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 "we should mau^the^same use of a boor 
 that the bee dob» op a ploweh shesteau 
 
 sweets prom it, but does not injure it," 
 
 ENDOWED BY 
 
 FRANCIS HUBER, B.S., M.D., P V S '77 
 
 H IN MEMORY or 
 
 A. JACOBI, M.D., LL.D. 
 
 MEDICUS, MAOISTtR, AMfCUS 
 
No, 7 IN THE PHYSICIANS' AND STUDENTS' READY 
 REFERENCE SERIES. 
 
 EPILEPSY: 
 
 ITS PATHOLOGY AND TREATMENT. 
 
 Being an Essay to which was Awaeded a Prize of Four 
 
 Thousand Francs by the Academie Royale de 
 
 Medecine le Belgique, December 31, 1889. 
 
 HOBART AMORY HARE, M.D. (^^^0, B.Sc, 
 
 Clinical Professor of the Diseases of Children and Demonstrator of Therapeutics in tlie 
 
 University of Pennsylvania; Physician to St. Agnes' Hospital and to the Children's 
 
 Dispensary of the Children's Hospital; Laureate of the Royal Academy of 
 
 Medicine in Belgium, of the Medical Society of London, etc.; 
 
 Memher of the Association uf American Physicians. 
 
 Philadelphia and London: 
 
 F. A. DAVIS, PUBLISHER, 
 1890. 
 
Entered according to Act of Congress, in the year 1890, by 
 
 F. A. DAVIS, 
 
 In the Office of the Librarian of Congress at Washington, D. C, U. S. A. 
 
 Philadelphia: 
 
 The Medical Bulletin Printing House, 
 
 1231 Filbert Street. 
 
TO 
 
 DR. THOMAS B. BRADFORD, 
 
 SURGEON TO THE DEIiAWAEE HOSPITAL 
 
 I DESIRE TO DEDICATE THIS ESSAY, 
 
 AS AN EVIDENCE OF 
 
 AFFECTION AND FRIENDSHIP. 
 
PREFACE. 
 
 This essay upon epilepsy was considered by the 
 Koyal Academy of Medicine in Belgium as worthy of 
 a prize of four thousand francs, and this must be the 
 chief excuse for its publication in the face of the large 
 amount of literature daily accumulating concerning 
 this important disease. 
 
 The author believes that it is fairly representative 
 of the views held as most correct by the best minds 
 of the profession, and has endeavored to separate the 
 good material in literature from a vast mass of super- 
 stition and nonsense which persons even in our own 
 generation have contributed. If this book can in 
 any way help the physician in the present, or aid in 
 the discovery of remedial measures capable of curing 
 epilepsy in the future, its publication will not be use- 
 less nor a burden upon a profession notorious for 
 its patience with authors. 
 
 222 S. 15th; St., PHiLADBiiPHiA, 
 August, 1890. 
 
EPILEPSY: 
 
 ITS PATHOLOGY AND TREATMENT, 
 
 EPILEPSY. 
 
 Synonyms. — Latin : Morbus sacer, Morbus vel sacer, 
 Morbus major, Morbus herculeus, Morbus comitialis, 
 Morbus convivialis, Morbus mensalis, Morbus inspu- 
 tatus, Morbus viridellus, Morbus vitriolatus, Morbus 
 sonticus, Morbus carducus, Morbus unaticatus, Morbus 
 foldus, Morbus sideratus, Morbus scelestus, Morbus 
 demonicus, Morbus deificus, Morbus astralis, Morbus 
 St. Yalentis and St. Joannis, Analepsia, Apoplexia 
 parva, Passio Caduca et Perditio. French : Epilepsie, 
 Grand mal, Haut raal, Epilepsia. German: Fallsucht, 
 Epilepsie. English: Epilepsy, Falling sickness. Faint- 
 ing sickness, Fits. Italian: Epilepsia. Scandinavian: 
 Epilepsin fallendsot. 
 
 Definition. — Epilepsy is to be defined as a disorder 
 of the nervous s^^stem characterized by sudden convul- 
 sive seizures of temporary duration, the muscles of the 
 parts affected being first in tonic spasm, then alternately 
 contracted and relaxed (clonic spasm), the attacks gen- 
 erally occurring at irregular intervals, and being always 
 accompanied by loss of consciousness, more or less com- 
 plete, in the typical disease. The movements also have 
 no relation with those of ordinary life. In rare instances, 
 however, one or more of these symptoms may be absent, 
 and yet the disease be epilepsy, 
 
 1 A (1) 
 
2 Epilepsy: its Pathology and Treatment. 
 
 Before the writer goes further he must endeavor to 
 make clear the meaning of the terms generally employed 
 in discussing this disease, in order that in using a given 
 term his meaning may be well defined. 
 
