THE MANAGEMENT OF CONVULSIONS, IN CHILDREN, DEPENDING UPON A HIGH TEMPERATURE

OF THE BODY.

GENTLEMEN:

BY

T. K. HOLMES, M.D.,

OF CHATHAM, ONTARIO, CANADA.

I purpose, in this short paper, to ask your attention to the management of convulsions, in children, depending upon a high temperature of the body. The subject will not be thought unworthy of consideration by any one who has seen this complication resist various plans of treatment, and prove fatal after hours of intense anxiety on the part of all concerned. The great frequency and fatality of convulsions, in children, should be a strong incentive to all physicians to avail themselves of every mode of reducing the mortality. In this city during the five years from 1844 to 1848 inclusive, 1729 children, under fifteen years of age, died of convulsions; a higher mortality than attended either cholera infantum, marasmus, pneumonia, or hydrocephalus, during the same years. It is neither possible nor desirable in this paper to enter into a lengthened discussion of all the phenomena connected with this subject. This has been done by most modern authors, and by none more lucidly or ably than by your distinguished countrymen, Meigs and Pepper.

It is admitted by all that eclampsia is a frequent complication in many febrile diseases, as scarlatina, measles, pneumonia, malarious fevers, etc., and by nearly all writers great prominence is given to the particular poisoning of the blood in these affections, as the chief factor in the causation of the convulsive fits which so often complicate them. While admitting that certain septicemic conditions may not be without influence in producing the convulsive attacks, I believe that the simple elevation of temperature, accompanying these diseases, is sufficient, in most cases, to account for them. In this connection it is worthy of note that those febrile diseases in which convulsions are common, are those usually marked by a high degree of temperature, although the specifie poison in each may be quite different; and that in other diseases, as smallpox, syphilis, and diphtheria, in which the blood-poisoning is very virulent, but the temperature not very high, convulsive seizures are comparatively rare. The experiments of Dr. Brunton prove that heat acts as a direct excitant to the heart, causing it to beat more frequently. directly as the elevation of temperature, and that cold has the opposite effect. These results are due to the influence of heat and cold upon the cardiac nerves, and from the extreme nervous irritability accompanying fever, as evinced by restlessness and liability to convulsions, it is fair to conclude that heat and cold act similarly on the cerebro-spinal system. While an elevated temperature causes increased frequency in the heart's action, it weakens the force of its contractions, a fact that should not be overlooked in the administration of some therapeutic agents which, however useful under other circumstances, become highly dan

This is

gerous when the heart has become weakened from any cause. especially true of aconite, veratrum viride, chloral hydrate, and bromide of potassium.

From observations upon thirty cases, of which I have preserved notes, the following propositions may be deduced: (1) That the nervous susceptibility of children under ten years of age strongly predisposes them to convulsions; (2) that in children of that age a temperature of 103° Fahr., and upwards, is very liable to excite an attack; (3) that the severity of the attack bears a direct ratio to the intensity of the fever; (4) that convulsions are more liable to occur during the first few hours of the pyrexial seizure, than at any subsequent period of its course; and (5) that whatever reduces the temperature, modifies or arrests the con

vulsions.

Regarding the first four propositions, few will differ, but while the fifth may be generally admitted, there is great diversity of opinion as to the best manner of accomplishing the reduction of temperature. The means at our disposal may be classed as interual remedies and external applications; the former including veratrum viride, aconite, digitalis, quinine, and salicine, with probably some others not as much used nor as well understood, and the latter consisting of cold applications to the surface of the body. Most of the remedies of the first class exercise a very depressing influence on the heart, and so are not applicable to these cases, quinine being almost the only one upon which any reliance can be safely placed. It generally happens, moreover, that in all severe cases of convulsions the child cannot swallow, and then remedies of the first class must be dispensed with altogether unless we resort to their adminis tration hypodermically, a proceeding not warranted by the results obtained.

