I have purposely dwelt long on this preliminary stage because it is only in it that treatment is likely to be of any service, while the very indefiniteness of the symptoms constantly leads to their being overlooked, or referred to teething, or thought at any rate to be a mere temporary ailment for which it is not worth while to call in the doctor.
After four or five days, however, the illness of the child becomes too marked to escape notice. All cheerfulness has fled, the eyes are closed to shut out the light, the child lies apparently dozing, but answers questions rationally, in a short quick manner in as few words as possible, and from time to time complains of its head, or utters a short, sharp lamentable cry. The night brings with it no other change than an increase of restlessness, attended sometimes with noisy cries, or with the wandering talk of delirium. Sickness often diminishes, but the bowels continue constipated, and it is to be noted that whereas in fevers the bowels are distended with wind, here all wind has disappeared and the belly is sunken to a striking degree.
Next comes the last stage. Each stage is distinguished by peculiarities of the pulse which tell the expert what is passing; quick and regular in the first stage; irregular and slower in the second; quick, variable, irregular from time to time in the third; growing more rapid and more feeble as the end arrives. Squinting, stupor, dilated pupil, difficulty of swallowing, tremulous limbs, convulsions, profound insensibility, such are the series of occurrences which bring on death usually within a fortnight, always within three weeks from the appearance of the first decided symptoms.
What are you to do in these cases? Above all save yourselves the heartbreak of feeling that you have overlooked the premonitory symptoms of the disease. Guard with special care the health of any child in whose family a disposition to consumptive disease has ever shown itself, and keep it at any cost from the risk of catching the hooping cough or measles. Since, too, it is not in early infancy, but after the age of one year, and in the majority of instances between the ages of three and six years that this disease occurs, that is to say, at the time when the brain begins to be most actively exercised, when the new world on which the child is just entering brings with it new wonders every day; be very careful not to over-stimulate its intelligence, over-excite its imagination, or over-strain its mental powers. After the age of ten the great danger is over; up to that time it is the health of the body which requires care; not fuss, not rearing like a hothouse plant, but the healthy training that may fortify the system.
When any signs such as I have described indicate the threatening of disease, do not look on them as within the scope of domestic management, but place the child at once under the watchful care of a skilful doctor. I have seen but one recovery in all my life, after the disease had fully set in, and that was a recovery almost worse than death.
Earache.—There is another form of inflammation of the brain which is likewise oftenest met with in children who are of weakly constitution, or of scrofulous habit, or in whom scarlet fever has left behind that very troublesome ailment, discharge from the ear. This is so tedious, so difficult to cure, so apt to return under the influence of very slight causes, that people are too ready to put up with it as an inconvenience which it is useless to try to remedy.
In addition, however, to the risk of the child's hearing being impaired by the extension of the mischief to the internal ear, there is another still greater danger, namely, that of the disease passing from the ear to the brain, and producing inflammation of its membranes, or even abscess of its substance.
It is therefore of the greatest moment that every case of chronic discharge from the ear should be looked on as important, and that no pains be spared to bring about its cure; and further, that during its continuance the slightest sign of disturbance of the brain—headache, sickness, feverishness, and dulness—should at once be noticed, and the advice of a competent doctor be immediately sought for.
These dangers, however, follow almost entirely on long-continued discharges from the ear, but do not attend that acute inflammation of the passage to the ear which is often met with in childhood, and the symptoms of which sometimes cause needless fear, from being taken for those of inflammation of the brain. Attacks of earache are most frequent before the first set of teeth have been cut, and are by no means rare in young children, who are perfectly unable to point out the seat of their sufferings. The attack sometimes comes on quite suddenly, but usually the child is languid and fretful for a period varying from a few hours to one or two days before acute pain is experienced. In this premonitory stage, however, it will often cry if tossed or moved briskly; noise seems unpleasant to it, and it does not care to be played with; while children who are still at the breast show a disinclination to suck, though they will take food from a spoon. The infant seeks to rest its head on its mother's shoulder, or, if lying in its cot, moves its head uneasily from side to side, and then buries its face in the pillow. If you watch closely, you will see that it is always the same side of the head which it seeks to bury in the pillow, or to rest on its nurse's arm, and that no other position seems to give any ease, except this one, which, after much restlessness, the child will take up, and to which, if disturbed, it will always return. The gentle support to the ear seems to soothe the little patient: it cries itself to sleep, but after a short doze, some fresh twinge of pain arouses it, or some accidental movement disturbs it, and it awakes crying aloud, and refusing to be pacified, and may continue so for hours together. Sometimes the ear is red, and the hand is often put to the affected side of the head, but neither of these symptoms is constant. The intensity of the pain seldom lasts for more than a few hours, when, in many instances a copious discharge of matter takes place from the ear, and the child is well. In some instances, indeed, the subsidence of the disease on one side is followed by a similar attack on the opposite side, and the same acute suffering is once more gone through, and terminates in the same manner. Sometimes, too, this complete cure does not take place, but the earache abates, or altogether ceases, for a day or two, and then returns; no discharge, or but a very scanty discharge, taking place, while, for weeks together, the child has but few intervals of perfect ease. In infants, earache seldom follows this chronic course, but it does sometimes in older children, and is then of the more importance, since it shows that the disease is no longer confined to the external passage, but has extended to the internal ear.
