CHAPTER VII. PROGNOSIS. “J'en ai guéri un très grand nombre."-TISSOT. "Elle conduit presque infailliblement à l'incurabilité par de lentes dégradations."-DELASIAUVE. THE prognosis of epilepsy in the present day is, it would seem, less favourable than was that of the last century; and the reasons for this are, or may be, threefold. The disease may be essentially less tractable; the physician may be less readily convinced of cure; and the term may sometimes include more or less than it does at other times. Of 115 cases of chronic convulsive disease which have fallen under my own care, all of which more or less closely resembled epilepsy-many of which had been termed epilepsy, and had been treated as such for several years,—there were 21 individuals who perfectly recovered, i. e. 18 per cent. Of these 115 cases there were 81 examples of true epilepsy; but of the epileptics only 8 absolutely recovered, equalling only 10 per cent. Of the cases not truly epileptic, there were 23 which belonged to the category of organic cerebral disease, or so-called "symptomatic epilepsy;" of these 10 were cured, 7 ameliorated, 4 were lost sight of, and 2 remained in statu quo. In 43 per cent., therefore, of so-called "symptomatic epilepsy," a cure was effected. There were, moreover, 11 examples of eccentric irritation, or of so-called "sympathetic epilepsy;" and of these 3 were cured, or 27 per cent.; and 5 individuals, or 45 per cent., were greatly improved. Among epileptics almost every case was more or less improved for a time, and in some instances the amendment was considerably prolonged. I have only regarded those cases as "cured," in which there has been perfect restoration to health which has lasted for at least four years; at most for nearly eight. These results of treatment in convulsive diseases generally, have been furnished in order to show wherein difficulty is to be expected; and in order further to remove the impression that might be given by the naked facts of simple epilepsy, in relation to treatment, viz. that very little is to be effected by the latter. I do not now deal with the prognosis of so-called "symptomatic epilepsy," i. e. of convulsions dependent upon organic disease of the nervous centres, such as tumour, meningitis, and the like; nor with that of the so-called "sympathetic epilepsy," i. e. of convulsive affections clearly connected with eccentric irritations,—the renal, uterine, gastric epilepsy, and so forth it is with the future of simple, true, or, as it has been called, "idiopathic epilepsy," that we have to do. This subject will be considered conveniently under three heads: 1st, the prognosis of epilepsy generally, i. e. as to the probability of cure, amelioration, or the reverse of the disease as a whole; 2ndly, that of the mental condition of the epileptic; and, 3rdly, that of the danger of individual attacks. I. The prognosis of epilepsy generally depends upon many considerations. The cause of the disease is thought to exercise a great influence upon its career. According to Georget,* Delasiauvet and others, the disease is especially rebellious when either hereditary or connate. Upon this point Herpin‡ is of a different opinion; and my own observation would lead me to agree with him, for I have known some instances of cure among cases of distinctly hereditary epilepsy. Zimmerman, quoted by Esquirol, § and Georget,|| state that when masturbation is the cause, the case is almost without hope; but I have seen a case which proves that this view is erroneous. So far as I have been able to gather, * Op. cit., p. 398. + Traité, ant. cit., p. 282. Du Pronostic, &c., ant. cit., p. 515. § Des Maladies Mentales, Tome II., p. 301. the nature of the exciting cause has not exerted any influence upon the prognosis, except in the following general manner, viz. that those cases have appeared the least tractable in which the origin of the malady was involved in the greatest mystery; and this, most obviously, because the knowledge or suspicion of cause, in other cases, placed in my hands some power to prevent, avert, or diminish the recurrence of its operation; a power, of course, wanting in the former group. The age at which the disease commences affects the prognosis considerably. There is a general concurrence in the opinion that early development of the malady is of favourable omen. Hippocrates said if the disease commenced after twenty-five it was incurable. Tissot and Esquirol† speak of the prognosis as good when the disease has shown itself between four and ten years of age, or at twelve. Peters says youth is favourable to a cure. Herpin says the prognosis is best at an advanced age, but next best when it is between ten and twenty years.§ In my own practice, those patients which recovered were, at the time of the fits ceasing, between the ages of fifteen and thirtytwo; and the disease had commenced at the ages of from thirteen to thirty-one. The mean age at commencement of eight cases of recovery was nineteen years; the mean age at the date of cure was twenty-one; and from this the important fact is gathered that the mean duration of the malady was but two years. Sex.