THE HISTORICAL BACkGROUND OF CONVULSIONSIN CHILDHOOD

BY

ROBERT A. SHANKS, M.B., M.R.C.P., F.R.F.P.S.(From the Department of Child Health, University of Glasgow)

Convulsions in childhood must be as old asmankind, and it would be remarkable if so strikingand terifying an affliction had not received attentionof one kind or another throughout the ages. In sofar as the attitude of a community to a convulsionis merely a reflection of its attitude to medicine andan indication of its scientific and ethical background,the history of convulsions can only be in essence thehistory of medicine or, as we are only concernedhere with chikirn, of paediatics. It may howeverbe of some interest to trace briefly the evolution ofthe present-day conception of convulsions inchildhood against the historical background.

EgyM Babyle, and IndaAlthough the civilizations of Egypt and Babylon,

and Brahninical medicine in India appear to havehad more or less enlightened views on the upbringingof children, little can be discovered of their preciseattitude to convulsions. It is nevertheless likelythat they all shared to some extent the view that aconvulsion was due to direct divine intervention ordemoniacal possession, a view that lingers evento-day in the words 'epilepsy ' and 'seizure.' Inancient Egypt this idea was carried to the extremeof holding all disease and even death to be due tothe intervention ofexternal agents (Finlayson): theseagents might apparently belong to this or the' other' world. Thus where the intervention wasnot obviously of this world, such as an assassin or afalling tree, the physician had the double duty ofidentifying the offending spirit and thereafter ofprescribing the specific treatment. Usually amuletsand incantations were regarded as indispensable.

Greece and RomeHippoates. European medicine begins properly

in Greece. The achievements of Athens in the timeof Pericles are perhaps the most astonishing in allhistory. Under the stimulus of victory over thePersians she produced architects, sculptors, anddramatists who remain unpassed to the presentday. It was at this time that Hippocrates, who wasthus a ctemporary of Socrates and Plato, livedand taught. Born in this era of untammeldphilosophical speculation, Hippocrates' genius

presents a remarkable difference from that of hisillustrious contemporaries; for he was the first totreat of nviicine as a practical study rather than asa speculative philosophy. His was a method ofobservation and inductive reasoning so ideallysuited to clinical medicine. His wrtings deal withmedicine, surgery, midwifery, embryology, climato-logy, dietetics, prognostics, and ethics but notspecifically with paediatrics. There are, however,numerous pertinent observations in his generalwritings and in particular his well-known treatiseon 'The Sacred Diseases,' or epilepsy. He differ-entiated between epilepsy and infantile convulsionsbut the distinction, as we miight expect, is not clear.

In the ' Aphorisms ' he points out that teethingis associated with a number of unhappy afflictionsincluding diarrhoea and convulsions,- this partiu-larly at the time of the eruption of the anines and infat constipated infants. Thus originated a belefthat over two thousand years of medical progresshas not quite eradicated. He also stated that thosewho were afflicted with the ' falling sickness ' beforethe age of fourteen might become free of it but thosewho were affected at the age of twenty-five wereusually troubled with it to the end. A moreimportant observation on infantile convulsionsoccurs in 'Prognostics' (Chapter 24) and is worthquoting verbatim (Adams' translation):'Now in children convulsions occur if there has

been acute fever, and if the bowel has not beenopen, and if they have been sleepless, and iffrightened, and if they have been screaming, and ifthey have changed colour acquiring a greenish orpale or livid or red colour. Convulsions occur mostreadily from just after birth up to the seventh year.But older children and men are no longer liable toconvulsions in fevers, unless some complicationwith violent and very grave symptoms has arisen,as, for example, happens with acute delirium.'This it will be seen epitomizes fairly well theviews on infantile convulsions held until the end ofthe ninetenth century.

In discussing epilepsy Hippocrates derided andrejected the view of those he termed ' the ancients 'that the condition had a supernatural cause asimplied by its name. He attributed the disearather to a specific pathology of the brain, namely,the obstruction by phlegm of the air (sic) in the

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ARCHIVES OF DISEASE IN CHILDHOODveins of the brain. He also described the aura oftrue epilepsy.The importance and greatness of Hippocrates in

the history of medicine lies not in the detail of hisconclusions, though many of these alone wouldentitle him to be remembered, but in his method ofclinical observation and in his insistence upon thenatural origin of disease. It is one of the ironiesof history that almost all that was sound in histeaching was forgotten while the dross was handeddown reverently through the ages to smotherindependent thought.

Aristotle. Aristotle, the most versatile of allphilosophers, also has a place in the history ofconvulsions. His father, a court physician, musthave spoken often of the great physician, Hippo-crates, who died when Aristotle was only fourteen.The medical writings of Aristotle, such as they are,for he was no physician, are at least reminiscent.In Book 7 (which is devoted to Man) of his treatiseOn the History of Animals' he writes:

' Children are very subject to spasms especiallythose that are in good condition and have abundanceof rich milk, or whose nurses are fat. Wine isinjurious in this complaint, and dark coloured winesmore so than those that are pale . . .' He furtherpoints out that these children usually die before theseventh day and it is for this reason that the namingof the child is postponed until then.

