Medical research; Epilepsy and multiple sclerosis

The following program is produced by the University of Michigan broadcasting service under a grant of 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 were here 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 formally dean and professor of neurology at Georgetown University's School of Medicine introductions 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 gland here at the University of Wisconsin and 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. Now 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 and 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 secondary in which we are working as an clinical electron Cephalon Griffy the brain waves and we have been doing some new things here with recording over extremely long periods of time in 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 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 and experimental epilepsy in 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 epileptics behavior by use of drug use in epilepsy their 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 they this is not a prolonged period of overt activity. And there's not the dominant theme in the patient's personality as rather an abrupt break with his usual activities. They have their say so that I wouldn't feel it in the matter of epilepsy and these drugs would have would come under any ethical problem because all they're trying to do is to bring a patient back to his normal state and and and of and avoid the interruptions of his consciousness by seizures. Are there different forms or kinds of epilepsy. Yes I think often times 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 FP and this comes from two Greek words epi which is means with and the verb

from Bano to take or to be taken. Now the interesting thing to me is that the Greeks did not call this ep a lamb be that someone is being taken with seizures but they put it in the future tense from the They've future form leps of my and which connotes the sword of Damocles that hangs over the head of someone who has seizures. This is something which will happen to him. And that denotes much of connotes rather much of the anxiety and fear and concern about a seizure occurring sometime in the future. Now we know that 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 Mal development smell formations in the early formation of the brain of the child. Are they scarred from a head injury later in life. Years and

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 coverings of the brain to the brain because of the inflammation of the many injuries and they may have seizures brain abscesses or uncommon nowadays because of the better treatment of infectious diseases. With the new drugs but they still do happen occasionally in a brain abscess may produce seizures brain tumors and occur in relatively small percentage of patients with epilepsy so that the patient with seizures himself should not be too worried about that 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 there are certain kinds of

seizures the so-called mom are. The little sickness as it was originally called by the French investigators in this area when in these conditions this is probably as near as one can come to epilepsy as a disease itself. The rest of the times it's symptomatic of 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 and different age ages and periods in life. I think for a moment let's like to discuss the kinds of seizures there are. I think the one that everyone knows best and most people have seen at least once in their lifetime is a grand mal convulsion or the major seizure Krai in the stiffening out. Then the shaking all over the tongue biting and dribbling

and Kasia me wetting patient wets himself and then after a long period of deep sleep and a headache and perhaps some vomiting and muscle aches afterwards this seizure and it made me hate it generalized seizure and then 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 and the period progressed to a grand mal 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 the turning of his head and eyes always say to the right or to the left eye with a pulling up of his right harm. Or he may start with numbness and tingling always in the right arm. Or he may start was seeing racial images or even hearing voices. I've 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 it tearing like that which is that the tip of the temporal lobe patient who starts with hearing voices is telling her that her seizures or his seizures to her to 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 these are sort of translations of symptoms into your physiology really which 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 doing exactly how one can take care of this best and make that patient for his seizures. Now there are other kinds of seizures also there's a team owl that I mentioned a moment ago. These are little seizures in children usually disappear by the age of 20 almost always by the age of 30. These occur many times a day. The child does stop and stare straight ahead for a few seconds. They seldom last more than 30 seconds and then the individual spell they may jerk they're ahead or I blink their eyes or jerk their arms in these and when they do they do them at a rate of three per second. This is it we know this a cuz when we take their brainwaves the spike is there at 3 percent I can incidence. And frequency rather. There the other seizure that I touched on earlier the so-called psycho motor seizure is the

one where patients say something or do something for which they are quite unaware. I think the best example I can give you of a psychomotor seizure. Was a patient of mine in Philadelphia who was a schoolteacher 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 the national anthem and everyone of course stood at attention then saying Oh Say Can You See That is everyone but my patient. He remained sitting in the chair in the front row of the faculty rubbing the arms of the chair and cursing on a bully over the way the PNAC of all parts of the national anthem he could be heard by the assembled group. And you know 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 actions of his the movement rubbing the arms of the chairs and they and the cursing they denoted anger and so on

there was some psychiatric correction and psychological manifestation of the demonstration of anger. These who are 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 the 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 the school board because he was Jewish and he could not be and that say this was the time. That's the German German Nazi Germany. I'm that much hung up on this. 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 healings Jackson the great British neurologist who first described these About seventy five years ago from 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. 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 and loose the Tory seizures as we call them where patients will only see images or in the 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. I actually 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 then we know that 1 out of 200 people have seizures. This means that 1 out of every 200 babies born baby expected to have a seizure sometime in life. We know that if the one of the parents has seizures that the incidence is higher it's about 1 out of 35 or 40 of the children of such an apparent age that will have seizures now if those seizures reduce aid to a head injury suffered no wara not automobile accident and their focal kinds of seizures in the brain laser focal then the chances of the child of the offspring of such a marriage having seizures is about 1 out of 81 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 of the one of a.

