State Provision for Epileptics. By William Francis Drewry, M. D., OF PETERSBURG, VA., First Assistant Physician Central State Hospital, etc. [Reprinted from Transactions of Medical Society of Virginia, 1895.] State Provision for Epileptics. By WILLIAM FRANCIS DREWRY, M. D., of Petersburg, Va., First Assistant Physician Central State Hospital, etc. The purpose of this paper is to direct attention to that neg- lected and abandoned class of defectives known as epileptics, and to plead, from the standpoint of physician, numaniiariuu and political economist, for a betterment of their condition. It is, however, beyond my power to convey in written words a proper idea of the abject wretchedness of many of these unfortunates. I hope others may be convinced, as I have been, that no other afflicted beings are in such urgent need of special institutions for their care and treatment. Epilepsy is, to the physician, the statistician and the sociolo- gist Hke, unknown and unknowable factors. As a concomi- tant > f idiocy,1 insanity and crime,2 this blight upon the human race assumes enormous proportions. Prognosis.—The etiology and pathology3 of epilepsy being so E. A. Osborne, Superintendent of the California Institution for the Feeble-Minded, is authority for the statement that in his experience epilepsy exists as a predisposing or complicating cause of feeble-mindedness in over sixty per cent, of all cases. (Institution Bulletin, February 1, 1894, page 13.) Dr. Miller, Superintendent Nebraska Asylum for Feeble-Minded, says he be- lieves that epilepsy in some form permanantly enfeebles more minds than all other complications. (Charitable Observer, January 1, 1894.) 2 According to Richter, most crimes, especially murder, burglary, common theft, embezzlement, and resistance of State power, come by epileptics, or in those with a tendency to epilepsy. (A. MacDonald.in Abnormal Man, etc., 1893, pages 51 and 77.) 3 Hirt, in his admirable book on Diseases of Nervous System, says, “ The struc- ture, as well as the physiological fun lions of the human brain, are, up to tbe present time, so little understood, that we are far from having any sure basis upon which to lay the foundations of a cerebral pathology. Epilepsy is a functional neurosis, the seat of w7hich is still unknown.” 4 little understood, the treatment must, of course, be more or less empirical. However pessimistic it may seem, the prognosis, so far as permanent recovery is concerned, is seldom favorable.4 No disease is more intractable to therapeutic measures alone. The larger one’s experience with it becomes, the deeper this con- viction is fixed. Few chronic diseases, however, are more amen- able to improvement, provided judicious treatment—prophylac- tic, medical and moral—is faithfully carried out The insid- iousness of its inception, the subtlety of its progress, its practica- ble incurability, its hereditary nature, its demoralizing effects, combine to make it one of the most dreaded maladies. And, in the language of Sachs, “the frequent development of dementia, idiocy, or of epileptic insanity in epileptics, makes the outlook gloomier still.” Prevalence of Epilepsy.—It is certainly a very widespread dis- order. No accurate data can be procured upon which to esti- mate the proportion of epileptics to the general population. For obvious reasons, little reliance can be placed in the census reports. In this country, the usually accepted ratio is two per thousand of the population. Some authorities,5 however, think it is much greater than that. One hundred and thirty-five thousand epi- leptics! What an enormous army of unfortunates distributed throughout our land, a great majority of whom are in a more or less helpless condition. Supposing 10 per cent.6 of these are insane and cared for in hospitals, there would still remain one hundred and twenty-two thousand of these afflicted beings hid- den away in private homes, brooding over their fearful malady, or confined—merely sheltered, fed and clothed—in the poor- houses, or wandering about in the most hopeless, abject misery— all waiting for some sympathetic soul to lead them to a happier condition of life. Epilepsy in Virginia.—Virginia has her proportion of these de- 4 The best authorities, Peterson among them, think that no more than one per cent, of idiopathic epilepsy in general practice get well. Sachs has seen but very few cases of absolute cure of genuine epilepsy. 5 Osborne and others. 6 Peterson thinks that the proportion of insane epileptics to the sane epilep- tics is very small, much less than ten per cent. (Jour. Amer. Med. Ass., Sep- tember 30, 1893.) 