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It was considered in biblical times that when a man fell in the street with a seizure the passers-by went over to spit on him, so that the demon could not get out of him and go to the passers-by.
The Romans, on the other hand, thought it was a good spirit, and when a seizure occurred in the senate, the senate adjourned sine die, as a sign of the gods that no more business was to be transacted that day.
I think the evidence that ours is an old disease is there, sir, without the mummy.
Mr. DOLLIVER. Is it definitely determined that it is a brain lesion which causes epilepsy?
Dr. FORSTER. Yes, sir. I think it was about in the 1600's when a British physician, Sir Thomas Willis, first concluded that the seizures arise from the brain.
It was about 1870 when Sir Hughlings Jackson, another British physician, pointed up the fact that it came from the outermost portion of the brain, the cortex, where the cells are.
In 1945 two American neurologists, Dr. Lennox and Dr. Gibbs, of Boston, proved it was an electrical discharge from the gray matter of the brain.
Now the work going on is to find out what sets off this gray matter both electrically and biochemically. These are the fields in which the future lies.
Mr. DOLLIVER. Are there any specific medical remedies that relieve the fits?
Dr. Forster. Yes, sir. During this era of mysticism and spirits, when epilepsy was known as ambulanta incantatus, it was then when neurology began to come forward that was the beginning of real treatment. This was almost that kind of fortuitous thing that Dr. Kety described for Dr. Windle's work.
Sir Stephen Hauptman in 1857 was presiding at a medical meeting, and learned that someone prescribed bromides as a means of decreasing sexual desires, and he was concerned with that, and he gave his patients bromides and found that the seizures disappeared. That was the beginning of the treatment.
In 1912, when phenobarbital was introduced as a sedative, the QED kind of mathematical interpretation was made that, if bromides are sedatives and if phenobarbital is a sedative and if bromides are good for seizures, then phenobarbital should be good for seizures.
Phenobarbital was tried and happened to be a success. Thank heaven that of all the barbiturate derivatives phenobarbital was the first one that was found, because it has turned out to be the best.
The next great stride was by the Boston group, Dr. Merritt and Dr. Putnam, who were concerned, because in order to keep some of their patients from having seizures they had to carry the anticonvulsant drugs to the point where they were drowsy, where the kiddies fell asleep in school and began to flunk. They felt that perhaps it was not necessary for a drug to be both a sedative and an anticonvulsant, that perhaps they were separate. They went to the drug houses and got from them the drugs that the chemists had designed for sedatives but which had failed to be sedatives. They tried these on cats, whom they gave electrical shock to cause seizures. Out of those drugs they chose the three which did the best job in stopping the induced seizures and transferred their use to the wards and the clinics of the hospitals and tried them there.
The best of those was dilantin, the next step forward.
Since then we have developed about 6 or 7 more drugs, 3 of which are aimed primarily at the child with the small seizure. One or two are aimed primarily at my friend, the schoolteacher, or his kind of problem, and the rest are aimed at the overall problem.
I think that is a thumbnail sketch of the development of the field, sir.
Mr. DOLLIVER. I take it from what you have said that these sedatives are merely a palliative rather than a cure?
Dr. FORSTER. Yes, sir. We wish we had something—we do not see it forthcoming yet—that would cure the disease and then the patient would no longer need to take medicine. Unfortunately these medicines are not even so selective that a patient can get by with just one of them. Most of the patients need a combination of such medicines, so that we do not even have one overall drug to control all kinds of seizures.
We may have a course of treatment of penicillin in neurosyphilis, for example, for 10 days or 2 weeks, and that is the end. Here at the present time the patient who has seizures, if he is in the fortunate group whose seizures are controlled, must then take these medications the rest of his life.
Mr. DOLLIVER. Is it self-medication? Do the patients take the medicine when they feel the seizures coming on?
Dr. FORSTER. It is much like the treatment of diabetes, sir. Each patient is himself a research project. We work it out until we get that level of medication which will completely stop his seizures. This is nailed down at the dose he is to take. It is explained to him very carefully that if he slips up on that dose he may expect trouble. We follow them repeatedly to be sure they are actually taking their medication.