In children who are too young to express their sufferings by words, the violence of their cries, coupled with the absence of any sign of disease in the chest or the bowels, naturally leads to the suspicion of something being wrong in the head. There are several facts, however, which may satisfy you that the case is not one of water on the brain—the child does not vomit, its bowels are not constipated, there is but little fever, the cries are loud and passionate, and are attended with shedding tears. If you watch closely, you will notice the dread of movement and the evident relief afforded by resting one side of the head, and always the same side, while often the movement of the hand to the head, and the redness of the ear, with the swelling at its entrance, will all serve to point to that organ as the source of the trouble. Sometimes, when in doubt, you will be able to satisfy yourselves that the cause of the suffering is in the ear by pressing the gristle of the organ slightly inwards, which will produce very evident pain on the affected side, while on the other side it will not occasion any suffering.
The treatment of this painful affection is very simple. In many instances the suffering is greatly relieved by warm fomentations, or by applying to the ear a poultice of hot bran or camomile flowers, while at the same time a little warm oil and laudanum are dropped into the ear. When these means do not bring relief, a leech applied on the bone directly behind the ear seldom fails to give ease; while the disposition to the frequent return of the attack is often controlled by a series of small blisters, not larger than a sixpence, behind the ear. As soon as the tendency has sufficiently abated to admit of it, the ear should be syringed out twice a day with warm water, or with equal parts of warm water and Goulard lotion; but if pain or discharge still continues, medical advice must in all cases be sought for.
Chronic Water on the Brain.—There is still another form of inflammation of the brain, concerning which a few words will suffice. It constitutes what is termed chronic water on the brain, and in this instance the term is a correct one, for the disease usually depends on a slow form of inflammation of the lining membrane of the cavities of the brain, often beginning before, still oftener very soon after, birth, which ends in the pouring out of a quantity of fluid into them sufficient to enlarge the head to three or four times its natural dimensions.
Such cases are very sad and very hopeless, and the great resource, which is sometimes adopted by medical men, of puncturing the head and letting out the fluid, is very seldom successful.
But there are more hopeful cases sometimes met with, those namely of children in whom, either from simple weakness, or from that constitutional disorder called rickets, bone formation has been backward, and the head has consequently long remained unclosed. If such children, either from the irritation of teething, or from the straining during paroxysms of hooping cough, suffer from congestion of the brain, fluid may be poured out, which, not being compressed by the too yielding skull, may in consequence enlarge it. These cases, however, may be distinguished from the other more serious ones by the date of their commencement, which is always much later than that of the other form, by the symptoms which attend them being less severe, and by the enlargement of the skull being far slighter.
Still they require watching, for while with improved health the enlargement ceases, the fluid is in a measure absorbed, and the head diminishes in size, though always remaining larger than the average; brain mischief is yet more readily set up in children with such antecedents than in others.
The anxiety of parents about the size or shape of their child's head after infancy has passed, is perfectly needless. When the head has once closed it always remains so. An odd shape, with an unusual protuberance of the forehead and the hind head, sometimes remain as the evidence of that condition in infancy to which I have just referred. It is, however, an evidence of mischief passed, not of mischief going on. In children too who have suffered from rickets, an affection rarely met with except among the poor in crowded cities, distortion of the limbs is often associated with a peculiar form of the skull, but in this too there is nothing to call for anxiety, still less to excite alarm. It is only a preternaturally small head and shelving forehead, which are found associated with mental deficiency; otherwise the greatest varieties of size and shape, of symmetry, or of want of it, may be associated with an equal variety of intellectual endowment, which is just as likely to be above as below the average.
Brain Disorder from Exhaustion.—It may at first sight appear strange that before leaving the subject of congestion and inflammation of the brain, I should find it necessary to give a caution against being misled by symptoms which though in some respects similar to those of congestion or inflammation, are in reality due to an exactly opposite condition.
