When I saw the child, on April 8th, he was lying in his mother's arms with his eyes half closed. His face was very pale, the pupils were equal, dilated, and immovable ; there was no squint; the fontanelle was very ele vated and tense; the head was retracted and the muscles at the back of the neck felt rigid. The temperature in the rectum was 99°, the pulse and respiration could not be counted for irregularity. The lungs and heart -were healthy. The child took the breast well, and sucked vigorously but by snatches.
He remained in this state, vomiting occasionally, until April 12th, when the sickness ceased and the patient seemed very much better. When seen on the 15th he appeared to be quite sensible. The pupils were dilated and acted imperfectly with light, i.e., when the eyelids were suddenly opened the pupils could not be seen to contract. The fontanelle was now rather depressed. Pulse, 168, very weak but regular. Skin cool. Head not retracted. After this the child soon became quite well, except that for some time afterwards he had a peculiar stare, the eyes being directed downwards, so as to show a rim of white above the cornea.
It is difficult to say to what these symptoms were clue if congestion of the brain and effusion of fluid induced by the convulsion were not the cause of them. The normal temperature seemed to exclude any inflamma tory condition ; while the somnolence, the immobility of pupils, the swollen and tense state of the fontanelle, and the retracted head pointed to some increase of pressure within the skull cavity. If we assume, ou the strength of Dr. Bastian's observations, that the congestion is the conse quence of wide-spread minute emboli obstructing the circulation through the brain, the frequent occurrence of symptoms such as the above is less difficult to account for.
Cases have been recorded and attributed to cerebral congestion in which loss of consciousness, with pyrexia, squinting, and general paralysis occurred, and passed off completely after a few days or hours. It is diffi cult to understand how a simple local congestion alone can give rise to elevation of temperature even in a young child. Such cases are obscure. and no sufficient explanation of them has yet been arrived at.
Many cases of so-called congestion of the brain are probably the con sequence of thrombosis of the cerebral sinuses. Dr. Lewis Smith has
shown this to be sometimes the case in pertussis ; and convulsions due to other causes may be accompanied by similar obstructions to the venous passages within the skull. Exact observations upon this point are to be de sired ; but it is probable that increased knowledge will in course of time greatly diminish the importance of mere fulness of cerebral veins as an agent in the production of nervous disturbance.
Diagnosis.—When we see a child who is suffering from symptoms indi cative of oppression of the brain, such as drowsiness, immobility of pupils, an elevated tense fontanelle, and a retracted head, we have to distinguish the case from one of meningitis or other serious cerebral disease. The history is here of the utmost importance. If the symptoms began with a convulsive attack preceded merely by signs of irritability of the nervous system, such as usually usher in a fit of eclampsia ; if the child be the sub ject of rickets, and if some cause such as swollen inflamed gums, otalgia, or digestive derangement, can be discovered to account for the nervous seizure, we may consider the symptoms to be due to filling of the cerebral vessels and effusion of serum into the cranial cavity. If the temperature be low, it is a confirmation of this diagnosis. Often, however, in these cases the heat of the body is increased as a consequence of the cause which has provoked the convulsion. Therefore a high temperature is not neces sarily to be interpreted as casting any doubt upon the accuracy of this opinion. In simple meningitis, which begins with violent convulsions followed by drowsiness and stupor, there is often a history of chronic otorrhcea ; and in most cases the convulsion has been preceded by signs of pain in the head. But besides the history, the symptoms in the two diseases differ in important particulars. In meningitis the child is at once seen to be seriously ill. He refuses his food, and is restless ; he con tracts his brows, raises his hand to his head, rolls his head from side to side, and, although heavy and stupid, manifests every sign of suffering. The temperature is high, but the pulse is comparatively slow (70-80). The fits continually recur, leaving the child more and more stupid and comatose. The pupils become unequal, rigidity of the joints comes on, and the child dies.