On epilepsy and epileptiform seizures : their causes, pathology and treatment

Front matter

Med

ON

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Preface To The Second Edition

The subject of epilepsy is one that embraces, perhaps more than any other limited department of medical science, the whole range of pathology and therapeutics. It is with this conviction that I have laboured at the changes which the present edition seemed to demand. I have sought in it to bring to bear not only my own matui^d experience, but also the advances in physiology and pathology with which the last few years have teemed.

The first edition was brought out a little more than three years ago, under circumstances which might palliate certain crudities of composition. As, however, it met with a reception beyond its merits, I indulge in the hope that its successor, worked out with the same love, though with more care, may not prove unacceptable to my medical brethren.

Although I have retained the mould in which the work was originally cast, I have, acting upon the advice of one well qualified to express an opinion, omitted the summary of cases given in the former edition. Instead of it I have interspersed numerous

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PREFACE TO THE SECOND EDITION.

illustrative cases, detailed more at length, through the body of the work. I trust that I have shown sufficient consideration for the reader’s patience in not admitting a larger number than was essential to the argument.

I have also appended a few of the formulae of some of the medicines that I have alluded to in the body of the work, and which may, perhaps, be useful to the younger members of the profession who do me the honour to peruse the following pages.

Throughout it has been my endeavour to be as exact as possible, and to use only such material, either of other authors or of my own, as belonged to the domain of fact. I have to the best of my ability avoided the introduction of hypothetical conclusions and vague statements ; still no one can be *more sensible of the shortcomings of the author than the author himself, but if my professional brethren confer upon the present volume that meed of praise which rewarded my first edition, my ambition will be fulfilled.

17, Manchester Square, March 30, 1861.

E. H. S.

Preface To The First Edition

The strides that have been made during the last fifty years in the science of physiology can scarcely be said to have been equalled by the advances of pathology and therapeutics. This remark applies even more to the relation existing between the physiology and pathology of the nervous system than of any other class of organs or functions.

The labours of Bell, Marshall Hall, Flour e ns, Magendie,- Muller, Brown-Sequard, have illumined a field which before the beginning of the present century was enveloped in darkness ; and though the light thus shed upon medicine has removed much that was obscure, though Alison, Romberg, Todd, and Holland, Bright, Longet, Watson, Lebert, and many others, have helped to reconstruct the foundations of medicine upon the newly-acquired physiological basis, it canuot be denied that much of what is still taught in schools, regaining the treatment of disease, and of nervous maladies in particular, rests only upon empiricism.

But although the physician is compelled to admit that his therapeutic resources have not yet acquired the same firm scientific basis that he finds in some departments of medicine, he knows that all the laws regarding

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PREFACE TO THE FIRST EDITION.

the preservation of health, the prevention of disease, the prolongation of life by these means, have been reduced almost to absolute certainty. Whether we take into consideration the diseases of one organ or system of organs, or another — whether we regard the diseases of childhood, manhood, or old age ; in all cases the paramount importance of carrying into practice the rules of prevention embodied in sanitary science, holds good. Here lies our strength, here our logical consistency. No caviller or scorner can oust us from the strong position which here we occupy ; for statistics, reason, and empiricism only serve to fortify it, while they mutually support one another.

While we concede a very high rank to sanitary science — a rank which may be said to bear the same relation to ordinary therapeutics that a multitude bears to the individuals composing it, — we may profit by the lessons it teaches us, by labouring for the prevention of'disease wherever we meet with it in the daily execution of professional duties.

The sick man necessarily desires, above all things, to he freed from his present malady ; but while the physician uses every appliance at his command to realize his patient’s wishes, he must take a wider scope, and seek to prevent the return of the disease, or to anticipate ■where the seeds have been or may be sown, hut have not yet, to the eye of the superficial observer, sprung into life.

In this direction, the study of diseases of the nervous system promises more fruit than we can expect

PREFACE TO THE FIRST EDITION.

XI to gather through the intervention of the Materia Medica alone. This, at least, is ray hope and my conviction, seeing how little has been achieved in the treatment of some forms of nervous diseases, although they have been the subject of earnest study from the beginning of medical science.