 It is an evidence of the paucity of our knowledge in 
 these convulsive disorders that the nomenclature em- 
 ployed is at once inaccurate and inexpressive even of 
 the little we know. Thus, many writers divide the 
 disease into idiopathic epilepsy and organic epileps}'-, 
 because in the one case we have not been able with 
 the means at our disposal to discover an}'- changes from 
 the normal in the parts when they are examined, and 
 in the other we find more or less gross lesions. It is 
 to be hoped that before long this ignorance may be 
 enlightened, for it is hardly possible to imagine that a 
 given number of cells can evince morbid tendencies for 
 years and still remain organically normal. Some changes 
 must occur which we are not quick enough to discover. 
 The term organic epilepsy is used as well to designate 
 not only direct morbid change in a given set of cells, but 
 to identify indirect perversion of their function produced 
 by the irritation or pressure or interference of nutrition 
 by a neighboring and demonstrable neoplasm. Of this 
 more will be said under the heading of Pathology. 
 
 History. — Almost as far back as we have records of 
 events the story of the disease called epilepsy reaches. 
 Long before medicine, as we know it at the present day, 
 took the shape which separated it from witchcraft and 
 sorcery, civil writings incidentally spoke of it, either 
 describing the disease in detail, or giving it a name 
 which in its meaning described the affection. Long be- 
 fore the time of Galen and Hippocrates we find mention 
 of its character, and the famous Greek just mentioned 
 has described it with a characteristic accuracy which 
 
History. 3 
 
 seems as true to the disease to-day as it was hundreds 
 of years ago. 
 
 Almost every century since their time has borne in its 
 medical annals some account of its symptoms, and prob- 
 ably no disease has ever given rise to more discussion, 
 both medical and otherwise, than the one before us ; for, 
 unlike those diseases of an epidemic character which 
 from time to time swept off thousands of the human 
 race, epilepsy, by its constancy at all times and in all 
 places, fastened itself upon single individuals and left 
 accurate impressions on the minds of its observ^ers, 
 who were not disturbed by the fear of contagion and 
 who therefore wrote nothing hastily. The very fact 
 that epilepsy asserted itself in the bodies of its victims 
 at the most inopportune times and before all men caused 
 it, too, to be brought to the notice of the people more than 
 other affections even more wide-spread, but which by 
 reason of their hidden nature were less frequently seen. 
 It is illustrative of the true birth of medicine that epi- 
 lepsy is rapidly passing from the cloud of ignorance 
 into the light of modern science. For over twenty cen- 
 turies it has passed among men as a something too in- 
 tangible to explain, too far beyond their power of treat- 
 ment to yield to any one, however skillful he might 
 be; yet in the past twenty years, at the most, more 
 progress has taken place in our knowledge as to its 
 entire course than in all the preceding centuries. If 
 we glance back among the older writers we find that 
 they tried new remedies as frequently as they failed in 
 treating the disease, and one after another advanced 
 hjq^othetical conclusions as to its causation in almost 
 every case, many of which were foolish even in the light 
 of their own knowledge. Every form of explanation 
 was attempted ; the clergy, the laity, and the most 
 
4 Epilepsy : its Pathology and Treatment. 
 
 ignorant of the common people shared the universal 
 privilege of inventing new theories and therapeutic 
 measures, and yet not one opinion has survived, and our 
 building of knowledge of epilepsy contains no stone 
 save those gathered in the last century. 
 
 One of the first efforts made by the earliest workers 
 of the present time was the denuding of epilepsy proper 
 of that enormous amount of surrounding drapery par- 
 taking of an epileptiform character, but at present rec- 
 ognized as arising from entirel}^ different causes. Spasm, 
 like dropsy, has come to be considered as a mere evi- 
 dence of some condition more or less defined, and not 
 as a disease itself. It is the result, not the cause. The 
 chief reason for all this improvement lies in the increased 
 desire for knowledge, which has brought about a vast 
 amount of original research in this field as well as in 
 others, and it has been well said by the famous German 
 physician, Nothnagel, that no affection of the human 
 race could be held up for which so much has been derived 
 of value from vivisection and experiments on the lower 
 animals than the disease now before us. 
 
 So much is to be said of the disease as we at present 
 know it that the writer cannot linger over the writings of 
 those of long ago, which, while interesting, are but grop- 
 ings in the dark and require much space, and we shall 
 pass over to the last few centuries, during which faint 
 glimmerings of light have begun to creep in. Early in 
 the sixteentli century the first reports of methods of cure 
 of a rational character appeared, and for many j^ears 
 formed almost entirelj^ the greater part of the literature 
 of epilepsy. Hector Boethius ^ in 1536 wrote of castra- 
 tion as a method of cure, not only directly but indirectly, 
 to prevent hereditary tendencies. According to this 
 
 * Cronikles Ucotlaud, Ediuburgli, 153U, lib. i. 
 
