Above the age of two years it is usual for the meningitis to assume a different shape. Convulsions are a less prominent symptom ; instead we find a more or less violent delirium. Hence Billiet—to whose labours all descriptions of meningitis in the child are so much indebted—has called it the "phrenitic " form. It is of longer duration than the convulsive variety, and resembles more meningitis as that disease occurs in the adult. The child complains of severe headache, is agitated and restless, and very rapidly becomes delirious. The delirium is noisy. The child raves about the pain in his head. His eyes are red and wild-looking, his pupils con tracted and often unequal in size. The pulse is quick and irregular, and may be completely intermittent. His temperature is high, marking 104° or 105', as in the preceding variety ; and his breathing is rapid, although usually regular. After some days the delirium becomes less violent. The child has intervals of quiet in which he appears to be unconscious. He lies with his eyelids half open and his eyes turned upwards, moaning oc casionally ; the muscles of his face twitch ; there is trismus or grinding of teeth ; and his head is often retracted upon his shoulders. As the disease progresses the coma becomes more constant, but at first a touch may ex cite violent delirious struggles, for there seems to be general hypemsthe sia making the slightest pressure painful. The pupils dilate, and are in sensible to light ; there is often oscillation of the globe of• the eye and squinting. The pulse becomes very frequent, and the respirations are of the Cheyne-Stokes type. There may be rigidity of the joints. The coma continues profound, and the patient gradually sinks and dies. Usually there is profuse sweating before death, although the temperature continues high ; and the disease may terminate in a fit of convulsions.
Sometimes the temperature falls considerably before death. At other times it rises rapidly to 108°, or even higher. The duration of the phreni tic form of the disease varies ; its course may be rapid like that of the con vulsive variety, but sometimes it is prolonged'to three, four, or more weeks. In these slower cases the illness often assumes a subacute type, with only slight elevations of temperature ; but at any time the heat of the body may undergb a sudden and apparently causeless increase.
In many cases inflammation of the dura water is accompanied by thrombosis of the cerebral sinuses. The symptoms, however, of this con dition are masked by those of the accompanying meningitis ; and its ex istence, therefore, can seldom be more than suspected. According to Gerhardt, we may sometimes detect on the affected side comparative emptiness of the jugular vein, which is no longer filled with blood from the obstructed sinus ; but this is a symptom the existence of which it must be difficult to ascertain. In ordinary cases the occurrence of shiver ing, or great variations in the temperature, with signs of metastatic deposits in the lungs (sudden dyspnoaa, cough, and perhaps scattered zones of crepitation about the chest or back) would point to the probable occur rence of cerebral phlebitis.
When meningitis occurs as a consequence of other causes than otitis, the symptoms are as described, with the addition, in most cases, of a pre liminary stage in which the child complains, if old enough, of headache, gradually increasing in intensity. He is feverish, vomits, is very restless, and his ideas are confused. The course of the disease is therefore rather longer than in the form described above.
Inflammation of the brain (encephalitis) is more frequently than the preceding a consequence of otitis. Indeed, it has been estimated that fully half of the cases of abscess of the brain are due to inflammation originating in the middle or internal ear. The inflammation is limited to certain spots, being usually confined to the cerebrum in the immediate neigh bourhood of the petrous bone. Sometimes, however, it is found in children, as it is commonly in the adult, in the cerebellum.
The symptoms are often obscured by meningitis, which may exist at the same time ; and there may be thrombosis of the cranial sinuses.
The disease begins with pain in the head, which is indicated in the young child by repeated screaming and frequent movement of the hand to the head. The child seems drowsy, and behaves as if only half awake. He takes food unwillingly or refuses it altogether. The bowels are generally confined, and there is usually vomiting. The temperature seldom rises above 102°. The pulse is generally slow (70 to 80), and the pupils are contracted. The drowsiness soon deepens into stupor, and there is rigid ity of the joints, usually limited to one side, with perhaps paresis or paralysis of the limbs. Much depends upon the seat of the abscess, and whether it affects the centres of special sense or interferes with the con duction of motor influences. Thus there may be incomplete hemiplegia from compression of the fibres of the internal capsule ; paralysis of the third nerve from pressure on the cerebral peduncle ; or paralysis of the facial nerve. The loss of power is almost invariably limited to one side of the body. Convulsions may occur ; there are frequent twitchings of the facial muscles, and the child grinds his teeth and makes movements with his mouth as if chewing. The stupor is not constant. At first the child can be roused by being spoken to loudly ; and occasionally the mind be comes clearer after a time. The child will often begin again to answer questions, and may even recognise his friends. The respirations are quick ened and very irregular ; the pulse, after the first few days, increases in rapidity, and often becomes intermittent. In acute cases the stupor soon becomes more profound, and deepens into a coma in which the child dies. Convulsions, if previously present, may cease when the patient becomes comatose, or may return before death. The temperature remains moder ately elevated throughout, or falls notably before the fatal termination, or rises to a high level during the last few holm of life.