5 fectives. In the three State hospitals for the white insane, there are 115, and in the hospital for the colored insane, 85 epileptics, or a total of 200. After repeated and persistent efforts, I ascertained that in forty out of sixty county poorhouses heard from, there are 45 white and 53 colored epileptics, or a total of 98. In the county poor- houses not heard from and in the city almshouses, there are probably as many more. The actual number, then, known to be in the State hospitals and in forty of the county poorhouses, is 298. Add to this the probable number in the city almshouses and in the rest of the county poorhouses, and the number of epi- leptics now being cared for in our public institutions would cer- tainly reach 400. Now, as to the number of epileptics outside of any institu- tion—those scattered throughout the State in their own fami- lies—there is no means of knowing. In order to arrive at some- thing like an approximate estimate of the number, I sent com- munications to two hundred representative physicians, distributed in every county throughout the State, asking the number of these patients in their respective localities (or practices) and the prob- able proportion to the general population. I got responses to about half of my letters. Ninety-three physicians reported an aggregate of 340, or an average of 3.5 for each. Ten of these physicians had no cases at all. Supposing the one hundred and seven who did not respond bad no cases, then the average for each of the total number (200) would be 1.7. In brief, for every two physicians there are prob- ably three epileptics. Of course, in some localities the disease is scarcely known, while in others it is quite common. I use, in my calculations, only the information gathered from those physicians who do not practice near each other, so that it is barely possible that any case was reported more than once. The prevailing opinion among the ninety-three practitioners from whom I heard was that there were three epileptics to each 1,000 of the population, or nearly 5,000 in the entire State. Even if this estimate is twice as large as it should be, the fact would still remain that epileptics constitute a very large part of our de- fective classes. In my opinion, the number would certainly reach 3,000. 6 Medico-Legal Aspect of Epilepsy.—In the medico-legal aspect of epilepsy, a singular indifference exists, yet the victims of this disease constitute an uncertain and dangerous element in society. Many breaches of the law and of the peace are closely connected with a vitiated epileptoid condition, ranging from masked epi- lepsy to the genuine grand mal. The mental aberration in epi- lepsy may vary from the slightest defection to the most profound dementia or furious mania. The epileptic dyscrasia betrays itself in sundry peculiar ways, and no one can tell when or how a sudden insane impulse may possess the erratic victim of fits. Some of the most revolting crimes have been committed by epileptics, not, however, through the innate depravity and wick- edness of the individual per se, but owing to the strange protean manifestation of his disease. McDonald, in his “ Abnormal Man,” is right when he says that they should be separated from other prisoners and treated medically. Misfortunes of Epileptics.—The life of an epileptic is, to a great extent, a secluded one, because a cruel irony of fate has ordained that the suddenness, the irregularity, and the distressing char- acter of the attacks, often interfere with his plans and expecta- tions. Shunned and neglected, left to himself to ponder over his hopeless malady, he grows up in ignorance, idleness and misery. The very nature of his affliction debars him from en- joying equal privileges and advantages with his more fortunate fellow-beings. The avenues of employment open to others are frequently closed to him.9 Deprived of many social advantages, opportunities for acquiring an education or trade, denied the privileges of the church and places of enjoyment and amuse- ment, many epileptics eventually deteriorate mentally, physi- cally and morally, becoming finally charges upon the public. Burden on the Family.—A victim of fits is an unconcealed skeleton at home, an object of ceaseless anxiety, requiring con- 9 Iii an admirable paper on the “Provision for Epileptics,” read at the Na- tional Conference of Charities and Correction, 1894, Hon. W. P. Letch worth, Commissioner of the New York State Board of Charities, said that all charity workers, whether medical or lay, have found it almost impossible to obtain employment for those who suffer from fits, with the result that the work- houses, alms-houses, and lunatic asylums, become the only places where these unfortunate people can be received. 7 stant oversight. He is a menace to the happiness and comfort of any family. His presence is disturbing and distressful. How horrible and despairing to loving parents is this specter of a hope- less epilepsy! At home it is, for obvious reasons, impossible to give the attention and treatment that the welfare of these patients demands. Even in the families of the rich they are deprived of the advantages essential to their well-being. But a large pro- portion of these afflicted families are already in poverty and ab- sorbed in struggles for a livelihood, hence the caring for a de- pendent who can contribute little more than nothing to his sup- port, becomes a heavy and grievous burden. Poorhouse Improper Place for Epileptics.—On account of the peculiar and distressing character of their infirmity, epileptics are refused admission to general hospitals. They should not be classed with paupers, because, in most instances, if opportunities are offered, they are able and willing to earn a livelihood. To the other inmates of the almshouse, epileptics are certainly very objectionable, and sometimes dangerous. Moreover, these insti- tutions being without resident physicians, experienced nurses and hospital equipments, are not prepared to give the care and treatment these patients, from the peculiar nature of their disease, should have. The Insane Asylum Not the Place for Epileptics.