EPILEPSY, WITH CASES.
Referring my readers for full information on the pathology and history
of epilepsy to Dr. Russell Reynolds’s exhaustive treatise on the subject
already referred to, I would mention, as shortly as possible, a few
facts which are necessary to be borne in mind, with especial reference
to the class of cases which I am now considering.
Dr. J. C. Prichard, in writing of diseases of the nervous system, has
well said that “few diseases are better characterized by them symptoms
than epilepsy; yet in this instance there is such a variety in the
phenomena as renders it difficult to contrive a definition in a few
words which may comprehend every form of the complaint.”
I have said that when convulsions become chronic they are considered to
take on an epileptiform character. Now, although we know that in a few
cases involuntary spasm may take place in sleep, _i.e._ with loss of
consciousness, I think we may, for all general purposes, take as a
definition of epilepsy a chronic convulsive disease, each convulsive
attack being accompanied with “sudden and complete loss of
consciousness,” this latter symptom being considered by the late Dr.
Todd[5] as “the pathognomonic symptom of the disease,” but only, as Dr.
Reynolds[6] has shown, “when it occurs as a paroxysmal or occasional
event.”
Footnote 5:
_Medical Times and Gazette_, August 5, 1854, p. 129.
Footnote 6:
_Op. cit._, p. 31.
The causes of epilepsy are various—“partly physical, partly immaterial.”
Of the former are injuries and tumours of the brain or meninges,
intestinal worms, renal and biliary calculi, &c. &c. These are termed by
Dr. Handfield Jones[7] “eccentric causes.” As “centric causes,” he names
“poisoning of the blood from retention of excrementitious matter; this,
by deranging the nutrition of the nervous tissue, generates the abnormal
excitability, which then manifests itself without any special irritant.
Various causes of exhaustion, such as hæmorrhage and excessive
discharges, venereal excesses, prolonged want of sleep, unremitting
pain,” &c., are all “centric” causes of epilepsy.
Footnote 7:
_Op. cit._, p. 209.
Dr. Reynolds is right in considering epilepsy an idiopathic disease,
inasmuch as it occurs, without discoverable organic lesion with which it
can be associated, and because there is no structural lesion of the
brain, or spinal cord, to be found constantly associated with it; but
when he says that it is idiopathic because, “in many cases, eccentric
irritation cannot be shown to be the cause of the attacks,” I cannot go
with him. Epilepsy is a name signifying a disease, which may be
idiopathic, or may arise from a variety of causes; but that eccentric
irritation is a powerful and very frequent cause, there is not the
slightest doubt. Dr. Reynolds classes it as second of six in a table
given in his book, physical conditions being mentioned as first; and
finding, in a hundred cases, that 24·63 have no assignable cause, and
18·84 are doubtful, he gives 13·04 as due to eccentric irritation.
In considering peripheral irritation of the pudic nerve as a cause of
this disease, we must, I think, consider mental emotion, which occupies
the highest rank in causes of epilepsy, in conjunction with that second
in the list,—eccentric irritation. I would, therefore, classify the
cause of epilepsy depending on such irritation as both eccentric and
centric. The former, inasmuch as it produces exhaustion, and, by
deranging the nutrition of the nervous tissue, generates abnormal
excitability; the latter, for that it is a physical excitant which is
not only “a mere provocative of the paroxysms, the convulsions being
supposed to ensue as the reflex results of irritation, but that it
actually _sets up_ in the nervous centres that state of excitability
which is the essence of the disorder.” Further still, looking on
epilepsy as a direct sequel of hysteria, when it is produced by
excitation of the pudic nerve, the patients are, in an eminent degree,
predisposed to the disease.
Women are also more naturally prone to epilepsy from mental emotion than
men; “Emotional disturbance being assigned,” says Dr. Reynolds, “as the
cause of their attacks in so many as 36 per cent., whereas in the male
sex there were only 13 per cent. who referred their diseases to that
cause.”
It would be out of place in a work of this nature to detail at length
the symptoms of these attacks. Whether they are truly epileptic will be
seen as the cases are related. I have been very careful to separate
those which seemed to be of an hysterical or epileptoid nature; and have
had the advantage of being able to show the greater number of them to
many eminent members of the medical profession, who have witnessed my
practice in the London Surgical Home.
