Chapter M: M——, was a stout Irish woman about forty years of age. She had (1)

suffered from a light form of epilepsy dating from the tenth year, and resulting, as she stated, from a fall, when she struck her head and was unconscious thereafter for some hours. No scar was visible, however. No satisfactory history could be obtained regarding her early life and the first paroxysms. In the beginning these were rather frequent, and she had as many as four or five a month. They afterward diminished in number and severity, and for many years she had but three or four in the course of the year. They were not very severe, and she was enabled to pursue her work as a housemaid, but did not keep her places for any great length of time. She rarely bit her tongue, but usually frothed at the mouth and became livid and convulsed for a short time. There was no history of one-sided spasms. As I have stated, I could gain no accurate account of the previous attacks, except that she nearly always had an aura of a peculiar character, which was a prominent feature of the seizure and very pronounced. She suddenly perceived a disagreeable odor, sometimes of smoke, sometimes of a fetid character, and {493} quite uncomplicated by other sensory warnings; and afterward became unconscious, and remained so for two or three minutes. She was invariably able to describe her sensations when she recovered, which she always did when I asked her, comparing her warning to the smell of burning rags, to the smell from a match, and, as she expressed it, it sometimes rose up in her head and choked her. She was under my observation for one or two years, but eventually developed phthisis, and died, her attacks occurring from time to time until her death.

Besides well-marked tuberculous lesions in the lungs, there was little of interest so far as the visceral examination was concerned. The brain was removed and its peculiarities were carefully observed. A great quantity of fluid was found, especially at the dependent portions of the membranes and in the ventricles, while the dura was thickened and pearly in spots. There was a condition that might be likened to a low grade of hemorrhagic pachymeningitis, and at the base of the brain old plastic changes were found, there being adhesions, especially in the region of the middle lobes, but more particularly on the right side and near the median line. The brain as a whole was small, and weighed forty-one ounces and a fraction. The sulci were deep and gaping, and the convolutions were distinct. There was no atrophy of the fore-brain convolutions, and no other pathological appearance was presented except that found in the meninges, but at the lower part of the temporo-sphenoidal lobe of the right side an appearance was found of an exceedingly interesting nature. At this point a decided shrinkage of tissue was discovered, with depression and adhesion of the pia, the induration involving the uncinate gyrus and parts of the adjacent convolutions, as represented in the drawing. No induration or softening of the great motor tracts was observed, and the optic thalamus and parts adjacent were uninvolved, as was the cord. An attempted microscopic examination, undertaken some months subsequently, was unsatisfactory, because of the bad condition of the brain, the preserving fluid having been improperly made. The olfactory nerves were not involved. The third frontal convolution was examined, but no disease was found there. Consequently, it is to be inferred that no lesion of the external root of the olfactory nerve existed.

DIAGNOSIS.—Having spoken of epilepsy as in most instances a symptomatic disorder, it would be proper to confine this section to the differentiation of the simpler and more classical form of the idiopathic disorder from certain purely eclamptic attacks or those due to cerebral tumor or {494} coarse degeneration. The epileptic attack itself is to be considered from its time of happening, its duration, the element of unconsciousness, its associations, and the antecedent history of the individual. It may be confounded with the similar phenomenon dependent upon cardiac weakness, uræmic poisoning, toxic or alcoholic saturation, etc.

Of course, when we find recurring seizures with a certain amount of what Carter-Gray calls quasi-periodicity, preferring perhaps the night, the early morning, or only the daytime, we are almost sure of epilepsy. This supposition is strengthened by the association with attacks of petit mal. The duration of an attack, which may be from a few seconds to several minutes, is also a guide, for in certain toxic and other paroxysms the rule is for a succession of attacks to occur.

The question of consciousness is one that has drawn forth a great deal of discussion, especially with reference to medico-legal cases. I think the majority of clinicians are agreed that loss of consciousness is an absolute belonging of epilepsy, yet there are cases in which the lapse is scarcely perceptible. It is a dangerous precedent to establish, for the convulsive symptoms in such cases are taken from the epileptoid category. It is quite true that there are many hemi-epilepsies in which the intellectual condition is one that may easily be mistaken. I have seen numerous cases in which an apparent conservation of consciousness remained throughout a slight monospasm, but I do not feel at all sure of this; and in cases of aborted or masked epilepsy there is a dual mental state which would readily deceive the lay observer. The case of Mrs. S—— is an example of this kind. After the obvious subsidence of the dramatic and conspicuous feature of the fit she remained for hours and days in a state of undoubted transposition, performing acts which required something more than a high degree of automatism—going to the table, talking about certain subjects which were suggested, with apparent ease, but not connecting them intelligently with her surroundings, as she would before and after the epileptoid state. After a time she apparently resumed her normal state, but was entirely unconscious of the happenings of her previous hours or days, not even recollecting her simplest actions. Julian Hawthorne's hero in _Archibald Malmaison_, though not drawn by a physician's pen, suggests the state of which I speak, and it has the merit of being based upon one of the elder Forbes Winslow's interesting cases.

