Part 5

Frequency of Attacks.--The rough average frequency of attacks, as estimated in the cases under consideration, was as follows:--

20 to 30 attacks per day in 3.7 per cent. 10 to 20 attacks per day in 7.4 per cent. 5 to 10 attacks per day in 14.8 per cent. 1 to 5 attacks per day in 40.7 per cent. 1 or more attacks per week in 22.2 per cent. 1 or more attacks per month in 7.4 per cent. At rarer intervals in 3.7 per cent.

Thus when epilepsia mitior exists, in the majority of cases the attacks are of daily occurrence.

Loss of consciousness, as ascertained in a series of cases, was

Complete in 48.3 per cent. Partial in 51.6 per cent.

Premonitory Symptoms.--These are not, as a rule, so well marked in epilepsia mitior as in E. Gravior; but frequently the aura is quite as distinctly appreciated. In the 28 per cent. of cases in which E. Mitior is associated with E. Gravior, the aura was apparently the same in both. Of the 10 per cent. cases of E. Mitior occurring by itself, the following is the record:--

No aura in 20 per cent. Sensation in epigastrium in 20 per cent. Loss of speech in 10 per cent. Violent pain in head in 10 per cent. Tingling of extremities in 10 per cent. Choking sensation in 10 per cent. Hallucination in 10 per cent. Vertigo in 10 per cent.

The number of cases in E. Mitior is too limited to warrant further generalization.

FOOTNOTES:

Reprinted from the "British Medical Journal" of March 15 & 22, 1879.

II.

AN INQUIRY

INTO THE

ACTION OF THE BROMIDES ON

EPILEPTIC ATTACKS.

Bromide of potassium is generally recognised as the most effective anti-epileptic remedy we at present possess. There exists, however, great difference of opinion as to its method of administration and to the amount of benefit which we may expect from its use. Some physicians who employ the drug after one method come to totally different conclusions as to its efficacy from those who use another. Many believe the remedy to be only useful in certain forms of the disease, and to be very uncertain and imperfect in its action. Others, again, maintain that it is positively injurious to the general health of the patient. These and other unsettled points the following inquiry attempts to make clear.

Epilepsy, like all other chronic diseases, presents great difficulties in scientifically estimating the exact value of any particular remedy; and unless the investigation of the subject is approached with the strictest impartiality, and observations made with rigid accuracy, we are liable to fall into the most misleading fallacies. I believe that these are to be avoided, and facts arrived at, however laborious it may be to the experimenter and wearisome to the student, only by the careful observation and elaborate record of an extensive series of cases. If, in epilepsy, the disease, from its prolonged duration, its doubtful causation and pathology, its serious complications and the many other mysterious circumstances connected with it, offers almost unsurmountable difficulties to any definite and uniform method of treatment and the systematic estimation of the same, its symptoms furnish us with tolerably accurate data upon which to base our observations. The attacks, although only symptoms, may be practically considered as representing the disease, as in the large majority of cases, in proportion as these are frequent and severe, so much the more serious is the affection. The influence of the bromides on these paroxysms is taken in the following inquiry to represent the action of these drugs on the epileptic state.

Before proceeding to detail the facts arrived at, it is necessary briefly to state the method of procedure adopted in treatment. Each case in succession, and without selection, which was pronounced to be epilepsy (all doubtful cases being eliminated), was considered as a subject suitable for experiment. The general circumstances of the individual were studied; his diet, hygienic surroundings, habits, and so on, if faulty, were, when practicable, improved. The bromides were then ordered, and taken without intermission for periods which will subsequently be detailed. The minimum quantity for an adult, to begin with, was thirty grains three times a day, the first dose half an hour before rising in the morning, the second in the middle of the day on an empty stomach, and the third at bedtime. This was continued for a fortnight, and if with success, was persevered with, according to circumstances, for a period varying from two to six months. If, on the other hand, the attacks were not materially diminished in frequency, the dose was immediately increased by ten grains at a time till the paroxysms were arrested. In this way as much as from sixty to eighty grains have been administered three times daily, and, with one or two isolated exceptions to be afterwards pointed out, I have met with no case of epilepsy which altogether resisted the influence of these large doses; and, moreover, I have never seen any really serious symptoms of poisoning or injury to the general health ensue in consequence. Sometimes these quantities of the drugs have been taken for many months with advantage; but as a rule it is preferable, when possible, after a few weeks gradually to diminish the dose and endeavour to secure that amount which, while it does not injuriously affect the general condition of the patient, serves to keep the epileptic attacks in subjection. The form of prescription to begin with in an adult has been as follows:--

