A SEMIANNUAL CRITICAL DIGEST OF SOME OF THE LITERATURE ON EPILEPSY

Régime of Hypochlorization.—The milk regimen is a simple way of carrying out the diet, but most patients do not like it. If used, 3 or 4 quarts are allowed in 24 hours. It is of course not necessary to place a patient on the minimum salt diet. As much as 5 gms. daily may be taken in food, and the diet will still be one of relative hypochlorization. The amount of salt in the diet may easily be varied.

Bromization.—If a patient is on full doses of bromides when the diet is begun, we must reduce gradually by I gm. of bromide daily until we reach a minimum of 2 gms. It is well, however, not to go to extremes of any kind until necessary. Thus we should see what can be accomplished with a daily amount of 5 gms. of salt and 4 gms. bromide. If the attacks are not controlled, these amounts may be varied, the one increased and the other diminished. An extra gm. daily of bromide may make all the difference possible in the number of attacks. After some time the proper dose for the patient can be determined. When improvement is assured, it is possible to run the salt up to 10 and 15 gms. daily without a return of the attacks. It is a question how long should this treatment be kept up. Toulouse's patients have used it for 7 months with excellent results. Bromism must be avoided; when the hebetude appears, the patient should be purged and placed on the salted milk regimen (3 gms. of salt to a liter). The drug should be suspended, but for a few days only.

Toulouse does not give bromides when the temperature is above 38.5°, as he finds a fever of this degree to be an antidote to epilepsy. With regard to the bromide salt, Toulouse adheres to the sodium throughout.

Näcke (14) has also written upon the dechloridizing treatment of Toulouse and Richet. Last May, Näcke paid a visit to Toulouse and studied the case-histories and charts of the latter. The sudden improvement shown by the seizure curves he regards as nothing less than wonderful. In some cases the curves show that attacks reappeared, but in others the improvement appeared to be continuous. When the treatment is discontinued the seizures reappear, but it is possible that perseverance in the treatment might lead to permanence of cure.

It is quite probable that this new form of therapy can find application outside of epilepsy. Very promising in theory is the outlook for the iodide treatment of syphilis in connection with hypochlorization. The aim of the author in contributing this short article is to earnestly request all epileptologists to give the Toulouse method a fair trial. It is interesting to note that the well-known psychiatrist Vaschide went to see Toulouse for the purpose of studying the epileptic paroxysms; but he reported to Näcke that his visit was unprofitable, for such were the therapeutic results obtained that he saw hardly any attacks during his stay. Näcke appears to be highly enthusiastic over the method. It is so novel and yet simple, so rational and sensible, so easily carried out, and so effective, that it appears to be a great advance in our therapy. Näcke believes, nevertheless, that it would be difficult to carry out in private practice, because of the great "salt-hunger" of many individuals, especially in Germany, where salt is thickly strewn upon bread and butter.

Roux (15) has applied the treatment of Toulouse and Richet to four epileptics. He holds that in hospital treatment there is only one way of accomplishing this, viz., the milk regimen, which secures a considerable diminution in ingested chlorine. Roux's cases were examples of typical epilepsy. They were put on the milk, watched carefully, and received besides 3 or 4 gms. of sodium bromide daily. The results were most satisfactory; in a few days the attacks diminished in intensity, became less frequent and wholly disappeared.

Roux wondered if there was more in the milk diet than a mere withholding of salt to get such striking results. The author believes that this secures intestinal antisepsis, preventing the formation of toxic substances. Roux tried the experiment of giving the patient last mentioned an extra amount of salt in connection with the milk and sodium bromide. She took, on consecutive days, 6, 8 and 10 gms. of free salt. On the third day the crisis reappeared with great violence. The extra salt was suppressed and the crisis did not reappear. Therefore the benefit of the milk regimen was thought to be due to the salt. Unfortunately the matter demands much further investigation before we can be positive in this conclusion.

Toulouse's (16) paper on "The Treatment of Epilepsy by Bromides and Hypochlorization" was read before the Société des hôpitaux, Jan. 12, 1900. This second paper, however, provoked a discussion, as follows:

Rendu. These results are very interesting; when we think of our helplessness in treating epilepsy the results are surprisingly good. But is there anything curative about this treatment? Will not the attacks reappear afterwards? Merklen. When chloride of sodium is in excess in the blood, does this result in irritation of nerve-elements with precipitation of neuroses? I have found hyperchloruria in neuroarthritides during paroxysms of neurasthenia of the pulsatile type (with cardiac and vascular palpitation). At such times analysis of the gastric juice showed hyperchlorhydria. Dupré. Was the urine examined to verify the existence of hypochloruria? It would also be of interest to measure the toxicity of the serum and urine during hypochlorization.

