34 CONVULSIONS-THEIR EXCITING CAUSES VARIOUS. during childhood in comparison with those instances in which they pass off without any serious result; and that in proportion to their frequency they less often betoken grave disease of the brain in the child than in the adult, while any cause which greatly excites the spinal system may be attended by them. The disturbance of the spinal system which ushers in fever in the adult, shows itself by shivering; while in the child the same disturbance often manifests itself, not by shivering but by convulsions. Convulsions may be induced in early life by a constipated state of the bowels, by the presence of worms in the intestinal canal, or of a calculus in the kidney, or by the pressure of a tooth upon the swollen gum,causes wholly inadequate to occasion so serious an occurrence in the grown person. Hence your first duty is, in every case, to ascertain where is the seat of the irritation which excited the nervous system to this tumultuous reaction. If the fits come on in an advanced stage of some serious disease, they are probably only the indications that death is busy at the centres of vitality; if they occur during hooping-cough, they point to a congested state of the brain, the consequence of the impeded circulation through the lungs; if they attack a child apparently in perfect health, they probably indicate that the stomach has been overloaded, or that some indigestible article of food has been taken; or, if this be certainly not the case, one of the eruptive fevers is perhaps about to come on; most likely either small-pox or scarlatina. To determine the cause of convulsions, you must acquaint yourself with the history of the child's health for some time before any threatening of them had appeared; you must learn whether the child has ever suffered from worms, whether its digestive functions have long been out of order, or whether the process of dentition, which is now perhaps going on, has been attended with much constitutional disturbance. But, besides all these points, your enquiries must be still more carefully directed to ascertain at the same ages, in the metropolis; and the second line, the proportion borne by deaths from convulsions to deaths from diseases of the nervous system in general. Deduced from the Fifth and Eighth Reports of the Registrar-General. PRECURSORS OF AN ATTACK. 335 whether any cerebral symptoms preceded the attack, and if so, what was their nature, since it is seldom that acute disease of the brain sets in with convulsions. You will sometimes, indeed, be told that the child was well until a convulsive seizure suddenly came on; but on enquiring minutely it will usually be found that some indications of cerebral disease had been present for days, though not sufficiently severe to attract much attention. In cases of apoplexy, of intense cerebral congestion, and of phrenitis, convulsions occur at a very early period; but even then, extreme drowsiness, great pain in the head, and vomiting, usually precede for a few hours the convulsive seizure. When the brain is thus seriously involved, the recovery from the convulsions is very imperfect; coma perhaps succeeds to them, or other evidences of cerebral disease are so marked as to leave no doubt of the brain being affected. Tubercle sometimes remains for a long time after its deposition in the brain, without giving rise to any well-marked symptoms, till its presence is at length announced by a fit of convulsions. These convulsions are seldom at first very severe, but you will learn to dread them more than those which assume a inore formidable appearance, from noticing either that one side of the body is exclusively affected, or, at least, that there is a marked preponderance of the affection on one side. It is well to bear in mind, too, that convulsions may occur from a want of blood in the brain as well as from its excess, and that the convulsions which come on in some ill-nourished infants may indicate a state of atrophy of the brain. I must, however, have said enough already to impress upon you the importance of narrowly scrutinising the meaning of every attack of convulsions. But though so important, there are few tasks more difficult. You have to maintain your own self-composure at a time when all around you have lost theirs; to extract truth as you best may from the imperfect, often exaggerated, accounts of anxious relatives; to observe not only minutely but quickly, and to come to a speedy decision: since while in those cases which require active treatment delay is almost synonymous with death, there is at least as great danger of destroying your patient by that "nimia diligentia" to which the prejudices of the nurse and the fears of the friends will often conspire to urge you. It is well to watch closely the first indications of that disturbance of the nervous system which will be likely to issue in convulsions. And here let me recommend you not to listen with too incredulous an ear to old nurses, who may tell you that a child has 336 DESCRIPTION OF A FIT. been much convulsed, while you find upon enquiry that it has not had any fit. When they say that a child has been much convulsed, they mean usually that it has shown many of the symptoms which forebode an attack of general convulsions. These forebodings are often induced by dyspepsia or by disorder of the bowels in young infants, and have been described by writers under the name of "inward