In epilepsy especially the results have been, if not barren, yet unsatisfactory ; and still the very fearful nature of the disorder, the strange and violent symptoms that characterize and almost seem to remove it from the domain of ordinary diseases, constantly attract new inquirers, each anxious that he may succeed in lifting the veil that shrouds the mystery. No individual, however, can expect to do this ; but each may, in his sphere, seek to aid in its ultimate removal ; and in this hope I have not shrunk from devoting much labour and time to a subject promising so little immediate reward.

The labour has been a labour of love; nor has it been undertaken without a full sense both of the difficulties in the way of the inquirer, and of the dangers of dogmatism and empiricism besetting his path.

With our present knowledge of hygiene, public and private, and with our acquaintance with the physiology of the nervous system, we are justified in expecting more decided benefit from a full development of our hygienic resources in combating epilepsy than by reiterated experiments with drugs alone. Although I have a high opinion of the value of medicines in the

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strict sense of the word, I place even a greater reliance upon the influence of hygienic and regiminal agents in combating chronic disease ; and believe that no medical man avails himself sufficiently of the powers at his command who does not constantly combine both modes of warfare. Upon these principles my own practice is based, which, in theory at least, it is my constant endeavour to render as rational as possible.

Although I have repeatedly published papers in the journals on Epilepsy and allied subjects, the present work stands by itself. It is in no way a republication of what has already appeared ; although, as a matter of course, I have used the same cases as the basis of the results to which I shall direct the reader’s attention. These observations have been tabulated, and are given in an abridged form at the conclusion of the book. With the exception of cases of too recent a date, I have put together all of which I have preserved notes, and which have been uuder my own care.

Of the results of my inquiries I will here say nothing, except to express my vivid sense of the fact that my achievements fall far short of the goal to be attained. I may, however, add a hope that, although my readers may differ from some of the views which I entertain, they may feel willing to admit that, in my pursuit after light, I am not found to be running after a will-o’-the-wisp.

Edward H. Sieveking.

17, Manchester Square, London,

September 9, 1857.

Contents

CHATTER I.

Introductory remarks — General description of epilepsy — The phenomena of the paroxysm — The character of the convulsions and of the spasm — The description of Lucretius — The condition of the eye — The state of lungs and heart — Insensibility — The definitions given by classical writers — Author’s remarks thereon pp. 1 — 13

Chapter II

Importance of an early recognition of epilepsy — Analysis of the individual symptoms — The premonitions — The aura, either subjective or objective — Its frequency — The premonitory fear — Curious features in the aura — Frequency of the aura in the author’s experience — Its varieties — The unconsciousness of epilepsy — The convulsions, clonic or tonic, occasionally absent — Exceptional phenomena — Marshall Hall’s views

Chapter III

Analysis f individual symptoms continued — Biting the tongue — The pulse in the paroxysm — Frequency of the fits — Periodicity — Lunar influences — Mead’s case — Nocturnal and diurnal influences — Boyd’s observations — Seasonal influences — Moreau’s observations — Headache — Cases of epileptic headache — Delirium and hallucinations pp. 38 — 60

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CONTENTS.

Chapter IV

The phenomena observed daring the free intervals — State of chylopoietic viscera — Pupil — Vertigo — Petit mal — The sequela; of epilepsy — Loss of memory — Patuity — Paralysis — Moreau’s statistics — Impaired circulation — Derangement of intellect — Fatality of epilepsy — Statistics of Registrar-General — Author’s calculations pp. 61 — 81

Chapter V

The cause of epilepsy — The demoniac controversy — Adams’ opinion — Bucknill’s views — Opinions of Churchmen — The frequency of epilepsy in England — In different troops — In the whole population — In France — Boudin’s statistics — Epidemics of epilepsy — Sex — Age — Hereditary influences — State of the organs of excretion and secretion — The kidneys — The digestive organs — Costiveness — The sexual organs — Marriage — Masturbation — Sexual derangement in males and females — Should epileptics marry ? pp. 85 — 142

Chapter VI

The exciting causes of epilepsy, primary and secondary — Psychical, physical influences — Diurnal changes — Smith’s experiments — Syphilis — Sleep — Intemperance — Centric and eccentric epilepsy — Short’s, Darwin’s, and La Motte’s cases.

