Epilepsy is a condition characterized by recurrent seizures which are unprovoked by any immediately identifiable cause (Hopkins & Shorvon, 1995). It is also known as a seizure disorder. A wide range of links and risk factors are associated with the condition, but most of the time the cause is unknown. Epilepsy is one of the most common neurological disorders, affecting approximately two and half million people in the US and about 50 million worldwide. Though seizures can occur at any age, epilepsy is most commonly seen in children and the elderly. Most respond well to treatment and can control their seizures, but for some it is a chronic illness. A clinical diagnosis is the first step to finding a potential cure for the disorder.
The diagnosis of epilepsy is usually made after the patient experiences a second unprovoked seizure (Leppik, 2002). Diagnosis is often difficult, however, since it is unlikely that the physician will actually see the patient experience and epileptic seizure, and therefore must rely heavily on patient’s history. An electroencephalography (EEG) is often used to examine the patient’s brain waves, and some forms of epilepsy can be revealed by a characteristic disturbance in electrical frequency (Bassick, 1993). The variations in frequency can take form as spikes or sharp waves (Fisher, 1995). The variations are divided into two groups, ictal electrograph abnormalities, which are disturbances resulting from seizure activity, and interictal electrograph abnormalities, or disturbances between seizures. The EEG can also give clues as to which region of the brain the disturbances arise from. Interictal temporal spikes will predict the side of seizure origin in 95% of patients if three times as many spikes appear in one temporal lobe as the other (Blume, 2002). A sleep EEG is also often done to examine the patient’s slow wave activity. Localized abnormal slow activity suggests a structural or vascular lesion in the brain, while localized absence of normal slow activity indicates underlying damage or atrophy (Fisher, 1995).
While an EEG is helpful in the determination of epilepsy type or cause it also shows much variation between patients and types. An EEG examination can show no abnormal activity in patients with some epilepsies and can also demonstrate apparent epileptic activity in patients with no history of the condition. Additional EEGs will not detect additional abnormalities. Spatial and temporal sampling limitations are often the cause of an unhelpful study of an epileptic patent (Fisher, 1995). Another problem with EEGs exists within its need for interpretation. Discrepancy often exists pertaining to which disturbances are considered significant. Imaging techniques are often used in addition to the EEG to help determine causation.
Several imaging methods are used to diagnose a patient with epilepsy. The objective of imaging in epilepsy is to identify a cause, through the identification of...
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THE intention of the Author, under this genus Epilepsia, is to describe that disease which has been most com∣monly in this island, called the Falling Sick∣ness: The reason why we chuse to give it the title of Epilepsy is, it being the general Term now in use amongst the most accurate and re∣cent Systematics: But before I attempt to enumerate the phaenomena and different symp∣toms accompanying it, I think it necessary, in order to avoid the danger of its being con∣founded with any other Genera, of the class of Neuroses of Dr. Cullen, or of the Spasmi of Sauvage, to which it pertains; to give it a Definition, which I shall endeavour to be as concise in as the matter will admit.
THE Epilepsy is a disease of the convulsive kind, returning periodically, affecting the ex∣tremities with various and irregular motions; every sense, as well as the faculties of the mind, for a certain time are altogether obli∣terated.
HISTORY OF THE DISEASE.
HAVING thus defined the disease, I shall next endeavour to illustrate its appearance more accurately in a detail of the particular symp∣toms attending it; but as I have before re∣marked that it is a periodical one, and as many circumstances shew the approach of these pe∣riods, it seems most proper to take our first observations from them. Before any one is seized with an Epileptic Fit, as it is called, he or she generally perceives the head to be in some degree affected by stupor, or a kind of swimming, which we express by the name Vertigo; the countenance is sometimes red and bloated, at other times in a collapsed state, the eyes sparkle and appear highly excited, a small inflammation or red spot is frequently perceived upon the white of them, increasing gradually till the time of accession; the cir∣cumambient parts are considerably distended; Page 7vision is diminished and vitiated in some de∣gree, sometimes indeed altogether absent.
The Iris has very different appearances, sometimes purple, at others black; the ears tingle, and sounds are difficultly heard; dis∣agreeable smells and tastes are also perceived.
The patient's discourse deviates much from what it is in health, being either quicker or slower, and at this time saliva is emitted from the mouth very copiously; the jugular veins are enlarged, and at last a loss of sense takes place.
Neither are the parts below these altogether free from complaint, but are affected with symptoms common to other spasmodic dis∣eases, particularly those of hysteria and hypo∣chondriari; but it frequently varies here, act∣ing differently in different temperaments; sometimes a pain is felt between the shoulders, the abdomen is drawn upwards, the tendons are convulsed, the heart and extremities trem∣ble, yawning and difficult respiration succeed, the extremities grow cold, the penis is prae∣ternaturally distended a sense of air or warm vapour is often perceived from the hypochon∣dria, extremities or lowest parts, ascending to the higher and to the senorium.
