?f the pathogenesis of the fit and to this end it may be helpful to trace briefly the ... trends of thought in order to understand the genesis of present day opinion. Since the ..... established that the benign convulsion associated with a febrile i.
GLASGOW
MEDICAL
JOURNAL
Vol. 32 (Vol.
SEPTEMBER 1951
No. 9
150 Old
The Journal
CONVULSIONS
Series). of
The Royal
IN
Medico-Chirurgical Society
CHILDHOOD TO
AND
of
Glasgow
THEIR
RELATION
EPILEPSY."!
ROBERT from the
A. SHANKS, M.D., M.R.C.P., F.R.F.P.S. Department of Child Health, University of Glasgow.
The sudden convulsion of an infant or young child must be one of the commonest emergencies encountered in paediatrics. One cannot be certain of the precise incidence as no doubt a large number of such cases is treated in their own homes. Nevertheless in the Royal Hospital for Sick Children, Yorkhill, convulsions of one kind or another account for admission to medical wards. Obviously from an adult hospital would be very much
some 6 to 10 per cent of the total
the
corresponding figure
smaller and this higher incidence of convulsions in the young has been "the subject of much speculation and controversy in the past and today still remains but ill-understood. ?ne
We have Henoch's (1893) authority for regarding a convulsion as the medical emergency in which therapy should not wait upon diagnosis.
He does not, needless to say, refer to the diagnosis of the convulsion per se but to the problem of determining the underlying cause. A generalized convulsion, from its very nature, is readily recognized as such, either on inspection or from the history obtained from an onlooker.
Other seizures, convulsions
are
'
petit mal, salaam fits, and the so-called inward perhaps less readily identified. Although these are all
such
'
as
seizures of a convulsive nature, the generalized convulsion. The very word the
'
seizure
'
we
shall be concerned here
with its Greek
'
mainly with '
equivalent epilepsy echoes present-day concept of the convulsive
age-long superstition behind the There is something almost atavistic in the horror with which the average onlooker reacts to the sight of a convulsion and the emotional ?vertones encountered by the physician called into such a case form a Significant contribution to the problem with which he has to deal. In these circumstances it is essential to have a clear picture in one's mind ?f the pathogenesis of the fit and to this end it may be helpful to trace briefly the evolution of our present day views on the nature of convulsions
fit.
in childhood.
258
GLASGOW MEDICAL
JOURNAL
history.
The historical reviewed 1948 &
background
1949a).
of convulsions
in childhood has been
has the literature of the twentieth century (Shanks, It will therefore only be necessary to sketch the main
elsewhere,
as
trends of thought in order to understand the genesis of present day opinion. Since the writings of Hippocrates, there has run as a constant thread
paediatric literature, the vague general excitability of infants, of an exaggerated response to concept as a manifestation of this, of convulsive proclivities. stimuli, and, ordinary before Soltmann Ivong (1876-78) gave his quasi-physiological benison to this belief, paediatric authors had stressed the eclamptogenic properties of such diverse stimuli as curdled milk (sic), intestinal worms and, above through
two thousand years of
of an excessive
all, erupting teeth. This attribution of etiological importance to a particular stimulus was always retrospective and therefore more than suspect. The not uncommon diagnosis of worms or colic could not generally be accounted sufficient cause for gloomy forebodings of an imminent convulsion. Nor
believe that the credulous Dr. Hillary
can one
Barbadoes, infants were thrown into convulsions reported felt constrained to walk always on tip-toe. Crf noise slightest one need scarcely point out that as all children cut teeth, tins teething
who '
that in the '
at the
can
hardly
be adduced
as
the
cause
when related to the total infant
of what is after
population. lasting support
Nevertheless this view received
all,
a rare
condition
in the researches of
Soltmann (1876-78) towards the end of the nineteenth century. found that whereas experimental convulsions were evoked less easily ?n stimulation of the cerebral cortex of young than of adult animals, the the nerves which in reverse obtained on stimulation of the
peripheral
readily led
young,
to
generalized
a
convulsion.
This difference between
the young and the adult was attributed to an immaturity of the nervous of system which found anatomical confirmation in the late myelinization nerve
fibres.
