it may do to briefly refer to some cases which do not present the
phenomenon first described by Charcot and Bourneville. The ordinary
hysterical attack is never attended by loss of consciousness, by any
of the pupillary changes so constant in epilepsy, by the mobility of
the pupil between the attacks which is present in a large number of
true epileptic individuals. There are never the succeeding changes of
color, and the seizures are commonly produced or attended by some
emotional disturbance, or are associated with ovarian disturbance.
Epilepsy is occasionally simulated by malingerers, and sometimes the
skill of the subject is so great as to even deceive the practised eye.
Prisoners, soldiers, and litigants may counterfeit an epilepsy, and go
through with great personal suffering to accomplish their purpose.
“Clegg, the dummy-chucker,” whose remarkable case has figured in the
medical journals, upon one occasion threw himself from an iron
platform to the stone floor of the jail, nearly twenty feet below, to
convince a suspicious physician of his honesty. The simulator rarely
bears close watching. The dilatation and contraction of the pupil
cannot be simulated, nor can the corneal or pupillary insensibility.
The fraud cannot voluntarily change his color, as is the case in true
epilepsy, and as a rule the thumbs of the impostor are never flexed,
as they should be. Suggestions for a purpose are readily heard, and
sometimes adopted, by the apparently unconscious man. Gottardi[42]
lays great stress upon the use of the ophthalmoscope as a means of
detecting simulated epilepsy. He calls attention to the frequency of
retinal changes with facial asymmetry and other evidences that suggest
cerebral disease or non-development. Gottardi has found that the pulse
in true epilepsy is always lower after an attack, but it soon reaches
its normal standard.
[Footnote 42: Abstract in _Journal of N. and M. Dis._, Oct., 1881, p.
843.]
The differentiation of idiopathic epilepsy from that due to syphilis
is possible when we consider the element of pain. Besides the tibial
pains of syphilis, the epilepsy thus produced is often preceded by
intense frontal headache, while that of ordinary epilepsy follows the
attack. The syphilitic epilepsy is not attended by so great or
continued a loss of consciousness as the non-specific form, and the
movements are apt to be most violent on one side or the other. The
association of the attacks with various bodily signs, such as nodes,
old scars, alopecia, erosions, etc., and in connection with possible
cranial nerve-paralyses, will throw light upon its true character. The
paralyses referred to seem most frequently to involve the motor
ocularis, abducens, and patheticus. Syphilitic epilepsy, too, is quite
irregular in its time of manifestation, and is not unrarely followed
by aphasia; but the interparoxysmal mental state is one of extreme
dulness, memory being blunted and there being a peculiar hebetude.
PROGNOSIS.—Within the past quarter of a century the ideas of the
medical profession regarding the curability of epilepsy have certainly
undergone a change. The statistics of Bennett and others show that
since the introduction of the bromic salts the proportion of cures has
{497} been decidedly increased. Nevertheless, the disease is a most
discouraging and troublesome one to manage, and especially is this the
case when it assumes the form of petit mal. The rapid recurrence of
light attacks is, as has already been said, very apt to lead not only
to mental enfeeblement, but is very often followed by very severe
paroxysms.
Epilepsy of a more or less constant form, in which the seizures
resemble each other, is far more incurable than that of variable type;
for example, we find that unilateral seizures are much more apt to be
associated with established cortical disease than when they are
general and simply explosive manifestations. It has been held that a
tendency to permanency is marked by a diminution in the extent of the
interval. This is by no means true. I have had cases under observation
for ten or twelve years in which attacks separated by intervals of six
months or one year marked the course of the disease, in which frequent
initial attacks were present. These cases I regard as very bad so far
as prognosis is concerned. I much prefer a history of irregular and
comparatively disorderly attacks. In female subjects the menstrual
influence is not always a bad factor. When we are enabled to remove
some production of an exciting cause in connection with the catamenia
the prognosis is more hopeful; but an opinion must be expressed with
great caution, especially in those cases beginning at an early age and
not after the establishment of the menses. Traumatic cases are not
always bad, but those in which the element of heredity plays a part
most certainly are, Herpin and Gowers to the contrary; and though
these cases for a time do well under treatment, its good effects are
not constant. Individuals with misshapen heads, whose deformity
suggests premature sutural ossification, are not susceptible to the
influence of treatment, and all other osseous changes, such as
exostosis, plaques in the dura, and bony growths, whose existence can
only be guessed at or inferred from suggestive appearances elsewhere,
give rise to a variety of epilepsy which is beyond the reach of drugs.
