Chapter 3 - General Remarks About Neurasthenia

"Do not muse at me, my most worthy friends;

I have a strange infirmity, which is nothing

To those that know me."

"Macbeth," Act III.

Starr's table shows that combinations of all types of epilepsy are possible, and that mental epilepsy is rare:

The majority of victims have attacks both by day and by night. Of 115,000 seizures tabulated by Clark, 55,000 occurred during the day (6 a.m. to 6 p.m.) and 60,000 by night.

The usual course of a case of epilepsy is somewhat as follows: the disease begins in childhood, the first convulsion, about the age of three, being followed some twelve months later by a second, and this again by a third within a few months. Then attacks occur more frequently until a regular periodicity—from one a day to one a year—is reached after about five years, and this frequently persists throughout life.

The effect of epilepsy on the general health is not serious, but it has a more serious effect on the mind, for epileptic children cannot go to school (though special schools are now doing something towards removing this serious disability), and grow up with an imperfect mental training. They become moody, fretful, ill-tempered, unmanageable, and at puberty fall victims to self-abuse, which helps to lead to neurasthenia. Then they may drift slowly into a state of mental weakness, and often require as much care as imbeciles. If the fits are severe from an early age, arrest of mental development and imbecility follow. If the disease be very mild in character, and especially if it be petit mal, the victim may be very precocious, get "pushed" at school, and later become eccentric or insane.

Adult victims necessarily lead a semi-invalid life, often cut off from wholesome work and from the pleasures of life, and become hypersensitive, timid, impulsive, forgetful, irritable, incapable of concentration, suspicious, show evidences of a weakened mind, have few interests, and are difficult to manage.

About 10 per cent—the very severe cases—go on to insanity; either temporary attacks of mania, calling for restraint, or permanent epileptic dementia with progressive loss of mind. Some victims are accidentally killed in, or die as a result of a fit; about 25 per cent—severe cases again—die in status epilepticus, but the majority after being sufferers throughout life are finally carried off by some other disease.

There are many exceptions to this general course. Some patients have attacks very infrequently, and are possessed of brilliant talent, though apt to be eccentric. Others may have a number of seizures in youth, and then "outgrow" the complaint.

A few victims are attacked only after excessive alcoholic or sexual indulgence, some women only during [pg 17] their menses, while other women are free from attacks during pregnancy, which state, however (contrary to popular belief), commonly aggravates the trouble. Victims may be free from attacks during the duration of, and for some time after, an infectious disease; while Spratling says that a consumptive epileptic may have no fits for months, or even years.

Some epileptics are normal in appearance, but many show signs of degeneration. This is common in the insane, but less frequent and pronounced in neurasthenics. An abnormal shape of the head or curvature of the skull, a high, arched palate, peculiarly-shaped ears, unusually large hands and feet, irregular teeth from narrow jaws, a small mouth, unequal length and size of the limbs, a projecting occiput, and poor physical development may be noted.

These are most pronounced in intractable cases, in whom mental peculiarities are most frequently seen—either dullness, stupidity and ungovernable temper, or very marked talent in one direction with as marked an incapacity in others. In all epileptics, the pupils of the eye are larger than normal, and, after contracting to bright light soon enlarge again.

The facial expression of most epileptics indicates abnormal mentality. When the seizures have been so frequent and severe as to cause mental decay, the actions are awkward, and the gait slouching and irregular. Progressive poor memory is one of the first signs of intellectual damage consequent upon severe epilepsy.

Though the disease may occur at any age, most cases occur before the age of twenty, there being good reason to look for other causes (often syphilis) in cases which occur after that age. Of 1,450 of Gowers' cases, 30 per cent commenced before the age of ten; 75 per cent before twenty. In Starr's 2,000 cases, 68 per cent commenced before the patient was twenty-one.

According to Turner [Possibly William Aldren Turner, 1864–1945], the first epoch is from birth to the age of six, during which 25 per cent of all cases commence, usually associated with mental backwardness, and some due to organic brain trouble. The second epoch is ten to twenty-two, the time of puberty and adolescence, during which time no less than 54 per cent of all cases commence. This is, par excellence, the age of onset of genuine epilepsy, the mean age of maximum onset being fourteen in men and sixteen in women. The remaining 21 per cent of cases occur after the age of twenty-two.

In 430 cases of epilepsy in children, Osler {Probably Sir William Osler, 1849-1919], found that 230 were attacked before they reached the age of five, 100 between five and ten, and 100 between ten and fifteen.

Epilepsy, then, is a disease of early youth, coming on when the development and growth of the nervous and reproductive systems is taking place. During this period, causes, insignificant for stable people, may light up the disease in those of unstable, nervous constitution, a fact which explains the importance of training the child.

Both sexes are attacked. If we consider only cases of true idiopathic epilepsy female patients are probably in excess, but in epilepsy in adults, from all causes, males predominate. In females, the menopause may arrest the disease.

In days gone by, epilepsy more rarely commenced after the age of twenty, but in these days of nerve stress it commences more frequently than formerly in people of mature age. A victim who has a fit for the first time after the age of twenty, however, should consult a nerve specialist immediately.

In its early stages there are no changes of the brain due to, or the cause of, epilepsy, but in long-standing, severe cases, well-marked, morbid changes may be found. These are the effects, not the cause, of the [pg 19] disease, and they vary in intensity according to the manner of death and the length and severity of the malady. They probably cause the mental decay and slouching gait mentioned before.

Fits may suddenly cease for a long time, but they usually recur, and most patients have them more or less regularly through life.

The fact that recovery is rare should not be hidden from patients and friends. Perhaps 8 per cent of all classes recover—and "recovery" may only be a long interval—but 4 per cent of these are Jacksonian, syphilitic or accident cases. Only one victim in every thirty recovers from true epilepsy; and these are very mild cases, in which the fits are infrequent, there is no mental impairment, and bromides are well borne. The earlier the onset, the more severe and frequent the attacks, the deeper the coma, and the worse the mental decay, the poorer the outlook.

Cure is exceptional, but by vigorous treatment the severity of the malady may be much abated. Petit mal is no more hopeful than grand mal; less so in cases with severe giddiness; in all cases, the better the physical condition and digestive powers of the patient, the brighter the outlook.

To sum up, epilepsy is a chronic abnormality of the higher nervous system, characterized by periodic attacks of alteration of consciousness, often accompanied by spasms of varying violence, affecting primarily the brain and secondarily the body, based on an abnormal readiness for action of the motor cells, occurring in persons with congenital nerve weakness, and leading to mental decay of various types and degrees of severity.

EPILEPSY, HYSTERIA, AND NEURASTHENIA

THEIR CAUSES, SYMPTOMS, & TREATMENT

GENERAL REMARKS