Arch Dis Child: first published as 10.1136/adc.26.129.441 on 1 October 1951. Downloaded from

CONVULSIONS (INCLUDING EPILEPSY) IN CHILDHOOD* BY DONALD PATERSON From the Health Centre for Children, Vancouver General Hospital, Vancouver, B.C., Canada. Of all the upsets which can happen to the infant or obstetrics when, in fact, he was not to blame. child, it would be safe to say that none is as alarming Hydrocephalus, microcephalus, walnut brain, may to the parents as a convulsion. A good knowledge all cause convulsions. Children suffering from this of the causes of convulsions is therefore essential, if type of convulsion often have spastic limbs, and the one is to handle the situation well, and relieve the condition is nowadays called cerebral palsy. During parental anxiety with authority. infancy babies frequently bend forward suddenly, The diagnosis may sometimes be difficult, for and the arms fly out on each side. This is the so- even 'windy pains ' with screaming may simulate called salaam type of epilepsy, or petit mal, which a convulsion in the parental mind. More often than may be repeated many times a day. These children not, we must base our diagnosis on the description are often plunged into status epilepticus when they given to us by the parents, as the attack is over before are attacked by some minor infection, such as a sore we see the child. Petit mal may be so fleeting that throat or a cold. it can, for some time, be mistaken for a mannerism Cerebral Haemorrhage from Trauma, Asphyxia, by the parents. and Cerebral Oedema. The child who has had a When called to a child with a convulsion nothing difficult birth, breech or head presentation with by copyright. can replace a very careful physical examination. prolonged labour and cord round the neck, is a The throat and ears should be viewed to exclude candidate for cerebral damage. Forceps delivery infection; the heart, lungs, and abdomen should also in a premature infant, or in cases in which the pelvis be examined, and, when possible, a specimen of is small and the head large, may cause a subdural urine should be analysed for sugar, acetone, albumen, haematoma. In such infants, no convulsions may blood, or pus. The eye grounds should be occur at the time. Only the characteristic shrill cry scrutinized for papilloedema and it should be and pathological alertness of the infant are present ascertained whether there is a squint; the remainder to warn us. Any sudden noise makes this baby of the central nervous system should be run over, start or jump, and handling causes the baby an and this examination should include testing for abnormal upset. On the other hand, the baby may http://adc.bmj.com/ Kernig's sign. An examination of the nervous twitch from the first, and it will be noticed that it system of an infant or child is less informative than fails to suck, cry, or breathe as well as it should. that of an adult, as the presence or absence of, for The fontanelle may bulge. A lumbar puncture example, the knee jerks, is not so significant. may show blood in the cerebrospinal fluid. A I propose describing what is usually called cerebral tap, however, may demonstrate a subdural epilepsy ' last of all. haematoma and this should be dealt with by

Since convulsions are a symptom and not a repeated tappings, and finally by an operation which on October 1, 2021 by guest. Protected disease, it would be well to begin by enumerating the will dissect out the clot and sac. Subdural haema- various conditions which will give rise to this toma may not, however, show itself for many weeks symptom. or months, and then the onset of hydrocephalus and convulsions suggests that diagnosis. Common Causes of Convulsions ,Cerebral Infections. When called to a case of Congenital Malformation of the Brain. Convul- convulsions in an infant or child, we should always sions due to some failure of the brain to develop ask ourselves, 'Has this child got meningitis or may show themselves at any age. So-called cerebral encephalitis ? ' The taking of the temperature is agenesis, or arrested development of the brain, may helpful, as in true epilepsy there is, as a rule, no fever. cause a convulsion shortly after birth, so that it Often a previous history of similar convulsions in a simulates the picture of cerebral trauma, and the febrile child will suggest the correct diagnosis, but practitioner may be blamed for his allegedly faulty it may be necessary to perform lumbar puncture before we can be certain. An examination of the * A clinical lecture given at a post-graduate course at the University of Alberta, Edmonton, Canada, in May, 1949. ears may reveal an acute infection, or there may be a 441 Arch Dis Child: first published as 10.1136/adc.26.129.441 on 1 October 1951. Downloaded from

