Practical observations on the convulsions of infants

Preface

Notwithstanding the frequent opportunities we unfortunately have of watching the progress of the convulsive affections of children, and of deliberately considering the relative advantages of different modes of treatment, much discrepancy of opinion is still found to exist in practice, both as to the nature and treatment of such maladies.

By some practitioners of considerable eminence, the slightest convulsive affection of children is looked upon as an invariable indication, if not of organic disease of the brain, of at least very serious cerebral dis-

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turbance ; and free and repeated bleeding, frequent purgation, and large doses of calomel, are the means almost indiscriminately had recourse to in the treatment of such cases. By others, on the contrary, a very different view is entertained of the great majority of the convulsive affections of children, and consequently a totally different practice is instituted. Whilst by the latter it is admitted that in children there does exist a powerful disposition to affections of the head, it is presumed, that convulsions frequently occur from causes which produce a very slight and transient impression upon the brain ; and that in such cases relief is not to be sought for by the employment of the formidable mode of treatment to which I have just adverted.

In my own limited circle of experience, I have had several opportunities of witnessing the injurious effects of the injudicious

PREFACE. Vll

application of the doctrine promulgated by the late highly respected Dr. John Clarke, " that in every case of convulsion, the brain is at the time organically affected either directly or indirectly*." He who will carefully observe the mode of the attack in many instances, and the sudden and complete cessation of the convulsive paroxysms of infants upon the removal of some local cause of irritation, must come to the conclusion, that no serious cerebral disturbance has existed, or is to be apprehended as a necessary consequence. It is undoubtedly true, that convulsions do frequently depend either upon a permanently disturbed state of the cerebral functions, or upon some organic lesion of the brain. But while we admit this fact, it is incumbent upon us, as much for our own reputation as for the

* Commentaries on the Diseases of Children, p. 90.

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safety of our patients, that we should not adopt the exclusive opinion which maintains, that we have always to contend with great determination of blood to the head, or organic disease of the brain. I do not imagine the existence of this error for the purpose of assuming the merit of its detection. Those who are best acquainted with the practice of some high authorities of the present day, will be aware that the treatment of the convulsive affections of infants is almost entirely founded upon the belief, that convulsion in every case, be it slight or severe, partial or general, either arises from, or will necessarily be followed by, some serious, although undefined cerebral disease. In every point of view, this part of the subject must be considered important, and I have therefore frequently adverted to it in the following pages.

I am not aware that any English author

PREFACE. IX

has written particularly upon the convulsive diseases of infants. The work of Baumes, " Sur les Convulsions dans l'Enfance," is well known. His divisions appear to me arbitrary, and unprofitable in practice. Even jaundice he enumerates as a species of convulsions. The recent publication of Dr. Brachet, " Sur les Causes des Convulsions chez les Enfans, et sur les Moyens d'y remedier," contains much valuable information. A minute detail of many cases of convulsions forms a principal feature in his work. I have not, however, adopted this obvious and easy mode of enlarging the size of a volume. The phenomena exhibited during the convulsive struggles claim less of our attention than the insidious derangements of health which precede the occurrence of the paroxysms, or the consequences which result from their frequent repetition.

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It may perhaps be objected, that the treatment I suggest as applicable to convulsive diseases, is little more than that which is required for many and various derangements of health, which every practitioner would enforce. Such is undoubtedly the case. Convulsions are rarely if ever idiopathic in the strict acceptation of the term. They are symptomatic of most of the diseases of infancy, and will consequently be frequently prevented by assiduous attention to the first deviations from health, and the timely application of treatment, which must vary with the constitution of the child, and the particular derangement or disease of which convulsion is a symptom, or to which it is likely to supervene.

Chapter I

ON THE FREQUENCY, THE CAUSES, AND SYM- PTOMS OF INFANTILE CONVULSIONS. — THE PROGNOSIS, AND APPEARANCES OBSERVED ON DISSECTION.

