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Epilepsy And Pseudo-epilepsy





EPILEPSY


With regard to the major neuroses generally, very much more
therapeutic benefit can be secured than in any other way that we know
by reassuring the patient's mind, by careful regulation of his life
and by such modifications of his occupation as will take him out of a
strenuous existence, so likely to be harmful to a nervous system
laboring under these serious handicaps. In recent years we have come
to realize that epilepsy, for instance, is more favorably influenced
by a simple outdoor life in the country without worries and cares,
with carefully regulated exercise in the open air and special
attention to the digestive tract, than by any formal remedial measures
or drug treatment. The fewer the emotional storms the less likelihood
of repetitions of attacks of epilepsy. No medicine is so effective in
prolonging the intervals between attacks as this placing of the
patient in favorable conditions of mind and body. Our experience with
the colony system has emphasized the fact that drug treatment is quite
a subsidiary factor in this general care for the patient. The most
important element in this treatment is the effect on the
patient's mind and the consequent gain in poise and in resistive
vitality against emotional explosions which are so often the immediate
occasion of attacks. This lessens their number and it is well known
that frequent repetition is likely to be associated with that
deterioration of the physical nature and mental condition which is
most to be dreaded.


Mental Influences.--When living a quiet placid life without worry
about himself or his concerns, the number of the epileptic attacks
goes down in a noteworthy degree and the intervals between them become
longer and longer. After years of quiet country living epileptics who
had two or three attacks a week have scarcely more than one a month,
if, indeed, that often, and their general condition is greatly
improved. We have had many remedies for the affection, only a few of
which have proved to be really therapeutic. The remainder have had
their effect through the mental influence that went with them, the
assurance of relief and the confidence that it aroused.

First attacks of epilepsy are not infrequently the result of an
immediately preceding fright or sudden emotion of some kind or other.
Gowers tells the story of a sentinel posted near a graveyard who was
very much disturbed by his proximity to the dead and who, during the
night, saw a white goat run past him, jump over a low wall and
disappear. He was sure it was a ghost. He had his first attack of
epilepsy shortly after. Children not infrequently have their first
attack after a scare from a dog or a rough-looking stranger who has
come near them. After the affection has established itself attacks of
epilepsy follow vehement mental disturbances of any kind. Sometimes
after a long interval of freedom from attacks a sudden strong emotion
is followed by a fit and then the epileptic habit is reestablished. In
order to be as free as possible from the affection patients must be
protected from emotional storms.


Power of Suggestion.---A strong proof of the favorable influence of
suggestion upon epilepsy was given when operations for epilepsy became
common about twenty years ago. A number of patients were operated on
by trephining, even though almost nothing else was done except to open
the dura and examine the brain, for often no definite pathological
condition to justify surgical intervention was found. But these
patients did not suffer from attacks of epilepsy for months and
sometimes years afterwards. Many surgeons reported these cases as
cured, as they apparently were when discharged from the hospitals, for
no attacks had recurred; but physicians had to treat them later when
their epilepsy redeveloped. The surgical procedure, as indeed might
have been expected from the findings, had given only temporary
betterment. The real therapeutic factor at work had probably been not
any definite change within the skull, but the suggestive influence of
the operation, the period of rest with favorable suggestion constantly
renewed, and the confidence of recovery inspired during convalescence.
Even in cases where adhesions were found between the dura and
calvarium and these were broken up, the relief afforded was usually
but temporary. The succession of events, the relief afforded and
subsequent relapse, probably represented the same influence of
suggestion as in the preceding cases with perhaps a slight physical
betterment in addition.

An important factor in the psychotherapeutics of epilepsy is to
relieve the patient as far as possible from the haunting dread of
insanity, which, especially if he has read much of the disease, is so
likely to hang over him as a pall because of the absolutely bad
prognosis which often occupies so prominent a place in older
text-books and articles on epilepsy. There is no doubt that in a great
many cases epilepsy is a progressive degenerative disease and that a
state of lowered mentality will eventually develop. There are many
cases, however, in which epilepsy is only a series of incidents which
does not seem to affect the intellectual life and which is quite
compatible not only with prolonged existence, but with mental
achievements of a high order and, above all, with a personality that
may be commanding in its power over others. This knowledge, which
unfortunately is not usually given in text-books because they are
studies in the pathology rather than in the psychology of epilepsy, is
extremely important for the epileptic. This view is of special
significance for those sufferers from the disease who are well
educated and in whom mentality means so much.


