James M. (James Meschter) Anders.

A text-book of the practice of medicine online

. (page 161 of 178)
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lesion. Among the causes of the former are brain-tumors, meningitis,
traumatism inflicted either at birth or subsequently, atrophy and sclerosis,
vascular disturbances, syphilis, and toxemia, both autogenous and exog-
enous.' Peripheral lesions too may give rise to it. Little can be said
about the idiopathic variety. Chaslin has endeavored to show tliat in
this form a constant lesion exists — viz., a diffuse sclerosis of the grav
matter, a neurogliar overgrowth — but his views have not been coiTobo-
rated. After all, we can only enumerate causes ; we do not know in any
case how these act, and we do not know the ultimate pathology. Manv
writers apply the name " epilepsy " only to the idiopathic form, while
others include all apyretic affections characterized by the occurrence of
fits, whether of centric or peripheral origin. Brown-Sequard believes that
the distinction between the various kinds of convulsions is artificial, and
that the correct classification should be based on the knowledge of the cause.



Btiology. — The causes are (1) predisposing, (2) exciting or deter-
mining. Among the former, which refer particularly to the idiopathic
form, are —

(a) Age. — The following tables show the early onset in a large ma-
jority of eases analyzed by Gowers, Hesse, and Osier :

Age at onset.

Proportion affected.
Obse r V e rs .

Before 10 422

From 11 to 20
" 21 " 30
" 31 " 40
" 41 " 50
" 51 " 60
" 61 '• 70


Age at onset (Osier;.


. . 74

. . 62

. . 51

. . 24

. . 17

. . 18

. . 19

. . 23

. 224
. 87
. 31
. 16
. 1



393 .

364 .


59 .

51 .

13 .

4 .



Age at onset (Osier).


Per cent.
. 33.3
. 42.
. 13.7
. 6.
. 3.4
. 1.2
. 0.3

. . 17
. . 27
. . 17
. . 18
. 15
. . 21
. .34



(h) Sex. — In Gowers' cases 54.6 per cent, were males, 45.4 per cent,
females. Under twenty-five years of age males are slightly in the major-
ity ; above twenty-five, the reverse is true.

(e) Heredity. — Family neuroses are common, but it is decidedly more
the exception than the rule to find either parent epileptic. Fer^ has given
us the lineage of 594 epileptics : 70 had epilepsy, 166 were insane, 88
paralyzed, 21 suffered from general paralysis, 72 from hysteria, 73 from
senile dementia, 33 from puerperal eclampsia, 61 from chorea. Among
the direct antecedents of these 594 epileptics, 1024 cases of nervous dis-
order had occurred.

{d) Alcohol. — The causal relationship between an abuse of alcohol by
the parents and epilepsy seems rather pronounced. F^re says that of
594 epileptics examined by him, 258 had parents who were hard drinkers.
Echeverria refers to 572, 257 of Avhich he believed could be traced directly
to the abuse of alcohol.

((') Syphilis does not predispose. When it gives rise to changes in
the brain and cord, which in turn cause epilepsy, it is in reality a deter-
mining cause.

(/) Eye-strain is no longer regarded seriously as a predisposing influ-

The exciting or determining causes are traumatisms, various morbid
conditions of the membranes of the brain or of the brain proper (e. g.
after hemiplegia), of the spinal cord or membranes, or peripheral irrita-
tion (dentition, worms, a cicatrix, an adherent prepuce, etc.). Not a few
cases are dependent upon toxic substances in the blood, as in uremia and
lead-poisoning. Excessive indulgence in alcohol or over-eating often


precipitates the attack. Great emotion, nervous shock (fright), and
masturbation are also said to be able to bring it about, though these
are rather doubtful causes. There are cases of bradycardia in which
epileptiform attacks occur (Stokes-Adams disease).

Symptoms. — Petit Mai. — In this condition the majority of cases
belong to the following type : The attack begins suddenly : perhaps while
talking to the patient his expression suddenly becomes blank, the face
pales, the pupils dilate, and he is evidently not conscious. In a moment
or two he gathers his scattered senses and picks up the thread of the
conversation. Very often he is not cognizant of any lapse of time or
has but a vague idea that something has occurred. If carefully observed,
fine clonic movements may be detected in many cases, it may be of the
facial muscles or of the hands. Convulsions never occur, the dominant
feature being the unconsciousness. On regaining consciousness the pati-
ent may act strangely and appear dazed ; it is seldom, however, that he
falls in attacks of this kind. Occasionally a peculiar dreamy state takes
the place of an ordinary attack, or the individual may be the victim of
imperative ideas. Falret has described a condition [epilepsie larve)
known as masked epilepsy, in which maniacal outbursts or explosions
of passion occur.