When we find paroxysmal attacks occurring in individuals with atypical heads, thick swollen lips, scarred tongues, and irregular teeth, we may strongly suspect the patient to be epileptic. To these we may add the appearance of the eyes, the fishy, lack-lustre expression which betokens old epilepsy. The hands are clammy and the skin mud-colored; the hair is dry and coarse; and the body often has a death-like odor.

In children, certain mental peculiarities are to be inquired into. Unnatural brightness or dulness—what may be called the clumsy organization—is often present, and the muscular use is often imperfect. We find that there is often but little nicety in walking, in using the hands, in speaking, or after learning to write there is an incapacity, with ever so much teaching, to develop a character or style. Such children can never become ambidextrous. These little points may seem trifling, but to the physician who carefully studies his cases they may prove of great help. The history of the nights may often lead to the discovery perhaps of a {495} long-existing nocturnal epilepsy. Incontinence of urine, blood upon the pillow, nightmares, morning headache, and petechiæ betoken unsuspected night attacks; and Le Grand du Saulk mentions the case of a young Englishman who committed a purposeless crime and was discovered to be epileptic, the diagnosis being confirmed by an antecedent history of nocturnal seizures, and subsequent watching resulted in the discovery of many night attacks.

As to special conditions with which the epilepsy may be confounded, I may refer to cardiac weakness. It not rarely happens that simple fainting attacks are confounded with those of an epileptic nature. Such is the case more often in heat-prostration, when some rigidity attends the loss of consciousness. The duration of such a state, the condition of the pulse and color, however, will easily clear up any doubts upon the part of the observer. The existence of a cause should also be considered, and the fact that usually the epileptic paroxysm is sudden, while a feeling of depression and feebleness precedes the fainting attack, should be remembered. I may present in tabular form the points of difference:

EPILEPSY. | SYNCOPE.
|
Loss of consciousness sudden. | Loss of consciousness follows
| feeling of faintness.
|
Period of complete unconsciousness | Unconscious throughout, no
usually short. | convulsions.
|
The existence of auræ of a | The existence of preliminary
well-defined type. | vague prostration, nausea, and
| irregular heart action.
|
Often involuntary discharge from | Quite rare or never.
bowels and bladder. |
|
Patient usually falls into heavy | After slight weakness patient
sleep or is indifferent after | is anxious and worried, and
convulsion. | quickly seeks relief.

The difficulty of diagnosis, however, is only in cases of petit mal.

There are light forms of auditory vertigo that may resemble vertiginous epilepsy. In the former there is never loss of consciousness, and the patient refers to the rotary character of the vertigo. A history of antecedent attacks, tinnitus, aural disease, and a certain constancy which is not a feature of petit mal, may be mentioned.

There are cases, however, which are puzzling, and come under the head of auditory epilepsy rather than auditory vertigo; and in these there is a multiplicity of expressions, the auditory symptoms predominating.

Of uræmic convulsions it is hardly necessary to speak. There is a previous history of renal disease which the microscope and less delicate tests will reveal, and clinically there is antecedent headache, some stupidity, and not unrarely thickness of speech and somnolence. There are some cases, however, which are obscure. I have known patients with chronic renal disease—such as waxy kidney, for instance—to develop a species of epilepsy, the paroxysms recurring from time to time and behaving very much as the idiopathic disease would; and their occurrence would mark some imprudence in diet or exposure, and their disappearance an improvement in the patient's general condition. The attacks were not classical, inasmuch as there seemed to be but one stage of violent clonic convulsion, preceded by intellectual dulness, and followed by a semi-comatose condition which was far mere profound than the somnolent {496} stage of epilepsy. The movements were not accompanied by a great degree of opisthotonos or pleurosthotonos.

Alcoholic and absinthic epilepsies are usually preceded and followed by symptoms indicative of profound saturation.

The consideration of hysterical epilepsy may be found elsewhere, but it may do to briefly refer to some cases which do not present the phenomenon first described by Charcot and Bourneville. The ordinary hysterical attack is never attended by loss of consciousness, by any of the pupillary changes so constant in epilepsy, by the mobility of the pupil between the attacks which is present in a large number of true epileptic individuals. There are never the succeeding changes of color, and the seizures are commonly produced or attended by some emotional disturbance, or are associated with ovarian disturbance.

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. Gottardi[42] 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.

[Footnote 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 {497} 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 {498} 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.”

He also finds, from an analysis of the same cases, the fact noted by others, that the prognosis is favorable in inverse proportion to the duration of the disease.

