A rickety little boy, aged two years, was admitted into the East Lon don Children's Hospital with the symptoms of severe pulmonary catarrh. For some months the child had been subject to otorrhoea, but there was no history of earache. He went on well at first ; the cough improved and his chest seemed greatly relieved, when, on December 7th, his temperature rose to 102°, and there was a copious discharge of pus from the left ear. The discharge continued through the week, but the child seemed to suffer little inconvenience from the state of his ear. He was lively, took his food with appetite, and his temperature, which for a few clays had been high, again sank to 99'.
On December 13th a change was noticed. The child screamed fre quently and seemed indifferent to his food. His temperature that evening was only 99°. On the morning of the 14th the temperature was still 99°, but the pulse, which had been always considerably over 100, was found to have fallen to 80. The child was drowsy and could not be thoroughly roused. He lay on his right side with a puffy-looking flushed face, grind ing his teeth and making other movements with his jaws. The pupils were equal, slightly contracted, and sluggish ; occasionally there was a. slight squint. Some rigidity was noticed of the right knee and elbow joints. The child took no notice of questions and refused food. At 6 PM. the temperature was 100° ; pulse, 96 ; respirations, 34 ; and in the evening the stupor deepened into coma.
For the next forty-eight hours the child's state continued much the. same. He was completely insensible, and squinted outwards with the right eye. During this time his temperature was 101°-101.4° ; pulse, 120 130 ; respiration, 21-48, and very irregular. The abdomen was slightly retracted ; the bowels were confined, and he vomited once.
On December 16th the bowels had been moved by aperients, and there was some approach to consciousness. The child resisted the feeding cup, and in the evening. seemed to recognise the nurse. He was heard to say " no " repeatedly when offered drink. He could move both his legs. The temperature was 100°-101°.
On December 17th the stupor was even less, although the patient re mained very drowsy ; he turned his bead when called loudly by name, and answered when asked to drink. There was no flushing of the face, nor any redness when pressure was made on the skin. Temperature, 100°-101.6° ; pulse, 156 ; respirations, 38. On the 18th the child had two fits. These were followed by no rigidity of the joints ; but the patient lay in a semi-coma tose condition, although it was still possible to rouse him by loud calling.
From that time he gradually sank, and died on the afternoon of the follow ing day. The temperature shortly before death was 101°. On examina tion of the body, the petrous part of the temporal bone was found de nuded of Jura matey at one spot, and the membrane around was much in flamed. An abscess was discovered in the adjacent cerebellum filled with offensive pus, and there was excess of fluid in the lateral ventricles.
The course of encephalitis is usually rapid. It may last only five or six days, or may be prolonged to two or three weeks. Sometimes after a time the acute symptoms disappear, consciousness is recovered, and the child's health may appear to be restored. It is even said that such children may grow up to adult age, the abscess having become encysted and ceasing to be a source of irritation.
Diagnosis..—Otitis should be suspected in all cases where a young child cries incessantly without any symptoms being detected—such as drawing up of the legs, tension of the abdominal wall, unhealthy evacuations, etc.— to draw attention to the belly. Abdominal pain is intermittent, and the cries cease when the uneasiness subsides. Earache is constant, and until relief is obtained by the discharge of pus from the meatus the child cries with a persistence which is very characteristic.
When purulent meningitis occurs, the onset of violent convulsions, with high fever, following upon sudden cessation of discharge from the ear, are very suspicious ; and when we remark that in the intervals of the fits the child remains drowsy and stupid, refuses food, and takes no notice of ac customed faces ; that he is restless, contracts his brows, and constantly moves his hand to his head, we can speak with some confidence as to the nature of the case. In reflex convulsions the mind is clear between the attacks. Drowsiness or stupor with recurring convulsive movements is very characteristic of a cerebral origin. An alteration in the pulse adds a new and important feature to the case. A pulse of 80 in a young child is a slow pulse. If the child be feverish, the contrast between the bodily heat and the comparative infrequency of the arterial pulsations is still more striking. Therefore if to the preceding symptoms we add a slow and per haps intermitting pulse, our suspicions are sufficiently confirmed.