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ACTIVE CONGESTION OF THE BRAIN.

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cerebral congestion deserves your notice; its importance depends still more on its constituting the first and curable stage of many diseases of the brain, which, unless arrested at the outset, soon pass beyond the resources of our art. Neither, indeed, must it be forgotten, that although inflammation, hæmorrhage, and the effusion of serum are the three results to one or other of which congestion of the cerebral vessels tends, yet the exceptions to their occurrence are by no means few, even when that congestion has been very considerable or of long continuance; and that not only may the functions of the brain be seriously disordered, but the life of the patient may be destroyed, without the anatomist being able to discover any one of these results, or, indeed, anything more than a general repletion of the vessels of the organ.*

Any cause which greatly increases the flow of blood to the head, or which greatly impedes its reflux, may give rise to a congested state of the brain; and, according as this state is induced by the one or the other cause, it is said to be active or passive. The head symptoms which sometimes usher in the eruptive fevers depend, in a measure, upon the former cause; the convulsions which frequently occur during a fit of hooping-cough result from the latter. The brain may become actively congested at the time of teething, or from exposure to the sun, or from a blow on the head; or a state of passive congestion may be induced by some mechanical impediment to the return of blood from the organ-such as the pressure of a hypertrophied thymus, or of enlarged and tuberculated bronchial glands upon the jugular veins; or it may be merely the result of a languid circulation from the want of pure air, or of nourishing

and sufficient food.

Active cerebral congestion is a not very unusual consequence of the disturbance of the circulation at the outset of the eruptive fevers. Convulsions and apoplectic symptoms sometimes come on suddenly in a child previously, to all appearance, in perfect health, and may even terminate in death in less than twenty-four hours. The brain is found loaded with blood, but all the other organs of the body are quite healthy. Some years ago I was requested to be present at the examination of the body of a boy not quite two years old, who had been in perfect health until the day before his death, which took place in such circumstances as I have just

* Dietl's Anatomische Klinik der Gehirnkrankheiten, 8vo. Wien, 1846, contains, at pp. 53–73, a very able exposition and defence of views concerning cerebral congestion in many respects similar to those expressed in this lecture.

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mentioned. The congested state of the cerebral vessels gave but little satisfactory information; but the same evening, the brother of the child was taken ill with vomiting, intense fever, and sorethroat. In a few hours a red rash appeared: the case was one of scarlet fever, and ran its course with considerable severity, though, happily, to a favourable termination. It is probable that the poison of the fever had affected the blood of both children, and that the consequent disturbance of the cerebral circulation was so violent as at once to destroy the life of the younger, while the elder brother survived the shock, and in him the disease soon presented its usual features. The history of most epidemics of scarlatina would afford other instances of a similar nature.'

But, alarming though these symptoms are, it is comparatively seldom that they end in death; for when they occur at the onset of the exanthemata they generally vanish almost as if by magic on the appearance of the eruption.

I was called one day to see a little girl two years old, who, until the day before, had never had an hour's illness. She had eaten a hearty dinner, and, though she vomited soon afterwards, did not seem otherwise indisposed, and slept well in the night. Immediately on waking in the morning, however, she had a fit, during which she was insensible, squinted, threw her limbs about, and occasionally screamed aloud. She continued very ill through the whole day; was hot and feverish during the night, having occasional attacks of convulsions, in which she stretched out her legs, threw back her head, now and then uttered a word or two, and then relapsed into a state of insensibility. This was her condition at half-past 10 A.M.-about twenty-four hours after the occurrence of the first fit. I bled her to 3iij., and would have drawn more blood if it had continued to flow; and then put eight leeches on her head, employed cold affusion, and gave active cathartics during the day, but without much benefit; and at midnight she was still insensible, rolling uneasily from side to side, boring with her head in the pillow, squinting, and making automatic movements with her mouth and tongue. I now put eight more leeches on the head, which bled profusely, and the bleeding was followed by great diminution in the convulsive movements. About 4 A.M. of the next day, the child fell asleep, and dozed for a few hours. She

* See Armstrong's notice of this suddenly fatal form of the disease, at p. 30 of his work on Scarlet Fever, &c. 2nd edit. London, 1817; and Von Ammon's mention of it in his description of the epidemic of malignant scarlatina at Dresden in 1831-2, in the Analekten über Kinderkrankheiten, 11tes Heft, p. 42. Stuttgart, 1836.

CONGESTION OF THE BRAIN.

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awoke sensible, and continued so. On my visit in the morning, I found her quiet and sensible, without any sign of convulsion; her face was very pale; her head, before so hot, was now quite cool; her pulse had sunk in frequency, and lost its fulness. An eruption of a papular character had appeared on the hands, arms, inside of the thighs, and slightly on the face. This eruption was the smallpox, and the disease ran its course with no unfavourable symptom.

