A Talk By Registrar,
National
Epilepsy
on
N. S. ALCOCK,
M.R.C.P.,
Hospital for Epilepsy
and Nervous Diseases
Most of my readers have probably seen a number of fits, but there are so many points about an actual fit which I want to emphasise that a description of one seems to be the only logical way of beginning this article. In the
by
normally functioning brain,
another cell in
some
other part.
cells
only
react when
A fit is caused
by
they
are
stimulated
cell somewhere in the
a
brain
beginning to discharge spontaneously. As an illustration one may liken a smoothly running factory. In this factory one individual suddenly becomes an agitator and starts a revolution, infecting first his immediate neighbours and finally the whole factory. the brain to
From this original focus in the brain a wave of excitation spreads to the of the brain cells, travelling faster and faster as it moves further away from the starting point. The wave may either die away?in which case it only produces a minor fit?or it may involve the whole brain, and in that case it produces rest
a
generalised
manifestation which *
began
or major fit. The first stage produced by the stimulation of
the fit.
of the fit a
small
is, therefore, the local round the original cell
area
This first stage of the fit is known
This articlc is based on a lecture delivered to the Welfare, Ath October, 1937,
Staffordshire
as
the
aura.
Association
for
As
a
Mental
8
MENTAL
anywhere in potential aurae,
fit may start number of
result of excitation of Present of "
"
silent
area
have
we
(1) (2) (3) (4)
a
the brain, we have therefore a correspondingly large each of which represents in one of its purer forms the small area of the brain.
of the brain itself is still limited; we know the function The rest we call the because if a silent areas
knowledge
about
only
a
WELFARE
is stimulated there is
knowledge
"
"
third of it.
the best defined
no
apparent result.
Of the
areas
of which
are
the motor area which produces movements of the body, the sensory area, lying in the parietal region, the visual area, in the occipital pole, and the area for speech which lies at the lower end of the motor and sensory for the two sides of speech?the expressive and the receptive.
areas
A fit may start in any of these areas. If it starts somewhere in the motor we get movement in some part of the body, perhaps the twitching of a
area,
thumb, and then the disturbance spreads to neighbouring areas of the of the brain and we get twitching of the side of: the face and the hand.
motor
area
rest of the
spreading faster and faster goes on to include body and then the other side of the body, becomes generalised.
Then the disturbance
first the whole of that side of the so
that the convulsion
interesting perhaps are the aurae that start on the receptive or sensory by a feeling in one part?described in various ways, a pins and needles ", electricity "; often the patient says an indescribable feeling."
More side. "
sort
These may begin of numbness ",
that it is The or
aura
old
in brown
There
they call
are
as
are
often
"deja
vue
One
describe.
a
flashes of
"
as one case
lady
visual one, either negative, such as a sense of blindness, light, and occasionally even more elaborate things, in which the patient always saw a country scene with a little,
may be
such
positive,
such
"
"
"
"
before his fits.
of taste and smell, and these are interesting in that accompanied by a sense of familiarity, what the French doctors "?something that the patient feels he knows very well but can't also
aurae
patient,
for
ago like an old these aurae with the well from
long
"
recently that it seems to come It is interesting perhaps to compare music hall known power that a smell has of bringing back
instance,
said to
me
associations.
by those who have seen lots of fits that many of them distinguishable first stage. This is undoubtedly true and is
It may be asserted have
no
aura?no
probably explained in two ways. In some there was a sensory aura but there is nothing to be seen by an observer and by the time the patient has come round he has forgotten about it. In other cases the fit began in one of the silent areas of the brain and by the time it has reached an area of known function it is spreading so quickly that only a generalised fit is observable. I have not tried to tell you of every
beginning
of fits
carefully
and
question
type of
your
aura
and if you observe the you will probably
patient carefully
MENTAL
discover many types which I have not mentioned,
epileptic
9
WELFARE as
for
example
the well-known
cry.