—They are not, unless their disease is allowed to go on unchecked, which, unfor- tunately, is too often the case, devoid of intelligence. It may be that only about the time of the attacks they are incapacitated for the ordinary duties and privileges of life, while during the intervals they may possess even marked intelligence and mental capacity. History records some remarkable instances of the kind.10 Any one who has had any practical experience with epileptics and the insane, knows that it is unwise to mingle them, such association being injurious to both classes. Every principle of 10 It has been repeatedly stated by writers that Handel, the great musician ; Dostojewsky, the author of “ The IdiotPetrarch, the poet and writer ; Napo- leon Bonaparte and Julius Caesar, the renowned soldiers; Mahomet, the prophet; St. Paul, the great Apostle, and the erratic Byron, were all sufferers from this “thorn in the flesh.” 8 humanity and justice revolts against this indiscriminate com- mingling of lunatics, paupers and epileptics in the same insti- tution. The State the Best Guardian of Epileptics.—What to do for this needy and troublesome class of the population is a question worthy of our deepest consideration. Protection and aid to the victims of the malady, as well as to society in general, demand that provision of some kind be made for their care. The State Government is well adapted to deal with the sub- ject, and should be called upon to take it in hand and urged most earnestly to give it that attention which its importance truly demands. In the onward march of charity, benevolence and civilization, human suffering of almost every other kind has received gov- ernmental aid, and it is a reproach upon this age of progress and enlightenment that almost nothing has been done to alleviate the pitiable condition of epileptics. It is pleasing, however, to know that in some quarters of the globe interest in them has been awakened, and that this interest is gaining ground. The question naturally arises, What is the wisest method of giving this much needed help to epileptics? Industrial Colony for Epileptics.—After years of experience and actual operation, it has become a recognized fact that the special requirements of epileptics are nowhere so well met as in the so- called farm colony. The prime objects of such a colony are to give each beneficiary the advantages of the most scientific medi- cal treatment, the most humane custodial care, means of regular productive employment, and facilities for acquiring an education or a trade. To accomplish these objects, palatial structures are not necessary. Plain, inexpensive pavilions or cottages, natural and homedike to most of the inmates, shops and other buildings for various industries, a hospital for the sick and infirm, halls or gymnasiums for recreation and amusement, chapels and school- houses, etc., all arranged on the village plan, and attached thereto a large farm, properly equipped, meet the requirements admira- bly. For those who become insane, isolated buildings of a suit- able character should be provided. In such an institution, the beneficiaries would not suffer the ignominy attached to the pauper 9 class, for they would be, in a degree, producers and not absolutely dependent. Origin of the Epileptic Colony—Care of Epileptics in Other Coun- tries.—The pioneer in this noble philanthropy was a French clergyman,11 who, in 1848, conceived the idea of grouping the indigent epileptics of his parish in pleasant, home-like buildings,, erected on a farm, where medical treatment, agreeable industrial pursuits in the open air, regular habits, proper diet and hygienic surroundings would, he thought, prove efficacious in lightening the burdens of the afflicted inmates. Inspired, doubtless, by the worthy example set by this benefi- cent man of God, and encouraged by the success attained in France, another Protestant clergyman12 was instrumental in es- tablishing, in 1869, the now justly celebrated Bielefeld Epileptic Colony, in Germany. This colony, after which many others have been, to a great extent, modeled, consists now of a farm of 1350 acres, upon which are dotted here and there, in irregular but picturesque manner, amid groves and gardens, orchards and vineyards, cottage homes adapted to the various grades of pa- tients, 1,200 in number, whose lives are passed in useful occupa- tions, pleasant diversions, learning trades, going to school, and in making other efforts to become useful and happy citizens. For the men there are thirty or forty different avocations, and for the women a dozen or more. This diversity of occupation furnishes ample opportunity for each beneficiary to engage in whatever best suits his or her taste and requirements. Infirma- ries for the sick and feeble, and a separate building specially for those who become excited or insane, are provided. The labor of the patients contributes so much to the support and growth of the colony, that it has become, in a great measure, self-sustain- ing. Says Peterson: “For nobility of conception and success in results, this wonderful charity has nowhere an equal.” Within the last two decades a number of these “ Colonies of Mercy” have sprung up in Germany, France, Holland, Switzer- 11 Rev. John Bost, a Lutheran preacher, was the name of this great bene- factor. His institution is still in a flourishing state, and reflects much credit upon its creative genius. 