With symptomatic epilepsies the case is sometimes different, for while
the seizures which arise from the irritation of a cerebral tumor are
almost as hopeless as the form I have just mentioned, we know from
experience that the epilepsy of syphilis and other allied diseases,
and those of toxic origin, with the exception sometimes of those
occasionally due to alcohol or lead, are curable. The meningeal
thickening of alcoholic origin or the encephalopathy of lead may be
the pathological bases of very intractable paroxysms.
So far as age is concerned, it may be stated that many eclamptic
seizures of young children which are due to well-recognized irritable
causes are promptly cured if there be no hydrops ventriculi or
preossification of the coronal sutures, and if the epileptic habit is
not established. The epilepsies of six or eight years' standing are
not encouraging from a therapeutic point of view, and those of
advanced life developing in aged persons are equally unfavorable.
The treatment of epilepsy due to heat-stroke is by no means
satisfactory, and, though the attacks are often separated by long
periods, they are apt to recur in spite of drugs.
Gowers has prepared several valuable tables which show the influence
of age upon recovery. He says: “The following table shows that age has
a distinct influence on prognosis. The percentage of the unimproved
{498} cases to the whole is 30 (43:143::30:100). The percentage of the
cases commencing at each age arrested and unimproved is stated, and
between brackets is indicated the excess of the arrested or unimproved
cases at each period of life over the proportion for the whole 30 and
70 per cent. respectively:
--------Cases.-------- ------Percentage.-------
Unimproved. Arrested. Unimproved. Arrested.
Under 10 14 29 32.5 (+2.5) 67.5
From 10-19 23 45 34 (+4) 66
20 and over 6 26 19 81 (+11)
-- -- -- --
43 100 30 70
Thus, the proportion of the cases commencing under twenty in which
arrest was obtained is considerably less than the proportion of cases
commencing over twenty, the difference amounting to about 13 per cent.
The period of the first twenty years of life at which the disease
commences has little influence, but the prognosis is little better in
the cases which commence under ten than in those which commence
between ten and twenty: arrest is more frequently obtained. The cases
which commence in women at the second climacteric period are also
obstinate, although not sufficiently numerous to be separately given.”
He also finds, from an analysis of the same cases, the fact noted by
others, that the prognosis is favorable in inverse proportion to the
duration of the disease.
Attacks which chiefly occur in the daytime are much more amenable to
treatment than the nocturnal seizures, and especially is this the case
in the tongue-biting form. Sudden blows upon the head or falls have
been known in isolated cases to effect an amelioration in the
patient's disease, but these examples are rare.
The existence of an aura is much better than if none existed.
Death from the attack itself is rare, yet in the large pauper
institution with which I was connected for many years I have known of
several cases. More often the death results from asphyxia resulting
from a bolus of food which chokes the patient or from a fall in some
dangerous place—into the fire or elsewhere. Accidental death from
drowning is more common than any other form.
The status epileptica into which patients sometimes pass who have had
many convulsions is occasionally a fatal termination of the malady,
and is always a serious feature.
