TREATMENT OF TRAUMATIC EPILEPSY.

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MEDICAL TREATMENT OF CONGENITAL PYLORIC STENOSIS.

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certainly relieve spasm at that site, accepted practice in this pylorus atdoother situations in the alimentary canal, spasms country, hospitals, for nearly all which are not uncommon in these cases, are not cases of congenital pyloric stenosis to be operated benefited by such operations. This view will be upon. As a result of good team-work the mortalitynew to most observers in this country, but it may rate has been slowly reduced so that Dr. F. J. some of those cases where vomiting PoYNTON, for example, in a recent reportwas explain continues after Rammstedt’s operation in an able to describe an 80 per cent. recovery in a series of cases. Despite this success most physicians unexplained manner. Dr. WOLFF quotes, with disapproval, a dictum from a surgical publicadealing with these infants have not felt convinced tion that " better one child too many operated of the absolute necessity for surgical intervention, and recent continental work with thickened feeds upon than one child too few." While this may hold, has been watched with interest. One difficulty he says, for acute appendicitis, the position is about accepting the conclusions of the German quite different when the physician is dealing with school has been that under the title of " pyloro- an infant only a few weeks old. He hints, also, have been included cases in which the that the widespread increase in the number of spasmus certain diagnosis of pyloric stenosis (by palpation cases of pyloric stenosis occurring in hospital of a pyloric tumour) has not been made and in records during the last few years is directly due to too much surgical interest in the condition. general too little information about the clinical While this may be dismissed as a provocative condition of the infants has been supplied. A when it is included in a paper with a statement recent paper by Dr. S. WOLFF, of Eisenach,2 however, meets these objections and his spectacular frankly anti-surgical bias, it should nevertheless results with medical treatment deserve close study. stimulate physicians to consider whether the present He is a sturdy opponent of the surgeons in this line of treatment by Rammstedt’s operation is the matter and his experience is a wide one. From best which medicine has to offer for a malady 1912 to 1930 some 98 cases of congenital pyloric where spontaneous cure is known to occur after stenosis were under his care, and he lays down the the third month of life. cardinal points in diagnosis as vomiting, constipation, visible gastric peristalsis, and the presence TREATMENT OF TRAUMATIC EPILEPSY. of a pyloric tumour. All these cases were treated NEUROLOGISTS have been aware for some time by him personally, the necessary procedures being carried out either by himself or under his direct of the important investigations into traumatic supervision. The diet he now gives to these infants epilepsy which have been conducted by Prof. consists of frequent small feeds of thickened OTFRIED FoERSTER of Breslau, and which have led protein milk with added sugar, although formerly him to develop a surgical technique for the treathe used to prefer breast milk. Subcutaneous ment of selected cases. The physiological basis of salines are injected at the onset in severe cases and this method of treatment is set out in two recent stomach wash-outs begin the treatment in all papers 12 by Prof. FoERSTER and Prof. WILDER cases. Atropine in the form of the valerianate PENFIELD, of Montreal, which will repay study by is given by the mouth in drop doses with each feed ; all who are interested either in epilepsy or in the Dr. WOLFF believes that this preparation is the surgery of the nervous system. A happy union of most useful because the sedative effect of the FOERSTER’S study of excitable cortical areas and valerian counteracts any tendency of the atropine PENFIELD’S investigations of the behaviour of scar tissue in the nervous system has produced fruitful to excite the central nervous system. The 98 cases treated during the 18-year period results. Not only has their collaboration suggested comprise 58 boys and 40 girls ; it is an interest- a plausible explanation for at least some forms of ing fact, commented upon by other observers, traumatic epilepsy, but it has also, if we accept the that the majority of cases occurred in the first explanation, provided a rational basis for surgical half of any year. Six only of the patients were treatment. FOERSTER, by electrical stimulation of operated upon and of the 92 cases medically the cerebral cortex in over one hundred patients treated only two died, giving a recovery-rate far under local anaesthesia, has outlined certain definite superior to anything yet produced by surgical epileptogenic cortical areas which extend conmethods. An interesting feature of Dr. WoLFF’s siderably beyond the " motor cortex " so called. series is the large number-80 out of the total In fact, such excitable areas are to be found in front 98-treated as out-patients. He classifies his of, and also behind, the precentral convolution as cases under the four headings of mild, moderately well as in the temporal and occipital lobes. The IT has

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to the risk of any surgical procedure. Dr. WoLFF points out that while plastic operations on the

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severe, severe, and very severe, and in a comprehensive table sets out full details about the weight and progress of each child, including a note whether in his view the infants would have stood an operation. Many of the cases described suffered 2

1 Practitioner, 1930, cxxv., 24. Jahrb. f. Kinderh., 1930, cxxviii., 287.

patterns which follow the stimulation of such areas provide a local sign which often makes it possible to localise the cortical focus of an epileptic discharge. These patterns are described in detail by FoEBSTBB and PENFIELD. The latter’s

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1 Foerster, O., and Penfield, W. G.: Brain, 1930, liii., 99. Penfield, W. G.: Canad. Med. Assoc. Jour., August, 1930, p.189.