The eructions also are very irregular, for besides the profusion of saliva, which has been spoken of above, the digestions of the in∣testines are foetid and very offensive, the urine Page 8is also discharged in greater quantity than is customary, and not sufficiently elaborated.
Nocturnal emissions of semen frequently happen from salacious dreaming, a sense of inflation is also perceived at the praecordia, the abdomen begins to swell and murmur, the appetite vitiated, requiring food either in too great or small quantity, some are excited by anger, others are depressed by sorrow or fear; others again are distracted by anxious cares, some transported by joy, by foolish and intemperate laughing; others within a short space of time run through all their different affections, sleep is either too profound or dis∣turbed with terrifying dreams; the incubus or night-mare frequently is an addition to these calamities. By the increase of these symptoms, at last the occasion appears, by which the patient is prostrated on the ground by a groan, all the senses and the faculty of the mind being abandoned.
Violent convulsions seize the whole body, the muscies of the face being differently dis∣torted, seem to express different senses of the mind as those of grief, joy, anger, love, &c. there is also a violent grinding or grating of the teeth takes place, to such a degree as some∣times to destroy part of their extremities; it is not unusual for the tongue to protrude a little out of the mouth, and the closing of the jaws frequently cause the teeth to cut it ex∣ceedingly; Page 9a livid appearance of the lips and under parts of the eyes takes place, which, in a short time, runs over the whole face; the palpebrae of the eyes are irregularly moved, but never are so far constricted as to cover all the white; the mouth is dry, sparm prevail∣ing in the beginning, afterwards it pours forth its saliva, the sparm not being solved; respi∣ration is performed with the greatest difficul∣ty and labor, as if a person was actually under efforts of strength, and the hands are clinched with great force, neither are the heart and ar∣teries free from distress, the pulsations of which are at first quick and small, in a short time they become full and slow, not having their proper force, and can scarcely be numbered, wanting their regular order; after this the venis of the face, also the praecordia and abdomen begin to swell; the excretions are also considerably disturbed, for instead of sa∣liva, which was before very profusely secreted, a soam arises in the mouth, also stools, urine, sweat and semen, are spontaneously evacuated, in an excited system, endued with great sen∣sibility; vomiting also happens sometimes.
All these symptoms by degrees begin to vanish, and the Convalescent Epileptic has not the appearance of death, or a moribund state, but a more natural sleep at last returns again; but yet not so sufficiently natural but that it Page 10represents Apoplexy. The breathing at last becomes less laborious; and a short space of time intervening, the patient, not conscious of any thing that has happened, is restored to his natural state: it rarely occurs that a per∣son recovers immediately all his faculties, upon the paroxysm subsiding; for generally there remains an inactivity to motion, in all the extremities, dullness of conception, pains of the head, and dimness of sight; all which continue some time. — The times of in∣terval between these accessions are very diffe∣rent; some are attacked every day, or some∣times twice in the day; others once in the month; and others again, at a much greater distance of time; but the accessions do not observe regular periods, even in the same per∣son; and the continuance of the accession also differs greatly, some only being distressed for a few minutes, others whole days: and here we conclude our account of the symptoms attend∣ing Epilepsy.
THE different remote causes, and the ef∣fects of those visible upon the brain of dis∣sected Epileptics, sufficiently demonstrate, that Epilepsy most frequently depends on a turgid state of the brain; these causes, whether they Page 11act directly upon the brain, or primarily on another part of the body, are at last transfer∣red to it, and there act*.
Those that act within the brain may, as sar as at present we have learnt from dissections, be properly reserred to six heads: 1. Mecha∣nical Stimuli—As a fractured cranium, and all cases of depression. 2. Chemical Sti∣muli—Collections of acrid fluids. 3. Mat∣ters preventing the free circulation of the blood, or proper action of the nerves, under which are comprehended tumor, ossifications, and compressions. 4. Where the vessels of the brain are preternaturally filled with blood. 5. Effusions of blood. 6. Effusions of Se∣rum.
It is obvious, beyond a doubt, that all these causes consist in a full and turgid state of the brain, which is the fourth cause; and an in∣crease of this, the fifth and the sixth follows either of these, when no hydropic habit is present; which may be easily detected by its symptoms, and distinguished from that state of turgiscency which we are endeavouring to in∣vestigate; an impeded circulation in the sinu∣ses of the brain, or jugular veins, will cause the arterious blood to act with greater impe∣tus, upon their exhalents, which will cause an effusion of serum; and a small effusion in the Page 12brain is more liable to do harm than in any other part; because here we have no absorb∣ents, and the veins only perform this office; so that a small quantity of serum effused, must accumulate by stagnation for want of this ab∣sorbent system.