It would not be right, indeed, to attribute the symptoms of disturbance of the nervous system that sometimes occur at the commencement of the eruptive fevers entirely to derangement of the cerebral circulation, for something is probably due to changes in the blood itself; but we see similar results produced by other causes, the immediate effect of which is to disturb the circulation and to favour congestion of the brain. Thus, exposure to the heat of the sun, even though the head had not been unprotected from its rays, may be followed by convulsions or by other indications of an overloaded state of the brain, and these symptoms may all subside as soon as the excited circulation has recovered its wonted balance. Of this I remember a striking instance in the case of a delicate boy, who, when a year old, was taken out by his nurse during one of the hottest days in June. He was quite well and cheerful when he left the house, but, after being out for some time, he began to breathe hurriedly and irregularly, and his nurse, in consequence, brought him home. I saw him about two hours afterwards. was then restless, fretful, and alarmed; his surface generally hot, and his head especially so, the brain pulsating forcibly through the anterior fontanelle; the pulse too rapid to be counted; the respiration hurried, laboured and irregular, and there were constant startings of the tendons of the extremities. The child was on the eve of an attack of convulsions; but the tepid bath relieved the heat of the skin, and the pulse fell, and the subsultus diminished. Light and sound were excluded from the room; he fell asleep, and awoke in a few hours refreshed and tranquillised, and on the next morning a little languor was all that remained of an illness which had seemed likely to prove so formidable.

He

Disorders of the nervous system are very frequent during the period of teething. Many of the symptoms which then occur are the direct result of irritation of the trifacial nerve, but others are the immediate consequence of congestion of the brain. Febrile disturbance almost always attends upon the process of dentition, and you can easily understand that when the circulation is in a state of permanent excitement, a very slight cause may suffice to

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CEREBRAL CONGESTION.

overturn its equilibrium, and occasion a greater flow of blood to the brain than the organ is able to bear.

But I need not occupy more time in pointing out to you the various circumstances which may give rise to active congestion of the brain. Let us now pass to a more minute examination of its

symptoms.

Cerebral congestion may, as you have seen, come on very suddenly, its symptoms from the first being alarming, and such as to call for immediate interference; or general uneasiness, a disordered state of the bowels, which are generally though not invariably constipated, and feverishness, may have for a few days preceded the more serious attack. The head by degrees becomes hot, the child grows restless and fretful, and seems distressed by light, or noise, or sudden motion; and children who are old enough sometimes complain of their head. One little boy, nearly three years old, who died of congestion of the brain, had seemed to suffer for some days before any alarming symptom came on, from severe pain in the head. He sometimes awoke crying from his sleep, or when awake would suddenly put his hands to his ears, exclaiming, “Oh, hurt! hurt!" Usually, too, vomiting occurs repeatedly; a symptom on the importance of which I have already insisted, since it is not only confirmatory of others, but also may exist before there is any well-marked indication of the head being affected, and when, though the child seems ailing, there is nothing definite about its illness. The degree of fever which attends this condition varies much, and its accessions are irregular; but the pulse is usually much and permanently quickened; and if the skull be unossified, the anterior fontanelle is either tense and prominent, or the brain is felt and seen to pulsate forcibly through it. The sleep is disturbed, the child often waking with a start, while there is occasional twitching of the muscles of its face, or of the tendons of its wrist.

The child may continue in this condition for many days, and then recover its health without any medical interference; but a slight cause will generally suffice to bring back the former indisposition. You will sometimes see striking instances of this in children while teething; the fever subsiding, the head growing cool, and the little patient appearing quite well, so soon as the tooth has cut through the gum, but the approach of each tooth to the surface being attended by the recurrence of the same symptoms.

But though the disturbance of the brain may pass away of its

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own accord, yet we cannot reckon on such a favourable result occurring, for symptoms such as I have mentioned are often the indications of the organism generally having begun to suffer from mischief which has been going on for months unnoticed, and which is now about to break out with all the formidable characters of acute hydrocephalus. Or should they have no such grave import, yet congestion of the brain is itself a serious, sometimes a fatal malady. Even though no treatment be adopted, indeed, the heat of head may diminish, and the flush of the face grow slighter and less constant; but the countenance becomes very heavy and anxious, the indifference to surrounding objects increases, and the child lies in a state of torpor or drowsiness; from which, however, it can at first be roused to complete consciousness. The manner, on being roused, is always fretful; but if old enough to talk, the child's answers are rational, though generally very short; and, murmuring "I am so sleepy, so sleepy," it subsides into its former drowsiness. The bowels generally continue constipated, and the vomiting seldom ceases, though it is sometimes less frequent than before. The pulse is usually smaller than in the other stage, and it is often irregular in its frequency, though not actually intermittent. An attack of convulsions sometimes marks the transition from the first to the second stage; or the child passes, without any apparent cause, from its previous torpor into a state of convulsion, which subsiding, leaves the torpor deeper than before. The fits return, and death may take place in one of them, or the torpor growing more profound after each convulsive seizure, the child at length dies comatose.

This second stage, if so it may be called, is usually of short duration; and if relief be not afforded by appropriate treatment, death is seldom delayed beyond forty-eight hours from the first fit, though no graver lesion may be discovered afterwards than a gorged state of the vessels of the brain and its membranes, and perhaps a little clear fluid in the ventricles and beneath the arachnoid.

Occasionally, indeed, death does not so speedily follow these symptoms; but they continue slightly modified for days, or even weeks, and, contrary to all expectation, recovery now and then takes place. This protracted course of the affection is, I believe, met with only in the case of very young children, in whom, the congestion having relieved itself by a copious effusion of serum into the ventricles, the yielding skull accommodates itself to its increased contents. The symptoms, though to a great extent the

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