Alexander. With Aristotle closes the period ofGrecian greatness in philosophy and medicine andwith his pupil, Alexander the Great, begins theHellenistic age famed for its mathematics andscience. The brief career of Alexander transformedthe Grecian world. In the third century B.C. theGreek city-states came to an abrupt end with therapid growth of the Macedonian Empire, butmeanwhile the Roman Empire was beginning totake form and in the second century B.C. Greekmedicine emigrated to Rome. There was noRoman tradition in medicine and indeed; beforethe Greek influx, Rome had 'got on for 600 yearswithout doctors ' according to the elder Pliny.

Celsu. Although medicine was practised almostexclusively by Greeks, the best account of it comesfrom the pen of a Roman. A. Cornelius Celsus isa subject of much controversy. He is usually saidto have lived during the reign of Tiberius Caesar,step-son of Augustus, and to have been a Romangentleman and not a physician. As to the first,Still would place him earlier, in the reign ofAugustus, thus making him a contemporary ofVirgil, Livy, and Horace. As to the second, thisis most vehemently denied by his translator, Grieve,as also but with more evidence by Still. His arethe earliest medical records extant after the Hippo-cratic writings, to which he shows great deference.Although he is the first to state that children shouldbe treated entirely differently from adults, he left nopaediatric writings and as regards convulsions dealtspecifically only with epilepsy. His views differlittle from those of Hippocrates. He emphasized

that convulsions may cease at puberty, andadvocated some rather startling remedies includingthe drinkilng of the blood of a newly-slain gladiator.Should these remedies be of no avail he tells us,the condition will probably last throughout life.which is not thereby shortened.

Soranus of Ephesus. Soranus of Ephesus, wholived in the second century, is the leading authorityupon obstetrics and gynaecology in antiquity. Hewas also a paediatrician and the latter part of hiswork upon diseases of women is apparently devotedto infant welfare and the treatment of the commonerdiseases of infancy. I have unfortunately beenunable to obtain a copy of this, but in the list ofcontents given by Still there is no mention ofconvulsions or epilepsy.

Galen. The ancient period closes with the nameof the greatest and most influential Greek physician.Galen, who lived from A.D. 131 to 201, founded asystem of physiology, pathology and pharmacy whichdominated Europe up to the time of Vesalius in thesixteenth century. At the age of 34 he settled inRome to become court physician to MarcusAurelius. He was a prolific writer but includedlittle of paediatrics. In his 'De Sanitute Tuenda'he treats of infant hygiene. There is also a discourseon an epileptic boy, for whom he recommendspurgation and squills together with full directionsas to diet and physical exercise. In a lesser khownwork 'On Medical Experience' he exemplifies theimportance of sequence in symptomatology thus:

' If, for example, convulsion follows fever, thisis a sign of death and if fever follows convulsion,this is a sign of safety.' Galen's importance liesin the wide acceptance which his attitude of mindto natural phenomena commanded. Gone wasthe clinical observation of Hippocrates, gone was theimaginative freedom of thought, the heritage of theGreeks. For Galen crystallized Greek thought intoa rigid system that explained everything, and theingenuity of physicians of the next fifteen hundredyears was exercised in the Procrustean task of fittingobserved facts to his principles.

The Empire of ByzantiumThe next six centuries saw the fall of the Western

Roman Empire and the establishment of theByzantine Empire in the east which was to lastanother thousand years. The degeneration of theRoman Empire into a great unwieldy administra-tive machine in which nearly every one of educationwas a civil servant gave it little strength to repelbarbarians from the north. Meanwhile the ChristianChurch was growing rapidly into a vast and inflex-ible hierarchy and attracted all the outstandingminds to her service. Already torn and buffetedwithin by theological controversies and obsessedwith the problems of heresy, she looked askance atall original thought and laid the foundations foran age of ignorance, superstition, and unspeakablecruelty which was to last over a thousand years untilthe renaissance. In this mental climate it would

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CONVULSIONS IN CHILDHOODhave been extraordinary had there been any out-standing contributions to medicine. The only nameof importance is that of Paul of Aegina, who livedfrom A.D. 625-690. He was the last of the Greekeclectics, and his emphasis that his work is notoginal but that of a mere scribe penning thethoughts of the masters is a sign of the times. Hehas nothing much to add to his predecessors; againhe emphas the importance of dentition inconvulsions, ind he sends to minimi the import-ance of epilepsy in children. He recommendsattention to diet and also the changing of a wetnu in cases of infantile convulsions. Here heforeshadows views on the dangers of breast milkwhich are carried to fantastic extremes in theeighteenth century.

