A Statistical Inquiry Into the Nature and Treatment of Epilepsy

by Alexander Hughes Bennett

ETIOLOGY.

This may conveniently be discussed under (1) Predisposing causes, and (2) Exciting causes.

1.—Predisposing Causes.

Sex and Sexual Conditions.—In one hundred unselected cases of epilepsy there were—

Males,	47 per cent.
Females,	53 per cent.

showing that practically the sexes were affected in equal proportions. Of the females there were—

Unmarried,	58.5 per cent.
Married,	41.5 per cent.

The greater number amongst the unmarried females is probably due to the list including children, and also to the fact that epilepsy is not an attraction to a man who purposes matrimony. Of the married females—

The attacks were uninfluenced by marriage in	68.1 per cent.
The attacks were diminished after marriage in	27.2 per cent.
The attacks were increased after marriage in	4.5 per cent.

Thus, in the majority of cases, marriage seems to have no influence on the epileptic attacks of women, although in 27.2 per cent. the fits appear to have been diminished after that ceremony.

Of the married females there were—

Children in	82.3 per cent.
No children in	17.6 per cent.

Age.—In one hundred cases the age at which the first attack of epilepsy took place will be seen from the following tables:—

	Males.	Females.	Total.
From 1 to 10 years	9	14	23
From 10 to 20 years	11	23	34
From 20 to 30 years	14	9	23
From 30 to 40 years	10	6	16
From 40 to 50 years	1	0	1
From 50 to 60 years	2	1	3

It will thus be seen that, in males, the most prevalent period for the first invasion of epilepsy is from the tenth to the thirtieth year; in females, from the first to the twentieth year. In both sexes the disease rarely commences after forty. The following table shows the ages of the patients under observation:—

	Males.	Females.	Total.
From 1 to 10 years	4	1	5
From 0 to 20 years	10	20	30
From 20 to 30 years	17	15	32
From 30 to 40 years	11	9	20
From 40 to 50 years	2	6	8
From 50 to 60 years	3	2	5

This indicates that cases of epilepsy comparatively rarely come under observation after the age of forty. A large series of cases would however be required to determine any definite conclusions as to the mortality and longevity of the patients.

Occupation and Profession.—These do not appear to have any special relation to the production of epilepsy.

Hereditary Tendency.—In each of the cases under observation a very careful inquiry was made into the family history. This was confined to the parents, grand parents, uncles, aunts, brothers, sisters, and children of the patient. The following are the results:—

No family history of epilepsy, insanity, nervous or other hereditary disorders in 59 per cent.

One or more members of family affected with one or more of the above disorders in 41 per cent.

Of these last, in which there was a tainted hereditary history, one or more members of the family suffered from—

Epilepsy in	63.4 per cent.
Insanity in	12.1 per cent.
Phthisis in	12.1 per cent.
Asthma in	2.4 per cent.
Apoplexy in	2.4 per cent.
Hysteria in	2.4 per cent.
Hemiplegia in	2.4 per cent.
Spinal complaint in	2.4 per cent.

Concerning the above table, it is to be remarked that frequently the patient had several relatives suffering from different diseases; for example, one with epilepsy, a second with insanity, and so on. In such a case these have been classified under epilepsy, and, if this did not exist, under insanity, or other afflictions in the above order.

Of those cases in which epilepsy was present in the family of the patient, it existed in the following members:—

Father in	11.5 per cent.
Mother in	7.6 per cent.
Father, mother, and brother in	3.8 per cent.
Mother and child in	3.8 per cent.
Grandmother, mother, and two sisters in	3.8 per cent.
Mother and sister in	3.8 per cent.
Grandfather in	7.6 per cent.
Grandmother in	3.8 per cent.
Brother in	11.5 per cent.
Sister in	11.5 per cent.
Two brothers in	3.8 per cent.
Sister and child in	7.6 per cent.
Brother and uncle in	3.8 per cent.
Two uncles in	3.8 per cent.
Uncle in	3.8 per cent.
Aunt in	3.8 per cent.
Child in	3.8 per cent.

From these figures it will be seen that in no less than 41 per cent. of the total number of cases there was a distinct family history of hereditary disease. Of these no less than 87.5 per cent. were affections of the nervous system, and 12.1 per cent. of phthisis. Of the former 63.4 per cent. had relatives afflicted with epilepsy, and 12.1 per cent. with insanity. Epilepsy, according to these figures is eminently a hereditary disease, and it is possible even to a greater extent than is here represented; for the family history is often very difficult to arrive at, in the class of persons on whom most of these observations were made, who, either from ignorance or from prejudice, display a great want of knowledge concerning the health of their ancestors.