Grand Mai or Haut Mai. — In many cases some subjective symptom
precedes the actual attack. In its most specialized form it is termed an
aura, and includes any phenomenon, motor and sensory, that ushers in an
attack. While the aura differs in different cases, it is almost invariably
constant in the same case, so that one will have a subjective sensation of
sound, another of light, either iiashes or colors, etc. There are other
signs that occasionally antedate an attack, and which may or may not
precede each attack (headache, drowsiness, change of disposition, palpita-
tion, perverted appetite, sexual or other, etc.). Many attacks begin pre-
cipitately with absolutely no previous warning. In such cases the patient
may or may not utter a piercing sound {epileptic cry), falling at the same
time, no matter where or in what position he may be. Hence the danger
to which epileptics are always subjected. A peculiar onset occurs in the
so-called '"• j)roeursive epilepsy," in which the patient suddenly starts off
and runs some distance before the paroxysm begins.

Paroxysmal Period. — In many cases, whether preceded by an aura or
not, this stage is ushered in by a spasm that is tonic in character. The
patient falls, perhaps because of the loss of consciousness, though in those
<;ases in which he drops precipitately he is probably thrown by the vio-
lence of the spasm. The head is usually extended, the muscles of the
larynx and trunk contracted, and hence the epileptic cry and the dysp-
nea, while the lower limbs are generally extended, the upper semiflexed,
and the fingers tightly clenched. This period of rigidity lasts but a few-
seconds before clonic convulsions appear.

Intercurrent contractions vary in different cases from very mild move-
ments to those so severe as to toss the individual about. The face, pale
at first, becomes congested, and the jaw works in churning the saliva into
a froth ; this is blood-tinged when the tongue is bitten. The respiration
is jerky, gasping, and there may be a loss of control of the bladder and
bowels. In idiopathic cases this stage lasts from one to five or six min-


utes. The spasms gradually diminish, and without regaining conscious-
ness the patient passes into a deep sleep, immediately preceded in some
cases, however, by coma in which the breathing is stertorous. During
the sleep, which lasts about an hour, the patient is completely relaxed.
On waking he usually appears confused and complains of feeling tired.
His limbs may ache for several days.

Occasionally attacks follow one another in quick succession, with no
period of consciousness intervening (status epilepticus) — a very dangerous

Post-epileptic phenomena are variable. The patient may become
maniacal, homicidal, or may simply be mentally deficient for a few days,
with perhaps some slight speech-disturbance. In the course of time every
epileptic's brain-power deteriorates. Paralysis sometimes occurs, is usually
transient, and may be unilateral or bilateral.

Nocturnal Epilepsy. — In this condition the attacks occur at night, and
may be entirely unknown either to the patient or his friends. He com-
plains from time to time of feeling tired on rising in the morning, his
limbs and head ache, and he is generally duller than usual ; he may even
be confused. Such a history is suggestive, and the suspicion is strength-
ened if in addition he has urinated involuntarily or if blood-spots are
found on his pillow.

Jacksonian epilepsy is characterized by spasm that is generally local
in character ; in fact, it is always so in the beginning, though occasionally
it may spread and become general. Consciousness is preserved in the
milder forms. Tingling or other subjective sensations may precede an
attack. They are usually due to some irritation of the motor cortex
(tumors, meningitis, softening, trauma, etc.). Subcortical lesions and
certain toxemic conditions can also give rise to it.

Myoclonus epilepsy is characterized by epileptic seizures of the ordi-
nary type, while in the interval between the attacks the patient sufters
from clonic spasms of various muscles. The spasms vary in intensity
from fibrillary tremors (myokymia) to violent spasms of the large mus-
cles (myoclonus, p. 1204). It may be a family disease.^

Diagnosis. — When a definite history is obtainable the difiiculty of
the diagnosis is less, particularly if an aura occurs. The attack can be
frequently diagnosed from other epileptoid conditions at the time by the
explosive onset, the brief tonic and somewhat longer clonic spasm, pro-
found unconsciousness followed by a deep sleep, and when these are pres-
ent by an involuntary passage of urine, frothing at the mouth, and
biting of the tongue.