A fit may consist only of the aura and then stop or it may go on to a generalised convulsion, composed of five stages :?(1) the aura, (2) the tonic stage when the patient falls, becomes unconscious and all his muscles go into a firm contraction, producing a rigid state in which the arms and legs are outstretched and stiff, and the hands and teeth are clenched. This lasts for some seconds and is followed by (3) the clonic stage, in which the muscles contract and relax alternatively and produce convulsions. These convulsions often involve the tongue and the jaws and it is the alternate projection and retraction of the tongue between the moving jaws that leads to the biting of the tongue. Then the convulsions die away, usually lasting 60 to 90 seconds and are succeeded by (4) the stage of relaxation, in which all the muscles go limp and it is in this stage that relaxation of the sphincters occurs. After this the patient gradually regains consciousness and passes into (5) the post-epileptic stage. In this there is practically always headache and many patients are drowsy, and sleep for a period. Occasionally in this stage there develops a condition known as automatism. In this the patient may perform complicated actions and afterwards have no recollection of them at all. Usually this stage of automatism is only a matter of a minute or two, but even though short it may be a matter of deep concern to the patient, for in this state he may, for example, undress himself or use obscene language in a way quite foreign to his usual nature.
Types
of Fits
There as
are
although
many
some
varying types
cases
run
true
minor fits and then, if untreated, are recognised while only having
of
fits,
and it is
important
to
recognise them,
type all their lives, some begin with may develop major ones later. If these cases minor fits the fits may be stopped more easily. to
one
are those that consist of an aura only, and they may be recognise by themselves; more often they are interspersed with larger attacks which begin with the same aura but instead of dying away, go on to a full fit. Thus the aura can be recognised when it occurs by itself.
The mildest fits
difficult to
have those in which there may be just a momentary blankness, (It is important when dealing with epilepsy to be second and are used correctly, as sure that the terms minute ", moment and vice versa, are in the habit of using second minute for patients many Then
a
we
second's unconsciousness. "
"
"
"
"
"
"
"
"
habit which may make evaluation of their story difficult.) These patients with momentary attacks are often cuffed at home or scolded at school for not attending, a
before the real nature of the condition is
they may escape patient just falls normal?and
so
realised; or if they come only infrequently recognition altogether. The next type is that in which the to the ground for a moment and then gets up again quite
the fits
gradually become
more
marked until
we
have the
typical
10
MENTAL
WELFARE
attack. In a certain number of cases one fit seems to set off a trigger and you get one fit succeeding another before the patient has had time to regain consciousness?what is known as status epilepticus?this in its severer types
major
may last
anything up to 48 hours or literally hundreds of fits.
even
longer
and
during
that time the
patient
may have
Some into
cases
hospital
only
every two
minutes and then has
to
seem
have
"
and I know of
status
one case
who
comes
three years and for 36-48 hours has fits every 3-5 more at all until the next attack.
or
no
This
tendency?that one fit predisposes the brain to have another?is one epilepsy and most cases have what is known as grouped that is, they have two or three fits in the course of a day and are epilepsy then free for a period until they again have another group. This factor is of importance in planning treatment and the earlier it is started and the more regularly the patients take their medicine the more chance there is of stopping their epilepsy. It also means that adequate doses must be quickly worked up to, and only reduced very slowly. "
of the main features of
The Differential In
Diagnosis whether
deciding questions to solve was
the
cause
:
of
or
Epilepsy a patient has epilepsy we have two separate the patient have a fit, and?secondly?if so, what
not
first, did
of the fit?
Dealing with the first; in a typical major attack with generalised convulsions, tongue biting, etc., there is no difficulty excepted occasionally with hysteria, and many of the readers of Mental Welfare will be familiar with the various points of difference.
There
just Epileptic phenomena are
a
few, however, which
are
characterised
by
I
their
think
are
brevity
worth
and
emphasising.
actual fit, as than 2?3 minutes; an
separate from the post epileptic phase, does not last more If in any patient fits a hysteric is seldom content with less than twenty minutes. occur at night, they are almost certainly epileptic, and lastly if there is any doub?:, remember that true epilepsy is much more common than hysterical fits. With minor fits the chief difficulty is in distinguishing them from faints, and this may be quite difficult especially in the early stages. There are, however, some things which will help; a faint usually has some obvious cause, such us
stuffy atmosphere, emotion, convalescence, or starvation (which is perhaps cause of all, and by which I mean being without food for any of over 6?7 hours, a fact which may not have been thought unusual period enough to be mentioned by the patient). In epilepsy there may be an aura of some sort; the fits tend to come on more frequently and more regularly and without precipitating causes, and even in minor attacks the headache and drowsiness afterwards tend to be more marked than with simple faints. A family historv a
the commonest
of
epilepsy
is often useful too.
