Some Certainties in the Thera- 
peutics of Epilepsy. 
BY 
C. L. DANA, M. D., 
PROFESSOR OF NERVOUS DISEASES IN THE NEW YORK 
POST-GRADUATE MEDICAL SCHOOL ; VISITING 
PHYSICIAN TO BELLEVUE HOSPITAL. 
REPRINTED FROM 
ffi&e Keto York jfEetncal Jtournal 
for April 2Jf, 1886. Reprinted from the New York Medical Journal 
for April 1886. 
SOME CERTAINTIES 
IN THE 
THERAPEUTICS OF EPILEPSY.* 
0. L. DANA, M. D., 
PROFESSOR OF NERVOUS DISEASES IN THE NEW YORK POST-GRADUATE MEDI- 
CAL SCHOOL ; VISITING PHYSICIAN TO BELLEVUE HOSPITAL. 
The ancients regarded epilepsy with a horror which 
plainly affected their views of its therapeutics. They had 
no specifics in the line of drugs, hut recommended the 
most violent counter-irritation, bleedings, purging, starva- 
tion, and such heroic mental remedies as a draught of 
blood fresh from a dying gladiator. On the part of the 
Hippocratic school and its later followers, Celsus, Galen, and 
Aretseus, there was a great deal of wise insistence upon “ a 
soft diet free from crudities,” and regular exercise. But 
we learn nothing more'than this from the medical fathers 
regarding the therapeutics of epilepsy. 
The views of various physicians of eminence for the one 
hundred and fifty years previous to the introduction of 
bromides are most interesting, and not without practical 
value. 
Great frugality and great exercise cure epilepsy, said 
* Read by title at the eightieth annual meeting of the Medical So- 
ciety of the State of New York; read before the Clinical Society of the 
New York Post-Graduate Medical School and Hospital, February 6, 
1886. SOME CERTAINTIES IN THE 
Boerhaave. Tissot thought that cases of centric epilepsy 
which valerian would not cure were incurable. Dr. Benja- 
min Rush recommended sugar of lead. Schroeder van der 
Kolk was an ardent advocate of counter-irritation and scari- 
fications. Graves cured several patients with Cotyledon um- 
bilicus. Sir Thomas Watson said that in ordinary forms 
of epilepsy he would expect more from turpentine than any 
other single remedy. Herpin professed to have cured over 
half of forty-eight cases with oxide of zinc; hut he subse- 
quently pinned his faith more strongly to Selinum palustre. 
Skoda stated that the best remedy against epilepsy was 
belladonna, and Trousseau appears to have had greater faith 
in it than any other drug, Marshall Hall believed in the 
efficacy of small doses of strychnine, and, for certain forms 
of epilepsy, advocated tracheotomy. All early writers 
insist strongly upon the importance of diet, exercise, and 
baths, the opinions being that epileptics should live on a 
spare diet composed of soft and easily digestible food. 
No more instructive chapter could be written than one 
giving a record of the changes and contradictions of opinion 
during the two thousand years in which medical experiences 
have been recorded regarding remedies for epilepsy. Thus, 
for a thousand years doctors gave hellebore for this disease; 
then it was found that it did no good ! But of late years 
we have arrived at more certainty, because, although we do 
not know much more about the disease, yet we have learned 
to weigh evidence more carefully, and to exclude sources of 
error in forming opinions. These sources of error are: 
1. The fact that, in some cases of epilepsy occurring in 
those quite young, or in adults, the attacks cease spontane- 
ously, either entirely or for a very long time. 
2. In epilepsies beginning before or during the time of 
puberty there is often a tendency for the attacks to lessen 
or cease after the nineteenth or twentieth year. THERAPEUTICS OF EPILEPSY. 
3 
3. Some cases of epilepsy, so called, are really cases of 
bysteroid convulsion or hysteria. 
4, Almost any new drug or change in treatment will 
lessen the number of attacks for a time. 
5. Reflex epileptoid convulsions are cured in a very 
great variety of ways, depending upon the kind of irri- 
tation. 
Bearing these sources of error in mind, we can still say 
that, despite many contradictions and much conflicting evi- 
dence, there are a few certainties regarding the therapeutics 
of epilepsy. One of these is that we can dispense with a 
long list of the remedies still popularly associated with epi- 
leptic therapeutics—e.g., salts of copper, lead, and silver, 
turpentine, nitro-glycerin, ergot, conium, Cocculus indicus, 
chloral, curare, indigo, oxygen, tartar emetic, galium, Canna- 
bis indica, and a host of ancient and odoriferous vegetable 
remedies, and we can limit our drug therapeutics to bro- 
mides, belladonna, zinc, digitalis, strychnine, valerian, amyl 
nitrite, and cod-liver oil. To this we may add counter-irri- 
tation, diet, exercise, hygiene, and, in traumatic cases, sur- 
gical measures. 
