No. 3157.

MARCH 1, 1884.

Clinical LectureON THE

TREATMENT OF PARTIAL EPILEPSY BYENCIRCLING BLISTERS, WITHTRANSFER OF THE AURA.

Delivered at the National Hospital for the Paralysed andEpileptic,

BY THOMAS BUZZARD, M.D., F.R.C.P.,PHYSICIAN TO THE HOSPITAL

GENTLEMEN,-There is a patient in this hospital (JohnM-, aged twenty-three) who came in on Oct. 25th laston account of fits. The first took place at nine years of age,the second at sixteen; and after that he was accustomed tohave every month or two an attack of the kind which hasbeen observed to take place since he has been in the hos-pital, though more slight, he says, in character. Aboutthree months before he came here, however, they began tobe extremely numerous, and Dr. Parry of Carnarvon, underwhose care he was, gives the following excellent descriptionof them: "The character of the attacks varies, being some-times accompanied by loss of consciousness, together withconvulsions of the right arm and leg; at other times the fitis merely a spasm of the arm or leg, or both, and that of theright side. Some three months ago he had a series of attacks,leaving him drowsy and feverish; and afterwards he hadsome paresis of the right arm and leg. Otherwise, he hashad no vomiting, headache, or other symptom pointing to,gross lesion of the brain, except it be the confinement of thespasm to the right side. The fits now generally occur be-tween 9 P.M. and 2 A.M.; and vary, being sometimes spasms ’,of the right arm and leg, and sometimes a complete fit. Hehad taken bromides for some time before I saw him, andhas also taken them since, together with arsenic, borax,belladonna, &c.; and his family is anxious to see if any-thing further could possibly be done to moderate the incom-plete seizures of the arm and leg, which chiefly distress himevery night."The patient’s own account of the beginning of a fit was

that "it feels like going to sleep in the big toe of the rightfoot, followed by numbness in the right calf, which runs upthe leg, often spreading to the genicals, then up the rightside and down the right arm; the foot twitches up." Hesometimes loses consciousness, and often not. It was ascer-tained by observation that, in an attack, convulsions firstaffected the right limbs, and subsequently, though to a

slight extent, the left. His gait when he came in wasparetic, the right foot sweeping the floor, and the right leg

being weaker than the left. The grasp of the right handmeasured 75° by the dynamometer; that of the left, 85°.There was no wasting of the right leg. Occasional twitch.ings which are observed on the right side of his face, thepatient says, he has been subject to ever since he had acut extending down the cheek from the inner canthus six orseven years ago. His eyesight appeared to be quite good,but notwithstanding this, the ophthalmoscope gave evidenceof slight optic neuritis (apparently of old-standing) in botheyes, but much more marked in the right than in the left.In the patient’s family there is no history of tubercle or ofnervous disease, and he has never had syphilis or anymechanical injury. The heart sounds are normal; the urineacid, containing no albumen or sugar. The man couldhimself give but little account of his condition duringseveral weeks preceding his admission, and said that he hadbeen only partially conscious. His memory was exceedinglybad, and he appeared to be in a state of mental obfuscation.On admission bromide of potassium was administered, at

first in doses of thirty grains, and, after five days, sixtygrains every night, and the fits were by this means reducedin number from nine during the first night to two or threeoccurring nightly afterwards. In the course of a week thepatient had had twenty-eight seizures whilst taking thebromide. These all commenced with convulsion of the rightlimbs, but in only some of them did he lose consciousness.Here is an account of one of them as noted down by the ward

attendant: "-Um not lose consciousness; called to theattendant and said, I I am having a fit.’ The right leg wasdrawn up to a right angle, right arm extended straight outfrom the side, left leg and arm straight down ; all four limbswere rigid. The right arm and leg were convulsed for a veryshort time only. Did not notice any impression on the faceand eves; only flushed during fit, and pale afterwards. Didnot bite tongue or pass water. Ankle clonus and knee-jerkexcessive immediately after the fit. Duration one minute."Each of the attacks, it must be noted, had been preceded bythe aura already described, a feeling as of the big toe of theright foot going to sleep, with numbness of the right calfspreading up the right side and down the right arm. It wasin these circumstances that on Nov. 2nd the bromide wasdiscontinued, no other drug being substituted. Blisteringfluid was now painted in the form of a ring, one inch inwidth, encircling the right leg just above the ankle, whichproduced well-marked vesication.Upon my visit to the ward on Nov. 7th I learned from the