History. 5 
 
 writer, the custom of castration with this object in 
 view existed for many years among the Scotch previous 
 to the time at which he wrote. Thus he states that, 
 while this treatment was accorded to epileptic males, 
 epileptic females were isolated, and if by chance they 
 conceived, both the mother and the child were to be 
 killed. Jean Taxil ^ also noted this means of cure as 
 long ago as 1603, but Platenus, Mercatus, and Heurnins,^ 
 along with Coelius Aurelianus,^ performed the operation 
 many years prior to these writers, and for the same pur- 
 pose, namely, of curing the disease, which, in one of its 
 forms, was generally believed in those days to be depend- 
 ent on the retention of semen, which, undergoing corrup- 
 tion, produced reflex convulsions by the irritation set up. 
 Very early in the history of medicine, however, these 
 views were largely held, for Arethaeus * asserts that 
 many physicians, among them the celebrated followers 
 of JEsclepius, thought that venery cures the epilepsy 
 which begins at puberty. The same opinion was held by 
 Scribonius Largus, and the retention of semen was the ex- 
 citing cause in the belief of all. It would seem, however, 
 that ph3^sicians of that day were as quick to contradict one 
 another as they are now, for Alfarius a Cruce contended 
 that the epilepsy of puberty was an incident of the age 
 of the individual, not of the retained semen, denying 
 that sexual intercourse ever gave relief except in very 
 rare instances. Unfortunately, this writer does not seem 
 to have impressed this teaching on his pupils, for one of 
 them, Sinabaldi,^ declared coitus to be a useful means 
 
 » Traite de TEpilepsie, etc., Toumon, 1603, p. 229. 
 " Opera Omnia, postrema editio, Lugduni, 1658 ; de Epilepsia, chap, 
 xxiii, p, 421. 
 
 ' Morb. Chron., lib. i, cap. iv. 
 
 * Opera Omnia. Morb. Chron., lib. i, cap. iv. 
 
 » Geueantbropia, Romae, 1643, p. 886. C. 
 
6 Epilepmi : if^ Pnthology and Treatment. 
 
 of cure in some forms of epileps}^ but not in all forms. 
 Tissot,^ who wrote, comparatively speaking, much more 
 recentl}^, argued that this retained semen, by corruption, 
 produced epileptic attacks, and by so doing brought one 
 of the oldest superstitions down to modern times. In 
 justice to the older writers, however, it should be said 
 that the}^ did not carry out these ideas to such an ex- 
 treme as to lose sight of the fact that other causes might 
 produce the disease. Indeed, Galen and others recog- 
 nized that sexual excesses might have similar results 
 with sexual continence. It should be remembered, too, 
 that epilepsy and coitus were supposed to be closely 
 associated, for epilepsy often came on during intercourse; 
 so that it was compared b}^ Democritus to a" seizure ": — 
 
 or, as Faustus has described it : — 
 
 " Turpis, et est morbi species horrenda cadueo." 
 
 The following extracts in regard to the more modern 
 superstitions will also be of interest to the reader, as 
 showins: how barbarous curative measures were em- 
 ployed in the eighteenth century ^ : — 
 
 To Mo7meur ilie Crimiiial Lieutenant- Oefieral and Preskle^it of the SeiiescJuiVa 
 Court of Lyons : — 
 Sieur Claude Pessoneaux, mercer of that town, humbly prays and 
 assures you that, for eight years, he has been subject to epilepsy, 
 which attacks him almost daily, even several times a day, and entirely 
 deprives him of consciousness. And as he has been informed that 
 several medical authors promise a cure from the administration of a 
 specific remedy, composed of various roots and the skull of a man who 
 has died a violent death — a remedy which, when properly prepared, has 
 the reputation of being most efficacious, according to the certificates 
 which M. Hedoin, physician to the king, and agreg^ of the College of 
 
 » Traite de 1' Epilepsia, Lausanne, 1785, p. 73. 
 
 ^ llev. Med. et Chirurg. de Paris, November, 1855. 
 
Hi dory. T 
 
 Medicine at Lyons, and the Sieur Aubernon, surgeon of Lyons, have 
 to-day given under their seal, which certificates your petitioner shows 
 and sets forth to you ; and as he has been informed that a criminal, 
 condemned by your judgment to be hanged, is about to be executed, 
 may it please you. Monsieur, to permit him, after the execution of this 
 miserable person, to remove the skull of his head, in order to employ it 
 in the preparation of this remedy ; and he will consider himself bound 
 to continue in prayer to God for your prosperity and health. 
 
 Pessoneaux. 
 
 Let this be shown to the Procureur-General of Lyons. 
 
