PETIT MAL is frequently a source of error in diagnosis and is sometimes entirely overlooked for years. Parents will tell you that the child has “attacks of staring,” “changes colour,” faints, or has momentary “staggers” and funny feelings. Not infrequently the nature of these attacks is only determined by an inquiry, after a child has been guilty of certain inexplicable acts, of which it is itself unconscious.

The features of petit mal present themselves in different ways in different cases. In one case, the child simply falls and as rapidly picks itself up again. In another, there may be a mere sudden, forward movement of the head, as in nodding. In a third, the child may stand motionless, or stagger slightly, the eyes having a curious far-away look, as if staring into space. In a fourth, this sudden fixed attitude may be associated with a transient paling and flushing of the face. More rarely, the only thing that calls for notice is some mischievous, senseless, dirty, or entirely inexplicable act or expression.

These acts are generally referred to as examples of post-epileptic automatism, and their recognition is of extreme importance for the welfare of the child. They may be simple or complicated in their nature. Let me illustrate this point by reference to a few cases:

The naughty dancer

A little girl was brought to me, because in her dancing-class she would occasionally, and apparently wilfully, break forth into absurd and grotesque steps of her own invention. For this, although she denied any knowledge of the act, she was punished. Sometime later, she was sent to the headmistress of her school with a message, and, while waiting for a reply at the desk, she suddenly seized an inky pen, smacked her mistress on the hand, and threw it into the air. On being asked for an explanation, she again professed entire ignorance, and was consequently referred to me for enquiry into the state of her mind. This inquiry elicited that the child on several occasions had been noticed to stand still with a blank staring expression, her face going pale, and her general appearance indicating entire, if momentary, oblivion to surrounding affairs. Such a phase had immediately preceded her assault on her mistress.

Hiding the post

In a second case, a little girl was sent to post some letters. She returned rather dazed and complaining of headache, and was sent home as unwell. Three days later some dirty letters were returned to the sender, with the explanation that they had been found in an area of the house, just beneath the grating. The child later had typical attacks of petit mal.

The forgetful cyclist

A boy riding a bicycle ran into some obstacle and damaged his cycle. He remembered thinking that he had better take it to be repaired, and his mind was then a blank, until he recovered his memory 24 hours later in hospital.

The intervening history of this boy is interesting as showing how much may be done in the post-epileptic state. A constable had found him lying on the pavement in a dazed condition, quite a distance from where the accident occurred. Further, there was no evidence, and no question raised by the patient at the time as to the whereabouts of his cycle. This was afterwards discovered in a neighbouring repairing shop, and it appears that the boy had taken it there to be mended. This boy was a known epileptic, and suffered from attacks of petit mal; the fitting together of the picture is, therefore, easy. He had an accident, injured his bicycle, made up his mind to get it mended, then had an attack of petit mal. In the post-epileptic subconscious stage, he proceeded to carry out the thoughts that had been in his mind immediately previous to his seizure. This accomplished, he set out for home, and on the way was seized with a second attack, or a major attack, so attracting the attention of a constable, who brought him to hospital.

Indications may be slight

But the subject of petit mal is not always detected by complicated actions of this nature – sometimes a ridiculous remark, an outburst of laughter, or incontinence of urine or faeces without any knowledge of the act, are the only indication of an attack.

The minor epileptic, then, in the stage of automatism, carries out the idea, or thought, which immediately preceded the attack. Such an idea or thought might be one that in the conscious state one would suppress.

One can imagine a small girl standing waiting for a message, thinking how amusing it would be to rap her mistress over the knuckles with an inky pen. Such an idea would, of course, in the conscious state be suppressed, through fear of punishment or natural knowledge of what is wrong. However, in the subject of petit mal, the suppressing force is removed by the seizure, and in the following sub-conscious state the paramount idea is realized in the form of an actual concrete mischievous act. Similarly, an absurd expression or a foul word heard on some previous occasion, and constantly recurring in the child’s mind, will find utterance after an attack of petit mal.

There is not always a clear distinction between grand mal and petit mal; in a great number of cases, both types exist together, and many children have minor epilepsy for years before a major attack draws attention to it. In some cases, the convulsions are localized, unconsciousness is transitory, and there is no fall.

Treatment

A case of epilepsy in a child should be treated at the earliest opportunity, and before doing so the need of prolonged and adequate attention should be explained to the parent. To give a dose of bromide when the child has had a fit is only shutting the stable door when the steed is stolen; and to say that he or she will grow out of it, is courting disaster for the child, disappointment for the parents, and a considerable loss of prestige for ourselves.