Attacks which chiefly occur in the daytime are much more amenable to treatment than the nocturnal seizures, and especially is this the case in the tongue-biting form. Sudden blows upon the head or falls have been known in isolated cases to effect an amelioration in the patient's disease, but these examples are rare.

The existence of an aura is much better than if none existed.

Death from the attack itself is rare, yet in the large pauper institution with which I was connected for many years I have known of several cases. More often the death results from asphyxia resulting from a bolus of food which chokes the patient or from a fall in some dangerous place—into the fire or elsewhere. Accidental death from drowning is more common than any other form.

The status epileptica into which patients sometimes pass who have had many convulsions is occasionally a fatal termination of the malady, and is always a serious feature.

The influence of different epochs in life is worthy of consideration: of menstruation, of marriage, of pregnancy, and of the menopause there is much to be said. I have sufficiently spoken of the establishment of the menstrual flow, and I would only add another word of caution against giving a too favorable prognosis except in those cases of very recent origin. Marriage appears to have very little to do with changing the attacks, unless they be of an hysteroid character. I have never known epilepsy to influence the course of a pregnancy in any unfavorable way, and I think this has been the observation of others. Gowers refers to cases in which the attacks ceased during the time the mother was carrying the child.

The occasional bad influence of the pregnant state has been illustrated {499} by a case reported by Terrillon.[43] This example was a woman who had been the victim of epilepsy of hereditary origin since her seventh year. At the commencement of menstruation her attacks became periodic, and recurred every two months, and she had several two or three days before the flow. Two pregnancies followed several years afterward. During the periods they were increased in number and severity, and occurred several times daily. She had more attacks at this period than in all the time after delivery.

[Footnote 43: _Annales de Gynécologie_, June, 1881, p. 401.]

I have found that the relief of uterine flexion or the establishment of menstruation has exercised a decidedly modifying influence for the better in several cases.

Sometimes the disease is interrupted by the menopause, but very often in my experience it has changed in type and been followed by mental degeneration.

The prognosis of the epileptoid mental state is serious in the extreme, and even when in early life the attacks are aborted or changed to perversion of the intellect or emotions existing as a complication, the hope of cure dwindles almost to nothing.

The spontaneous cure of epilepsy is rare. Its course, however, is more often interrupted by some intercurrent disease. Of 33 cases observed by Delasiauve in which there was some complicating disease, such as erysipelas, pneumonia, pleurisy, acute articular rheumatism, burns and contusions, scarlatina, erythema, or the condition of pregnancy, it was found that in 25 cases there was a decided improvement (une heureuse influence), and in 8 only was there no modification of the attacks. Axenfeld is disposed to believe that acute and febrile disorders more decidedly influence the course of epilepsy than those of a chronic nature. The influence of either may be small or may diminish the number of attacks without curing the disease.

TREATMENT.—The treatment of epilepsy depends so much upon the form of the disease that no arbitrary rule can be laid down upon general principles, and we must bear in mind the necessity for removing the exciting causes if possible, the preservation of the balance of cerebral blood-pressure and cell-equilibrium, and the nutrition of the cerebral mass. It may be our purpose to remove various toxæmic or cachectic states as well. As a minor division of treatment we must consider the abortion of the attack when auræ are detected. It has been the custom, I think among too many, to manage the disease in an empirical manner, depending upon some routine course of treatment, such as the indiscriminate use of the bromides, for example. I am convinced that the intractable character of the disease has come to be greatly exaggerated through failures attendant upon the wholesale use of the bromic salts, without regard to the indication in each particular case. It behooves us first to select a reliable bromide, and then to give it with relation to the time of the fit, its severity, and the condition of the individual. The importance of this has impressed me very often. An equally divided daily dose will not do a patient who has matutinal attacks the same good as will a large dose at night, and in certain anæmic individuals the bromides very often increase the attack. Then, too, the cases in which seizures of petit mal predominate are not benefited to the extent that those are in which {500} the repetition of severe attacks is the feature. The bromide should always be well diluted and given when the stomach is empty or nearly so. The bromide of sodium is, to my mind, the most serviceable salt, and when given alone or combined with the bromide of ammonium is better than the potassic salt or the various others. It should be carefully kept in solution or in waxed-paper powders in a tight preserve-jar. As to its method of administration, I much prefer the use of a solution which shall combine other adjuvants which I will presently mention, and separate powders as well, which may be used to reinforce the dose. The latter are to be employed by the patient in the event of an unlooked-for series of attacks, and are to be used to the point of producing mild bromism at the time. In certain cases it is all-important to take into consideration the condition of the heart. In some cases where there is manifest and continued cerebral congestion, with full vessels and hard pulse, I have found that the combination with chloral or aconite was desirable. In other cases where the heart's action was irregular and weak my experience with digitalis and nitro-glycerin or with strychnine was most happy. In those cases that passed large quantities of clear urine of low specific gravity the action of nitro-glycerin and digitalis has been most prompt, and the same has been true of epilepsies of migrainous origin.