442 ARCHIVES OF DISEASE IN CHILDHOOD mastoid infection which could spread to the wide open and congested. The child may now meninges. A purpuric rash would suggest meningo- twitch for a moment, then relaxes. In a minute or coccal meningitis. The presence of a stiff neck two the child awakens, looks about in a dazed suggests meningitis or meningism, and only a fashion, gets up and runs about as before, apparently lumbar puncture will indicate which itis. none the worse for the episode. This type of In tuberculous meningitis the convulsions occur, convulsion may happen several times a day; the as a rule, late in the disease, but occasionally this parents are afraid to cross or discipline the child, form of meningitis is ushered in by a fit. who in turn becomes more and more exacting. Infections Outside the Nervous System. The Sedatives have no real effect. Such children are commonest cause of convulsions in the first three or usually ' only ' children, or the youngest of a grown- four years of life is an infection in the ear, throat, up family, or adopted children. They are frequently chest or kidney, or the onset of one of the acute spoilt or undisciplined, and have not been taught exanthemata, such as measles, chickenpox, scarlet self-control. The treatment appears to be a training fever, or mumps. Some children tend to have a in self-control. Once the parents understand that convulsion with any high fever, when it takes the the child will not die in an attack, which can be place of a rigor. It has been suggested that the aborted by the sudden application of a cold sponge infection alters the blood chemistry which, in turn, or cloth applied to the face at the very beginning, causes a rise in cerebrospinal fluid pressure, causing they soon discipline the child and a cure results. the convulsion. Certainly the cerebrospinal fluid You may ask why such children are able to hold pressure is raised in such cases whatever the cause. their breath; have they an enlarged thymus ? Are In a series of cases studied, it was found that the they rachitic ? The answer to both questions is no, average number of convulsions was five, and that but I do not know the pathology of cases of this these recurred with each bout of infection, at about kind. three or four month intervals. In the spasms of whooping cough a convulsion of

It is curious how seldom the onset of the infection this type may occur, but, on the other hand, actual by copyright. is suspected, and the first evidence of it is the sudden cerebral haemorrhage may also occur with a resulting convulsion. The worry over this episode often mental change or permanent hemiplegia afterwards. causes the underlying infection to be repeatedly Fortunately the majority of children recover overlooked, and to remain unsuspected. A careful completely. taking of the temperature, and a physical examina- Tetany or Spasmophilia. This may be termed tion will usually reveal the cause, and relieve the ' nervous rickets ' or 'low calcium rickets ' as minds of the anxious parents. It also gives the opposed to the low phosphorus rickets seen in bony practitioner a chance to treat the cause rather than rickets. Both sorts of rickets may, of course, be the symptom. As a rule such cases are not presented present at the same time. The low blood calcium

beyond the age of 4 or 5 years, and no sequelae, level makes the nervous system very excitable, and http://adc.bmj.com/ such as mental defect or paralysis, are found later on. increases the conductivity of the peripheral nerves. On the other hand, a backward child with some There is often a spasm of the glottis with laryngismus cerebral lesion also tends to have symptomatic stridulus accompanying the convulsion. The excit- convulsions with a passing infection, so that a ing cause may be the onset of an infection, the shock knowledge of the child's state of health before the of an accident, or a digestive upset. It is claimed convulsions is necessary if one is to rule out this that the cutting of a tooth, phimosis, or worms may situation. There are, however, some cases in which start an attack. symptomatic convulsions have been diagnosed The treatment for tetany or spasmophilia is the on October 1, 2021 by guest. Protected and repeated episodes have occurred, which later intravenous or intramuscular administration of prove to have an unsuspected cerebral origin, and calcium chloride in doses of from 3 to 6 grains. the good prognosis given at the time proves un- Vitamin D, as cod-liver oil or one of the fish liver oil founded. Fortunately these cases are rare. preparations, together with real or artificial sunshine, Asphyxia. The classical example of asphyxia is and a good diet