The influence of different epochs in life is worthy of consideration:
of menstruation, of marriage, of pregnancy, and of the menopause there
is much to be said. I have sufficiently spoken of the establishment of
the menstrual flow, and I would only add another word of caution
against giving a too favorable prognosis except in those cases of very
recent origin. Marriage appears to have very little to do with
changing the attacks, unless they be of an hysteroid character. I have
never known epilepsy to influence the course of a pregnancy in any
unfavorable way, and I think this has been the observation of others.
Gowers refers to cases in which the attacks ceased during the time the
mother was carrying the child.
The occasional bad influence of the pregnant state has been
illustrated {499} by a case reported by Terrillon.[43] This example
was a woman who had been the victim of epilepsy of hereditary origin
since her seventh year. At the commencement of menstruation her
attacks became periodic, and recurred every two months, and she had
several two or three days before the flow. Two pregnancies followed
several years afterward. During the periods they were increased in
number and severity, and occurred several times daily. She had more
attacks at this period than in all the time after delivery.
[Footnote 43: _Annales de Gynécologie_, June, 1881, p. 401.]
I have found that the relief of uterine flexion or the establishment
of menstruation has exercised a decidedly modifying influence for the
better in several cases.
Sometimes the disease is interrupted by the menopause, but very often
in my experience it has changed in type and been followed by mental
degeneration.
The prognosis of the epileptoid mental state is serious in the
extreme, and even when in early life the attacks are aborted or
changed to perversion of the intellect or emotions existing as a
complication, the hope of cure dwindles almost to nothing.
The spontaneous cure of epilepsy is rare. Its course, however, is more
often interrupted by some intercurrent disease. Of 33 cases observed
by Delasiauve in which there was some complicating disease, such as
erysipelas, pneumonia, pleurisy, acute articular rheumatism, burns and
contusions, scarlatina, erythema, or the condition of pregnancy, it
was found that in 25 cases there was a decided improvement (une
heureuse influence), and in 8 only was there no modification of the
attacks. Axenfeld is disposed to believe that acute and febrile
disorders more decidedly influence the course of epilepsy than those
of a chronic nature. The influence of either may be small or may
diminish the number of attacks without curing the disease.
TREATMENT.—The treatment of epilepsy depends so much upon the form of
the disease that no arbitrary rule can be laid down upon general
principles, and we must bear in mind the necessity for removing the
exciting causes if possible, the preservation of the balance of
cerebral blood-pressure and cell-equilibrium, and the nutrition of the
cerebral mass. It may be our purpose to remove various toxæmic or
cachectic states as well. As a minor division of treatment we must
consider the abortion of the attack when auræ are detected. It has
been the custom, I think among too many, to manage the disease in an
empirical manner, depending upon some routine course of treatment,
such as the indiscriminate use of the bromides, for example. I am
convinced that the intractable character of the disease has come to be
greatly exaggerated through failures attendant upon the wholesale use
of the bromic salts, without regard to the indication in each
particular case. It behooves us first to select a reliable bromide,
and then to give it with relation to the time of the fit, its
severity, and the condition of the individual. The importance of this
has impressed me very often. An equally divided daily dose will not do
a patient who has matutinal attacks the same good as will a large dose
at night, and in certain anæmic individuals the bromides very often
increase the attack. Then, too, the cases in which seizures of petit
mal predominate are not benefited to the extent that those are in
which {500} the repetition of severe attacks is the feature. The
bromide should always be well diluted and given when the stomach is
empty or nearly so. The bromide of sodium is, to my mind, the most
serviceable salt, and when given alone or combined with the bromide of
ammonium is better than the potassic salt or the various others. It
should be carefully kept in solution or in waxed-paper powders in a
tight preserve-jar. As to its method of administration, I much prefer
the use of a solution which shall combine other adjuvants which I will
presently mention, and separate powders as well, which may be used to
reinforce the dose. The latter are to be employed by the patient in
the event of an unlooked-for series of attacks, and are to be used to
the point of producing mild bromism at the time. In certain cases it
is all-important to take into consideration the condition of the
heart. In some cases where there is manifest and continued cerebral
congestion, with full vessels and hard pulse, I have found that the
combination with chloral or aconite was desirable. In other cases
where the heart's action was irregular and weak my experience with
digitalis and nitro-glycerin or with strychnine was most happy. In
those cases that passed large quantities of clear urine of low
specific gravity the action of nitro-glycerin and digitalis has been
most prompt, and the same has been true of epilepsies of migrainous
origin.