MENTAL
11
WELFARE
regard to the second question, it is a mistake to regard epilepsy as a Any brain if sufficiently stimulated will produce a fit. Some brains, however require a much slighter stimulus than others. A fit, therefore, may be the reaction of a healthy brain to some disease outside the nervous system altogether : for example some cases of kidney disease have fits; or it may be some disease in the brain itself, the commonest being a tumour growing in or on the brain. With
disease itself.
On the other hand
brains
to produce fits for no obvious cause This is really just idiopathic epilepsy a nice word to cover our ignorance as undoubtedly there is some pathological cause for them, but so far we have not been able to discover the exact thing. Perhaps one should say rather it is the combination of two factors?one the unknown and the other the peculiar liability of that brain to have fits. This liability is often hereditary to a certain degree and so one finds that a proportion of epileptics have a family history of epilepsy. This is shown sometimes by cases of head injury. A severe injury to the head may be followed by epilepsy and often in the cases which develop epilepsy after a head injury it is found that there is a history either of convulsions as a child or of epilepsy in other members of the family, showing that again we have the two factors,?the inherited liability of the brain to have fits and the precipitating cause of the injury which brings
and these
this
are
the
cases
some
which
we
seem
call
"
out.
In the great majority of cases we cannot find the second or precipitating and so we have to treat the other side, that is, the over-excitability of the
cause
brain. T reatment actual fit, all that
to do is to prevent the patient hurting him from biting his tongue. You should particular prevent therefore lay him down on the ground, loose any tight covering and put something between his teeth. There is no object in trying to stop the convulsions and it is better to let the patient move as he will and observe the form the fit is taking.
In
an
himself and in
one
needs
to
If you are interested in epilepsy, remember that the instructive part of a fit is the beginning because, as I have explained, once the disturbance has become
general throughout patient should just
the
brain,
be left
to
fits tend have his
to
fall into the
sleep
same
pattern. After
a
fit the
out.
General Treatment Here
should
just advise a normal routine, perhaps avoiding excitement ordinary patient. It is also a good rule that no epileptic should be allowed to bathe. The question of marriage often comes up, and at the hospital we are in the habit of allowing those who have no family history of epilepsy to have no restrictions, but if there is a family history advising against children. a
little
one
more
than in the
WELFARE
MENTAL
12
Drugs much the most
By two as
useful
most
drugs
belladonna which
are
treatment and what I one
epileptic
of the treatment is by drugs and the luminal and bromide; there are some others such occasionally useful. The most important principle in
important part are
to
chiefly want ought to
emphasise
is the fact that if
a
has
patient
take medicine every day for the rest of his take a very large dose, but I am sure that this
fit then he
life. It may not be necessary to is the right principle. This may seem rather sweeping but the fact that a patient has, without obvious cause, had one fit means that there is a constitutional of the brain and that this will require treatment comes in here that one fit predisposes the brain
instability point also
permanently. to
The
others and the
patient has the more difficult the fits are to control. Many people will compromise with saying that it is sufficient to take medicine for two years after the last fit, but the following case may illustrate the dangers of this. A patient came to the National hospital in 1909 when she was 16 with a history of fits for seven years recently coming once a week, she was put on medicine and the fits stopped in about 2?3 years, and in 1916 when she was more
fits
a
23, she had been
medicine for four years since her last fit, and decided Two years later she was back again with a recurrence and medicine and this time it was seven years before the fits
on
again. again put on stopped again; then in 1922 1936; recently, however, she not to come was
she
again
came
became free and remained
back
again having
attending
till
had another fit?the first
for 15 years. I feel sure that if only she had continued her medicine regularly she would have avoided not only the fit now but also the previous seven years of fits.
