EPILEPSY, a disorder the essential symptom of which is a recurring, abrupt loss or alteration of consciousness, includes many types of seizures, e.g., convulsions, emotional explosions, irritable periods, vertigoes, and psychic clouding. There are normal gradations of consciousness, as sleep, degrees of atten tiveness or mental concentration, etc. Convulsions, because of their alarming appearance, early impressed mankind. This con tinued, preventing recognition of mental traits and important minor phenomena of the epilepsies. Symptomatic convulsions occur in other disorders, e.g., uraemia, diabetes, eclampsia, psy chosis, and in infancy and childhood, especially at the onset of acute infections.
Facts pertaining to heredity are not established sufficiently to formulate laws regarding transmission of epilepsies. Direct similar heredity in epilepsy is uncommon. Infections and mal nutrition during foetal life, infancy, and childhood may damage vital systems and produce subsequent epilepsy. The majority of epilepsies seem due to multiple factors. Injurious influences affecting the brain during early life may permit later of other wise harmless influences exciting seizures. Without such predis position, normal functioning of essential organs would withstand the influence which produces epilepsy. Paralytics surviving from birth injury usually become epileptic. Finer changes in the nerv ous system from birth injury often cause subsequent mental defect, epilepsy, or both. In many epileptics the heart and large blood-vessels are abnormally small. There may be other organ inferiorities. Seemingly inhibition, not stimulation of the cerebral cortex, resulting in loss of control over lower brain centres (decerebration) produces impairment or loss of consciousness with convulsive manifestations. Regressive changes may result in lack of inhibitory control of the brain.
The gravity of a skull injury bears no relationship to develop ment of traumatic epilepsy, which sometimes follows compara tively slight head injuries. Only a small proportion of head in juries in children or adults result in epilepsy. In epileptics having frequent seizures, the brain at autopsy may appear quite normal, finer changes being found upon microscopic examination. In cases with marked abnormalities there may have been few seizures. Such brain changes are considered in some to have been predis posing, in others resultant or merely concomitant.
The immediate cause of epileptic phenomena is cerebral vas cular disturbance with resulting nutritive upset and transitory oedema of parts of the brain. Such vasomotor disturbance in the brain cannot ordinarily be demonstrated in life nor found post mortem. It may be caused by insufficient or excessive activity of endocrines, protein sensitization, passage from the intestines into the circulation of toxins which eventually reach the brain, toxic substances produced locally in the brain as a result of vascular disturbance in encephalitis, brain tumour, arteriosclerosis, brain scars with adhesions, etc. Faulty metabolism of foods may result in substances toxic to brain cells and cause seizures, although simple retention of ordinary waste products may not so act. Some investigators claim an acidosis, others an alkalosis, precipi tates seizures. Attacks may be induced by excess or undue diminu tion of blood sugar, sudden lowering or increase of blood pressure, great loss of blood, increased intracranial pressure, etc. Some maintain a severe convulsion automatically adjusts faulty metabo lism resulting in an interval of relatively normal health. Habit may act in causing recurrence of seizures. The importance of eyestrain, teething, worms, scars on extremities, abnormalities of sex organs, etc., as reflex causes, has been exaggerated. Appar ently menstruation, pregnancy, and menopause provoke some seizures. Up to 20 years of age the two sexes are equally affected, subsequently males exceed because of habits, occupation, etc.
Some describe the epileptic as one with inherited defect which causes various types of stress, ultimately psychic in character, producing reactions of unconsciousness, recurring periodically, which permits riddance of a particular, adaptive demand through regression to the unconscious, a state of peace and harmony, comparable to existence before reality had become part of the mental demand. Mentality of epileptics may range from normal to marked defectiveness. Deprivation, retardation, and deteriora tion are factors acting in many. A number are highly intelligent, the majority living normally in their community never reaching institutions. In some, outstanding symptoms are ego-centricity, supersensitiveness, emotional poverty, self-satisfaction, superficial religious manifestations, and abnormal fluctuation of attention.