IT appears, from a return made by Dr. Clarke at the end of the year 1792, that of 17,650 children born in the Lying-in Hospital of Dublin, a sixth part died during the first year of their existence, and that nineteen out of twenty fell victims to convulsions. Dr. Lange has recorded, that at Copenhagen, during a period of thirteen years, no less than 12,769 children perished from epilepsy. In his opinion the prevalence of this dreadfully fatal disease was to be attributed to the luxurious and effeminate education which was practised in every class of society.

That infants are particularly subject to convulsive affections is a fact which has been admitted by every observer " sous toutes les latitudes, sous la zdne brulante des tropiques, comme sous la zdne glac6e du Spitzberg*."

It has been said that the number of children who perish from convulsions is much exaggerated ; — that in a great majority of cases in which they occur, convulsions can only be regarded as a symptom of some other disease, the fatal termination of which has contributed to increase the various returns, from public and private sources, of deaths from "General Convulsions." To a

* Brachet sur les Convulsions. Paris 1824.

certain extent the objection as to the accuracy of such returns may be well founded. It is doubtless true, that the death of a child is occasionally attributed to the accidental occurrence of a convulsive paroxysm, when it was destroyed by some other disease, of which that was comparatively an unimportant symptom.

Every allowance, however, being made for these probably erroneous records, it cannot be denied that a vast number of children are suddenly cut off by an unexpected attack of convulsions, which not unfrequently occurs when no previous derangement of health could be discovered, or at a time when any malady under which the child was labouring began to assume a less severe aspect, and to justify a confident and favourable prognosis. The occurrence of such cases is no less distressing to the parents than prejudicial to the practitioner.

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We never escape from censure when we have raised hopes which are suddenly and unexpectedly blasted, however impossible it might have been for human foresight to anticipate an unfavourable termination. Although, then, the convulsions of children are in most cases symptomatic of some other disease, they are of sufficient importance to admit of a separate consideration, inasmuch as they not unfrequently destroy life in a few moments, when it was not endangered by the malady which excited them. Notwithstanding, however, the universal admission of the fact, that convulsions are always to be regarded with apprehension, I am inclined to believe, from frequent personal observation, that no cases are dismissed in general practice with less attention than those which pass under the convenient term of Convulsions.

It is, indeed, a source of frequent lamentationwith physicians, and not unfrequently of neglect, — which is so commonly the offspring of despair, — that the diseases of children are particularly difficult to detect, from their inability of describing their sufferings. I consider this difficulty more imaginary than real. He who will take the trouble to regard with attention the looks, the gestures, and the general demeanour of children in health, will have but little difficulty to detect the first advances of disease ; although considerable experience may be required to determine the precise nature of the malady, or its appropriate treatment. Dr. P. Buchan justly observes, that " persons actually engaged in the practice of medicine must be aware, that it is often no less difficult to sift the truth out of the figurative and theoretical language in which adults are apt to clothe their feelings, than it is to judge of the unadulterated expressions of distress exhibited by an infant suffering from disease." If in the latter case we have to contend with an inability to describe symptoms, we shall find the various and frequently inexplicable motives to deception present a no less formidable obstacle to our investigations in the former.

In young children attacks of convulsions so commonly occur, that they are not unfrequently looked upon with indifference even by parents, until their frequent repetition has strengthened the natural or acquired predisposition to their occurrence, and the best-directed efforts of the practitioner must be unavailing. The general axiom of " Remove the cause and the effect will cease" is inapplicable to many derangements of the animal economy, and more particularly to those affecting the nervous system. When convulsions have once taken place, even in the most healthy subject, the brain and nervous system retain for a long and indefinite period such a morbid sensibility, that a return of them is to be apprehended from the most trifling causes, long after the originally exciting cause has been entirely removed.

It is at all times a task of much difficulty to conquer the habit of recurrence of convulsive motions when muscles have frequently been affected by them. The greater the general weakness and constitutional irritability, the stronger will be the tendency of convulsive motions to form a habit.