are also necessary. Calcium seen in the child with breath-holding convulsions. gluconate may be given by the mouthindailydrachm Such children, when aged about 1 year or 18 months, doses with benefit. In addition, chloral hydrate is get into a rage or temper when they fall, when a toy indicated in sufficient doses to produce sedation. is removed from their hands, when they are put on their pot, or are being dressed; then they hold their Rare Causes of Convulsions breath. The sequence of events is well known. I have discussed the commoner causes of convul- First there is steadily increasing cyanosis; then the sions and we now come to the rarer causes. child becomes unconscious and stiff with the eyes Lead Encephalopathy. This is the commonest Arch Dis Child: first published as 10.1136/adc.26.129.441 on 1 October 1951. Downloaded from CONVULSIONS IN CHILDHOOD 443 cause of convulsions in infancy or childhood due to diagnosis when there is a previous history of poisoning (Brown and Tisdall*). The nibbling of diabetes. paint on cots and toys and crayons may continue from Diarrhoea. As a termination in cases of severe two to four months before symptoms occur, but if the diarrhoea, convulsions may occur and are probably diet is rich in calcium in the form of plenty of milk, due to dehydration with insufficient elimination of the symptoms develop slowly, because calcium urea and other body breakdown products. The produces an insoluble salt with lead. An acute treatment is saline and glucose given intravenously. infection may precipitate symptoms, which consist Poisoning. Poisons such as strychnine will cause of irritability, abdominal pain, anorexia, constipa- convulsions. tion, vomiting, and mental retardation. Later, convulsions occur and may last from 12 to 36 hours Treatment of the Convulsive State or may occur at intervals over weeks. The diagnosis is made by radiography of the long bones and ribs, Treatment involves the appreciation and treatment where a white line is found at the growing ends and of the underlying cause of the convulsion, and the at the costochondral junctions. Blood smears show treatment of the convulsion itself by sedation and punctate basophilia or stippling, and an examina- lumbar puncture. tion of the urine shows an increase of lead. A thorough physical examination which reveals an The treatment is to administer calcium by mouth infection of the throat, ears, lungs, or kidneys and or intravenously and is best done by means of bladder calls immediately for appropriate antibiotic calcium lactate or calcium gluconate. Vitamin D or other treatment. Where cerebral haemorrhage will help to fix the lead and prevent symptoms. In is suspected, it may often be best to disturb the the British Isles this must be a very rare cause of infant as little as possible until the state of shock is convulsions, as I do not recall seeing a single case over. Later a lumbar puncture or a cerebral tap there, and in nearly two years' residence in can be undertaken. In cerebral infections the Vancouver, I have seen no case diagnosed as lead sulphonamide drugs and antibiotics will be given. encephalopathy. How should the convulsion itself be treated ? by copyright. Uraemia. This disease should be seriously What can the parents be told to do while the doctor considered if the convulsion continues any length of is on the way to help them ? What about the time- time. An examination of the urine is necessary. honoured mustard bath ? Clearly the parents must A history suggesting previous nephritis, the finding be given something to do to keep them occupied. of retinal haemorrhages or exudate, would all It is doubtful, if the child has a temperature of 1040, suggest the possibility of uraemia. A blood urea whether a mustard bath or even a warm bath is a test would confirm the diagnosis. good thing, but if the child feels feverish, tepid Tetanus. This is a rare cause of convulsions, and sponging, and the application of an ice pack to the as a rule there is no loss of consciousness. Handling head are good therapeutic procedures. In cases or any slight stimulus produces a generalized spasm where there is no fever a hot mustard bath is http://adc.bmj.com/ and the characteristic facies (risus sardonicus) and indicated, and will help to relax the child. opisthotonos, and as a result the diagnosis is A saline or weak soap and water enema should be comparatively simple. given. The temperature should be taken, and some- Measles and Chickenpox Encephalitis and Mumps, thing placed between the teeth to prevent the child and Meniingitis. These may all be ushered in by a from biting the tongue. convulsion, but the diagnosis should not be difficult Sedation should be begun. Sodium pheno- because of