Chapter VII

The pathological anatomy of epilepsy— The import of the lesions found — Boyd’s investigations — Ferrus’ and Parchappe’s inquiries— Wenzel’s autopsies — Various lesions— Schroeder van der Folk’s observations — Remarks — Esquirol’s inquiries— Further remarks PP- 161 — 188

CONTENTS.

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Chapter VIII

The theory of epilepsy — General remarks — Its proximate cause — ■ Esquirol’s classification— Prichard’s view— General remarks — Sir A. Cooper’s experiments — Schroeder van der Kolk’s theory — Brown-Sequard’s experiments and doctrine — Ivussmaul and Tenner’s views and experiments — Remarks — The influence of habit — Relation of epilepsy to kindred diseases — Metastasis in epilepsy — State of the blood in epilepsy — Handfield Jones’ case and remarks— Acute and chronic epilepsy — Cases in illustration of author’s remarks pp. 1S9 — 232

Chapter IX

The treatment of epilepsy — During the paroxysm — Removal of all restraint. — Avoid over-active treatment — Cool air — Sinapisms and the like — Compression of carotids — Cold applications — Galvanism — Volatile stimulants — Treatment of premonitory symptoms — Illustrative cases by the author — Ligatures — Dry-cupping — Internal remedies— Radical treatment of the disease — Trephining — Moral treatment — Derivation from the head — Various counter-irritants : the actual cautery, blisters, setons, tartrate of antimony ointment — The abstraction of blood — Illustrative cases — Ligature of carotids — Purgatives — Turpentine — Salts of iron — Case — Zinc — Cases — The valerianates — Silver — Prommann’s case — Nitro-niuriatic acid — Digitalis — Iodides — Bromides — Cases — Belladonna — Indigo — Cotyledon umbilicus — Mistletoe pp. 233 — 299

Chapter X

The hygienic treatment of epilepsy — Influence of air — Exercise — Baths : special directions for their employment — Quautity and quality of food — Period for taking it — Rest of body and mind — Balance of the mental powers — Education of children — Their home management — Quack remedies, and their influence on the mind — Moral regimen — The physician a school-inspector — Conclusion pp. 300 — 321

Appendix of Formula; . .

ON EPILEPSY

AND

EPILEPTIFORM SEIZURES.

Chapter I

Introductory remarks — General description of epilepsy — The phenomena of the paroxysm — The character of the convulsions and of the spasm — The description of Lucretius — The condition of the eye — The state of lungs and heart — Insensibility — The definitions given by classical writers — Author’s remarks thereon.

The history of epilepsy, more than of other affections of the nervous system, until the most recent periods has been the history of one of the weakest sides of medical science; it exhibits the inadequacy of our therapeutic measures to cope with a mysterious power in a painful degree. The prominent features of the disease were too palpable not to be early recognised ; while their violence and suddenness struck the mind of the laity with awe, inducing in the beholder a conviction of an influence altogether removed from the ordinary phenomena of disease. The prevalent belief in the demoniac causation of epilepsy was combated by Hippocrates as it has been by recent writers of our own era ; while even to the present day the ancient belief in lunar influences, as connected with the production of epilepsy, holds its ground in, as

B well as out of, the profession. Nor have there been wanting at all times earnest inquirers, who have carefully studied the disease in question ; but if their investigations were barren, or, at least, fraught with less positive results than have rewarded students in other departments of pathology, this is mainly attributable to the fact, that the physiology of the nervous system has been, until the second quarter of the present century, a domain unknown and uncultivated by medical men. Without a definite physiological basis no derangement of function can possibly be understood ; and although we have not yet attained to a solution of all the difficulties connected with the subject before us, there can be little doubt that we are in the right way to its achievement. Before entering into an analysis of the present theory or pathology of the disease, based upon recent advances of physiology, it will be well to examine its phenomena in detail.

