LECTURE XIII.

CONVULSIONS, independent of organic cerebral disease—their two forms. The acute form, how distinguishable from those dependent on disease of the brainpractical importance of the distinction-rules for their treatment. The chronic form-relation to them of SPASM OF THE GLOTTIS-import of this spasm-one of several signs of disorder of nervous system. Relation of these convulsions to processes of development in teething-but exciting causes various. Symptomsdescription of carpo-pedal contractions-ways in which death is produced. Treatment-rules for diet and for the regulation of the bowels-caution with respect to lancing the gums-occasional necessity for free depletion-case in illustration. Suggestions as to general management, and prevention of an attack. Use of chloroform. Remarks on some anomalous forms of convulsion, and on the Eclampsia Nutans.

In the third of these Lectures, when passing in review the different signs of disorder of the nervous system I made some remarks on the subject of convulsions. I tried to show you how their import varies in different circumstances; how at one time they betoken real disease of the nervous centres, at another only betray their irritation from some cause which, if death occur, may yet leave behind no trace such as the skill of the anatomist can discover.

Cases of the former kind have hitherto exclusively engaged our attention, but we must not quit the study of disorders of the nervous system without some consideration of the latter. In the adult, fits sometimes occur independent of obvious cerebral disease; the patient falls to the ground struggling and insensible; but after a time the convulsion ceases, consciousness returns, and the patient recovers. Our anxiety in such cases is much less for the present than for the future: death in the fit is a rare accident, but what we dread is the recurrence of the fits, the weakening of the intellect, the slow impairment of the health which epilepsy brings with it. In the child our apprehension is two-fold; for the frailer machinery is more readily brought to a stand-still, and the risk of death in the fit is far greater than in the adult; while should the child survive,

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the convulsions of infancy may issue in the epilepsy of riper years; and, in fact, seem to do so in a very large number of instances.

The convulsions of infancy and early childhood generally assume one of two characters. Either they are sudden in their onset, violent in their character, frequent in their return, or they come on gradually, and after various forebodings, present less violence, occur at longer intervals, but are not therefore by any means devoid of peril. Cases of the first kind run some risk of being overtreated, from their supposed dependence on active cerebral mischief; cases of the second kind often excite less apprehension than they really warrant, until their symptoms have become manifest in their full intensity.

Some of the most marked examples of the sudden access of violent convulsions which have come under my notice have been in children in whom they succeeded to the sudden drying up of an eruption on the scalp. Even in such cases, however, where we might most readily suspect some direct influence on the brain, the character of the fits is widely different from that which we observe in instances of real cerebral disease. The illness preceding them is neither very marked nor of long duration, while, when the fits come on, instead of only one side of the body, or one set of muscles being affected, sometimes one side is convulsed, sometimes the other, or both are involved equally. Even after the fits have frequently returned, paralysis does not succeed to them, and often neither sleep nor coma, while frequently consciousness returns, even before the convulsive movements have completely ceased, and the pupils, though dilated during the fit, act again almost or quite as well as ever as soon as it has passed off. Vomiting does not precede nor accompany the attack; nor an obstinately constipated state of the bowels; and the abdomen is often much distended with flatus, the endeavour to get rid of which produces troublesome hiccough, while the inspiration is often accompanied by a peculiar crowing sound. There is at no time the burning heat of the head which is observed in active inflammatory disease of the brain; there are not the piercing cry, nor the constant wail, nor the tearless eyes, nor the shrunken abdomen, nor the automatic movements of one side, and the contraction of the limbs on the other, which attend upon tubercular hydrocephalus.

These characteristics are such as ought to prevent the by no means unusual error of regarding the attack as symptomatic of active disease of the brain; and under that impression depleting the child freely, dosing it with mercury in large quantities, and

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at short intervals; a course of proceeding by which all chances of recovery are frustrated, and hopes, small at first, are altogether destroyed.

The state of the child before the occurrence of the fits, and the amount of apparent congestion of the brain, must in cases of this kind determine the question of depletion. Moderate depletion once is often well borne, but the persistence of the fits must not be thought necessarily to indicate the propriety of its repetition. If the attack succeeded to the rapid disappearance of some eruption on the scalp, an attempt may be made to reproduce it by rubbing in every three hours an ointment composed of one drachm of powdered ipecacuanha to an ounce of lard; which generally produces an abundant papular eruption in the course of from 12 to 24 hours. If a purgative be indicated, a single dose of calomel has the advantage of acting surely and speedily, but mercury, given in any other manner or with any other object, is out of place. The flatus by which the intestines are distended is got rid of better by an assafœtida enema than by any other means; while the application to the abdomen of a cloth dipped in a stimulating liniment (such, for instance, as a drachm of oil of turpentine, five drachms of the simple camphor liniment, and six drachms of olive oil), and that covered by a light linseed meal poultice, both serves as a counterirritant, prevents the reproduction of the flatus, and relieves that spasm of the abdominal muscles which in many of these cases adds very painfully to the infant's sufferings. These measures having been adopted, you may now, according to the general condition of the patient, prescribe either some carminative medicine with small doses of ether, or of the fœtid spirits of ammonia, or a single dose of Dover's powder, if restlessness and excitability have outlasted the other symptoms; or a simple saline, as the citrate of potash, with small doses of the tincture of henbane; or the hydrocyanic acid with a little chloric ether at short intervals-a sedative which, whenever there is a doubt as to the expediency of employing direct narcotics, has always seemed to me of especial value.

