One other point there is also to be borne in mind; namely, that the child is compelled by the vague sensation of hitherto unknown dread, not to conceal the early symptoms of epilepsy as the grown person would do; longing as the child does for love and sympathy, and weakened in its moral force, it craves for more love, more sympathy, it exaggerates its symptoms, it assumes some which do not exist at all. The conclusion is a natural one, but none the less mistaken, that the child who is discovered to be shamming has nothing the matter with it—is simply a naughty child. This is a fact of much importance, on which I shall have occasion to insist further on.
In the child, as in the adult, epilepsy blunts the intellect as well as weakens the moral powers; and does both more speedily and more effectually in proportion as the child is younger, and its mind and will are less developed. And yet this has its compensation; for as the powers fade quickly, so, if the attacks cease, they recover with surprising rapidity, and as the moral powers are the first to suffer, so they are the first to regain—I will not say full vigour, but at least a degree which raises the children to be objects of specially tender affection, rather than of pity and compassion.
The conditions which justify the most hopeful view of any case of epilepsy are then, first, the absence of any history of frequently recurring convulsions in early infancy; secondly, the existence of a distinct exciting cause for the attacks; thirdly, the rarity of their return far more than their slight severity; and lastly, the more the attacks approach in character to what one knows as hysteria, the less profound the insensibility in the fit, the shorter its duration afterwards, the greater are the grounds for hope that the seizures will eventually cease.
Cases of this last class are to some degree, at any rate, under the child's control. I have several times seen a fit warded off by the threat of the shower bath, or even by calling to the child, and sending it to fetch something in another room. Such cases may indeed pass into ordinary epilepsy, but often, under judicious management, moral rather than medical, they cease, so that one can venture on taking a more hopeful view of them than of others.
And this brings me to the question of what can be done, or rather what can parents do to promote recovery from epilepsy. First of all, do not listen to what you may hear about this medicine or the other being a specific for it. There is no specific whatever for epilepsy, but there are certain remedies which in skilful hands do have a real though limited power to control the frequency and lessen the severity of the attacks. Next, there are cases in which the attacks depend on some definite cause; it may be indigestion, or constipation, or the cutting of the second set of teeth, and on the irritation produced by those teeth being too crowded. Thus, I remember a boy twelve years old, in whom two severe epileptic fits occurred apparently without cause. He was cutting his back grinding teeth, and in the lower jaw the teeth seemed overcrowded. I had a tooth extracted on either side, the fits ceased, and when I last heard of him many years afterwards they had not returned.
Epilepsy often lasts for many years, and no one's memory is retentive enough to be trusted with all the details between the different attacks, the causes which seemed to produce them, the measures which appeared at different times to be of service. I am therefore accustomed to advise people, any of whose children have the misfortune to be epileptic, to write as brief an account as possible of the child's previous history, and to supplement it by a daily record kept in parallel columns of date, food, state of bowels, sleep, medicine, attacks, specifying their character and duration; and general remarks, which would bear on the child's temper and general condition, and in which column any probable exciting cause of an attack would be recorded. It is surprising how much important information is gathered in a few months from such a record kept faithfully.
The diet should be mild, nutritious, but as a general rule unstimulating; and should include meat comparatively seldom, and in small quantities. Some fifty years ago, a very distinguished American physician, Dr. Jackson of Boston, in the United States, insisted very strongly on the importance of a diet exclusively of milk and vegetables in greatly lessening the frequency and severity of epileptic attacks. I believe in the great majority of cases of epilepsy in childhood Dr. Jackson's advice is worth following. And I may add that, while I have little faith in the influence of mere drugs, I have a yearly increasing confidence in that of judicious management, mental and moral, as well as physical.
