Medical research; Epilepsy and multiple sclerosis

The following program is produced by the University of Michigan Broadcasting Service under a grant in aid from the National Educational Television and Radio Center in cooperation with the National Association of Educational Broadcasters. Neurological Diseases, Epilepsy and Multiple Sclerosis, a program from the series Human Behavior, Social and Medical Research, produced by the University of Michigan Broadcasting Service. You will hear today Dr. Francis Forster of the University of Wisconsin School of Medicine. My name is Glenn Phillips. In this program, we will hear the interview conducted with Dr. Forster, formerly Dean and Professor of Neurology at Georgetown University School of Medicine. The productions to his answers have been re-recorded for the sake of audio clarity. One of the most mystifying of all diseases is epilepsy. It has been stated that one and one half million American people suffer from this disease.

Great strides have been made in less than a century, primarily because of the use of controllable drugs. Dr. Forster began by discussing some current research. Glenn here at the University of Wisconsin in our own research in epilepsy. This is along three lines. One of them is the search for a new and better drug for the control of seizures. There are 10 or 12 drugs available at the present time, but these will control the seizures in 85 or 90 percent of patients. We're not happy with that. We're trying to find more drugs, better drugs, so that we can control everyone's seizures and also so that we can come up with drugs that are a little less toxic than the ones we have at the present time. Now the second area in which we are working is in clinical electroencephalography, the brain waves, and we have been doing some new things here with recording over extremely long periods of time and particular types of patients, so that patients in whom we have had difficulty

in the past in arriving at a sharp diagnosis or a clear diagnosis as to the cause of their seizures and so on. We find that by recording under certain conditions in a long period of time, we are able to make a better diagnosis and thereby establish the better way of treating those patients. The third is in the experimental field, we're doing some work in experimental epilepsy and animals, evolving some new techniques of producing seizures in animals and in the hope that this will give us another tool for studying epilepsy in animals and arrive at conclusions that might be relevant and pertinent to the patient. What about the control of an epileptic's behavior by use of drugs? In epilepsy, the behavior is not in the sense of abnormal behavior from the psychological side except in those very occasional patients who have seizures in which they say or do

something which they do not recall. These seizures are short-lived, they're only a matter of a few minutes and so this is not a prolonged period of over-activity and it's not the dominant theme in the patient's personality, it's rather an abrupt break with his usual activities, so that I wouldn't feel it in the matter of epilepsy. These drugs would come under any ethical problem because all they're trying to do is to bring a patient back to his normal state and avoid the interruptions of his consciousness by seizures. Are there different forms or kinds of epilepsy? Yes, oftentimes people think that epilepsy is a disease, this is not exactly so, actually the word epilepsy comes from the original Greek, the Greeks called it Epilepsia and this

comes from two Greek words, epi which is means with and the verb Lombano to take or to be taken. Now the interesting thing to me is that the Greeks did not call this Epilembia that someone is being taken with seizures but they put it in the future form, lepsomie, which connotes the sort of democlease that hangs over the head of someone with seizures, this is something which will happen to him and connotes rather much of the anxiety and fear and concern about a seizure occurring sometime in the future. Now, we know that the seizures are not a disease in themselves, they arise from various disturbances that occur in the brain, they may be due to head injuries or male developments, male formations in the early formation of the brain of the child, they are scarred from

head injury later in life, years ago people with meningitis almost uniformly died with the advent of the new drugs now, patients live but occasionally some of them will have some scarring of their covering to the brain to the brain because of the inflammation of the meninges and they may have seizures. Brain abscesses are uncommon nowadays because of the better treatment of infectious diseases with the new drugs but they still do happen occasionally and a brain abscess may produce seizures. Brain tumors occur in relatively small percentage of patients with epilepsy so that the patient with seizures himself should not be too worried about, they shouldn't worry and fret about this, but the doctors who take care of patients with epilepsy of course always bear this in mind and then of course there are cases of epilepsy that we do not understand why they happen, these are cases in which there is a rather definite family history and the

seizures began between the ages of 10 and 20 and they are certain kinds of seizures the so-called Patee, Moll or the little sickness as it was originally called by the French investigators in this area, in these conditions this is probably as near as one can come to epilepsy as a disease itself and the rest of the times it's symptomatic epilepsy or the epilepsy is symptomatic of some other disturbance that happened to the brain. Do the forms of epilepsy differ between a child and an adult, also are the seizures different? There are differences in the seizures at different ages, ages, periods in life. I think for a moment let's, I'd like to discuss the kinds of seizures there are. I think the one that everyone knows best and that most people have seen at least once in their lifetime is the grandmail convulsion or the major seizure, the cry and the stiffening out and the shaking all over the tongue biting and drooling and occasionally wetting patient