The features that characterize epilepsy are symptoms of a powerfully convulsive character, sudden and brief ; which, while they undoubtedly affect the general health of the sufferer, and induce him to attribute his entire morbid condition to them, also attract the attention of his friends and of the medical man generally so largely as to cause less prominent symptoms to be overlooked, which, however, belong as much to the entire portrait of the disease as the pai’oxysm. It is not to be wondered at that the suddenness of the seizure, the violence of the accompanying phenomena, the apparent inability of art to contribute much to their alleviation or arrest, should so often paralyze the hopes of the patient and of his friends. If we turn for an instant to other forms of disease, we shall find analogous instances, in which morbid conditions prevail, which do not attract

PRELIMINARY REMARKS.

much attention or cause serious apprehension until a climax is reached which taxes the entire vigour of the system, or proves beyond the control of nature or of art. Thus, during the prevalence of cholera the noxious influence of the poison is manifested very generally throughout the population by the almost universal occurrence of diarrhoea, which is amenable to simple hygienic and medicinal treatment, and is undoubtedly due to the same poison which induces the more fatal form to which the name of cholera is applied.* It has. been shown that, while the curability of algide cholera by art is altogether a matter of doubt, there is no doubt that we may prevent or anticipate it by arresting the mild form which it puts on in the premonitory diarrhoea. We shall see that something similar occurs in epilepsy; and that our knowledge of the disease will be warped and very imperfect, so long as we have regard only to the fit that embraces all the characteristics to be found in scientific definitions, and overlook those minor symptoms which occur during the free intervals, but do not amount to the sad dignity of a paroxysm; It will, however, be convenient to commence the observations I have to make upon the disease by a delineation of a well-marked paroxysm or seizure itself. Having done this, I shall enter upon the bearing and value of the individual elements or symptoms of the paroxysm, and then examiue the state of the patient during what is termed the free interval.

A brief and peculiar sensation, which has received

* See Beport of the Committee for Scientific Inquiries in relation to the Cholera Epidemic of 1854, p. 10. Untersuchungen und Beobachtungen iiber die Verbreitungs-art der Cholera, &c. Von Dr. Max Pettenkofer. Miinchen, 1855.

B 2 the technical denomination of an aura, and which varies much in character, announces in many cases to the person on the point of being attacked that something peculiar is about to happen. The patient is suddenly deprived of consciousness and sensibility, a deadly pallor overspreads the face, and, often uttering a scream of a shrill, unearthly character, he falls as if hit by a gunshot, striking against anything that may intercept him, and injuring himself more or less, according to the nature of the opposing obstacle. There is entire unconsciousness ; hence the patient does not protect himself, and falls into the fire, or into the water, upon sharp angles, or upon the rug, without any regard to personal consequences. It is this that renders extreme watchfulness necessary on the part of the attendants of epileptic subjects, while it suggests a ready means of recognising the malingerer or impostor. One of my patients, a boy of eight years, was nearly drowned by falling into a canal ; another, a man, dislocated his jawbone in a fit ; a third again, a female, broke her collarbone. Such cases might be multiplied, and minor injuries, cuts, bruises, and the like, are innumerable.

The pallor of the countenance yields to a livid flush, deepening with the increasing convulsions that supervene ; the neck often swells, the surface veins of the head and neck in these cases becoming distended, as if about to burst ; the tongue is thrust out between the teeth ; respiration is laboured, and often suffocative ; and bloody froth issues from the mouth.

This order of the phenomena, however, may vary or be modified in every possible form. I have in the same individual seen intense lividity and jactitation in one attack, who in another showed nothing approaching to venous congestion, where, in fact, one would have description of the epileptic paroxysm. 5 rather been disposed, from the throbbing of the arteries and the high complexion, to assume active determination of blood.

The limbs and features are convulsed and distorted, and it seems as though the restraining power of the muscular system had been destroyed or taken captive, and were running riot under some hidden but uncontrollable influence.

There is something necessarily suggestive of the influence of demoniac agency in these spasmodic throes ; and without entering into a theological discussion on the terminology employed by the ancients or in sacred writ, it may be admitted that the epileptic paroxysm is peculiarly of a character to convey the impression that it is altogether beyond the ordinary range of physiological disturbances.

The convulsions that ensue are more or less violent, and generally show a predominance on one side of the body. The extremities are thrown about in sudden jerks, much like the movements of an animal recently dead whom we submit to the shocks of a galvanic battery. It has appeared to me that the left side is the one most frequently affected. The spasmodic action is shown most in the flexors, in some of which it amounts to a permanent tonic contraction ; the thumbs are drawn across the palm of the hand, and the fingers are at times clenched so firmly, that when relaxation takes place the nails are found to have left deep marks. Similarly the toes are forcibly flexed. The closed fingers are popularly regarded as so essential an element in the disease, that it is commonly considered necessary to force the thumbs and fingers open ; a proceeding which is utterly useless, and can lead to no beneficial result.