The first requisite in all cases is a firm and gentle rule of love on the part of those who have charge of the child. As violent and sudden excitement of any kind will often bring on an epileptic seizure, so the influence of the opposite condition in warding off its attacks is very remarkable; and on several occasions I have received patients into the Children's Hospital who were reported to have epileptic seizures several times in a day, and who nevertheless remained a fortnight or more in the institution without any attack coming on. The disorder, however, was not cured, but only kept in check by the gentle rule to which the little ones were subjected. The order goes for much in these cases; the novelty goes for something too, for almost invariably I have found that after a time the apparent improvement becomes less marked, and though they continued better than when they first came to the hospital, the children were still epileptic; the advance of the disease had been retarded, but its progress had not been arrested. The quiet then which suits the epileptic, is not the quiet of listless, apathetic idleness, but the judicious alternation of tranquil occupation and amusement. The mind must not be left to slumber from the apprehension of work bringing on a fit, but the work must, as far as possible, be such as to interest the child. In the occupations of epileptics therefore, pursuits which not merely employ the mental faculties, but also give work to the hands, such as gardening, carpentering, or the tending of animals, are specially to be recommended; and if by these the mind can be kept awake, the grand object of teaching is answered, and backwardness in reading, writing, or those kinds of knowledge which other children at the same age have acquired, is of very little moment. Many epileptics have an indistinct articulation, and almost all have a slouching gait, and an awkward manner. The former can often be corrected to a considerable degree by teaching the child simple chants, which are almost always easily acquired, and practised with pleasure. The latter may be rectified by drilling, not carried out into tedious minutiæ, but limited to simple movements; and the irksomeness of drill is almost completely done away with by music, while I believe that the accustoming a child to the strict control and regulation of all its voluntary movements is of very great importance indeed as a curative agent.
It is difficult to carry out these minute precautions on which so much depends in the home with other children of the same family. It is therefore, I believe, better for the child, painful though it is to the parents, that he should be placed under the care of some competent person who will devote the whole of his time to the care of the patient.
St. Vitus's Dance.—A state of unconsciousness, accompanied with more or less violent involuntary movements, is characteristic of epilepsy. Involuntary movements without loss of consciousness constitute the disorder commonly known as St. Vitus's Dance. It is rare in early childhood, becomes more common after the age of five, and attains its greatest frequency between the ages of ten and fifteen, girls, owing to their more impressionable nervous system, being affected by it more than twice as often as boys.
It seldom comes on in a child previously in perfect health, and strangely enough it occurs with special frequency in children who have before suffered from rheumatism. Sudden shock or fright is often said to have been its exciting cause; but even then the symptoms seldom come at once, but are gradually developed in the course of two or three days. At first, it is noticed that the child has certain odd fidgety movements, usually of one arm, next of the leg of the same side, so that it stumbles in walking, and then the muscles of the face become affected, the child grimacing strangely, and next the limbs of the opposite side become involved, and as things go on from bad to worse, the child becomes unable to hold anything in its hand, to walk, or even to stand, and even if on the ground still writhes about with the strangest contortions of its body. If matters grow still worse, the child becomes unable to put out its tongue, it swallows with difficulty, it loses not only the power of distinct articulation but even the faculty of speech, while the mind itself becomes weakened, the child seems half idiotic, and even though the movements lessen in violence, power over the limbs is lost for the time, and they seem almost paralysed. Happily cases so severe are very rare, and it is rarer still for them to have a fatal termination. Almost invariably recovery takes place by degrees, the movements lessen, swallowing is performed with less difficulty, the power of speech, returns, and the intellect regains its brightness: but the child is left with a special liability to return of the affection, though the first attack is usually the most severe.