We can limit this still further and say that the success- 
ful treatment of essential epilepsy is based mainly upon the 
following: 
First and foremost, dietetic and hygienic measures. 
Second, bromides. 
Third, belladonna. 
Fourth, zinc. 
Fifth, habit-breaking drugs and measures. 
If one may be permitted to be aphoristic on subjects 
like this, I would express my views regarding the therapeu- 
tics of epilepsy as follows : 
I. Diet, exercise, and proper hygienic treatment, includ- 
ing baths, rank above all other single therapeutic measures. SOME CERTAINTIES IN THE 
If I had to choose between them and bromides even, I 
would select the former. On the whole, I fear that the 
reign of bromides has made the condition of epileptics more 
miserable than it was before, and has done our patients an 
actual harm. At the best, not more than live or ten per 
cent, of epileptics can be cured, while the majority are re- 
duced by bromides to a state of physical enfeeblement and 
distressing mental hebetude. Besides, physicians now fly 
to the bromides, and, trusting to them, neglect the search- 
ing inquiry into the exciting cause, or the careful direction 
of the patient’s habits, which are so essential. 
All medical experience unites in ascribing benefit to 
judicious regulation of diet and exercise. The only differ- 
ence of late years is that we do not now believe epileptics 
should be starved. 
Epileptics should live on a plain, easily digestible diet, 
containing a preponderance of fat. A special meat diet, or 
milk diet, or farinaceous diet, is not injurious nor curative. 
It all depends upon the patient. A meat diet may be best 
if the patient is lithsemic or has a fermentative dyspepsia. 
A milk diet is especially useful for children and erythritic 
women. The meals should be small, and, in cases of vora- 
cious appetite, four, five, or six light meals a day should be 
given. No heavy meal should be taken within four hours 
of sleeping. Indeed, no heavy meals should ever be taken 
by epileptics. Special diets have often to be rigidly laid 
down simply as a matter of discipline, since patients will 
not follow any general directions. I believe that the urine 
and digestive functions should be carefully studied, and 
that thus we shall find indications for selecting the right 
kind of food. 
11. The bromides take the second rank in the treatment 
of epilepsy. 
All bromides act alike in this disease. If one does not THERAPEUTICS OF EPILEPSY. 
5 
cure, another will not. Occasionally changing and mixing 
reduces the attacks for a time, and benefits the stomach. 
111. The best bromides are those of potassium, sodium, 
ammonium, and hydrogen (hydrobromic acid) ; possibly we 
may add nickel. 
Bromide of potassium is the most trustworthy. 
Bromide of sodium is more agreeable to the taste, less 
irritating to the stomach, and milder in its effects, but is 
eventually just as depressing as other forms. 
Bromide of ammonium has a brief stimulant effect on 
the circidation. 
Hydrobromic acid is useful in those cases in which 
there are indigestion and phosphaturia, and an alkali is con- 
tra-indicated. It produces acne less readily than the alka- 
line bromides. 
IV. Bromides should be given in daily doses of 3j, 
increased gradually until the attacks are suppressed, or the 
dose reaches 3iv to § j daily. Few patients can tolerate 
more than this latter dose. Thorough broraidization should 
be always tried if necessary to stop the fits, and it may be 
occasionally repeated. But bromidization is sometimes in- 
jurious, even making the disease worse, and it must always 
be employed with caution. 
Y. When the fits are suppressed, the bromides should 
be carefully reduced, but never entirely stopped for at least 
two years after the last fit. 
VI. In most cases, and especially in nocturnal epilepsy, 
an extra large dose of bromide should be given at night. 
YII. It is very important that bromides should be 
chemically pure, that their use should be continued a very 
long time, and that their depressing effects should be offset 
by tonics and all possible roborant measures. 
YII I. The best non-specific adjuvants (drugs) to the 
bromides are potassium iodide (in syphilitic epilepsy), potas- 6 
SOME CERTAINTIES IN THE 
sium bicarbonate (in lithsemic and rheumatic states), car- 
bonate of ammonium, the hypophosphites, arsenic, iron, and 
quinine. 