The Eastern Empim was also subject to repeatedattacks, but while that of the west was attacked bynorthern barbarians who became Christians in theprocess, that of the east was attacked by Moham-medans who developed an important religion andculture of their own. Moreover, the religioustolerance of their regime attracted many persecutedChristians from the west, although admittedly, bythe simple expedient of a tax, large numbers wereenticed into the fold of Islam. The Arabian schoolof m ine which here grew up became the mostenlightened of its time, and two Pesians are note-worthy, Rhazes in the ninth century, and Avicennain the tenth.Rlzes. Rhazes was the first to devote an entire

treatise to the di of children and his writingswere still quoted as authoritative in the fifteenth andsixtnth centuries. A beautiful vellum-bound copyof a Latin translation of his works, printed inVenice in 1508, is to be found in the Library of theRoyal Faculty of Physicians and Surgeons inGlasgow. The treatise ' De egritudinibus purorum 'is quite short, and the chapter ' De epilepsiapueorum' is but a paragraph of Hippocraticorthodoxy. The next chapter, also quite short, isentitled ' De quadam passione quae dicitur materpuerorunt' This is the first mention of a strangeterm which was later used frequently for anythingfrom epilepsy to ' night-terrors.' In Arabianmediine it appeared to mean convulsions asopposed to epilepsy. Rhazes cites the usual causesof infantile convulsions as the cause of materpuerorum. Later it appears to mean the same asepilepsy (Mercuriale and Roelans), while later stillit was used more in the sense of ' night-terrors ' inchildren and globus hystericus in adults. Hence'King Lear ' (Act 2, scene 4):

' ! how this mother swells up toward myheart;

Hysterica passio! down, thou climbingsorrow ! '

Aviceama Avicenna, more famous as a philo-sophw though renowned as a physician as well,wrote largely of infant hygiene in 'Canticum de

Medicina.' In ' Canonis Mediinae ' he lists thediseass of infants with little more than -a statementof their occurnce, and advocates most drasticremedies such as bleeding and cupping, all dirctedat the unfortunate wet-nurse. He attributes theconvulsions of dentition to fermentation in the gutand, of course, quotes Hippocrates.

From the Dark Ages to the RemissaneThe dark ages which followed added little to

medical knowledge although the famous school ofSalerno in the ninth century and that of Montpellierin the twelfth may be mentioned. It was theinvention of the pnntmg press in the middle ofthe fifteenth century that paved the way for therenaissance with which our modern history begins.The change i mental outlook which characterzesthis period was determined by the diminishingauthority of the church and the increasing authorityof science. Temporal authority was now vested inthe state, with a result that the culture of the penodwas more lay than clerical and, moreover, this layculture was less subject to supervision and directionby the state than that of the middle ages had beenby the church. The authonty of science however,came much later than the rejection of the authorityof the church; there was nothing scientific in theItalian renaissance. The advance of medicinetherefore lagged rather behind, and it need notsurprise us to find that the earlier works printedhave much in common with that of the Greekeclectics and tend to be commentaries upon theGreek and Arabian schools of medicine but moreenlightened commentaries perhaps. Three paediatricincunabula of this period are worth a more detailedstudy; the first by Paolo Bagllardus, the second byBartholomaeus Metlinger, and the third byCorelius Roelans. One may also mention ananonymous little book which was often quoted byRoelans and is attributed by Sudhoff to the twelfthcentury, named ' Diseases of Children Still in theCradle.' This is entirely therapeutic and recom-mends for epilepsy peony grass and the curdledmilk of a hae.

Bagellardus was the author of thefirst printed text-book of paediatrics, entitled' Libellus de egritunibus infantum ' and dated 1472.The first part is devoted to child care and thesecond to diseases, in which he treats of epilepsyand convulsions of children. On epilepsy he citesboth Hippocrates and Avicenna and emphasizes itsdanger at an early age: ' If it happen at birth, it isnot to be cured, or scarcely ever.' In nurselings thetreatment is directed at the unfortunate nurse, andthe list of ditary restictions to be imposed uponher would daunt the most altruistic of souls. Forolder sufferers the materia nmdica is as picuresqueas ever and ranges from the mere suspension of anemerald round the neck to the drinking of the dust(sic) of a burnt 'prickly pig.' It is hard to, see inwhat way convulsions should differ from epilepsy,but it would seem from the short description he