There have been various methods of using the bromide suggested which are more or less practical. The writers of a few years ago suggested the prompt production of bromism—a state in which the patient should be kept for a long time. This I strongly disapprove of, not only because the mental and physical depression is a very disagreeable and sometimes permanent condition, but because I have found that the attacks are often increased after a time, though at first they may have been suppressed. Others believe in giving the bromides at intervals, with periods when no medicine at all is administered.

For my own part, I am in favor of the establishment of a mild bromism which does not extend beyond a slight anæsthesia of the fauces or the appearance of slight acne. If I find it necessary to increase the dose, I give cod-liver oil, iron, and bark or some of the many preparations of the hypophosphites for a time; and they do not diminish the specific effects of the drug to any great extent. In the event of a series of attacks I direct the patient to take an extra dose at such time as will anticipate the seizure.

This treatment should be kept up for at least two or three years after the attacks have disappeared, and it may be even necessary to continue a bromide course in a small way for an unlimited period.

If there be an hysterical element, or if ovarian excitement is supposed to have anything to do with the attacks, the combination of cannabis indica is strongly recommended. This suggestion holds good in the cases where migraine is associated with the epilepsy, or the latter is an outgrowth of the former.

Next to the bromides of potassium and sodium I have been very successful with the nickel bromide. I find that it is retained with little trouble, producing no gastric derangement if taken after eating. A syrup prepared by most of the good pharmacists is preferable to any other method of administering the salt. Quite recently Leaman[44] has reported {501} two cases of severe epilepsy which were greatly benefited. His conclusion is that it does most good in the form of the disease when the attacks are separated by long intervals.

[Footnote 44: _Med. News_, Apr. 18, 1885.]

The bromate of potassium, which has been used by Weir Mitchell[45] and Hinsdale, may be worthy of a trial. It should never be given, however, in larger doses than five or ten grains thrice daily. These investigators found that thirty grains slowed the heart very considerably, and forty grains produced watery discharges from the bowels and drowsiness. In their hands, notwithstanding these disagreeable effects, it controlled the seizures. The hydrobromate of conia is a comparatively new remedy which has been recommended. My own experience does not support that of Wolfenden.[46] Severe cases were treated by him with benefit. The dose he recommends is half a grain, and not more than four and a half grains are to be given in twenty-four hours. Headache and dizziness attended its use.

[Footnote 45: _Med. News_, Dec. 27, 1884, p. 718.]

[Footnote 46: _Practitioner_, June, 1884.]

Erlenmeyer[47] is an advocate of the mixed treatment, and his best results have been obtained by combining the bromides of potassium, sodium, and ammonium in the proportion of 1:1:½. He thinks much greater permanency of effect follows such a combination. A curious result witnessed by this author is the fact that the acne produced by one salt given alone is apt to disappear when the combination is administered.

[Footnote 47: _Centralblatt für Nervenheilkunde, Psychiatrie, etc._, No. 18, 1884.]

A solution of hydrobromic acid, prepared after Fothergill and Wade's formula, is recommended by H. C. Wood of Philadelphia,[48] who presented the record of its use in twelve cases of obstinate epilepsy. It seems that in his hands large doses acted much better than when the bromides were given alone. He recommends ounce iij per diem. My own experience, which I detailed some years ago, was to the effect that it possessed no virtues whatever in ordinary doses. The solution is so difficult to take, and so disagreeable in every way, that many patients prefer almost any other treatment. It cannot be doubted that some cases of epilepsy are benefited by a change of treatment, no matter what, and possibly Wood's cases belong to this class.

[Footnote 48: _Med. News_, Feb. 23, 1884.]

Belladonna and ergot are remedies that have had many advocates, Trousseau being the most pronounced champion of the former. Their use in the lighter attacks is attended sometimes by the most happy results, but they cannot be said to have any permanent effect. The first is advantageous because of its power to diminish reflex excitement, and in those undeveloped infantile convulsions which are often grouped under the head of eclampsia its virtues are decided. Belladonna or its alkaloid may be given in combination with the bromides. Ergot or ergotin, in spite of its undeservedly bad reputation, may be given in large doses, one to two drachms of the tincture thrice daily, or five grains of the aqueous extract in the course of the day. Of chloral there is not much to be said. At one time it was thought to possess great virtues, especially in combination with the bromides, but subsequent experience has taught me that its use has many drawbacks, and only in exceptional cases is it to be recommended—viz. in those in which there is a disposition to excitement—either as a substitute for the attack or as a sequel.