IX. The other chief adjuvants to the bromides are diet, 
exercise, a regular life, hydrotherapy, counter-irritation on the 
neck, and, in the line of drugs, zinc, belladonna, strychnine, 
valerian, and the nitrites. Combinations of bromides with 
the other drugs mentioned will lessen attacks when bromides 
alone will not. 
Other drugs which sometimes help the bromides are 
digitalis, Cannabis indica, ergot, conium, chloral, the salts 
of copper, picrotoxin, and borax. None of these do any 
permanent good alone, and their value as adjuvants is not 
uniform or generally conceded. 
X. The best substitutes for the bromides, when these do 
no good or do harm, are belladonna, zinc, strychnine, glo- 
noin, borax, and alteratives. 
XI. Bromides stop the fits in from five to ten per cent, of 
cases, oftener if given early in the disease, if given to young 
children, and if given in cases that develop after twenty-one. 
Bromides lessen the fits in from eighty to eighty-five 
per cent, of cases. 
Bromides do no good, or do actual harm, as regards fre- 
quency of attacks, in from five to ten per cent, of cases. 
Bromides do no actual good to the patient in a much larger 
proportion of cases. 
XII. To prevent bromide acne, arsenic, calcium sulphide, 
baths, and diuretics are the best measures, or hydrobromic 
acid may be used. 
To prevent bromidization, adopt all possible roborant 
measures: use salt-water baths and regular physical exer- 
cise, give black coffee, caffeine, cocaine, mineral acids, 
strychnine, bitter tonics, cod-liver oil, or give large doses of 
the bromides every three days only. THERAPEUTICS OF EPILEPSY. 
In all cases dilute the bromide preferably with carbonic- 
acid water or Yichy in the proportion of six ounces of 
water to a scruple of the drug. 
The continuous administration of an alkaline bromide in 
an alkaline water sometimes affects the bladder, and then 
the bromide can be given dissolved in hydrobromic acid. 
XIII. The remedies that are especially useful in petit 
mat are, after the bromides, belladonna, glonoin (?), Can- 
nabis indica (?), cod-liver oil, ergot (?), counter-irritation at 
the back of the neck, and cold spinal douches. 
XIY. For epilepsy in children, besides the bromides it 
is advisable to employ a milk diet, rest, and oxide of zinc. 
Belladonna, if tried, should be given cautiously. 
XY. For adults and chronic cases, use the bromides, 
belladonna, iodide of potassium, and ammoniated sulphate 
f copper. Oxide of zinc is here of less value. 
XYI. For nocturnal epilepsy, increase the dose of bro- 
mide at night, and add chloral or digitalis. Give also, if 
needed, strychnine. liaising the head of the bed or making 
the patient sleep in a chair at night are measures to be 
tried. 
XVII. For hysterical and erythritic cases, with or in 
place of bromides give a diet of milk and vegetables. Try 
turpentine, valerian, or zinc. Belladonna is usually contra- 
indicated. 
XYIII. Counter-irritation by means of blisters, issues, 
and setons at the back of the neck, is a useful adjunct to 
treatment, especially in petit mal and in cases with mental 
derangement. 
XIX. For the status epilepticus, give large enemata of 
chloral, and use emetics and purges. Venesection is often 
efficacious, morphine is dangerous, chloroform is only pal- 
liative, and nitrite of amyl is of little value. 
XX. To prevent impending attacks, the best remedy is 8 
SOME CERTAINTIES IN THE 
nitrite of amyl, which may he carried in a phial filled with 
cotton. Inhalation of chloroform or ammonia, the internal 
administration of ammonia, spirits of lavender, or alcohol, 
a sternutatory, and pressure on the carotids—all are measures 
which sometimes stop the attack. 
XXI. Alterative and habit-breaking drugs, such as mer- 
cury, iodide of potassium, arsenic, antimony, are useful in 
epilepsy. 
XXII. No surgical measures upon ovaries, uterus, testi- 
cles, cranium, or elsewhere will cure an established long- 
standing epilepsy except in rare cases. Such operations, 
if done, should be undertaken early, before the patient has 
had an excessive number of fits. 
Ligaturing the vertebrals has already killed two patients, 
and has no standing in the surgical therapeutics of epilepsy. 
Oophorectomy is not indicated in true epilepsy. 
Ligaturing the carotids is a measure fallen into disuse. 
Trephining in traumatic cases of epilepsy has cured less 
than one half of patients. 
Trephining cures some cases even when there is no 
depression of bone. 