We so commonly find a strong, and perhaps invincible disposition remain to the x occurrence of nervous diseases, which have originally been induced by the application of accidental and trifling causes, that it is not necessary to dwell upon the subject. But what is precisely the change which is effected upon the brain and nervous system, — in what consists the difference between a brain thus predisposed, from one which has never been exposed to a shock capable of producing disease, has never yet been satisfactorily explained, and probably never will. But little elucidative evidence has as yet been obtained upon this point even from dissection. Children not unfrequently die with all the symptoms of hydrocephalus, or after having suffered violent and repeated paroxysms of convulsions ; and upon examination post mortem, we find the brain and its meninges to all appearances perfectly healthy. Whenever we do detect structural derangement, it must be the effect of derangement of action or function ; and in many cases death takes place before any organic destruction has been produced by the functional lesion.

It is not necessary to enter further into the consideration of the anatomical and physiological peculiarities of the animal economy during the infant state, than is sufficient to explain the origin of the well-known aptitude of infants to convulsive diseases. It has been remarked by Boerhaave, that every disease of childhood is accompanied by nervous symptoms, and most of them by convulsive affections of some part of the body, although they may be frequently so slight as to escape attention. The great disposition of infants to nervous affections is not to be wondered at, when we consider that the habit of bearing either external or internal impressions is yet to be acquired. " Every stimulus acts in an inverse ratio to the frequency of its application*;" and, until the frail mind and body of the infant are accustomed by habit to have their powers acted upon with impunity, the most hazardous susceptibility

* Crichton on Mental Derangement.

must necessarily exist. The muscles during infancy are pale, soft, and fragile ; their contractions are quick, frequent, and feeble ; and the external surface of the body is endowed with a very high degree of sensibility, in consequence of the nerves being covered only with a very fine thin cuticle. Hence, from very slight impressions arise very powerful effects. The circulation of the blood is very rapid, the arterial pulsations nearly double those of the adult. The capillary circulation is also infinitely more active. The lymphatic system exerts a more powerful influence upon the general economy of the infant than upon the adult. The muscular fibre as well as the skin is highly sensitive. The nerves are large in proportion to the size of the body. They resemble medullary pulps. Both the cerebral and ganglionic nerves are much more strongly developed in relation to the body than at any other period of life. The brain is large, and the nerves which proceed from it of a very considerable size. As we advance in years the coats of the nerves and the muscular fibres become firmer, and our susceptibility to external impressions is consequently diminished. Hence it is, that in proportion as we advance in years convulsions are less likely to take place. They sometimes occur during the period of youth. In the adult they are rare ; and they scarcely ever happen in old age. The sensations of a child are quick but transient. When any reaction takes place in the system, it is powerful and sudden, and coincides with the general mobility : — motion, indeed, is the language of an infant.

All children are not equally disposed to convulsions. Levret, Mauriceau, Baumes, and other writers, affirm that it may be established as an axiom, that children born with large heads, or whose heads increase in size disproportionately to the other parts of their bodies, will have convulsions. In my own practice I have seen convulsions occur very frequently in children with small heads. In rickety children the size of the head is disproportionately large ; and, from the general symptoms of rachitis, it is evident that the head and spinal marrow are considerably affected : the brain increases rapidly in size, the senses are usually very acute, and convulsions are very frequent attendants of this distressing malady. It not unfrequently happens, when some children of the same parents are affected with rachitis, that others, who are exempted from this disease, are at a very early age destroyed by convulsions*. The children of parents who

* Diet, des Sciences Medicales, tome xlvi. p. 602.

marry at too early or too advanced an age are more susceptible of convulsions than the progeny of those persons who marry in the prime of life.

