Definition.—A condition in which there is a sudden, though temporary, loss of consciousness, with or without convulsions. When the attack is but momentary and without convulsions, or with but slight tremors, it is termed petit mal. Where the attack is severe, unconsciousness is prolonged, and there is severe general convulsions, it is known as grand mal.
Etiology.—The causes may be properly divided into predisposing and exciting.
Predisposing.—Heredity, according to Fere, is a strong predisposing factor, in that a marked neurotic taint is to be found in the lineage of epileptics. Not that there is a direct transmission from parent to child, for this is rare, but where not due to pressure, a history of insanity, hysteria, paralysis, insomnia, suicide, chorea, puerperal eclampsia, and other vices of the nervous system can be traced to one or both parents.
Consanguinity has been considered by some as favoring epilepsy, but in all probability such cases were coincidences rather than predisposing factors.
Age.—One-third of the cases occur before the thirteenth year, two-thirds before the nineteenth year, and the remaining third before the thirtieth year.
Alcoholism.—The fact that nearly one-half of all epileptics recorded are children of parents addicted to drink, is a significant factor.
Scarlet Fever and Puerperal Eclampsia.—Gowers states that scarlet fever is the disease that is most frequently followed by epilepsy, while Fere has observed epilepsy following puerperal eclampsia. All these conditions, however, only prepare the soil for some one of the many exciting causes.
Exciting Causes.—Favorable conditions being present, a variety of exciting causes may precipitate an attack. Thus traumatisms, syphilitic neoplasms in brain or cord, meningeal irritation, great emotion, nervous shock, acute alcoholism, toxic substances in the blood, an overloaded stomach, masturbation, an elongated or adherent prepuce, an adherent clitoris, scar tissue in the uterine cervix, teething, intestinal parasites, etc., may be mentioned.
One peculiar feature of the disease is that the epileptic habit having once been firmly established, the disease is prone to continue, even though the cause is seemingly removed.
Pathology.—There is no characteristic pathological condition found that is constant. In some there will be organic changes, such as tumors, meningeal changes, pressure from bone, or from syphilitic deposits, and other demonstrable wrongs; but these same conditions may be present in patients that never suffer from epileptic seizures. Of the idiopathic variety no pathological wrongs can be found. When due to reflex causes, tissue changes are frequently present at the source of irritation, as of the rectum, uterine cervix, urethra, ovary, perineum, etc.
Chaslin claims to have found a characteristic non-inflammatory degeneration, in which the neuroglia of the brain is transformed into an abnormal tissue, and that this degeneration is a result of a vice in development. The finding of this degeneration in all cases, however, has not been corroborated.
Symptoms.—Grand Mal.—Prodromal symptoms, or aura, frequently occur in this form, and may last but a few moments or occur a few days before the onset of an attack. Where of long duration, the patient becomes morose, cross, sullen, irritable, or melancholy. Where brief, it may be a sense of fear, an idea of impending danger, or there may be flashes of light, or loss of hearing, or a perverted hearing, such as whistling, "buzzing, musical sounds, or hissing; again, disagreeable odors, or a peculiar taste; or there may be discomfort in the epigastric region; sometimes it takes the form of numbness or tingling in the extremities, as the foot or hand, gradually extending to the head. Whether or not the attack is preceded by aura, the attack is sudden.
The Attack.—A sudden pallor of the face, a frightened look, followed by a wild piercing scream, known as the epileptic cry, and the patient falls unconscious in the throes of a convulsion. Many times there is not a sound or warning symptom, the patient falling unconscious in a spasm.
With the first unconsciousness, tonic spasms come on, and all the muscles of the body are in a tetanic rigidity. The face is congested and distorted by the facial spasm, the head thrown backward or rotated to one side, and the jaws are locked. The phalanges are flexed, the thumbs drawn into the palm, the wrists flexed, and the arm at the elbow. The legs are extended and the feet everted. The circulation is sometimes so greatly impeded as to cause rupture of the vessels, and hemorrhage from the nose, ears, bronchi, and sometimes into the cerebrum, takes place. This stage lasts from a few seconds to one or two minutes, to be succeeded by the stage of clonic spasm.