This is
doctors at a
a
used to have
fit the first time
lesson and
that it is difficult
principle
hospital
a
saying
to
that the
teach
patients
and
lucky
ones are
those that have
one
of the
miss their medicine, because then they learn their to go on taking medicine for the rest of their lives. There
they
happy popular prejudice that long continued medication like this will lead to some unknown damage, but there is a patient at hospital who first attended in 1879 and several who began during the 1880 decade, and who have taken medicine three times a day ever since without any obvious ill effect. is also
are
a
The idea in treatment then is as
possible,
and the
logical
to start as soon as
possible given
conclusion of this is the rule
and go above.
on as
long
Prognosis I do not want it to be
thought from these remarks on treatment that it is possible completely every case of epilepsy, yet I do think that the outlook is a good deal better than is usually realised, and no case is so bad that there is not a possibility of controlling the fits completely in time. My impressions are that they can be controlled in about 50 per cent of cases, and that if treatment can be started early, the proportion may be higher than this; in the remaining cases treatment can nearly always effect some improvement. to
control
MENTAL
B
WELFARE
from this, the dangers that an epileptic runs are of three sorts, being that of injuring himself in a fit, usually through falling or occasionally through the muscular contractions of the fit itself. Next, those cases are in danger until this is controlled, and which have status epilepticus lastly, on to mental lead continued fits may degeneration. On the whole, however, long patients seem to survive their fits remarkably well, and any of these dangers is of surprisingly rare occurrence, but the economic difficulties met with are numerous, and the chance of leading a normal life is made very difficult.
Apart
the chief
"
"
Epilepsy
and Mental
Deficiency
I feel that you will be
relationship The
of
epilepsy
wondering when deficiency.
]
am
going
to talk
about the
and mental
of the
relationship of epilepsy and mental deficiency can be classes?first, cases in which the epilepsy and mental broadly defect are both due to some underlying cause. Here we have such conditions as : congenital syphilis?which may cause the one, the other, or both?and tuberose it also sclerosis; happen that after some of the childish illnesses, such as may measles or whooping cough, there is an inflammation of the brain which may lead both to fits and mental deterioration. The importance of these cases is that they should be recognised, as they may require treatment apart from that merely for the control of their epilepsy. subject
divided into three
The second class is that in which this
seems
to
in
itself may lead to mental defects; which have numerous minor attacks,
epilepsy
happen particularly epilepsy
cases
whether because this form of
is more difficult to treat, or whether from other cause, is not known. It is partly because of these cases that it is important to start the treatment of epilepsy early and to carry it out thoroughly,
some so
it is not
possible to predict which cases are going to go this way; and once they begun to deteriorate, treatment is more difficult; it is, however, even then by no means hopeless, but if the fits can be stopped some of these patients make a most astonishing return to the normal state.
as
have
Lastly we have the cases?perhaps this is the largest group of all?of patients start by being mentally defective and then later develop epilepsy. Here again the epilepsy is an adverse factor, from two points of view?first because it may lead to further mental deterioration, and secondly because it may lead in the case of children to exclusion from the Special Schools; treatment in these patients also, therefore, comes to be of importance.
who
There is another factor in London. A
only too commonly associated normal, epileptic child stands a considerable
with
epilepsy, at least being excluded
risk of
from School. 1 do not know what the attitude of the school authorities here is, but in London 1 am fairly frequently meeting cases of this sort, and the result only too often is that
by
the time the fits
are
controlled the child is
over
school age
MENTAL
14 and has had does
not
no
help
WELFARE
education; thus the fact that he has ceased
him very much in his
subsequent
to suffer from
epilepsy
career.
just part of the popular prejudice against epilepsy, which is quit:proportion to the gravity of the disease, and the enquiry initiated by the Central Association for Mental Welfare into the conditions of life of epileptics, is to be cordially welcomed for there are many ways in which their lot could be improved. Perhaps the two ways in which help is most needed are with regard to schooling and occupation. One sees so many cases that are only having and healthy, and who yet find it an occasional fit and are otherwise well quite impossible to keep a job. There are, of course, a certain number of occupations that are unsuitable, but the suitable ones are much more numerous than most people will realise. I know of several patients who are working quite successfully as shop assistants, clerks, or in domestic work, with the rare employer who is reasonable. Usually, however, the trouble is that if they say they are epileptic they will not get the job, and if they conceal it, the first time they have a fit they are dismissed. From the hospital point of view there is also an additional complication, for employed patients are often not able to get the This is
out
of
time off If
to
one
fetch their medicine.
public to realise that epilepsy is not really such a majority of people with it are perfectly normal in epileptics could be greatly improved and the need
could educate the
dread disease, and that the between the fits, the lot of for social work
on
their behalf is
a
considerable
one.
