Petit Mal Attacks Research Articles

Landmark article Sept 17, 1938: Sodium diphenyl hydantoinate in the treatment of convulsive disorders. By H. Houston Merritt and Tracy J. Putnam.

In a previous study it has been shown that sodium diphenyl hydantoinate is effective in preventing electrically induced convulsive seizures in cats. The drug is relatively nontoxic and well tolerated by the usual laboratory animals. A clinical trial of sodium diphenyl hydantoinate was made in 200 patients with frequent convulsive seizures which had not been relieved by the previous modes of therapy. In 142 such patients who have received the treatment for periods varying from two to eleven months, grand mal attacks were relieved in 58 per cent and greatly decreased in frequency in an additional 27 per cent; petit mal attacks were relieved in 35 per cent and greatly decreased in frequency in an additional 49 per cent, and psychic equivalent attacks were relieved in 67 per cent and greatly decreased in frequency in 33 per cent. There were no fatalities. A toxic dermatitis occurred in ten patients (5 per cent), nonthrombocytopenic purpura in one patient and minor (in many instances, transient) toxic reactions, tremors, ataxia, dizziness and the like in approximately 15 per cent.

Fixed dilated pupils in petit mal attacks

The pupillary size and light reflex were measured by photographic means during 1710 'absence' attacks induced by photic stimulation in six patients with epilepsy. Pupillary dilatation unreactive to light stimulation, facial pallor and perspiration were consistently recorded during all petit mal attacks simultaneously with three cycles per second (cps) spike and wave complexes. Miosis and facial flushing followed the attacks. This recording technique provides clinically useful evidence of seizure activity. The identification of mydriasis can clarify the ambiguity of ordinary clinical observations in 'absence' attacks.

Selective deprivation of sleep in pycnoleptic children

1. Selective deprivation of slow-wave and paradoxical sleep was performed in 10 children with pycnoleptic attacks (8 of them before anticonvulsive treatment, 2 of them while under medication). The frequency and duration of petit mal attacks were intraindividually compared during night sleep and after waking for a 5-h period. 2. After deprivation of slow-wave sleep with reduction of EEG stages 3 and 4 to about one-third of the baseline but normal duration of sleep, petit mal attacks are more frequent and long-lasting than after normal sleep or selective deprivation of REM sleep. 3. Although total sleep time is significantly diminished after selective deprivation of paradoxical sleep the frequency of attacks during the waking state was lower than after normal sleep and deprivation of slow wave sleep. This observation shows a clear i nfluence of the quality of sleep on the frequency of epileptic attacks. 4. During sleep petit mal seizures were mainly found during stages 2 and paradoxical sleep. Single spike and irregular spike were discharges, however, occurred more frequently during slow-wave sleep. Their frequency was not significantly different in the deprivation conditions. 5. In contrast to experimental data in animals, REM deprivation is less provoking to epileptic attacks outside sleep than deprivation of stages 3 and 4 sleep. Therefore a sufficient amount of slow-wave should be preserved for pycnoleptic children.

Relation between ocular manifestations and onset of spike-and-wave discharges in petit mal epilepsy.

Ocular manifestations are prominent in petit mal attacks. The nuclei innervating the extraocular muscles lie in mesencephalic and pontine regions of the brainstem which have been regarded by some as critical areas in the generation of petit mal attacks. Ocular signs and their timing relative to spike-and-wave onset were studied cinematographically in 4 patients with petit mal epilepsy. Each patient showed a consistent pattern of eye deviation or fixation during spike-wave bursts. Neither the activation of oculomotor pathways, as indicated by eye deviation, nor their inactivation, as suggested by interruption of ongoing elicited ocular activity, preceded the appearance of spikewaves. Because ocular manifestations began only after the onset of spike-wave, this study provided no evidence that brainstem oculomotor regions were involved in the initiation of these petit mal attacks.

ENVIRONMENTAL INTERACTION AND MEMORY DURING PETIT MAL (ABSENCE) SEIZURES

The authors reviewed videotape records of petit mal or absence seizures in order to examine psychologic components of the petit mal attack. Four patients are reported in detail and specific seizures from four other patients are mentioned. Many seizures were associated with the retention of visuomotor coordination. Some patients attended to an auditory cue and produced a verbal response during a seizure. The degree of memory loss for events occurring during a seizure varied from complete amnesia to total retention of memory. The authors conclude that most neurology textbooks oversimplify the complex mental changes which accompany a petit mal attack.