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ARCHIVES OF DISEASE IN CHILDHOODgives of convulsions that these were attacks ofrigidity or-even opisthotonus rather than clonicconvulsions. The pathogenesis is Hippocratic butthe treatment amatic. ' Yet I know from

that I have seen many infants so stithat they could not be bent upward or downward,who, by the mere application on the spondyles ofthe neck of oil of white lilies or wet hyssop, arerelieved and cured by the favour of the Lord fromsuch a contraction.'Meduger. The next year saw the publication of

another paediatric treatise but this time in thevenacular. Metlinger wrote ' hn Regiment deritmgen Kinder' with the same r l obeisanceto the classic authorities danded by custom butthe obeisance is perhaps a little more formal andeven casual. In the section devoted to disease hedeals only with convulsions and although there ismuch of the familiar ga Ial therapeutics a breathof realism pervades the whole chapter. ' It shouldbe known that when convulsions affect a child soonafter birth it generally dies My advice is to protectthe children with the help of God. Children maydie from this but one should protect those thatcome later.' ' It is advised that the nursing womanbehave herself, avoid sin, avoid eating apples, beclean, and not give the child too much at a nursingbut little and often.'Roekas. Cornelius Roelans is the author of a

rare incuabulum which was unknown untilexhumed by Sudhoff. An almost identical text,however, was published a hundred years later bySebastian of Austria under his own name. Roelans'book has no title page but begins with a preface inwhich he modestly styles himself ' aggregator' orcompier. He cites a formidable array ofauthoritiesand lists fity-two dis in descending order fromhead to foot. He also deals with both epilepsy and' spasms.' If any authorities preponderate in hiscompilation it is perhaps those of the Arabianschool, Avicenna and Rhazes.

h S CntwyGuilhe deB The sixteenth century is of

much more interest to the paediatric historian andamong a galaxy of names who contributed to theadvance of medicine at that time, one, Guillaumede Baillou or Gulielmus Ballonius, wrote on con-vulsions. He was the first to describe whooping-cough and the first epidemiologist of modern times.He is also author of one of the first medicaldictionaries. Although he wrote towards the end ofthe sixteenth century, his works were published onlysome considerable time after his death. In ' DeConvulsionibus,' written in 1587, we have the sameconstant reference to the ancient masters, while acombination of the view held by Hippocrates thatthe nasal discharge of coryza, or pituita, comesdirectly from the brain, with that of the cerebralorigin of convulsions, leads rather interestingly to asuggestion of the pathological basis for the associa-tion of convulsions with respiratory infections.

_-SSer momsi Also to thisperiod belong Sebastianus Austrius, who plagiaridthe works of Cornelius Roelans, HieonymusMeurialis, and Sc6vole de Ste. Marthe. OfSebastin of Austria, although his works wererepublished a hundred years later interlarded withprolix commentaries by Nicolas Fontanus andtherefor presumably regarded as of some import-ance, little more need be said; the last word is withthe masters. Mercurialis, writing towards the endof the century, shows more originality of thoughtbut with no particular reference to convulsions.Sc6vole de Ste. Marthe might also be passed overbut for the remarkable form in which his tratiseon children, ' Paedotrophia,' was written. A Latinepic upon the care of children would seem to be ina strange medium. More remarkable still is itsapparent populaIty at this time. It was twicetranslated into English in verse. The sole con-tribution to the study of convulsions that he makesis the elegant presentation of an inelegant remedy,namely, the powdered ash of human skull.Thoms Player. The sixteenth century also saw

the pubLication of the first book on the di ofchildren written in English The earliest editionextant of 'The boke of children ' by ThomasPhayer or Phaer is dated 1545 (the edition con-sulted, 1546). The fame of Thomas Phayer as alawyer and a physiian was almost eclipsed by hisreown as a poet but his medical works nevertheiessoccupied an important place in the 1meical literaturefor the next half century. He devoted one chapterto the ' falling-evil caled in the greek tongueepilepsia.' As to etiology he states that it is' sometime by nature received of the parents, andthat it is impossible or difficile to cure, sometime byevil and unwholesome diet, whereby ther isengendered many cold and moist humours in thebrain.' Othewise he is largey concerned withprophylaxis and treatment. For the formr herecommends as carms to be hung round the neck,' mistletoe of the oak taken in the month of March,and the moon decreasing ' and 'the stone that isfound in the belly of the young swallow being th,efirst brood of the dame.' In his therapeutics onefeels that the poet has as much to say as thephysician: one should give with water and honey,the 'maw of leveret,' powdered root of peony, or'the purple violet that creepeth on the ground ingardens and is called in English, " heartsease."'

Tbe meet CyetwyOn the whole the sixteenth century was more

occupied with theology than with science. Inmedicine there was little more than some crudetheorizing and meagre observation. The scientificawakening that followed the religious liberation ofth renaissance was largely of the seventeenthcentury, clminating with the publication ofNewton's 'Principia' in 1687. Rene Descartes,who is regarded as the founder of modernphilosophy, also contributed to modern sience

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CONVULSIONS IN CHILDHOODand in parficular to physiology. It is as aphilospher, however, that he has had most inflon medicine and science i general. His break withth scholasticism of the past and his examinationde novo of the problem of existec paved the wayfor a rational investigation of the phenomenalworld.The great advances in every direction of human

activity during the seventeeth century permit onlyofpassing reference. The names of Kepler, Galileo,and Newton in scienc4, Descartes, Hobbes, Spinoza,and Locke in philosophy, and Sydnham, Harvey,and Glisson in mdiicine are eloquent of the great-ness of this period. Of those concerned withchildren in general and convulsions in particular,a more detailed consideration may be of interest.Nicolas Fontanus may be dismissed as belongingat heart to a former century. Similarly J. Starsmarewhose ' Children's Diseases ' published anony-mously in 1664 contains nothing new in theconception of convulsions except an ill-definedrelationship to the phases of the moon.