{502} The use of the iodide of potassium in combination with the bromides is of great service in symptomatic epilepsies or those of syphilitic origin. The iodide should be pushed, so that the patient may take three or four drachms daily, and its injurious gastric action and unpleasant taste may be done away with by administering it in large quantities of milk or some mild alkaline water, such as Vichy. Among the other remedies used and advocated by various writers are hyoscyamine, the salts of zinc, chloral, the ammonio-sulphate of copper, picrotoxin, strychnine, curare,—all of which have little or no effect in permanently changing the course of the disease. Cerebral galvanism, if properly employed, is certainly worthy of a trial as an adjuvant.

As abortants we may resort to diffusible stimulants—ammonia, alcohol, or some carminative. If the aura be perceived, a drachm of the aromatic spirits of ammonia or a glass of sherry will often prevent subsequent developments, and the inhalation of ten or fifteen drops of nitrite of amyl will avert the attack. Nitrite of amyl may be conveniently used in the form of pearls, which may be first crushed in the handkerchief. The nitrite of soda, which has been recommended as a substitute, is an unstable and dangerous drug, and is not to be recommended.

I called attention some years ago to the virtues of nitro-glycerin as an abortant in epilepsy. It may be given in alcoholic solution or tablets from 1/50-1/25 of a grain at a dose, to be perhaps repeated. Great care should be taken to procure a reliable preparation.

When a sensory aura proceeds from a particular locality in preference, the application of some local form of irritant is strongly recommended. A blister or light touch of the button of the actual cautery will do, and if the point of origin be one of the extremities a circular blister or cautery-line, after the method recommended by Buzzard, will be serviceable in the treatment of the case.

Buzzard has observed the fact, in several of his patients who complained of a sensory aura in the biceps, that when an encircling blister was applied just above this spot the attacks were aborted. In more than one of his cases of partial epilepsy the extraordinary result of a transfer of the convulsion to the other extremity is noted. He found that the circle should be complete, for a blister which half encircled the arm did no good. I have used the same treatment in cases of writer's cramp with marked benefit.

Brown-Séquard has pointed out the good effects of forcible and painful extension of one finger or toe if the aura is of sufficient duration to enable the individual to resort to this procedure.

The condition known as the status epilepticus is best treated by amyl nitrite, which can be administered frequently. Repeated doses of nitro-glycerin, so that its full effects are produced, do more good than chloroform or any of the well-known anæsthetics.

Of setons I have very little to say. At best, they are a barbarous and painful mode of treatment, and, although cures have been effected, I have never been much encouraged by their so-called influence.

Certain intractable cases are helped by surgical procedure, and trephining has sometimes resulted in a cure. I know of one brilliant result obtained by Leo of this city in an old epileptic, in which the use of the instrument over the occipital region resulted in a complete removal of {503} the disease. It is especially recommended in cases in which the form of the attacks bears some relation to the probable disturbance of the cortical motor-centres; and even in such cases there must be constancy in the method of expression of the convulsion. So often do we find meningeal thickening of an extensive district that it is manifest that trephining would do little or no good. The statistics of the operation are unsatisfactory, for in the large mass of testimony there is great want of exactness as to the pathological suggestions of the attack, and a great deal about the method of procedure and recovery from the operation itself, and very little about the phenomena of the disease.

The diet of the epileptic should be of the most simple kind. Merson,[49] whose carefully-prepared paper is full of valuable statistics, is strongly in favor of vegetable diet, and his results are encouraging. I am convinced that many children never would have become hysterical or epileptic but for injudicious indulgence in animal food. Whenever possible, I confine my patient to a diet of fish, poultry, and fresh vegetables, with fruit. As an exciting cause the overloading of the stomach has so often precipitated attacks as to lead Paget and others to invent the term gastric epilepsy for this form of the disease. The greatest care must be paid not only to diet, but to the general habits of the patient—over-exercise, especially after eating, the avoidance of hot places and high altitudes. A residence by the seashore is preferable to mountainous places; and excitement, over-study, and all agencies favoring cerebral congestion are to be avoided.

[Footnote 49: _West Riding Reports_, vol. v. p. 1.]

{504}

THE NEURAL DISORDERS OF WRITERS AND ARTISANS.

BY MORRIS J. LEWIS, M.D.

DEFINITION.—These neural disorders consist of a certain train of nervous symptoms, such as spasm, paralysis, pain, tremor, vaso-motor disturbances, etc., either alone or in more or less complicated combinations, which follow certain muscular acts and are occasionally accompanied by a marked condition of general nervousness; they occur in many of the occupations of every-day life that require for their performance a constant muscular strain combined with more or less delicate movements of co-ordination continued for long periods at a time.

SYNONYMS.—Among the terms used to designate the various forms of the affections produced in the manner just stated may be mentioned the following:

Special Terms.—Writers' cramp, Scriveners' palsy, Steel-pen palsy, Chorea scriptorum, Paralysis notariorum, Graphospasmus, Mogigraphia, Crampe des écrivains, Nevrose des écrivains, Schreibekrampf, Le mal télégraphique, Crampe télégraphique, Klavierkrampf, Pianists' cramp, Tailors' cramp, Loss of grip, etc.