Although this
rather facile
by contemporary authorities, as
the
cause
of infantile
the
concept did
doctrine of
convulsions became
'
not pass
unchallenged
peripheral irritation lU firmly entrenched
twentieth century medicine.
By
the turn of the
century there had already begun
an
inquiry
the association between convulsions in childhood and later
seizures
or
subject
which is still
idiopathic epilepsy. a
A
great deal
controversial
topic.
hit0
recurrent
has been written upon thlS
Few arguments
can
have
bedevilled by the lack of precise definition. Failure to appreciate a the several meanings given to the word epilepsy even today causes
been
so
'
'
compatible views in empty logomachy. Epilepsy with its fear and often unjustifiable connotation of recurrent convulsions and exorable mental deterioration is a diagnosis dreaded by parents a physician alike. The suggestion that all convulsions were essential!) clash of
250
CONVULSIONS IN CHILDHOOD?SHANKS
epileptic in nature inevitably therefore met with fierce opposition. On the other hand, the proponents of this view in no way implied so gloomy a prognosis but maintained, and I think rightly, that the difference between the infant with the isolated fit and the confirmed epileptic, though it may be, is merely one of degree and not of kind. This in way alters the prognosis of the isolated fit, yet this confusion of terms as recently as 1949 has been responsible for acute differences of opinion
great no
(Nathan
&
Ransford,
1949 and
subsequent correspondence).
The association of the
spasmophilic diathesis or tetany with infantile convulsions has also received considerable attention. It was customary at this time to distinguish therefore between epileptic and spasmophilic convulsions. In addition separate consideration was given to the isolated convulsion that so often heralded the onset of an acute infection in
infancy
and childhood.
^oltmann's
(1905)
category of
gave the
these did not,
disease
name
of
These
were
the fits that
peripheral irritation and Gelegenheitskrampfe or '
'
neatly under Hochsinger
to which '
casual' convulsions,
of course, include convulsions associated with manifest
of the central
nervous
Hochsinger's casual convulsion of the problem of infantile
system.
May be said to represent the keystone convulsions. The nature and significance
the onset of
came so
acute infection
of the isolated convulsion at
is of vital
importance to our correct Management of convulsions in childhood because upon this depends by corollary, its prognosis. Whatever one's view of the nature of convulsions, whether or not one believes them all to be epileptic, it is certain that some children have one convulsion, or a short burst of convulsions and therean
a^er have no more ; others have recurrences, possibly not for many ^ears after, and may ultimately require anti-convulsive treatment for remainder of their lives. Some children have convulsions associated Mth severe disease of the central nervous system which may, as in
Meningitis, require urgent specific
treatment ; others show
no
demon-
lesion even at examination post mortem. The differentiation etween these is essential to their proper management and this will be c?nsidered in more detail.
strable
PRESENT POSITION.
The place of the spasmophilic diathesis, or hypocalcaemia in the etiology of infantile convulsions, been dealt with elsewhere (Shanks, 1949b). It may however be ^aslnterest to examine this aspect more thoroughly, particularly in a
spasmophilic
'll0re
precisely,
diathesis.
of
c?untry which has had greater claim than its southern neighbour to the ?P?nymous commemoration implicit in der Englische Krankheit.' The '
P?calcaemia
?
of tetany is normally an accompaniment of the metabolic 0r(ier of rickets and with the striking fall in the incidence of this ease in the last twenty-five years there has been an equal diminution tlie incidence of tetany.
200
GLASGOW MEDICAL
In
an
analysis
JOURNAL
infancy and childhood 1922-1946 which has been century quarter of clinic^ the association already papers quoted,
of the incidence of convulsions in
in three
quinquennia
reported
in detail in the
over
the
rickets and tetany with convulsions was noted. The cases were divided into those in which there was demonstrable disease of the central nervous
system, including
those with obvious recurrent
spontaneous convulsions
and those in which there
epilepsy (Group A), (Group B). These figures
or
are
given
was 110
such evident
The almost
in Table 1.
complete
Tari.k 1. The association of clinical rickets and
tetany
with convulsions.
1942-4(1
1022-2(1 liickets
Tetany
Rickets
Tetany
Tetany
Rickets
Group A
Convulsions
associated
with disease of the central nervous system (including
obvious
epilepsy)
Group b Convulsions
not
associ-
ated with disease of the central
nervous
svsteni 2:!