preceding diseases. the barbital may be given in doses of i to J grain on October 1, 2021 by guest. Protected Hypoglycaemic Convulsions. Convulsions of this subcutaneously in infants. Chloral hydrate may be type are reported in normal individuals whose blood given in doses of four to eight grains rectally. A sugar level is too low. They are said to occur in the general anaesthetic of chloroform or ether may be night or very early morning when the blood sugar used. Magnesium sulphate may be given intra- level is at its lowest; such children can be cured by muscularly (20 ml. of an 8% solution injected into doses of glucose at bedtime. muscles of the thigh or buttock). Other sedatives Diabetes. In diabetics, attacks of hypoglycaemia which are useful are seconal or amytal, and from occur after an overdose of insulin, and are ushered in I to 5 grains should be given by mouth or rectum by faintness, sweating, mental confusion, and depending upon the age of the child. Avertin may tremors. It is not difficult to make the correct be given rectally in doses of 0-1 ml. of avertin fluid per kg. body weight, made up to a 2j% solution in distilled water. Paraldehyde (four minims per lb. * Brown, A. and Tisdall, F. (1949). 'Common Procedures in the Practice of Paediatrics ' Toronto. body weight or 1 dr. per 14 lb.) is administered 30 Arch Dis Child: first published as 10.1136/adc.26.129.441 on 1 October 1951. Downloaded from 444 ARCHIVES OF DISEASE IN CHILDHOOD rectally to infants and children in ten times its grand mal and petit mal, or which take the place of volume of normal saline. the big or little attacks. One should mention If convulsions continue, a lumbar puncture should that attacks at night are on the whole more common be performed, and 10 to 15 ml. of cerebrospinal than those in the day time. fluid withdrawn. Treatment of Epilepsy. The following drugs are Epilepsy particularly useful in each type of convulsion. In cases of grand mal, or convulsive seizures, pheno- Let us now turn to epilepsy of the idiopathic type. barbital, dilantin (epanutin), mesontoin, mebaral, or By this I mean cases with major or minor convulsions dilantin and bromides should be used. The use of for which no adequate cause can be found. This tridione is contra-indicated. definition excludes the obvious hydrocephalic, In psychomotor seizures dilantin is the only drug microcephalic, and birth trauma cases. which is generally useful, and may be combined with In very young children it is extremely difficult to tridione. Phenobarbital is disappointing. Meson- differentiate early epileptic cases from those with toin may be helpful. the symptomatic convulsions we have just been In cases of petit mal, phenobarbital, mebaral, discussing, especially if it is the first convulsion. glutamic acid, amphetamine sulphate (benzedrine), Epileptic seizures are not common in babies, but and dilantin have all been used, but tridione is the by 6 years of age they begin to show up rapidly, and drug of choice. by 10 years, one-half of all epileptics have had their Grand and petit mal should be treated as grand first attack. Although often we cannot find a true mal. organic basis for the fits, recent investigations with In status epilepticus phenobarbitone (sodium the electroencephalogram have proved many cases luminal) should be given by injection, and paralde- to have an area of scarring or old degeneration or hyde rectally or intramuscularly. under-development, or some early tumour forma- It should be noted that bromides are not now tion, and these may be proved at operation. Electric used. Phenobarbital (phenylethylbarbituric acid) potentials are present in the living brain cortex, and may produce a rash like that of scarlet fever, and by copyright. they arise from the nerve cells of the cortex. In in- drowsiness. It is dispensed in tablets of i, 1, and fants these potentials are slow, say under 6 per second, 1I grains, and in an elixir, one teaspoonful of which but in children, aged 3 years, they have risen to 7 per contains i grain. The sodium salt is used for second. They reach 10 per second at 10 to 15 years, injection. The physician should begin with I grain, and this is the adult pattern. With any disturbance and work up to twice or three times this dose. in brain function, such as that caused by an expand- Methylethylphenylbarbituric acid ('mebaral', or ing lesion, brain degeneration, or epilepsy, slow in Europe 'prominal ') is a substitute for pheno- waves make their appearance, and may appear in barbital and is dispensed in tablets of I or 3 grains. hyperventilation or over-breathing. Behaviour The dose is one to three. Diphenylhydantoin sodium problem children often show cerebral asymmetry. (phenytoin sodium) or dilantin sodium ('epanutin ') http://adc.bmj.com/ Generally speaking, slow frequency waves and is suitable for use in psychomotor seizures. The bilateral asymmetry found in those above infancy complications which can be caused by this drug suggest functional abnormality of the brain, but no are muscular incoordination, nystagmus, double sweeping conclusions can be drawn. vision, unsteady gait, giddiness, a measles-like rash. Large numbers of convulsions cause punctate It is dispensed in sealed capsules of i or 11 grains. haemorrhages into the brain, and ultimately Children under 2 years should be given a dose of cerebral sclerosis and softening may occur. 