 80th Octobre, 1706. Claret La Tourrette, 
 
 On behalf of the king I do not forbid the concessions of the 
 present request [Signature illegible.] 
 
 Lyons, 30 Novembre, 1706. 
 Let it be done according to the decree of theProcureur-G6n6ral. 
 Lyons, 30 Novembre, 1706. Claret La Tourrette. 
 
 To Monsieur tfie Cnrainal Lieutenant- General in the SenescTial's Court of 
 Lymis : — 
 
 The sisters, rector, and governors of the General Almshouse in 
 Lyons humbly pray and assure you that they require in pharmacy 
 several skulls of persons who have died violent deaths, in order to use 
 them in the composition of several very necessary remedies, — among 
 others, of one against epilepsy, to which several persons in the above- 
 named house are subject. 
 
 They are, therefore, obliged to have recourse to you. May it please 
 you. Monsieur, considering the necessity above pointed out, and for the 
 good of the poor, to permit the surgeon of the aforesaid house to select 
 and remove from the burial-place of the Penitent Sisters of Mercy such 
 skulls as they may find proper for the preparation of the aforesaid 
 remedies ; and to this end the said Penitent Sisters be invited to permit 
 the said memorial, and the poor of the said Almshouse will pray for 
 your prosperity and health. Bourg, Christin. 
 
 Let it be done as it is required. 
 Lyons, 13 Septembre, 1710. Claret La Tourrette. 
 
 Another old theory resembled very closely that by 
 which insane persons received the designation of " luna- 
 tic," namely, that epilepsy was always worse during the 
 moon's phases. This notion was held until very recent 
 times, wlien M. Moreau proved it to be untrue by an 
 
8 Epilepsy: its Pathology and Treatment. 
 
 enormous collection of evidence against it. Thus, be 
 saw no less than 47,637 fits, of which 26,313 were be- 
 tween the phases of the moon and 16,324 during its 
 phases. 
 
 Even at the present day superstitions are very rife 
 among the lower classes, and all kinds of filthy decoc- 
 tions are employed against epilepsy. The writer is told 
 that in Melbourne, Australia, snakes' heads in rum haA'e 
 held until very lately a high reputation for the relief of 
 epilepsy. Even supposedly sane individuals of rank at 
 the present day are guilty of the most wretched super- 
 stitions. The following is of interest, as showing this, 
 taken from an address by the President of the Ecken- 
 foerder Shooting Club to its members: — 
 
 Her Highness, Princess Bismarck, wishes to receive, before the 18th 
 inst., as many magpies as possible, from the burned remains of which 
 to make an anti-epileptic powder. I permit myself, high and well-born 
 sir, to entreat you to shoot as many magpies as you can in your pre- 
 serves, and to forward the same to the Chief Forester, Lange, at Fried- 
 ricksruhe, or hither. 
 
 Symptoms. — One of the first and most marked S3'mp- 
 toms of an oncoming attack of epilepsy is a peculiar 
 sensation felt in some portion of the body, generally 
 below the brain, which graduallj' rises up over the patient, 
 either rapidl}^ or slowly, like an oncoming cloud, until, 
 the head having been reached, the patient is immediately 
 convulsed and unconscious, and almost instantly is seen 
 to be in the very acme of the nervous storm. Simul- 
 taneously with the arrival of the aura in the cervical 
 region the person utters a peculiar cry or scream, so 
 wild, so harsh, and so characteristic that it has been 
 called the " epileptic cry," being probably due not so 
 much to a voluntary impulse as to a sudden expulsion 
 of tlie air from the thorax by the convulsive contraction 
 
Symptoms. 9 
 
 of the abdominal muscles, as well as those of the thorax, 
 and its rapid passage through the glottis narrowed by 
 rigid spasm of the muscles governing this opening. 
 Synchronously with this cry the muscles of the whole 
 body, in a widespread attack, become strongly con- 
 tracted until they are in a tonic spasm, and then, having 
 momentarily relaxed, pass into alternating relaxations 
 and contractions, which throw the sufferer now to this 
 side, now to that. 
 
 With the tonic spasm the muscles of the face 
 often produce hideous distortions of the features, in 
 some cases bringing about the so-called risus sardon- 
 icus; the head may be drawn to one side, and under 
 these circumstances the eyes are generally turned in 
 the same direction ; the jaws are locked one against 
 the other, and the lower jaw may also be drawn away 
 from the median line of the face in the same direction as 
 the eyeballs. Sometimes the whole body is rotated. In 
 the 910 cases! analyzed by the writer complete rotation 
 to the right is mentioned as being present in 49 persons, 
 and to the left in 52 cases. There is, therefore, no 
 difference worthy of note in these numbers. 
 