The spasm is shown very uniformly in the muscles that close the jaw. The spasm of the muscles of the jaw is, like the spasm of other parts, clonic or tonic. In the former case the result is that the patient grinds his teeth ; and this is often done with such force as to break them. In the latter, the mouth is so firmly closed, that it may be impossible to open it or to introduce anything. This spasm is sometimes sufficiently violent to cause dislocation of the jaw. Dr. Cooke* quotes a case from Van Swieten-in which this occurred. In consequence of the spasm, the inside of the cheeks and the tongue are very frequently lacerated and bitten by the patient. Hence bleeding at the mouth is a common symptom of the epileptic paroxysm, and one that may be relied upon as a pathognomonic sign, since persons who feign the disease will not be aware of its importance as a symptom, nor have the courage to produce a lesion sufficient for the purpose. If, as is frequently the case, the tongue is thrust out of the mouth during an interval of relaxation of the masseter and pterygoid muscles, and the jaw then spasmodically closed upon it, the protruded part becomes livid from congestion, and the appearance of the patient is rendered more than ordinarily frightful. The tongue, or rather a portion of the organ, has actually been bitten off during the paroxysm ; but this is a very rare occurrence, since the spasm is generally relaxed before the teeth are able to sever the protruded part.

Owing to the saliva accumulating in the mouth, and the breath being entangled in it, the patient in expiration "forces out froth from between his lips, and the froth is

* Treatise on Nervous Diseases, vol. ii.

CHARACTER OF THE SPASMS. 7

frequently bloody if any abrasion or lesion has occurred within the mouth.

Ut fulminis ictu

The spasmodic action is also shown iu the voluntary muscles of the eyes, which are frequently turned up so as to leave little more than the sclerotic visible, the pupil and iris being concealed under the upper lid. This is not, however, a uniform or persistent symptom, as the eye may be closed, or the upturning only be brief. The pupil is commonly contracted, but by no means, as would appear from the statements of authors, invariably so. I have seen them very much dilated. I have observed them vary at different periods of the same paroxysm. Thus I have found them dilated at the early part of the attack, and subsequently become contracted ; but at both times from internal causes, the influence or withdrawal of light not alteriug the condition. They are, however, always insusceptible during the profound paroxysm to the stimulus of light, and this fact may be used as a means of diagnosis in cases

* T. Lueretii Cari, De Rerum Natura, libri sex. Lib. iii. v. 486. Lucretius in these lines and those subsequently quoted clearly describes an attack of epilepsy ; he uses it as an illustration of his argument regarding the immortality, or rather the mortality of the mind ( animus ) ; he is of opinion that because the immaterial principle is affected by disease, and is liable to be cured by remedies that cure the body, like the latter it is destructible s—

of feigned epilepsy. It is manifest that the iris partakes in the spasmodic action affecting the muscles generally, and this may he either tonic or clonic. The congestion that takes place to the head is particularly shown in the eye becoming suffused and bloodshot, at times leaving considerable ecchymoses in the conjunctiva.

Small extravasations have been seen under the skin of the head and face from the same cause. Internal congestion is also found to affect the brain and meninges, as is demonstrated in those cases where epilepsy proves fatal in the paroxysm itself.

The breathing is short and hurried, as in a person violently agitated ; the disturbance of the respiration appears to be proportionate to the violence of the paroxysm. The same applies to the action of the heart; but no derangement of either function is observed to be connected with the epileptic paroxysm which can be regarded as in any way pathognomonic.

In severe and prolonged seizures, either from exhaustion or from being poisoned by the highly carbonized blood, the heart appears to become so oppressed as almost to cease contracting. In one case of deep interest to myself, a fatal issue seemed actually to have taken place, from the pulse getting gradually feebler and appearing altogether to stop ; the patient, however, rallied and survived for some years.