R. Pot. bromid., gr. xv. Ammon. bromid., gr. xv. Sp. ammon. aromat., m. xx. Infus. quassia, ad [Symbol: Apothecaries' ounce]j

M. Ft. haust. ter die, sumendus.

According to the age of the patient so must the dose be regulated; at the same time, children bear the drug very well. The average quantity to begin with for a child of ten or twelve years has been twenty grains thrice daily.

In this manner I have personally treated about two hundred cases, and in all of these most careful records have been kept, not only of their past history, present condition, etc., but of their progress during observation. All these, however, are not available for the present inquiry. It is necessary in order to judge of the true effect of a drug in epilepsy that the patient should be under its influence continuously for a certain period of time. Now, a large number of patients, especially amongst the working classes, cannot or will not be induced to persevere in the prolonged treatment necessary in so chronic a disease. They either weary of the monotony of drinking physic, especially if, as is often the case, they are relieved for the time, or other circumstances prevent their carrying out the regimen to its full extent. The minimum time I have fixed as a test for judging the influence of the bromides on epileptic seizures is six months, and the maximum in my own experience extends to four years. All other cases have been eliminated. I have arranged this experience in the form of tables for reference, in which will be seen at a glance--1st, the average number of attacks per month in each case prior to treatment; 2nd, the average number of attacks per month after treatment; and 3rd, in the event of these being fewer than one seizure per month, the total number during the last six months of treatment.

TABLE I.--Sixty Cases of Epilepsy, showing Results of Treatment by the Bromides during a Period of from 6 Months to 1 Year.

Average Average Number No. number number attacks of attacks attacks during Case. per month per month last 6 before after months of treatment. treatment. treatment.

1 900 60 -- 2 600 5 -- 3 600 90 -- 4 450 12 -- 5 300 2 -- 6 240 90 -- 7 180 60 -- 8 150 5 -- 9 150 8 -- 10 150 7 -- 11 120 3 -- 12 120 120 -- 13 90 3 -- 14 90 9 -- 15 70 20 -- 16 60 4 -- 17 60 6 -- 18 60 90 -- 19 30 7 -- 20 30 1 -- 21 30 2 -- 22 30 10 -- 23 16 8 -- 24 16 2 -- 25 12 4 -- 26 12 12 -- 27 12 3 -- 28 8 0 0 29 8 2 -- 30 8 1 -- 31 8 1 -- 32 8 -- 4 33 8 1 -- 34 8 4 -- 35 6 0 0 36 5 -- 5 37 5 0 0 38 4 2 -- 39 4 1 -- 40 4 1 -- 41 4 1 -- 42 4 -- 2 43 4 -- 3 44 2 -- 3 45 2 -- 2 46 2 -- 1 47 2 -- 1 48 2 -- 4 49 2 -- 1 50 2 -- 2 51 1 0 0 52 1 -- 2 53 1 0 0 54 1 1 -- 55 1 0 0 56 1 0 0 57 1 -- 1 58 1 -- 1 59 1 -- 1 60 1 150 --

TABLE II.--Thirty-two Cases of Epilepsy, showing Results of Treatment by the Bromides during a period of from 1 to 2 Years.

Average Average Number No. number number attacks of attacks attacks during Case. per month per month last 6 before after months of treatment. treatment. treatment.

1 900 60 -- 2 600 120 -- 3 300 30 -- 4 180 60 -- 5 150 -- 2 6 150 1 -- 7 90 9 -- 8 90 15 -- 9 60 2 -- 10 6 -- 4 11 30 -- 1 12 30 4 -- 13 30 2 -- 14 30 3 -- 15 16 -- 8 16 12 3 -- 17 8 0 0 18 8 -- 3 19 8 -- 4 20 8 -- 1 21 8 -- 10 22 6 -- 1 23 4 -- 4 24 4 -- 4 25 4 2 -- 26 2 -- 1 27 2 -- 2 28 2 -- 2 29 1 0 0 30 1 0 0 31 1 -- 3 32 1 -- 3