-Men are more easily cured than women, said Scribonius: Herpin's opinion is that the reverse is true. In regard of my own experience, the former statement is correct. Duration.-Romberg says, Every year the resistance to recovery increases;" and on this point there would appear to be unanimity of opinion. Herpin states that under three months' duration of the attacks the chances of success are great; but it may be questioned whether, in some cases, the diagnosis of epilepsy could be established during this time. Time of the attacks.—Long intervals are of evil omen,** in the * Euvres, Tome VII., p. 215. De Epilepsia, p. 12. Manual, Vol. II., p. 217. ** Millar, De Epilepsia, p. 21. + Op. cit., p. 316. Op. cit., p. 524. opinion of some; but of doubtful influence, according to others. Repeated paroxysms are "très dangereuses." Nocturnal attacks are more rebellious than diurnal, according to Delasiauve.† There is no difference to be observed on this score, according to Herpin; whereas Dr. Watson says it is a "good prognostic sign," when fits, having occurred during the day, begin to limit themselves to the night; § and in this opinion I fully concur. Mental condition of the patient.-Hasse says, "Bildet sich während der Zwischen-zeiten eine psychische Störung deutlicher aus, und tritt ein körperlicher und geistiger Verfall ein, so bleibt die Krankheit unheilbar."|| Esquirol states that "l'épilepsie compliquée d'aliénation mentale ne guérit jamais ;"¶ yet, in spite of these great authorities, I must say that their proposition is incorrect. I have known such cases to recover perfectly. General health.-Herpin says that it is a good sign when the general conformation and complexion are good, and vice versâ ;** but, so far as I have seen, these conditions have nothing to do with the prognosis of epilepsy. II. Prognosis in regard of the mental condition of epileptics is next in importance to that of the disease as a whole. For information on this point we may refer to Chapter IV., Natural History. From this it appears— 1. That the presence of hereditary taint or predisposition is without definite influence upon the mental chances of epileptics. 2. That the female sex is an unfavourable condition.‡‡ 3. That commencement of the disease after childhood and after puberty is also of unfavourable omen; that late rather than early commencement is a predisponent to intellectual failure; that this is true of each sex separately and of them both together when the patients are divided at either the tenth, sixteenth, or twentieth year. 4. That the duration of the disease is of questionable influence; but that the preservation of mental integrity even for a short time after the outbreak of the attacks affords strong probability that the intellectual powers may be retained. When the mind has suffered much it has, as a rule, suffered early; and hence the inference just stated. 5. That the mental state is not to be calculated from the presence or absence of those interparoxysmal phenomena which show the existence of disturbance in the centre of motility. 6. That the general health does not determine the existence or degree of intellectual impairment; but that the latter is more commonly associated with a vigorous condition of the former than with the reverse. 7. That the inference to be drawn from the number of attacks is similar to that from the duration of the disease, viz. that it is without direct value, but that from the fact of intellect being preserved after several seizures have occurred affords hope that it may be continued notwithstanding their repetition. 8. That a rapid rate of occurrence of attacks, or high rate of frequency, is of unfavourable omen. 9. That the severity of the convulsive paroxysm is without definite influence upon the mental chances. 10. That the character of the attack is of considerable importance, viz. that "le petit mal" is more prejudicial than “le haut mal." III. The danger to life of the attacks appears, according to Schroeder van der Kolk, to be represented to some degree by the absence of bitten tongue;* inasmuch as in those cases where this symptom did not occur capillary dilatation was found specially developed in the course of the vagus, and thus the respiratory functions were most seriously involved. The danger to life, however, in the epileptic is a somewhat remote contingency. It rarely happens that the fits have proved directly fatal. Instances are to be found of death from cardiac disease,† and from cerebral complication; and I have known a case in which a pauper was said to have died in an attack, but the real cause of asphyxial convulsions and of death * On the Minute Structure and Functions, &c. Syd. Soc. Trans., p. 252. + See Cases X. and XII., pp. 230 and 232. |