; the limbs may be the seat of spaStic rigid ity from disease of the spinal cord ; and in girls of ten or twelve years old the so-called hysterical contractions of the joints are by no means rare.
A common form of rigidity is that which affects the muscles of the nucha and causes retraction of the head upon the shoulders. This symp tom is a common one in cases of cerebral disease, and is a certain sign of intra-cranial lesion. Mere stiffness of the neck is not here referred to. This may be due to many causes, such as cervical caries, rheumatism, etc. In the retraction of the head so often induced by brain affection the head is drawn backwards upon the shoulders by rigidly contracted muscles at the back of the neck. This 'condition may be associated with rigidity of limbs, epileptiform fits, and hydrocephalus. It is often due to basic men ingitis, and may be the consequences of mere distention of the lateral ventricles with fluid. It is a grave symptom, although not necessarily a fatal one. Sometimes it is intermittent.' Besides the symptoms connected especially with the brain, others de rived from disturbance of distant organs may furnish signs not to be neg lected of a cerebral origin. So great is the sympathy between the various organs of the body in early life that disease in the central nervous system is invariably associated with more or less general disorder of function.
Vomiting is rarely absent in cases of cerebral disease. It happens not only after meals, but at other times ; and when retching occurs on an empty stomach, or is excited by merely raising the child up from his bed, it is a very characteristic symptom. Constipation, also, if obstinate, is a sign not without importance ; and if associated with vomiting, and occur ring in a child in whom gradual failure of health has been noticed, is very suspicious of tubercular • meningitis. Even the amount of tension of the abdominal wall is a matter not to be disregarded. In tubercular menin gitis the softness and loss of elasticity of the parietes is sufficiently obvious to the touch, and at the same time the wall is depressed and retracted in a manner peculiar to this disease.
The state of the breathing must be noticed. In many forms of brain lesion the respirations become very irregular, and this alteration of rhythm may be sometimes a very important sign. In tubercular meningitis, espe cially, great irregularity of breathing, with frequent sighs and occasional long pauses during which the chest-walls are not seen to move, is a valuable aid to diagnosis when the nature of the disease is doubtful. There is a peculiar form of breathing, called from the writers who have drawn atten tion to it the " Cheyne-Stokes " type, which, although not peculiar to cere bral disease, is yet often noticed in such affections. It consists of a series of inspirations gradually increasing in depth and strength, and then as gradually diminishing, until the movement of the chest-wall is hardly per ceptible. There are many theories as to the pathology of this peculiar respiration. In most of them a supposed diminution in the excitability of the respiratory centre is a prominent feature. This type of breathing is often associated with headache and delirium, and may be found in disor ders of the heart and kidneys as well as of the brain. Still, when it is found, whatever be the disease, some nervous complication is usually present.
Information can also be derived from the state of the circulation. In the earlier period of meningitis the pulse often falls in frequency and at the same time becomes intermittent. If a child with a temperature of 102° have a pulse of 70°, especially if its rhythm be irregular, we should suspect the presence of tubercular meningitis. It must not be forgotten, however, that a slow pulse is not uncommon in children during convalescence from acute disease, and that this slow pulse may be irregular or even completely intermit at times, especially during sleep. We must not, therefore, attach too great importance to this symptom alone, unless the temperature be elevated, and the child's state be one to excite anxiety.
Again, a remarkable modification in the vascularity of the skin is often seen in cases of tubercular meningitis. The child often flushes up sud denly, and slight pressure upon the skin, especially that of the face, the abdomen, and the front of the thighs, produces a bright redness which re mains for many minutes. This cerebral flush (called by Trousseau, who first drew attention to it, lathe cerebrale), although perhaps more vivid and persistent in this disease, is yet not peculiar to tubercular meningitis. It may be often produced by gentle pressure in sensitive children, especially if they are the subjects of pyrexia.