The Individual in Epilepsy.--In epilepsy, indeed, the individual
counts much more than his ailment, and even in severe cases of
epilepsy there are individuals to whom the recurring convulsions are
only annoying occurrences of life, somewhat dangerous because of the
risks encountered during unconsciousness, but without any ulterior
significance for degeneration of character or intellectual power. As a
matter of fact, there are many men in history who were epileptics and
who yet succeeded in great work of many kinds, even purely
intellectual, unhampered by this condition, and some of them have
proved to be leaders in achievement. In his paper read before the
National Association for the Study of Epilepsy and the Care and
Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew
Woods discussed what certain famous epileptics had accomplished in
spite of epilepsy. He takes three typical examples--Julius Caesar,
Mohammed and Lord Byron--the founders, respectively, of an empire, a
religion and a school of poetry--with regard to whom there is
convincing evidence that they were epileptics. A fourth name, that of
Napoleon, might easily have been added. Greater accomplishments than
these epileptics made in their various departments are not to be found
in the history of the race.

Many other names of epileptics distinguished for achievement might
well have been added to the list. The argument that would be founded
on their lives is not that epileptics are necessarily or even usually
of high intelligence, but that some of them, at least, retain in spite
of the major neurosis, or even serious brain disorder, whichever it
may be, all their intellectual qualities undisturbed. Lombroso,
arguing from the other standpoint, has pointed out that there is a
close relation between genius and insanity, and he sets down epilepsy
as one of the forms of insanity (mental un-health) often associated
with extraordinary mental qualities. A study of this subject is
extremely reassuring to the epileptic who is prone to think from
traditions with regard to the disease that his fate is almost sure to
be a gradual lapse into imbecility. No epileptic is likely to be at
all worried over the suggestion that epilepsy and genius are allied,
for since he has the one he is quite willing that the other shall
follow.


Treatment.--Reassurance is especially important when patients develop
epilepsy in adult life. There is an unfortunate social stigma attached
to the disease which adds to the unfavorable suggestions that are
likely to run with it. This probably cannot be overcome, for it is a
heritage, not alone of many generations, but of many centuries.
Our better knowledge of epilepsy, however, should gradually take the
disease out of the sphere of suspected mystery in which it has been
popularly placed and set it among the diseases to which human nature
is liable, but which is surely as physical in its character as any
other. If a favorable attitude of mind on the patient's part can be
secured there is less necessity for many of the disturbing drugs that
are used and there seems to be no doubt that even in producing the
effect of these, such as it is, suggestion of a favorable character
plays a large role. Over and over again in the history of the
affection we have had remedies introduced which have seemed to be
quite efficient in producing longer intervals between attacks, making
the patient less nervous and putting him in better physical health.
After a time, however, these have proved to be quite useless, or at
most of but very slight value. It was suggestion that gave them their
apparent value, and this suggestion must be used without the drugs
whenever possible.

The bromides have done good in the treatment of epilepsy, but they are
the only drugs that maintain the reputation they first had. All the
others accomplished whatever benefit they conferred on the patient,
and some of them for a time seemed to excellent authorities of large
experience to give marvelous results, through their influence over the
patient's mind. Nothing can produce more confidence in the physician
who is using suggestion for epilepsy than this fact. Even the
bromides, unless used carefully, easily do more harm than good and
they have often worked mischief. Favorable suggestion cannot do harm.
At the present time those of largest experience in the treatment of
epileptics, the directors of farm colonies, as Dr. Shanahan of Craig
Colony, insist that diet, hygiene, especially hydrotherapy, are of
much more importance than drugs, but that the patient's attitude of
mind towards himself and his malady and the future of it is even more
important. He must have occupation of mind so as not to worry about
himself. He must have recreation so as to relieve the gloom so likely
to come in the disease. He must have outdoor air and proper exercise,
which these patients are so prone to neglect.