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researches into the process of scarring which follows however, suggests on the basis of W. W. W .sTFFE’ss experimental injury of the brain have shown that work that variations in the severity of the injury, widely different reactions occur according to especially whether or not the dura is penetrated, whether or not the damaged cerebral tissue isare an important factor in the production of this removed. If it remains, a scar containing connec-sequel. Nevertheless, even in traumatic epilepsy tive tissue and fibrous astrocytes is rapidly formed there is sometimes clear evidence of predisposition and becomes densely attached to the overlyingin the family history. It would be interesting also meninges and invaded by a rich plexus of newly know whether FoERSTER and PBNFlELD’s obserformed blood-vessels. The scar contracts steadily vations throw any light upon the difference between for a period of years, and this contraction is the various clinical forms of focal epilepsy. At one is the slow march of the Jacksonian attack ; responsible for the displacement of the cerebral ventricles towards the lesion which FoERSTER has at the other the brief focal onset of a generalised demonstrated by encephalography. It is suggested fit, while epilepsia partialis continua remains a by FoERSTER and PENFFELD that such scars are : localised convulsion. Further, traumatic epilepsy first manifests itself in the Jacksonian form responsible for the occurrence of traumatic epilepsy, means of vasomotor changes reflexly may in course of time develop into fits which are possibly by induced by changes of tension. Surgical excision of ! generalised from the onset of the attack. such scars, if the bone-flap is not replaced, is ! This work puts traumatic epilepsy in a new light followed by a more favourable type of gliosis which and it is reasonable that operative treatment does not exert a similar traction upon the cerebral should be considered in such cases. Whether it tissues. This is held to be the explanation of the should be carried out in a given case will depend beneficial results of such operations following upon several factors, especially whether the pattern which patients, formerly epileptic, have been free of the fit or the presence of physical signs indicates from fits for a number of years. epileptogenic focus, whether encephalography FoERSTER and PENFIELD’s work suggests reflecevidence of a scar, and, perhaps most tions of both theoretical and practical interest. important, whether a surgeon with experience of SARGENT reported that among 18,000 cases of guntechnique is available. Physiologically it is shot wounds of the head, 800, or 4t per cent., doubtful whether there is any reason for separating developed secondary epilepsy. This incidence has . traumatic from other forms of epilepsy, for in many been interpreted as evidence in favour of someso-called " idiopathic " cases there is as good underlying predisposition to convulsions which is: evidence for the focal origin of the fit. A better present in only a small proportion of individuals,understanding of traumatic epilepsy, therefore, and which is assumed to be necessary if cerebral11 cannot fail to enlighten us upon the pathogenesis trauma is to give rise to epilepsy. PENFIELD, I of convulsions in general. I

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ANNOTATIONS has a soul, but he has consciousness and memoriesconscious, subconscious, and unconscious. Unless I NOWADAYSit is widely taught that the the physician takes stock of these, he is not taking must be regarded as a whole and not .as an example stock of the individual. Every illness has its psychoin nosology. But there is still occasion for Dr. and the good clinician faced with a aspect, logical F. G. Crookshank’s trenchant attack on what he patient who complains of vomiting ought not, in his calls " the organic school," or "school of mortuary absorption either in the digestive prescription, the medicine," and the " neuro-humoral school, who test-meal or the areas of hyperalgesia, to forget also detest taking cognisance of what they call the to ask-in an appropriate manner-" What are you subjective no less heartily than do the mortuary sick of Dr. Crookshank takes his stand on the doctors refuse to admit the importance of the merely work of Alfred Adler and his followers, and finds in functional.’’ He urges the need for a comprehensive this school the most .satisfactory marriage between view of the individual, who is ill because he has " lost and clinical medicine. Adler’s principles, psychology whole-th." It is, he thinks, a relic of mediaeval put briefly, are that some inferiority or inadequacy demonology to say that we are " attacked " by in a bodily organ will account for disease, especially disease, and the apparent support given to this functional disease, without the intervention of any attitude by bacteriology has been weakened by extrinsic factor, and that neuroses and psychoses increasing recognition of the importance of the commonly develop in association with organfactor of resistance. Dr. Crookshank would no more inferiorities. An organ which, because of some allow us to suffer from " an attack of neurasthenia morphological or functional inferiority, is the weakest —or presumably typhoid or in-fluenza-than an in the chain, is more likely than others to break attack of adultery." He is an ardent apostle of the down under stress, but this congenital or acquired truth that, to study and diagnose any case completely, may be expressed in successful compenthe doctor must consider the patient physically as inferiority in which itself causes or carefully as any member of the organic school could distress. Or over-compensation, the purely psychological sense of wish; physiologically, in the spirit of the neuro- inferiority, which is the heritage of everyone, may humoral school; and-neither more nor less important attach itself, if not overcome by suitable training psychologically. It is not necessary to say that he and by personal courage, to the organ which suffers and so establish a "functional" 1 Individual Psychology and General Medicine. F. G. Crook- from some defect, shank, F.R.C.P. Psyche, Cambridge, 1930, pp. 27, 1s. "Every neurosis,’’ Dr. Crookshank says, , disorder. THE

PATIENT AS A WHOLE.

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