CASE XXXIV. EPILEPTIC FITS—TWELVE YEARS’ DURATION—OPERATION—CURE.
S. F., æt. 41, single; admitted into the London Surgical Home Dec. 16,
1861.
_History._—Was always ailing, and hysterical for many years. Catamenia
appeared early, and always rather profuse. For the last twelve years
has suffered from epileptic fits; recurring frequently every week or
fortnight, and lately as often as every day. Has constant headaches;
is losing memory and all power of concentrating her ideas. Has no
premonition of seizure; falls down; is unconscious; has frequently
bitten her tongue; and “froths” at the mouth. Says she has had several
attacks of hæmatemesis. She was a dressmaker, and had so frequently,
on her way to or from business, fallen in the streets, that she had
been carried into almost every hospital in London, and a large number
of open surgeries.
_On examination_ there was found every indication of irritation about
the vulva, and also a small polypus of the os uteri, which latter was
large and patulous.
Dec. 19. Usual operation of excision; polypus uteri also removed.
The recovery of this patient was rapid and uninterrupted. After the
operation, she never had a fit, and hardly a headache. She was
discharged Jan. 20, 1862, perfectly well, and with greatly increased
mental power. When heard of at commencement of 1864, she remained
well, and had had no recurrence of any of her old symptoms.
CASE XXXV. EPILEPTIC FITS—FIVE YEARS’ DURATION—PRECEDED BY CATALEPTIC
FITS, DURING THE TEN PREVIOUS YEARS—OPERATION—CURE.
In the beginning of April, 1862, a single lady, æt. 28, came under my
notice, giving the following account of herself.—When about ten years
old had a fit, whilst she was sitting at needlework; she fell down
suddenly as if dead, and remained insensible for two hours; was very
ill for three weeks after the attack. Was quite well until the age of
fourteen, when she began to have them every three months. When about
twenty-two had an interval of eleven months without a fit, but
frequently fainted during that period. During the time she was in the
fits she would be perfectly unconscious. She was told that her limbs
were quite rigid, and always remained in the exact position in which
they were when the fit commenced. In 1857 the fits changed in their
nature—the patient at first falling down quietly, but subsequently
becoming very convulsed, and trying to hurt herself. The first of this
nature lasted two hours and three-quarters. Has lately had them much
oftener, but not always of the severe form. Has had eight severe fits
in the last two years and a half, besides the milder, which come
sometimes a dozen in a fortnight. Is unconscious, but always knows
when she has had one. Foams at the mouth, but makes no noise. Has
frequently fallen down suddenly in church and other public places. Has
been under many physicians, all of whom have been of opinion that she
is suffering from genuine epilepsy.
April 2. Clitoris excised.
April 6. Has had no attack, but complains of occasional pain in the
top of her head.
She never had an attack after the operation. Returned home in a month,
and shortly afterwards she was thrown out of a pony chaise; she had no
fit, but wrote that, prior to treatment, a very much slighter accident
would have immediately produced one.
I heard of this lady later in the year; she was still quite well. Not
having heard since from her, as was agreed when she left me, I am
satisfied that she has had no relapse.
CASE XXXVI. EPILEPTIC FITS—MANY YEARS’ DURATION—OPERATION—CURE.
N. L. M., æt. 21; admitted into the London Surgical Home May 9, 1863.
_History._—Married four years and had two children; the labours have
been bad, and followed by severe hæmorrhage. Had aborted at six weeks,
a fortnight previous to admission, and had lost a large quantity of
blood. First suffered from epileptic fits at puberty; had several
before marriage, and has had four or five since marriage; but has
never had a fit when pregnant. Not very regular in menstruation, which
is accompanied with severe pain. Has constant pain on right side of
head, in back, loins, &c. Great pain in micturating and on defecation.
She is always totally unconscious during the fits, and they are
followed by extreme prostration. Is of melancholy aspect, excessively
anæmic, and somewhat chlorotic; even the mucous membranes (of mouth
especially) are blanched. The cause of her fits being diagnosed, the
usual _operation_ was performed May 14.
May 18. Progressing excellently.
May 20. There was great irritability of the bladder, which, however,
was immediately relieved by an alkaline and henbane mixture.
