and the direction of the pathways of the fibers from these centers is known. Therefore, it is possible to locate accurately a lesion of the brain, either a tumor, cyst, abscess, or morbid growth, from the pressure-symptoms which they produce. Areas of sclerosis and hemorrhage, destroying or impairing the centers and nerves or the tracts from the centers are determined in the same manner. A lesion in a definite part of the brain will involve certain centers and nerves which will produce paralysis of the parts supplied by those nerves. Thus, if there is a hemor- rhage or a tumor pressing on what is known as Broca's area in the brain, which is the speech center, there will be impairment or loss of the function of speech. If this 182 DISEASES OF CHILDREN FOR NURSES symptom is present with other symptoms of cerebral involvement, such as persistant headache or unconscious- ness, choked disk (a condition of the eye), and paralysis of other parts of the body, there is a tumor involving Broca's area. A more accurate diagnosis than this can be made. The position of the motor areas around the fissures of Rolando are 'upside down,' the leg area above, the arm in the center, and the face below. The first symptoms of irri- tation to nervous structures are convulsions. Convulsions due to brain irritation of the motor areas are characteristic. They begin in the part that corresponds to that portion of the brain which is irritated. If the irritation is in the hand area of the motor region the convulsion will start in the hand, gradually extend up the arm, and then become general. This form of convulsion is termed Jacksonian epilepsy. A finer distinction than locating the lesion in the hand area can be made. If the positions in the different areas in the motor region are known, by watching this convulsion which starts in the hand, and by noting what parts are successively involved, the extent and direction of the convulsion can be determined. If, after the convulsive movements reach the shoulder, they involve the corner of the mouth it is plain that the lesion in the brain extends downward. If, on the other hand, the leg is the next part to become involved the lesion extends upward. This will impress the nurse with the necessity of observing a convulsion carefully so that the diagnosis can be accurately made, for brain surgery demands accuracv, and as so many lesions of the brain can be treated only by surgical means, its importance can be appreciated.
<Callout type="important" title="Important">Accurately diagnosing the location of a lesion is crucial for proper treatment.</Callout>
Nervous Diseases I 83 A nurse will be able to observe convulsions more closely than anybody else; therefore, she should note the kind of convulsion, whether tonic or clonic, where it begins, what parts are successively involved, in which direction the eyes and head turn, for in destructive lesions the head and eyes are usually turned toward the side of the lesion of the brain, and in irritating lesions to the opposite side. Also note what parts of the face are involved, as the nerves supplying the face emerge from the skull at different levels. A lesion at one level might involve a nerve after it had crossed, giving a paralysis on the same side as the lesion instead of the opposite, as is the rule, producing the so- called crossed paralysis; while at another level it may be affected before it has decussated, giving a paralysis on the opposite side of the face. This knowledge gives aid in the determination of the level of the lesion.
Also note whether the eyelids are drooped and whether the patient is conscious or unconscious. CONVULSIONS Convulsions occur frequently in childhood. They are due to direct irritation of the cortex or to reflex irritation. The poisons generated by the acute infectious diseases may so irritate the cortex that convulsions occur during the course of these diseases. Convulsions often usher in an attack of illness in children. Reflexly, indigestion, teething, and other trivial causes at times produce general convulsions. This is due to the instability of the nervous system at this early stage.
<Callout type="warning" title="Warning">Be cautious when interpreting convulsions as they can be caused by serious underlying conditions.</Callout>
Treatment. — A mustard tub, temperature no° F., for five minutes is the best method to employ (see page 373).
CEREBRAL PARALYSIS Birth palsy in children is not uncommon. It is caused by a hemorrhage upon the cortex of the brain; rarely the hemorrhage occurs within the brain substance. The hemorrhage usually occurs during the birth of the child. The resulting paralysis may be a hemiplegia, half of the body being involved; monoplegia, one extremity; diplegia, two extremities; or a paraplegia, below the waist. Contractures occur and the children are usually mentally deficient or crippled.
