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Isaac G. Briggs.

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Epileptiform Seizures are convulsions due to causes other than epilepsy,
and only a doctor can tell if an attack be epileptic or not and prescribe
appropriate treatment. To give "patent" medicines for "fits", to a man who
may be suffering from lead poisoning or heart disease, is criminal.

Convulsions in Children often occur before or after some other ailment.
Such children need careful training, but less than 10 per cent of children
who have convulsions become epileptic. Epilepsy should only be suspected if
the first attack occurs in a previously healthy child of over two years of
age. There are many possible causes for infantile convulsions, and but one
treatment; call in a doctor _at once_, and, while waiting for him, put the
child in a warm bath (not over 100° F.) in a quiet, darkened room, and hold
a sponge wrung out of hot water to the throat at intervals of five minutes.
Never give "soothing syrups" or "teething powders".

The "soothing" portion of such preparations is some essential oil, like
aniseed, caraway or dill, and there are often present strong drugs
unsuitable for children. According to the analyses made by the British
Medical Association, the following are the _essential_ ingredients of some
well-known preparations for children:

Mrs. Winslow's Soothing Potassium Bromide,
Syrup. Aniseed, and Syrup
(sugar and water).

Woodward's Gripe Sodium Bicarbonate,
Water. Caraway, and Syrup.

Atkinson and Barker's Pot. and Magnesium
Royal Infant Bicarbonate, several
Preservative. Oils, and Syrup.

Mrs. Johnson's American Spirits of Salt, Common
Soothing Syrup. Salt, and Honey.

Convulsions During Pregnancy. Send for a doctor instantly.

Feigned Epilepsy is an all-too-common "ailment". The false fit, as a rule,
is very much overdone. The face is red from exertion instead of livid from
heart and lung embarrassment, the spasms are too vigorous but not jerky
enough, the skin is hot and dry instead of hot and clammy, the hands may be
clenched, but the thumb will be _outside_ instead of _inside_ the palm,
foam comes in volumes but is unmixed with blood, and the whole thing is
kept up far too long. Almost before a crowd can gather an epileptic seizure
is over, whereas the sham sufferer does not begin seriously to exhibit his
questionable talents until a crowd has appeared.

Pressure on the eye, which will blink while the "sufferer" will swear;
bending back the thumb and pressing in the end of the nail, when the hand
will be withdrawn in feigned but not in true epilepsy; blowing snuff up the
nose, which induces sneezing in the sham fit alone, or using a cold douche
will all expose the miserable trick.

It is, unfortunately, far easier to suggest than to apply these tests, for
anyone foolish enough to try experiments within reach of the wildly-waving
arms will probably get such a buffet as will damp his ardour for amateur
diagnosis for some time.

* * * * *

CHAPTER III

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.

* * * * *

CHAPTER IV

CAUSES OF EPILEPSY

"Find out the cause of this effect,
Or rather say, the cause of this defect,
For this effect defective comes by cause."
"Hamlet," Act II.

THE MECHANISM OF THE FIT

The brain consists of cells of _grey matter_, grouped together to form
centres for thought, action or sensation, and _white matter_, consisting of
nerve strands, which act as lines of communication between different parts
of brain and body. The wrinkled surface (_cortex_) of the brain, is covered
with grey matter, which dips into the fissures. There are also islands of
grey matter embedded in the white.

The front part of the brain is supposed, with some probability, to be the
seat of intelligence, while a ribbon three inches wide stretched over the
head from ear to ear would roughly cover the Rolandic area, in which are
contained the _motor cells_ through which impulse is translated to action.
These motor cells are controlled by _inhibitory cells_, which act as brakes
and release nerve energy in a gentle stream; otherwise our movements would
be convulsive in their violence, and life would be impossible through
inability usefully to direct our energy.

That is how inhibition acts physically; mentally it is the power to
restrain impulses until reason has suggested the wisest course.

Irritation of the cortex, especially the motor area, causes convulsions,
and experiment has shown that epilepsy may be due to a disease or
instability of certain inhibitory cells of the cortex. The motor cells of
epileptics are restrained, with some difficulty, by these cells in normal
times. When irritation from any cause throws additional strain on the motor
cells, the defective brakes fail, and the uncontrolled energy, instead of
flowing in a gentle stream through the usual channels, bursts forth in a
tidal wave through other areas of the brain, causes unconsciousness, and
exhausts itself in those violent convulsions of the limbs which we term a
fit.

The Primary Cause of epilepsy is an inherent instability of the nervous
system.