May 31. Has not had any return of her bad symptoms until to-day, when,
on being removed to a strange ward, she had a fit, not of violent
character, and followed by a heavy drowsiness.
June 2. Is quite herself again.
July 4. Has left quite well in every respect, and when heard of many
months later remained well.
_Remarks._—The fit following on change of this patient from one ward
to another where there were strangers, shows how important it is for a
permanent cure, that visitors and relatives should not be allowed to
excite and agitate a patient suffering from these attacks after an
operation is performed, and when the mind is hardly restored to its
natural balance.
CASE XXXVII. EPILEPTIC FITS—TWO YEARS’ DURATION—OPERATION—CURE.
H. C., æt. 20, single; admitted into the London Surgical Home Feb. 24,
1864.
_History._—About three years since, first commenced ailing.
Menstruation ceased for four months, when it appeared for two days.
Fifteen months then elapsed before the function was restored.
Epileptic fits have been developed for about two years. The patient at
the commencement of an attack is strongly convulsed, has no
premonition, and is perfectly unconscious. Frequently falls when
walking in the streets. Has often hurt herself in her falls, and also
bitten her tongue. Has the usual symptoms of bearing-down of the womb,
and pain in the loins. No pain in defecation. Bowels costive. Pain in
micturition, and sometimes retention of urine, occasionally not
passing any for two days.
March 3. Clitoris excised in the usual manner under chloroform. Was
restless and hysterical for the first six days, when she improved
daily, became cheerful, and much more intelligent. She never had
another fit, and on April 13, being quite cured, was, at her own
request, retained in the Home as a servant. She remained there under
observation for six months, during which time she had not only no
return of her former attacks, but progressively improved in health,
and her menstruation became quite regular.
Since that time she has been living as cook in a family which I
frequently visit, and it is therefore certain that she remains
perfectly well.
CASE XXXVIII. SEVERE AND FREQUENT EPILEPTIC FITS FOR THREE YEARS AND A
HALF—OPERATION—CURE.
C. T., æt. 21; admitted into the London Surgical Home June 23, 1864.
_History._—Health always good till three years ago, when, after a
severe fright, she became very excited and had a fit. Since that time
has been continually subject to them. She never passes a day without
two or three, and frequently has as many as six, or even eight, in the
twenty-four hours. Is most subject to them at night when sleeping. Is
always suffering from headache. Her mental powers are somewhat
impaired, as she has very slight recollection of persons, or of
events, from day to day. Catamenia very irregular. Has not menstruated
since March last. Bowels costive; pulse regular and firm. Is of a
sallow complexion, with vacant and weak expression of countenance.
Acknowledges great and constant irritation of pudic nerve.
During the day previous to operation, special notice was taken of the
nature of the fits. They are epileptic; for although she does not foam
at the mouth, she has, on more than one occasion, _bitten her tongue_,
and is _perfectly unconscious_. There is no rigidity, but a constant
struggling, and, unless restrained, the hands always, during an
attack, are carried to the seat of irritation.
June 23. The usual operation of excision was performed under
chloroform. As soon as she recovered, she managed to remove the
dressings. Hæmorrhage for two hours was the result. When arrested, two
grains of opium were administered, which produced sleep. On awaking,
she again endeavoured to remove the dressings; but, her hands being
confined, she was unable to do so. She had no more fits, and but a few
hysterical attacks. On July 17th she was discharged, as her parents
were anxious for her return. She had not then had a fit of any kind
for sixteen days.
August 15. I received the following letter from her father:—
“Dear Sir,—It would be very unkind in me, and much out of place, to
hide from you and the world at large what have been my feelings during
the past three weeks. My daughter, C. T., came to your Home, Stanley
Terrace, Notting Hill, on the 23rd of June last, to be treated by you
for epilepsy, or epileptic fits, having been afflicted for three years
and a half. The class of fit you may better judge of than myself;
sufficient to say, they were very bad and very frequent. I am happy to
say, and acquaint you, that since her return she has not had a single
symptom of fit or hysteria of any kind. Her general health is also
very good, and fast improving, and I do hope, by the blessing of God,
she may continue so. If you have any desire to see her, I shall feel
in duty bound to let her wait upon you, with her mother, at any time
you may think fit to appoint, as your opinion just at this time might
have a still more happy effect for the future. You are quite at
liberty to use this for the benefit of the Institution in whatever way
you may like or seem good.”