<Callout type="tip" title="Tip">Recognizing the type of paralysis can help in determining the extent of brain damage.</Callout>
Cerebral paralysis may occur after birth, in which case the same symptoms are found. Erb's paralysis is a form of paralysis affecting the upper portion of the arm, due to injury during birth.
Apoplexy is the term applied to a hemorrhage in the brain. Thrombosis of the sinuses of the dura occurs at times, most frequently after an operation upon the mastoid cells. Abscess and tumors are rare in childhood. They cause pressure symptoms. The most common tumors are tubercular in character.
<Callout type="risk" title="Risk">Ignoring signs of a brain hemorrhage can lead to severe complications or death.</Callout>
Hydrocephalus is a condition in which there is excessive fluid in the ventricles or in the arachnoid cavities. It gives to the head a peculiar shape. It is large and round, the sutures and fontanels are enlarged, the convolutions of the brain are flattened, and usually there is imbecility.
Cretinism is a congenital affection characterized by a lack of physical development due to an abnormal condition of the 'thyroid gland. The symptoms are myxedema (a waxy condition of the subcutaneous tissues), an ab- normally large tongue, and idiocy or imbecility.
Deaf-mutism is due to congenital or early loss of hearing. As the child has never heard spoken words he is unable to imitate the proper sounds. Aphasia is a failure of word memory, an inability to utter words, to comprehend them, or to write them.
EPILEPSY The disease apparently depends upon the instability of the motor centers, so that from trivial exciting causes violent discharges occur from time to time. The disease is divided into grand mal and petit mal.
Symptoms.— Grand Mal.— A peculiar sensation called an aura sweeps like a wave over the child. This is followed by unconsciousness and violent general con- vulsions, clonic in type. The child bites its tongue and froths at the mouth. The convulsion lasts for a few minutes and is followed by coma and later by automatism, in which the child performs certain automatic acts. Convulsions occur at varying intervals, showing a tendency to increase in number and severity.
Petit mal is exhibited by momentary loss of conscious- ness with pallor, without convulsive movements.
Treatment. — For the Attack. — This consists in measures to prevent the children from injuring themselves. Some- thing should be placed in the mouth to prevent biting of the tongue; further than this nothing can be done. If they should show any vicious traits after a convulsion, they should be carefully watched, as they are not responsible.
Prophylaxis. — Nitrite of amyl inhalations will at times ward off an attack.
HYSTERIA Hysteria is a functional disease of the nervous system associated with impaired will power and increased sensi- tiveness to impressions. Hysteric children are ill and should be treated accordingly. No doubt when our methods for examining the brain and spinal cord have improved, a definite lesion will be found. The impatience which some people show toward children suffering from hysteria is wrong.
Symptoms. — These are varied. They may be motor, sensory, and psychic. Motor symptoms may be paralysis, usually hemiplegia, spasms, or convulsions. In hysteric convulsions the child is conscious, there is an absence of aura, the tongue is not bitten, the eyes are partially closed, and there is some emotion. The convulsions are tonic, or, if clonic, purpose- ful in character, and the seizures are of long duration.
Sensory symptoms may be complete loss of sensation in certain parts; the special senses may be impaired. The children may have hyperesthesia, clavus (the feeling of a nail being driven into the head), spinal irritations, globus hystericus (the sensation of a ball in the throat), and severe pain in the stomach.
Psychic Symptoms. — There is a great lack of will power, the children are easily moved to laughter or tears, and they have a fondness for sympathy. At times there is delirium and other mental conditions.
CHOREA (ST. VITUS' DANCE) A nervous affection especially common in childhood and characterized by irregular movements which increase under excitement and cease during sleep. The first manifestations are usually those of awkward- ness in movement, and restlessness. These grow worse until the disease is fully advanced, when there are peculiar jerking, disorderly movements of the various members of the body or involvement of the whole body. The move- ment may be so marked that the child cannot use its arms in eating, it stumbles when walking, and grotesque expressions are produced from the involvement of the face. Involvement of the larynx causes stammering, involvement of the muscles of the pharynx causes choking fits and difficulty in swallowing, involvement of the tongue causes its withdrawal to be associated with an audible click. When the child's attention is called to the move- ments they invariably become worse. Frequently a heart murmur develops. The disease lasts from six to ten weeks. Prognosis is good. Occasionally there are deaths from exhaustion.