 The arms are strong^ flexed at the elbows, while the 
 hand is still more strongly flexed at the wrist ; the fingers 
 are also so bent into the palm of the hand that not unfre- 
 quently the skin in this region is found indented by the 
 nails. To speak briefly, the arms, legs, and body are 
 drawn and jerked in the direction of the most powerful 
 muscles, and, as a consequence of this, opisthotonos, 
 during the tonic stage, is by no means uncommon. Ex- 
 ceptions to this rule do, however, frequently occur, and 
 when present show that the paroxysm is exerting its 
 chief influence on the weaker muscles, while the stronger 
 
 ^ University Medical Magazine, 1889. 
 1* 
 
10 Epilepsy: ?7s Patholofjy and Treatment. 
 
 ones are affected at least to a less degree. As a general 
 rule, too, the muscles of one side suffer more than those 
 of the other. Unfortunately the writer finds, in the cases 
 collected hj him, that in only 158 instances were any 
 remarks on this point made. In these 158 the right side 
 was most affected in 77 cases, and the left side in 81 cases. 
 It is evident, therefore, that both sides suffer about 
 equally. The author has not attempted to analyze these 
 cases as to relative frequency of the general S3'mptoms, 
 as it would hardly be justifiable, for in some of the cases 
 the^' may have occurred and the reporter neglected to 
 name any one of them. 
 
 The legs may be firml}^ flexed on the abdomen, 
 while the fingers are rigidly extended. The change in 
 the color of the face is very marked and almost typical 
 of the disease, being at first pale, then flushed, the flush- 
 ing deepening often into a livid purple, owing to the 
 asphj^xia produced by the convulsive contraction of the 
 thorax. In some cases the eyelids are widely drawn 
 apart so that the eye, owing to its fixation, has a staring 
 appearance ; in others they are so tightly closed that the 
 fingers of the on-looker can scarcely force the lids apart. 
 The staring but blank expression of the eyes is also 
 increased by the slow dilatation of the pupils, which 
 always accompanies the asphyxia. 
 
 The duration of these tonic contractions rarely ex- 
 ceeds two minutes, and in most cases is limited to but a 
 few seconds. It is followed by clonic spasms, already 
 described, which are ushered in by more or less violent 
 tossings, but whose onset is forewarned by peculiar vi- 
 bratory thrills, which run through all the affected muscles. 
 The eyelids tremble, the body changes its position ever 
 so slightly, and then, as if the vibrations gained greater 
 and greater power with each moment the fibrillary trem- 
 
Symptoms. 1 1 
 
 ors give wfij" to miisciilar contractions. The expression 
 of the face, which in the preceding stage was set and 
 firm, is now constantl}^ changed by the movements of the 
 facial muscles; the jaws, no longer locked together, are 
 gnashed and crunched one upon the other ; the tongue is 
 alternately protruded and drawn back, and, as a conse- 
 quence, is often caught between the teeth and bitten and 
 lacerated. The excessive movements of the muscles of 
 mastication force the increased quantities of liquid 
 secreted b}^ the salivary glands from the mouth in the 
 form of froth, which is often stained with blood by reason 
 of the injuries to the tongue. The constancy of the 
 convulsive movements now becomes less and less marked ; 
 well-developed remissions occur between each toss of 
 the bod}^, until the movements cease entirely ; but it 
 should be constantly borne in mind that the prolonga- 
 tion of the remissions does not produce any decrease in 
 the severity of the intervening spasm, the final spasm 
 often being even more violent than the first. 
 
 The intense discoloration of the face begins to pass 
 away as soon as the remissions, by their length, permit 
 the blood to be oxygenated, its disappearance being 
 temporarily arrested by each paroxysm. Finally, the 
 spasms having ceased, the patient lies before us relaxed, 
 unconscious, and exhausted, and passes into a deep sleep 
 or coma, which lasts a variable length of time, and from 
 which he cannot be aroused except very rarely, and then 
 with great difficulty. 
 
 Absolute coma was recorded in the writer's collec- 
 tion of cases as present in 104 cases, in 12 others it was 
 marked as absent, and in the remaining cases the person 
 keeping the record failed to report concerning it. 
 
 Even when the sleep has passed away the brain is 
 evidently disturbed in its functions for some hours or 
 
12 Ejnlepsy : its Pathology and Treatment. 
 
 perhaps days, and headache is, not rarel}^, complained 
 of after the patient seems like himself in other respects. 
 The sphincters are very rarel}^ relaxed, although the 
 urine ma^^ be voided, as may also the faeces. According 
 to Gowers^ this relaxation is more commonly associated 
 with nocturnal epilepsy, and this opinion coincides with 
 the writer's experience. 
 
 That urinary incontinence is extremely rare is shown 
 by the fact that in the cases collected b}^ the writer (970) 
 it was only recorded as occurring in 45 cases. 
 
