POINTS ON THE TREATMENT 
OF EPILEPSY. 
An Abstract of a Lecture delivered before the Class of the 
Kansas City Medical College, at the 
City Hospital. 
By S. GROVER BURNETT, A. M., M. D., 
KANSAS CITY, MO., 
Lecturer on Clinical Diseases of the Nervous System, 
Kansas City Medical College. 
REPORTED BY COLFAX SANDERSON, ESQ. 
bepbint: 
THE MEDICAL HEBALD, 
ST. JOSEPH, MO. 
1890 Points on the Treatment of Epilepsy.-Burnett. 
Points on the Treatment of Epilepsy. 
An Abstract of a Lecture delivered before the Class of the Kansas City Medical 
College, at the City Hospital, 
By S. GROVER BURNETT, A.M., M.D., Kansas City, Mo., 
Lecturer on Clinical Diseases of the Nervous System, 
Kansas City Medical College. 
REPORTED BY COLFAX SANDERSON, ESQ. 
Gentlemen:-At our last meeting we had concluded the consideration of 
of the general symptomatology and the principal aetiolgical factors of epilepsy. 
In this lecture our remarks will be confined principally to the treatment of 
this affection, making sufficient bearing, however, upon the the pathology and 
aetiology to make our remarks practicable. This case here before you is one 
of the cases presented to you previously, but as the treatment was not then 
mentioned, I desire to bring him before you again to illustrate one point in 
the past methods of the treatment of epilepsy. The first to attract our atten- 
tion is the man's peculiar complexion; this is characteristic of the systemic con- 
dition resulting from the prolonged and injudicious use of argenti nitras. 
At one time the nitrate of silver was given heroically, but at the present time 
is considered to be of little or no value whatever in the treatment of epilepsy. 
Unfortunately in dealing with epilepsy, we have no standard or uniform 
pathology to reason from. Therefore we consider it first as a symptomatic 
affection which may result from numerous pathological conditions. Of organic 
or symptomatic epilepsies, we find them arising from encephalic and nonence- 
phalic or peripheal diseases; traumatism may give rise to either form of the 
disease. Frequently toxaemic conditions are to be held directly and indirectly 
as potent factors concerned in the genesis of epilepsy. Uremia is probably the 
most productive in this condition, and the diathetic diseases, such as gout and 
rheumatism, are held responsible by some writers as also being influential. 
However, these are usually easily recognized and a proper analysis of the 
indications will enable us to establish a rational line of treatment. 
But, again, unfortunately for our easy progress, we find a stumbling 
block in the form of a class of cases in which we can find no gross lesion or 
toxaemic state present; hence, for convenience sake, we call this idiopathic 
until we can do better. However, I am glad to say scientific and pathologi- 
cal researches are throwing some light on the subject and each year the num- 
ber of idiopathic cases are becoming reduced. 
Dr. Seguin reported a case illustrating this point conclusively. The 
patient, a physician's wife, was for a long time under the care of Brown 
Sequard, and during this period was examined by many eminent men. Her 
seizures were both severe and mild, characteristically epileptic, were bilateral 
and accompanied with an ascending epigrastic aura. All indications present 
were purely and simply that of a common epileptic. Shortly after the patient 
came under Dr. Seguin's observation, there were hemi-symptoms developed, 
such as numbness, anaesthesia and paresis, and subsequently chocked disc 
appeared. The post mortem revealed a gliomatous tumor occupying the left 
thalamus and internal capsule. Dr. Seguin believes this growth to have been 
present from the first, some eleven years before, that it grew slowly in the 
beginning and finally took on a rapid growth. 
From this, then, we can understand how we may be led to consider an Points on the Treatment of Epilepsy.-Burnett. 
affection of this character as being idiopathic at first, which may in time 
develop its real organic significance. 
We find the idiopathic form presenting itself for study in several phases, 
all of which we are forced to look at with a certain amount of indefiniteness 
The first to attract us is the presence of some hereditary tendency which may 
be either direct or indirect. There may be a parental history of over-indul- 
gence and debauchery, excessive sexuality and alcoholism, perhaps syphilis, 
and added to this a most potent factor, namely chronic starvation. 
In examining cases, I usually look for some of the following, viz., cranial 
asymmetry, microcephalus, rachitis in children, hydrocephalus, and a history of 
forceps delivery, or an asphyxial state at birth, with or without convulsions. 