Petit Mal Status in Adults

Petit mal is primarily a childhood disorder and becomes less common in adult life. Petit mal status (spike-wave stupor) is an unusual complication, but one third of cases reported since 1950 have been in young adults, usually under 40 years old. Four adults who had petit mal since childhood are presented. Three of these patients, one of whom was age 61, had discrete episodes of petit mal status, while the fourth had prolonged depression of mental function due to constantly recurring petit mal attacks. These patients were initially thought to be psychotic. The clinical features of these and of previously reported cases of petit mal status are considered; their salient characteristics are emphasized, and the differential diagnosis is discussed.

The "Senseless Crime"

To the Editor:— In a recent issue ofThe Journal(vol 186, Oct 19, 1963, adv p 41), there are quotations from a lecture on Seizure and the 'Senseless Crime.' This lecture, held at an international meeting in London, contains erroneous statements. Specifically, petit mal is described as one of the aphasic intervals of suspended consciousness without suspension of motor activity which provide occasions when the sufferer may commit a violent or senseless crime without being aware of it. Any contemporary student of epilepsy will reject this statement as contradictory to all known clinical and pathophysiological characteristics of this disorder. By no stretch of imagination will it be possible for an individual during a petit mal attack to perform the most simple goal-directed motor activity —let alone a violent crime. Epileptic patients bear enough social prejudice and should not be subjected to the additional stigma of being considered potential

THE RELATIONSHIP BETWEEN GENERALIZED PAROXYSMAL E.E.G. DISCHARGES AND VARIOUS TEST SITUATIONS IN TWO EPILEPTIC PATIENTS.

Thisinvestigation wascarried outontwopatients suffering fromso-called primary subcortical epilepsy. Serial studies weremadebothofvariations inthe amountofparoxysmal electrical activity recorded fromthebrain during theperformance ofpsychological tests andofchanges intestperformance in thepresence ofparoxysmal discharges. Thereisno doubtthatchanges inthealpha rhythm canbeshowntoaccompany alterations in behaviour inallsubjects. Theparoxysmal E.E.G. discharges recorded fromepileptics haverarely been studied fromthispoint ofview. Itis,however, widely heldthatpetit malattacks donotoccur randomly withrespect tomental state. Lennoxand Lennox(1960), whotended toequate theelectroencephalographic dysrhythmia withtheclinical ictus, considered thatpetit malattacks occurless often whenthepatient iskeptoccupied. According toPond(1961), petit malattacks maybeprecipitated byemotional disturbance. Inthepresent investigationa series ofE.E.G.examinations andof psychological tests wascarried outparipassuin order todetermine whether there weresystematic differences intheamountofparoxysmal activity recorded indifferent test situations. Suchdifferences aswerefoundwerethenfurther explored inan attempt todiscover thefactors responsible forthem. Autonomic function seemed tobeonevariable of possible significance, andrespiration andpulse rate weretherefore recorded throughout. Theinvestigation wasalsoplanned topermit the studyofchanges intestperformance during the occurrence ofgeneralized paroxysmal discharges. Patients wereselected whoseE.E.G.records contained brief generalized wave-spike discharges, without clinical accompaniments. A distinction is oftendrawn(Kiloh andOsselton, 1961)between such'inter-seizure' discharges andtheelectrical disturbance associated withpetit mal attacks. However, brief discharges donotdiffer qualitatively intheir E.E.G. parameters frombursts oflonger duration andmight beexpected tohavebehavioural correlates whichcouldbemeasured bya more refined methodthanclinical observation. A number ofstudies havebeenmadeofresponses topsychological tests during brief discharges butthefindings areconflicting. Schwab(1941) andCornil, Gastaut, andCorriol (1951) stated thatreaction times are delayed, butPrechtl, Boeke, andSchut (1961) found noimpairment intherateofperformance onaserial reaction test, andMilstein andStevens (1961) foundno impairment inauditory learning and avoidance conditioning during brief generalized discharges. KooiandHovey(1957) recorded spontaneous paroxysmal discharges inepileptics during intelligence testing. Theystated that although thequestions wereusually heardan adequate solution wasnevergiven during bursts ofbilateral synchronous activity. However, theydonotstate theduration andnumberofthedischarges, andit isnotclear whether thereported association is significant. Although these findings areconflicting, there are