This mistake, however, is very possible; doctors themselves sometimes fall into it, and some distinguished physicians have thought it worth their while to lay down very minute rules for distinguishing between the two opposite states. Headache we all know attends an overfull condition of the vessels of the brain, and grown persons usually suffer from it severely before an attack of apoplexy; but we also know that bad headache accompanies states of great weakness, and that it is one of the most distressing consequences from which a woman suffers who has lost much blood in her confinement. In just the same way, the infant who has been exhausted by diarrhœa or by some trying illness, or who after weaning has been kept on a diet not sufficiently nutritious, may show symptoms of disorder of the brain.
It may become irritable, restless, very startlish, with occasional flushings of the face, moaning in its sleep, and sleeping with half-closed eyes. But the head is not hotter than the rest of the body; if the head is not closed, the open part or fontanelle is not tense and pulsating, but flat or even depressed, the hands and feet are cool, and very readily become cold; there may be occasional vomiting, but nothing like the constant sickness of real brain-disease, the bowels are not shrunken but distended, constipation is not present, but on the contrary there is a disposition to diarrhœa. If the symptoms are misinterpreted and wrongly treated, unmistakable signs of exhaustion at last come on, and the child may die from its not being borne in mind that results at first sight much the same may flow from causes diametrically opposite.
The moral of this is too obvious for me to need insist upon it. Cold to the head, low diet, aperients, possibly leeches, are needed in the one case; increased nourishment, perhaps stimulants, in the other. In every instance where symptoms of brain disorder occur in the child, remember the grievous consequences of a mistake as to their nature, and seek for further help and guidance to preserve you from the possibility of error.
Spasmodic Croup.—I have already tried to explain how, in early life, the brain is often unequal to control the sensitiveness of the nervous system to various sources of irritation from without, and how, in consequence this irritation manifests itself by those involuntary movements which we call convulsions. But in addition to, or in the place of those violent contortions or convulsions, the same condition shows itself sometimes in disordered action of the muscles which subserve parts not directly subject to the will, as those for instance which open and close the entrance to the windpipe, or glottis as it is called in medical phraseology.
Cases in which this occurs are known in popular language as child-crowing, or spasmodic croup, from the peculiar catch or crow which accompanies the entrance of air through the spasmodically contracted opening of the windpipe; a spasm which if severe and sufficiently continued closes the opening altogether, so that after fruitless efforts to get its breath the child dies suffocated. This affection occurs chiefly during teething, just as the fits of a hysterical girl oftenest occur during the transition from girlhood to womanhood; but many other causes besides the local irritation of the teeth may produce it, such as constipation, indigestible food, or disorder of the bowels.
It does not often occur in perfectly healthy children; but an infant who is attacked by it is usually observed to have been drooping for some time previously, to have lost its appetite, to have become fretful by day and restless at night, and to present many of those ill-defined ailments which are popularly ascribed to teething. At length, after these symptoms have lasted for a few days or weeks, a slight crowing sound is occasionally heard with the child's respiration, shorter, more high-pitched, but less loud than the hoop of hooping cough. Usually it is first noticed on the child awaking out of sleep, but sometimes it is perceived during a fit of crying, or comes on while the infant is sucking. The spasm may have been excited by some temporary cause, and the sound which is its token may not be heard again; but generally it returns after the lapse of a few hours, or of a day or two, and its loudness usually increases in proportion as its return becomes more frequent. It will soon be found that certain conditions favour its occurrence; that the child wakes suddenly with an attack of it, that excitement induces it, or the act of swallowing, or the effort at sucking, so that the child will drop the nipple, make a peculiar croupy sound with its breathing, and then return to the breast again. Throughout the whole course of the affection, its attacks will be found to be more frequent by night than by day; and to occur mostly soon after the child has lain down to sleep, or towards midnight, when the first sound sleep is drawing to a close.