Mr. DOLLIVER. The fact is then, to sum up, a patient suffering from epilepsy is in a position where, if he gets into the hands of a competent neurologist, his disease can be brought under control completely at the present time?
Dr. FORSTER. Yes, sir. We think we can control about 80 percent at the present time.
Mr. DOLLIVER. Thank you, Mr. Chairman. That is all.
Mr. CARLYLE. Doctor, it seems to be thought by some that when a child is afflicted with epilepsy he will in all probability, in many cases, outgrow that affliction. Is that true?
Dr. FORSTER. There are a number of children who have the small seizures or little lapses, and in that sort the general tendency is not to have those later in life. If they are present in the youngster, usually by the age of 20 they disappear. If not, they are very rare after the age of 30.
Now, there is one other problem, though. Those children oftentimes develop real convulsions later on in life. For the major seizures, though, there is no tendency to outgrow them.
Mr. CARLYLE. That is all, Mr. Chairman.
Mr. HESELTON. Mr. Chairman?
Mr. HESELTON. Doctor, is there a shortage of personnel in connection with treatment of this disease?
Dr. FORSTER. Yes, sir. We are limited by that number of neurologists Dr. Traeger referred to, the 250 across the country. That is one of our problems.
Mr. HESELTON. In this instance is it because of the lack of training facilities and trained personnel, or are the young people not interested in this work?
Dr. FORSTER. We are finding more and more young people interested in it, Mr. Heselton. Those of us who are working in this field constantly attract younger men to us.
Let me say that I happened to be an intern at the Boston City Hospital when Dr. Lennox was working there, and Dr. Merritt and Dr. Putnam were doing these original trials on dilantin. There was no other course in life but this.
I think each of us has gone off from there and set up a group of our followers in the same fashion, so that we are disciples of disciples now.
I am sure that with all of us spotted all over the country, as we are now, with more facilities we could meet that problem.
Mr. HESELTON. Do our medical schools offer adequate courses, generally speaking ?
Dr. FORSTER. Well, those schools with strong neurological departments do. We in the American League Against Epilepsy who are primarily concerned with this are anxious to increase the student interest in the field of epilepsy. During my presidency we went out and raised a fund of $100,000 through people interested in the problem and from families who have members with seizures, and so on.
That money was divided up in prizes and it was announced it would be used over a year's period for the medical students who did the best research or wrote the best papers. There were about 15 prizes. The money was divided up.
We stimulated interest in every medical school. We had students from almost every medical school sending in papers. We were not interested in the papers and we were not interested in them getting the money. We were interested in having them work in this field.
Mr. HESELTON. What is the story about the research being done in this field?
Dr. FORSTER. Well, sir, as to the research being done in this field, the electroencephalograph research, which Mr. Heller brought out before, is in our field, and it is pointed out that this is a matter of measuring electrical abnormal discharges of the brain.
The next problem is: Why the abnormal discharge?
There is at the present time a group of investigators who are ferreting into the problems of the underlying chemistry of the brain and the underlying chemistry that produces the electrical discharge. That is one type of investigation.
Since the central nervous system, the brain, is such a complex interconnected system, another group of investigations going on is concerned with the process of hunting for that particular spot, somewhere dead center, we could say, which can fire out to all the rest of the brain and throw the entire brain into convulsive activity.
Now, the other investigative work that is going on, or some of it, is a bit pedestrian, that most of us are doing in the clinics, in trying new drugs and critically trying to assay them.
On this business of treatment, though, nowadays with the further development of science, we should look elsewhere for that, rather than just taking a drug like phenobarbital, that has a ring moved over a little bit, and trying that for a couple of years and seeing that it is not any good and trying another one. The real hitting at the problem is by those people who are trying to tag the carbon molecule of phenobarbital with an atom and trace it and find out where it goes.
That is also true of all those people studying the enzyme chemistry of the drug and the effect on the brain. By that type of approach we think we may be able to come far closer in shorter order than by merely using the trial-and-error method most of us are using.
