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.