Reflexes demand a word, and in this instance I would impress upon you 
the importance of not being led into one-sided reasoning through the influence 
of various popular crazes, such as eye strain, uterine or ovarian irritation. At 
one time the profession resorted to the wholesale castration of women for the 
cure of hystero-epilepsy. 
As great a craze, however, as has been known to the profession, is that 
inaugurated by Dr. Stevens and fanned to a flame by his friend, Dr. Ranney, of 
New York. I refer to the indiscriminate cutting of eye muscles by these 
gentlemen for the relief of eye strain, which they consider a direct cause of 
epilepsy and various diseases of the nervous system. Dr. Stevens persuaded 
himself that eye strain, due to imperfect accomodation, was the key note to 
the genesis of epilepsy, and his procedure was that of withdrawing the 
bromides, cutting the eye muscles and giving glasses. As a result of 
blind enthusiasm fully fifty per cent of recoveries was reported; of course the 
profession was astounded. A commission was appointed by the New York 
Neurological Society to test the efficacy of a procedure which promised such 
a renovation of degenerated humanity, the same to be done conjointly with 
Dr. Stevens. After a period of two and a half years, they made their report 
in November, 1889, to the society, which report consisted of, I think, nine 
cases, not one of which was cured, three slightly improved, and the remainder 
were unimproved. There were other cases not included in this report, as 
they became much worse after a short period of treatment and withdrew from 
the cause rather than be sacrificed to science in an unscientific manner. 
This one-ideaism, though still in progress, is certainly void of any prac- 
tically scientific advancement, and must ultimately find its usefulness confined 
to a more limited field than that claimed for it by Dr. Stevens and his disciples. 
While I make war on crazes and mono-ideas, do not infer that I discard 
all irritations from this consideration, for I believe they have their injurious 
effects and must be sought for and removed; they may be due to various 
causes, such as ovarian or uterine disorders, a phimosis, eye strain, nasal 
polypi, etc. These certainly are not to be overlooked, but while they are 
attracting your attention, do not lose sight of your primary disease (the 
epilepsy), which is slowly but surely blotting out both the intellectual and 
physical forces of your patient. 
Irritations in epilepsy act about as follows: They are constantly sending 
nervous impressions to an already anaemic and functionally crippled group of 
corticle cells These become surcharged, due to the accumulation of these 
abnormal impressions, the equilibrium of energy and the restraining power of 
energy is overcome, and as a natural consequence an explosion of nerve force 
(a fit) takes place. This disturbance of celluar force may at first be localized, 
but when the equilibrium between the generation of force and liberation of 
force has been overcome in a single convolution, and the explosion takes place, Points on the Treatment of Epilepsy.-Rurnett. 
its tendency is to disturb the equilibrium in the adjoining convolution, and 
should it spread from one gyrus to another we may have the entire corticle 
area implicated and a general convulsion resulting, though, as just stated, the 
morbid process to begin with may have been, in a sense, localized. From 
this, 1 trust, you will be practical in your summary of conclusions on this sub- 
ject and put the secondary or irritative phenomena in the category to which 
they belong. 
In idiopathatic epilepsies, then, I would say, be rational in your plan of 
treatment; be searching in your examination and eliminate all discoverable 
secondary causes, and in connection with this do not overlook the hygienic 
conditions. The regulation of the diet is of great importance; avoid all indi- 
gestible material and advise a mild and nutritious form of food. 
Be guarded in your reports as cured. Seguin and others report cases 
where the seizures have returned after an immunity of from three to eleven 
years; hence, while the convulsions may have apparently ceased, showing our 
ability to control them and hold them in check, their tendency to return after 
so long a period of absence would indicate the difficulty of entirely eradicat- 
ing the real seat of the disease. 
Medication.-In adopting a line of treatment do not be in a hurry, but 
take plenty of time, see your patient often for the purpose of adjusting the dose, 
studying the case well, and observing the indications and contra-indications. 
Many drugs have been used, but our time is limited and we will confine our 
remarks to the use of the bromides principally. Remember we do not pre- 
scribe the drug as an enemy to the disease, but it is given for the purpose of 
overcoming the excitability, and thereby bringing the hypersensitiveness of 
the corticle cells to within a point of control. That we may accomplish this 
without plunging our patient into a deplorable state of bromism is no easy 
matter, unless extreme care be taken at the commencement so as to find the 
exact dosage required to bring about a condition just short of the bromic stage. 
The "■haphazard" plan of seeing a case once or twice and prescribing a 
bromide three times a day as is so often done by a certain class of physicians, 
is a very injudical line of procedure and merits severe criticism to say the least; 
the patient is sure to either get too much or too little of the drug, both of 
which are deleterious, and must bring discredit upon his physician sooner or 
later. 