An hereditary predisposition to convulsive affections has been observed by many respectable authorities. Boerhaave states, that all the children of an epileptic man died of the same disease. Lorry relates the history of a family of which the father, mother, and their children, were affected with convulsions from the most trifling cause. As an additional proof of the hereditary nature of the nervous affection in this instance, it should be observed, that all the children were equally subject to convulsions, although they were brought up in different situations, and their education was totally dissimilar. A crowd of authorities of the highest reputation might be adduced to prove that convulsions are not unfrequently hereditary. Those who require any particular confirmation of this opinion may consult the works of Hoffman, Horstius, Forestus, Sauvages, Willis, Tissot, Pujol, &c. &c. There is, indeed, no reason why a disposition to convulsive diseases should not be transmitted from parents to their offspring, as well as a disposition to other maladies. The children of women in high life, who enfeeble their health by late hours, hot and crowded rooms, and irregular diet, are undoubtedly more disposed to convulsive affections than the children of those females who are regular in their mode of living, and who enjoy the calm tranquillity of a country life.

In warm countries the sensibility of individuals of every age, both to mental and corporeal impressions, is much more highly developed than in colder climates. Hence the adage, "An African will start if you touch him ; but to make a Muscovite feel, you must scorch him." — Dr. Hillary observes, that the children of the isle of Barbadoes are so irritable that they are thrown into convulsions by the slightest noise.

If we seek for a precise definition of convulsions in different authors, we shall find the same perplexing contradictions which so frequently obstruct our progress in medical writers. But not to enter into a useless verbal criticism, it may be said, that when there is either an alternate and involuntary contraction and relaxation of the muscles, or a permanent contraction of the muscles, convulsion exists. The contraction may be so trifling as scarcely to attract attention ; or it may be exerted in the highest possible degree which the muscular structure is capable of supporting without rupture of its fibres. When the muscular contraction is permanent, it is then termed a tonic convulsion. In this species, the involuntary contraction of the muscles renders them motionless, and incapable of renewing their motion until the entire cessation of the convulsion. When there is an alternate contraction and relaxation, — a rapid succession of irregular action and rest in the muscles affected, — the term clonic convulsion is employed. Dr. Good proposes a rational alteration in the generally adopted nomenclature of convulsive affections. He offers the term Entasia, and observes, " By many nosologists the genus is called tonos or tonus, which is here dropped in favour of the present term (Entasia), because tonus or tone is employed by physiologists and pathologists, in direct opposition to irregular vehemence or rigidity, to import a healthy and perfect vigour or energy of the muscles ; and by therapeutists to signify medicines capable of producing such or similar effects." By Cullen and some other writers the term spasm is applied exclusively to the fixed contraction of parts ; while convulsion is meant to designate that preternatural motion which is the general, if not the constant character of the convulsive affections of children. The duration of a convulsive paroxysm is uncertain : it may last only for a few minutes in some cases, whilst in others it may continue for one or two days. In the latter cases, however, there is some remission of the convulsive violence : the infant appears tranquil for some moments, and is again subjected to the same distressing and involuntary struggles. The terms spasm and convulsion are not unfrequently used as synonymes. Under the term spasm the ancients included every kind of convulsions. In the present day it is applied, generally, to denote a very slight contraction or tension of a muscle, which in many cases leads to more decided convulsion.

The parts most commonly the seat of convulsions are the eyes, the features of the face, the superior and inferior extremities, and the respiratory muscles. It perhaps never happens that the features retain their natural tranquillity of expression while other parts of the body are convulsed, although the preternatural movements of the face are sometimes slight.

Each part may be separately and successively affected, or the whole frame may be convulsed at the same moment. The convulsive movements are sometimes confined to one side of the body. This variety does not, however, alter the nature of the disease, and is not of sufficient importance to warrant the distinction which has been adopted by some authors of general and partial convulsions. They are each produced by the same causes, and require the same general treatment.