During this stage the whole body becomes agitated by the alternate contraction and relaxation of the muscles. The eyes twitch or roll, the muscles of the face incessantly move, which gives the features a hideous expression; the jaws open and close; there is grinding of the teeth, and biting of the tongue; there is a hurried, jerky respiration; a bloody, frothy foam escapes from the lips, and there is jerking of the limbs and body. Not infrequently the feces and urine are passed during the convulsive action. The pupils are usually very much dilated during this stage, and the return to the normal may be the first evidence of a cessation of the attack. The respiration during this convulsive period is slow, stertorous, and irregular. Where the convulsions are long continued, the temperature may reach 105°, 106°, or more.
This stage lasts from three to five minutes, when the patient recovers consciousness, or falls into a heavy sleep, lasting for a few minutes or hours. On awakening, the patient complains of muscular soreness and headache.
Nocturnal Epilepsy.—The attack occurs in the night, and may be unknown to patient or friends. When a patient of rather dull mind complains at intervals of feeling tired, has a headache, in fact there is general muscular soreness, and the patient seems dazed and confused, and if, in addition, he has involuntarily wet the bed, the probability is that of epilepsy, and if the pillow shows some blood-stains, there can be little doubt as to the cause.
Petit Mal.—In this form there is no convulsion, and the patient does not fall. The attack comes on suddenly without any premonitory warning; the patient suddenly loses consciousness, the speech, or whatever he was doing, being suddenly and momentarily stopped, to be resumed again in a few seconds. If talking, he resumes the broken sentence as though nothing had occurred, the patient being rarely aware of his condition. In rare cases he may fall, but there is no convulsion. In some cases the patient appears a little dazed for a few moments after the attack.
Jacksonian Epilepsy.—This is characterized by spasms of a local character, though, as the disease advances, they may become general. Tingling and other sensory sensations may precede an attack.
Consciousness, as a rule, is maintained. This is sometimes called cortical epilepsy, and is due to irritation of the cortical motor centers of the brain.
Diagnosis.—A typical case of epilepsy can hardly be mistaken for any other lesion. The picture is so striking and horrible that a novice in medicine will recognize it. The sudden attack, the patient falling in a convulsive fit, the tonic, followed by the clonic spasms, the frothing at the mouth, and the coma or deep sleep following, make the diagnosis very easy. In petit mal it may not be so easy to recognize unless we have the history of previous attacks.
Hysterical convulsions will be recognized by the more regular rhythm of the spasms and the general history.
Prognosis.—This is unfavorable in idiopathic cases, though, where symptomatic, a cure may be effected where the cause can be removed. However, the habit once acquired and continued for some months, is one of the most difficult and stubborn lesions to overcome.
Epilepsy seldom proves fatal, but with the advance of years the intellect becomes more feeble, sometimes resulting in insanity or imbecility.
Treatment.—A careful search must be instituted for the exciting cause, and since this is often found to arise at some distant point, like the rectum, the uterus, the ovaries, the urethra, or the stomach, all wrongs of this character should be corrected. An adherent foreskin should be released, and, where elongated or constricted, circumcision be performed.
All wrongs of the stomach should be corrected, and the patient placed on a nourishing but easily digested diet: It should consist largely of fruits, cereals, and vegetables, meats being allowed sparingly. The bowels should receive careful attention, constipation being avoided. Cold sponge-baths once or twice daily are also beneficial. Where the disease has followed injuries to the head sufficient to produce scalp wounds, scar tissue should be removed, and if there be any depressions causing irritation, surgical measures must be used before any relief can be promised. If pressure result from a tumor or abscess, the skull should be trephined and the pressure overcome.
During an attack the patient should be placed in a horizontal position, the clothing loosened about the throat, and cork, rubber, or a soft piece of wood placed between the teeth to preserve the tongue from injury. Where the convulsions are very intense, chloroform should be used till the throes subside, when the patient should be allowed to sleep till spontaneous awakening occurs.
The medical treatment for epilepsy has not been attended with very satisfactory results. The bromids are used probably more frequently than all other remedies combined, yet few, if any, recoveries can be recorded from its use. That it is a good nervine sedative, however, none will deny, and some relief may be obtained from its administration.
Nitrate of amyl inhaled during the aura has prevented the attack.
Oenanthe crocata and solanum carolinensis have proven useful in my hands. Gelsemium must not be overlooked when selecting agents for this lesion. Each case needs careful study and the various conditions met as they arise,