Epilepsy is occasionally simulated by malingerers, and sometimes the skill of the subject is so great as to even deceive the practised eye. Prisoners, soldiers, and litigants may counterfeit an epilepsy, and go through with great personal suffering to accomplish their purpose. “Clegg, the dummy-chucker,” whose remarkable case has figured in the medical journals, upon one occasion threw himself from an iron platform to the stone floor of the jail, nearly twenty feet below, to convince a suspicious physician of his honesty. The simulator rarely bears close watching. The dilatation and contraction of the pupil cannot be simulated, nor can the corneal or pupillary insensibility. The fraud cannot voluntarily change his color, as is the case in true epilepsy, and as a rule the thumbs of the impostor are never flexed, as they should be. Suggestions for a purpose are readily heard, and sometimes adopted, by the apparently unconscious man. Gottardi42 lays great stress upon the use of the ophthalmoscope as a means of detecting simulated epilepsy. He calls attention to the frequency of retinal changes with facial asymmetry and other evidences that suggest cerebral disease or non-development. Gottardi has found that the pulse in true epilepsy is always lower after an attack, but it soon reaches its normal standard.

42 Abstract in Journal of N. and M. Dis., Oct., 1881, p. 843.

The differentiation of idiopathic epilepsy from that due to syphilis is possible when we consider the element of pain. Besides the tibial pains of syphilis, the epilepsy thus produced is often preceded by intense frontal headache, while that of ordinary epilepsy follows the attack. The syphilitic epilepsy is not attended by so great or continued a loss of consciousness as the non-specific form, and the movements are apt to be most violent on one side or the other. The association of the attacks with various bodily signs, such as nodes, old scars, alopecia, erosions, etc., and in connection with possible cranial nerve-paralyses, will throw light upon its true character. The paralyses referred to seem most frequently to involve the motor ocularis, abducens, and patheticus. Syphilitic epilepsy, too, is quite irregular in its time of manifestation, and is not unrarely followed by aphasia; but the interparoxysmal mental state is one of extreme dulness, memory being blunted and there being a peculiar hebetude.

PROGNOSIS.—Within the past quarter of a century the ideas of the medical profession regarding the curability of epilepsy have certainly undergone a change. The statistics of Bennett and others show that since the introduction of the bromic salts the proportion of cures has been decidedly increased. Nevertheless, the disease is a most discouraging and troublesome one to manage, and especially is this the case when it assumes the form of petit mal. The rapid recurrence of light attacks is, as has already been said, very apt to lead not only to mental enfeeblement, but is very often followed by very severe paroxysms.

Epilepsy of a more or less constant form, in which the seizures resemble each other, is far more incurable than that of variable type; for example, we find that unilateral seizures are much more apt to be associated with established cortical disease than when they are general and simply explosive manifestations. It has been held that a tendency to permanency is marked by a diminution in the extent of the interval. This is by no means true. I have had cases under observation for ten or twelve years in which attacks separated by intervals of six months or one year marked the course of the disease, in which frequent initial attacks were present. These cases I regard as very bad so far as prognosis is concerned. I much prefer a history of irregular and comparatively disorderly attacks. In female subjects the menstrual influence is not always a bad factor. When we are enabled to remove some production of an exciting cause in connection with the catamenia the prognosis is more hopeful; but an opinion must be expressed with great caution, especially in those cases beginning at an early age and not after the establishment of the menses. Traumatic cases are not always bad, but those in which the element of heredity plays a part most certainly are, Herpin and Gowers to the contrary; and though these cases for a time do well under treatment, its good effects are not constant. Individuals with misshapen heads, whose deformity suggests premature sutural ossification, are not susceptible to the influence of treatment, and all other osseous changes, such as exostosis, plaques in the dura, and bony growths, whose existence can only be guessed at or inferred from suggestive appearances elsewhere, give rise to a variety of epilepsy which is beyond the reach of drugs. With symptomatic epilepsies the case is sometimes different, for while the seizures which arise from the irritation of a cerebral tumor are almost as hopeless as the form I have just mentioned, we know from experience that the epilepsy of syphilis and other allied diseases, and those of toxic origin, with the exception sometimes of those occasionally due to alcohol or lead, are curable. The meningeal thickening of alcoholic origin or the encephalopathy of lead may be the pathological bases of very intractable paroxysms.

So far as age is concerned, it may be stated that many eclamptic seizures of young children which are due to well-recognized irritable causes are promptly cured if there be no hydrops ventriculi or preossification of the coronal sutures, and if the epileptic habit is not established. The epilepsies of six or eight years' standing are not encouraging from a therapeutic point of view, and those of advanced life developing in aged persons are equally unfavorable.

The treatment of epilepsy due to heat-stroke is by no means satisfactory, and, though the attacks are often separated by long periods, they are apt to recur in spite of drugs.

Gowers has prepared several valuable tables which show the influence of age upon recovery. He says: “The following table shows that age has a distinct influence on prognosis. The percentage of the unimproved cases to the whole is 30 (43:143::30:100). The percentage of the cases commencing at each age arrested and unimproved is stated, and between brackets is indicated the excess of the arrested or unimproved cases at each period of life over the proportion for the whole 30 and 70 per cent. respectively:

———Cases.——— ———Percentage.———
Unimproved. Arrested. Unimproved. Arrested.
Under 10 14 29 32.5 (+2.5) 67.5
From 10-19 23 45 34 (+4) 66
20 and over 6 26 19 81 (+11)
43 100 30 70

Thus, the proportion of the cases commencing under twenty in which arrest was obtained is considerably less than the proportion of cases commencing over twenty, the difference amounting to about 13 per cent. The period of the first twenty years of life at which the disease commences has little influence, but the prognosis is little better in the cases which commence under ten than in those which commence between ten and twenty: arrest is more frequently obtained. The cases which commence in women at the second climacteric period are also obstinate, although not sufficiently numerous to be separately given.”