Even at the best, however, the disorder is always tedious, as is shown by the fact that its average duration is seventy days. It is very natural, therefore, that parents should be anxious when they see that their child has some awkward or ungainly habit, some odd trick or gesture never noticed before, lest it should be the beginning of this tedious ailment. Now it is well to remember that St. Vitus's dance does not begin with twitching of the muscles of the face, but that its earliest symptoms are involuntary movements of the arms and twitching of the fingers, and that contortions of the face do not come on till afterwards. Movements of this sort too, even when not limited to the face, vary in the course of a few days in the parts which they affect, and show themselves, now in winking the eyes, then in grimacing, in twitching of the muscles of the face or neck, or in some awkward gait or manner. These are all best left unnoticed, for they are almost invariably made worse if the child's attention is called to them. They are, or at least before the days of Board Schools they were, scarcely ever met with among the children of the poor, for they almost invariably depend on mental strain; not of necessity on undue length of the hours of study, or on the difficulty of the tasks imposed, but often on a child's anxiety to make progress and to keep up with his schoolfellows. In corroboration of this being their cause I may say that, contrary to the rule which obtains with St. Vitus's dance, these movements are more frequent in boys than in girls, for the over-mental strain of boys comes earlier; that of girls seldom occurs before the time of transition to womanhood, and its results are then different, though much graver. In cases of this kind, lessening the mental strain is almost always followed by a cessation of the movements; change of air, country amusements, and a generally tonic treatment perfect the cure, and dancing and gymnastics overcome the remains of any awkward habit.
The movements in real St. Vitus's dance do not shift about as these do from one part to another, but tend to involve various parts in succession, without previously ceasing where they had begun.
The relative share which the parents and the doctor take in the treatment of these cases depends to a great extent on their severity. While attention to the state of the bowels, and a generally tonic treatment are almost always needed, gymnastics and drill are often of very great service in the slighter cases; and a very distinguished Paris physician was accustomed to send children thus affected to march round the Place Vendôme, keeping step while the band was playing. The utility of gymnastics turns very much on the degree in which the child is able by attention to control his movements, and when either as in young children fixed attention cannot be roused, or as in severe cases the effort only adds to the child's nervousness, and in consequence increases the movements, they must be given up. All drill and gymnastics are best carried out in class with other children, and regulated not simply by word of mouth, but by a tune or chant. When recovery is in progress gymnastics will then in almost all instances find their place.
Even when drill and gymnastics cannot be practised, regulated movements of the limbs carried out twice a day for ten minutes at a time are of very real service. Another's will here takes the place of that of the patient, and the limbs are thus taught, though far more imperfectly, to act in concert.
Two or three more cautions may still be of service. Do not keep a child out of bed, and force it to try to exert itself when the movements are very severe; continued movement, voluntary or involuntary, fatigues. Let the child lie in bed; it rests there, and the movements, which always cease during sleep, become at once greatly lessened. So important indeed is it to avoid the exhaustion caused by incessant violent movement, that in bad cases it is sometimes necessary to swathe the limbs in flannel bandages, and so to confine them to splints in order to restrain them. Next, do not become over-anxious because the child grows stupid and ceases to talk; intelligence and the power of speech will certainly come back again. And, lastly, do not be impatient and think your medical adviser incompetent because the disorder lasts so long. An average duration of seventy days implies that while sometimes it ceases sooner, in others it lasts much longer than the two weary months of watching and waiting with which in any case you must lay your account.
Paralysis, or Palsy.—When speaking of St. Vitus's dance I said that there was a partial loss of power in the limbs as well as an inability to control their movements. After a fit of convulsions, or an epileptic seizure, power over some limb is often lost for a time which may vary from a few minutes to some hours. In the course of some serious diseases of the brain, one of the manifestations of the mischief is the impairment or the loss of power over one arm or leg, rarely over both; and lastly, that terrible disease diphtheria is often followed by a paralysis so general that the patient is sometimes for days unable to move even a finger, although the condition may eventually pass away.
There is, however, a very real paralysis which occurs sometimes in infants and young children. It comes on for the most part quite suddenly, often unaccompanied by any sign of brain disorder, but tending nevertheless to issue in great permanent impairment of the power over the affected limb or limbs, and eventually to interfere with their growth and thus to produce serious deformity.
It is in general impossible to assign any distinct exciting cause for the affection, though the fact that in two-thirds of the cases it occurs between the ages of six months and three years, proves it to be in some way intimately associated with teething. The oldest child in whom I have ever seen it was aged between seven and eight years, and the youngest a little under six months. It is of excessive rarity for the arm alone to be affected, but it is by no means unusual for the legs alone to be paralysed; though in the majority of instances power is lost on one side only, the leg and arm being both involved.