Attacks may be classified as follows : motor seizures, with or without apparent loss of consciousness; sensory seizures; psychic disturbances, acute or chronic. All symptoms considered part of the disorder are modifications of one or all of these reactions. Automatism, a part of certain seizures, is frequently unrecognized, the individual unconsciously committing certain acts. Medico legally such periods as well as psychic phenomena of epilepsy are of importance. Many present "epileptic optimism," i.e., failure to appreciate the necessity for avoiding dangerous situations or assuming undue responsibilities. An epileptic may appreciate the onset of a seizure, but not recall it by lack of memory fixation. Numerous factors seemingly favour occurrence of seizure, e.g., circulatory changes accompanying onset and cessation of sleep, puberty, dietary indiscretions, emotional reactions, atmospheric humidity, etc.
Minor attacks are often overlooked, as the person may not fall ; simply pauses for an instant, looks strange, then resumes con scious life. He may fall and immediately arise, such seizure being mistaken for syncope, but distinguished by suddenness of onset and recovery. Ramsay Hunt suggests attacks are due to sudden momentary loss of postural muscular control, associated with transient unconsciousness. Recurring mild attacks in children may be a forerunner of epilepsy or cease without impairment.
Cerebral apoplexy seldom occurs in severe convulsions, although minute haemorrhages without doubt do, causing recurrence of symptoms. Study of the seizure itself does not with certainty differentiate those due to organic disease from those due to psychic cause. Research has thus far failed to prove perversions of func tion or organs peculiar to the epilepsies. No drug is specific be cause essential epilepsy is not a disease, but a symptom complex resulting from unknown underlying conditions. The basis of treat ment is to find and remove, at least minimize, factors that ad versely influence the central nervous system.
The epileptic should be placed under proper guidance early, not necessarily public surveillance, but a physician or person competent to advise. In effecting readjustment of life, it is nec essary carefully to analyze symptoms and individualize treatment possible to carry out. The mode of living cannot be entirely changed, let alone environment ; nevertheless, many circumstances or habits which act injuriously may be diminished. The patient must be considered as a whole and not solely as presenting types of seizures. Reasonable restriction of diet, allowing for main tenance of normal nutrition, with exclusion of articles difficult to digest will accomplish as much as extreme methods of prolonged starvation. Some are benefited with increase of fats, some by other food groups, depending on chemical examinations of blood, urine, etc. Due care must be given to the elimination of waste products. Surgery is indicated only in certain symptomatic epilepsies, e.g., brain tumour and to relieve conditions lowering general health.
The longer the freedom from seizures, and the better the ad justment to ordinary environments, the better the prognosis. Carelessness in mode of life may result in recurrence of seizures. Remissions over more or less prolonged periods, irrespective of treatment, are not uncommon. Spontaneous arrest seemingly occurs in some. Expectation of life in epileptics is some 20 years less than in others. To effect material improvement there must be only disturbed function, not destruction, of portions of the central nervous system and related organs. Psychic-malad justments, lack of adaptation of organs and the individual as a whole, i.e., constitutional instability, the environment created by neurotic relations or associates, or the ordinary environment to the stresses of which the abnormal person cannot react properly are factors influencing epilepsy. An epileptic ordinarily presents the reactions common to mankind, a fact to be remembered in prescribing for him. Salts of bromine have been used with more or less success for 70 years. Sodium or strontium salts produce least irritation in the gastrointestinal tract. If bromides are used particular care must be given to elimination and avoidance of deleterious influence on the mentality. Favourable results have followed the use of luminal (phenyl-barbital) in diminish ing frequency of seizures, especially of the severer type, or holding them completely in abeyance. Alleged "cure-alls" often do much harm. Marriage of epileptics should be discouraged because of possibility of transmission of the condition to off spring, incompatibility of temperament, and difficulty of assum ing responsibility. Educational work among younger epileptics is beneficial, e.g., discipline should be inculcated, interests aroused and self-control developed. Responsibility begets con fidence. The epileptic should be allowed to participate in activi ties of his circle, permitting energy outlets. The feeling that he is a person set apart from relations and associates has a bad influence on mental functioning and metabolism. Occupation inducing normal healthy fatigue is most beneficial.
(See EPILEPTIC FIT.) (W. T. S.)