Total Total number of admiswith convulsions (percentage of total adsions
missions from all in
parenthesis)
causes
4r>4
..
disappearance of standing and one
(7.9)
382
389 ("-9'
(10.1)
is both rickets and tetany in the period 1942-46 would have imagined this to have resulted in a
fall in the total number of infants with convulsions.
This,
0
^
n-li It has
rate is
reassuring^
only about
12 per cent. This figure is low and should be borne in mind in giving the prognosis of any the
recurrence
convulsion in
a
child.
epilepsy are essentially indefinite ; aP'u h?N question provocation already discussed, it may be asked many fits a child can have before he is considered epileptic. This questi011' eS being one of definition, is logically unanswerable. It is neverthe ha\e important from the point of view of treatment and prognosis to rule. working The criteria of
from the
diagnosis
of
of
Some additional assistance may be obtained from time relation of the iit to any accompanying illness. It seems The initial
fit.
established that the
benign
convulsion associated with
a
fairl}^^
febrile of
i
an a
only at the onset. A fit which occurs during the course infection, unless it is agonal, suggests either the onset of a coiupllca or that spontaneous recurrence is likely. occurs
^ ^
CONVULSIONS IN CHILDHOOD?SHANKS
already referred to,
In the series
according
to the
time of
an
analysis
(Table 2).
occurrence
was
263
made of convulsions
Convulsions
were
regarded
Table 2. Distribution of initial, continued and terminal convulsions.
1932-36
1922-2(1
Group A C< hivulsii ins associated
Initial
with
Continued
primary
disease
of the central
nervous
Actual
Actual
Actual
figures
figures
figures
11.(? 104
Terminal
23.9
42
67.1
126
9.0
15.1
system Group b Convulsions not associated with primary dis-
Continued
ease of the central vous
ner-
95
38.3
98
43.2
120
48.4
96
42.3
67
Terminal
33
13.3
33
14.5
24
Initial
40
34.5
system
Tetany?116
64.6
Continued
cases
as
initial
illness death.
when
they
were
0.9
1
Terminal
restricted to the first
twenty-four
hours of
they occurred only within twenty-four hours of All other convulsions were classed as continuous. As before, the convulsions were broadly grouped into those associated with manifest and terminal when
disease
of the central nervous system
convulsions addition
or
all
epilepsy (Group A), cases
of tetany
including
and those not
were
recurrent
so
spontaneous
associated
(Group B).
similarly arranged.
The proportion of initial convulsions in Group
B is significantly in that than A, in which Group 1942-46) period bV their nature, recurrence is to be expected. This contributes to the evidence in favour of the relatively benign character of the initial convulsion when contrasted with that prolonged beyond the first twenty-four ll(>urs of illness. It is interesting to note that tetany (Table 2) may be c?nsidered to occupy a position intermediate between these two groups aild it is tempting to suppose that the lower incidence of hypocalcaemia in the 1942-46 period has had an ameliorating effect upon convulsions
greater
(especially
in the
ass?ciated with infection.
During the period 1942-46, 58 per cent of convulsions in Group B N\ere confined to the first twenty-four hours of illness. It is therefore safe to say that a child who has fits prolonged beyond this period, always Provided that there is no inflammatory disease of the central nervous systeni, is very much more likely to have a recurrence than one in whom convulsions
are
confined to the first twentv-four hours,
lhe number
2(34
GLASGOW MEDICAL
of fits is not in itself
so
important of repeated
illness. A short burst
from Sweden in
(1941), writing
as
JOURNAL
tlie time relative to the onset of the
convulsions is not
a
uncommon.