1-3 grains. Phenobarbital may be given along with The picture of a fit may be divided into the aura, dilantin. on October 1, 2021 by guest. Protected the loss of consciousness when the child often falls Methylphenylhydantoin (' mesontoin ') is reported down, the convulsion which follows with its tonic to be superior to dilantin, especially if the patient and clonic phase, and finally relaxation and sleep. does not tolerate dilantin. It does not produce The loss of sphincter control is frequent. ataxia, but skin rashes, and possibly aplastic In a petit mal attack, these 'absent moments', or anaemia. little turns, may last a moment or two only. There Trimethyloxazolidinidione (' tridione ') is suitable may be several dozen in the day. The sequelae of for petit mal, but not for grand mal. In about attacks may be mental confusion, transitory one-third of the cases, petit mal seizures disappear hemiplegia, or status epilepticus. after its use, another third are much improved, and Psychomotor Attacks. Some children get temper 17% are not helped. Often attacks do not return tantrums and screaming attacks which are either after medication. The drug should be given for as present by themselves or interspersed between short a time as possible. The electroencephalogram Arch Dis Child: first published as 10.1136/adc.26.129.441 on 1 October 1951. Downloaded from

CONVULSIONS IN CHILDHOOD 445 may become normal and then the drug can be stopped. Psychotherapy is a very useful supportive therapy Side effects of this drug include a generalized rash like and is most important. The convulsions affect both measles, and, when this occurs, the drug should be the child and the parents psychologically and it is stopped until the rash disappears. Older children important to be optimistic. Exercise and activities, may get photophobia, and a glare effect in sunshine. for example, swimming and bicycling, should, The most serious effect is aplastic anaemia. The however, be restricted where the safety or the rights leucopenia is a neutropenia. The blood should be of others are involved. Feelings of guilt on the part examined monthly. Anaemia appears late. Deaths of the parents because of possible hereditary causes have been reported, usually in older children. An of the child's illness must be combated, and the infant may be given one of the 41 grain capsules family and patient should be advised to live as if this daily in a spoonful of food. From 2 to 4 years, two disorder did not exist. The child's mind should be capsules should be given a day; for children over 5, kept thoroughly occupied. three capsules a day. This amount may need to be The gloomy prognosis usually given is notjustified, doubled to get good results. according to Lennox.* It is impossible in an Treatment Other than by Drugs. It is a clinical individual case, particularly if the child is very young, observation that seizures, are relatively infrequent to forecast the mental state the child will attain in when the patient is physically or mentally busy. The adolescence. Since this appears to be a fact, it is explanation given is that with activity the CO2 and much better to give the parents a most guarded lactic acid content of the brain cells rises, and its outlook for the future except in the case of children alkalinity is reduced. The more acid the brain, the whose mentality is obviously grossly affected. Also, less irritable are the nerves. A ketogenic diet is one it used to be taught that there was steady mental which contains three or four times as much fat as deterioration, but one must conclude that this is now protein and carbohydrate combined. Ketone bodies quite incorrect. inhibit attacks. Limitation of fluid is also associated with the use of the diet, but both have fallen into by copyright. disuse since better drugs have become available. * William G. Lennox (1948). A monograph on Therapeutic Agents in the Treatment of Epileptiform Seizures in 'Advances in Pediatrics,' Surgery is not usually of any use. Vol. 3, pp. 91-130. http://adc.bmj.com/ on October 1, 2021 by guest. Protected