Those who have studied the subject most in recent years agree that the
great majority of cases of epilepsy are not primarily due to acquired
causes, but to some congenital defect, so that there is an inherent
instability of the nervous system. This makes the patient liable to
explosions of nerve force, figuratively represented as boilings over
of nervous energy, when not properly inhibited. Once such a paroxysm
occurs it is likely to happen again, and very often it brings on
gradual degeneration of the nervous system and of mentality. In many
cases, however, this degeneration can be delayed or even completely
kept off by putting the patient under favorable conditions. These
patients need, above all, to realize that they cannot live the
strenuous life nor even the ordinary busy life of most people. They
are as cripples compelled to limit the sphere of their activities. If
they will but take this to heart, however, and not attempt too busy
occupations, they may live quite happy lives for many years, and if
mentally content and without worrying anxieties they will have so few
attacks as to incur only to a slight degree the dangers inevitably
associated with fits of unconsciousness. To get the epileptic's mind
into a condition of satisfaction with his condition must be the main
portion of the treatment.




PSEUDO-EPILEPSY


There is a large and important field of psychotherapeutics in a class
of cases so closely related to epilepsy that it is often extremely
difficult to make the differential diagnosis between the two varieties
of seizure. Fifteen years ago, while I was at the Salpetriere, there
was much discussion of a variety of attack called hystero-epilepsy, in
which the patients' symptoms were such that it was difficult if not
practically impossible to decide whether the case was true epilepsy or
merely hysteria. Personally I do not think there is any third,
intermediate variety deserving a separate term. The attacks are either
hysterical, or, to use a less objectionable name, neurotic, or they
are genuinely epileptic, that is, due to some as yet not well-defined
change in the brain, and therefore not likely ever to be completely
relieved. To decide whether a given case is neurotic or epileptic,
however, is sometimes quite out of the question until long and careful
study of it has been made. It is true that such signs as full loss of
consciousness, biting of the tongue, the so-called epileptic cry,
involuntary urination, dangerous falls and the like in the midst of an
attack, have often been declared to be signs of true epilepsy, but
there are cases in which one or other of these signs has been present,
yet the subsequent course of the affection has shown them to be
functional and not organic in origin.


Neurotic Simulation of Epilepsy.--Nearly every physician who has
reasonably large experience with neurotic patients has seen cases in
which there were recurrent attacks of loss of consciousness that came
on sometimes at most inopportune moments, that rendered the patient
quite incapable of caring for himself for the moment, yet lacked many
of the signs of true epilepsy. Teachers sometimes complain of a
complete lapse of memory that begins without warning and then recurs
at intervals, making their work very difficult. Preachers sometimes
bring the story of having lost the thread of their discourse and
forgetting absolutely what they were talking about, there being a
complete blank for some seconds at least. Occasionally such lapses are
associated with falls that resemble fainting spells and seem to be
accompanied by complete loss of consciousness. Usually after them
there is a distinct tired feeling and an inclination to sleep, though,
as a rule, there is a more marked tendency to want to get away from
observation. Some of the cases are much more severe than those
described and the conclusion that they are true epilepsy seems
inevitable, yet they recover so completely that this conclusion is
negatived.

Occasionally such attacks occur only when the patient has been
strenuously exerting mind or body for a much longer period than usual.
In teachers it is likely to occur toward the end of the year or in the
midst of the hard work about examination time. In students this same
period is likely to be a favorite starting point for the attacks and
they recur oftener at this time than at others. Very often there is a
story of some digestive disturbance in connection with the attacks. At
times it seems possible to trace them to some interference with the
cerebral circulation through a distended stomach pressing upward
through the diaphragm and interfering with the heart action. In such
cases stomach resonance will sometimes be found as high as the fifth
rib and the apex beat may be pushed out to the nipple line or
beyond it. This may be true though there are no signs of valvular
lesions and no symptoms or physical signs of dilatation or hypertrophy
of the heart.