Neither fever nor disturbance of the intellectual functions forms a part of the symptoms of a paroxysm of simple convulsions. A child may not be able to hear during the paroxysm ; but this is not a proof that its faculties are destroyed. The muscles are no longer obedient to the will. Mr. Thompson of Whitehaven has recorded a curious case in the Medical Repository, of loss of speech and hearing in a child eighteen months old, who had been suddenly seized with convulsions : her vivacity remained, and her health was unimpaired. She continued in this state until her sixteenth year, when after the noise of a public rejoicing she was observed to recover the sense of hearing, and she soon began to articulate. There is much difficulty in establishing c 2 clear distinctions between the various species of nervous affections : they pass into each other imperceptibly in many cases, and the line of distinction is scarcely to be denned. There is a strict analogy between epilepsy and simple convulsions : the muscular system is in each disorder affected in a very similar manner. An attack of epilepsy, however, commences and terminates by a state of stupor and dulness, which for a time destroys the senses and intellectual faculties. Such is not the termination of convulsions, properly so called. From whatever cause convulsions may occur in highly irritable children, the attack may run into true epilepsy, idiotism, or paralysis. Epileptic paroxysms also return without any obvious cause, and are frequently periodical. The cause of simple convulsions, on the contrary, may generally be determined. The periodical return of the accessions of many nervous diseases is a subject of considerable interest, and one which is very little understood. Dr.Pitcairn relates the case of a man of thirty years of age, who from the age of nine years experienced each year in March and September, at the commencement of a new moon, a convulsive attack of the right arm. I have at this moment a case under my care, of a young lady, who has been seen by many practitioners, and amongst others by my friends Messrs. Arnott and Ward, who for three years has been affected with a remarkable convulsive cough, which commences in November without any apparent indisposition. It ceases as suddenly as it begins, but has lasted for several weeks at each attack. In this case there is a trifling distortion of the spine. The head is of a remarkable shape. There is also slight strabismus.

In the opinion of Hoffman, the principal difference between epilepsy and simple convulsions consists in their seat. Epilepsy he considered to arise from affection of the brain and its membranes, and simple convulsions from the spinal marrow and its coverings.

It is to be observed, that sometimes only a portion of a muscle is influenced by the convulsive action, while the other parts of it are in perfect repose. The violence of the muscular contractions sometimes gives considerable pain. Baumes observes, that cases of convulsions have been seen of such intense violence, that the teeth have been broken, the eyes thrown from their sockets, and blood driven from the nose, or effused into the cellular tissue, producing a general ecchymosis of the body; and that even the limbs have been luxated or fractured. Such cases are doubtless rare. I have never witnessed any examples of such extraordinary violence in convulsions as to produce any of the above-mentioned accidents. Lieutaud has recorded some cases in which fracture of the bones occurred. Slight ecchymosis is not an uncommon consequence.

Every part possessing muscular fibres is obnoxious to convulsions. To detail ail the convulsive movements which are occasionally exhibited to our view during the paroxysm, would be to enumerate the alternate contraction and relaxation of all the muscles of the body. " The most common case of convulsion," says Dr. Clarke (Commentaries on the Diseases of Children, p. 81), "is that in which there is an universal spasmodic contraction of all the voluntary and many of the involuntary muscles of the body, accompanied by foaming at the mouth, protrusion of the tongue, staring of the eyes, distortion of the eyeballs, laborious and obstructed respiration, sometimes accompanied with a violent redness of the face and scalp in the beginning of the paroxysm, followed by a purple colour of the whole body at the end of it. This latter symptom sometimes continues till the child dies." Such is undoubtedly a clear description of a very severe paroxysm of convulsions. We seldom, however, witness so exquisite a form of the attack. The redness of the face and scalp is not usual ; neither is foaming at the mouth a very common appearance in simple convulsions, although Dr. Brachet* decidedly errs in defining the paroxysm to be " toujours sans ecume a la bouche."

Whether the convulsions have been continued or intermittent, the cessation of the paroxysm takes place in the same manner : the convulsions become gradually less vio-

* Brachet sur les Convulsions. Paris 1824.

lent and less frequent ; the eye projects less from its orbit, and loses by degrees the unnatural expression seen during the fit ; the face resumes its usual look, and the little patient appears unconscious of any disturbance. If he speaks, he merely evinces great lassitude, and complains perhaps of headache. A refreshing sleep frequently succeeds the attack.