PETIT MAL EPILEPSY

Eighty-eight cases of petit mal epilepsy in children are reviewed. The clinical characteristics and differential diagnosis of petit mal are presented in detail. Aspects discussed and significant findings are as follows: Petit mal is a relatively infrequent type of epileptic manifestation (4.4%). Petit mal is rare before 2½ years of age. Twenty-three per cent of the children had attacks for over 3 years prior to their first visit suggesting the limitations of therapy. A history of seizures in parents or siblings was present in 21% of the cases. Whereas, only 10% had apparent lesions of the central nervous system, the incidence of intellectual retardation 24%, is similar to that found in our reviews of jacksonian and psychomotor epilepsy. Sixty-one per cent had non-petit mal seizures (chiefly grand mal). In 63%, these first appeared with or after the onset of petit mal. Petit mal attacks were precipitated by hyperventilation in 93% of the cases. Ninety per cent of the children had seizure formations in at least one electroencephalographic tracing. Sixty-four per cent showed spike and wave patterns; in 26%, other convulsive patterns were noted. Recommendations in therapy and results are reported. The review suggests that petit mal is not entirely benign and unaccompanied by cerebral pathologic changes with effect on mentality or personality, nor spontaneously cured at puberty. The high incidence of grand mal and other seizures in these children is emphasized and prophylactic therapy suggested.

Telemetric Electroencephalography for Hospitalized Seizure Patients

TELEMETRY (making measurements at a distance) is not new. The electrical activity of the heart was telemetered by FM transmission in 1943. The technical achievements of the past 2 decades, however, have greatly advanced this science. Miniaturization of amplifiers and transmitters now offers a possible way of monitoring biological phenomena in free-moving patients in the hospital environment. The following application in clinical neurology is an example. Neurologists frequently have patients whose symptoms suggest a seizure disorder, but whose routine electroencephalograms have been repeatedly normal. Activation techniques (hyperventilation, sleep, photic stimulation, pentylenetetrazol, and so forth) also may fail to bring out the abnormalities. Usually, patients cannot be studied electroencephalographically for prolonged periods of up to 24 hours or for days on end. Telemetry, by permitting freedom of movement, facilitates prolonged recording sessions. It also may find clinical application in patients with frequent, very brief, petit mal attacks. In order to evaluate

Ethosuximide in the treatment of epilepsy.

THIS STUDY deals with the effectiveness of ethosuximide (Zarontin) in the treatment of 100 patients with recurrent, short, mild seizures, mostly typical petit mal attacks. Interest in the succcinimides began with the demonstration of their anticonvulsant effects in experimental animals by Miller et al. and by Chen et al. This led to the clinical evaluation of phensuximide (Milontin) and, later, of methsuximide (Celontin). Although both of these compounds have a place in the treatment of convulsive disorders, they are of limited value in petit mal. The third succinimide, ethosuximide, which is the subject of this report, was found to be highly protective against pentylenetetrazol (Metrazol)-induced seizures in experimental animals. A number of encouraging reports on its effectiveness in controlling petit mal epilepsy have appeared. Method The 100 patients reported on are from the Seizure Clinic population at the Columbia-Presbyterian Medical Center, or are private patients under the management of neurologists

Intestinal Helminths in Dogs and Cats of the Bermuda Islands and Their Potential Public Health Significance, with a Report of a Probable Case of Visceral Larva Migrans

Various helmlinth parasites of dogs and cats are known to develop or live in man (Echinococcus spp., Toxocara spp., Dipylidium caninurm, Ancylostonma braziliense, A. caninum, Uncinaria stenocephala, and possibly Tr'ichuris vulpis) and some are capable of causing very serious pathological conditions. Of the human infections acquired through close association with dogs and cats in the United States, England, Puerto Rico, and undoubtedly other areas, perhaps next to Echinococcus the most significant, widespread, and damaging is that known as visceral larva migrans caused by the roundworn of dogs, Toxocara canis. The roundworm of the cat, T. cati, may also be of some importance in causing this disease in man. Visceral larva migrans is primarily a disease of toddleage children who ingest soil polluted with the eggs of Toxocara. Since Toxocara does not mature in man, a paratenic host, no eggs are produced for easy diagnosis. The second stage larvae may migrate through the organ systems (liver, lungs, brain, kidneys, eyes) for several weeks and remain alive encapsulated for many months, sometimes causing petit mal attacks, blindness, and even death (Beaver, 1956). Dent (1960) and Ashton (1960) indicate that eye infections have been found following mild Toxocara infections in which symptoms were not outstanding. A usual clinical finding, even in the absence of other symptoms, is eosinophilia frequently exceeding 50 percent persisting at a high level usually for a year or more, but which may be absent in eye infections.