Robert Pemmell Robert Pemmell, a practitionerin Cranebrook in Kent, was the author, a hundredyears after Phayer, of the second book on diseasein children published in English. Te full title ofthis book, including as it does an apologia,, isworthy of reproduction. ' De Morbis Puerorum,or a Treatise of the Diseases of Children with TheirCauses Signs, Prognosticks, and Cures, for thebenefit of such as do not understand the LatinTongue, and very useful for all such as are House-keepers and have Children.' In his chapter on'The Falling Sickness or Convulsion ' he does notdifferentiate between epilepsy and convulsions andlists among the possible causes, ' corruption ' of themilk 'which does often happen when the nurse isof ill complexion,' also worm, smallpox, measles,or other fevers. Some cases may be hereditary ordue to 'vehement pains of the teeth,' ' suddenfears,' or a thrashing. Of more interest are hiscomments upon phklgm (presumably upper respira-tory infection) as a cause. ' Some will have phlegmto be the cause of Falling Sickness; but if it were so,then why might not old men (whose brains arephlegmatic) have the Falling Sickness ...: There-fore the Falling Sickness doth not proceed fromphlegm, but rather from an occult and sharpquality, which doth oppress the membranes of thebrain. For although children do abound withphlegm (from whence suffocating rheums and otherdiseaes be bred) yet doth not the Falling Siknessfollow except there be some venomous and corruptvapour joined therewith.'There follow also a few pertinent remarks in the

chapter upon dentition, where he quotes Hippo-crates as authority for citing teething as a cause ofconvulsions. He reiterates the danger of this periodand a propos lancing the gums he is ' confident thatthe want hereof doth occasion the death of many achild.'

Thor Wilis. In 1667 Thomas Willis, thecelebrated author of 'Cerebri Anatome,' wrote atsome length upon the subject of convulsions. Herefor the first time we have a logical approach to theproblemL He deals largely with epilepsy butcomments that in children the term 'convulsion'is usually employed. To convulsions in childhoodhe devotes a separate chapter. Epilepsy may behereditary or acquired, primary or sympathetic.It is priwary when the brain is first affected andsympathetic when the brain is drawn into sympathywith other parts of the body such as the stomach,spken, uterus, and intestines. He also differentiatesbetween what we would term grand mal and petitmal. The immediate cause of epilepsy he gives asan ' inordinate motion of the spirits in the brain.'He finds convulsions in children to be most

common in the first month of life and duringdentition. The prognosis is by far the worst in thenewborn. He distinguishes two kinds of convulsionin children. The first might be called toxic, and heincludes those caused by excessive heat or cold,dietary excesses, changes of air and by the suddendisappearance of an exanthem. The second mightbe termed reflex and he attributes these to irritationof peripheral nerves such as by milk curdled in thestomach, worms or teething He describes in somedetail how dentition causes convulsions reflexly.The growing tooth causes pressure on the fifth nerveand so presumably stimulates the brain. Withregard to treatment, he advocates lancing of thegums, or 'friction ' and also purgig, enemata,bleedng, and vesicants. His appreciation of thevalue of post-mortem examination and his tulyscientific approach to the interpretation of hisresults Ar a notable advance.

Walter MHi 1689 is an important landmarkin the history of paediatrics. So far there had beenno generally accepted text-book of paediatricswritten by a physician. Walter Harris supplied thiswant, and his book 'De Morbis Acutis Infantum'became the standard work on the subject andremained so, being translated into English in 1742,until the appearance of Underwood's treatise in1789. As the relationship of teething to convulsionswill play an important part in tracing the modernviews on convulsions from this time onwards, it isof interest to quote Harris verbatim (Martyn'stranslation): 'Of all the Disorders which threatenthe Lives of Infants, there is none that is wont toproduce so many grievous Symptoms as a dflicultand laborious Breeding of Teeth.' Apart fromdentition he makes no reference to etiological factorsm convulsions except one that he styles hereditaryand which is apparently limited to the newborn.He attributes this to a 'Foulxss contracted in theWomb.'

Th Ei CeatwyThe eighteenth century which virtually begins in

the final decades of the seventeenth, was a periodof relief and escape; relief from the strain of a

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ARCHIIVES OF DISEASE IN CHILDHOODmysterious universe. Pope's oft quoted coupletwell illustrates the feling of the times:

'Nature and Natue's laws lay hid in night:God said, Let Newton be ! and all was light!'

