EPILEPSY.
BY ALLAN MCLANE HAMILTON, M.D.
SYNONYMS.—Epilepsia; l'Épilepsie (Fr.); Fallsücht (Ger.); Epilessia (Ital.); Epilepsin fallendsot (Scand.); Falling sickness; Fainting sickness.
DEFINITION.—According to the most recent authorities, an epileptic attack is nothing more nor less than a discharge of nervous energy from an overexcited, or what may be called a dynamo-pregnant nerve-centre, or collection of centres, and the predominance of motor or sensory phenomena determines the extent and order of the parts involved. As a rule, an epileptic paroxysm is but a symptomatic expression of a complex derangement, and it is best to formulate our nomenclature with the idea, in the first place, of location; in the second, with reference to the prominence of motor or sensory expressions; and, finally, with regard to etiology.
HISTORY.—There is probably no nervous disease which has been more extensively written upon (even in ancient times) than that under consideration. We find references to it as early as the tenth century, when it figured in the text of Avicennes. Hippocrates called it ιερόν νοσεμα, or sacred malady, and πάθοϛ παιδήιον, or malady of children, believing that the attacks had their origin always in early infancy and never later. Plato and Aretæus advanced the theory that the disease sprang from a thirst for gold, and equally absurd and unreasonable explanations are found in the writings of the fathers of medicine. The older French writers were diligent investigators, but with them prevailed the tendency to explain the origin of the disease by mysticism, and among many it was supposed to bear some connection with the coming of St. John. The popular humoral theory of the malady originated by Mercurialis was afterward opposed by Averrhoes and Fernel, but even to this day it has devoted adherents. Bouchet and Causauvieilh maintained that the disease was inflammatory—a view that was vigorously combated by Bouillaud and Delasiauve. The theory of Broussais—which was and is the basis of the conclusions of modern investigators—is that it is dependent upon cerebral irritation. It is hardly necessary to refer to the many untenable and curious attempts that have been made to explain the pathology of the malady: suffice it to say that many of them were as extravagant as that of Vepfer, who considered the pineal gland to be the locus morbi of the affection—a conclusion in which Descartes coincided. Marshall Hall was the first writer to advance the theory of reflex irritation, believing that gastro-enteric or uterine irritation acted upon the brain. In later years Schroeder Van der Kolk, Reynolds, and others have written quite fully upon the part played by the medulla, while recently numerous French and German writers—among them Bourneville, Meynert, Sommers, and Tagges—have attached much importance to the discovery of a sclerosis of parts lying at the floor of the lateral ventricles.
Perhaps our knowledge of epilepsy has received its greatest impetus from the elaborate and exact researches of Hughlings-Jackson; and his observations, taken in connection with the recent work of the numerous students of localization, open up a new field of research, and, as matters stand, the future study of epilepsy must be fruitful in the extreme.
DIVISION.—It has been the custom to divide the epilepsies into epilepsia gravior and epilepsia mitior, the haut mal and petit mal of the French. These terms are in one way misleading, and only define differences in degree. The terms general and limited would much more properly express the forms of attack, and I shall use them as far as possible in the present article. A general epilepsy is one that corresponds with haut mal, in which there is an extensive convulsion, absolute loss of consciousness, and perversion of a widespread character. Limited epilepsy includes those forms in which there is a convulsion confined to a small group of muscles, and in which loss of consciousness plays an unimportant part. Under this latter head belongs the form known as petit mal and those monospasms which depend upon a cortical irritative lesion. There are other divisions which partake of the nature of one or the other, and are unilateral and dependent upon the destructive discharge of a motor centre. Under this head may be placed the epilepsie partielle of the French or the hemi-epilepsy or Jacksonian epilepsy of the English. There are also irregular or aborted attacks—the so-called masked epilepsy—and lastly the sensory varieties.
ETIOLOGY.—It cannot be denied that heredity plays the most important part in the genesis of epilepsy. Nearly one-half of my own cases when carefully investigated were clearly traceable to some inherited predisposition. Insanity, epilepsy, and phthisis in ancestral history stamp their constitutional imprint upon the unfortunate descendant, and the history of ten cases from my notebook (see Table) will show the extent of saturation that may exist in paternal or maternal branches and the evolution of the disease in male and female subjects. The statistics of other writers, though not showing quite so large a proportion of cases with hereditary history as my own, are quite significant. Gowers found that in “1218 cases, 429, or 35 per cent., presented evidence of neurotic inheritance.” Echeverria estimated the proportion of hereditary cases at 28 per cent., while Reynolds fixes it at 31 per cent. Of 980 cases, the notes of which I have examined, many of whom have been under my personal care, 435 presented a family history of insanity, phthisis, epilepsy, cerebral apoplexy, tumor, or some lesser neurosis. So far as the history of hereditary influence is known, it appears that females are more apt to present this form of epilepsy than males, and, according to Gowers's as well as my own investigations, the transmission comes from the mother's side more frequently than the other. So far as my own inquiries have gone, I find insanity more often among the progenitors of the epileptic than any other nervous disease, and in many cases phthisis. I am inclined, therefore, to give greater weight to this relationship than Nothnagel and others. Anstie, Bastian, Savage, and other careful clinicians have pointed out not only the close connection between phthisis and epilepsy, but between the former disease and migraine; and no one who has seen much of epilepsy can fail to be impressed with the frequent association of migraine with the more serious convulsive affection of which it is quite often the precursor. Perhaps the fact that phthisis was found so often—in 230 of my 980 cases—may be due to the fact that many of the patients were of the lower classes and among the Irish, who in this country are so frequently phthisical.