Trephining for epilepsy is an operation which has called 
out more contributions to medical literature than any other 
single anti-epileptic measure unless it is the bromides. Sixty- 
nine reports of one or more cases are indexed in the Surgeon- 
General’s catalogue. The very large majority of the writers 
report favorable effects, and at least nineteen announce in 
their title a cure. A study of these reports furnishes no 
basis for any generalization, however, since the fatal or 
unsuccessful cases rarely get into print. My own views are 
based upon the cases of trephining about which I personally 
know. I believe that the measure is one that should be 
more widely resorted to, now that opening the cranial cavity 
has been made so safe and can be done under cocaine with- THERAPEUTICS OF EPILEPSY. 
9 
out giving a general anaesthetic. That the operation is being 
done more frequently seems probable from the steadily in- 
creasing number of reports of cases. In the decade ] 850- 
1860 there were only two; between 1860 and 1870, seven- 
teen; between 1870 and 1882, twenty-eight. 
In instructive contradiction to this is the record with re- 
gard to certain other surgical measures, such as arteriotomy, 
tracheotomy, and castration. I know of no recommenda- 
tion of arteriotomy since that of Peraire in 1847. Reports 
on the utility of tracheotomy were made by nine persons 
between 1850 and 1860 ; since then we hear nothing from 
it. Cauterization of the larynx is confined to the same dec- 
ade. Ligature of the carotids was tried by several pre- 
vious to 1850. During the subsequent decade reports were 
made upon it by Mott, Stephen Smith, J, R. Wood, and 
several others ; but since then nothing has been heard from 
the operation as a remedy for epilepsy until Alexander called 
attention to it a few years ago for the purpose of recom- 
mending as a substitute ligature of the vertebrals. 
It is by a similar study of the survival of the fittest (by 
which no pun is intended) that one is able to drop from the 
list of anti-epileptic drugs such once-vaunted remedies as 
galium, lead, chloroform, indigo, alisma plantago, selinum, 
antimony, cocculus indicus, Sedum acre, quinine, hydrocya- 
nate of iron, scutellaria, morphine, cantharides, mistletoe, 
asafoetida, leaving as remedies of certain or occasional value 
those which have been already mentioned. 
In my own personal experience of somewhat over eighty 
cases I have been much helped in reaching definite conclu- 
sions by studying records kept in a diagrammatic way on 
sheets arranged for the purpose. The following will show 
the arrangement of these record charts. No one can realize 
until he has accumulated a number how instructive they 
are to their possessor ; 10 
SOME CERTAINTIES IN THE 
RECORD-CHART FOR CASES OF EPILEPSY. 
L. M., female, 17, s. Essential epilepsy, grand mat, petit mal, and epileptic automatism, 
No organic disease. 
Month, 
1 2 3 4 5 6 7 8 9 1011 12131415 16171819 20 21 22 23 24 25 26 2728 29 30 31 
Days of month. 
Treatment. 
1883. 
Jan. 
None. 
Feh. 
HBr, sol. 5 per ct., 
3 iij daily. 
March 
HBr, sol. 10 per 
ct., 3 iij daily. 
April 
Naßr, 3 jss ; 01. 
morrhuse. ZnO, 
gr. xv. 
May 
Same. 
June 
Nitrite of sodium, 
gr. xv daily. 
July 
Naßr, 3vj daily. 
Tinct. belladon- 
na, HI 50. 
The line ends each month at the number of attacks 
which the patient had daring that month. If there are 
more than thirty-one, it is indicated by figures. The days 
on which the attack occurred are also indicated by a figure. 
Only part of the record is here given. 
I give below a few special modes of treatment advocated 
by physicians of experience in the treatment of epilepsy. It 
should he remembered, however, that epilepsy, least of all 
diseases, can be treated in a routine way. 
SPECIAL MODES OF TREATMENT. 
The zinc treatment of Herpin was as follows : Give gr. 
ij-| of zinc oxide ter in die, increase the dose by gr. a every 
week until gr. xj are taken t. i. d. Keep this up for at least 
three months. It appears that Herpin subsequently used to THERAPEUTICS OF EPILEPSY. 
11 
add or alternate with ammonio-sulphate of copper or sell- 
num. 
The belladonna treatment of Trousseau : 
5 Ext. belladon. £ol„ ) , M 
Pulv. belladon. fol., ) 
Then increase the dose by one pill daily each month until 
twenty pills are taken night and morning. The treatment 
must be continued for a year. 
