The Individual in Epilepsy.—In epilepsy, indeed, the individual counts much more than his ailment, and even in severe cases of epilepsy there are individuals to whom the recurring convulsions are only annoying occurrences of life, somewhat dangerous because of the risks encountered during unconsciousness, but without any ulterior significance for degeneration of character or intellectual power. As a matter of fact, there are many men in history who were epileptics and who yet succeeded in great work of many kinds, even purely intellectual, unhampered by this condition, and some of them have proved to be leaders in achievement. In his paper read before the National Association for the Study of Epilepsy and the Care and Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew Woods discussed what certain famous epileptics had accomplished in spite of epilepsy. He takes three typical examples—Julius Caesar, Mohammed and Lord Byron—the founders, respectively, of an empire, a religion and a school of poetry—with regard to whom there is convincing evidence that they were epileptics. A fourth name, that of Napoleon, might easily have been added. Greater accomplishments than these epileptics made in their various departments are not to be found in the history of the race.
Many other names of epileptics distinguished for achievement might well have been added to the list. The argument that would be founded on their lives is not that epileptics are necessarily or even usually of high intelligence, but that some of them, at least, retain in spite of the major neurosis, or even serious brain disorder, whichever it may be, all their intellectual qualities undisturbed. Lombroso, arguing from the other standpoint, has pointed out that there is a close relation between genius and insanity, and he sets down epilepsy as one of the forms of insanity (mental un-health) often associated with extraordinary mental qualities. A study of this subject is extremely reassuring to the epileptic who is prone to think from traditions with regard to the disease that his fate is almost sure to be a gradual lapse into imbecility. No epileptic is likely to be at all worried over the suggestion that epilepsy and genius are allied, for since he has the one he is quite willing that the other shall follow.
Treatment.—Reassurance is especially important when patients develop epilepsy in adult life. There is an unfortunate social stigma attached to the disease which adds to the unfavorable suggestions that are likely to run with it. This probably cannot be overcome, for it is a heritage, not alone of many [{537}] generations, but of many centuries. Our better knowledge of epilepsy, however, should gradually take the disease out of the sphere of suspected mystery in which it has been popularly placed and set it among the diseases to which human nature is liable, but which is surely as physical in its character as any other. If a favorable attitude of mind on the patient's part can be secured there is less necessity for many of the disturbing drugs that are used and there seems to be no doubt that even in producing the effect of these, such as it is, suggestion of a favorable character plays a large role. Over and over again in the history of the affection we have had remedies introduced which have seemed to be quite efficient in producing longer intervals between attacks, making the patient less nervous and putting him in better physical health. After a time, however, these have proved to be quite useless, or at most of but very slight value. It was suggestion that gave them their apparent value, and this suggestion must be used without the drugs whenever possible.
The bromides have done good in the treatment of epilepsy, but they are the only drugs that maintain the reputation they first had. All the others accomplished whatever benefit they conferred on the patient, and some of them for a time seemed to excellent authorities of large experience to give marvelous results, through their influence over the patient's mind. Nothing can produce more confidence in the physician who is using suggestion for epilepsy than this fact. Even the bromides, unless used carefully, easily do more harm than good and they have often worked mischief. Favorable suggestion cannot do harm. At the present time those of largest experience in the treatment of epileptics, the directors of farm colonies, as Dr. Shanahan of Craig Colony, insist that diet, hygiene, especially hydrotherapy, are of much more importance than drugs, but that the patient's attitude of mind towards himself and his malady and the future of it is even more important. He must have occupation of mind so as not to worry about himself. He must have recreation so as to relieve the gloom so likely to come in the disease. He must have outdoor air and proper exercise, which these patients are so prone to neglect.
Those who have studied the subject most in recent years agree that the great majority of cases of epilepsy are not primarily due to acquired causes, but to some congenital defect, so that there is an inherent instability of the nervous system. This makes the patient liable to explosions of nerve force, figuratively represented as boilings over of nervous energy, when not properly inhibited. Once such a paroxysm occurs it is likely to happen again, and very often it brings on gradual degeneration of the nervous system and of mentality. In many cases, however, this degeneration can be delayed or even completely kept off by putting the patient under favorable conditions. These patients need, above all, to realize that they cannot live the strenuous life nor even the ordinary busy life of most people. They are as cripples compelled to limit the sphere of their activities. If they will but take this to heart, however, and not attempt too busy occupations, they may live quite happy lives for many years, and if mentally content and without worrying anxieties they will have so few attacks as to incur only to a slight degree the dangers inevitably associated with fits of unconsciousness. To get the epileptic's mind into a condition of satisfaction with his condition must be the main portion of the treatment.
PSEUDO-EPILEPSY
There is a large and important field of psychotherapeutics in a class of cases so closely related to epilepsy that it is often extremely difficult to make the differential diagnosis between the two varieties of seizure. Fifteen years ago, while I was at the Salpêtrière, there was much discussion of a variety of attack called hystero-epilepsy, in which the patients' symptoms were such that it was difficult if not practically impossible to decide whether the case was true epilepsy or merely hysteria. Personally I do not think there is any third, intermediate variety deserving a separate term. The attacks are either hysterical, or, to use a less objectionable name, neurotic, or they are genuinely epileptic, that is, due to some as yet not well-defined change in the brain, and therefore not likely ever to be completely relieved. To decide whether a given case is neurotic or epileptic, however, is sometimes quite out of the question until long and careful study of it has been made. It is true that such signs as full loss of consciousness, biting of the tongue, the so-called epileptic cry, involuntary urination, dangerous falls and the like in the midst of an attack, have often been declared to be signs of true epilepsy, but there are cases in which one or other of these signs has been present, yet the subsequent course of the affection has shown them to be functional and not organic in origin.
Neurotic Simulation of Epilepsy.—Nearly every physician who has reasonably large experience with neurotic patients has seen cases in which there were recurrent attacks of loss of consciousness that came on sometimes at most inopportune moments, that rendered the patient quite incapable of caring for himself for the moment, yet lacked many of the signs of true epilepsy. Teachers sometimes complain of a complete lapse of memory that begins without warning and then recurs at intervals, making their work very difficult. Preachers sometimes bring the story of having lost the thread of their discourse and forgetting absolutely what they were talking about, there being a complete blank for some seconds at least. Occasionally such lapses are associated with falls that resemble fainting spells and seem to be accompanied by complete loss of consciousness. Usually after them there is a distinct tired feeling and an inclination to sleep, though, as a rule, there is a more marked tendency to want to get away from observation. Some of the cases are much more severe than those described and the conclusion that they are true epilepsy seems inevitable, yet they recover so completely that this conclusion is negatived.
Occasionally such attacks occur only when the patient has been strenuously exerting mind or body for a much longer period than usual. In teachers it is likely to occur toward the end of the year or in the midst of the hard work about examination time. In students this same period is likely to be a favorite starting point for the attacks and they recur oftener at this time than at others. Very often there is a story of some digestive disturbance in connection with the attacks. At times it seems possible to trace them to some interference with the cerebral circulation through a distended stomach pressing upward through the diaphragm and interfering with the heart action. In such cases stomach resonance will sometimes be found as high as the fifth rib [{539}] and the apex beat may be pushed out to the nipple line or beyond it. This may be true though there are no signs of valvular lesions and no symptoms or physical signs of dilatation or hypertrophy of the heart.