Within certain limits, this treatment must of course be modified according to the exact nature of the case, but enough has already been said to mark out the general principles upon which your treatment should be conducted; while even if the attack had seemed at first to present some obscurity as to its cause, a few hours will suffice for its removal, will develop the signs of cerebral inflammation, if that were impending, or will bring to light the character of the fever which is making this stormy onset. So long

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as, notwithstanding the frequency of the return of the fits, recovery is complete after each, so long as the power of deglutition subsists, and the natural hue of the lips and face announces the oxygenation of the blood to be well performed, you may give on the whole a favourable prognosis, though always guarding it by admission of the possibility of the child dying in a fit from that spasm of the glottis, and consequent arrest of breathing, which is the great source of danger in infantile convulsions.

This Spasm of the Glottis is, indeed, one of the most remarkable features in many convulsive affections of infancy and childhood; though more especially of that variety to which I have referred as coming on gradually and pursuing a somewhat chronic

course.

So prominent a feature, indeed, is it of this latter class of convulsions, that attention has been very generally directed to this one symptom, almost to the exclusion of the other signs of disorder of the nervous system by which it is accompanied, and the various terms, spasmodic croup, child-crowing, spasm of the glottis, and laryngismus stridulus, show how great has been the disposition to regard it as a distinct and independent disease. Hence has resulted the inconvenience, that attention being directed exclusively to the affection of the respiratory function, local causes have been too much sought for to account for the local symptom; defective, if not erroneous explanations of its occurrence have been proposed, and sufficient regard has not been paid in its treatment to the great diversity of conditions under which it may supervene.

The sobbing breathing, or the sense of choking, so characteristic of the hysterical patient, are but instances of spasm of the respiratory muscles, similar to those which we observe in the infant, and equally due to the great excitability of the nervous system. In the hysterical girl, fits are frequently superadded to the affection of the respiratory muscles; and in the child, spasm of the muscles of the extremities, giving rise to the drawing of the thumb into the palm, and to the separation of the great toe from the other toes, or to the forcible extension of the foot upon the ankle, is seldom absent; while general convulsions often supervene under slight causes, or even without any apparent reason. In both cases the affections are usually attendant upon important processes of development, since while in the former instance they generally come on about the period of puberty, they oftenest occur in the latter during the time of teething; and this with so great frequency, that in 31 out of 37 cases of which I have preserved a record, the symptoms manifested

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themselves between the age of 6 months and 2 years, or just at that time when the process of dentition is going on with the greatest activity. The direct irritation of the trifacial nerve in teething has no doubt a great share in the production of the symptom at that time, but I apprehend that we should be in error if we confined our attention entirely to the local cause, and attributed this, more than any other form of convulsive affection, which occurs at this time, simply to the mechanical irritation of the teeth pressing on or cutting through the gum. The period of teething, like that of puberty, constitutes one of the great epochs of life; it is a time when great changes are going on in the whole organism-when the animal machine, being in a state of increased activity, its parts are more than usually apt to get out of order. New diseases appear, or such as were before of rare occurrence become frequent; catarrhal affections and disorders of the intestinal mucous membrane are extremely prevalent, and the brain grows more than ever liable to congestion of its vessels. In these circumstances, the various spasmodic affections, of which spasm of the glottis is the most striking and the most important, often occur as the secondary rather than as the primary result of dentition. The child has cut some of its teeth without any symptom of disorder of the nervous system making its appearance, but at length it suffers an attack of diarrhoea, or the bowels are allowed to become constipated, or signs of cerebral congestion show themselves. A crowing sound now becomes audible with the inspiration, and with it some or all of the whole train of convulsive symptoms which I shall presently describe make their appearance. It may be that the gums are not swollen, nor any tooth near the surface just at the moment when the signs of disturbance of the nervous system occurred, but their connection with the process of dentition is not the less undeniable. In many instances, too, though these symptoms may subside as the health improves, yet so great is the nervous excitability of the patient, that they return when he cuts another tooth, and this even without a recurrence of that general disorder which attended them on the former occasion.

The various sources of irritation, however, that give rise to these affections are not limited to the period of teething; and hence they may be met with before the commencement of that process as well as after its termination. By no one has this fact been more clearly stated, or the mode of action of the various exciting causes more successfully explained, than by the late Dr. Marshall Hall.