National
Epilepsy
on
N. S. ALCOCK,
M.R.C.P.,
Hospital for Epilepsy
and Nervous Diseases
Most of my readers have probably seen a number of fits, but there are so many points about an actual fit which I want to emphasise that a description of one seems to be the only logical way of beginning this article. In the
by
normally functioning brain,
another cell in
some
other part.
cells
only
react when
A fit is caused
by
they
are
stimulated
cell somewhere in the
a
brain
beginning to discharge spontaneously. As an illustration one may liken a smoothly running factory. In this factory one individual suddenly becomes an agitator and starts a revolution, infecting first his immediate neighbours and finally the whole factory. the brain to
From this original focus in the brain a wave of excitation spreads to the of the brain cells, travelling faster and faster as it moves further away from the starting point. The wave may either die away?in which case it only produces a minor fit?or it may involve the whole brain, and in that case it produces rest
a
generalised
manifestation which *
began
or major fit. The first stage produced by the stimulation of
the fit.
of the fit a
small
is, therefore, the local round the original cell
area
This first stage of the fit is known
This articlc is based on a lecture delivered to the Welfare, Ath October, 1937,
Staffordshire
as
the
aura.
Association
for
As
a
Mental
8
MENTAL
anywhere in potential aurae,
fit may start number of
result of excitation of Present of "
"
silent
area
have
we
(1) (2) (3) (4)
a
the brain, we have therefore a correspondingly large each of which represents in one of its purer forms the small area of the brain.
of the brain itself is still limited; we know the function The rest we call the because if a silent areas
knowledge
about
only
a
WELFARE
is stimulated there is
knowledge
"
"
third of it.
the best defined
no
apparent result.
Of the
areas
of which
are
the motor area which produces movements of the body, the sensory area, lying in the parietal region, the visual area, in the occipital pole, and the area for speech which lies at the lower end of the motor and sensory for the two sides of speech?the expressive and the receptive.
areas
A fit may start in any of these areas. If it starts somewhere in the motor we get movement in some part of the body, perhaps the twitching of a
area,
thumb, and then the disturbance spreads to neighbouring areas of the of the brain and we get twitching of the side of: the face and the hand.
motor
area
rest of the
spreading faster and faster goes on to include body and then the other side of the body, becomes generalised.
Then the disturbance
first the whole of that side of the so
that the convulsion
interesting perhaps are the aurae that start on the receptive or sensory by a feeling in one part?described in various ways, a pins and needles ", electricity "; often the patient says an indescribable feeling."
More side. "
sort
These may begin of numbness ",
that it is The or
aura
old
in brown
There
they call
are
as
are
often
"deja
vue
One
describe.
a
flashes of
"
as one case
lady
visual one, either negative, such as a sense of blindness, light, and occasionally even more elaborate things, in which the patient always saw a country scene with a little,
may be
such
positive,
such
"
"
"
"
before his fits.
of taste and smell, and these are interesting in that accompanied by a sense of familiarity, what the French doctors "?something that the patient feels he knows very well but can't also
aurae
patient,
for
ago like an old these aurae with the well from
long
"
recently that it seems to come It is interesting perhaps to compare music hall known power that a smell has of bringing back
instance,
said to
me
associations.
by those who have seen lots of fits that many of them distinguishable first stage. This is undoubtedly true and is
It may be asserted have
no
aura?no
probably explained in two ways. In some there was a sensory aura but there is nothing to be seen by an observer and by the time the patient has come round he has forgotten about it. In other cases the fit began in one of the silent areas of the brain and by the time it has reached an area of known function it is spreading so quickly that only a generalised fit is observable. I have not tried to tell you of every
beginning
of fits
carefully
and
question
type of
your
aura
and if you observe the you will probably
patient carefully
MENTAL
discover many types which I have not mentioned,
epileptic
9
WELFARE as
for
example
the well-known
cry.