General Terms.—Professional dyscinesiæ, Professional impotence, Anapeiratic paralysis, Nevrose co-ordinatrice des professions, Functional spasm, Fatigue diseases, Professional hyperkineses, etc.

None of these terms are satisfactory, and, in fact, it is difficult to fine one that will include the various symptoms arising from the habitual use of a muscle or group of muscles, in the same way for long periods at a time, in the different occupations known to give rise to these neuroses, without including diseases belonging to entirely different classes.

It is with some hesitation that I suggest the term copodyscinesia (_κόπος_, toil, weariness, fatigue; and _δυσκινησια—δυς_, faulty, difficult, hard, and _κινησις_, motion, movement) as signifying difficult or faulty motion due to constant repetition of the same act.

HISTORY.—Some of these neuroses have been recognized for years; this is particularly true of writers' cramp, the earliest notice of which I have been able to discover is in a small work by Ramazini,[1] printed in 1746.

[Footnote 1: Bern. Ramazini, _Treatise on the Diseases of Tradesmen, etc._, translated by Dr. James, London, 1746.]

Most of the articles upon this subject have been written during the last fifteen or twenty years.

{505} ETIOLOGY.—Many of our every-day actions, which we perform almost automatically, are the result of months and even years of practice; this is well exemplified in the act of writing. At first each letter is made by a separate and deliberate act of volition, and considerable thought has to be expended upon its formation; but little by little the preponderance of the volitional element decreases, until at last we write with but little consciousness of each separate movement, and the act becomes almost an automatic one, the sentence being conceived and the hand committing it to paper with but little thought of the intermediate muscular acts. In a somewhat analogous manner do we learn to walk, each movement being laborious and requiring much thought for its execution: in addition to this, we must regulate the amount of the movement and keep in abeyance all associated muscular action.

This last is spoken of by Hasse[2] as an important factor in the etiology of these affections. When, however, any one of the various muscles whose integrity is necessary for the automatic performance of any act becomes affected, let the lesion be in the muscle itself or anywhere in the nerve-substance between it and its centre, or in that centre itself in such a way as to hinder its free response to the nervous stimulus, then the will has to be especially directed to the act in order to counteract the effect of the disability, and some other muscle or group of muscles must be substituted in the place of the one incapacitated. That which was previously performed easily and without fatigue now becomes difficult and exhausting.

[Footnote 2: _Handbuch der speciellen Pathologie u. Therapie_, “Krankheiten des Nervensystems,” 1te A., Bd. iv., 1869.]

It will be in place here to consider in detail the action of the muscles concerned in performing one or two of the acts most prolific of the affections under consideration.

The first of these that will be examined is the act of writing.

Generally speaking, the methods of writing may be divided into two: 1st, where the fingers do all the stroke movements, the arm remaining quiescent except for the lateral movement; 2d, where the pen is held steadily by the fingers and the letters formed by the movement of the whole arm. In the latter the muscles of the hand and forearm are used almost entirely for pen-prehension and poising, although there is generally a slight finger movement for the long strokes; the forearm is allowed to rest upon the bellies of the flexor muscles as a sort of movable fulcrum, the pectorales, teres major, and latissimus dorsi, together with the biceps and triceps, being mainly employed in forming the letters.

This last method of writing is the one mostly taught in the public schools at the present day; and as a large number of muscles are brought into play, and as there is a more even division of the work, it is claimed that fatigue is not so soon complained of as in the first or older method.

The act of writing is primarily divisible, according to Poore,[3] into three acts: 1st, the act of prehension; 2d, the act of moving the pen; 3d, the poising of the forearm and hand. The muscles concerned in the act of prehension are—the first two dorsal interossei, the opponens, abductor, and flexor brevis pollicis, and, to some extent, the flexor longus pollicis and the extensors of the thumb. The adductor should also be included in this enumeration.

[Footnote 3: G. V. Poore, _Electricity in Medicine and Surgery_, London, 1876.]

{506} The muscles employed in the movement of the pen differ somewhat according to the method of writing. In the finger movement Poore enumerates the following muscles as the ones used, viz.: flexor longus pollicis, extensor secundi internodii pollicis, flexor profundis digitorum, extensor communis digitorum, and also, to a lesser degree, the interossei.

In the second method of writing these muscles are comparatively quiet, except in making the letters which extend far above or below the line, while the muscles previously mentioned when describing this method are the ones called into play. The poising of the arm and hand is mainly accomplished by the supinator longus, supinator brevis, and possibly by the extensors of the thumb.