Toulouse replied that Merklen's question was quite new to him. In answer to Rendu, he admitted that although there had been 7 months' immunity owing to treatment, attacks had returned on suspension of the regimen. He did not know whether there was anything to be hoped for in the way of cure if the regimen was persisted in indefinitely. With regard to the urine, the proportion of chlorine to bromine remained almost unchanged throughout.

Linossier believed that Toulouse's interesting results were susceptible of a very simple explanation. Some years ago Nencki and Schumow-Simanowski showed that bromine could be substituted for chlorine in the tissues. After only ten days of bromine treatment they found more bromine than chlorine in the tissues of a dog. In the kidneys and bone-marrow the proportion was 2 to 1. The bromide is not to be regarded as a foreign substance, but as a true mineral constituent of the tissues. When the bromine is discontinued, it becomes in turn replaced by alimentary chlorine, but it is four months before it is completely eliminated. It is evident, then, that bromine may partly replace chlorine chemically and physiologically as well. A good example of this sort is found in the gastric juice. In a bromized animal the latter secretion has part of its chlorhydric acid replaced by bromhydric acid.

An organism impoverished in chlorine has all its tissues greedy to take up chlorine, and perhaps bromine as well. If the salts are now exhibited they do not immediately appear in the urine because first taken up by the tissues. Thus bromides would also be taken up with avidity and economically. It is the bromide which is fixed in the tissues which produces the therapeutic effect and not that which circulates in the blood.

An interesting question is, "What could be done with the iodides plus hypochloruration?"

In an article upon the Surgical Treatment of Traumatic Jacksonian Epilepsy, Graff (17) states that a stage of pessimism succeeded to the optimistic views of the curability of traumatic epilepsy by operation. At present we have a few rays of light illuminating a dark subject.

The careful statistical table of von Bergmann and Braun shows a total of only eight cures out of several hundred cases. Since then other surgeons have published more favorable figures.

Von Bergmann claimed that the shorter the interval between trauma and convulsions, the better the prognosis. If this is true, there are certain exceptions. No one has studied this entire subject with more earnestness than Kocher. Operation upon these cases, he says, is of benefit because of the resulting lowering of intracranial pressure. Experiments leave no doubt that there is a relationship between epileptic attacks and intracranial pressure. But Graff has carefully gone over these experiments and cannot corroborate the findings of Kocher and his pupils. Increase of pressure and hyperemia are not enough to account for epilepsy; if they were, we should have convulsions in many organic brain diseases. Kocher has invariably found a state of chronic œdema in the pia and arachnoid in the course of his operations; in certain cases there was also dilatation of the lateral ventricles or cysts containing cerebrospinal fluid. In all his cases he has endeavored to drain off this excess of fluid, and this precaution may explain why his results are superior to those of other operators. In cases which relapse he demonstrates that bony occlusion of the trephine opening had interfered with this drainage. In a series of II operations, Kocher obtained 6 radical cures.

With regard to the opening to be made, it is better not to attempt to localize too closely the "exact" method; but to make a wide opening to make allowance for the "individual variation" which is known to occur. The exact technique of operation may be omitted, as of interest chiefly to a few operators. After the interference an important principle arises as to the policy of leaving a ventilating opening, as practised by Kocher. The author is unable to decide this point. Kocher's results, of course, speak in favor of a patent opening. By the old method of closure he got but 14 per cent cures; but under his special technique (splitting the dura, etc.) his percentage of cures ran up to 54.7 per cent. The best results came about in cases in which adhesions could be separated. Under such circumstances Kocher's percentage of cures was 88 per cent. It appears safe to say that the more radical the interference the better the result, as the actual exciting cause is more likely to be found.

Upon what sort of cases shall we operate? Many factors may be named, the more severe the case, and the more rebellious to non-surgical treatment, the shorter the interval between injury and convulsions, the more evidence of anatomical lesion, etc., etc.

Braatr's perforator, Gigle's saw, and other modern instruments have supplanted the old trephine and chisel.

In conclusion, I believe the Toulouse chlorine starvation treatment is rational and bound to form a permanent part of the future treatment of epilepsy. I have seen it of benefit in two ofmy own cases in a trial of nearly a year. Only a careful test of the method lasting several years in a large number of cases can prove its exact value. As to the surgical treatment of epilepsy, honors seem about even between those holding contending views of its efficacy.