GENERAL REMARKS
"Do not muse at me, my most worthy friends;
I have a strange infirmity, which is nothing
To those that know me."
"Macbeth," Act III.
Starr's table shows that combinations of all types of epilepsy are
possible, and that mental epilepsy is rare:
Grand mal 1150
Grand and petit mal 589
Petit mal 179
Jacksonian 37
Mental 16
Grand mal and Jacksonian 10
Grand mal, petit mal and Jacksonian 8
Grand mal and mental 3
Grand mal, petit mal and mental 6
Petit mal and mental 2
Fits by day only 660
Fits day and night 880
Fits by night only 380
The majority of victims have attacks both by day and by night. Of 115,000
seizures tabulated by Clark, 55,000 occurred during the day (6 a.m. to 6
p.m.) and 60,000 by night.
The _usual course_ of a case of epilepsy is somewhat as follows: the
disease begins in childhood, the first convulsion, about the age of three,
being followed some twelve months later by a second, and this again by a
third within a few months. Then attacks occur more frequently until a
regular periodicity--from one a day to one a year--is reached after about
five years, and this frequently persists throughout life.
The effect of epilepsy on the general health is not serious, but it has a
more serious effect on the mind, for epileptic children cannot go to school
(though special schools are now doing something towards removing this
serious disability), and grow up with an imperfect mental training. They
become moody, fretful, ill-tempered, unmanageable, and at puberty fall
victims to self-abuse, which helps to lead to neurasthenia. Then they may
drift slowly into a state of mental weakness, and often require as much
care as imbeciles. If the fits are severe from an early age, arrest of
mental development and imbecility follow. If the disease be very mild in
character, and especially if it be _petit mal_, the victim may be very
precocious, get "pushed" at school, and later become eccentric or insane.
Adult victims necessarily lead a semi-invalid life, often cut off from
wholesome work and from the pleasures of life, and become hypersensitive,
timid, impulsive, forgetful, irritable, incapable of concentration,
suspicious, show evidences of a weakened mind, have few interests, and are
difficult to manage.
About 10 per cent--the very severe cases--go on to insanity; either
temporary attacks of mania, calling for restraint, or permanent epileptic
dementia with progressive loss of mind. Some victims are accidentally
killed in, or die as a result of a fit; about 25 per cent--severe cases
again--die in _status epilepticus_, but the majority after being sufferers
throughout life are finally carried off by some other disease.
There are many exceptions to this general course. Some patients have
attacks very infrequently, and are possessed of brilliant talent, though
apt to be eccentric. Others may have a number of seizures in youth, and
then "outgrow" the complaint.
A few victims are attacked only after excessive alcoholic or sexual
indulgence, some women only during their menses, while other women are free
from attacks during pregnancy, which state, however (contrary to popular
belief), commonly aggravates the trouble. Victims may be free from attacks
during the duration of, and for some time after, an infectious disease;
while Spratling says that a consumptive epileptic may have no fits for
months, or even years.
Some epileptics are normal in appearance, but many show signs of
degeneration. This is common in the insane, but less frequent and
pronounced in neurasthenics. An abnormal shape of the head or curvature of
the skull, a high, arched palate, peculiarly-shaped ears, unusually large
hands and feet, irregular teeth from narrow jaws, a small mouth, unequal
length and size of the limbs, a projecting occiput, and poor physical
development may be noted.
These are most pronounced in intractable cases, in whom mental
peculiarities are most frequently seen--either dullness, stupidity and
ungovernable temper, or very marked talent in one direction with as marked
an incapacity in others. In all epileptics, the pupils of the eye are
larger than normal, and, after contracting to bright light soon enlarge
again.
The facial expression of most epileptics indicates abnormal mentality. When
the seizures have been so frequent and severe as to cause mental decay, the
actions are awkward, and the gait slouching and irregular. Progressive poor
memory is one of the first signs of intellectual damage consequent upon
severe epilepsy.
Though the disease may occur at any age, most cases occur before the age of
twenty, there being good reason to look for other causes (often syphilis)
in cases which occur after that age. Of 1,450 of Gowers' cases, 30 per cent
commenced before the age of ten; 75 per cent before twenty. In Starr's
2,000 cases, 68 per cent commenced before the patient was twenty-one.
According to Turner, the first epoch is from birth to the age of six,
during which 25 per cent of all cases commence, usually associated with
mental backwardness, and some due to organic brain trouble. The second
epoch is ten to twenty-two, the time of puberty and adolescence, during
which time no less than 54 per cent of all cases commence. This is, _par
excellence_, the age of onset of genuine epilepsy, the mean age of maximum
onset being fourteen in men and sixteen in women. The remaining 21 per cent
of cases occur after the age of twenty-two.
In 430 cases of epilepsy in children, Osler found that 230 were attacked
before they reached the age of five, 100 between five and ten, and 100
between ten and fifteen.
Epilepsy, then, is a disease of early youth, coming on when the development
and growth of the nervous and reproductive systems is taking place. During
this period, causes, insignificant for stable people, may light up the
disease in those of unstable, nervous constitution, a fact which explains
the importance of training the child.
Both sexes are attacked. If we consider only cases of true idiopathic
epilepsy female patients are probably in excess, but in epilepsy in adults,
from all causes, males predominate. In females, the menopause may arrest
the disease.
In days gone by, epilepsy more rarely commenced after the age of twenty,
but in these days of nerve stress it commences more frequently than
formerly in people of mature age. A victim who has a fit for the first time
after the age of twenty, however, should consult a nerve specialist
immediately.
In its early stages there are no changes of the brain due to, or the cause
of, epilepsy, but in long-standing, severe cases, well-marked, morbid
changes may be found. These are the effects, not the cause, of the disease,
and they vary in intensity according to the manner of death and the length
and severity of the malady. They probably cause the mental decay and
slouching gait mentioned before.
Fits may suddenly cease for a long time, but they usually recur, and most
patients have them more or less regularly through life.
The fact that recovery is rare should not be hidden from patients and
friends. Perhaps 8 per cent of all classes recover--and "recovery" may only
be a long interval--but 4 per cent of these are Jacksonian, syphilitic or
accident cases. Only one victim in every thirty recovers from true
epilepsy; and these are very mild cases, in which the fits are infrequent,
there is no mental impairment, and bromides are well borne. The earlier the
onset, the more severe and frequent the attacks, the deeper the coma, and
the worse the mental decay, the poorer the outlook.
_Cure is exceptional_, but by vigorous treatment the severity of the malady
may be much abated. _Petit mal_ is no more hopeful than _grand mal_; less
so in cases with severe giddiness; in all cases, the better the physical
condition and digestive powers of the patient, the brighter the outlook.
To sum up, epilepsy is a chronic abnormality of the higher nervous system,
characterized by periodic attacks of alteration of consciousness, often
accompanied by spasms of varying violence, affecting primarily the brain
and secondarily the body, based on an abnormal readiness for action of the
motor cells, occurring in persons with congenital nerve weakness, and
leading to mental decay of various types and degrees of severity.
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