Herlitz
detailed examination of the so-called
initial fever convulsions in children, found that convulsions occurred within twenty-four hours of the first symptom in 60 per cent of cases. Ekholm and Niemineva
(1950)
record substantially similar findings
from Finland and both these results accord well with
for the last five year
ours
from
Glasgow
period.
prognosis. Age at the time of the convulsion has prognostic feature (Lennox, 1949a & b). Lennox convulsions to occur most commonly (two-thirds of aU
The age of onset and been considered as a
found febrile
cases)
between
under
one
and three years of age and from this she cites onset This rather as an unfavourable prognostic factor.
one
year of age
surprising conclusion does not accord with the usually accepted view that benign convulsions occur most frequently in the first year of life. Our own figures from Glasgow do not support Lennox's findingsTable 3 gives the figures of age-incidence for the series referred to above. Tahi.k
A^e
incidence of convulsions in three
GROUP A
Group 15
Convulsions attributed to
attributed to primary disease of the central
primary disease of the central
irth to
3/12 3/12 and under (1/12 (5/12 and under 12 12 12/12 and under 18/12 18/12 and under 2 yrs.
nervous
Convulsions not
system
nervous
system
1922
1932
1942
1922
1932
1942
to
to
to
to
to
to
i (.)28
48
11
30
20
18
50
20
11
..
..
five-year periods.
j |
2 yrs. and under 3 yrs 3 yrs. and under 5 yrs yrs.
Tetany 11
12 1(.)
9
9
19
2!
10
23
21
31
28
28
39
40
11
12
227
213
Total
t or not upon whether ner convulsions were associated with manifest disease of the central reciirr ^ system (Groups A & B) and as before, those with obvious ^ Aconvulsions or were included in Group
As
before, there
are
two main groups
dependent
spontaneous epilepsy define apparent that Group B will include all febrile convulsions as con other with with those associated convulsions Lennox, together but who had It will be
loss of the
no
fever
seen
peak
admission. to that in 1942-4(5 this group shows in addition age-incidence between six and eighteen months,
^ -
011
^
265
CONVULSIONS IN CHILDHOOD?SHANKS
the number of convulsions in the first three months of life.
increase in
To make the
comparison more exact one may take the figures (again iu for the first year of life on the one hand and those between one and three years of age on the other. The following totals are obtained. Group B)
In 1942-46 there
were
100
under
cases
one
year and 79 between
one
and
figures were 144 and 59 while in 1922-26 they were 136 and 89 respectively. As far as our experience in this country is concerned it seems still true therefore that the benign initial convulsion occurs most frequently in the first year of life. Similar figures are given by Peterman (1946) and Ekholm and Niemineva
three years of age.
In 1932-36 these
(1950). It is interesting to note the similarity of the age-incidence of the 1 Hi cases of tetany (Table .'}) to that of convulsions in Group B in 1922-2(5.
In both these groups the greatest incidence was found between the ages ?f three and eighteen months, the period in which rickets is most often seen. ?f
This must be
regarded
at this time.
tetany
indicated by
the results of
?^eimineva, 1950),
as a
further indication of the
That this situation
where
a
over
was
importance
not confined to Scotland
Finnish survey quoted above (Ekholm & the period 1920 to 1941 and in a series
strictly comparable to Group B in our own, 61 out of 221 were diagnozed as spasmophilia. Moreover the characteristic age-incidence and seasonal incidence
shared by all their cases and not confined to those with spasmophilia. It would be interesting to know whether the was
nianifest
incidence
Epilepsy
of
spasmophilia
as a
was
any less in the later years of this survey.
There is
paediatric problem.
a
prevalent
view that
epilepsy
the Hippocratic should not be diagnozed in childhood. This, based vie\v of epilepsy, is humanitarian rather than scientific. It has been shown repeatedly that epilepsy is often primarily a condition occurring into children and which is frequently but not invariably prolonged of review adult life. It will suffice to quote Zappert (1932), who, from a least at the literature and an analysis of his own cases, concluded that
?ne-third of
cases
-pilcpsy
a
on
began under the
age of ten years.
preventible condition. There would obviously be little considering so minutely the prospect of recurrence and interpreting so narrowly the concept of epilepsy if it were merely a matter as
Point in
academic prognostics.
:?ncerned, Sed,
although
^pposed
As far
to
it is
be.
not
always
so
what
one
should tell the parents is epilepsy should ever be
a condition as it is popularly strongly emphasized however that epilepsy under favourable conditions
dreadful
It cannot be too
e
1
as
it seems doubtful whether the term
is a very real possibility that la> be preventible. There can be no doubt that convulsions beget llA u^i?ns and that uncontrolled convulsions lead in themselves to
?^ressive
mental
impairment.