 Having described a typical attack of epilepsy, let us 
 proceed to an analysis of the various symptoms detailed. 
 Very commonly in epilepsy we find that the patient is 
 covered, during or after the paroxysm, by a profuse 
 sweat, which has been assigned b}^ some to the excess- 
 ive muscular movements and by others to vasomotor 
 changes which they think occur. Emminghaus^ has made 
 reports and studied this matter in order to determine 
 which of these theories is the true one, and inclines to the 
 belief that it is due solel}'' to vasomotor disturbance, but 
 it is probable that both the muscular movement and the 
 changes in the circulatory system are at fault. In some 
 cases the muscular movements may amount to almost 
 nothing, and under these circumstances any sweat must 
 be due entirel}^ to a disordered peripheral circulation and 
 its nerve-supply, or to disturbances in the nerves govern- 
 ing the sweat-glands. Those who believe completel}' in 
 the neurotic origin of the sweat point out very forcibly 
 that often in the most severe fits no sweating takes place. 
 
 The Aura. — One of the most interesting and impor- 
 tant of all the symptoms described is the so-called aura, 
 and some difference of opinion has arisen as to the fre- 
 
 » Dispases of the Nervous System, vol. ii, p. 081. 
 Arch. f. Psycliiatrle, 1874. 
 
The Aura. 13 
 
 quency of its occurrence, some authors stating it to be 
 very rare, while others see it very constantly. There 
 can be little doubt that in many cases it is as constantly 
 present as in others it is absent, and it would appear 
 that the nationality of the subject has something to 
 do with the occurrence of this signal of the attack ; at 
 least, if we may judge by the statements of the chief 
 authors of each nation. Thus, in America Wood^ states 
 that " the aura is wanting in a very large proportion of 
 the cases of true epilepsy," and Hammond agrees with 
 him^ In Enoland Gowers states it to occur in about 
 one-half the cases, and Bristowe^ states it to be not un- 
 common. In France and Belgium the aura appears to 
 be present in more than half the cases, in one form or 
 another, as it is also in Germany, according to the most 
 prominent neurologists.* In the 970 cases collected 
 by the writer it was found that the aura was recorded 
 as present in 362 cases and absent in 138 cases. In the 
 remainins: 470 cases the occurrence of an aura was not 
 mentioned. 
 
 The following table shows the character of the aura 
 in the cases where it was recorded : — 
 
 Tingling, 45. Dizziness, 15. Chilliness, 7. 
 
 Visual, 27. Numbness, 15. Laughter, 4. 
 
 Pain, 26. Disturbed respirations, 14. Drowsiness, 3. 
 
 Twitching, 21. Gastric, 15. Faintness, 3. 
 
 Epigastric, 20. Cramp in muscles, 11. Abdominal, 3. 
 
 Headache, 16. Olfactory, 11. Aphasia, 3. 
 
 Auditory, 16. Mental, 8. Unclassified, 44. 
 
 The word aura is derived from the Latin, signif3nng 
 vapor, and its application to certain symptoms of epi- 
 lepsy arises from the old Greek theory that the fit began 
 
 ^ Nervous Diseases and their Diagnosis, p. 103. 
 ^Ibid., p. 682. 
 
 'Theory and Practice of Medicine, 6th ed., p. 1114. 
 * Nothnagel. 
 
14 Epilepsy: its Pathology and Treatment. 
 
 by the ascent of a vapor in the veins of the extremities. 
 In later times it was imagined that the nervous impulse 
 causing the spasm arose in the part where the aura first 
 appeared, since the attack could be put aside by the 
 tightening of a ligature around the arm or leg ; but this 
 is held b}^ most of tlie students of the disease at the 
 present day to be impossible, since the application of a 
 ligature, where the convulsion is due to brain-tumor, 
 may stop the onset of the paroxysm. It cannot be gain- 
 said that this is true, but while the lesion may be present 
 in the brain it is no reason that the impulse for the con- 
 vulsion may not arise peripherally by a species of refer- 
 ence of the irritation to that part, and in the so-called 
 reflex epilepsies there can be no doubt that the impulse 
 is peripheral, not centric. In the writer's own practice 
 he has seen a case which to a certain extent contradicted 
 the opinion that the impulse does not ever arise except 
 in the centre. Thus, in a case of adherent prepuce the 
 aura always began in the penis, and the attack could be 
 put aside by tightly grasping that organ. Circumcision 
 cured the epileps}^, which could not therefore have had 
 its origin centrically ; further than this, the whole list 
 of reflex epilepsies show that the aura and the cause of 
 the attack ma}^ exist in the same part of an extremity. 
 Then, too, we have nothing as 3'et to prove that it is 
 impossible for a centric nervous lesion to produce such 
 functional changes peripherally as to cause disease in 
 that part. Ever^^ one knows how disease of the brain 
 ma^'' cause descending degeneration in the spinal cord, 
 or ascending disease of the cord produce brain-lesions, 
 and direct physiological experiment has proved that a 
 nervous lesion in the peripher}^ may cause not onl}^ cen- 
 tric changes but peripheral changes elsewhere entirely 
 separate from the part primarily injured; as, for ex- 
 