Differential Diagnosis. — In uremia the state of the urine (catheterize
if necessary), and often the odor, serve to difi'ereutiate it. It mav be
impossible to detect fraud, so perfectly is the disease simulated by those
anxious to excite pity, judicial or otherwise, or by those whose accom-
plices rifle the pockets of sympathetic bystanders. Hysteria may also
resemble it very closely, (jowers has tabulated the chief difterences as
follows :

'Clark, Re.v. Neurol, ami I'sychit., .July, 1007, p. 532.


Epilepsy. Hysteroid.

Apparent cause . . . None. Emotion.

Warning Any, but especially unilateral Palpitation, malaise, choking.

or epigastric aura. bilateral foot-aura.

Onset Always sudden. Often gradual.

Scream At onset. During course.

Convulsion Rigidity followed by "jerk- Rigidity or " struggling,"

ing ; " rarely rigidity alone. throwing about of limbs oi

head, arching of back.

Pupils Dilated and immobile. Mobile and active.

Biting Tongue. Lips, hands, or other people

or things. Very rare.

Micturition Frequent. Never.

Defecation Occasional. Never.

Talking Never. Frequent.

Duration A few minutes. More than ten minutes, often

much longer.
Bestraint necessary . . To prevent accident. To control violence.

Termination Spontaneous. Spontaneous or induced

(water, etc.).

Prognosis. — Idiopathic epilepsy very rarely is cured. In most
cases it will be found that an apparent recovery is merely a prolonged
intermission. Cases that are evidently symptomatic are sometimes
curable if the cause can be removed. Death is seldom due directly to
an attack. Fatal accidents may, however, be caused by an attack.

Treatment. — When an aura occurs, advantage may indirectly be
taken of it to aid in aborting the attack. The only efficient remedy is
nitrite of amyl inhaled as in angina pectoris. In Jacksonian epilepsy,
constriction of the limb in which the aura occurs may sometimes be suffi-
cient. Salt, a popular remedy, is useless. Every effort should be made
to lessen the liability of danger to the patient — first from falling, and
secondly, from the violence of the spasms. One may at times be justified
in using ether or chloroform by inhalation to control the severity of the
convulsions. After loosening the clothing, and putting a cork or some-
thing between the teeth to prevent biting the tongue, nothing more can
be done at the time. Between the attacks special care should be taken
to put the system in good condition, and all sources of worry and irrita-
tion should be removed so far as possible. Particular attention should
be given to the stomach and bowels and the removal of all sources of
reflex irritations, as eye-strain, adenoids, intranasal obstructions, bad
teeth, adherent prepuce, etc. The food should be light and easily
digestible, and systematic gastric lavage is often advantageous.

As to medicinal measures, the bromids are of the greatest value. The
sodium and potassium salts are most commonly employed, the former,
as a rule, being better borne by the stomach. They may be given
in milk or in one of the medicated Avaters. Strontium bromid has oeen
used rather extensively of late, and has yielded excellent results. While
idiosyncrasies are met with, it may generally be given in from 15- to 30-
gr. doses (0.972-1.944) three or four times a day, and preferably after
meals. Each case must be treated according to its special indications.
Symptoms of bromism (acne, sore throat, drowsiness, and gastric disturb-
ance) should be carefully guarded against. Should they develop, the
dose of bromid must be reduced, and Fowler's solution administered for


a few (lays. II. C, Wood recommends that the hitter .should be given
continuously with the bromids, thereby preventing or, at all events, lessen-
ing the liability to bromism. Other remedies sometimes employed are
nitroglycerin (hypodermically), cannabis indica, silver nitrate, zinc, bora.x.
solanum or horse nettle, chloral, antipyrin, trional, and tetronal. Sur-
gical measures occasionally yield good results, this being particularly true
in focal epilepsy. In idiopathic epilepsy removal of the motor cortex
has been tried in those cases in which an aura sugcrested a local oriorin —
e. g., in a center for a particular group of muscles. The results have been
discouraging : in all cases the attacks recurring with increased severity
after an interval of remission. It is a curious fact that almost any sur-
gical operation will diminish or check the epileptic attacks for a time,
and I have known as simple a procedure as venesection to aftbrd com-
plete relief in a severe case for several months. The results ascribed to
various operations may be explained in large part by this fact.