what's himself and then after it a long period of deep sleep in the headache and perhaps some vomiting and muscle aches afterwards, this seizure may be a generalized seizure and it may start from the whole brain electrically and clinically as one sees the patient all parts of the body are involved at the same time. However, sometimes these are actually focal seizures that progress to a grandmail. In other words, they start in one part of the brain electrically and they clinically they may start in one part of the body and spread to involve the entire body in an instance like this. A patient may start with turning of his head and eyes always say to the right or to the left or with a pulling up of his right arm or he may start with numbness and tingling always in the right arm or he may start with seeing visual images or even hearing voices

as seen occasional patients who started these seizures by hearing music and one of them was a musician who could draw the score for three and a half bars of the music and then she was unconscious. So that a seizure that starts, this is when a patient tells us this, we translate this into what we know of the physiology of the brain, a patient who says, I hear music and shows you the score of it, you know that this is starting in the music appreciation center if we can use a term like that which is the tip of the temporal lobe, a patient who starts with hearing voices is telling you that her seizures or his seizures started a little farther back in the temporal lobe and a patient who starts out with seeing images and so on is having his start in the occipital lobe or the visual part of the brain. So that these are sort of translations of symptoms into neurophysiology really, this is what makes epilepsy in itself so fascinating and I think it helps to point out something

which I was afraid might be understood that I said earlier about each patient being a research problem, it's a research to put it down into the exact part of the brain and then to exactly how one can take care of this best and make that patient free as seizures. Now there are other kinds of seizures also, there is the petit mole that I mentioned a moment ago, these are little seizures in children, they usually disappear by the age of 20 almost always by the age of 30. These occur many times a day, a child will just stop and stare straight ahead for a few seconds, they sell them last more than 30 seconds in an individual spell. They may jerk their eye head or eye, blink their eyes or jerk their arms in these and when they do they do them at a rate of 3 per second, we know this because when we take their brain waves the spike is there at 3 per second incidence and frequency rather. The other seizure that I touched on earlier, the so-called psychomotor seizure is the one

where patients say something or do something where which they are quite unaware, I think the best example I can give you of a psychomotor seizure is a patient of mine in Philadelphia who was a school teacher and there was a general assembly of the school with the students in the amphitheater, the faculty on the stage, the flag was flying, the school band struck up our national anthem and everyone of course stood at attention and saying, oh say can you see, that is everyone but my patient, he remains sitting in the chair in the front row of the faculty rubbing the arms of the chair and cursing audibly over the, the issimo parts of the national anthem, he could be heard by the assembly group and he didn't know what he had done when it was over but he could tell by the attitude of his colleagues that something was not quite right, these were purposeful move actions of his, the movement rubbing the arms of the chairs in the cursing, they denoted anger and so on, there was

some psychiatric correction and psychological manifestation and the demonstration of anger, these were irrelevant, this was certainly no time to show anger and cursing and so they were purposeful and irrelevant and he had an amnesia for them, he didn't know what had happened when he came out of this seizure that lasted about three or four minutes, he had no idea what he had done but he knew that it was bad, it's rather interesting that I was able to save his job with a school board because he was Jewish and he could not be a Nazi, this was the time of the Nazi German, a Nazi Germany and much hung upon his race. There are also other kinds of focal seizures which do not progress to a loss of consciousness, these are called Jacksonian seizures usually in honor of Eulings Jackson, the great British neurologist who first described these about 75 years ago, a little more than that and

these will start in one part of the body as a twitching movement and spread to involve most of the side of the body and they may also instead of being motor that is with twitching they may be sensory and being numbness or peculiar feeling which the patient often has a hard time describing, there are some other less frequent seizures, hallucinatory seizures as we call them where patients will only see images and hear the music without proceeding on to a major seizure but these are quite rare. What role if any at all does heredity play in epilepsy? This certainly is not as grim as many people have thought it to be for a long time, actually and I believe that the way to look at this is that whether or not one has seizures is not a matter of black and white but it is shades of gray, there is no one in whom a seizure could not be produced using certain stimulation or certain chemical injections.