The Aura. 15 
 
 ample, the famous experiments of Brown-Seqiiard, where 
 section of the sciatic nerve in the leg of a guinea-pig 
 produced structural alterations of the skin of the face, 
 and in which an epileptic attack could be brought on at 
 any time by pinching that area, or the disease cured by 
 removal of that portion of the skin. 
 
 It will be remembered that, as a general rule, re- 
 ceptive nerve-centres refer impulses to their peripheral 
 nerves; as, for example, the pain in the knee and ankle 
 in coxalgia, or the stomach-pain of vertebral disease ; 
 and so may the irritation of a brain-tumor be referred 
 to the periphery, and, gradually increasing, cause a 
 convulsion by sending to the motor centres irritating 
 messages. This theory is also supported by the fact 
 that the area involved in the brain is accurately pointed 
 out by the point of origin of the aura. If, for example, 
 the aura is in the hand, the hand-centre is probably 
 diseased. 
 
 The writer has stepped aside to discuss this point a 
 little more fully than is, perhaps, necessary, were it not 
 that, while he is a firm believer in the idea that all 
 epilepsies are essentially centric, he fears that there is 
 a tendency just at present to regard with suspicion the 
 occurrence of reflex epilepsy arising peripherally. 
 
 The aura, or warning, while possessing general char- 
 acteristics in common in all cases, is by no means iden- 
 tical in each individual. B}'^ far the largest number of 
 cases, where it is present, have it in an extremit}^, and, 
 if it be not there, then it is probably in the stomach ; 
 while it is not uncommon to see persons suffering from 
 epilepsy who have as an aura a general, indefinable sen- 
 sation all over the body. In much more rare instances 
 the aura3 are situated in the organs of special sense, and 
 are evidenced by sudden attacks of blindness or of deaf- 
 
16 Epilepsy: its Pathology and Treatment. 
 
 ness. It is worthy of note, however, that whereas the 
 anrae may differ in every case in origin, seat, and limi- 
 tation, they are remarkably constant in the same indi- 
 vidual, rarely, if ever, changing unless to grow more or 
 less well defined. A careful analysis of an enormous 
 number of cases b}'^ hundreds of observers shows that the 
 aura most commonly met with is that beginning in the 
 hand; next, that beginning in the leg or foot; next most 
 common, that arising in some of the viscera, and after 
 these those which arise in the face and tongue. The 
 rarest form of aura is that which arises in the sides of 
 the trunk. 
 
 Not only may the seat of the aura be various, but its 
 sensations may be even more aberrant. Undoubtedly 
 the most common sensation is the indescribable sen- 
 sation of a vapor or cloud, already spoken of, but in a 
 large number of cases the sensations are described as 
 being quite painful, or perhaps as partaking of the 
 feeling that the part is in active movement when in 
 reality it is still quiet. Others speak of it as a sensa- 
 tion of cold, others of heat or burning, and still others 
 of trembling and indescribable distress. In certain 
 cases the sensation is confined to the spot where it is 
 first noticed, and fails to travel upward or toward the 
 central nervous system. When the seat of the aura 
 is in the thorax or abdomen, it frequently produces, 
 as it travels upward, a sense of strangulation, which is 
 only a seeming arrest of respiration, since in the slowly- 
 moving aurse the glottis is not closed until some mo- 
 ments later. Aurae in these regions are nearly always 
 associated with the distribution of the pneumogastric 
 nerves and the respiratory portions of the spinal acces- 
 sory nerves. Generally the visceral sensations occur in 
 the middle line, rarely to the left of that line, and 
 
The Aura. IT 
 
 scarcely ever to the right. A very curious fact in re- 
 gard to the abdominal aurse is, that when pain is felt in 
 the epigastrium it never ascends to the head, but re- 
 mains in this region till the convulsion comes on, 
 whereas if the sensation is not one of pain it frequently 
 extends to the cerebrum. Cli. Bonet^ mentions an in- 
 teresting case of a man of 50 years, who had an epileptic 
 aura consisting in a swelling of the groin. 
 
 The vagus nerve, as has already been stated, seems to 
 carry out a large part of the sensation of the aura, both 
 in its gastric branches and respiratory filaments. The 
 cardiac filaments also show signs of being concerned by 
 palpitations, pain, or cardiac discomfort. 
 