There have been various methods of using the bromide suggested which
are more or less practical. The writers of a few years ago suggested
the prompt production of bromism—a state in which the patient should
be kept for a long time. This I strongly disapprove of, not only
because the mental and physical depression is a very disagreeable and
sometimes permanent condition, but because I have found that the
attacks are often increased after a time, though at first they may
have been suppressed. Others believe in giving the bromides at
intervals, with periods when no medicine at all is administered.
For my own part, I am in favor of the establishment of a mild bromism
which does not extend beyond a slight anæsthesia of the fauces or the
appearance of slight acne. If I find it necessary to increase the
dose, I give cod-liver oil, iron, and bark or some of the many
preparations of the hypophosphites for a time; and they do not
diminish the specific effects of the drug to any great extent. In the
event of a series of attacks I direct the patient to take an extra
dose at such time as will anticipate the seizure.
This treatment should be kept up for at least two or three years after
the attacks have disappeared, and it may be even necessary to continue
a bromide course in a small way for an unlimited period.
If there be an hysterical element, or if ovarian excitement is
supposed to have anything to do with the attacks, the combination of
cannabis indica is strongly recommended. This suggestion holds good in
the cases where migraine is associated with the epilepsy, or the
latter is an outgrowth of the former.
Next to the bromides of potassium and sodium I have been very
successful with the nickel bromide. I find that it is retained with
little trouble, producing no gastric derangement if taken after
eating. A syrup prepared by most of the good pharmacists is preferable
to any other method of administering the salt. Quite recently
Leaman[44] has reported {501} two cases of severe epilepsy which were
greatly benefited. His conclusion is that it does most good in the
form of the disease when the attacks are separated by long intervals.
[Footnote 44: _Med. News_, Apr. 18, 1885.]
The bromate of potassium, which has been used by Weir Mitchell[45] and
Hinsdale, may be worthy of a trial. It should never be given, however,
in larger doses than five or ten grains thrice daily. These
investigators found that thirty grains slowed the heart very
considerably, and forty grains produced watery discharges from the
bowels and drowsiness. In their hands, notwithstanding these
disagreeable effects, it controlled the seizures. The hydrobromate of
conia is a comparatively new remedy which has been recommended. My own
experience does not support that of Wolfenden.[46] Severe cases were
treated by him with benefit. The dose he recommends is half a grain,
and not more than four and a half grains are to be given in
twenty-four hours. Headache and dizziness attended its use.
[Footnote 45: _Med. News_, Dec. 27, 1884, p. 718.]
[Footnote 46: _Practitioner_, June, 1884.]
Erlenmeyer[47] is an advocate of the mixed treatment, and his best
results have been obtained by combining the bromides of potassium,
sodium, and ammonium in the proportion of 1:1:½. He thinks much
greater permanency of effect follows such a combination. A curious
result witnessed by this author is the fact that the acne produced by
one salt given alone is apt to disappear when the combination is
administered.
[Footnote 47: _Centralblatt für Nervenheilkunde, Psychiatrie, etc._,
No. 18, 1884.]
A solution of hydrobromic acid, prepared after Fothergill and Wade's
formula, is recommended by H. C. Wood of Philadelphia,[48] who
presented the record of its use in twelve cases of obstinate epilepsy.