A child goes to bed quite well, or at the worst having seemed slightly ailing and feverish for a day or two, and on waking in the morning it is suddenly discovered that power is lost over one leg or both, or over both arm and leg of one side. The loss of power is at first seldom complete, though neither arm nor leg can be used to any good purpose, and during the ensuing twenty-four hours the palsy often grows worse, and sometimes affects one or both limbs of the opposite side. After that time recovery in general begins. It is now and then speedy, so that in three or four days all trace of the paralysis may have disappeared. This, however, is a fortunate exception to the general rule, which is that amendment is very tardy, showing itself first in the arm, afterwards in the leg, and, if both sides have been affected, more on one side than on the other. Unless the improvement is very rapid, it is almost always only partial, and the palsied limb, though it does not lose sensation, regains but little power; it grows much more slowly than the other, is always colder and wastes considerably, while, some muscles still retaining more power than others, it becomes twisted out of shape, and requires all the skill of the orthopædic surgeon to remedy or at least to lessen the consequent deformity.
It has been ascertained that this form of palsy depends on a state of congestion, or overfilling of the minute blood-vessels of the spinal marrow. When the child gets well the congestion has passed away; but it does this speedily, and recovery is then rapid as well as complete. If it does not soon pass away, other changes take place in the spinal marrow, and recovery is then slow, incomplete, or even does not take place at all.
Remedies are unfortunately of little avail here, but it is evident that when the palsy is quite recent all movement of the limb must be mischievous, and that the congestion of the spinal marrow to which it is due will be most likely to abate under the influence of perfect quiet, rest in bed, and soothing or fever medicines, or of such as are calculated to overcome constipation, or to correct any fault of digestion, while the importance of teething, and the possible expediency of lancing the gums must not be forgotten.
Afterwards comes the time for exercise of the paralysed limb, for friction, for shampooing, for galvanism; all continued perhaps for months or years with unwearied patience, and I must add with reasonable expectations as to the result. The only additional remark which I have to make is this, that to gain any real good from galvanism, a battery must be procured under the direction of some medical man specially skilled in the use of electricity, and the mode of employing it must be learned thoroughly from him. It is merely idle to purchase a toy machine, and, giving it to the nurse to turn the handle for ten minutes twice a day, to fancy that you are making a serious trial of the effects of galvanism. As a mere money question, a costly machine, and several fees paid in order to be thoroughly instructed in the way to use it, is much cheaper than a cripple child.
A few words may not be out of place with reference to cases in which paralysis is mistakenly supposed to exist. Much anxiety is sometimes expressed by parents concerning children who have long passed the usual age without making any attempt to walk; or who having once walked seem to have lost that power. Now it often happens that after any weakening illness a child ceases for some weeks to walk, just as it ceases to talk. The power in both cases was newly acquired, it called for effort which, when strength is regained, will be put forth once more. The same applies to other instances in which children are late in learning to walk; or who, having once walked, leave off walking when a back tooth, or when one of the eye teeth is coming near the surface of the gum, and regaining the power lose it again, or lose at least the desire to exert it more than once during the active progress of teething. But, holding the child under its arms, you have but to put its feet to the ground, and at once it will draw up its legs though it will make no other movement; or take it on your lap and tickle the soles of its feet, and laughing or crying, as the mood takes it, it will move its legs about as freely as you could wish and show that the power is still there, though for the present the child will not take the trouble to exert it.
Gradual loss of power over one or other leg, especially if attended with pain either in the back or in the knee or hip, should always call for attention, and induce you to seek at once for medical advice. Such cases generally occur later in childhood than the conditions of which I spoke in the former paragraph, and may depend on disease of the spine or of the hip-joint, two serious conditions which it needs the medical expert to discover and to treat.
