CASES OF SPASM OF THE GLOTTIS.

199

Although the benefit that accrues from fresh air, or from a change of air, is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such exposure followed by a severe attack of dyspnoea, or by the occurrence of general convulsions. The hazard of such an occurrence is greater in proportion to the severity and long continuance of the affection; and, in such cases, the excitability of the spinal cord, and the irritability of the surface, seem sometimes to become as great as they may be observed to be in frogs when narcotised, whom you may then throw into convulsions by merely shaking the table on which they are placed. It is possible that this condition in the infant may be due to a cause not unlike that which produces it in the lower animal. In the latter, it is manifestly due to the influence on the nervous system of blood impregnated with opium; in the former, a similar influence may be exerted by blood the proper depuration of which has been prevented by the frequent recurrence of spasm of the glottis.

There is also another reason for caution in exposing the child to cold or wind, namely, that the occurrence of catarrh is almost sure to be followed by an aggravation of the spasmodic affection. On more than one occasion I have seen the supervention of catarrh convert a very mild into a very serious attack; and once the exacerbation of the symptoms thus produced was the cause of the infant's death.

The parents should in every instance be made fully aware of the uncertainty that attends this affection-of the possibility of death taking place very suddenly and unexpectedly.

In the paroxysm itself but little can be done. Cold water may be dashed on the face, and the fauces may be irritated, or the finger passed down into the pharynx, so as to bring on if possible the effort to vomit, while at the same time the legs and lower part of the body may be placed in a hot bath.

The remarkable observations of MM. Braun and Chiari* on the employment of chloroform in puerperal convulsions, and a short paper by Dr. Simpson, of Edinburgh,† on its utility in the convulsions of children, drew my attention to it, and I have tried it extensively, and in many instances with advantage. In cases where depletion is inadmissible, where the convulsions are not obviously due to organic disease of the brain, while they are both severe in their character and are returning with frequency, the inhalation

* Klinik der Geburtshülfe, etc., part ii. p. 249, 8vc. Erlangen, 1853.
† Obstetric Works, vol. ii. p. 470, from Ed. Monthly Journal, Jan. 1852.

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PECULIAR FORMS OF CONVULSION.

of chloroform sometimes altogether arrests them. It is also of service in attacks of a more chronic kind, in which, though convulsions are less violent, yet the irritability of the nervous system is extreme, and every change of posture, and every attempt at deglutition, are followed either by threatenings of a fit, or by actual convulsions. Its efficient use, however, is not easy to secure, since it requires the constant presence in the house of some one competent to administer it; while if entrusted to the parents or to a nurse, the fears of the former, and the want of intelligence of the latter, generally render its employment merely nominal. Even when most skilfully administered, too, the efficacy of the remedy soon ceases, if, from the return of the convulsions, the necessity should arise for its being given at very short intervals. In these circumstances the narcotism soon becomes very partial, and the fits recur altogether unmitigated by it-a result which I have also observed in puerperal convulsions. I have never seen mischief follow from its use; but its power of doing good seems usually to be more evanescent than that of other sedatives.

There are still a few points connected with the derangements of the nervous system in early life, which require a brief notice before I close this lecture. And first, with reference to cases, happily rare, of violent, causeless, and fatal convulsions in early life, independent of disease of the brain. Such attacks are very unusual after the completion of dentition; sometimes they occur without any apparent exciting cause, but more frequently they follow on some slight error in diet, or on slight exposure to the heat of the sun, or on the drying up of some cutaneous eruption, or of some long existing strumous sore. They are characterised by the violence of the convulsive movements, by the depth of the coma which succeeds to them, and by the very rapid failure of the child's powers. I think, too, it may be said, that convulsions attended by such circumstances warrant more serious apprehension in children of three or four years old, than in infants of a year or eighteen months. For this the reason doubtless is, that at an age when the nervous system is less susceptible than in infancy, an attack of this kind implies a graver disturbance, and one less likely to pass away. Death in these seizures seems to take place, not from sudden asphyxia, as in spasm of the glottis, but from the slower influence of the perpetual disturbance of the respiratory process, or from exhaustion of the nervous powers, just as one sees it do in cases of puerperal convulsions; the skin becoming colder, the pulse more feeble after each attack, and complete collapse being induced within twenty-four,

sometimes within twelve hours from the first seizure. With reference to the share which is borne by the imperfect aëration of the blood in destroying the patient in some of these cases, M. Trousseau* makes some remarks, distinguished by his usual acuteness. He notices that the state is not dissimilar from that of a person on whom tracheotomy has been performed in the extreme period of croup. The obstacle to the entrance of air may have been removed by the operation, but the consequences of the previous long-continued interruption to the aëration of the blood remain, and they gradually destroy life. Just in the same way, the often-repeated convulsions bring with them great disturbance of respiration and circulation, and scarcely is one fit over when a second and a third return, and leave no time for breathing and the heart's action to resume their regular course. Thus it happens that when at length a state of calm succeeds to the attack, even though respiration may seem to be regular, it is a delusive calm, and the child dies some hours later without any fresh convulsion, without marked oppression, without the appearance of any new symptom of importance. He dies, if I may be allowed to say so, not of actual asphyxia but of the results of asphyxia.'