The sixth cause is therefore an effect of the two foregoing; nor does the first act imme∣diately, unless by giving that full habit we have been discussing, or in some degree assist∣ed by that, we are certain it does not give a more certain Epilepsy, and the cure of every Epilepsy coming from this origin, consists in a diminution of the full habit.—What per∣tains to the second, I agree that acrid chemi∣cal Stimuli are both obnoxious to, and capable of giving Epilepsy; but as such I deny its ca∣pability of giving one where the paroxysm is continued longer, and when the stimulus is present, and the fit has been more durable, and serous colluvies found extravasated; I contend that it is the effect of the disease, and of the impetus of the blood, which before has been elucidated.
The third cause is the only one remaining to be reconciled to our general opinion, under which are classed, hard tumors and consertions in the brain, impeding the free circulation through it: this is pretty well explained by the first and second cause; such is a compres∣sion of the softer parts into a praeternatural Page 13hardness: this cause therefore seems to me to act as a stimulus, quickening the circulation of the blood through its vessels; therefore this, as well as the first cause, if not directly, yet in effect produces the plenitude necessary for our proposition; and the same may be added with respect to the other four causes, which have been before enumerated, and properly reconciled, as terminating similarly.
These conclusions are or the greatest advan∣tage in practice, and clearly shew us how we ought to diminish the Plethoric habit of Epi∣leptics, and recommend abstinence: this is an excellent example of the use of dissections in investigating proximate causes of diseases, though much neglected at present by phy∣sicians.
Not that I mean to affirm, or give it as my opinion, that there is no Epilepsy but what depends on Plethora; many depend on inani∣tion, others on neither cause: more are how∣ever to be referred to it than at first view we imagine.
I remember a case of Epilepsy, remarked by my most ingenious master and illustrious pro∣fessor, Dr. Cullen, at Edinburgh, which was brought on by fear; and yet before every re∣turn of the paroxysm an inflammation of one of the eyes was clearly perceived.
As we have gone pretty fully through these causes, which act within the Cranium, let us Page 14endeavour, in order more certainly to estab∣lish the nature of the disease, as depending on this plethoric state of the Brain, to shew how causes originally acting elsewhere, or at a distance, produce the same effects.
Impressions of different kinds, acting upon the senses in general, give Epilepsy, according to their degree of impulse; they do not act as being of distinct or different kinds, but by force of impression, or reflect sensations, ex∣cited (as they are called) and this may be re∣conciled to all the senses, except that of smell, upon which odours seem to act parti∣cularly; neither have these the power of act∣ing, unless sufficiently strong. So a consider∣able degree of pain, of any part—joy, and what is still more, fear, which is carried to a degree of terror, have produced Epilepsy.—Terror acts more powerfully as a stimulus than joy; because we are modified by nature to attend more peculiarly to those motions of the mind, which free us from danger, than those which elevate us to sudden prosperity.—And why not? when we consider, that sud∣den destruction is escaped in one case, and only transitory pleasure acquired in the other.—Chemical Stimuli act also in like manner; some upon the whole system, others only on a particular part, as by stimulating the sto∣mach; and these do not act specifically, but according to their strength do they produce Page 15Epilepsy.—Odours, indeed, as we have be∣fore said, seem to have a peculiar mode of action, and some other causes produce the dis∣ease from encreased irritability of the patient; as among children, dentition, calculi, and worms. And these causes act in the same manner as those within the brain, viz. by stimulating the brain to more violent motions, and quickening the circulation of the blood through it; which, from our former ob∣servations, seems to be the most frequent cause of Epilepsy. But having before said, that Epilepsy might arise from a contrary state, we shall run over these causes, as not being of so much consequence and impor∣tance, with less precision.
Perturbations of the mind, by diminishing the action of the brain, produce a tempora∣ry Epilepsy, quickly terminating in either death or health, as is observed in the effects of great and sudden joy, or terror; but it would have been sufficient only to have men∣tioned these once, as they very commonly bring on death in a similar manner; as by Palsy, Apoplexy, Syncope, and Convulsions.—Some of the affections of the mind give a more con∣tinued Epilepsy, and one more pertinent to our proposition, as Fear; which, by diminish∣ing in a certain manner the mobility of the nervous power, seems, by an inherent law in our system, to give in a certain ratio, a re∣action Page 16of the efforts of the brain, which is even greater than natural; or the remem∣brance of this same cause of fear is often very surficient to bring back the disease.—There is a fact of a pregnant woman being fatigued with trying a new gown, which by diminish∣ing the excitement of the Sensorium, gave that reaction necessary for the production of an Epileptic fit; the sight of which gown, for sometime after, was sufficient to renew the paroxysm. Atonia of the stomach some∣times is sufficient to give Epilepsy; such as is made by distention after eating, as is ob∣served by Galen.—Fumes of Ipecacuana taken into the stomach, are capable of producing the same effects; also Mercury, and many other matters; the Variolous contagion, induced by inoculation; and the Aura Epileptica, and finally, compression of the brain, which pro∣duces Epilepsy, such as generally precedes Apoplexy or Palsy.