attendant that during the night of Nov. 2nd (after theapplication of the blister) there had been no fit, but that anattack occurred on the 3rd, one again on the 4tb, two on the5th, and two on the 6th. The patient himself now volun-teered the remark that since the blister was applied hefelt the twitching in the left leg at the beginning of anattack. This had never happened to him before. At thesame time, when closely questioned, he reported that therewas some. but not nearly so much, twitching as usual inthe right leg. Another blister was now applied just abovethe last, which had healed. From that time he wententirely without any fit for nineteen days. On the night ofthe 25th an attack took place, preceded by an aura in thepubic region, and on the 26th another, which commencedwith a peculiar sensation in the right groin. In neither wasthere any trace at all of the original aura, and, indeed, innone of the attacks which have since taken place has therebeen any return of it. A third blister above the precedingone was applied on Nov. 30th. On Dec. 1st there wasagain a fit, beginning with an aura in the right groin, oneon the 2nd, 7th, 15th, 16th, 22nd, 26th, 27tb, and Jan. 1st.A fourth blister had been applied on Dec. 12th. A ring ofcauterisation was produced by the thermo-cautery aroundthe right leg on Jan. 4th, and by the same means onJan. 16th around the left leg. Since then there have beentwo attacks in which the aura has again been a peculiarfeeling in the right groin. With the diminution of attacksthe patient has greatly improved in health, and especiallyin his memory and mental power. The weakness of theright leg has quite disappeared, and the grasp of the righthand now measures about the same as that of the left.

I do not intend to dwell upon the pathological aspects ofthis case. It is, perhaps, sufficient to say that the characterof the attacks and the presence of optic neuritis suggestsome kind of coarse lesion of the cortical grey matter of thebrain. On the therapeutical, and also on the physiological,side the case seems to me to present points of importanceand interest. A very marked change as regards the fre-quency of attacks in this patient has followed the applica-tion of rings of blister to the limb which was the seat of theaura. Now, this, in my opinion, is not a mere coincidence,but a veritable effect of the treatment. In this method wehave, I believe, a palliative remedy of some importance forthose cases of epileptiform convulsions which begin uni-laterally with a well-defined aura in some part of a limb. Itis more than fifteen years since I first recorded some resultsof this treatment in such cases,2 and since that time I haveemployed the same method with success in so many casesof what is called partial epilepsy as to leave no doubt inmy mind that it is frequently of great service. In themajority of cases the treatment has a distinct effect upon thenumber of the attacks, now and then stopping them alto-gether for considerable periods, and in other instances occa-sioning a very marked prolongation of the intervals betweenthe seizures. It is true that this does not occur in all cases,even if they are apparently very appropriate in character.I frequently also fail to obtain very beneficial results incases where the unilateral character is but ill-defined. Butcertainly as regards that form of epileptiform seizures whichhas become associated with the name of my colleague,

1 The first recorded observation of ankle clonus and exaggerated kneephenomenon occurring after an epileptiform seizure we owe to Dr.Hughlings Jackson; vide Medical Times and Gazette, Feb. 12th, 1881.

2 On the Interception of the Epileptic Aura by Blistering (Prac-titioner, October, 1868).

374

Dr. IIugblings-Jackson, the results of this method are dig-tinctly of an encouraging kind.On the physiological side the strange influence which has

been exerted in this case upon the site of the premonitoryaura by the application of the blisters is very interesting.There has been a transfer of the aura from the right footand leg first to the left foot, and later to the right groin.Here again I am able to state that we are dealing withsomething which is not a chance coincidence but a resultof the application. I drew attention to the phenomenonof transfer for the first time, so far as I know, in myearliest paper upon this method of treatment,3 and havesince described numerous examples of it.’ There is nomarked uniformity in the mode of transfer in such cases.For example, in one patient a tickling in the left arm hadalways preceded the fit. After the application of a blisterencircling this limb the tickling was transferred to the leftleg. In another case characterised by a similar aura, thefits, as well as the tickling, ceased after the application ofa ring of blister. In a third a sense of numbness in the lqftwrist was transferred to the right wrist. This was a caseof cerebral tumour, as a subsequent autopsy showed. Anotherpatient was a woman whose tits had always been precededby cramp in the right hand, and who, after the blister, wasaffected with cramp in both hands before her fits. Inthe case of a patient whose fits had always been pre-ceded by cramp in the left foot and shaking of it, withnumbness of the lcft leg, a ring of blister was appliedto this leg and in subsequent attacks it was the rightleg which became numb and shook. Tingling in theleft arm was the aura in another case, and after blisteringa jerking of both arms and the left leg would takeplace at the beginning of a fit. Strangest perhaps ofall was the case of a female patient whose attacks alwayscommenced with cramp in the left hand. She had sufferedfrom a severe fit two days before she came to the hospital,and the left hand then still remained quite powerless, asindeed she told us was always the case for a few daysafter a fit. An encircling blister was applied to the leftwrist. Next day the left hand had quite regained itspower, but the patient complained that the right handhad ipso facto become weak. A few days later, when shecame to the hospital, the dynamometer showed 40° as thegrasp of the left hand, and only 18° as that of the right. Ina young woman with hemiplegia from old depressed fractureof the skull, convulsion of the muscles of the limbs and faceon the opposite side of the body to that which had formerlybeen affected followed the application of two rings of blisterto that forearm which had been the seat of the initiatoryspasm. My experience as regards both the therapeuticalvalue of this method and the occurrence of transfer of theaura has quite recently received independent corroborationat the hands of Professor Hirt of Breslau, who has publishedseveral interesting examples, 5 In one case of unilateralconvulsions without loss of consciousness, in which theattacks were exceedingly numerous every day, and alwayspreceded by a tickling in the left arm above which theblister was applied, the attacks ceased, and did not recurduring the six months preceding the report. In a secondcase, the aura was a trembling of the great toe of the rightfoot. Blistering was followed by cessation of attacks fortwo months, and in a fit which then occurred it was noticedthat the trembling affected the big toe of the left foot. Athird case is that of a shoemaker, in whom the cessationof attacks consequent on the treatment was attended bysuch feelings of discomfort as to cause him to regret hisprevious condition ! In another example there was transferof the aura, which consisted of over-extension of the ourthand fifth fingers of the left hand to the other side. At the esame time, as happened also in a case of mine, to which Ihave just referred, a transitory loss of power, which waswont to be experienced in the right hand for a day or twoafter the fit, was now noticed in the left limb. In a fifthcase there was transfer of an aura in the little finger to theother side. In four of these cases the therapeutical resultswere highly satisfactory, especially in the second, in which,after the transfer of the aura, rings of blister were appliedsimultaneously to both feet.