(Hemicrania ; Sick Headache.)

Definition. — A neurosis characterized by severe attacks of headache,
often paroxysmal and more or less periodic, with disturbances of vision
and with or without nausea and vomiting.

Pathology. — This is profoundly obscure, since no lesion has ever
been discovered. By some it is thought to be a vaso-motor disturbance.
Arterio-sclerosis has been present in many cases, but this is also frequently
met with where no sign of migraine has ever occurred. Very rarely the
disease has been observed in some subjects to replace an attack of epilepsy
or even to alternate with true epileptic attacks.

Htiology. — The condition is frequently hereditary, and in the large
majority of the cases that I have seen it has been transmitted by or
through the mother. Various other neuroses are common in families
subject to this condition. Females are more frequently affected than
males, and migraine seems to be associated with diseases peculiar to
women, especially menstrual disorders. Among the exciting causes may
be mentioned gastric disturbances, dental irritation, naso-pharyngeal dis-
eases (adenoids, etc.). eye-strain, grief, emotion — in short, anything that
tends to lower the physical or mental tone occurring in those hereditarily
predi.sposed. Recently attention has been called to auto-intoxication
(leukomainic poisoning) as a cause of certain cases.

Symptoms. — As a rule, the patient can prognosticate an attack.
In the cases of slow onset he may feel indisposed for some hours before,
being languid, with general discomfort and perhaps nausea. In other
cases various subjective sensations occur, lasting from a few minutes to
several hours. Of these, disturbances of vision are most common, such
as flashes of light, spectra, visions of animals or weird forms, or scotoma,
etc. Auditory sensations are rare, as are those of the other special senses.


Transient palsies and aphasia also may occur. After these phenomena
have existed for some time headache supervenes, when, as a rule, they
cease. The pain, at least in the beginning, is usually unilateral, as the
name suggests, though later it may and often does involve the entire
cranium, spreading from a single point of origin — over one eye for in-
stance. The affected region may be tender to the touch or it may be
the seat of numbness or tingling. Nausea and vomiting commonly occur,
with or without vertigo. A brief period of unconsciousness occurs in
some cases, and spasmodic movements may also be observed occasionally.
This fact is of particular interest, since it serves to support the view that
migraine is in some Avay related to epilepsy, and, as has been stated,
attacks of migraine and epilepsy may alternate. Unlike epilepsy,
migraine does not tend to impair the mental faculties, no matter how
long the patient has been afflicted. During an attack, however, he may
have melancholia or be incapacitated mentally and physically for two or
three days.

Course. — The disease generally begins in early life, and in nearly
half of the cases before the fifteenth year, recurring with a certain degree
of periodicity until old age, when it often passes away. It may cease in
women at the menopause, and in men between the fortieth and fiftieth

The prognosis is good as far as life is concerned. This disease is
incurable, though the condition of the patient may be alleviated.

Treatment. — The management of the disease may be considered
under two heads : (1) treatment of the attack, and (2) the treatment be-
tween the attacks, which necessarily includes prevention. The patient
should be put to bed in a slightly darkened room, and all sources of noise
and confusion should be removed as far as possible. The attack may be
so severe as to justify the use of morphin hypodermically. The coal-tar
derivatives have met with most favor, however, as remedial measures, and
preferably antipyrin and phenacetin, though their occasional depressing
effect should be borne in mind. The following has given excellent results
in my hands :

^. Caffein. citrat., 3ss (2.0) ;


Sodii bicarb., da. z] (4.0);

Pulv. aromat., gr. xij (0.777).

M. et ft. chartse No. xij.
Sig. One every three hours.

Acetanilid may often be substituted for phenacetin with apparent ad-
vantage. In twenty-four hours this may be discontinued, and potassium
bromid should be given in liq. ammon. acetatis in doses of gr. x to xv
(0.648—0.972). Local applications of menthol, or fly-blisters may be
employed, or even superficial points may be made with the actual cautery.
The rapidly interrupted faradic current applied with a dry wire brush
over the painful side of the head may give temporary relief.