Dosage Laws.-First-Your success will depend largely on your ability 
to observe indications and contra-indications. We find different individuals 
given different systemic effects from equal doses of the drug; for instance, a 
young woman twenty-three years of age being given three fifteen-grain doses 
for ten days, came readily under the pysioligical effect of the drug, when on 
the other hand I have given from sixty to two hundred grains a day in other 
cases without any serious effect. 
Second.-Physiological experiments are always based upon the size and 
weight of the animal; hence, we should remember this in prescribing for 
adults and children, for their capacity for withstanding the drug will be in ac- 
cordance, or proportionately, to the weight and size of the individual, with the 
exception of children seven years of age and younger. Under this age, clini- 
cally, it seems they bear larger doses, proportionately, than do adults, of both 
the bromides and iodides. This is explained on the grounds that while so 
young the assimilation and elimination are more active than at more ad- 
vanced ages. 
Third.-Organic heart disease, cerebral neoplasm (or anything organic Points on the Treatment of Epilepsy.-Rurnett. 
pertaining to the brain), weak heart, sluggish circulation, all of which increa g 
the tendency to bromism by reducing the general vitality of the patient. This 
then renders the examination of the heart and circulation imperative to success- 
ful prescribing, and it is the recognition of such complications that enables us 
to use auxiliary drugs to advantage; in weak heart, strophan thus should be 
given (see article on strophanthus, by the author, in Kansas City Medical 
Record, October, 1890); in organic heart disease, digitalis is indicated. 
Fourth.-The third therapeutical factor to be accomplished is to keep the 
patient just short of bromism. Impending bromism should be readily recog- 
nized, but do not depend on the acne as a guide, for it is of little value. 
Acne depends more upon a peculiarity of the patient for its production than 
it does upon the amount of the drug taken; abnormal conditions of the 
sebaceous glands, deficient activity of the skin, and imperfect action of the 
excretory organs generally are potent factors in the production of acne. 
Where acne is annoying or severe it may be prevented or relieved by the 
use of Fowler's solution of arsenic, providing the bromide is given properly 
diluted. The indications of bromism are, loss of reflex action of the fauces 
and soft palate, dull, listless and lethargic state, weakened heart and circula- 
tion, weakness of muscular action, staggering gait and anorexia. Now if the 
drug be pushed, more severe symptoms are produced, such as increased knee 
reflex, dementia, imperfect speech, foul breath, hallucinations, possibly active 
delirium, and prior to death a typhoid condition. From this you will compre- 
hend the importance of keeping the patient just short of bromism and the deli- 
cacy required to perfect the same; we must avoid insufficient amount thereby 
not allowing the nerve centers to regain sufficient excitability to permit of an 
attack and at the same time keeping your patient out of an undesirable state 
of bromism. That bromides produce mental enfeeblement and insanity is not 
received with favor by good authorities to-day. Statistics show that fewer epi- 
leptics become demented and insane to-day, when properly treated with bro 
mides, than they did years ago. The inherent tendency of the disease is 
toward mental degeneracy, and unless active therapeutical measures are in- 
stalled, insanity or dementia ultimately await the epileptic if an intercurrent dis- 
ease does not end his life. 
Fifth.-The choice of bromides and the manner in which they should be 
given are now to be considered. My hospital experience coincides with the 
popular teaching of to-day, namely, that a simple bromide is to be preferred 
to that of any combination of bromides. If there is any choice between the 
bromides it is in favor of the bromide of sodium; chemically one atom contains 
78 per cent of bromine, while bromide of potassium contains 53 per cent of 
bromine. The former is less irritating to the digestive organs and when given 
well diluted it is not unpleasant to the taste; the latter is a heart depressant, 
irritates delicate digestive organs, and is unpleasant to the taste. However, 
it has seemed to me in some instances that the bromide of potassium has been 
more effective in controlling very severe epilepsies than has the sodium-salt, 
though I use the latter in the majority of cases. In the hospital we used a 
solution of a certain known strength, and when we spoke of so many minims 
or measures, we knew at once the amount of the drug it contained and 1 have 
continued to use it on account of its easy calculation; it is one to four: 
ty Sodii Bromidi gi 
M. Aq. ad 
One teaspoon contains about fifteen grains. 