It follows that
no
child
or
adult should
2C0
GLASGOW MEDICAL
be allowed to have
repeated
JOURNAL
energetic attempts to use phenopossible barbitone unnecessarily than to await until repeated fits have confirmed the diagnosis. A confirmed epileptic is an incurable epileptic. The advances in our understanding of the problems of epilepsy consequent upon the development of electro-encephalography have so far not been such as to necessitate electro-encephalograms in all cases with convulsions. It is fortunately still possible to reach a reliable and achieve diagnosis adequate treatment without the aid of such and specialised knowledge equipment as electro-encephalography entails. fits without the most
control them in the shortest
time.
It is better to
SUMMARY.
Although there are valid objections to the usual use of the term epilepsy as a clinical entity, it cannot be conveniently avoided. It should be emphasized, however, that there is no real justification for considering the
isolated convulsive episodes in childhood
recurrent
By
the
spontaneous
same
convulsions of
epilepsy
possible to discuss convulsions in problem separate from that of epilepsy.
token it is not
and childhood
as
a
differing from the anything but degree.
as
in
infancy When
considering as a whole all children who have convulsions at one time or another, it is not possible to draw a sharp dividing line between groups ; they form on the contrary a continuous series ranging from the isolated fit at the
one
epileptic at the other. It has help in tentatively assessing the The importance of prophylactic
extreme to the uncontrollable
been shown how the clinical
picture
may
convulsive threshold in any one case. treatment in preventing a further increase in the convulsive tendency has also been stressed.
Apart from medicinal treatment, the physician has an important part to play in the general management of recurrent convulsions ; f?r there can be 110 condition in which psychological and social factors are more important. When one considers the almost superstitious fear m which they are held, one cannot wonder that both parents and patients need all the guidance and sympathy that their medical practitioner has to bestow. It is true that the unattractive personality which the expel"" ieuced physician recognizes as epileptic is probably an innate feature of some cases. Nevertheless it is not difficult to see how the fear of the '
'
convulsion, together with the agony of being the centre of that percipient cruelty so characteristic of the school-child, will readily produce a sense of separateness that leads the epileptic to walk alone. Is it too much to a11 suggest that some of this epileptic behaviour may be the result of can a sensitive mind ? How far the patient egregious disability upon '
'
helped to adjust himself to his environment (and advice as to propet employment must be included), will of course depend to a large extent" Nevertheless, the physician's duty in tins upon the patient himself. be
CONVULSIONS IN CHILDHOOD?SHANKS
matter is
therapy prompt
plain
and
one
is second in and
persistent
-J67
may reiterate that control of epilepsy by adequate importance only to the policy of prevention by treatment of convulsions in
early
life.
ACKNOWLEDGEMENTS. I should like to express my indebtedness to Professor Stanley Graham for his encouragement and advice in the preparation of this paper.
REFERENCES.
Crump, E. P. (1945). Journal-Lancet. 65 : 182 Ekholrn, li. & Niemineva, K. (1950). Acta paedialr. Stockh. 39 Henoch, 13. (1893). Vorlesung iiber KinderKr., Berlin Herlitz, C. W. (1941). Acta paediatr. Stockh. (Suppl. 1). 29 : 1 Hochsinger, K. (1905). Dtsch. Klin. 7 : 479 Lennox, M. A. (1949a). J. Pediat. 35 : 427 Lennox, M. A. (1949b). Amer. J. Dis. Child. 78 : 868 Nathan, P. W. & Ransford, P. M. (1949). Brit. med. J. 1 : 421 Peterman, M. G. (1946). Amer. J. Dis. Child. 72 : 399 Shanks, R. A. (1948). Arch. Dis. Childh. 23 : 281 Shanks, R. A. (1949a). Amer. J. Dis. Child. 78 : 763 Shanks, R. A. (1949b). Arch. Dis. Childh. 24 : 208 Soltmann, O. (1876). Jahrb. Kinderheilk. 9 : 106 Soltuiann, O. (1877). Jahrb. Kinderheilk. 11 : 101 Soltmann, O. (1878). Jahrb. Kinderheilk. 12 : 1 ^appert, J. (1932). Ergebn. inn. Med. 43 : 149
:
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