From a study of what has been written it will be seen that there are two classes of muscular actions concerned: 1st, the steady contraction of the muscles that poise the hand and hold the pen; and 2d, the intermittent contractions of the muscles concerned in moving the pen: both of these classes are equally important in the etiology of writers' cramp.

Chronic fatigue of the muscles is undoubtedly, in some cases, a precursor, if not a cause, of copodyscinesia, and, according to Poore,[4] is occasionally the expression of hyperæmia or mild inflammation of a motor nerve. Acute local fatigue has symptoms which are well known to us all after having taken violent exercise, cramp and pain being the two most prominent ones.

[Footnote 4: “Writers' Cramp and Impaired Writing-Power,” _Medico-Chirurgical Transactions_, vol. lxi.]

Any student who has dissected much has experienced the intense feeling of fatigue in the muscles required to hold the dissecting forceps, particularly when the spring is a little too strong. Much the same thing is noticed when one who has not been accustomed to write much is for some cause compelled to do so; he will probably notice that in a few hours he is exerting a greater amount of muscular force in pen-prehension than usual, and may even find that he is producing a disagreeable feeling in the distal phalanges by the pressure he is using; he will also probably be aware of a burning sensation between the shoulder-blades.

These symptoms are in all probability dependent upon, or are at least coincident with, a hyperæmia of the nerves and spinal cord, and, if persisted in for a long time without proper intervals of rest must sooner or later interfere with the healthy condition of the spinal cord, as well as of the nerves and muscles of the hand and arm.

Poore, while considering the symptoms of fatigue as in large part peripheral in origin, readily admits that they must generally be accompanied by central changes.

The manner of writing and of holding the pen is of considerable influence in the causation of this trouble. Practically, the fluent writer is more apt to contract this affection than he who writes badly, for the latter seldom obtains a position where steady copying is to be done; theoretically the reverse is true if the amount of work in the two cases is the same.

When the pen-holder is allowed to drop below the head of the first metacarpal bone the movements of the fingers are restricted; the middle and fore finger upon one side of the holder and the thumb on the other act upon the principle of the toggle-joint, so well known in mechanics, and, {507} as the pen-holder is drawn backward to make a stroke, bind the distal phalanges tightly against the holder: this in a short time causes fatigue and awkwardness in writing; but if the holder is made to cross the proximal extremity of the first phalanx of the fore finger the toggle-joint movement is destroyed.

These remarks apply of necessity more strongly to the finger movements than to the conjoined finger-and-arm movement.

Writing with a pencil is not as liable to bring on fatigue and nervous trouble as pen-writing, this being mainly owing to the fact that with the former no particular angle is required to be maintained between the point and the paper; there is therefore less effort at poising, as the pencil may be rotated at pleasure, while with the pen one angle has to be maintained. The same remarks should apply to the fluid pencils (stylographic and Mackinnon pens) now so universally used; in fact, they have been considered by Putnam[5] as much easier to write with than the pencil, as less weight need be applied upon the tip in order to write.

[Footnote 5: J. J. Putnam, M.D., “A New Adjuvant in the Treatment of Writers' Palsy,” _Boston Med. and Surg. Journ._, vol. ci. p. 320, 1879.]

The idea that these troubles of writers were due to using steel pens, as once thought, is manifestly without foundation, as the affection was recognized before the time of the introduction of steel pens, which was from 1800 to 1820.

Fine sharp pens are, however, more productive of evil than composition pens or those with a broad soft nib, as they do not move as easily over the paper, and therefore introduce a difficulty, although a slight one, in the act of writing. The theory that the chemical action between the ink and the metallic pens, and the friction of the pen on the paper, generate sufficient electricity to affect the fingers through the medium of the metallic portion of the pen-holder is too preposterous to mention, except to show what curious reasons are given in attempting to explain obscure and difficult subjects.

The next occupation which very frequently gives rise to these affections is telegraphy.

The invention of the Morse telegraph in 1844, and its general introduction, both here and abroad, a few years later, has proved a most fertile source of copodyscinesia, although but little has been written on this form of neurosis, Onimus,[6] Robinson,[7] and Fulton[8] being among the few to describe it, although several later writers mention its existence.

[Footnote 6: “Le Mal télégraphique ou Crampe télégraphique,” _Compte Rend. Soc. de Biol._, 1878, 6, S. V. 92-96; also “Crampe des Employés au Télégraph,” _Gaz. méd. de Paris_, 1875, p. 175.]

[Footnote 7: Edmund Robinson, M.D., “Cases of Telegraphists' Cramp” (4 cases), _British Med. Journ._, Nov. 4, 1882.]

[Footnote 8: Thomas Weymss Fulton, “Telegraphists' Cramp,” _Edinburgh Clin. and Path. Journ._, Feb. 2, 1884.]