When the patient tells you he is taking one or one and a half teaspoon- Report on the Treatment of Epilepsy.-Burnett. 
fuls, you calculate at once the amount of the drug he is taking. Combining other 
drugs with your bromide is no advantage and only tends to complicate the 
dosage system Water is the best and only vehicle that I use and advise for 
the administration of the bromides, and the more diluted the solution is, the 
better it is for the patient. Many times during my early practice have I had 
to deal with very unpleasant gastric symptoms due to giving the bromides in 
too concetrated a form. I direct a patient to take from half to a tumblerful 
of water to be used in the administration of from fifteen to thirty grains of the 
drug, and that this should be taken at leisure. It is not desirable to throw it 
all into the stomach at once. This mode of administration prevents irrritation 
and facilitates absorption,and the excessive fluidity promotes elimination,thereby 
being a prophylactic to the acne with which we so often have to contend. 
There is some advantage in using some of the alkaline waters or rendering 
the water alkaline by the addition of a few grains of bi-carbonate of soda. 
Sixth.- When to administer the drug will vary with each case. In order 
to ascertain this point, as much information as can be obtained from the 
friends and patient is essential, and for a time the case must be studied with a 
view to finding out at what particular time in the twenty-four hours the 
seizures are most apt to occur. Also if there is any tendency to periodicity in 
the occurrence. To accomplish this, I find the table given below of much 
assistance. So far as I am aware, this form of recording these cases is only 
used by myself. You will observe it gives the date, day of the week, and 
which six hours in the twenty-four to which the convulsion belongs; also if the 
seizure is of the petit-mal or grand-mal variety. Such a record will often be 
found of utility in after treatment, as it may enable us to anticipate series of 
seizures and ward them off: 
- 
Sunday. 
Monday. 
Tuesday. 
Wednesday. 
Thursday. 
Friday. 
Saturday. 
A M 
P M 
A M 
p 
M 
A M 
P M 
A M 
P M 
A M 
P M 
A M 
P M 
A M 
r m 
DATE 
2 
3 
4 
6 
6 
4 
8 
Mild 
1 
1 
Severe... 
2 
3 
1 
। 2 
1 
1 
DATE 
9 
10 
11 
12 
13 
14 
15 
Mild 
11 
1 
Severe.. . 
1 
DATE 
16 
1 
7 
18 
19 
20 
21 
22 
Mild 
1 
1 
Severe... 
1 
1' 
NOVEMBER, 1890. 
The author's table illustrating a three week's record, showing number of severe and mild convulsions, 
and each recoided in the period of six hours of the twenty-four to which it belongs. By the addition of 
dotted lines to each a. m. and p. m. a record of every three hours in the twenty four could be kept. You 
will observe by the end of the first week the severity of the seizures was changed. 
Where we are able to anticipate the attacks I prefer giving most, if not 
all, of the bromide required to influence the patient for the twenty-four hours, 
from four to six hours prior to their expected development. This may be 
termed the expectant plan of treatment, but it is also the expectant plan that 
gives us so much success in treating malaria with quinine. Diurnal and noc- 
turnal attacks frequently come on with marked regularity and the table will 
at once show to which side of midnight or mid-day each seizure belongs. 
When they come on before midnight I prefer giving the entire amount of the Points on the Treatment of Epilepsy.-Burnett. 
bromide, required to influence the patient for the twenty-four hours, in the 
early part of the evening so as to get a full bromide effect just prior to the 
expected attack. Again if the fits come on in the after part of the night, or 
just before rising, I direct the patient to be awakened in time to receive his 
full dose whereby the seizures are often prevented. This habit must be 
broken if you expect to benefit your patient. When we have an irregularity 
of the development of the attacks then we must give the drug at stated inter- 
vals in sufficient amount to keep the nervous system in an even state of quiet- 
ude and non-irritability. The drug administered in the morning, on rising, is 
readily assimilated, and this is a good time to give it, unless it irritates the 
stomach; should it do this then you must wait until food has been taken into 
the stomach. Bromides and iodides are not borne well by many on an empty 
stomach, and this is important to remember as our digestive process must be 
preserved. 
After obtaining the required amount of the bromide to ward off the 
attacks the patient may go a long time without any change in the dosage 
system already established. In females, however, we frequently find the 
attacks undergoing some change just prior to, during, or following the mens- 
trual period. In such an instance I anticipate the period, and increase the 
dose for the time being, and often prevent, or mitigate, this exacerbation. 
After a few days are past then you should substitute the original dose again 
until the approach of the next menstrual flux when the prophylactic plan 
should be repeated. For instance, if the usual dosage is from fifteen to thirty 
grains a day I increase the amount to forty, sixty, or more grains for the few 
dangerous days of menstruation. We have other instances requiring both 
increase and decrease in dosage that should be here considered, though the 
continuous dosage is the feature to bear in mind. 
