In other eases, epilepsy can be excluded with more or less certainty after the first examination, and some other positive diagnosis can be made in its stead.
Aside from those cases in which the symptomatic nature of the convulsion at once becomes evident from the long duration (several hours) of the first attack, the attending high fever or other phenomena, there are in the main two diseases that have to be differentiated—"late eclarnpsia" and hysteria.
By the term "late eclampsia" I mean convulsions developing on the foundation of the spasmophile diathesis and differing from the ordinary eclamptic attacks of early childhood only by the greater age of the individual attacked. They usually, but not always, represent repetitions of the infantile convulsions. They simulate epilepsy chiefly in that they occur during the fifth to the eighth year of life (possibly somewhat later) and differ from eclampsia by the presence of pronounced tetanoid symptoms and their favorable prognosis.
Hysterical convulsions and dazed conditions are not rare in older children, that is, at the period of life when epilepsy frequently begins. If the physician has an opportunity of observing the attack himself, the ab sence of pupillary rigidity, of analgesia and other characteristic symp toms will usually- enable him to arrive at a correct diagnosis; but a hysterical child is not always willing to perform for the physician's benefit, and even in the hospital the physician is not always so for tunate as to witness the attack.
In such cases the differential diagnosis, aside from the general considerations discussed in the chapter on Hysteria, must be made by the aid of the following special points:— If the attack is violent and comes on suddenly, if the patient is injured during the attack, and urine and feces are evacuated involun tarily; if it is followed by prolonged sleep and the patient has no recollection of its occurrence, epilepsy- is the more probable diagnosis. Uniformity, short duration, and recurrence at approximately regular intervals of a few weeks, also point to the diagnosis of epilepsy.
On the other hand, if the conditions are exactly opposite with respect to the above-mentioned points, it is a much less powerful argument in favor of hysteria. It is only when the patient distinctly remembers the attack when it is brought on by emotion, and suggestive treatment is followed by permanent recovery that the diagnosis of hysteria can be made with any degree of certainty. We would especially- warn against overestimating the significance of the temporary disappearance of the attacks under suggestive treatment; for a temporary cure of this kind may be simulated by what is the result of pure accident in cases which are undoubtedly epileptic.
The prognosis of epilepsy is always exceedingly- grave. Aside from the fact that the patient may die in the attack as the result of some accident or from exhaustion, it is rarely possible to prevent recurrence of the attacks and the gradual development of the post-epileptic physi cal and mental decay. The diagnosis must be questioned in all cases with rapid recovery.
The treatment of epilepsy- is a thankless task, even if it is institutecl very soon after the first attacks. As the treatment is the same in child
hood as in adults, we shall merely touch upon the most important points.
Treatment.—The epileptic attack itself usually calls for no special treatment, except to guard the child from injury during the convulsions, from biting its tongue, and from aspiration of the tongue, by drawing the member forward. If there is high fever, wet paeks may be tried. If the attack is abnormally protracted and in the status epileptieus chloral in doses of 0.5 to 1.0 to 2.0 Gm..S to 15 to 30 grains) per reetum, or inhalations of chloroform act as a sufficient sedative.
To prevent recurrenee of the attack the ehild should be placed under the best hygienic surroundings that can be achieved with regard to diet, sleep, and light mental occupation under proper supervision; and in addition, medicinal treatment must be begun at once. If there is a possi bility of the epilepsy- being of the symptomatic type, and even in the absence of any suspicion of syphilis, a vigorous course of treatment with mercury and potassium iodide should be tried because of their known favorable effects on inflammatory brain processes. If, however, no results are obtained, the treatment must not be kept up longer than from four to six weeks. The administration of bromides must then be begun. The potassium salt, or Erlenmeyer's bromide mixture (potas sium bromide and sodium bromide, of each 1.0 Gni. grains , ammonium bromide 0.5 Gm. grains), or one of the newer organic bromide combina tions may be selected. Whether gradually aseencling or descending closes should be prescribed, or a eonstant do.se given for a considerable period appears to be a matter of taste.
The important point is not to be satisfied with small doses of bro mides if no result is obtained. The attacks must be suppressed, if neces sary- by- the exhibition of as much as 3 to 5 to 6 Cm. 45 to 60 to 90 gr.) per day, to a child of five years, and S to 10 to 12 Gm. (2 to 21 to 3 drams) to a child of ten years. Under medical supervision there is no danger in doses of this size, and the disturbances collectively know-n as "bromism" ean, if necessary, be made to disappear rapidly by with drawing the drug for a time. If a cure, or only a moderate improvement in the severity of the epileptic manifestations is effeeted by- the bromide treatment, it should be continued indefinitely, possibly with occasional short interruptions. This is the unanimous opinion of all competent physicians'.
In order to reinforce the effect of the bromides and enable the patient to get along with as small a quantity as possible, when it is to be taken for a long time, we may adopt the suggestion of Riehet and Toulouse to keep the patient on a diet containing as little salt as possible.
If very little or no effect at all is produced by the bromides, bella donna or a combination of bromides and opium, after Flechsig, may be tried, although but little is to be hoped from this method.
The question of surgical interference rarely conies up in the case of children. The indications are the same ilS in adults.
Many of these unfortunates end their lives in institutions for the care of epileptics.