Neuralgia and Headache.—In the grown person neuralgia, as many of us know to our cost, is by no means infrequent; in the child it is very rare, and when a child complains of severe pain in the head, or of severe pain to the knee or hip apart from rheumatism, it is almost invariably the sign of disease of the brain in the one case, of the hip-joint in the other. To this rule there are indeed exceptions, but it will always be well to leave it to the doctor to determine—no easy matter by the bye—whether any given case is one of the rare exceptions or not.
There is, however, one form of real neuralgic headache which is by no means rare in children after the commencement of the second dentition, and which sometimes goes on into early manhood or womanhood, when it becomes what is commonly known as sick headache. It is essentially an ailment of development, incidental to the time when the brain is first called on for the performance of its higher functions.
It does not by any means always depend on over-study, though I do not remember meeting with it in children who had not yet gone into the school-room; and I have frequently found it dependent on too continuous application, though the number of hours devoted to study in the course of the day may not have been by any means excessive.
The child's brain soon tires, and the arrangement, so convenient to parents of morning lessons and afternoon play, works far less well for it than if the time were more equally divided between the two.
The attacks not infrequently come on on waking in the morning, and rapidly become worse, the pain, which is almost always referred to the forehead, being attended with much intolerance of light and sound, with nausea, and often with actual vomiting. Like the vomiting of sea-sickness, however, previous stomach disorder has no necessary share in its production, and I may add, indeed, that it is often difficult to assign any special exciting cause for the attack. The suffering is more often relieved by warm or tepid than by cold applications, and not infrequently pressure or a tight bandage greatly mitigates it. In no case does the attack last more than twelve hours—usually not more than half that time; it passes off with sleep, and leaves the patient weak and with a degree of tenderness of the head to the touch.
Such attacks may occur every fortnight, ten days, or even oftener, but their very frequent return, instead of increasing apprehension, should diminish anxiety. A first attack, indeed, may seem as though it threatened mischief, till it is seen how speedily and completely it passes off, and when afterwards a second or a third attack comes on with the same severity of onset, the same rapid worsening, and the same quick passing away, you will feel convinced that the symptoms have no grave meaning.
There is a headache of quite a different kind to which I must for a moment refer, that, namely, which depends entirely on imperfect vision, and for which spectacles are the remedy, not physic. The infirmity is not noticed during the first few years of life, but in later childhood, when a tolerably close attention to study has become necessary. Some of the minor degrees of short-sightedness, and want of power of adaptation of the eyes, such as exists in the aged, soon begin to interfere sensibly with the child's comfort, and the strain to which the eyes are subject produces a constant pain over the brow, the cause of which is often unsuspected.13
In all cases, therefore, in which a child complains of constant pain over the brow for which there is no obvious cause, it is well to take the opinion of an oculist, who can best ascertain the power of reading at different distances and with each eye separately, and the real cause of symptoms which had occasioned much anxiety is thus often brought to light.
Night Terrors.—Before taking leave of the disorders of the nervous system, I must briefly mention the Nightmare, or Night Terrors of children, which often cause a degree of alarm quite out of proportion to their real importance.
It happens sometimes that a child who has gone to bed apparently well, and who has slept soundly for a short time, awakes suddenly with a sharp and piercing cry. The child will be found sitting up in bed, crying out as if in an agony of fear, 'Oh dear! Oh dear! take it away! father! mother!' while terror is depicted on its countenance, and it does not recognise its parents, who, alarmed by the shrieks, have come into its room, but seems wholly occupied by the fearful impression that has roused it from sleep. By degrees consciousness returns; the child now clings to its mother or its nurse, sometimes wants to be taken up and carried about the room, and by degrees, sometimes in ten minutes, sometimes in half-an-hour, it grows quiet and falls asleep; and then usually the rest of the night is passed undisturbed, though sometimes a second or even a third attack may occur before daybreak.
Seizures of this kind may come on in a great variety of circumstances, and may either happen only two or three times, or may continue to recur at intervals for several weeks. The great point, however, to bear in mind is that they depend invariably on some disorder of the stomach or bowels, and are never an evidence of the commencement of real disease of the brain.