3 Practitioner, October, 1868.4 Clinical Lectures on Diseases of the Nervous System. 1882. Lecture

24 : On Phenomena of Transfer produced in Epileptic Patients by theApplication of Encircling Blisters.5 Ueber das Auftreten von Transfert-Erscheinungen während der

Behandlung der partiellen Epilepsie. Neurologisches Centralblatt,No. 1, January, 1884. Leipzig.

Until our information as to the position of receptivecentres for impressions of common sensations is more exactthan it is at present, it would be idle, I think, to wastemuch time in speculating upon the ?nOd1tS operandi of peri.pheral irritation in producing these results. There wouldseem to be sufficient evidence to show that epileptiformconvulsion beginning unilaterally depends upon a lesion ofthe cortex cerehri. Thanks to the clinical researches ofHughlings Jackson and the experimental observations ofHitzig and Ferrier, we know a good deal about the locatisa-tion of centres for movements in the cortex, and somethingrespecting those for certain forms of special sensation. Butas regards the situation of the centres which receive im-pressions of common sensation, we can do little more thaninfer that the place of reception for impressions coming fromthe skin covering a limb is probably in close associationwith the centre for the movement of its muscles. If thisbe so, the irritation of a blister causing a molecular change,,which is propagated centripetally, may be supposed capableof influencing in some way the liberation of movement.As a matter of detail I would say that in my experience a

distinct advantage has shown itself in the blister beingemployed in the form of a ring or bracelet encircling thelimb. An effect has been produced where the previousapplication of a quadrilateral blister has failed. A ring ofblister applied, as it has been in the case of JohnM—,above the ankles, involves cutaneous branches derived fromthe lumbar as well as the sacral plexus through the anteriorcrural and sciatic nerves. A blister acting upon these nervesmay be conceived therefore to be capable of producing amore intense impression than one which should only affectthe branches derived from one or other of these largenerve?. But I am disposed to doubt whether it is requisiteto employ blisters so wide as those which I have used inthis case. In some of my cases they have been narrower,and, so far as I am aware, this has been no disadvantage.Those which Professor Hirt says that he employed were buthalf an inch in width, and I think it very probable that.a still narrower ring than this would be found sufficient.That is certainly the case when Paquelin’s thermo-cauteryis used. It is, of course, desirable to avoid inflicting unneces-sary discomfort, but, as a rule, I have not found that thepain of the blister presents any serious obstacle to itsemployment.

Annual AddressDelivered on February 6th at the

OBSTETRICAL SOCIETY OF LONDON,BY HENRY GERVIS, M.D. LOND., F.R.C.P.,

PRESIDENT OF THE SOCIETY.

(Concluded from p. 331.)

THUS much for our work, our success, and our aspirationsin the year that is gone. Would that my few remarks mighthave ended here, but there yet remains a duty that I wouldgladly escape, the duty of offering you some slight memorialnotices of those whom death has claimed from among us.

[After briefly passing in review the careers of Mr. B.

Spaull of Hammersmith, Mr. T. Blease of Altrincham,Mr. Jardine Murray of Brighton, and Mr. AinsworthSchofield, the medical missionary, of whom obituary noticeshave already appeared in our columns, Dr. Gervis continued -.1

In Mr. Philip Harper, who died on Nov. 29th, we lost anoriginal Fellow of toe Society, reducing now the number ofthose who shared in its inauguration to thirty-eight Mr.Harper was a Fellow of the Royal College of Surgeons,of the Royal Medical and Chirurgical and Zoological andEntomological Societies. In the earlier years of our Societyhe was a contributor to our Transactions, and took a frequent share in our debates. In the very first volume of ourTransactions I find an important paper from him "On theMore Frequent Use of the Forceps as a Means of Lesseningboth Maternal and Fcotal Mortality," and in looking throughhis paper and the account of the debate which followed, onecannot but be struck with the change which twenty-fiveyears have brought about in tne general estimation of thevalue of the forceps. Every speaker on that occasion, and