It seems that in his hands large doses acted much better than when the
bromides were given alone. He recommends ounce iij per diem. My own
experience, which I detailed some years ago, was to the effect that it
possessed no virtues whatever in ordinary doses. The solution is so
difficult to take, and so disagreeable in every way, that many
patients prefer almost any other treatment. It cannot be doubted that
some cases of epilepsy are benefited by a change of treatment, no
matter what, and possibly Wood's cases belong to this class.
[Footnote 48: _Med. News_, Feb. 23, 1884.]
Belladonna and ergot are remedies that have had many advocates,
Trousseau being the most pronounced champion of the former. Their use
in the lighter attacks is attended sometimes by the most happy
results, but they cannot be said to have any permanent effect. The
first is advantageous because of its power to diminish reflex
excitement, and in those undeveloped infantile convulsions which are
often grouped under the head of eclampsia its virtues are decided.
Belladonna or its alkaloid may be given in combination with the
bromides. Ergot or ergotin, in spite of its undeservedly bad
reputation, may be given in large doses, one to two drachms of the
tincture thrice daily, or five grains of the aqueous extract in the
course of the day. Of chloral there is not much to be said. At one
time it was thought to possess great virtues, especially in
combination with the bromides, but subsequent experience has taught me
that its use has many drawbacks, and only in exceptional cases is it
to be recommended—viz. in those in which there is a disposition to
excitement—either as a substitute for the attack or as a sequel.
{502} The use of the iodide of potassium in combination with the
bromides is of great service in symptomatic epilepsies or those of
syphilitic origin. The iodide should be pushed, so that the patient
may take three or four drachms daily, and its injurious gastric action
and unpleasant taste may be done away with by administering it in
large quantities of milk or some mild alkaline water, such as Vichy.
Among the other remedies used and advocated by various writers are
hyoscyamine, the salts of zinc, chloral, the ammonio-sulphate of
copper, picrotoxin, strychnine, curare,—all of which have little or no
effect in permanently changing the course of the disease. Cerebral
galvanism, if properly employed, is certainly worthy of a trial as an
adjuvant.
As abortants we may resort to diffusible stimulants—ammonia, alcohol,
or some carminative. If the aura be perceived, a drachm of the
aromatic spirits of ammonia or a glass of sherry will often prevent
subsequent developments, and the inhalation of ten or fifteen drops of
nitrite of amyl will avert the attack. Nitrite of amyl may be
conveniently used in the form of pearls, which may be first crushed in
the handkerchief. The nitrite of soda, which has been recommended as a
substitute, is an unstable and dangerous drug, and is not to be
recommended.
I called attention some years ago to the virtues of nitro-glycerin as
an abortant in epilepsy. It may be given in alcoholic solution or
tablets from 1/50-1/25 of a grain at a dose, to be perhaps repeated.
Great care should be taken to procure a reliable preparation.
When a sensory aura proceeds from a particular locality in preference,
the application of some local form of irritant is strongly
recommended. A blister or light touch of the button of the actual
cautery will do, and if the point of origin be one of the extremities
a circular blister or cautery-line, after the method recommended by
Buzzard, will be serviceable in the treatment of the case.
Buzzard has observed the fact, in several of his patients who
complained of a sensory aura in the biceps, that when an encircling
blister was applied just above this spot the attacks were aborted. In
more than one of his cases of partial epilepsy the extraordinary
result of a transfer of the convulsion to the other extremity is
noted. He found that the circle should be complete, for a blister
which half encircled the arm did no good. I have used the same
treatment in cases of writer's cramp with marked benefit.
Brown-Séquard has pointed out the good effects of forcible and painful
extension of one finger or toe if the aura is of sufficient duration
to enable the individual to resort to this procedure.
The condition known as the status epilepticus is best treated by amyl
nitrite, which can be administered frequently. Repeated doses of
nitro-glycerin, so that its full effects are produced, do more good
than chloroform or any of the well-known anæsthetics.
Of setons I have very little to say. At best, they are a barbarous and
painful mode of treatment, and, although cures have been effected, I
have never been much encouraged by their so-called influence.