In an ordinary case of extension of the inflammation to the meninges the sequence of symptoms is as follows : A little child of a few years old has a discharge of purulent matter from the ear. This may have followed an attack of severe earache, or may have begun without pain and continued without discomfort, although the hearing on that side has been noticed to be dull. The otorrhma continues for several months. Occasionally the child is feverish and complains of acute pain in the affected ear and side of the head. At the same time the discharge from the meatus ceases to flow. After some hours, however, the pain subsides and the running re appears. At length the patient is seized with high fever, and has an attack of violent convulsions. After several repetitions of the fits, in the intervals of which he seems drowsy and stupid, he sinks into a state of coma and dies within the week. This is called the convulsive form—long standing otorrhcea ; then, suddenly, fever, convulsions, coma, death. It is the shape the disease takes in babies and children under two years of age.
The fever is high. The temperature rises to between 104° and 105°, and undergoes at first little remission in the mornings. The pulse almost always intermits more or less completely, and very often falls in frequency, sinking to 75 or SO. This, however, is a very variable symptom, and sometimes the pulse remains quick throughout. Pain in the affected side of the head is seldom absent. The youngest children, in the intervals of convulsions, may be noticed to moan and put their hands to their heads. Respirations are quickened and may be perfectly regular, although some times we notice sighing respirations, and the breathing towards the end may assume the Cheyne-Stokes type. The pupils are generally contracted at first, and become dilated later. They are often unequal in size. There may be squinting of one or both eyes, and sometimes we note a paralysis of the face on the affected side.
The convulsions are violent, and, for the most part, bilateral. In the intervals consciousness is not completely restored, the child is heavy and stupefied, taking little notice of persons and things around, although his attention can be usually attracted by calling him loudly by name. He is very restless, and often keeps one or more of his limbs in constant move ment. Rigiclity of the joints may be present, and if there is any accom panying spinal meningitis, the head is firmly retracted on the shoulders with rigidity of the muscles of the nucha. The abdomen is seldom markedly retracted as in tubercular meningitis, and the characteristic doughy feel of the abdominal wall is also usually absent. The child re fuses his bottle, and often can scarcely be made to swallow liquid from a spoon. The disease runs its course rapidly. After a day or two the con
vulsions become less frequent. The child lies plunged in a deep stupor, and after remaining comatose for a variable time, dies without any return of consciousness. ''Sometimes convulsions immediately precede death.
In certain cases the disease may run an even shorter course, and death take place with startling rapidity.
A little boy, aged twelve months, strong-looking and well nourished, was seized with vomiting at 1 A.M. on February 16th, and continued to vomit at intervals for twelve hours. He then had several fits, and at 3 P.M. was brought to the East London Children's Hospital. He was seen by Mr. Scott Battams, the house surgeon, who noted that all the limbs were con vulsed and the pupils were dilated. When the fits ceased the child still continued insensible ; there was nystagmus ; the pupils were equal and di lated, and acted well with light ; the conjunctiv2e were insensitive ; there was no squint ; the cerebral flush was fairly marked ; the limbs were flaccid.
At 8 P.M. the child was still insensible. He had had no more fits ; pulse, 150, with occasional intermissions ; respirations, 40 ; temperature, 103° • pupils equal, and still acted with light.
All through the night the child remained insensible. There was no vomiting, and the convulsions were not repeated. No twitching was noticed, and the head was not retracted. He died at 8 A.M. Before death the temperature was 104°.
On examination of the brain, the whole convexity was found coated with yellow lymph which had extended to the under surface of the frontal lobes, and had glued the anterior and middle lobes to one another. There was no flattening of the convolutions ; no excess of fluid in the ventricles ; no exudation in the optic space ; and no inflammation of the membranes at the base of the brain. No gray granulations could be seen ; the brain was firm, and seemed perfectly healthy ; the cerebral sinuses contained semifluid dark blood.
In this case there was slight discharge from the ears, but without of fensive smell. It is doubtful if this had any part in producing the menin gitis, for the clura mater covering the petrous bones had a healthy appear ance. Nothing in the history of the child could be discovered to account for the illness, for although he had had a cough for a fortnight, and had whooped during the last two days, this could not be looked upon as a determining cause of the inflammation. It may be remarked that the symptoms above described resemble exactly those often present in cases of meningeal haemorrhage in the young child, with the excep tion that in this case the temperature was elevated. A raised tempera ture, present in meningitis and absent in hmmorrhage, appears to be the single important symptom by which the two diseases may be dis tinguished.