Electroencephalographic abnormalities in addition to bilaterally synchronous 3 mper second spike and wave activity in petit mal

1. 1. In 100 consecutive patients in whom clinical petit mal attacks were associated with 3 per sec. spike and wave activity the presence of focal, lateral and diffuse EEG abnormalities was studied. 2. 2. In 51 cases the background activity of the EEG was essentially normal. In 35 cases focal or lateralizing abnormalities were present. In 14 cases the background activity was diffusely abnormal. 3. 3. Sixty-two patients were female. The average age of onset of petit mal was seven years. Nineteen had close relatives with a history of convulsions. Six patients had abnormal neurologic findings. Eleven were low in intelligence. Forty patients had atypical features to their seizures. Forty-nine had other types of seizures in addition to petit mal. Possible etiologic factors were present in the histories of only six patients. 4. 4. Correlations were noted between the presence of EEG abnormalities other than synchronous 3 per sec. spike and wave activity and ( a) mental retardation and ( b) abnormal findings on neurologic examination. 5. 5. The possible meaning of the high incidence of abnormalities, other than 3 per sec. spike and wave discharges, in terms of the genesis of petit mal activity is discussed.

N-methyl-alpha, alpha-methyl-phenylsuccinimide in psychomotor epilepsy therapy.

Introduction In two previous reports * it was stated that in the course of investigation on the effect of N-methyl-α,α-methylphenylsuccinimide (PM 396) upon petit mal epilepsy, a favorable action of this drug was noted on the psychomotor element sometimes associated with petit mal attacks. Since to date psychomotor epilepsy is the most difficult of all forms of epilepsy to treat and there are no outstanding drugs in the therapeutic armamentarium for the treatment of this condition, this particular investigation was carried further. It is now possible to report results on 35 cases of psychomotor epilepsy treated with this drug. Pharmacology N-methyl-α,α-methylphenylsuccinimide (hereinafter designated by its laboratory number PM 396) was synthesized in the laboratories of Parke, Davis & Company. Figure 1 shows the chemical Submitted for publication Dec. 1, 1955. From the Columbia University College of Physicians and Surgeons, and the Division of Child Neurology, the Neurological Institute of New York.

Disturbance of Conciousness in Petit Mai Epilepsy

Summary 1 In eight patients with petit mal EEGs (approximately thirty) were taken. During the seizure patterns various external stimuli were applied. In these cases clinical and electroencc-phalographic changes were observed simultaneously and relationships between the two were studied. 2 In petit mal attacks there are various degrees of alteration of consciousness grading from almost no loss of consciousness to complete lapse of consciousness. Between subclinical and clinical seizures there is a transition, and it is difficult to determine a definite border line between the two. 3 liven in a single petit mal seizure the degree of disturbance of consciousness is not constant but is altered in various ways spontaneously or following various stimuli. This can be confirmed by applying various stimuli during die seizure. 4 There are often no changes in the seizure waves in spite of changes of consciousness during a petit mal seizure. Even though various responses are elicited by stimuli the petit mal waves sometimes continue unchanged. Therefore even though petit mal waves usually do show the presence of disturbance of consciousness, they do not always indicate the degree of alteration of consciousness during the seizure.

Use of methylphenyl-succinimide in treatment of petit mal epilepsy.