Little less than that that will develop diabetes or that could develop tuberculosis. And so I think if we thought of all the ills that occurred we'd almost be afraid to have children that would be a sorry situation. Diabetes can be controlled to a very great tennis players in this country and play Davis Cup tennis while carefully watching their blood sugar epileptics have done some fabulous things would be a poorer world if we didn't have an epileptic Van Gogh democracy's on. For example or are epileptic and the world is better for their writings and for their art work. There are 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 there hadn't. 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 the one up Glenn because so often when parents realize that their child has epilepsy they have their heart stricken and think immediately of some youngster 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 in the spasticity all develop from the brain damage. They are not related one to the other that is 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 a mental retardation. The minor seizures in the psychomotor and the petit mal seizures do not damage the brain. They meant your seizures may and you have. It's surprising to us sometimes to find a

patient who hasn't been taking medication and who comes in for the first time in to tabulate that they may have had a thousand or 2000 convulsions and are carrying on at a very good rate in their in their household or business duties so that the seizures do not. Damage the brain to a great degree at least. No these are the most important things about the mental retardation as in And so that families shouldn't feel that mental retardation is a part of epilepsy at home. Is it possible to describe an epileptic personality as going the descriptions of an epileptic personality or that someone is egocentric and suspicious and doesn't get along well with other people tends to be alone in this somewhat selfish and for a long time this was thought to be part and parcel of having epilepsy. Actually this is not hard to understand. If we take the supposed

youngster who's in grade school and begins to have seizures his classmates nickname him Fitzy 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 in the high school and into the social swing of things a little bit where dating and so on begin to be a little important and he's not dated. Occasionally some very lovely girl in the class has an act of Christian charity will ask him to a movie or let him take her to a movie or 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 get to do this for this poor chap. Then 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 wins in Michigan I believe was one of the leaders in this role. That is the University of Michigan. You know in allowing epileptics to attend their classes

oftentimes this is not so. And he may be barred from entrance into a particular college because he has seizures. If he does make it is chances of making a fraternity are virtually nil. He's getting his dating problem when he graduates and applies for a job and 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 sit in the Personnel Manager but may throw it in the wastebasket in front of him saying I'm sorry sir we don't hire epileptics and then we wonder why the epileptic is a selfish self-centered 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. I mean there are certain things they shouldn't do that they shouldn't drive a car when their seizures

are not controlled. They shouldn't let them work at high levels of high tension linemen and things like that. But by and large they are the most important thing is to get these people to live in for all the normal and active life to help them in job placement to help keep them in a job they see again the business of the handicapped person who have given the chance who do who are 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 diong estimates there are between 250000 300000 multiple sclerosis patients in the United States. I asked Dr. Forster to explain multiple sclerosis multiple sclerosis is a very peculiar disease is peculiar in the sense that there is nothing like it in any other system of the body the nervous system and this is what makes it so

difficult to unravel and fathom. It is not an infectious disease but it one in the opening of bacteriology and viral logy there were numerous attempts to try to find the organism that caused it. All of these have been unsuccessful. So that is not the infectious disease classification. There was a period of time when it was thought that perhaps it's an unusual kind of vascular disease so many many studies were carried out both pathological studies and clinical studies. And this also proved fruitless. And we are reasonably certain in the least there are present concepts that this is not a vascular disease with the 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 who were allergic to. And this again proved fruitless and the use of drugs that are used in the allergy that allergic diseases elsewhere has not been for people

in the treatment of multiple sclerosis. So by way of background then this disease is something most peculiar to the nervous system now the nervous system has a different type. It has different types of cells than any other system of the body even the cells that hold the nerve cells together are different. And so that way it will we will. 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. This is one reason why it has been so hard done Ravel and why so much work has been done without really getting to the bottom of it. Oh as far as the disease is concerned the word multiple and sclerosis sclerosis is merely 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 you can't live that they can't be due to a lesion in one particular area for example or the nerve to the eye and may be in the wrong. 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 kind of comically impossible. And you know immediately then that the patient has multiple involvement of different parts of his nervous system. Now these are all sort of divided in into her brain the patient may have involved when there was a high first and then this may get better and then the involvement of the cerebellum. This me improves someone and then he gets involvement of his spinal cord. So the ripples grow Susans a disease it's dispersed in time and in space within the nervous system either unique psychological problems presented by the patient or the family to the doctor. Yes one of the most difficult parts of that is there is no disease in the whole of

medicine where it is harder to give a prognosis there. As I noted this disease is divided in the space and 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 are just die of other things in the meantime so that their multiple sclerosis hasn't really been important short of the time when the first attack. Unfortunately this is not common and usually there are recurrences and so on that they have pace and usually has about 17 years between the first attack and his being bedridden. But this it too is not. This is in the average of a large number of cases with a wide span. And so I think one of our most difficult problems is to try to give some kind of an idea to the family and the patient with the

what to expect. It is really not possible to give and anywhere near accurate evaluation. We know that in the individual cases you watch it develop and so on you oftentimes get clues so that you are able to be a little sharper in the prognosis than what I've said. But not that we're not satisfied with our ability to prognosticate in this disease at home. However the one of the most hopeful things is that with a tremendous amount of research going on in this area and the 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 the

way many patients will recover from that first attack and have absolutely no signs whatsoever. And of course in that case it one could not diagnose a tall 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 5 or 10 years ago saying something by an awful mom I just can get this data and assimilated into the present picture and you know then if a certain kind of eye signs were present at that time and certain kinds of spinal chord signs present at this time you're reasonably sure of the diagnosis. Also we do a very detailed eye examinations

on patients who are suspected of having multiple sclerosis because we can pick up small slight involvement of the eyes. A 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 or 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 trouble of 10 15 years ago and a small change in the eye examination done with these newer techniques and they elevated gamma globulin in the spinal fluid and one is reasonably sure that there are in fact positive for the diagnosis of 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 diong 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 NEA E.B. Radio Network.