Far less hopeless are cases, with which we also meet occasionally, of the exceedingly frequent recurrence of convulsions; five, ten, or more taking place every day, for days or weeks together. Such attacks are seldom or never met with after the completion of dentition. The danger to life seems to lessen with the frequency of their recurrence, but there is hazard lest they should end by becoming habitual; while, further, there seems to be a very decided relation between the liability to convulsions in early infancy, and the development of epilepsy in subsequent childhood.

One word, in conclusion, with reference to that peculiar form of convulsion, to which, from the movements that characterise it, the name of Eclampsia Nutans,† or the Salaam convulsion, has been given, and in which some observers have thought they recog nised the signs of a special disease. Infants and children affected by it bow the head and bend the body slightly forward, a movement which is repeated with great rapidity, sometimes twenty,

* Clinique Médicale de l'Hôtel Dien de Paris, vol. ii. 8vo. Paris, 1 ƐC2, p. 95. Four cases of this affection were described by Mr. Newnham in the British Record of Obstetric Medicine, March 15, 1849; two are related by Dr. Faber, in J. 1. Kinderkr., vol. xiv. p. 260; two by Dr. Ebert, Annalen der Charité zu Berlin, 1850; one by Dr. Willshire at a meeting of the Westminster Medical Society, March, 1851; and probably others may be found in the medical journals.

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PECULIAR FORMS OF CONVULSION.

fifty, or even a hundred times, and then ceases, but returns once or oftener in the twenty-four hours. During the attack the child seems bewildered, but complete consciousness returns as soon as the movements end; and in one case which was under my care, the infant seemed relieved, and quite bright and happy the moment that the movements ceased. In connection with these attacks, there is a general failure of health, and enfeebling of the mental powers, but they do not tend to destroy life, nor are they connected with any special form of cerebral disease, nor have they any invariable issue.

Their tendency, however, unquestionably is, to pass into confirmed epilepsy; and the bowing of the head seldom lasts for more than a few weeks without some other convulsive movement becoming associated with it. Often it is a slight convulsive movement of one or other arm, but attacks of general convulsions occasionally intervene, and at last they take the place almost or altogether of the previous bowings of the head, and the case becomes one of ordinary epilepsy, with in general very considerable impairment of the intellect. Just the same course, however, is observed to be followed by other partial convulsions, though such convulsions seldom attract attention by their singularity to the same extent as the Eclampsia Nutans. Some years ago, however, I saw an infant, seven months old, in whom attacks of an oscillatory movement of the head from side to side came on just in the same manner, and associated with the same impairment of the general health, as usually attends the Salaam convulsion. The rarity of the latter affection, too, consists not in the nature of the movement, but in its frequent repetition, and I have often observed the first sign of incipient epilepsy in the child to be a sudden bowing downwards of the head, instantaneously recovered from, and just attracting notice by the bruising of the forehead, which had struck against a table or chair. Next this bowing ceases to be confined to the neck, and the child falls forwards on the ground, though still the attack is so momentary, that it rises again immediately, and it sometimes is not until after an attack of general convulsion has awakened the anxiety of relatives, that any meaning begins to be attached to what was long supposed to be merely the effect of a child's heedlessness, or of its not having thoroughly learnt to walk. Such cases are but a few illustrations of the fact already so often insisted on, that in the study as in the treatment of the diseases of early life, nothing is too trivial to notice-that the slightest occurrences often have the gravest import.

LECTURE XIV.

EPILEPSY-its causes-illustrative tables-its general character and influence on the mind. Circumstances which must regulate our prognosis. Treatment-futility of specifics-general management-employment of belladonna.

CHOREA-not exclusively a disease of childhood-causes which influence its occurrence -its relation to rheumatism. Symptoms, prognosis, and treatment. Partial

chorea.

WE yesterday studied the convulsions of early childhood in their gravest aspect, as immediately threatening life; but a painful interest attaches to them independent of the anxiety which they excite lest they should prove immediately fatal. There is the dread of their persistence, or of the child being left with his nervous system so shaken that fits may recur at some later period; that convulsions in infancy or childhood may issue in epilepsy in youth or manhood. Nor, indeed, does this seem to be a groundless fear, for of 68 cases which form the basis of M. Herpin's* elaborate work on epilepsy, 17 or 25 per cent. date from the first five years of existence; and of 63 cases that came under my own observation in young persons under the age of 14 years, 38 dated back to the first four years of life, 20 occurred between the ages of 4 and 10, and 5 between 10 and 12.

TABLE,

Showing Age of Patients at Commencement of Attacks of Epilepsy.

* Du Pronostic, etc., de l'Épilepsie, 8vo. Paris, 1852, p. 336.