TETANY A tonic spasm of the muscles of the extremities. It gives rise to a peculiar position of the hand called the obstetric hand in which the lingers are slightly bent, the thumb held almost at a right angle across the palm, and the whole hand is slightly everted. This spasm lasts for a variable length of time and can be excited by making pressure upon the nerve trunks and blood-vessels of the extremities (Trousseau's sign). The disease is usually associated with laryngismus strid- ulus and recovery nearly always takes place.
HABIT SPASM A peculiar form of spasm caused by habitual grimaces or movements of the head, finally becoming uncontrollable. This condition is also called tic.
NYSTAGMUS A constant movement of the eyes. It may be lateral, horizontal, or rotary.
NODDING SPASM OR SPASMUS GYRANS A peculiar form of movement seen in children characterized by a continuous nodding of the head. It is associated with nystagmus. Recovery usually takes place in a month or two.
TORTICOLLIS OR WRY-NECK This is a tonic spasm of the sternomastoid muscle. At times it is persistent.
Treatment. — If due to rheumatism the neck should be ironed with a hot iron, over a piece of flannel first laid on the skin for protection.
Disorders of Speech. — Stuttering or stammering and lisping are the most common.
Disorders of sleep, such as night terrors, are common. The children awake from sleep with a cry of terror; they fail to recognize those around them, and they exhibit symptoms of fright.
Diseases of the Spinal Cord The junctions of the different columns of the spinal cord are: The anterior and lateral columns — motor; the posterior columns — sensory; the anterior horns of gray matter — trophic and motor.
MYELITIS Myelitis is an inflammaton of a segmant of the cord involving the anterior, lateral, and posterior columns and the gray matter.
Symptoms. — At first there is irritation, producing pain and fever. The pain is a peculiar one called a girdle pain. The reflexes are increased; there are pares- thesias and convulsive movements. Later, when the inflammatory product becomes sufficient to produce pressure, there is a loss of sensation instead of pain and paresthesias. The reflexes are lost, there is paralysis instead of convulsions, and there is degeneration of the muscles and bed-sores.
SCLEROSIS Sclerosis is an atrophy of the structure of the part affected with an overgrowth of connective tissue. Sclerosis in the spinal cord is an atrophy of the nerve elements and an overgrowth of the neurilemma (the connective tissue of the cord). Lateral sclerosis is the term applied when this degen- eration attacks the lateral columns of the cord. This disease does not affect the sensory fibers; the main motor fibers which run through the anterior columns are intact and there are no trophic disturbances.
Symptoms. — Exaggerated knee-jerks, ankle-clonus, and scissors gait.
Acute Anterior Poliomyelitis or Infantile Paraly- sis.— This is an acute disease which occurs almost exclu- sively in young children and is characterized by the destruction of the large nerve cells in the anterior horns of gray matter.
Symptoms. — The paralysis comes on very suddenly. The child goes to bed well and the following morning he cannot move his legs, or at times his arms. Certain groups of muscles in the upper and lower extremities are involved, chiefly the latter. The paralysis at first is widespread, but tends to improve up to a certain point, where it remains stationary. The muscles affected atrophy, and the usefulness of the limb is obtained by an over-development of other muscles which perform the function of the muscles which have been destroyed to a limited degree.
Syringomyelia is a disease of the spinal cord in which there is a cavity in the cord.
Landry's paralysis is an ascending form of paralysis beginning in the legs and rapidly involving the entire body. Friedrich's ataxia is a form of sclerosis of the spinal cord which develops in childhood and lasts from twenty to thirty years. Atrophies of the muscles of different parts of the body are seen, due to disease of the spinal cord.
Pseudohypertrophy of the muscles is a condition in which the muscles are apparently enlarged, but actually are degenerating.