A twelvemonth later, this patient was still free from any return of
the fits.
CASE XXXIX. EPILEPSY, WITH DEMENTIA—ONE YEAR’S DURATION—OPERATION—CURE.
A. H., æt. 17; admitted into the London Surgical Home June 28, 1864.
_History._—Catamenia first appeared three years ago. They have
continued regular to the present time. About twelve months since was
observed, whenever sent on an errand from home, that she would wander
about in an absent manner, and return home having forgotten all about
any message which had been given her. About this time fits were first
developed; they increased in frequency and intensity, and she now has
them daily, and one or more of less violent character nearly every
night in her sleep. When seized, she falls, struggles violently, foams
at the mouth, often bites her tongue, and is totally unconscious to
all around her. After a fit, she sinks into a deep sleep, which lasts
for two hours. Has no recollection on awaking of what has taken place.
Acknowledges to frequent injurious habits, but is unconscious of their
being the cause of her illness. Is vague in all her ideas and
conversation, and has almost entirely lost her memory.
Both history and personal examination plainly showed what was the
cause of her attacks.
On July 7 the clitoris was completely excised. She had no return of
the fits; and on the 23rd the following report appears in the
case-book:—“Left her bed to-day. Is greatly changed; quite rational in
all her movements; converses freely and quietly, remembers passing
events from day to day, and it is indeed almost impossible to
recognize in her the half-idiotic, almost demented girl who entered
the Home less than a month ago.”
She remained in the Home some time longer for observation. Fits never
returned; her mind improved daily, and she was discharged as perfectly
cured.
CASE XL. EPILEPTIC FITS—TWO YEARS AND A HALF DURATION—OPERATION—RELIEF.
S. Z., æt. 16, single; admitted into the London Surgical Home October
20, 1865.
_History._—Was strong and well until two and a half years ago, when
she had an epileptic fit in the middle of the night. Can assign no
cause for the attack. For a long time had a fit once a month, but
latterly once a week. The catamenia appeared six months before the
first fit, and have always been regular. There is no exacerbation at
menstrual epoch. Complains of great irritation of pudendals for three
years.
Nov. 2. Since admission this patient has been watched: she has had two
fits, both of a genuine epileptic character.
Mr. Brown this day performed his usual operation. She went on well
till the 10th, when she had a slight fit; there being irresistible
irritation, the hands were restrained. A lotion of bromide of ammonium
was ordered to be applied to the wound, and 20 grains of the bromide
to be given in water three times daily.
She convalesced well, and had no more attacks till the 29th, when, her
hands having been released only a few minutes previously, she had a
fit, and the nurse found one hand on the wound. She was conscious
during the attack, which was not so violent as before treatment.
Dec. 2. Discharged relieved. If this patient could be under control
for a few months, she would probably be cured.
CASE XLI. EPILEPTIC FITS, WITH DEMENTIA—THIRTY YEARS’
DURATION—OPERATION—CURE.
M. F., æt. 44, single; admitted into the London Surgical Home December
8, 1865.
_History._—Epileptic fits first attacked her when she was about 14, at
which age she menstruated. For the first few years there was a long
interval between each, but they gradually became more frequent and
violent. Latterly she has had several during the week of each
menstrual period, and as a rule none in the interval. Catamenia have
been tolerably regular in appearance, but rather profuse. Is tall,
pale, and thin; has a dull and somewhat vacant expression; is very
eccentric in her manners and conversation; is frequently observed,
both day and night, by the nurses to practise injurious habits, to
which she acknowledges for the last thirty years. The fits are genuine
epileptic.
_On examination_, there is evidence of very long-continued peripheral
irritation, and also a fissure of rectum.
Dec. 12. The usual operation on clitoris and rectum.
Dec. 13. In the absence of nurse, removed the dressing, and
immediately had a fit. To have opium 1 grain, with ¼ grain of extract
of belladonna, every six hours.
Under this treatment the patient improved daily, became cheerful,
rational, tractable, and much more sensible in her conversation.
She passed two menstrual epochs, but without a fit, and she was
discharged perfectly cured.
I have a much larger number of cases occurring in private practice, but,
for that reason, am obliged to omit them. I shall, however, when a
longer time has elapsed, publish them.