A fit may consist only of the aura and then stop or it may go on to a generalised convulsion, composed of five stages :?(1) the aura, (2) the tonic stage when the patient falls, becomes unconscious and all his muscles go into a firm contraction, producing a rigid state in which the arms and legs are outstretched and stiff, and the hands and teeth are clenched. This lasts for some seconds and is followed by (3) the clonic stage, in which the muscles contract and relax alternatively and produce convulsions. These convulsions often involve the tongue and the jaws and it is the alternate projection and retraction of the tongue between the moving jaws that leads to the biting of the tongue. Then the convulsions die away, usually lasting 60 to 90 seconds and are succeeded by (4) the stage of relaxation, in which all the muscles go limp and it is in this stage that relaxation of the sphincters occurs. After this the patient gradually regains consciousness and passes into (5) the post-epileptic stage. In this there is practically always headache and many patients are drowsy, and sleep for a period. Occasionally in this stage there develops a condition known as automatism. In this the patient may perform complicated actions and afterwards have no recollection of them at all. Usually this stage of automatism is only a matter of a minute or two, but even though short it may be a matter of deep concern to the patient, for in this state he may, for example, undress himself or use obscene language in a way quite foreign to his usual nature.
Types
of Fits
There as
are
although
many
some
varying types
cases
run
true
minor fits and then, if untreated, are recognised while only having
of
fits,
and it is
important
to
recognise them,
type all their lives, some begin with may develop major ones later. If these cases minor fits the fits may be stopped more easily. to
one
are those that consist of an aura only, and they may be recognise by themselves; more often they are interspersed with larger attacks which begin with the same aura but instead of dying away, go on to a full fit. Thus the aura can be recognised when it occurs by itself.
The mildest fits
difficult to
have those in which there may be just a momentary blankness, (It is important when dealing with epilepsy to be second and are used correctly, as sure that the terms minute ", moment and vice versa, are in the habit of using second minute for patients many Then
a
we
second's unconsciousness. "
"
"
"
"
"
"
"
"
habit which may make evaluation of their story difficult.) These patients with momentary attacks are often cuffed at home or scolded at school for not attending, a
before the real nature of the condition is
they may escape patient just falls normal?and
so
realised; or if they come only infrequently recognition altogether. The next type is that in which the to the ground for a moment and then gets up again quite
the fits
gradually become
more
marked until
we
have the
typical
10
MENTAL
WELFARE
attack. In a certain number of cases one fit seems to set off a trigger and you get one fit succeeding another before the patient has had time to regain consciousness?what is known as status epilepticus?this in its severer types
major
may last
anything up to 48 hours or literally hundreds of fits.
even
longer
and
during
that time the
patient
may have
Some into
cases
hospital
only
every two
minutes and then has
to
seem
have
"
and I know of
status
one case
who
comes
three years and for 36-48 hours has fits every 3-5 more at all until the next attack.
or
no
This
tendency?that one fit predisposes the brain to have another?is one epilepsy and most cases have what is known as grouped that is, they have two or three fits in the course of a day and are epilepsy then free for a period until they again have another group. This factor is of importance in planning treatment and the earlier it is started and the more regularly the patients take their medicine the more chance there is of stopping their epilepsy. It also means that adequate doses must be quickly worked up to, and only reduced very slowly. "
of the main features of
The Differential In
Diagnosis whether
deciding questions to solve was
the
cause
:
of
or
Epilepsy a patient has epilepsy we have two separate the patient have a fit, and?secondly?if so, what
not
first, did
of the fit?
Dealing with the first; in a typical major attack with generalised convulsions, tongue biting, etc., there is no difficulty excepted occasionally with hysteria, and many of the readers of Mental Welfare will be familiar with the various points of difference.
There
just Epileptic phenomena are
a
few, however, which
are
characterised
by
I
their
think
are
brevity
worth
and
emphasising.
actual fit, as than 2?3 minutes; an
separate from the post epileptic phase, does not last more If in any patient fits a hysteric is seldom content with less than twenty minutes. occur at night, they are almost certainly epileptic, and lastly if there is any doub?:, remember that true epilepsy is much more common than hysterical fits. With minor fits the chief difficulty is in distinguishing them from faints, and this may be quite difficult especially in the early stages. There are, however, some things which will help; a faint usually has some obvious cause, such us
stuffy atmosphere, emotion, convalescence, or starvation (which is perhaps cause of all, and by which I mean being without food for any of over 6?7 hours, a fact which may not have been thought unusual period enough to be mentioned by the patient). In epilepsy there may be an aura of some sort; the fits tend to come on more frequently and more regularly and without precipitating causes, and even in minor attacks the headache and drowsiness afterwards tend to be more marked than with simple faints. A family historv a
the commonest
of
epilepsy
is often useful too.