Increase is necessary, First-After prolonged use of drugs in young 
persons, for here we have increase in weight and size, which physiologically 
demands an increase to preserve the same systemic effect, unless convalescence 
has taken place. In girls the development of the menses require increased 
dose. 
Second-Anything fatiguing or exciting should be preceded by an extra 
dose, such as going out on a short journey or attending an entertainment of 
some kind. It is by attending to these little things that we are enabled to 
break up the spasmodic habit which eventually brings success. The dose 
should be decreased from various causes; first an immunity from the attacks 
for three years justifies a decreased dose to be made very gradually so that by. 
the end of the fourth year, in favorable cases, the medicine may be discon- 
tinued, but even then I advise a dose to be taken prior to an expected extra 
excitement or fatigue. 
Third-Bromides have greater effect on the system during not and debil- 
itating weather; maximum doses are well borne in cold weather; hence during 
the hot months the dose should be reduced. 
Fourth-Acute illness and traumatisms are of themselves against epileptic 
seizures and are really prophylactics while they exist. Also, the system 
under such conditions yields more readily to the bromides and we may 
get complete bromism unless the dose is reduced or discontinued 
during the active period of the acute affection. My friend Dr. Powell 
relates a case recently of a chronic epileptic who received a fracture of a limb, 
and by some, it was thought peculiar that the patient had no more seizures for 
the time being; this is simply one of the peculiarities of epilepsy. The details Points on the Treatment of Epilepsy.- Burnett. 
here given may seem a little prolonged but when I tell you that they are not 
to be found in your books on this subject, and that your success in medicine 
will be the outgrowth of your practical knowledge of the little things in this 
connection,! trust you may see the necessity for giving it a kindly consideration. 
The question arises should the patient be allowed to carry out his own 
dosage system ? I should say most certainly not for no epileptic is at all 
times in a proper mental state to consider anything of importance. Mental 
defects of all degrees are present at some time in various cases. Their mem- 
ory at intervals is a blank; the patient may have no knowledge of having had 
a seizure, or a series of seizures, and medication is neglected. Again they 
think they are getting better and are justified in leaving off the medicine, 
which of itself, is a sufficient reason for not allowing self administration. It 
is some trouble it is true for another member of the family to attend to this 
but if properly done the result often will justify the means. 
Frankness, on the part of the physician, in acquainting the parents with 
the details will often be of utility in many respects. It is not desirable for an 
epileptic to mingle in society generally; such will certainly bring humility, 
and probably deletrious results, hence his association should be in the hands 
of his immediate family, and at the courting period the patient himself should 
be acquainted with the impropriety of forming matrimonial relations; by so 
doing much misery may be prevented. 
Chloral bromide treatment.-Occasionally we find a case where the 
bromides alone do not give the desired result; the patient does not do well, 
he has digestive defects, undesirable degree of dementia may be present with 
convulsions continuing, severe confluent acne (ulcus elevatum described by 
Seguin in Archives of Medicine, New York, 1882), may be present. It is true 
this class of cases is not often encountered, but when we do meet with them 
they are the very ones that bother us greatly and tax our resources. 
In my hospital practice wre combined bromide with chloral with advantage 
in these cases; for each grain of bromide reduction from the dose a grain of 
chloral hydrate was added. The amount of chloral given will vary from three 
to ten grains, though in the majority of cases it is not necessary to go above 
six grains at a single dose. To commence on I use about the following com- 
bination, viz: 
ft Chloral Hydt. (Schering's crystals ) 3JJj 
Sodii bromidi 3'ss 
Aquae, ad...... Mxiij 
M Each teaspoonful contains about three grains of chloral and twelve grains of 
bromide. 
The amount of chloral can be increased proportionally as may be indi- 
cated. Sometimes the patient manifests a desire to sleep after substituting 
the chloral, but just let him sleep as no damage is going to be done by it and 
in a short time it will pass away leaving your patient mentally brighter than 
when he was confined to bromides alone. 
I have intentionally omitted the use of other drugs as our time has been 
too limited to allow us to deal expansively with so large a subject as this, 
however, you must be ready in all morbid conditions to recognize the neces- 
sity of instituting a general systemic treatment when indicated. I trust from 
the foregoing that you will understand me as being an advocate of the con- 
tinuous, systematic, and non-intermittent treatment of epilepsy.