fits." A child thus affected lies as though asleep, winks its imperfectly closed eyes, and gently twitches the muscles of its face-a movement especially observable about the lips, which are drawn as though into a smile. Sometimes, too, this movement of the mouth is seen during sleep, and poets have told us that it is the "angel's whisper" which makes the babe to smile-a pretty conceit of which we can scarcely forgive science for robbing us. If this condition increase, the child breathes with difficulty, its respiration sometimes seems for a moment almost stopped, and a livid ring surrounds the mouth. At every little noise the child wakes up; it makes a gentle moaning, brings up the milk while sleeping, or often passes a great quantity of wind, especially if the abdomen. be gently rubbed. When the intestinal disorder is relieved, these symptoms speedily subside; nor have we much reason to fear general convulsions so long as no more serious forebodings show themselves. There is more cause for apprehension, however, when we see the thumbs drawn into the palm either habitually, or during sleep; when the eyes are never more than half closed during sleep; when the twitching of the muscles is no longer confined to the angles of the mouth, but affects the face and extremities; when the child awakes with a sudden start, its face. growing flushed or livid, its eyes turning up under the upper eyelid, or the pupils suddenly dilating, while the countenance wears an expression of great anxiety or alarm, and the child either utters a shriek or sometimes begins to cry. When a fit comes on, the muscles of the face twitch, the body is stiff, immovable, and then in a short time, in a state of twitching motion, the head and neck are drawn backwards, and the limbs violently flexed and extended. Sometimes these movements are confined to certain muscles, or are limited to one side. At the same time neither consciousness nor sensation is present. The eye is fixed and does not see; the finger may be passed over it without winking; the pupil is immovably contracted or dilated; the ear is insensible even to loud sounds; the pulse is small, very frequent, often too small and too frequent to be counted; the breathing DESCRIPTION OF A FIT. 37 hurried, laboured, and irregular; the skin bathed in abundant perspiration. After this condition has lasted for a minute, or ten minutes, or an hour or more, the convulsions cease; and the child either falls asleep, or lies for a short time as if it were bewildered, or bursts into crying, and then returns to its senses, or sinks into a state of coma in which it may either be perfectly motionless, or twitching of some muscles may still continue; or, lastly, it may die in the fit. This, however, is not usual except when the convulsions have come on in subjects exhausted by previous disease, or when they are the result of apoplexy or of intense cerebral congestion, such as takes place occasionally in hooping-cough, or when they are associated with that closed state of the larynx which occurs sometimes in spasmodic croup. This preliminary examination of the symptoms of disturbance of the nervous system has placed us in a position to commence our investigation of the different forms of cerebral disease; on which we will enter at the next lecture. ד. LECTURE IV. CONGESTION OF THE BRAIN.-Active congestion may come on at the onset of eruptive fevers, or be induced by exposure to the sun, or may attend dentition, or be excited by various other causes-Symptoms in each of its three stages-Treatment-Special rules for depletion and the application of cold-Active measures not always appropriate. Passive congestion may supervene on hooping-cough, or be connected with disorder of the digestive organs in weakly children, or be induced by unfavourable hygienic causes-Its symptoms and treatment. IN In my last lecture I endeavoured to point out to you some of the reasons for the greater frequency of affections of the nervous system in infancy and childhood than at other periods of life. I dwelt especially upon certain structural peculiarities of the brain, and of its bony case, which render the cerebral vessels liable to become overloaded with blood, under the influence of causes that would be wholly inadequate to produce such an effect in the adult. With the advance of the ossification of the skull, and the closure of its fontanelles and sutures, these peculiarities are rendered fewer and less important; but still a remarkable liability to congestion of its vessels continues to characterise the brain through all the years of early childhood. A late distinguished German physician, Dr. Mauthner, of Vienna,* on examining the bodies of 229 children who had died at different ages and of various diseases, found a congested state of the vessels of the brain in 186 of the number. In some of these cases it is probable that this condition had come on only a short time before the patients' death, since in them no symptoms of cerebral disturbance had appeared during the progress of their illness; but in many it was not so; and I shall have occasion to warn you over and over again to be on the watch against congestion of the brain, as a condition which is very likely to come on in the course of affections even of distant organs. Nor is it merely as a serious complication of many other diseases that this p. 12. Die Krankheiten des Gehirns und Rückenmarks bei Kindern. 8vo. Wien, 1844, |