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at the same time. The ends of the cut hair are exhalent surfaces, which keep the head cool. The dress of very young children should be both light and warm, easily secured without pins, which prick and tease the skin, and the child should be soused in tepid water daily, and rubbed dry quickly. Such are Foville's invaluable remarks on the management of children, but especially on the evil effects of a heavy head-dress.
ART. III.—On the Cerebral Affections of Infancy and Childhood. By
VALENTINE DUKE, Esq., M.D. (Being the Council Prize Essay, awarded at the Annual Meeting of the Provincial Medical and Sur
gical Association, held at Bath.) 1848. We feel anxious to place before our readers the most recent observations in connexion with the physiology and pathology of the nervous system. We therefore have selected, for analytical review, an Essay, just published in the “ Transactions of the Provincial Medical and Surgical Association,” by Dr. Duke, on the cerebral diseases of children.
This class of affections is deserving of greater consideration than it has hitherto received from the hands of those competent by practical experience to enlighten the profession on the frequently obscure points connected with the cerebral diseases of early life. These affections are common during the periods of infancy and childhood. They are often most fatal,—most insidious in their progress,—most obscure in their origin,-most difficult of diagnosis, and, alas ! very frequently setting at defiance all the resources of our art. Owing to the impossibility of obtaining accurate information from the patients themselves, the physician is required to exercise great tact and discrimination in the detection of the diseases of the brain and nervous system, with the view of recognising at the earliest period the first symptoms of disease; for, at this stage, it may be possible to prevent the brain and its appendages from becoming organically affected. None but those who have had some practical acquaintance with the management of the diseases of early life, are competent to appreciate the difficulties which the physician has often to encounter in the treatment of the cerebral affections of children. The medical man is not often called in “until the time has passed, when the early observation of symptoms might have afforded greater facilities for drawing inferences. Unfortunately, it happens, often too, that cerebral affections are so insidious in their approach, so masked by some prominent, remote, sympathetic affection, or so little characterized by any very decided pathognomonic symptoms, that they are overlooked by the friends in the early stages, and the doctor is called in, only to be able to confirm the apprehension that has been accidentally excited for the safety of the head. The child may have been astray for some time, and have lost flesh,— but it was only teething, and has often been so before. True, it has had vomiting, but then the food disagreed; or if it be an infant suckling, the mother has been anxious, and has lost her rest—enough to cause that. There is a ready and familiar way to account for every symptom, but the lurking disease is overlooked, or not suspected. The supervention of convulsions, screaming, severe head-ache, or perhaps, sudden coma, arouses anxiety, and directs attention to the head, and then, too often, irremediable mischief has been done.
In relation to the medical literature connected with this department of practical medicine, Dr. Duke observes, that "until the work of Dr. Whytt (published in Edinburgh) appeared, this subject had not received any real scientific attention.” The writings of Drs. Fothergill, Watson, Dobson, Rush (of Philadelphia), Quin (of Dublin), Cheyne, West, Wiltshire, Marshall Hall, are referred to. Dr. Duke makes no mention of Mr. W. C. Dendy's valuable monograph, “On the Cerebral Diseases of Children, particularly in reference to their early Manifestations and Treatment,” which appeared in an early number of the “ Psychological Journal."
The author commences his treatise with the subject of “ Congestion of the Brain.” This affection, he says, is of rare occurrence in early life. It is generally the result of a neglected state of the bowels, exposure to cold, and causes impeding the return of blood to the head. He has known this affection terminate fatally in twenty-four hours—the result of sudden passion in the nurse. He believes congestion of the brain is occasionally the consequence of mothers, whilst suckling, freely indulging in spirituous and fermented liquors. It also occurs during the course of the exanthemata and hooping-cough. The symptoms of the disease, as recorded by Maunsell and Evanson, are, stupidity and heaviness, “ the head looking full, and being perhaps hotter than usual, the veins distended and dark coloured, the countenance livid, and the pulse slow, or irregular; the pupils are usually dilated, and the eyes looking vacant; a permanently elevated and convex condition of the fontanelles leaves no doubt of its existence. If unrelieved, these symptoms may be followed by effusion, and death take place in twenty-four hours.”
The treatment consists (after removing the cause) in cold applications to the head, which, with perhaps the general warm bath, and freely acting on the bowels, will generally be sufficient; but if the lividity of countenance, or the nature of the breathing, denotes danger, we must apply leeches. Blisters will also be found useful, and both these remedies are recommended to be applied to the extremities, rather than the head. The nape of the neck should be selected as the part best suited for blistering. Tonics and stimulants may be necessary to prevent a recurrence of the symptoms of congestion.
Irritation, or Erethism of the Brain, is generally associated with dentition. There is increased irritability of the sensorium, and susceptibility to impressions. The child, startled by the slightest noise and light, is uneasy and fretful. The eyelids are generally closed; the flexion of the thumb on the palm of the hand is a peculiar symptom. The child is watchful, and gets little sleep. It is distinguished from congestion of the brain by the absence of stupor, and the tendency to coma. Hydrocephalus is the frequent sequel of this condition of the brain. The treatment consists in allaying irritability, procuring sleep, and supporting the strength by light stimulating nourishment. Evacuate the bowels by enemata and mild aperients—apply cold to the head, and warmth to the feet. The latter object is effected best by means of flannel, wrung out of hot water, rolled round the feet and legs—this again being wrapped up in a warm, dry piece of flannel, or small blanket. Change of air sometimes acts like a charm. The state of the gums must, of course, be attended to, and if necessary the gum lancet ought to be freely used.
