D.C. Das Gupta, M.B. (Cal. Univ.).
Hardly is there any condition which upsets the parents of a child more than the convulsions of infants. The suddenness of its appearance, the clonic-tonic movements, the struggle, the fear of immediate death all contribute to their loss of mental equilibrium and utter helplessness. No less is the difficulty of the doctor, who has a double duty to perform to find out the cause of the convulsions of his little patient, who, in most cases, is not as yet gifted with the power of giving out his case and to quieten an equally convulsive parents.
As we meet with cases of convulsions of children very frequently in our practice, we should have a thorough knowledge of the diagnosis, prognosis and and treatment of infantile convulsions, so that we may do full justice to them, and that very quickly too when the occasion demands.
Dr. E. Feer, Director of the University Childrens Clinic, Zurich, say, “General convulsions are extremely common during the first two or three years of childhood. The laity recognises them under the term first or spasms, mothers are in great fear of them. The clonic-tonic twitchings are most noticeable in the face, about the mouth and eyes and in the hands and feet. Usually however the entire body is involved. Clinically all the convulsions resemble each other so closely that no diagnosis as to the etiology can be made from one attack only.”.
Both sexes are affected equally. About a third of the cases takes place during the first year of life, two-thirds during the first two years. Apart from Epilepsy, convulsions are rare after the age of 5 or 6. They are of more serious import in infants under 6 months than in older children and also in anaemic and weakly infants. The more common age for convulsion is from the 7th to the 8th month and upwards. It is at this period that we meet not only severe and general convulsions, but many cases of local convulsive spasms or rigidity, e.g. strabismus, laryngismus, tetany or contracture (rigid inturning of thumbs upon the palms and rigid flexion of the feet).
Convulsions may occur in infants a few days or a few weeks old, they are often associated with unnatural drowsiness and very generally pass off in a few days.
In infants of several weeks, they are liable to come on suddenly, occur one after another in quick succession and associated with Pyrexia. These attacks are mostly due to indigestion from casein of the cows milk and a w et-nurse is the proper remedy. Several such attacks that look alarming, do perfectly well by simple attention to diet and a few simple remedies.
General convulsions of infants and children may be seen in the following condition :-.
(1) Hereditary syphilis. (2) Congenital heart disease. (3) Cerebral paralysis. (4) Onset of acute fevers. (5) Meningitis. (6) Drug poisoning. (7) Enlarged thymus. (8) Idiocy. (9) Rickets. (10) Epilepsy (minor and major).
In Hereditary Syphilis, convulsions often prove fatal during the first week of life. For the rest, in about half the patients, rickets is the predisposing cause; in many of the others, some local irritation, such as inflammation of the gums in dentition, of the nose and ears, the presence of irritating food or worms in the intestine, renal or vesical calculus or phimosis, can be found; while convulsions at the onset of acute infectious diseases such as scarlet fever, pneumonia. measles, whooping cough or during their course and in nephritis are not infrequent.
Overdosing with drugs such as strychnine, atropine, santonine, morphia or with alcohol may bring on convulsions. Fright and overstrung emotions are included among the causes of infantile convulsions. How far inheritance, the neurotic or neuropathic taint is responsible for them is uncertain. Convulsions occur in children with enlargement of the thymus gland, the so called Status Lymphaticus and in these not infrequently a fit is a fatal issue. It must be remembered that in any child there may be early evidence of Epilepsy or of organic brain disease. Their diagnosis demands a very careful examination of the child, and also of its diet and the hygiene of its daily life.
They may be due to congenital heart disease, when there will be enlargement of the heart, cardiac murmurs, and some degree of cyanosis. In children with organic diseases of the brain (encephalus, congenital or acquired, cerebral paralysis, spastic paraplegia, etc.) there will be paralysis, spasm, muscular atrophy and probably mental defect. If the convulsions are due to the onset of some acute infectious disorder, they will come on suddenly in a child previously well and will be accompanied by high fever, followed by the characteristic rash. Similar convulsions and fever may occur in Meningitis, usually towards the end of the disease.
They are not rare in whooping cough, particularly in rachitic infants, being precipitated by the asphyxia resulting from the whooping, and not rarely causing death. The diagnosis of fits due to drugs or alcohol, taken either by the child or by the mother if the child is being suckled, will depend upon obtaining an adequate history of the case. In what way enlargement of thymus brings about convulsions is not known ; the condition is fortunately rare and is hardly ever diagnosed during life. The fits occurring in hydrocephalus and the various degrees of mental defects need only to be mentioned.
Most convulsions occurring between the ages of three months and four or five years are due to Rickets. Normally, the nervous system is unstable in all young children the power of cerebral inhibition is not acquired for several years. In Rickets this instability is much increased, and finds expression in irritability, fits of screaming, restlessness, inability to sleep well at night and in more serious troubles of tetany, laryngismus stridulus and convulsions. Any child with fits should be scrutinised for rickets.
Though rickets is the main predisposing cause of infantile convulsion, it must be remembered that they are actually brought on by some secondary exciting cause, such as gastro-intestinal disturbance with diarrhoea or vomiting or reflex irritation of any sort.
Then comes the idiopathic cases, for which we can find no cause. These arise in a child who is apparently in fairly good health and convulsions may pass off after a time or which not infrequently becomes established so that the child suffers from fits from that time onward at varying intervals. A considerable number of such cases are examples of genuine epilepsy.
Sir William Gowers put the proportion of cases of epilepsy beginning as convulsions in infancy at 10 per cent. Epilepsy may certainly begin in early life, so that when we see a child who is suffering from violent convulsions for which we find no cause, we must bear in mind that we may be dealing with the first stage of epilepsy.
The age of the patient forms a valuable diagnostic aid. In the newly born, convulsions are most often due to birth injuries, with tetanus and meningitis in the second place. Even during the succeeding three or four months, most convulsive attacks are due to organic disorders, such as developmental defects of brain, hydrocephalus, syphilis, meningitis, etc. or they may be due to severe disturbances of nutrition or terminal in pneumonia.
After the fourth month up to the end of the second year, the spasmophilic convulsions are the most frequent. During the first, year, we may have, beside the spasmophilic, convulsions without fever due chiefly to syphilis, hydrocephalus and sclerosis. In the last half of the first year, tuberculous meningitis must be added as a cause.
As regards prognosis children often do not die in convulsions unless the convulsions are themselves merely the final scene in a mortal complaint that is unless they are simply a symptom of terminal asphyxia. Convulsions as a disease are not immediately fatal, unless when very severe and repeated and in quite young infants.
Remember that in a considerable proportion of the cases the convulsions may persist in the form of epilepsy and remember that nearly all or quite a large number of children who suffer from convulsions, manifest in later life nervous disorders of different sorts. Convulsions if frequently repeated may cause permanent mental impairment and they often leave behind, too, traces of cerebral damage in the form of stammering or a squint.