The abdominal viscera do not suffer in any characteristic way. In violent seizures, the contents of the stomach are at times expelled by vomiting ; occasionally involuntary defecation and micturition occur during or towards the close of the fit, and erections and seminal discharges have also been observed to take place. None of these symptoms are sufficiently uniform to lay claim to the dignity of a pathognomonic sign. They are, however,

DESCRIPTION OF LUCRETIUS. 9

of importance when they occur, as indicating the extent to which the system is under the control of the disease.

During the continuance of the symptoms of which I have hitherto spoken, the insensibility of the patient continues complete ; we are unable to rouse him by any of the means that would suffice to awake even a profound sleeper; the mental functions are incomplete abeyance, and even the reflex actions are arrested. After the lapse of from ten to twenty minutes the convulsive movements subside, profuse perspiration commonly ensues, consciousness returns, and the patient is restored to comparative health. A temporary swelling of the face is sometimes observed after the fits ; after repeated attacks, a bloated condition often remains, which gives the confirmed epileptic a peculiar recognisable expression.

The fit is very commonly followed by considerable drowsiness; the patient sinks into a deep sleep, sometimes almost comatose, but ordinarily presenting no morbid features ; it appears to be .granted by nature for the purpose of restoring the enfeebled and exhausted powers. At times a condition identical with that of delirium tremens persists for a day or two after the paroxysm. Headache, for a longer or shorter period, very commonly remains after the epileptic seizure. In mild cases, however, the patient recovers his ordinary state of health immediately, and feels as if nothing had happened.

* Lucretius, ibid.

Such is the ordinary course of an epileptic paroxysm ; but though it is common to meet with the symptoms just detailed, they all, more or less, differ in frequency and uniformity.

The definition which Sauvages* gave of epilepsy was this : “ Est morbus clonicus universalis chronicus et periodicus, cum sensuum feriatione in paroxysmo et ante-actorum oblivione.” The description which we find in Galen runs thus: “Verum et epilepsiaf con-

t Though “ epilepsia ” is here used by the learned translator of Galen, the more common appellation of epilepsy, employed by Latin authors, was morbus comitialis, which was derived from the fact that, if a person was seized with a fit during the comitia, the meeting was dissolved on account of the unfavourable omen supposed to be involved in the occurrence. Facciolati under Comitialis Morbus says, “ Katio appellationis est quia si quis forte ipso comitiorum tempore illo (sc. morbo) corriperetur, comitia dissolvi ac in alium diem differri necesse erat; ut ex Festo in Prohibere et ex Seren. Samm. discimus.” It appears that Pliny, who speaks frequently of epilepsy, uses comitialis as a substantive for an epileptic (e.g., Nat. Hist. lib. xx. cap. 5). In discussing the use of Staphylinos or Pastinaca erratica, he observes : “ Philistio [doubtless an apothecary of the day], in lacte coquit at ad stranguriam dat radicis uncias quatuor ; ex aqua hydropicis, similiter et opisthotonicis et pleuriticis et comitialibus.”

I may take this opportunity of adverting to the large knowledge which Galen had already acquired of the disease, and to the fact that much of what we now teach respecting it was taught, as well as many of the errors which we still combat were recognised and combated by this great physician. Any one who desires only a superficial view of his teachings regarding epilepsy, will find instruction in perusing the admirable index to Kuhn’s edition of his collected works published at Leipsic in 1833. Tom. xx.

DEFINITIONS OF EPILEPSY.

vulsio est omnium corporis partium, non continua ut emprosthotonos, opisthotonos, et tetanos sed quee ex temporum accidit intervallis, neque solum hac re sed mentis quoque ac sensuum oblsesione, a jam dictis convulsiouibus differt ; unde constat,” he continues, “ in superioribus corporis partibus, cerebro videlicet, hujus affectus ortum esse.” Except that the second definition is rather more lengthy, the sense is essentially the same as that conveyed by the first.

And if we compare the description of more recent authors of epilepsy with the above two, we shall find but little altered. The prominent features of the paroxysms are, in fact, so marked, that there could be little difference in the accounts given of them. This opinion has been so fully realized by some, that, for instance, Dr. Lysons,* a physician who wrote upon epilepsy in the last century, prefaces his observations and cases with the remark that “ the epilepsy is too well known to need description.”