MENTAL
11
WELFARE
regard to the second question, it is a mistake to regard epilepsy as a Any brain if sufficiently stimulated will produce a fit. Some brains, however require a much slighter stimulus than others. A fit, therefore, may be the reaction of a healthy brain to some disease outside the nervous system altogether : for example some cases of kidney disease have fits; or it may be some disease in the brain itself, the commonest being a tumour growing in or on the brain. With
disease itself.
On the other hand
brains
to produce fits for no obvious cause This is really just idiopathic epilepsy a nice word to cover our ignorance as undoubtedly there is some pathological cause for them, but so far we have not been able to discover the exact thing. Perhaps one should say rather it is the combination of two factors?one the unknown and the other the peculiar liability of that brain to have fits. This liability is often hereditary to a certain degree and so one finds that a proportion of epileptics have a family history of epilepsy. This is shown sometimes by cases of head injury. A severe injury to the head may be followed by epilepsy and often in the cases which develop epilepsy after a head injury it is found that there is a history either of convulsions as a child or of epilepsy in other members of the family, showing that again we have the two factors,?the inherited liability of the brain to have fits and the precipitating cause of the injury which brings
and these
this
are
the
cases
some
which
we
seem
call
"
out.
In the great majority of cases we cannot find the second or precipitating and so we have to treat the other side, that is, the over-excitability of the
cause
brain. T reatment actual fit, all that
to do is to prevent the patient hurting him from biting his tongue. You should particular prevent therefore lay him down on the ground, loose any tight covering and put something between his teeth. There is no object in trying to stop the convulsions and it is better to let the patient move as he will and observe the form the fit is taking.
In
an
himself and in
one
needs
to
If you are interested in epilepsy, remember that the instructive part of a fit is the beginning because, as I have explained, once the disturbance has become
general throughout patient should just
the
brain,
be left
to
fits tend have his
to
fall into the
sleep
same
pattern. After
a
fit the
out.
General Treatment Here
should
just advise a normal routine, perhaps avoiding excitement ordinary patient. It is also a good rule that no epileptic should be allowed to bathe. The question of marriage often comes up, and at the hospital we are in the habit of allowing those who have no family history of epilepsy to have no restrictions, but if there is a family history advising against children. a
little
one
more
than in the
WELFARE
MENTAL
12
Drugs much the most
By two as
useful
most
drugs
belladonna which
are
treatment and what I one
epileptic
of the treatment is by drugs and the luminal and bromide; there are some others such occasionally useful. The most important principle in
important part are
to
chiefly want ought to
emphasise
is the fact that if
a
has
patient
take medicine every day for the rest of his take a very large dose, but I am sure that this
fit then he
life. It may not be necessary to is the right principle. This may seem rather sweeping but the fact that a patient has, without obvious cause, had one fit means that there is a constitutional of the brain and that this will require treatment comes in here that one fit predisposes the brain
instability point also
permanently. to
The
others and the
patient has the more difficult the fits are to control. Many people will compromise with saying that it is sufficient to take medicine for two years after the last fit, but the following case may illustrate the dangers of this. A patient came to the National hospital in 1909 when she was 16 with a history of fits for seven years recently coming once a week, she was put on medicine and the fits stopped in about 2?3 years, and in 1916 when she was more
fits
a
23, she had been
medicine for four years since her last fit, and decided Two years later she was back again with a recurrence and medicine and this time it was seven years before the fits
on
again. again put on stopped again; then in 1922 1936; recently, however, she not to come was
she
again
came
became free and remained
back
again having
attending
till
had another fit?the first
for 15 years. I feel sure that if only she had continued her medicine regularly she would have avoided not only the fit now but also the previous seven years of fits.