The Suggestive Element.--Analysis shows the real course of the
trouble in these cases. The sufferer is usually following a sedentary
occupation, not getting much exercise or diversion and prone to
introspection. Many symptoms of themselves of no importance have been
emphasized by concentration of attention on them. Especially is this
true of any heart irregularity. The patient has dreaded for some time
lest the feeling of pressure in the precordia and of discomfort in the
heart might not sometime interfere with him in the midst of his
teaching or preaching duties. Some day when he is feeling much worse
than usual, in the midst of his work, there comes over him the feeling
that now his intellect is going to stop action because there is
something the matter with him. The sudden concentration of his
attention on this with the fear of the consequences and the
uncomfortable feeling that he will not be able to go on with his flow
of ideas, cuts off the thread of what he is thinking about and puts
but one single object before him--this possibility of failure of
mental action. Usually the first attack is only such an interruption
as is thus indicated. The fear of subsequent attacks, the worry over
what has happened, the dread that some serious mental affection or
nervous disease is at work emphasizes introspection and subsequent
attacks are even more likely to be serious, and especially to last
longer than the first.

The more the cases are studied the more the conclusion comes that in
many of these instances it is nothing more than auto-suggestion that
is responsible for the mental lapse. It is true that some physical
condition may be the occasion, though the mental state is the active
immediate cause. Suddenly concentrated attention on the dread of
mental interruption inhibits mental action and what was dreaded
follows almost necessarily. It is a sort of auto-hypnotism in which
the patient's train of thought is interrupted by a momentary or longer
hypnotic state the causes of which can be traced. Even when there is a
real organic lesion of the heart, the lapses of memory and even of
reasoning power that occasionally occur, have often seemed to me to be
due rather to the patient's dread than to any real physical condition.
I cannot think that there is a sufficient interruption of the cerebral
circulation, even though only for a moment, to cause such a lapse. It
is a question of nerve interferences rather than of blood supply. If
the blood were diverted, even though only for a moment, or if there
was a stoppage, the consequences would be more serious and more
lasting than they are.

What evidently happens is some disturbance of neurotic connections
within the brain brought on by sudden dread or emotion. The will has
lost control or has seriously disturbed the conducting apparatus. The
best proof that this is what happens and that it is not the result of
organic change is found in the fact that when the physical occasion,
that is, the digestive disturbance or the heart palpitation which is
the initial factor in these states, is relieved, the attacks do not
take place. Patients in whom they have occurred even for years cease
to have them. This improvement does not begin, however, until their
solicitude over their condition has been lessened by a confident
declaration to them that they are suffering from merely functional and
local reflex conditions apart from the brain itself. Usually it needs
to be made clear to them, too, that their anxiety in the matter
means much more for the continuance of the attacks than any physical
condition.

Almost invariably patients somewhat resent this suggestion. Their
response to this explanation of their ailment usually is that the
attacks come on them when they are not particularly expecting them and
that there is first some physical symptom which might readily be taken
for a sort of aura to a genuine epileptic attack and then the attack
itself comes on. It is this preceding symptom, pain or discomfort, or
whatever else it may be, that provokes the suggestive element and
brings about the state of quasi-hypnosis, which is the main part of
their attack.


Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are
very mild, though if the word epilepsy has been mentioned there
naturally arises a feeling of dread in patient and friends with
consequent unfavorable suggestion. A type not infrequently seen has
for its main symptom a period, usually of but short duration, in which
there is an intense tired feeling so that even the eyelids droop and
require effort to lift them. During such attacks the respirations may
slow down to fifteen or below, though usually the pulse is inclined to
be rapid. The feeling of fatigue is almost entirely subjective, in the
sense that, if patients are required to do something, they are able to
accomplish it by a little urging, though a moment before they were
sure that they could not. Such attacks are invariably functional, have
no organic basis and do not deserve the name of epilepsy. If called
hysterics this will cause the patient, who is often a woman, to rouse
herself and so gradually overcome them. They are really a loss of
confidence in one's power to do things and a passing astasia-abasia.
The use of the word hysterics may cause the patient to lose the
sympathy of her friends, though she may need it; for often there is an
underlying pathological condition not in the nervous but in the
somatic system. Sometimes the patients are anemic, sometimes they have
an abortive form of Graves' disease, and sometimes they are low in
nutrition.