Convulsions rarely appear during the night : the reason is obvious ; it is the season of tranquillity, during which the patient is removed from various stimuli.

Towards the termination of many long and debilitating diseases a sudden starting of particular muscles is frequently observed. This convulsive symptom is termed subsultus, and usually indicates much danger. The muscles which have long tendons are particularly subject to subsultus. Irregular motions of the involuntary muscles frequently occur, and are denned by the name of Palpitations. The heart is most frequently affected by them. Every palpitation results from a sudden contraction of the part, and must be considered as partaking of a convulsive character.

Of the Proximate Cause or nature of convulsions we are, and probably shall ever remain, in doubt. We are equally unable to detect the essential nature of most other diseases. We cannot expect positively to determine the proximate cause of convulsions, until we become acquainted with the medium by which the muscles are connected with the common sensorium and volition of the mind, and with the nature of the nervous power. In the absence of more precise information, however, many conclusions of much practical utility may be derived from a patient observation of the various phenomena connected with convulsive actions. An acquaintance with the healthy actions of the animal economy must be presumed. In disease, we must mark with attention the manner and degree in which the diseased actions of a part differ from its healthy actions.

During a state of health some muscles contract by the effort of the will. In some the intervention of the will is not apparent, although the muscular action is subservient to the will to a certain extent. The action of other muscles is altogether involuntary. The velocity and force of muscular contractions are in relation to the degree of the excitement that is applied, and to the powers of the animal. These contractions are soon succeeded by relaxation ; and they are not again repeated until excited by the will or the irritation peculiar to the part. During convulsions the voluntary muscles are excited without the concurrence of the will ; or if an effort of volition is excited, the muscles do not obey its dictates, as would be the case in a state of health. Without, then, possessing a knowledge of the essential nature of convulsions, it must be evident that wherever convulsive motions take place, some morbid change must exist in the seat of volition, or in the nerves, or in both ; or that the muscles may have undergone some morbid alteration, in consequence of which they exhibit the various phenomena of convulsions without any alteration in the nervous system.

From numerous experiments which have been made, and which are too well known to require particular reference, it is certain that the perfection of the faculties of sense and motion requires a healthy condition of the nervous system. Convulsions, however, do not necessarily succeed every disease of the nerves. Dr. Pring has shown that inflammation of a nerve does not of itself produce specific effects which are displayed in the phenomena of convulsive affections. Convulsions frequently occur from local injury of nerves ; but it is remarkable that the muscles to which the injured nerve is distributed may be the last affected with convulsive action.

Convulsions of infants are commonly divided by writers into idiopathic and symptomatic. The propriety of this distinction is doubtful. It is at least certain that in a very great majority of cases convulsions are symptomatic ; and it might probably be asserted with accuracy that they are never idiopathic. Such certainly has been the result of my own observation, although I am diffident of stating decidedly an opinion in opposition to the many authorities of high respectability who adopt the above division. When the brain is acted upon immediately by any cause, and convulsions supervene, they are considered to be idiopathic. But in such cases the convulsive action is secondary to some deviation from the natural condition of the brain, and is therefore, in point of fact, as strictly symptomatic as if it were the consequence of derangement orisrinatins: in some distant organ and subsequently reflected upon the brain. From the imperfection of our knowledge, or the carelessness of our inquiries, the derangement of which convulsions are symptomatic no doubt frequently escapes detection, and the attack is looked upon as idiopathic.

It is an undoubted fact, that convulsions of children are of much more frequent occurrence in the present day than at any former period. The cause of this increase I do not pretend to determine. It may perhaps be fairly inferred that the vast increase of nervous diseases is to be imputed to the modern and vicious system of educating infants. It is at least certain that all diseases of that class have increased in proportion as polished education has removed children from the bodily freedom and carelessness of mind, which to a certain extent are so essentially necessary to the preservation of their health. In ancient Europe convulsive affections were scarcely, known. It will not be denied that mismanagement in the diet of children is a frequent cause of local irritation, which sooner or later gives rise to convulsions in many cases.