12 Von Bodelschwingh, a Protestant pastor, started his institution in West- phalia, with one cottage and a garden and twelve patients. 10 land, England13 and Sweden;14 all of which are doing a grand work for suffering humanity. Care of Epileptics in this Country.—This country, progressive in almost everything, and abounding in charity, has been singu- larly slow in recognizing her duty to the thousands of epileptics scattered everywhere throughout our land. True, a few human- itarian associations and legislative enactments have for their ob- ject the mitigation of their wretched condition, but there is little tangible proof of our real sympathy for these afflicted and aban- doned fellow creatures. The first decided step made on this continent, and probably in the world, in the humanitarian care of epileptics exclusively by the State, was made by Ohio.15 She opened, in 1893, her hos- pital for epileptics. The plans adopted contemplate the erection 13 Dr. William Alexander, aided by the liberality of a wealthy citizen of England, established in 1889 the Maghull Home, near Liverpool, where a lim- ited number of epileptics receive care and treatment in accordance with the most advanced theories. The results of this praise-worthy movement have been so gratifying that efforts are being made to enlarge its capacity. In Surrey, the Countess of Mearth, prompted by her generous and benevolent spirit, has established a pleasant refuge for epileptic girls and women, having a capacity for about fifty. In London, there are one or two hospitals where recent cases of epilepsy are received and given special treatment. The National Society for the Employment of Epileptics has purchased a farm in Buckinghamshiie, upon which there is in course of erection suitable cottages to accommodate and give employment to several hundred (eight hundred, I think,) sane epileptics. Separate provision will be made for adult males, adult females, and children. Here w;ll be provided “a home forthose necessitous epileptics, who are able and willing to work, but for whom their friends are unable to procure employment on account of the affliction which bars their admission into ordinary fields of industry.” 14 In 1892, there was built at Wilhelmsro, in Sweden, the nucleus of a home for epileptic children. The methods adopted there are those in vogue at La Force, France. 15 There is only one State Hospital exclusively for epileptics in this country— the one at Gallipolis, Ohio. In 1890, a bill favorable to the establishment of a hospital for epileptics was passed by the Ohio Legislature. The corner-stone was laid November 12th, 1891. To General Brinkerhoff, President of the State Board of Charities, belongs the greatest credit for this noble charity, for he was untiring in his efforts to get the authorities to recognize the wants of the epileptics of his State. 11 of thirty-six buildings for patients, a number of shops to provide opportunities for the industrial and educational training, as far as practicable, of all the indigent epileptics in the State. In time, more land will be purchased, in order to enlarge the facili- ties for employment of the inmates and to supply the institution with all needed vegetables, fruits, etc. Already, nine pavilions have been completed and are occupied by five hundred patients, whose condition, I am informed by the authorities, has very much improved under the care, proper diet, systematic medical treatment, improved hygienic surroundings, regular labor and exercise; all of which they have the benefit of daily. The medical treatment is conducted by experienced physicians, who are making careful scientific investigations, that will in time bear good fruit. The Ohio Hospital for Epileptics, sane and insane, is a recognized success and blessing. With a high resolve and determined purpose, Dr. Frederick Peterson and Hon.W. P. Letchworth, backed up by the State Board of Charities, were instrumental in getting the New York Legis- lature of 1894 to recognize the State’s obligation to these un- favored people. The result was the establishment of the Sonyea Colony for Epileptics, which, with its 1,800 acres of fertile land, abundant water supply, healthy surroundings, cottages, work- shops, schools, churches, etc., possesses excellent advantages for the proper accommodation of several hundred epileptics The objects of this great colony are to provide gratuitously the hu- mane, curative, scientific, and economical treatment and care of dependent sane epileptics. It is thought that this institution will in a few years become self-supporting. The last Legislature of Massachusetts, just and generous, author- ized the establishment and maintenance, at the public expense, of a hospital-home for epileptics. The hospital cottage at Baldwinsville,16 Mass., though a private benevolent institution for non-insane epileptic children, receives a liberal donation from the State. 16 This was the first charity institution for epileptics in this country. It was opened in 1882, as a private benevolent establishment, wuth nine patients. Now there are more than one hundred little sufferers domiciled here. 12 In California,17 Pennsylvania,18 Maryland,19 Minnesota and Michigan,20 limited provision, on the industrial and educational plan, has been made at the State institutions for the feeble- minded, for the care of sane epileptics. Illinois, Wisconsin, and other States are being urged by their respective medical societies and boards of charities to erect separate institutions for this class of people. Virginia’s Duty to Her Dependent Epileptics.