Sig. One a. m. and p. m. for one month. 
Gowers's method consists in giving the bromides in sin- 
gle doses at intervals of from two to five days, these single 
doses being gradually increased. Thus the patient takes 
3 j on the first day, 3 jss. on the third day, 3 ij on the 
sixth day, 3 iij on the ninth day, 3 iv on the fourteenth day, 
and so on until the maximum dose of about 3 j is reached, 
when the drug is decreased in the same way. 
I have found this a very good method if during the in- 
tervals tonics and adjuvant measures are employed. 
The method of Meynert, in many cases, is to give fifteen 
grains of bromide of potassium three times daily, and in- 
crease the dose by fifteen grains every time a fit occurs until 
they are suppressed. 
A mixed treatment like the following is recommended 
by Ball and Handheld Jones ; 
1. Ammon, bromid., j .. , - . 
Sodii bromid., \ 3 J ’ 
Infas. Valerianae f x. M. 
Sig. | ij daily, increasing until 3 ijss. of the bromides 
are taken daily. 
2. At the same time take a pill: 
Ijf Ext. belladonnm gr, ; 
Zinci oxidi gr. iij. M. 
Sig. One, morning and night. 12 
SOME CERTAINTIES IN THE 
3. A drastic purge weekly. 
An acid mixture for epileptics, which I have found effi- 
cient in two cases which resisted other forms of medicine 
was : 
Acid, hydrobromic. dil., 10 per cent. 3 j; 
Atropinse hydrobromat gr. -g-i-g; 
Zinci citrat gr. iv. M, 
Sig. Take this t. i. d., and gradually double the dose. 
A mixture alleged to be very efficient is : 
5, Potass, bromid gr. xv ; 
Sodii arsenit gr. ; 
Picrotoxin gr. T|-g. M. 
Gradually increase. 
In illustration of the evidence collected from other 
writers I submit a record, showing the opinions expressed pro 
and con regarding three drugs : belladonna, zinc, and am- 
inonio-sulphate of copper, I have similar tables showing 
the state of opinion regarding most of the remaining drugs 
used in epilepsy, hut it is not necessary to publish them. 
It goes without saying that certainties in the therapeutics 
of epilepsy can not be obtained by a single observer, and 
that no one would be justified in dogmatizing upon his own 
experience alone. Art is long, but life is not so short as 
Hippocrates found it, since the physician of to-day has the 
recorded experiences of over two thousand years upon which 
to work. 
The Value of Belladonna and Atropine in Epilepsy.—Recom- 
mended in the seventeenth century by Munch ; in the eighteenth century 
by Theden, Stoll, Hufeland; since then by Bretonneau, Demme (2 cures in 
8 cases), Sroeter, Steiner, Niemeyer, Ball, Handheld Jones; Skoda: the 
surest anti-epileptic; Trousseau cured 40 out of 150 cases; Calovi, 1 
cure reported; Crosio, 1 cure reported; Kroon cured 1, improved 15, 
out of 34; Brown-Sequard, Gowers, Echeverria, Hamilton, Putzel, K6ll- 
- Leidesdorf, Le Coste, 1 cure reported. THERAPEUTICS OE EPILEPSY. 
13 
Adverse Views.—l have found belladonna of no value (Hammond). 
Of doubtful benefit given alone (James Russell). Of very doubtful 
value (Radcliffe). Lessens attacks, but not curative (Reynolds). 
Oxide of Zinc.—Recommended by Bracket, Richter, J. Frank, Loe- 
benstein; Herpin cured 28 out of 48; Steiner, Watson; Sch. Yan der 
Kolk: in large doses, sometimes curative; Reynolds: a useful drug; 
Kroon, in 20 cases, cured 3, improved 11; Nothnagel got good results 
in young patients ; Gowers: useful in hysteroid epilepsy, and as a syner- 
gist to bromides; Hammond: decidedly useful in form of bromide; 
James Russell: decided benefit in 6 out of 20. 
Adverse Views.—Of doubtful value; its prolonged use causes tabes 
sicca (Radcliffe). J. Moreau gave it in nine cases with no benefit. 
Ammoniated Sulphate op Copper.—Nothnagel: may be beneficial, 
especially in adults; Herpin: very useful; Brown-Sequard: it ranks 
high among anti-epileptics. 
Adverse Views.—The salts of copper are useless (Reynolds). Of not 
much use (Radcliffe). Of no benefit (Gowers). 
50 West Forty-sixth Street, February 8, 1886. REASONS WHY 
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