Telegraph operators, particularly those employed in large cities, whose time is nearly all taken up with their work, are more exposed to the causes of copodyscinesia than those following other trades. They are not only exposed to the danger of contracting the affection by using the telegraph-key in transmitting messages, but when not so employed are receiving messages by sound and writing them down, frequently at the rate of thirty to forty, or even more, words per minute. Thirty words a minute is good telegraphy: this would require, on the average, nearly 600 {508} separate contractions. This would be 36,000 contractions per hour, while to write the same sentences would require about 10,000 less.

The operators employed by the Associated Press, although comparatively few in number, two hundred probably including all in the United States, write for hours at a time, using a stylus and manifold writing-books, making as many as twelve copies at one writing; this obliges them to grasp the stylus very firmly and to press with considerable force, making the act of writing much more difficult.

In addition to the work mentioned above, those who have large numbers of messages to transmit become so expert that to save time they make a record concerning the last message sent with the left hand, while they are telegraphing the next one with the right hand. A complicated act of co-ordination is thus being performed with each hand, the difficulty of which may be appreciated by any one if he but try to perform it.

An editorial in the _London Lancet_[9] states that “telegraphers' cramp will, we have little doubt, take its stand among the last-mentioned curiosities” (milkers' cramp, hammer palsy, etc.), and “that the telegraph clerk usually enjoys repeated intervals of complete rest, and runs consequently hardly any risk.”

[Footnote 9: 1875, vol. i. p. 585.]

Hammond[10] likewise states that telegraphers' cramp is rare in the United States, but a slight investigation proves these two statements to be, unfortunately, very far from the truth. According to recent statistics,[11] the Western Union Telegraph Company employs nearly twenty thousand operators, who transmit annually over thirty-five million messages, and as investigation seems to prove that a very large number, if not the majority, sooner or later show some symptoms of copodyscinesia, it becomes evident that this neurosis is far from rare, although hitherto almost entirely overlooked by the medical profession.

[Footnote 10: Wm. A. Hammond, M.D., _Dis. Nervous System_, 6th ed., New York, p. 789.]

[Footnote 11: J. B. Abernethy, _Commercial and Railway Telegraphy_, Cleveland, Ohio, 1883, 2d ed.]

Operators are very loath to confess that they are suffering from loss of grip, as they have termed it, for then they are considered as less efficient than formerly, and may be asked to resign in favor of one not affected, or be lowered in their salary—a point of great moment, as telegraphy is their means of support. This accounts for the apparent small number of the cases.

In telegraphing, the knob of the key, a circular disc of hard rubber more than one inch in diameter, and placed about one and a half inches above the level of the table, is grasped, as a rule, between the thumb and middle finger, with the tip of the index finger resting on top, the position being quite analogous to the method of pen-prehension, the strain, although much less, falling on the same muscles, but as all lateral movements of the key are impossible, the muscles employed in poising are not brought into play as in writing. The arm is either allowed to rest upon the table, upon the flexor mass of muscles of the forearm near the elbow as a kind of movable fulcrum, or is held with the forearm parallel to the table and a short distance above it.

The movements of telegraphing are made by the alternate action of the triceps, which depresses the wrist by extending the forearm, assisted by the flexor carpi radialis, flexor carpi ulnaris, flexor sublimis, and flexor {509} profundus digitorum on the one hand, and the biceps and supinator longus, which elevate the wrist by flexing the forearm, assisted by the extensor carpi radialis longior, extensor carpi radialis brevior, extensor carpi ulnaris, and extensor communis digitorum on the other.

The movement of the key-knob, being about the one-twenty-fifth of an inch, is so slight that it may be entirely ignored, so that with the fingers upon the key and the forearm resting upon the table near the elbow the motion must be a downward and upward one of the wrist; when, however, the arm is held above the table and parallel to it, the motion is more extended, the shoulder-muscles being used to support the arm.

The wrist is held in a supple manner, and not rigidly, the momentum of the downward movement being used to close the circuit; this, as before stated, is made mainly by the triceps, and is checked by the flexors and supinator longus.

The extensors of the wrist and fingers have a double duty to perform, for, besides assisting in recovering from the downward stroke, they have to support the hand during the whole act of telegraphing, in order to prevent the weight from resting on the key, which would prevent quickness in making and breaking the circuit.

On long circuits, particularly in wet weather, when much electricity escapes from the line, the movements have to be made with much more decision than usual in order to make the signals intelligible at the distant station.

The accompanying diagram shows well the movement of the wrist as above described, the hand and wrist moving into the position of the dotted lines when the downward stroke is made.

Our hand is essentially a prehensile organ, and as such causes us to educate the flexors the most; the extensors, being mainly used to relax the grasp of the fingers, are weaker, and the constant strain spoken of above, being thrown upon them, explains the fact that in telegraph operating these are the muscles most frequently attacked by cramp. (See Symptomatology.)