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.