To quote Basil WiLey, Nature's laws had beenexplained by the New Philosophy; sanity, culture,and civilization had revived; and at last, across thegulf of the monkish and deluded past, one couldsalute the ancients from an eminence perhaps aslofty as their own.' The tempo ofadvance in scienceand medicine was now increasing. Observationand experiment was laying the foundation ofmodern medicine. One has only to mention someof the names, Linnaeus, Rutherford, Priestley, Johnand William Hunter, Auenbrugger, Heberden, Pott,to illustrate the greatness of this century.

Underwood. It is thus with rather a sense ofdisappointment that one reads the chapter onconvulsions in Underwood's 'A Treatise on theDiseases of Children' published in 1789. ForUnderwood's text-book remained the authoritativework on the subject for over sixty years and iscertainly in style and mental approach, the fore-runner of the modern scientific text-book. He firstdescribes convulsions as being of two kinds,symptomatic and idiopathic, the latter being dueto a morbid affection of the brain. He doubtshimself, however, the validity of this distinction andis inclined to call all convulsions, in infancy at least,symptomatic as one can usually find in every case,a cause. Of these causes the most important aretething and alimentary irritation, and he instancesindigestibility of food and intestincal parasites andeven 'wind' as potent causes of convulsions. Inaddition he attrbutes some cases to a dhngerousquality of the breast milk which can be causedapparently by emotional changes in the mother orwet-nurse and he gives an example of a woman whohad a fright and who thereupon suckled her childwhich straightway had a fit. For treatment herecommends purges, enemata, and bleding.

Another famous work is Baumes' 'Trait6des Convulsions dans l'Enfance' written in 1805.He believed convulsions to be largely constitutionaland attributable to 'l s facheuses impressons del'air.' The 'curdled breast milk ' is given greatprominence, and he instances the child of a collaguewho had a convulsion after sucking at the brstof its nurse who had immediately before been veryangry. The choicest anecdote is that of a womanwho, knowing apparently of the danrs to herchid, after having lost her temper suckled her littedog; the dog at once had a fit All views arecarried to extremes and he described convulsionsof such vioience as to break bones and laceratetissues. He treats at great lngth of diet andhygiene as prophylactic measures. He also listsevery known helminth as a cause of convulsionsand would differentiate between the syndromesproduced by each worm.

Te Ealy Niimeth Ce-qwyJohn E1am. John Burns inluded a chapter on

diseass of children in his text-book of midwiferyand gynaecology in 1814. He classified convulsiosinto those due to a primary affection of the brain,e.g hydrocephalus, and those in which the affectionof the brain is ' in sympathy ' with some otherorgan in a state of irritation. The causes of the'irritation ' are the usual ones, and he includesBaunes' impure air. He also includes trismus ofthe newborn as due to constipation though he statesthat others believe it to be due to an infection of theumbilicus.

Join Clarke. The next important contributionwas that of John Clarke in 1814. His ' Commen-taries on some of the most important diseases ofchildren ' contains the first clear-cut clinicaldescription of tetany including laryngismus stridulus,carpo-pedal spasn, and convulsions. Although noetiological basis could be given for this condition,the separation of one group of convulsions onclnical grounds marked an important step in theirclassification. In addition there is a long chapteron infantile convulsions. He comments upon thelarge number of children shown as dying of con-vulsions in the London Bills of Mortality, but pointsout that terminal convulsions are not uncommonin infancy and that the probability is that a largenumber of deaths are so recorded whereas theunderlying primary condition is not noted. Thuswe have two clear-cut classes ofconvulsion separatedfrom the main body, the convulsions of tetany(though not, in fact so-caled until named byCorvisart) and the non-specific terminal convulsions.

Joln North In 1826 John North published his'Practical observations on the convulsions ofinfants.' He lists as the main causes of convulsions'large or enlarging heads,' ' rachitis,' and ' heredi-tary predisposition,' and this is the first record thatI have found of rickets being a cause of convulsions.However the fumdamital cause is the greatersensitivity of children. This snsitiity is apparentlygreater in the tropics and he quotes a colleague, oneDr. Hillary, who ' observes that the children in theIsle of Barbadoe are so imtable that they arethrown into a convulsi at the slightest noise.'Loss ofconsciousness is not essential to the diagnosisof convulsions, which he differentiates from epilepsyin which loss of consciousness is the rule. Fromthis he goes on to the patholoical fantasy thatepilepsy is derived from the brain and its membraneswhereas simple convulsions come from the cord.Simple convulsions he divides into symptomatic andidiopathic though he also doubts the latter. Hefinds convulsions occur seldom at night, a fact thathe attributes to ther being fewer stimuli. Hecomments upon a iarked incease in the incidenceof convulsions and attributes it to over education.At this time children wse given advanced t ingat a very much earlier age than to-day. Hiscof the symptomatic convulsions are the usual ones

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CONVULSIONS IN CHILDHOODsuch as teething and constipation, though hecastigates Baumes for his emphasis on heLminths asa cause. He mentions, however, that in Germanythe current opinion was that children rarely if eversuffered from the effects of dentition. He alsodescribes carpo-pedal spasm as a prodromal sign ofconvulsions. He perpetuates the idea of harmfulbreast milk as a cause but the suggestion thatsuckling during menstruation may cause convul-sions, he tells us, ' requires no further notice thanthe mention of its absurdity.' In addition hederides the common superstition in nurses thatconstipation in an infant denotes strength andadvocates a purgative in all cases. He has two newetiological factors for convulsions of the newborn,retention of meconium and the shining of too brighta light on the child immediately after birth.

