No. of Case.Average number attacks per month before treatment.Average number attacks per month after treatment.Number of attacks during six months of treatment.
160060—
230015—
360—8
430—4
530—8
630—2
7162—
812—8
98—2
108—1
118—3
124—1
1341—
1446—
15100
16100
171—3

Table IV.—Eight Cases of Epilepsy, showing the Results of Treatment by the Bromides during a period of from Three to Four Years.

No. of Case.Average number attacks per month before treatment.Average number attacks per month after treatment.Number of attacks during six months of treatment.
13003—
2601—
3604—
4301—
516—10
612—3
7800
8100

These four tables consist of all the characteristic cases of epilepsy which came under notice, without selection of any kind, all being included, no matter what their form or severity, their age, complication with organic disease, etc. In analyzing this miscellaneous series, the chief fact to be noticed, whether the period of treatment has been limited to six months or extended to four years, is the remarkable effect of treatment upon the number of the epileptic seizures. Of the total 117 cases, in 14, or about 12.1 per cent., the attacks were entirely arrested during the whole period of treatment. In 97, or about 83.3 per cent., the monthly number of seizures was diminished. In 3, or about 2.3 per cent., there was no change either for better or worse; and in 3, or about 2.3 per cent., the attacks were more frequent after treatment.

With regard to the fourteen cases which were free from attacks during treatment, it cannot, of course, be maintained that all of these were cured in the strict sense of the term. It is probable that if any of them discontinued the medicine the seizures would return. Still, the results are such as to encourage a hope that if the bromides are persevered with, and the attacks arrested for a sufficiently long period, a permanent result might be anticipated. Even should no such ultimate object be realized, it is obvious that an agent which can, during its administration, completely cut short the distressing epileptic paroxysms, without injuriously affecting the mental or bodily health, is of immense importance. Take, for example, cases 7 and 8 of Table IV., where, prior to treatment, in the one case eight fits a month, and in the other one, were completely arrested during a period of nearly four years. The experience of physicians agrees in considering that the danger of epilepsy, both to mind and body, is in great part directly proportionate to the severity of its symptoms. If these latter can be completely arrested, even should we be compelled to continue the treatment, if this is without injury to the patient, it is as close an approach to cure as we can ever expect to arrive at by therapeutic means. The permanent nature of the improvement, and the possibility of subsequent discontinuance of the bromides without return of the disease, is a question I shall not enter into, as my own personal experience is not yet sufficiently extended to be able to form a practical opinion. A satisfactory solution of this problem could only be made after a life-long private practice, or by the accumulated experience of many observers. With hospital patients such is almost impossible, as they are lost sight of, especially if they recover.

Of the total 117 cases which compose the tables, we find that in no less than 97 were the attacks beneficially influenced by the bromides. In the different cases this improvement varies in degree, but in most of them it is very considerable—for example, Nos. 2, 5, 8, 11, 20, in Table I; Nos. 5, 6, 11, 15, in Table II; Nos. 3, 4, 5, 6, in Table III; and all the cases in Table IV. In these and others the attacks, if not actually arrested, were so enormously curtailed, both in number and severity, in comparison to what existed before treatment, as to constitute a most important change in the condition of the patient. In those cases in which improvement was not so well marked, in many it was most decided, and in frequent instances caused life, which had become a burden to the patient and his friends, to be bearable.

Of the total number of cases, in 3 the administration of the bromides had no effect whatever in diminishing the attacks, and in 3 others the number of seizures was greater after treatment than before. Whether in these last this circumstance was the result of the drug, or due to some co-incident augmentation of the disease itself, I cannot decide, but am inclined to believe in the latter as the explanation.

After a consideration of these facts it is difficult to understand why most physicians look upon epilepsy as an opprobrium medicinæ, and of all diseases as one of the least amenable to treatment, and the despair of the therapeutist. For example, Nothnagel, one of the most recent and representative authorities on the subject, in speaking of the treatment of epilepsy, says, "Many remedies and methods of treatment have isolated successes to show, but nothing is to be depended on; nothing can, on a careful discrimination of cases, afford a sure prospect of recovery, or even improvement." Such a statement indicates either an imperfect method of treatment, or that in Germany epilepsy is more intractable than in this country, as a "careful discrimination" of the above cases affords a "sure prospect of improvement" and a reasonable one of recovery. That a critical spirit and healthy scepticism should exist regarding the vague and imperfect accounts of the efficacy of various drugs in disease is, I believe, necessary to arrive at the truth; at the same time, we must not refuse to credit evidence sufficiently based on observation and experiment. The above collection of cases are facts, carefully and laboriously recorded, and not originally intended for the purpose which they at present fulfil. Having been brought up in the belief that epilepsy was one of the most intractable of diseases, no one is more surprised than myself at the readiness with which it responds to treatment. So far, then, from this affection being the despair of the profession, I believe that of all chronic nervous diseases it is the one most amenable to treatment by drugs, resulting, if not in complete cure, in great amelioration of the symptoms which practically constitute the disease.

An important consideration next arises. Assuming that practically the treatment in all cases is alike, are there any special circumstances which explain why some patients should have no attacks while under the influence of the drugs, while others are only relieved; why some—though the number is very small—should receive no benefit, and others have a larger number of attacks after treatment? On a careful examination of all the clinical facts of each case, no explanation can be found, the same form of attack, the same complications and circumstances, occupying each group. For example, one of those who had no attacks during treatment was a woman who had been afflicted with epilepsy for eighteen years, of a severe form, with general convulsions, biting tongue, etc. Another was a very delicate, nervous woman, who suffered, in addition to the seizures, from pulmonary and laryngeal phthisis, who came of a family impregnated with epilepsy, and whose intellect was greatly impaired. By far the largest class are those benefited by treatment, and these comprehend every species of case, chronic and recent, complicated, inherited, in the old and young, and so on; yet the most careful analysis fails to discover why some should be more amenable to treatment than others, or give any indication which might be useful in prognosis. Neither does a study of the few cases which the bromides did not affect, or those which increased in severity under their influence, throw any light upon the subject, as some of these latter gave no indications beforehand of their unfortunate termination, and in none of them was there any serious complication or special departure from good mental or bodily health.

Another point must be noted, although there is no statistical method of demonstrating the fact, namely, that in those cases in which the attacks were not completely arrested, but only diminished in number, those seizures which remained were frequently greatly modified in character while the patient was under the influence of the bromides. These were less severe, and characterized by the patients as "slight," while formerly they were "strong." This by itself often proves of great service, as, instead of a severe convulsive fit, in which the patient severely injures himself, bites his tongue, etc., he has what he calls a "sensation," in other words, an abortive attack.