For the antipyrexial action of quinine, veratrum viride, aconite, and digitalis, I would refer to the experiments of Dr. Roberts Bartholow, of Cincinnati, which have been published in one of a series of clinical lectures edited by Dr. Seguin, of New York. From a study of the physiological action and therapeutic influence of these remedies, it is plain that their modus operandi, in reducing the temperature, is quite different from that of cold applied to the surface of the body. In the former, the result is accomplished by interrupting the conditions which render rapid chemico-vital change in the capillary system possible; in the latter, it is accomplished by the simple abstraction of heat already generated. By the former, it is accomplished slowly, imperfectly, and with great risk to the patient; by the latter, the same is done rapidly, perfectly, and, in at least the great majority of cases, without risk. It is chiefly with the view of illustrating the curative influence of remedies of the second class that I have ventured to ask your attention even for a few minutes. For this purpose I have transcribed from my case book the following

cases:

CASE I.-July 3, 1876. M. Arnold, two years of age, strong and well developed, was taken suddenly ill last evening with dysentery and high fever which lasted all night, and at seven o'clock this morning had a pretty severe convulsion. At eight I saw him for the first time, and found the temperature 1039 F., and the child restless. I gave a large dose of castor oil, and also one-third of a drop of tincture of aconite, to be repeated every hour while fever lasted. Another convulsion occurred at ten o'clock, and a third at half-past ten, when I arrived in time to check its violence with chloroform. At noon, the castor oil had operated well. At 2 P. M., convulsions returned, and continued for

two hours with no intermission, although the patient was partially under the influence of chloroform during the time. At 4 P. M. they were as violent as possible, the temperature was 105° F., the pulse 150 and very weak, and death seemed imminent. I now put the child into a tepid bath, and rapidly cooled it to 50° F. by the addition of ice and iced water. At the end of ten minutes the breathing became easier, in fifteen minutes the temperature was 103° F., and in twenty minutes it had fallen to 99° F., and the pulse to 110 beats per minute. I then dried the child and wrapped him in a blanket. He was very much better, but the breathing was still somewhat noisy and labored, and there were two slight fits during the first half hour succeeding the bath; the temperature also began to rise again, and had reached 101° when I again put him into the same cold water for five minutes. The temperature now fell to 984, and the pulse in the same time to 100 beats per minute. The child slept naturally for half an hour, and awoke apparently quite well. There was no return of fever, and no further treatment was required.

One can scarcely avoid the conclusion that the convulsions in this case were caused by a high temperature alone. The previously healthy state of the child, the freedom of the alimentary canal from anything irritating, for the castor oil had acted thoroughly two hours before the most violent attack came on, the absence of any other appreciable, centric, exciting cause, and the almost instantaneous cessation of the convulsions when the temperature had fallen below 99°, all support this conclusion.

CASE II.-Sept. 26, 1872. P. T., æt. 8 years, was never ill until noon to-day, when he had a chill for a few minutes, followed by fever and convulsions, which still continued when I arrived at one P. M. His temperature was 106, and his pulse 140, full, and regular. The attendants had just removed him from a warm bath and wrapped him in a blanket. It was impossible to get him to swallow anything. I at once applied cold to the head, administered an enema, and put him under the influence of chloroform. This modified the violence of the spasms, but they returned immediately when the effects of the anesthetic were allowed to pass off. The enema acted well, and the chloroform was continued, but the temperature was unchanged, the pulse became gradually weaker and more frequent, and after three hours the patient died. As this boy had been well until now, and as no other exciting cause could be traced, it is not unreasonable to conclude that the high temperature led to the fatal result.

CASE III-July 12, 1876, 10 A. M. C. S., a well-nourished male child, five months old, has had diarrhoea for three days, and the mother thinks fever also, but was not very ill until yesterday afternoon, since which time he has neither nursed nor slept, but has constantly uttered half suppressed cries. The child is pale, the hands and feet quite cool, and the skin dry. Gave a purgative dose of rhubarb and soda.

3 P. M. The rhubarb has acted on the bowels three times, the last evacuation having been quite natural in color. The hands, feet, and legs are quite cold; the pulse almost imperceptible; the pupils not larger than pins' heads; the thumbs contracted; the face pinched, and of a leaden hue; and the thirst most intense. The axillary temperature, to my surprise, was 105° F., for I had been deceived by the coldness of the extremities and the general appearance of the patient, and did not expect to find the temperature so high. I now gave the child half a drachm of brandy, and placed it in a tepid bath, adding water from the well until the whole was quite cold. In ten minutes the temperature fell to 103°, and the child went to sleep for the first time in thirty hours. When the temperature had fallen to 100°, I wrapped the child in a blanket, and he continued to sleep most of the afternoon and was not thirsty. As the temperature fell, the pulse became slower and fuller, and the pupils larger.