This means therefore that everyone has a potentiality of developing seizures. Some people are more prone to develop them than others, this kind of a tendency may be inherited but that we know that one out of 200 people have seizures, this means that one out of every 200 babies born may be expected to have a seizure sometime in life. We know that if one of the parents has seizures at the incidence is higher, it is about one out of 35 or 40 of the children of such a parentage that will have seizures. Now if those seizures are due say to a head injury suffered in the war or an auto automobile accident and their focal kind of seizures and the brainwaves are focal, then the chance of the offspring of such a marriage having seizures is about one out of 80 or one out of 100. So the odds are not bad, one doesn't think of the one out of 200 children that might have

epilepsy, develop epilepsy or the one out of a little less than that that will develop diabetes or that could develop tuberculosis. And so on, I think if we thought of all the ills that occur, we'd almost be afraid to have children. That would be a sorry situation, diabetes can be controlled. Two of our great tennis players in this country played Davis cup tennis, carefully watching their blood sugar. Epileptics have done some fabulous things, it'd be a poor world if we didn't have epileptics, Van Gogh, Demompasson, for example, or epileptic and the world is better for their writings and for their artwork, their numerous others also in the cultural side. There have been many outstanding scientists who have had epilepsy and the world indeed would not be as nice a place to live in if these people had not been born.

Is there any chance that an epileptic might develop mental deterioration or retardation? I'm glad you brought that one up and glad because so often when parents realize that their child has epilepsy, they are harsh, dricken and think immediately of some youngsters that they knew in school or on the playground or in their village, who had seizures, was spastic and was mentally retarded and they think that this is what the future holds for their child. Actually in a case like that, the problem is that the child has brain damage and the seizures and the mental retardation and the spasticity all developed from the brain damage, they are not related one to the other. But as the epilepsy, the seizures did not produce the retardation and that they are all dependent upon the amount of brain damage and therefore the seizures did not cause the mental retardation.

The minor seizures in the psychomotor and the petty mal seizures do not damage the brain. The major seizures may and yet it's surprising to us sometimes to find a patient who hasn't been taking medication and who comes in for the first time and to tabulate that they may have had 1,000 or 2,000 convulsions and are carrying on at a very good rate in their household or business duties so that the seizures do not damage the brain to a great degree at least. Now these are the most important things about mental retardation and so that families shouldn't feel that mental retardation is a part of epilepsy at all. Is it possible to describe an epileptic personality? Yes, go ahead and the descriptions of an epileptic personality are that someone is egocentric and suspicious and doesn't get along well with other people, tends to be alone and is somewhat selfish and for a long time it was thought to be part and parcel of having epilepsy.

Actually this is not hard to understand if we suppose a youngster who's in grade school and begins to have seizures, his classmates nickname him Fitsy or Jerky, when they choose up sides for a baseball team he's always the last one picked and if there are enough kids to go around he's not picked. He gets into high school and into the social swing of things a little bit, we're dating and so on, we begin to be a little important and he's not dated. Occasionally some very lovely girl in the class is an active Christian charity, we'll ask him to let him take her to a movie, something of that sort but this is a sympathy thing and all the rest of the girls say how nice and how sweet of her to do this for this poor chap. When he goes along in high school and he begins to think about his future education he finds that some colleges are not as enlightened as many of our great ones and Michigan I believe was one of the leaders in this role at his University of Michigan in allowing

epileptics to attend their classes, often times this is not so and he may be barred from entrance into particular college because he has seizures. If he does make it his chances of making a fraternity are virtually nil, he again has dating problems when he graduates and applies for a job, he fills out the application form and the secretary looks at it, he's filled it out honestly and says that he has epilepsy, he doesn't even send it into the personnel manager but may throw it in the waste basket in front of him saying I'm sorry sir, we don't hire epileptics and then we wonder why the epileptic is selfish, self-centered, a little irritable, a little suspicious and doesn't get along well with other people. The epileptic personality represents what society has done to him rather than what he's doing to society. This touches upon the point in the handling of epileptics, we must not restrict them too much.

There are certain things they shouldn't do, they shouldn't drive a car when their seizures are not controlled, they shouldn't work at high levels of high tension alignment and things like that but by and large the most important thing is to get these people to live a full and normal and active life, to help them in job placement, to help keep them in a job and again that business of the handicapped person who have given a chance will do above and beyond the call of duty. We move now to the second area of the program, multiple sclerosis. The University of Michigan Consultant for this program Dr. Russell De Young estimates there are between 250,000 and 300,000 multiple sclerotic patients in the United States. I asked Dr. Forster to explain multiple sclerosis. Multiple sclerosis is a very peculiar disease. It's peculiar in the sense that there is nothing like it in any other system of the body

than the nervous system and this is what makes it so difficult to unravel and fathom. It is not an infectious disease but when the opening of bacteriology and virology there were numerous attempts to try to find the organism that caused it, all of these have been unsuccessful so that it is not an infectious disease classification and there was a period of time when it was thought that perhaps it's an unusual kind of vascular disease. So many studies were carried out, both pathological studies and clinical studies and this also proved fruitless and we are reasonably certain, at least in our present concepts, that this is not a vascular disease with a development of allergy, it was thought that perhaps this is a peculiar kind of an allergic disease and there were many, many studies made to determine what patients with multiple sclerosis were allergic to and this again proved fruitless and the use of drugs that are used in allergy diseases elsewhere, it had not been fruitful