—Will Virginia, upon whose soil was erected the first public21 hospital on this continent, exclusively for the care of the insane, and who built the first, and still has the largest, asylum for insane Negroes in the world,22 be any longer derelict in her duty to her poor epi- leptics? Will she refuse to respond to the cry of these unfor- tunates? I believe not. The State care of epileptics is a subject worthy of the most serious and earnest thought, and is of the deepest interest to all the people. Whether this care should consist in a hospital, pure 17 About one hundred epileptic children are cared for in the Home for the Feeble-Minded. The able superintendent, Dr. Osborne, writes that “the de- pand for admission of epileptics has been steady, persistent, and far in excess of our means to provide for their care.” 18 The St. Clement’s Hospital for the care of indigent sane epileptics of Phil- adelphia, maintained chiefly by private donations, has been in existence three or four years, and is doing a good work on a small scale. Steps are now being taken looking to the “ organization of a colony-farm, convenient to Philadel- phia, on which can be erected necessary buildings, including an infirmary, work-shops, and separate small cottages, wherein the patients, according to their mental and physical conditions, can be cared for in the most approved manner.” At the Elwyn School for Feeble-Minded, about one hundred epileptic chil- dren are being cared for in a separate building. The State Lunacy Commis- sion, in 1893, urged the Legislature to make separate, suitable accommodation for epileptics upon an industrial basis. 19 The Maryland Institution for Feeble-Minded will soon erect a building especially for poor epileptics. Under the auspices of the King’s Daughters, a small farm-colony for epileptics is being conducted near the city of Baltimore. 20 Michigan has begun the erection of farm cottages for her epileptics and feeble-minded, to be conducted on the industrial plan. 21 Eastern State Hospital, at Williamsburg, Va., opened in 1773. Pennsyl- vania had in 1752 provided accommodations for the insane in a general hospital in Philadelphia. 22 Central State Hospital, established first near Richmond, ip 1870, removed in 1885 to Petersburg, accommodates 840 insane negroes. 13 and simple, or a colony on the plan I have outlined, or whether special accommodations should be provided at institutions for other defectives—the insane or the feeble-minded—are questions for mature consideration. Suggestions —In an article published in the Virginia Medical Monthly, September, 1894, I advocated the State care of all de- pendent epileptics in an institution exclusively for them. I re- iterate the opinion expressed in that paper, viz: That a farm- colony, conducted on the industrial and educational plan, and provided with every facility for the most scientific medical treat- ment of the patients, as sketched in the foregoing pages, would meet the requirements better than any other method yet sug- gested. It is feasible; it is economical; it is humane. It has been tried elsewhere, and demonstrated beyond question to be a practical success. Who should reap the benefits of such an institution? First. The epileptics now confined in the hospitals for the in- sane. By removing these, two hundred in number, sufficient room would be gained at these institutions to accommodate, probably, all the insane of the State in need of care and treat- ment, at least for a while. Second. All the epileptics now in the county and city poor- houses—certainly as many as two hundred. Third. Dependent sane epileptics—each county and city to have a number of patients proportioned to its population. Fourth. A limited number of pay patients, who may be in pressing need of special treatment and care. Fifth. Both white and colored epileptics—separate and distinct provision being made for each race, both under the same general management. To determine the question of epilepsy, proper legal proceed- ings should be had, as in the case of insanity. The State, how- ever, is sadly in need of a better law regarding the commitment of the insane. The Duty of Physicians.—Our law-makers need to be reminded of the necessity and humaneness of special pro vision, for epilep- tics. Let us, Fellows of the Medical Society of Virginia, with a broad and comprehensive devotion to the general good and to 14 individual happiness, use our best efforts in the creation of a just public sentiment regarding this matter, and, as far as lies in our power, try to “raise the fallen, cheer the faint, and heal the broken-hearted.” Public sentiment, the potent power that accom- plishes great deeds of mercy and benevolence, never arrays itself against the afflicted and suffering. Only the ignoramus or the narrow-minded bigot will dare discourage any effort to help such unfortunates. If there be any such, tell them the old proverb, “Whoso stoppeth his ears at the cry of the poor, he also shall cry himself, but shall not be heard.” It is not, I believe, utopian to hope that in the near future our State will awaken to a recognition of her duty to her epileptics, and see the wisdom of making that provision for them which is clearlv demanded by every consideration of justice, equity and philanthropy.