This is
doctors at a
a
used to have
fit the first time
lesson and
that it is difficult
principle
hospital
a
saying
to
that the
teach
patients
and
lucky
ones are
those that have
one
of the
miss their medicine, because then they learn their to go on taking medicine for the rest of their lives. There
they
happy popular prejudice that long continued medication like this will lead to some unknown damage, but there is a patient at hospital who first attended in 1879 and several who began during the 1880 decade, and who have taken medicine three times a day ever since without any obvious ill effect. is also
are
a
The idea in treatment then is as
possible,
and the
logical
to start as soon as
possible given
conclusion of this is the rule
and go above.
on as
long
Prognosis I do not want it to be
thought from these remarks on treatment that it is possible completely every case of epilepsy, yet I do think that the outlook is a good deal better than is usually realised, and no case is so bad that there is not a possibility of controlling the fits completely in time. My impressions are that they can be controlled in about 50 per cent of cases, and that if treatment can be started early, the proportion may be higher than this; in the remaining cases treatment can nearly always effect some improvement. to
control
MENTAL
B
WELFARE
from this, the dangers that an epileptic runs are of three sorts, being that of injuring himself in a fit, usually through falling or occasionally through the muscular contractions of the fit itself. Next, those cases are in danger until this is controlled, and which have status epilepticus lastly, on to mental lead continued fits may degeneration. On the whole, however, long patients seem to survive their fits remarkably well, and any of these dangers is of surprisingly rare occurrence, but the economic difficulties met with are numerous, and the chance of leading a normal life is made very difficult.
Apart
the chief
"
"
Epilepsy
and Mental
Deficiency
I feel that you will be
relationship The
of
epilepsy
wondering when deficiency.
]
am
going
to talk
about the
and mental
of the
relationship of epilepsy and mental deficiency can be classes?first, cases in which the epilepsy and mental broadly defect are both due to some underlying cause. Here we have such conditions as : congenital syphilis?which may cause the one, the other, or both?and tuberose it also sclerosis; happen that after some of the childish illnesses, such as may measles or whooping cough, there is an inflammation of the brain which may lead both to fits and mental deterioration. The importance of these cases is that they should be recognised, as they may require treatment apart from that merely for the control of their epilepsy. subject
divided into three
The second class is that in which this
seems
to
in
itself may lead to mental defects; which have numerous minor attacks,
epilepsy
happen particularly epilepsy
cases
whether because this form of
is more difficult to treat, or whether from other cause, is not known. It is partly because of these cases that it is important to start the treatment of epilepsy early and to carry it out thoroughly,
some so
it is not
possible to predict which cases are going to go this way; and once they begun to deteriorate, treatment is more difficult; it is, however, even then by no means hopeless, but if the fits can be stopped some of these patients make a most astonishing return to the normal state.
as
have
Lastly we have the cases?perhaps this is the largest group of all?of patients start by being mentally defective and then later develop epilepsy. Here again the epilepsy is an adverse factor, from two points of view?first because it may lead to further mental deterioration, and secondly because it may lead in the case of children to exclusion from the Special Schools; treatment in these patients also, therefore, comes to be of importance.
who
There is another factor in London. A
only too commonly associated normal, epileptic child stands a considerable
with
epilepsy, at least being excluded
risk of
from School. 1 do not know what the attitude of the school authorities here is, but in London 1 am fairly frequently meeting cases of this sort, and the result only too often is that
by
the time the fits
are
controlled the child is
over
school age
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14 and has had does
not
no
help
WELFARE
education; thus the fact that he has ceased
him very much in his
subsequent
to suffer from
epilepsy
career.
just part of the popular prejudice against epilepsy, which is quit:proportion to the gravity of the disease, and the enquiry initiated by the Central Association for Mental Welfare into the conditions of life of epileptics, is to be cordially welcomed for there are many ways in which their lot could be improved. Perhaps the two ways in which help is most needed are with regard to schooling and occupation. One sees so many cases that are only having and healthy, and who yet find it an occasional fit and are otherwise well quite impossible to keep a job. There are, of course, a certain number of occupations that are unsuitable, but the suitable ones are much more numerous than most people will realise. I know of several patients who are working quite successfully as shop assistants, clerks, or in domestic work, with the rare employer who is reasonable. Usually, however, the trouble is that if they say they are epileptic they will not get the job, and if they conceal it, the first time they have a fit they are dismissed. From the hospital point of view there is also an additional complication, for employed patients are often not able to get the This is
out
of
time off If
to
one
fetch their medicine.
public to realise that epilepsy is not really such a majority of people with it are perfectly normal in epileptics could be greatly improved and the need
could educate the
dread disease, and that the between the fits, the lot of for social work
on
their behalf is
a
considerable
one.