Between the attacks the general health should be carefully looked
after. The so-called uric-acid diathesis is common in subjects of migraine.
Haig staunchly advocates the use of salicylates in such cases in addition
to the dietetic measures. Anemia should be treated by iron in some


form, dialyzed or Blaud's pill. The bowels should be kept normal by
means of some saline (Hunyadi, etc.), or by the fluid extract of cascara
sagrada. An examination of the stomach-contents often shows the
existence of anacidity ; when this is corrected there is usually marked
improvement in the migraine. The extract of cannabis indica is em-
ployed by some over a long period of time, just as the bromids are in
epilepsy. It is given in doses of gr. i to ^ (0.0162-0.0324), two or
three times a day. after meals. While exercise and fresh air are admir-
able adjuvants to any form of treatment, it must not be forgotten that
fatigue invites an attack. Proper rest, care and regularity in dieting,
and the avoidance of excitement are the chief points to be'observed.


[Sydenham's Chorea; St. Vitus' s or St. Anthony's Dance.)

Definition. — The type of chorea described by Sydenham is a more
or less acute disease, in certain respects resembling an acute infectious
process, and by some regarded as such. It has a special predilection for
children, and is characterized by involuntary muscular contractions, by
usually slight and rarely-marked mental change, by a great liability to
endocarditis and a tendency to recurrence, particularly during the spring
and fall. It has a close relation to acute articular rheumatism.

Pathology. — No definite lesion can be ascribed to the disease,
though, as is usual in such cases, a great variety of lesions have been
described. Chief among these is the embolic theory, advanced by
Kirkes and subscribed to by Bastian and Hughlings Jackson. Since
emboli are not found in every case, however, they cannot be the sole
cause. The infectious theor}^ has also been mentioned above, and certain
cases unquestionably seem to be due to micro-organismal activity. It
may be assumed that the cause is the same as that of acute articular
rheumatism. Many cases develop suddenly, following fright or some
other nervous shock, though these can scarcely be included in either of
the two classes just mentioned. Acute chorea may also be due to func-
tional instability of the nerve-centers, or it may possibly result from the
irritation of antitoxins.

Ktiology. — (1) Age. — By far the greatest number of cases occur
before the twentieth year ; in fact, the condition is rare after that age,
most cases occurring between the tenth and fifteenth years.

Sex. — Females are most frequently attacked, and probably in two-
thirds of all cases.

Race. — Acute chorea is rarely met with except among the white races.

Infectious diseases do not seem to have any predisposing influence.
The relationship, however, between chorea and rheumatism is difl^icult
to ascertain. The milder form of this latter trouble can be readily over-
looked in voung children, but if we include, as Sturges does, all cases


with a history of "growing pains," the relation is of course greater.
English statistics show a higher percentage with a rheumatic history than
those of any other country, probably because rheumatism is more com-
mon in that country than elsewhere. In the United States unmistakable
rheumatic attacks occur in but a small proportion of choreic patients
either before or during the actual attack of chorea. The latter disease
may be, as I have repeatedly observed, followed by rheumatism later in

Mndocarditis. — As has already been stated, some observers regard
chorea as the result of a cerebral embolus due to fragments of fibrin
being washed from the valves and carried into the circulation to the cere-
bral vessels. Endocarditis occurs in many cases of chorea, but as a com-
plication, not a cause.

Pregnancy. — Chorea occurring during pregnancy is apt to be severe.
It is most prone to develop during the earlier months, and especially in
primiparse. It often assumes the maniacal type.

Heredity. — In about 10 per cent, of the cases a history of chorea can
be obtained in other members of the family. Children of neurotic stock
are more susceptible than those of a normal type, and in such individuals
worry, fright, or mental shock from any cause, also the strain of puberty
or of education, are very liable to induce an attack. I have several
times seen chorea follow attacks of religious fervor in young girls.

The influence of reflex irritation is probably much overrated, whether
intestinal, genital, or from ocular defects.

Symptoms. — The common or ordinary form is frequently met with,
particularly at seasonal changes (H. C. Wood), and especially during the
spring and fall. Primary attacks may occur at any time, but recurrent
outbreaks are most prone to develop in the spring. There is a slight
affection manifested by restlessness, disturbed rest at night, and by irreg-
ular and spasmodic muscular movements^ that are most marked in, or en-
tirely confined to, the upper extremities, the head, or the facial muscles ; or
the condition may be unilateral. They usually cease during sleep. Endo-
carditis may not give rise to characteristic signs. More or less muscular

Online LibraryJames M. (James Meschter) AndersA text-book of the practice of medicine → online text (page 161 of 178)