Secondary Causes are factors which cause the first fit in a person with
predisposing nervous instability; later, the brain gets the _fit habit_,
and attacks recur independently of the secondary cause. In most cases no
secondary causes can be discovered, and the disease is then termed
_idiopathic_, for want of an explanation.

Injuries to the brain may cause epilepsy, and many cases date from birth, a
difficult labour having caused a minute injury to the brain.

Some accident is often wrongly alleged as the cause of fits, for most
victims come of a bad stock, and when the first fit occurs, their relatives
recollect an injury or a fright in the past, which is said to be the cause.

Great fright may cause epilepsy, as in the case of a nervous girl whose
brother entered her room, covered with a sheet, as a "ghost", a "joke" that
was followed by a fit within an hour.

Sunstroke may cause fits, and a few cases follow infectious diseases.

Alcoholism is a strong secondary factor, fits often occurring during a
drinking-bout and in topers, but in many cases, drunkenness, instead of
being the cause, is only the result of a lack of self-control following
epilepsy.

Pregnancy may be a secondary cause of the malady: it may lead to more
frequent and severe seizures in women who are already victims; bring on a
recurrence of the malady after it has apparently been cured; or, very
rarely, induce a temporary or permanent cure.

Epilepsy may be due to abortives. These drugs wreck the constitution of the
undesired children, who contract epilepsy from causes which would not so
have affected them had they started fairly. In many families, the first
child, who was wanted, is normal; some or all the others, who were not
desired and on whom attempts were probably made to prevent birth, are
neuropaths, as are many illegitimate children. It cannot too emphatically
be stated that there is no drug known which will procure abortion without
putting the woman's life in so grave a danger as to prevent medical men
using it; legal abortion is always procured surgically. Dealing in
abortifacients would be a capital offence under the laws of a rational
community.

Self-abuse may perhaps play some part in epilepsy commencing or recurring
after the age of ten.

The onset of menstruation often coincides with the onset of epilepsy, and
in some cases irregularity of the menses seems to be a secondary or
exciting cause.

Exciting Causes aggravate the trouble when present, causing more frequent
and severe seizures. The chief are irritation of stomach and bowels (from
decaying teeth, unchewed, unsuitable, or indigestible food, constipation,
or diarrhoea), exhaustion, work immediately after a meal, passion or
excitement, fright, worry, mental work, alcoholism, sexual excess, nasal
growths, eye-strain; in short, anything that irritates brain or body.

Theories as to Cause. Epilepsy is usually classed as a _functional
disorder_; that is, the brain cells are physically normal, but, for some
unknown reason, they act abnormally at certain times. This term is a very
loose one, and there is reason to believe that the basis of epilepsy is
some obscure disease of the brain which has not been detected by present
methods.

The new school of psychologists regard the malady as a mental _complex_ - a
system of ideas strongly influenced by the emotions - the convulsions being
but minor symptoms.

Fits are most frequent between 9-10 p.m. the hours of deepest repose. One
school says this is due to anæmia of the brain during sleep. Clark traces
the cause to lessened inhibitory powers owing to the higher brain centres
being at rest, while Haig claims to have explained the high incidence at
this hour by the fact that uric acid is present in the system in the
greatest amount at this time.

Some doctors have thought, on the contrary, that _excess_ of blood in the
head was the cause, but results of treatment so directed did not bear out
the sanguine hopes built on the theory.

The fact that convulsions occur in diabetes and alcoholism, suggested that
epilepsy was due to poisons circulating in the blood, and thus irritating
the brain. Every act uses up cell material and leaves waste products,
exactly as the production of steam uses up coal and leaves ashes. Various
waste products have been found in more than normal quantities in the blood
of epileptics, but it is uncertain whether accumulation of waste products
causes the seizure.

A convincing theory must satisfactorily account for all the widely diverse
phenomena seen in epilepsy, and the problem must remain largely a matter of
speculation, until research work has given us a far deeper insight into the
biochemistry of both the brain cells, and the germ-plasm than we have at
present.

* * * * *

CHAPTER V

PREVENTION OF ATTACKS

In health matters, prevention is nine points of the law.

Some patients are obsessed by a peculiar sensation (the "aura") just before
a fit. This warning takes many forms, the two most common being a "sinking"
or feeling of distress in the stomach, and giddiness. The character of the
aura is very variable - terror, excitement, numbness, tingling,
irritability, twitching, a feeling of something passing up from the toes to
the head, delusions of sight, smell, taste, or hearing (ringing, or
buzzing, etc.), palpitation, throbbing in the head, an impulse to run or
spin around - any of these may warn a victim that a fit is at hand. Some
patients "lose themselves" and make curious mistakes in talking.

