CHAPTER VII.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 chronicconvulsive 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.”

5.Medical Times and Gazette, August 5, 1854, p. 129.

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.

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 actuallysets upin 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.

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” atthe 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 examinationthere was found every indication of irritation about the vulva, and also a small polypus of theos 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.

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 thelast 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.

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. Thecause of her fits being diagnosed, the usualoperationwas 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.

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.

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 isperfectly 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.

M. F., æt. 44, single; admitted into the London Surgical Home December 8, 1865.

History.—Epileptic fits first attacked her when she was about14, 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.

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