At first, the child seems, during the intervals of the attack, much as before; except, perhaps, that it is rather more pettish and wilful; but it is not long before graver symptoms than the occasional occurrence of an unusual sound when the child draws a deep breath excite attention, and give rise to alarm. Fits of difficult breathing occasionally come on, in which the child throws its head back, while its face and lips become livid, or an ashy paleness surrounds the mouth, slight convulsive movements pass over the muscles of the face; the chest is motionless, and suffocation seems impending. But in a few seconds the spasm yields, expiration is effected, and a long loud crowing inspiration succeeds, or the child begins to cry. Breathing now goes on naturally: the crowing is not repeated, or the crying ceases; a look of apprehension dwells for a moment on the infant's features, but then passes away; it turns once more to its playthings, or begins sucking again as if nothing were the matter. A few hours, or even a few days, may pass before this alarming occurrence is again observed, but it does recur, and another symptom of the disturbance of the nervous system is soon superadded, if it has not, as is often the case, existed from the very beginning. This consists in a peculiar contraction of the hands and feet; a state which may likewise not infrequently be noticed during infancy, unattended by any peculiarity in breathing. It differs much in degree; sometimes the thumb is simply drawn into the palm while the fingers are unaffected; at other times the fingers are closed more or less firmly, and the thumb is shut into the palm; or, coupled with this, the hand itself is forcibly flexed on the wrist. In the slightest degree of affection of the foot, the great toe is drawn a little away from the other toes; in severer degrees the toe is drawn away still further, and the whole foot is forcibly bent upon the ankle, and its sole directed a little inwards. Affection of the hands generally precedes the affection of the feet, and may even exist without it, but the spasmodic contraction of the feet never exists without the hands being involved likewise. At first this state is temporary, but it does not come on and cease simultaneously with the attacks of crowing breathing, though generally much aggravated during its paroxysms. Sometimes a child in whom the crowing breathing has been heard, will awake in the morning with the hands and feet firmly bent, though he may not have had any attack of difficult breathing during the night. When the contraction is but slight, children still use their hands; but when considerable they cannot employ them, and they sometimes cry, as if the contraction of the muscles were attended with pain. Sometimes, too, there is a degree of puffiness both of hands and feet, a sort of dropsical condition, which, whenever it is present, adds much to the anxiety with reference to the child.
As the condition becomes more serious, a slight crowing sound is heard each time the child draws its breath, the fits of difficult breathing are much more severe; they last longer, and sometimes end in general convulsions. The breathing now does not return at once to its natural frequency, but continues hurried for a few minutes after the occurrence of each fit of difficult breathing, and is sometimes attended with a little wheezing. The slightest cause is now sufficient to bring on an attack; it may be produced by a current of air, by a sudden change of temperature, by slight pressure on the windpipe, by the act of swallowing, or by momentary excitement. The state of sleep seems particularly favourable to its occurrence, and the short fitful dozes are interrupted by the return of impending suffocation, in one paroxysm of which longer and severer than the others the infant may fall back dead.
It scarcely need be said that the great majority of cases have no such sad ending as I have described, but still, whenever this spasm exists, even in a slight degree, there is always the possibility, never to be forgotten, of a sudden catastrophe. Usually, after some tooth has been cut which caused special irritation, or as disorder of the bowels has been set right, the symptoms abate by degrees, and then cease altogether, though liable to be reproduced by the same causes as those to which they were originally due.
The seeking out and removing the exciting causes must be the care of the medical man, but there are some special precautions which come within the mother's own province to observe.
First of all, as sudden excitement, and especially a fit of crying, are likely to bring on the attack, and since there is a possibility that any attack may prove fatal, the greatest care must be taken in the management of the child to avoid all unnecessary occasion of annoyance or of distress.
Although the benefit that accrues from fresh air, or from a change of air, is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such exposure followed by a severe attack of difficult breathing, or by the occurrence of general convulsions. Another reason for caution in this respect is that the occurrence of catarrh is almost sure to be followed by an aggravation of the spasmodic affection, which, though previously slight, may thereby be rendered serious or even dangerous.
I have nothing to add to what I have already said with reference to the treatment of the attack, when actual convulsions come on. Since, however, in this affection convulsions may occur quite unexpectedly at any moment, it is well always to have a basin of cold water and a bunch of feathers handy, in order to be able at once to dash the water on the child's face, and induce that deep inspiration which saves it from the threatening danger. If this should not suffice, the finger must be put into the mouth, and run over the back of the tongue in the way that I have already explained when speaking of convulsions. Now and then it happens, though but very rarely, that violent general convulsions come on in infancy quite independent of spasmodic croup, not preceded nor attended by any sign of disease of the brain, and which end in the course of some hours or of a few days in death, the child being partly worn out by the violence of the muscular movements, partly by the disturbance of breathing which each fit occasions. Happily, however, in most of these instances the convulsions by degrees lessen both in violence and frequency, and the child recovers.
Epilepsy.—There is one other point of view from which convulsions in infancy and early childhood must be looked on with apprehension, and that is from their being frequently followed in after years by epilepsy. In nearly a fifth of all cases of epilepsy in childhood that have come under my notice the first occurrence of fits dated back to early infancy, and this, even though an interval of years had passed between the last fit in infancy and the first in childhood. It seems, indeed, as though there were in these cases a peculiar abiding sensitiveness of the nervous system, which, dating back from very early life, dependent often on hereditary predisposition, was kindled into activity by any special cause, such as the cutting of the second set of teeth, or the transition from boyhood or girlhood to manhood or womanhood.