8 P. M. Temperature 1030, pupils natural; the child sleeps well and looks placid. Bath repeated, and temperature reduced in five minutes to 990.

13th, 10 A. M. Child rested well all night; nurses; temperature 103°. As he appeared quite easy, I merely ordered a dose of castor oil.

11 A. M. Child has had two severe convulsions in the last ten minutes, and is insensible, and the temperature has risen to 10510. Repeated the cold bath, and reduced temperature to 9810, when the child became quiet and slept. After this the temperature never rose above 101°, the bath was not repeated, and in a few days the child was well.

The coldness of the extremities and the weakness of the pulse in this case made me hesitate before resorting to the cold bath, but as death seemed imminent, and as the axillary temperature was so high, I concluded that any other means would fail, and that some risk was justifiable. It is remarkable that during the hour preceding the convulsions, the temperature rose from 103° to 1051°. I could cite a number of cases resembling the three here detailed, half of which would go to show the superiority of the treatment by cold baths over every other, when the temperature is high; and my friend and co-delegate here, Dr. Murphy, informs me that his experience with this plan of treatment entirely

coincides with mine.

Where other indications for treatment exist, as malaria, teething, offensive accumulation in the alimentary canal, etc., it of course becomes. necessary to attend to these also. In pursuing the plan I here recommend, I have always been guided by the thermometer, never resorting to the bath when the temperature has been below 100°, and always removing the patient from the water when the axillary temperature has fallen to nearly the normal standard of health.

It is much better to have the water tepid at first, on account of the excitement and alarm produced by sudden cold. I have not ventured to use the cold bath in convulsions complicating pneumonia, my experience being chiefly confined to those occurring in connection with dysentery, diarrhoea, cholera infantum, and malarious fevers. In these diseases, when the fever is high, although there be no convulsion, I have found no remedy that approaches the cold bath in its power of allaying nervous irritation and procuring quiet rest, and I am fully persuaded that all who resort to this mode of treatment once, will do so again.

DISCUSSION ON DR. HOLMES'S PAPER.

After the reading of the preceding paper, the President, Dr. ROBErt Barnes, of London, said:-Where there is an increased temperature in children, there is always some trouble with the blood, poisoning, or something else, which leads to convulsions. The question is, what develops convulsion? what is the first cause? It has been found that as the temperature rises, there is an increased liability to convulsions, and that as the temperature sinks, there is a decrease in this liability. Do we find that high temperatures always produce convulsions? In children, there is an exalted nervous irritabilty like that in pregnant women. Do they always have an increase of temperature? I have watched cases in which there has been no rise whatever-in uræmic convulsions after scarlet fever, for instance. In simple pyrexia I believe that cold water can be used to reduce the temperature; I have wiped the surface of the body with it, and found it to act well. The cold water acts by evaporation, and consequently reduces the temperature. The cold bath is a powerful remedy; its use by the Germans is a revival of a remedy first employed by Dr. Currie. Dr. THOMAS F. ROCHESTER, of Buffalo, N. Y., said:-I have paid consider

able attention to infantile disorders, and think I can corroborate the views advanced by Dr. Holmes in many respects. The subject is one which requires more attention than is paid to it. The reduction of the temperature by water, I regard as more safe than by the use of drugs. In my own city there have been many children lost, during the hot season, from what is called summercomplaint, which is ascribed wholly to the elevation of the temperature, but this I deem an error. The thermometer rises to 90° or 100°, the sky is blue and the sun bright, and yet the mortality is not as great as it is when the atmosphere cools off. Some years ago we had, in my city, a hot, dry spell, with but little sickness among the children; a hail storm came without any premonition, and at once infantile disorders set in. The diminution in the heat had caused the whole trouble. I have not examined the temperature before and after such atmospheric changes, but to me it seems conclusive that the fall in the temperature produces more diseases of children than the rise. I speak of convulsions as associated with the diseases of children, and make my remarks only in that connection.

Dr. HOLMES, in reply, said:-I have lost a good many children from high temperature; and now think it well to reduce the frequency of the heart beats, for, as they become slower, the exhaustion lessens, and the beat becomes more forcible. My views are embodied in the short paper presented, and are based upon experience gleaned from my own practice.