Diseases of the Nerves NEURITIS Neuritis is an inflammation of a nerve, and is character- ized by pain and tenderness along the course of the nerve. It is associated with various forms of paresthesias. The part supplied by the nerve is at first hyperesthetic, later anesthetic. In severe inflammations paralysis of the part supplied by the nerve develops.
Sciatica is inflammation of the sciatic nerve character- ized by the above symptoms along its course in the pos- terior part of the thigh. It is worse at night and at the approach of stormy weather.
Left-side Sciatic Bell's palsy of eight years' standing in a girl ten years of age (Friihwald and Westcott I. Multiple neuritis is an inflammation of a number of nerves. The most common cause in childhood is diph- theria.
Symptoms. — There is pain over the deep nerve-trunks, paralysis, and wrist-drop and foot-drop due to paralysis of the extensor muscles.
Postdiphtheritic paralysis is a form of multiple neuritis occurring after diphtheria in which the muscles of swallowing are at first attacked, the other muscles of the throat and body being successively involved. Recovery usually follows. If the children die the cause of death is heart failure due to paralysis of the pneumogastric nerve (see page 281).
Bell's Palsy.— A paralysis of the muscles of expression (Fig. 59) affecting one side of the face and due to in- jury or disease of the seventh cranial nerve.
NURSING IN NERVOUS DISEASES When symptoms of irritation of the central nervous system exist the child should be placed in a dark room, kept as quiet as possible, and the covers should be sup- ported by a frame to prevent the discomfort of their weight. Scrupulous cleanliness must be employed to prevent bed-sores.
The position of the child must be frequently changed, parts resting upon the bed must be protected, using air-cushions and water-beds for this purpose. The symptoms developing in the course of nervous diseases must be accurately recorded, convulsions must be observed, and their starting-point, character, extent, and duration reported.
In lumbar puncture the fluid is collected in a sterile test-tube with an aseptic cotton stopper. At times feeding must be administered by the medicine, dropper, gavage, or enema. The temperature, pulse, and respirations should be taken three times a day.
Key Takeaways
- Accurately diagnosing the location of brain lesions is crucial for proper treatment.
- Convulsions can be caused by direct irritation or reflex irritation in the cortex.
- Jacksonian epilepsy starts from a specific area and spreads according to the motor areas' layout.
Practical Tips
- Be observant of the starting point, type, and duration of convulsions to accurately diagnose their cause.
- Maintain a dark and quiet environment for children experiencing nervous diseases to prevent further irritation.
- Use air-cushions or water-beds to protect parts of the body resting on the bed.
Warnings & Risks
- Ignoring signs of brain hemorrhage can lead to severe complications or death.
- Be cautious when interpreting convulsions as they can be caused by serious underlying conditions.
- Proper diagnosis is essential for effective treatment, especially in cases requiring surgery.
Modern Application
While the techniques described in this chapter are historical and may not directly apply to modern survival situations, the principles of accurate observation and careful diagnosis remain crucial. Modern medical technology has improved diagnostic tools significantly but the importance of detailed patient history and clinical assessment remains unchanged. This knowledge can still be valuable for recognizing symptoms that require immediate attention or specialized care.
Frequently Asked Questions
Q: What is Jacksonian epilepsy, and how does it help in diagnosing brain lesions?
Jacksonian epilepsy starts from a specific area of the motor cortex and spreads according to the layout of the motor areas. By observing where the convulsion begins and how it progresses, nurses can accurately locate the lesion in the brain, which is crucial for proper diagnosis and treatment.
Q: How should a nurse handle a child experiencing a convulsion?
A nurse should place the child in a dark room to minimize sensory stimulation, keep them as quiet as possible, support the covers with a frame to prevent discomfort from their weight, and protect parts of the body resting on the bed using air-cushions or water-beds. They should also record the starting point, type, extent, and duration of the convulsion for accurate reporting.
Q: What are some common causes of convulsions in children?
Convulsions can be caused by direct irritation of the cortex or reflex irritation due to various factors such as acute infectious diseases, indigestion, teething, and other trivial causes. These conditions can lead to general convulsions due to the instability of the nervous system at an early stage.