General health prior to the first attack.—As far as could be ascertained this was—

Unimpaired in	90 per cent.
Delicate in	10 per cent.

By the term delicate is understood any chronic derangement of health. The figures serve to indicate that, in the large majority of cases epilepsy has no necessary connection with the impaired general health of the patient.

Special illnesses prior to the first attack.—There were—

No antecedent diseases in	78 per cent.
Antecedent diseases in	32 per cent.

Of these persons who, prior to the first attack of epilepsy, had suffered from illnesses, the details are as follows:—

Convulsions at dentition in	43.7 per cent.
Rheumatic fever in	12.5 per cent.
Chorea in	6.2 per cent.
Mental derangement in	6.2 per cent.
Constant headache in	6.2 per cent.
Suppurating glands in	3.1 per cent.
Brain fever (?) in	3.1 per cent.
Small-pox in	3.1 per cent.
Typhus fever in	3.1 per cent.
Spinal curvature in	3.1 per cent.
Somnambulism in	3.1 per cent.
Scarlatina in	3.1 per cent.

The only special feature of this table is the fact that, of the cases of epilepsy under observation, convulsions at dentition were positively ascertained in 15 per cent. of the total number of cases, and in 43.7 per cent. of those having suffered from former illnesses. Here also the percentage is probably in reality greater, as it is obvious that many of the patients were ignorant as to whether or not these symptoms existed. There is no evidence that any of the other illnesses had any relation to the epilepsy.

Temperance and Intemperance.—On this head nothing definite could be ascertained. The patients either do not tell the truth, or have very elastic notions as to moderation in the use of alcoholic stimuli.

2.—Exciting Causes.

To ascertain the exciting causes of epileptic seizures with exactitude is usually a matter of very great difficulty. It is simple enough when the results directly follow the cause; but this is not commonly the case. If, for example, a man, after a blow on the head (having been previously in good health) becomes suddenly seized with epileptic attacks within a few hours or days of the accident, we may fairly assume that the injury has originated or developed his illness. But should the seizure not supervene for some months or years afterwards, the external wound having in the meantime completely recovered, there remains on this question a considerable element of doubt. In the same way a patient often attributes the attacks to a fright which may have occurred weeks or months before they began; yet great care should be taken in accepting such a statement: on the other hand, it should not be utterly ignored. Again, if a person develops epilepsy after severe and prolonged domestic trouble or affliction, how are we accurately to determine the relation between the two? These difficulties render an exact method of ascertaining the exciting causes almost impossible, and this can only be approximated by a careful consideration of the entire history and circumstances of the case. Taking these into consideration, the following statements have been drawn up, in which only those conditions are recorded, where from a review of the whole case a reasonable relation was found to exist between cause and effect.

In a hundred unselected cases of epilepsy there were—

No apparent exciting cause in	43 per cent.
Possible exciting cause in	57 per cent.

Of the cases where a possible exciting cause was present, the following is an analysis:—

Blow or injury to head in	28.1 per cent.
Uterine disorder in	22.8 per cent.
Domestic trouble in	15.7 per cent.
Disease of the nervous system in	8.7 per cent.
Fright in	5.2 per cent.
Depression in	5.2 per cent.
Pregnancy in	5.2 per cent.
Mental strain in	3.5 per cent.
Sunstroke in	3.5 per cent.
Emotion in	1.7 per cent.

Thus, in no fewer than 16 per cent. of the total number of cases, and 28.1 of those in which a possible exciting cause was present, did epileptic seizures follow injuries to the head. Of the cases recorded under uterine disorders, it must be stated that these conditions were as much the accompaniments as the cause of epilepsy, the relations between the two being as follows:—

Attacks occurring at menstrual periods in	61.5 per cent.
Attacks associated with irregular menstruation in	30.7 per cent.
Attacks associated with uterine disease in	7.6 per cent.

An attempt was made in twenty-two cases to ascertain whether, in women, the age at which the epileptic attacks began had any relation to the period at which the catamenia commenced, with the following results:—

Average age at which attacks began	14.6 years
Average age at which catamenia began	14.6 years

This shows singularly enough exactly the same figures, and serves to point out, that in women, the earliest manifestation of puberty is a decided exciting cause for epileptic attacks. It must however be stated that, in the female epileptics, the attacks commenced before the age of puberty in 16.9 per cent. of their numbers. Of the 8.7 per cent. of cases included under the term "diseases of the nervous system," the epilepsy was associated with hemiplegia in all.