Mr. HESELTON. Do you know whether the Atomic Energy Commission in its medical program has given any attention to this!
Dr. FORSTER. I cannot speak for certain on that. I know that the University of Buffalo laboratory was set up for this particular problem about a year and a half or 2 years ago. I am not sure what the relationship was with the Atomic Energy Commission.
Dr. TRAEGER. May I answer that, Mr. Heselton ?
Dr. TRAEGER. The Atomic Energy Commission provides radioactive isotopes for laboratory workers and research people to use to tag certain medications, with the idea of being able to trace those medications.
You see, when you give a person medicine you do not know where it goes. You assume it goes to the brain, to the thyroid, to the joint, or whatever it is. If you tag it with a radioactive atom you can follow it to see where it goes.
The function of the Atomic Energy Commission is to provide certain types of radioactive materials which can so be used.
Mr. HESELTON. What is the situation in this country as compared to other countries ? Are we more suspectible to this?
Dr. FORSTER. No, sir.
Dr. FORSTER. This is generally true. Vherever there are valid statistics the incidence is approximately the same.
Mr. HESELTON. Does climate have anything to do with the incidence ?
Dr. FORSTER. No.
Dr. FORSTER. I wonder, Mr. Chairman, if I might for a moment put on my other coat.
The matter of the medical schools was brought up several times. Speaking now as a dean, I think I might be able to give you some information you may like to know.
Obviously you wonder why the universities, which we have long looked to as the citadels in knowledge, are not forthcoming in backing research. This is not only true for this institute but for all institutes.
I would like, in case you are not aware of the plight of the medical schools, to say that at the present time the tuition range in medical schools in most areas is somewhere in the neighborhood of $900 per year per student, which we think is terrific, really, but the cost of educating that student in the medical school averages, across the country, around $3,300 per year. Therefore, we in the medical schools are operating at a loss.
The private philanthropic funds are no longer available, or to a very limited degree, so that the medical schools have that particular plight.
Actually, I happen to be more fortunate than most of my colleagues because the rector of our university understands what we are doing. For most of the deans of medical schools one of the chief jobs is to sell the president of the university on the idea of not letting go of the medical school, because they look at it as the hole in the bucket of the finances of the university, and they feel that the medical school is siphoning out the funds of the whole university.
If you do not mind that parenthetic interjection, sir, I think that is the situation in the medical schools.
The CHAIRMAN. That is a very thoughtful suggestion you have made, and it certainly will have the consideration of the committee. I would not want to infer that we had not already done so. That has been a subject which has given the committee in the past considerable trouble in its endeavor to solve the problem. However, it is one that should be solved, and we can only hope, with the spirit of optimism that pervades these hearings, that we will find some way of doing it.
Mr. PRIEST. Mr. Chairman, would the chairman yield?
Mr. PRIEST. I do not want to ask the chairman a question he might not be in a position to answer, but I just wonder if the chairman knows whether or not the Department of Health, Education, and Welfare has now or is considering some program to submit to the Congress on this question of medical education! Has that been considered, so far as you know?
(Discussion off the record.)
The CHAIRMAN. I regret, Mr. Priest, that I am not able to make as definite an answer as I would like. There have been indications that such a program is in process. I hope that it will not take too long to process the program in the Department. Having in mind, however, that it is a new department, you can readily realize that it is not easy for them to come up quickly with a general program.
However, there is every indication that it is under consideration, and if the Department does not come up with a program maybe this committee should come up with a program.
Mr. PRIEST. Very good.
The CHAIRMAN. It is our intention to see that something is done. I know the great interest that you have had in this whole subject in the years that have passed. I feel very fortunate that you are a member of this committee and are participating, as you have, in these hearings. It will be very helpful in the days that are to come.
I also want to take this opportunity of saying that I am greatly pleased at the interest which has been shown by the members of the committee both on the majority side and on the minority side in these days of the recess of Congress, when you have yet felt the responsibility attached to your positions, which has brought you back into Washington for the purpose of participating in these hearings.
Are there any questions, gentlemen ?