The Modern PeriodIn the next thirty years such text-books as those

of Evanson and Maunsell in Dublin, and Radcliffecontinue in much the same vein. Towards the endof the nineteenth century, however, the tempo ofscientific advancement was accelerating to reach thebreathtaking speed of the present day and thegreatness of the fin-de-siecle may properly be takenas the beginning of the modern period.KussmaIl and Tenner. In 1859 Kussmaul and

Tenner described some important observations onthe pathogenesis of convulsions. As a result ofvarious animal experiments to determine therelationship between haemorrhage and convulsions,they concluded that convulsions might be producedby (1) rapid loss of blood, (2) sudden stoppage offlow of arterial blood to the brain such as producedby ligature, spasm, inflammation, or excitement,(3) rapid transformation of arterial blood to venousas in asphyxia, which, of course, would explain theassociation of convulsions with laryngismusstridulus. They further conclude that some casesof epilepsy may be caused in this way.

Trousseau. In 1862 Trousseau published his*Clinique MWdicale de l'H6tel-Dieu de Paris.'Although he devotes a great deal of space to theconsideration of tetany, including of course adetailed description of the sign that goes by hisname, he does not relate it in any way to infantileconvulsions. Indeed there is a lot that is already veryfamiliar in his description of infantile convulsions.He classifies them as idiopathic or symptomatic,the formner showing no discernible pathologicalchange in the central nervous system exceptsome congestion which he regards as secondary.Otherwise we have the predisposing factors ofheredity, underfeeding, haemorrhage, high fever,exposure to cold or emotional upsets, and above alL,local irritation including ill-fitting clothes andsinapism. The symptomatic convulsions are dueeither to demonstrable disease of the central nervoussystem or in sympathy with disease in some otherpart of the body such as the exanthemata.

Hughings Jackson. The most impressive articleof this period is one by Hughlings Jackson thatappeared in Reynold's System of Medicine' in1868. Jackson emphasises that a convulsion is asymptom and not a disease and this, thoughapparently simple, is a most important advance inour understanding of the problem. For considera-tion he divides convulsions into those affectingchildren up to seven years of age and those affectingchildren over seven.On convulsions in the former age group he say-s

they differ from adult convulsions onlv in theimmaturity of the nervous system, and he considersthem as equivalent to delirium in adults. He citescerebral haemorrhage as a cause of convulsions inthe newborn. He condemns the use of the termsessential' or 'idiopathic' convulsions or

eclampsia, for he believes these convulsions to differin no essential from epilepsy. He describes crowingand carpo-pedal spasm in convulsions but while headmits that these occur more frequently in rachiticchildren he includes them with other localizingindications as a manifestation of the site in thebrain of the nervous discharge. Hughlings Jacksonis of course responsible for the conception ofepileptic discharge and that the site of maximaldischarge would determine the type of manifestationat the beginning of the attack. This, as Symondspoints out, was intended to apply to epilepsy as awhole and not only to traumatic epilepsy which heused however to illustrate his point. It seemsparticularly unfortunate that the term 'Jacksonianepilepsy was used to denote epilepsy arising froma macroscopic pathological focus in the brain whenno such restricted concept was intended by Jackson.He was concerned with the localization of the lesionand not with its pathology and would, one feelssure, have agreed that the commonest cause of aJacksonian attack is idiopathic epilepsy. He nextmakes the vitally important point that such factorsas over-eating, worms, and teething will not produceconvulsions in a healthy nervous system. He doesnot try to differentiate between eclampsia (oridiopathic convulsions of childhood) and epilepsybut points out that many epileptics give a historvof convulsions in childhood which had been dis-regarded. For treatment he condemns the routineuse of purges, emetics, and lancing of gums andrather doubtfully allows their use if there is anobvious indication.

Soitman. The experimental work of Soltmannin 1876-78 is of great importance in the study ofconvulsions in children. He was the first toapproach the problem of the greater susceptibilityof children to convulsions experimentally. Hedemonstrated in animals aged one to ten days, thatstimulation of the cortex produced no result whereasthere was hyper-excitability of the peripheral nerves.He reckoned the ten days to be the equivalent ofsix months in man and postulated immaturity of thenervous system with failure of the reflex inhibiting

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288 ARCHIVES OF DISEASE IN CHILDHOODmotor centre of the brain. This was an importantphysiological observation but the corollary that anyperipheral ' irritation ' might therefore be respons-ible for a convulsion seems decidedly retrograde,particularly in the light of the previous work ofHughlings Jackson. However, Soltmann's viewsdid not pass unchallenged and Fleischmann madethe pertinent observation that in burns-anespecially striking form of ' peripheral irritation '-convulsions did not occur, while Henoch pointedout that the liability of children to convulsions wasnot limited to the first six months or even the firstyear of life.

