In cases of congestion and effusion upon the brain the child, although heavy and stupid, is quiet and shows no distress. Usually he takes his bottle well, and this is an important sign. The fits are rarely repeated after the drowsiness has become marked. The pupils, although sluggish, are not unequal in size ; and although the head may be retracted there is no rigidity of the joints.
Tubercular meningitis sometimes, although rarely, begins with a con vulsion ; but unless the cerebral symptoms occur as a terminal phase of acute general tuberculosis, the disease afterwards runs its normal course, which is very unlike that of cerebral congestion. It must be remembered, however, that a primary tubercular meningitis is a rarity under the age of two years, while the cases of cerebral congestion we have been considering are almost limited to the first two years of life. The difference of age is therefore an important element in the diagnosis. Still, apart from other considerations, congestion of the brain may be usually recognised by re marking that although drowsy and stupid the child is not actually uncon scious ; that he continues to take his bottle well ; that his pupils are never unequal ; that there is no rigidity of joints, and that loss of power, although it may occur as a consequence of violent convulsions, passes off in a few hours unless there be some cause for it more serious than mere exhaustion of nervous force. The occurrence of squint lasting more than a few hours is very suspicious of a small haemorrhage. It occurred, however, in the case narrated in another chapter (see Convulsions), without anything being discovered in the brain beyond congestion of vessels and effusion of serum.
Prognosis.—There is always reason for great anxiety when a young child shows signs of abnormal heaviness and drowsiness. The mistake must not, however, be made of attributing to centric disease natural sleepi ness due to disturbed rest from digestive derangement. It happened to me once to be summoned some distance into the country to see a child of a few weeks old who was said to have congestion of the brain because it was always falling asleep. I found that the child's bowels were disordered, and that it was evidently tortured by frequent griping pains. Every few
minutes it drew its legs up, bent itself backwards, and uttered a feeble cry. After some seconds its features relaxed, its eyes closed, and it seemed to sleep, almost immediately afterwards it was aroused by a fresh attack of pain. This state of things had continued for forty-eight hours. During all that time the child had been prevented from obtaining natural sleep owing to the abdominal pains which roused it almost as soon as its eyes were closed. After a good dose of castor-oil, which relieved its bowels of the irritating matter, the child enjoyed a refreshing sleep and awoke quite well.
The majority of cases of stupor following convulsions recover ; but we should be careful not to commit ourselves to a too hopeful prognosis un less improvement begin early and go on apace. As long as the child con tinues to take his food well the prognosis is favourable. If he refuse his food, if the drowsiness deepen, the pupils become unequal, or squinting occur, the child will probably die.
When drowsiness is noticed in children as a result of impediment to the return of blood from the head, the prognosis is determined by the na ture and severity of the disease which has given rise to the passive conges tion.
Treatment.—When called to a child who has been left heavy and stupid by an attack of convulsions, and we have reason to fear an effusion of fluid into the skull cavity, our first care should be to clear out the alimentary canal by a dose of calomel and jalapine. We should afterwards keep up a free action of the bowels by frequent closes of any suitable saline aperient. The child should be kept perfectly quiet in a large well ventilated room carefully shaded from a too strong light. If he be at the breast, no other food should be allowed. If he be brought up by hand, milk and barley water should be given, and but little farinaceous food. If the gums are tense and swollen, they may be lanced ; but uuless actual irritation arise from this cause the operation is better avoided. If thought desirable cold may be applied to the head. In some cases counter-irritation with mustard poultices to the chest and spine has seemed to be of service.
In passive congestion the treatment is that of the disease which has given rise to the hyperemia.