The warning is nearly always the same each time with the same patient, and
is more common in mild than in severe cases. Rarely, the attack does not go
beyond this stage.

When the patient becomes conscious of the aura he should sit in a large
chair, or lie down on the floor, well away from fire, and from anything
that can be capsized. He must never try to go upstairs to bed. Some one
should draw the blind, as light is irritating.

If the warning lasts some minutes, the patient should carry with him, a
bottle of uncoated one-hundredth-grain tabloids of

Nitroglycerin, replacing the screw cap with a cork, so that they can
quickly be extracted. When the warning occurs, one - or two - should be
taken, and the head bent forward. The arteries are dilated, the
blood-pressure thus lowered, and the attack _may_ be averted.

The use of nitroglycerin is based on the theory that seizures are caused by
anæmia due to vasomotor constriction. Success is only occasional, but this
is so welcome as to justify the habitual use of the method.

If the aura be brief, buy a few "pearls" of Amyl Nitrite, crush one in your
handkerchief, and sniff the vapour. This has the same affect as
nitroglycerin, but the action occurs in 15 seconds and only persists 7
minutes. A headache occasionally follows the use of these drugs, and they
should not be employed without professional advice.

When the warning is felt in the hand or foot, a strap should be worn round
the ankle or wrist, and pulled tight when the aura commences. This
sometimes aborts a fit, as biting a finger in which the aura commences may
also do.

If a victim feels unwell after a meal, he must never eat the next meal at
the usual time, simply because it _is_ the usual time.

Should a patient feel unwell between, say, dinner and tea, instead of
eating his tea he must empty his bowels by an enema, or croton oil (see
chemist), and his stomach by drinking a pint of warm water in which has
been stirred a tablespoonful of mustard powder and a teaspoonful of salt.
After vomiting, drink warm water.

_Never attempt to empty the stomach at the onset of a definite aura_, for
if the seizure occurs, the vomit will probably obstruct the trachea, and
suffocate the victim.

After the stomach has been empty ten minutes, the patient should take a
double dose of bromides (Chapter XIX) and go to bed. Next morning he will
be well, whereas if he eats but a single piece of bread-and-butter he will
probably have a fit within five minutes.

Unfortunately, in 60 per cent of cases, there is no warning at all, while
in those cases which do exhibit an aura, the measures mentioned above more
often fail than succeed.

* * * * *

CHAPTER VI

FIRST-AID TO VICTIMS

"First-aid is the assistance which can be given in case of emergency by
those who, with certain easily acquired knowledge are in a position,
not only to relieve the sufferer, but also to prevent further mischief
being done pending the arrival of a doctor." - Dickey.

_Never try to cut short a fit_. Placing smelling-salts beneath the nose,
together with all other remedies for people who have "fainted", are useless
in epilepsy.

Lay the patient on his back, with head slightly raised; admit air freely;
remove scarf or collar and tie, unfasten waistcoat, shirt, stays or other
tight garments, and if it be known or observed that the victim wears
artificial teeth, remove them.

If five people are at hand, let two persons grasp each a leg of the victim,
holding it above the ankle and above the knee; two others should each hold
a hand and the shoulder; the fifth supports the head. Do not kneel opposite
the feet or you may receive a severe kick. Prevent the limbs from striking
the floor, but _allow them full play_. If the victim rolls on his face
gently turn him on his back.

Roll a large handkerchief up _from the side_ (not diagonally) and holding
one end firmly, tie a knot in the other end, and place it between the teeth
to protect the tongue; or slide the handle of a spoon or a piece of smooth
wood between the teeth, and thus hold the tongue down. Soft articles like
cork and indiarubber should not be used, for if they are bitten through,
the rear portion will fall down the throat and choke the victim.

After the fit, lower the head to one side to clear any vomitus which, if
left, might be drawn into the windpipe, lift the patient on to a couch,
cover him warmly, and let him sleep. An epileptic's bed should be placed on
the ground floor; if his bed be upstairs, it is difficult to get him there
after an attack, while he may at any time fall downstairs and be killed.

Any effort to rouse him will only make the post-epileptic stupor more
severe, but whether he sleeps or not, he must carefully be watched, for
patients in this state are apt to slip away, often half-clothed, and travel
towards nowhere in particular at a wonderfully rapid rate.

If several fits follow one another, or if one is very long or severe, send
for a doctor.

When a seizure occurs in public, a constable should be summoned, who, being
a "St. John" man, will be of far more use than bystanders brimming over
with sympathy - _and ignorance_. If some kindly householder near by will


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Online LibraryIsaac G. BriggsEpilepsy, Hysteria, and Neurasthenia → online text (page 2 of 10)