In the child, just as in the grown person, epilepsy manifests itself in two different ways; either by momentary unconsciousness, or by violent convulsions, in which latter there is little distinction from the occasional fit which may be observed at any period of infancy.
The attacks of momentary unconsciousness often pass long unnoticed. They occur, perhaps, when the child is at play or at meals; it stops as if dazed, its eye fixed on vacancy; if standing, it does not fall, nor does it drop the toy or the spoon which it was holding from its hand. If speaking, it just breaks off in the midst of the half-uttered sentence. Then, in less time than it takes to tell, it suddenly looks up again, finishes what it was saying, or goes on with its play, or with its meal as though nothing had happened; or it suffices to call the child and the cloud passes from its face, and it is itself again; and the nurse or perhaps even the mother, thinks that it is some odd trick which the child has got. By degrees the attacks become more frequent, and may continue to recur several times a day without any obvious cause, even for months; and this without any change in their character. By degrees, however, under their influence, an alteration takes place slowly in the child's disposition. It loses its cheerfulness and brightness, its face assumes a heavy look, it becomes fretful, and its intelligence grows duller.
Almost invariably after the attacks of this, which has been called the petit mal, have continued for some months, a change begins to take place, which does not fail to excite attention and to cause alarm. If seated, the child's head drops forward for a moment, and strikes against the table; if standing, it becomes for an instant dizzy, and staggers, or even falls, and then there is twitching of one limb, or of the muscles of the face, and then the complete fit of epilepsy, ushered in sometimes, but not always, by a momentary cry, and then the convulsive twitching of one limb, followed in a minute or in less time by convulsions of the whole body as well as of the limbs. The upturned eyes, which do not see, are horribly distorted, the child foams at the mouth, it is insensible, and the insensibility deepens into stupor, or is followed by heavy sleep, for a quarter of an hour, or an hour or more, from which the patient arouses feeling tired and bruised, and often with an aching head, but with no remembrance of what has passed during the seizure so distressing to bystanders.
It has throughout been my endeavour not to lose sight of those for whom this little book has been written, and with reference to epilepsy, as with reference to many other things, I pass over much that would be important to the practitioner of medicine, to dwell on those points which mainly interest the parents, and which they are perfectly able to appreciate.
The question is often put as to the probability of fits terminating in epilepsy; or, on the other hand, as to the ground for hope in any case that epileptic attacks, which have already often recurred, will eventually cease. In the first place, no conclusion can safely be drawn from the severity of a convulsion, nor from its general character, as to the probability of its frequent recurrence, or of its passing into permanent epilepsy. The severity of a fit certainly affords no reason for this apprehension, nor does its recurrence, so long as a distinct exciting cause can be discovered for each return. The fits, which cease in the teething child when the gum is lanced, and which, on each succeeding return are equally relieved by the same proceeding, do not imply that there is any great tendency on their part to become habitual. In the same way, the attacks which follow on constipation, or on indigestion, or on some other definite exciting cause, may probably with care be guarded against, and their return prevented. It is not the violence of a single fit, nor even the frequent return of fits for a limited time, which warrants the gravest apprehension; but it is their recurrence when all observable causes of irritation have passed away; it is their return when the child is otherwise apparently in perfect health.
If, on the one hand, the violence of a convulsion does not by any means imply the greater proportionate risk of its recurrence, so neither can any hopeful conclusion be drawn from the slightness of an attack, or from its momentary duration. In childhood, such attacks are at least as common preludes to confirmed epilepsy as in the adult, and are the more deserving of attention from their very liability to be overlooked. I believe, too, that an imperfect suspension of consciousness, the child knowing what passes, though unable to speak, is not very uncommon, and further, that it is far from unusual to have the early stage of epilepsy in childhood announced by sudden incoherent talking for a few seconds, or by a wild look; a cry of surprise, or a short fit of sobbing, announcing as in a hysterical girl, the close of the paroxysm. The early symptoms of epilepsy in childhood are also the more likely to be misinterpreted from the circumstance that they are frequently accompanied by a moral perversion much more striking than any loss of mental power. It is true that in early life there are alternations of intellectual activity and mental indolence, of quickness and comparative dulness, which all who have had much to do with education are well aware of, and which are perfectly compatible with health of body and health of mind. But changes in the moral character of a child who is still under the same influences, have a far deeper meaning than is often attached to them; a child does not suddenly become wayward, fretful, passionate, or mischievous, except under the pressure of some grave cause.