WHILE comparatively excellent drugs are available for the control or reduction of grand mal seizures, the agents which are used in the treatment of intractable petit mal attacks are often inadequate. Although bromides are now little used, heavy reliance still rests on the barbiturates, phenobarbital, and mephobarbital (mebaral ® ) and in recent years on the new drug trimethadione (tridione ® ). Sedation, barbiturate rashes, and slowing of the mental processes are obvious disadvantages of the phenobarbital derivatives, while photophobia, drug rash, and leukopenia handicap the usefulness of trimethadione. The compound (N-methyl-α-phenylsuccinimide 1 ) which is discussed in this presentation has been found to equal or to surpass trimethadione in therapeutic efficacy and, in addition, is relatively nontoxic. In laboratory and clinical tests N-methyl-α-phenylsuccinimide has been designated as PM 334 and will hereinafter be so designated for the sake of brevity. PM 334 was selected for chemical trial from a large number of

The incidence of focal and non-focal EEG abnormalities in clinical epilepsy

1. 1. A group of patients with clinical epilepsy have been studied in various centers across Canada. 2. 2. In 428 civilian patients, 38 per cent had focal EEG abnormalities. 3. 3. In 262 veterans and service patients who were carefully studied, 66.5 per cent had focal EEG abnormalities. 4. 4. In another group of 175 veterans, 39.5 per cent had focal EEG abnormalities. 5. 5. In the total series of 865 patients, 47 per cent had focal EEG abnormalities. 6. 6. This figure was identical with the percentage of focal EEG abnormalities found in 2 previous groups of patients studied at the Montreal Neurological Institute. 7. 7. In a total of 2648 patients with clinical epilepsy, focal EEG abnormalities were the largest single group of EEG disturbances. 8. 8. The percentage of focal disturbances uncovered depends to a considerable extent on the technique and care used in doing localization studies. 9. 9. Eighty-one per cent of patients with clinically focal seizures had a focal EEG abnormality. 10. 10. Although 80 per cent of patients with petit mal attacks had bilaterally synchronous EEG disturbances, the latter also occurred in 53 per cent of patients who had grand mal attacks only. This form of discharge therefore, although commonly seen in petit mal, is by no means pathognomonic. Nor is it only seen in idiopathic epilepsy, though they are very frequently associated. 11. 11. Diffuse dysrhythmias were most frequently associated with patients who had only grand mal seizures. 12. 12. Bilaterally synchronous disturbances were much more common in patients whose seizures began before the age of 25 years. 13. 13. Focal EEG abnormalities were much more common in patients over 25 years of age and particularly if the attacks began after the age of 25 years. 14. 14. Diffuse dysrhythmias were evenly distributed in all age groups. 15. 15. Borderline or normal EEG records were seen more frequently in patients with grand mal attacks only and in older patients particularly after the age of 56 years. 16. 16. The lowest percentage of normal and borderline records were seen in patients with petit mal and in infants and young children.

Petit mal epilepsy occurring in status.

STATUS epilepticus is a well known clinical condition. The closely repeated generalized convulsions constitute a clinical entity known from ancient times. Petit mal status is a condition less widely known. Lennox 1 described three types of petit mal attacks: the akinetic and the myoclonic type and the short stare. Akinetic seizures are transient and characterized by falling if the patient is not supported; the myoclonic type has jerking movements of the body, head or extremities, characteristically at a rate of 3 per second. The short stare type of petit mal is characterized by a brief loss of consciousness without overt movements. The myoclonic petit mal attacks, occurring in rapid sequence over a period of time, as a petit mal status, may be readily recognized. In the akinetic type, the repeated loss of posture is evident. The rapidly repeated short stares are more difficult to recognize as petit mal seizures, and

A Note on the Ammonia and Glutamine Content of the Cerebrospinal Fluid

Tashiro (1922) showed that the isolated frog nerve liberates ammonia on stimulation, and Richter and Dawson (1948) have recently found that ammonia is liberated on stimulation by the brain. Ammonia is very toxic to the brain, on which it has an irritant action; but the brain may be protected to some extent by the enzyme system described by Krebs (1935), which can detoxicate ammonia by combination with glutamic acid to form glutamine. Sapirstein (1943) obtained evidence that this system is active in vivo by showing that glutamic acid increases the resistance of animals to convulsions produced by injecting ammonium chloride. The toxic action of ammonia on the brain is also of interest in connection with the view that it may be concerned in certain forms of epilepsy (Harris, 1945). This view is supported by the observations of Price, Waelsch and Putnam (1943) on the inhibitory action of glutamic acid on petit mal attacks.

Studies on Epilepsy: The Petit Mal Attack as a Response Within the Central Nervous System to Distress in Organism-Environment Integration

Studies on Epilepsy: The Petit Mal Attack as a Response Within the Central Nervous System to Distress in Organism-Environment Integration