Henoch. Henoch was a pupil of Schonlein andone of the 4principal German contributors topaediatrics. In his 'Lectures on Children'sDiseases ' he discusses the pathology of convulsionsin relation to the recent work of Kussmaul andTenner and also suggests head injury as an occasionalcause with extravasation of blood into the medulla.In repeated convulsions, however, he recommendsexamining the bones for ' according to my experi-ence, the tendency to convulsions is favoured bynothing so strongly as rickets.' In children agedsix months to three years with convulsions, ricketswas usually more or less marked and laryngismuseither concomitant or alternating with the convul-sion, almost constant. He considers rickets to bemore important than dentition in this connexion.In reflex causes he places irritation of the gut first,though he had seen no case that could be attributableto worms. In convulsions associated with a febrileillness he suggests an analogy with the rigor of anadult. In addition he points out that any fit maybe the first sign of epilepsy.

Gowers. Gowers in 1893 defines epilepsy as theresult of the tendency of the brain to discharge, andseparates other convulsions arising from causesother than primary states of the brain, under thehead of eclampsia though he specifically excludesfrom this the ' single fit at the onset of an acuteinfection or in consequence of an indigestible meal.'He attributes the special liability of children toeclampsia to the non-myelinated state of the nervefibres and to the fact that the lower centres inchildhood are further advanced than the highercontrolled centres. However, he goes on to saythat the next most potent cause is rickets (then ofcourse regarded as -a 'constitutional ' disease ofunknown etiology) and attributes to rickets themajority of so-called teething convulsions. Henotes the association of carpo-pedal spasm andlaryngismus with rachitic convulsions. He accepts,however, gastro-intestinal irritation by indigestiblefood or worms as a cause.

Paul Simon. Paul Simon, writing in Grancher,Comby, and Marfan's text-book in 1898, alsocriticizes Soltmann's theory on the ground that asall children do not have convulsions though theyare all exposed to some degree of the peripheralirritation that should cause them, there must be

some specific predisposition. This he suggests maybe hereditary or due to debility especially of thenervous system as in prematurity, artificial feeding,haemorrhage, intestinal flux, congenital syphilis, andrickets. He denies that teething is ever a cause ofconvulsions but cites temper at being thwartedas one.

The Beginnings of Real Inquiry into InfantileConvulsions and Epilepsy

Now for the first time there begins a real enquiryinto the prognosis of infantile convulsions and theirrelation, if any, to epilepsy. In 1843 Rilliet andBarthez put the question without coming to anyvery definite conclusion. Infantile convulsions mayor may not be epileptic and time alone will tell.Bouchut in 1855 believed all infantile convulsionsto be incidental and with a good prognosis. Soalso D'Espine and Picot (1877), who denied therelation of eclampsia (or infantile convulsions) toepilepsy, terming the former' un accident ephem~re.'On the other hand Comby in 1897 and Fere in thesame year called all infantile convulsions epileptic.They both stressed the importance of heredity as anetiological factor, and Comby, while accepting asprecipitating factors dyspepsia, gastro-enteritis,rickets, and eruptive fevers and pneumonia, doubtedthe importance of dentition. In America, Waltonand Carter (1891) joined the optimists and concludedthat 'epileptics are at least no more likely to havehad infantile convulsions and conversely a childsuffering from infantile convulsions is no morelikely to suffer from epilepsy in life after a period ofimmunity has removed the case from the class ofepilepsy beginning in infancy and becomingcontinuous.'Thus we come to the twentieth century and the

present day, a description of which is beyond thecompass of this paper. Beginning with Hochsinger,and Thiemich, with contributions from Husler,Patrick and Levy, Graham, Herlitz, Lennox,Peterman, and Thom, the study of convulsions ininfancy and childhood has been established upon alogical basis, and if there are still problems to solveat least a great deal of the ground has been cleared.

I record with pleasure my gratitude to Prof.Stanley Graham for valuable criticism and advice;I am also indebted to the Librarians of the RoyalFaculty of Physicians and Surgeons and of theRoyal Society of Medicine for much searching intheir respective basements.

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Fisher, H. A. L. (1944). A History of Europe.Edward Arnold and Co. London.

Garrison, F. H. (1923). History of Pediatrics inAbt's Pediatrics. W. B. Saunders and Co.Philadelphia and London.- (1929). An introduction to the History ofMedicine. W. B. Saunders and Co. Phila-delphia and London.

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