in the treatment of multiple sclerosis so by a way of a background then this disease is something most peculiar to the nervous system. Now the nervous system has different types of cells than any other system of the body even the cells that hold the nerve cells together are different and all that way this is one disease that is totally different from the diseases elsewhere in the body and it doesn't fall into the usual kinds of investigations and this is one reason why it has been so hard done, gravel and why so much work has been done without really getting to the bottom of it. As far as a disease is concerned the word multiple and sclerosis, sclerosis is meaning a way of saying hardening and it means that there are multiple hardened areas in the brain and spinal cord and these are of different ages when one looks at them pathologically.

The patient has symptoms that are very, very diverse through the nervous system which show that they can't be due to a lesion in one particular area for example the nerve to the eye may be involved, some of the parts of the spinal cord, some of the parts of the cerebellum and one cannot bring these pathways together into one particular place it's anatomically impossible and you know immediately then that the patient has multiple involvement of different parts of his nervous system. Now these are also divided in time, the patient may have an involvement of his eye first and then this may get better and then involvement of his cerebellum, this may improve someone and then he gets involvement of his spinal cord. So multiple sclerosis is a disease it's dispersed in time and in space within the nervous system. Are there unique psychological problems presented by the patient or the family to the doctor?

Yes and one of the most difficult parts of that is there is no disease in all of medicine or is harder to give a prognosis. As I noted this disease is divided in space and in time and sometimes there may be 20 or 30 years between attacks in this disease and there are patients who have a relatively slight first attack from which they recover and they may go 20 or 30 years before the second attack comes. Some people die of other things in the meantime so that their multiple sclerosis hasn't really been important short of the time in the first attack and fortunately this is not common and usually there are recurrences and so on that the patient usually has about 17 years between the first attack and his being bedridden but this too is not, this is an average of a large number of cases with a wide span and so I think one of my most difficult problems

is to try to give some kind of an idea to the family and the patient to what to expect. It is really not possible to give anywhere near accurate evaluation. We know that in the individual case as you watch it develop and so on you oftentimes get clues so that you are able to be a little sharper in prognosis than what I just said but not satisfied with the our ability to prognosticate in this disease at all. However one of the most hopeful things is that with a tremendous amount of research going on in this area and a large amount of basic research in the chemistry of the nervous system it seems quite possible that there will be a breakthrough in this disease before too long and in time to help most of the people who are living now under the shadow of multiple sclerosis.

Is it possible to diagnose multiple sclerosis at other times that is the normal times or only during an attack? Obviously many patients will recover from that first attack and have absolutely no signs whatsoever and of course in that case one could not diagnose it at all in the interim in between. Usually there are some slight signs or moderate degree of signs that are picked up on the neurological examination. There is of course the history which is so important and the report from the doctor who saw the patient during the original episode, the high examination and so on and doctors are very, very good about communicating with each other upon request and sending this data so that the doctor who sees a patient today who was seen five or ten years ago by an ophthalmologist can get this data and assimilate it into the present picture and you know then if certain kind of eye signs were present at that time and certain kinds of spinal cord

signs present at this time you are reasonably sure of the diagnosis. Also we do very detailed eye examinations on patients who are suspected of having multiple sclerosis because we can pick up small slight involvement of the visual system that are not apparent to the patient sometimes and that when these are present they help in the diagnosis and then in some of the newer neurochemistry studies of the spinal fluid we found that the protein fraction is different in multiple sclerosis there is an abnormally high gamma globulin in the spinal fluid and if one finds in a patient with spinal cord disease and of a peculiar type with a history of having had some high trouble ten, fifteen years ago and a small change in the eye examination done with these newer techniques and a elevated gamma globulin in the spinal fluid and one is reasonably sure that the in fact positive

that the diagnosis is multiple sclerosis. Today we have heard Dr. Francis Forster discussing epilepsy and multiple sclerosis. Next week you will hear Dr. Harriet P. Dustin of the Cleveland Clinic as she discusses hyper and hypotension. On the next program from the series Human Behavior, Social and Medical Research, consultant for this program was Dr. Russell De Young of the University of Michigan Medical School. Glenn Phillips speaking asking that you join us next week and thanking you for being with us at this time. This program has been produced by the University of Michigan Broadcasting Service under a grant in aid from the National Educational Television and Radio Center in cooperation with the National Association of Educational Broadcasters. This is the NEB radio network.