The Hydrencephaloid Disease is divided into two stages, the first, that of irritability; the second, of torpor. In the former there is a feeble attempt at reaction; in the latter, the powers appear to be prostrate. Dr. Duke observes, “ If we trace the history of the case, we shall generally find that there has been some considerable evacuation, either loss of blood in the cure of some other affection, or long existing diarrhea. The infant at first is irritable and peevish; he starts upon being touched, and is over-sensitive. There is sighing and moaning during sleep, and sometimes screaming. Here are symptoms, some of which are present in the erethism of the brain, and some in hydrocephalus; and it will require the closest attention to the history of the case to enable us to discriminate between them. As the disease advances, the exhaustion is more apparent; the countenance becomes pale, and the cheeks cool; the eyelids are half closed, the eyes fixed, and unattracted by any object placed before them; the pupils unmoved by light; vomiting is sometimes present, and the bowels are rather free than constipated, though the evacuations are unhealthy. You must meet these symptoms by supporting the system, administering gentle stimulants, and such moderate doses of opium as may allay irritability, or check diarrhæa, if present. Dover's powder is a very manageable form in which to use this medicine, and the starch enema, with opium, will be generally effectual when diarrhea exists. If vomiting be present, we must try to allay it by administering small quantities of nourishment, as chicken-broth; or, if the exhaustion be very great, by stimulants, as wine, or even brandy. A small blister, for an hour, over the stomach, will often materially assist in checking vomiting. If there be great coldness of the surface, we may use the warm bath for a short time; and the water may be made stimulating, by the addition of some mustard. After the symptoms have been subdued, tonics must be administered to prevent relapse, and, as before-mentioned, change of air is most desirable. Should we, by oversight or mistake of its real character, treat this case by continued depletion, our patient would assuredly sink rapidly, and die comatose, or convulsed.
The application of cold to the head, so useful in most of the cerebral affections of infancy, would here be badly borne.
Should the symptoms not be relieved, the child may die seemingly exhausted, and examination would very likely show considerable serous effusion in the ventricles; but then this would have been more of a passive nature, than the result of acute inflammation.
Symptoms of exhaustion are frequently seen in children who are imperfectly nourished, either on account of deficient supply, or the bad quality of the nurse's milk. These matters must be closely inquired into by the physician, and his treatment regulated accordingly. The change of a nurse, under such circumstances, is imperatively called for,
Great attention should also be paid to the nourishment a child receives after being weaned, especially if that process has been suddenly carried into effect, from any necessary cause. The assimilating powers of the digestive apparatus are weak, and disease of the brain may result from deficient nutriment.
Convulsions of Children.-On this subject, Dr. Duke broaches nothing novel. This is a common affection in early life, and is often dependent upon some irritation existing in the primæ viæ, or from difficult teething. Delicate children are more liable to this disease. When the robust are attacked, the danger to life is greater. Dr. West observes that convulsions in infancy and childhood appear to take the place of delirium in adult life. In the treatment of this class of affections, we shall "generally proceed safely in ordering cooling applications to the head, having the bowels well freed, and directing the use of the tepid or warm bath; sprinkling cold water in the face is a means also recommended; I have seen it shorten and prevent the seizure.
When some distinctive symptoms are present, localizing the cause, we can apply ourselves more particularly to their removal. Carminatives, with turpentine and assafætida enemata, will procure the discharge of flatus, generally followed by great relief.
“ Lancing the gums should never be neglected; it will often induce sound sleep, and hinder a return of the attack. Sometimes, especially where there is a tendency to somnolence or coma after the seizure, the application of a couple of leeches will considerably lessen the liability to a recurrence. In such a case, we must be very cautious in the use of cold to the head.”
Acute Meningitis is a most rapidly fatal disease. Fortunately, it is of rare occurrence. Dr. Duke considers it a distinct affection. It generally comes on suddenly, and attacks children previously healthy and robust. This disease is often the consequence of exposure, for a lengthened period, to the rays of the sun, blows on the head, the sudden suppression of purulent discharge from the ear, the repercussion of cutaneous affections of the scalp. This affection is divided into the phrenitic and convulsive forms. We do not see the practical value of this division, because the two affections are so often blended together. Our author says the phrenitic form occurs more frequently in children of four years old, and upwards, who have begun to exercise actively the reasoning powers (?); the latter, in younger infants.
“The convulsive form usually commences suddenly, by an attack of convulsions, general or partial. There is febrile disturbance, but not so great as in the phrenitic variety; vomiting and constipation are not so usually observed. The convulsions are repeated at short intervals; and between times, the child remains either very much agitated or comatose, with the pupils mostly contracted, and very likely there is squinting; sometimes we have hemiplegia.
"A rigor, followed by fever and vomiting, with head-ache, intolerance of light and noise, quick pulse, hot and burning skin" generally accompanies the phrenitic form. The child is restless, and answers questions abruptly. “ The intellect becomes soon engaged, and, as the disease advances, the symptoms indicative of derangement of the nervous system become more marked; the head-ache is intense, with frowning; delirium, of a violent character, is present, alternating with stupor. Convulsions now occur, and there is strabismus, with contracted pupil. The child lies with his eyes closed, and face averted from the light; he often starts and screams with the violent pain, which is so severe as quite to deprive him of sleep. The respiration and circulation are also much affected; the former is hurried and irregular, presenting that character so well known in fever, as cerebral breathing. The pulse is very quick, and generally strong and full, but variable. The face is alternately