These conditions give the indication for treatment. What is needed is,
of course, improvement of the general condition, but, above all, a
restoration of the patient's confidence in herself. Once it is made
clear to her that the attacks are largely subjective, that is, are due
to a feeling of prostration because of the fear that she is unable to
do something, then the intervals between the attacks will gradually
grow longer. It is important that long hours of sleep should be
advised with plenty of fresh air, and that whatever disturbances of
the digestive system are present should be carefully treated.


Pseudo-Epilepsy and the Menopause.--A number of these cases of
pseudo-epilepsy occur at the menopause. They seem particularly likely
to occur in women who have not much to occupy themselves with.
Childless women who have no cares and enjoy every luxury sometimes
seem to have these pseudo-epileptic attacks as equivalents for the
flushings of the ordinary menopause. During "a rush of blood to the
head" they lose control of themselves. Occasionally mothers who have
two or three daughters and who get their menopause late in life, that
is, well after fifty, are especially likely to suffer in the same way.
The solicitude of those near them seems to eliminate some of their
power of inhibition and makes them think overmuch of themselves. If
then they keep much at home, as women at this time are prone to do,
have few diversions of mind, little fresh air and exercise,
there is an accumulation of unused nervous energy which dissipates
itself in explosive attacks very like epilepsy. It is with regard to
these that the term hystero-epilepsy almost seems justified. Just as
soon as occupation and diversion of mind and relaxation of the
solicitude of friends for them is secured they begin to get better.

The differential diagnosis of these cases is made from the absence of
certain of the pathognomic signs of true epilepsy. The tongue is not
bitten, involuntary urination does not take place, and when the
patient falls she does not hurt herself as a rule, though occasionally
the fall may result in accidental abrasions or bruises, but these are
quite trivial. If stress is laid upon the fact before these patients
that they do not present any or all of the symptoms of epilepsy, some
of them are likely to occur a little later. Slight abrasions on the
tongue will be noted and the sputum will become a little bloody. Even
very cleanly women will sometimes wet themselves. It is not a
deliberate attempt at deception, but their curious psycho-neurotic
condition causes suggestion to act upon them. Their attacks are really
auto-hypnotic and during these the remarks made by the physician occur
as suggestions and then are accomplished. If the suggestions in this
matter have been carelessly made by previous physicians the attacks
will so closely simulate true epilepsy that it will often be almost
impossible to differentiate them with assurance.

In the preliminary diagnosis of these cases, as well as of all other
cases of pseudo-epilepsy, we must, as far as possible, avoid the use
of the word epilepsy, even of hystero-epilepsy. The unfavorable
suggestion attached to such terms will have the worst possible effect.
There is no need to fear that the patient will be any less taken care
of, if the disease is called by some other name, for instance,
neurotic paroxysms or nervous attacks.


Cure by Suggestion.--Such patients are often cured by remedial
measures of one kind or another that are administered with the
confident declaration that they will get well. A number of cases of
epilepsy which were really of this character have been reported cured
by Eddyism. A number also have been very favorably influenced by
osteopathic treatment. Needless to say, the reports of such cured
cases have not been diminished in significance by the publicity
bureaus of these various cults. Mental healing has relieved a number
more. Usually this relief has been afforded these cases after they had
tried regular physicians who had treated them in the ordinary way with
bromides, without doing anything more than causing them to miss a few
attacks for a temporary period of relief, if even that, giving them
bromism and further increasing their solicitude about themselves by
unconsciously emphasizing their ideas as to how serious epilepsy can
be. The cures of these cases are not due to the various treatments to
which the patients proclaim their debt of gratitude, but to the
confident assurance given them that their condition is not serious,
and will be cured. After analysis of their attacks has shown them to
be neurotic and not genuinely epileptic, the regular medical
practitioner can readily do as much and even more; for psychotherapy
has much more to do in affording relief in these cases than any other
form of treatment. It must be applied with confidence and the results
are often most favorable.





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Previous: Paresis



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