There causes, from the effects, and method of cure, are very clearly seen to act, by giv∣ing a state of the brain, contrary to excite∣ment, which we chuse to call by the name Collapse; but then these act very rarely when compared with the former; neither do they essentially deviate from our proposition.
From innumerable dissections of Lieutaud, Morgagni, and others, of Epileptic patients; also in the opinion of the greatest characters in Page 17Physic, Albertinius and Hossman, and many others, truly honoured and esteemed for their practice, it appears, that they, for the most part, frequently treated Epilepsy as a disease strictly connected with Plethora; and this also particularly agrees with the opinions and doctrines of my late most worthy Master and Instructor, Doctor Cullen, of Edinburgh, Pro∣fessor of the Institutes and Practice of Physic; whole name I am at a loss for words to adorn with that reverence, gratitude, and affection, that it demands of me; but will always en∣deavour to keep it in view in my practice.—I am also of opinion, that this turgescent state, which we have been endeavouring to establish, will, argued fairly, most easily in∣vestigate the nature and cure of the Epilepsy.
For the more clear and accurate elucida∣tion of the proximate cause of this disease, let us consider those habits that are most pre∣disposed to it.—Those Systems inclined to Epilepsy, are generally endowed with encreas∣ed mobility: by this I mean persons subject to sudden, irregular and violent motions of the mind; and is it not highly probable, that the state of the brain in these habits, which is moved by every impulse of stimuli, and every change of tension, is similar?
This mobility is encreased by repetition, and, after sometime, become habitual, and al∣most natural, according to the law of irrita∣bility, Page 18(by which I mean the power of con∣traction of muscles) it is encreased and fa∣cilitated by motion.—This explains the rea∣son why, after one paroxysm others can be produced by less active and weaker stimuli, and seems as if they were produced even spon∣taneously; for which reason it has been called a voluntary and feigned disease. This mobi∣lity assists us much in the investigation of the proximate cause of every Epilepsy.—There are two causes of mobility:
- 1. Debility of muscular fibres.
- 2. Excess of tension.
The first cause is clearly elucidated in in∣fants, who are particularly obnoxious to Epi∣leptic fits, a debile state of muscular fibres, or of the original stamina, can give such a cer∣tain condition of the nervous power, which makes it more adapted to irregular motions, which we call encreased mobility: but per∣haps this reasoning may appear too subtile; so I shall pass to the other cause of mobi∣lity, viz.
Excess of tension.—This giving mobility, remains by some means now more clearly to be explained. Stretching fibres beyond their tone, gives encrease of mobility: so fibres immoderately distended by the Potentiae No∣centes; Page 19such as exercise, heat, drunkenness, &c. especially in a Plethoric system; when the force of these is removed, they immediate∣ly relax themselves, in a certain ratio, as they have been before distended; and in like man∣ner are their oscillations encreased; which re∣mission, or relaxation, must frequently neces∣sarily take place in the brain.—This tension, which depends on the quantity and impetus of the humours, frequently remits; an ex∣planation of which, by an example of an elas∣tic cord, may perhaps render it more easy to conceive: if such a cord is extended, by force or by any weight, to a certain length, it will require a greater force, or weight, to stretch it as much more, than was at first applied: and in a ratio, according to the degree of disten∣sion, so will be the resilition, the distending power being removed: or, I may explain the same thing by a pendulum; as far as you re∣move it by the hand from the center of gra∣vity in one direction, giving it liberty, it will, in a certain ratio, go so much farther from it on the reverse side.—A full, turgid state of the brain is analogous to this; the oscillations of which are produced either spontaneously, or by faults occuring elsewhere; as Plethora al∣ways encreases itself.
But besides this cause of Epilepsy, consist∣ing in the excitement of the brain, or in its greater oscillations, that is excess of tension Page 20connected with debility; a defect of tension, debility being present, will produce the same effects.—This is a peculiar law of our system; as excitement produces Collapse, so, in return, does sedative powers produce Excitements.—For the motions of our minds run into con∣trary extremes.—Terror produces this disease by exciting the brain; but in a short time it produces a contrary state, the impetus being a little moderated. Exquisite titillation brings about the same phaenomenon, as is observed by Aristotle:
Omne animal post coitum triste.
And other sedative causes act in like manner. We shall however leave these discussions, and pass to the cure of Epilepsy, depending on a turgescent state of the vessels of the brain.