 In the aura associated with the nerves of special sense 
 the most common perversion of function has been found 
 to be that of sight, which, according to Charcot and 
 Gowers,2 is twice as frequent as all the other special- 
 sense aurse put together. It may consist of a single or, 
 more commonlj^, many colors, floating before the e3^es, 
 red and blue being those most usually seen (indeed, no 
 other color is ever seen alone), or it may consist in a 
 sudden diminution or increase in the size of all sur- 
 rounding objects. In others the ocular symptoms exist, 
 but are entirely beyond the ability of the patient to 
 describe, while diplopia, blindness, or complex visions 
 may be present. Thus, in some cases, the vision of an 
 old woman or man, holding in the hand a hammer, with 
 which a blow is about to be struck, has ushered in an 
 attack and all succeeding attacks. One of the oldest 
 reports of such cases that we have is one of Joannis 
 Schenckius,^ who, in 1665, recorded the instance of 
 
 * Sepulcretum Anatom., lib. i, sect, xii, p. 291. 
 ^ioc.ciY., p. 684. 
 
 * Observatiouum Medicarum Rariorum, Frankf urti, 1665, lib. i ; de 
 Epilepsia, p. 104. 
 
18 Epilepsy: its Pathology and Treatment. 
 
 a 3^oung man who alwa^^s saw a woman offering her- 
 self to him in a lascivious manner before each fit, which 
 was accompanied each time by an emission of semen. 
 In other cases flashes of light and sparks may po^s 
 before the eyes, or objects seem to move toward tlie 
 patient more and more rapidlj^, and as they reach him 
 he is thrown down by the convulsion. Contrariwise, 
 the objects may appear to be leaving him, and as they 
 grow dim in the distance the parox^^sm seizes the 
 patient. The writer might go on enumerating the 
 various ocular disturbances almost indefinitely were it 
 not that it would be useless and tiresom-e to the reader, 
 who, after what has been said, must have been impressed 
 with the idea tliat any vision or aberrant movement of 
 the apparatus vision may occur. 
 
 Auditory disturbances are also frequently present as 
 aurae. Thus, tliere may be a whizzing or buzzing sound, 
 or a crashing, which grows louder and louder until the 
 patient falls ; or, instead of these, a desperate still- 
 ness which the loudest sound cannot dispel, and which 
 cannot be distinguished from ordinary deafness save 
 in the transient character of the loss of hearing. Short 
 peals of music sometimes float the patient into an 
 attack. Drums beat martial airs and fifes may seem 
 to play. 
 
 The third form of perversion of special sense is that 
 of smell. Thus, in one patient there ma}' be an odor of 
 phosphorus, in another of verdigris, in a third of some 
 common or rare drug. Sometimes the subjective odors 
 are agreeable, sometimes disagreeable, although, even if 
 the odors are in themselves not unpleasant, they speedily 
 become so, owing to their association in the patient's 
 mind with the disease. 
 
 The infrequent forms of special-sense aurse are those 
 
The Aura. 19 
 
 of taste, and in these the gustatory apparatus may per- 
 ceive flavors pleasant or vile, sometimes bitter or 
 metallic. 
 
 -. Still one other seat may give rise to an aura, namely, 
 the brain. Psychical aurae, as they are called, almost 
 always consist in an intense feeling of alarm and terror, 
 or they may consist, in very rare cases, of a certain in- 
 tellectual thought or idea. In this form of aura the idea 
 of an imminent danger to the person by reason of an 
 apparent threatening act of a bystander may drive the 
 patient to inflict a blow in self-defense which may be 
 fatal, but of which, after the fit, he has no recollection. 
 Of this I shall speak when considering epilepsy in its 
 relation to crime. So dreamy is the mental condition 
 in some cases that, while the patient is conscious of the 
 passage of ideas, he cannot, either before or after, ex- 
 press what they were. Hughlings- Jackson calls this the 
 "voluminous state." Probably the most uncommon 
 symptom is that given by Gowers, and consists in a 
 sensation that something is morally wrong. 
 
 The cephalic aurae A^ary quite as much as those found 
 elsewhere, and may be evidenced by giddiness, vertigo, 
 fullness of the head, or sensations of heat or cold either 
 within or without the skull. Nausea may attend the 
 vertigo if it is })rolonged. 
 
 The frequency of this symptom may be judged from 
 the following table, and the relative frequency as com- 
 pared to the other symptoms is also to be found on 
 pages 22 and 23 : — 
 
 Vertigo, 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Per Cent, 
 
 Doubtful, , 
 Absent, 
 
 ^ 
 
 ^JJ23 
 
 1|« 
 
 %\68 
 
 Present occasionally, 
 
 10 |n 
 
 ^|io 
 
 «J.i 
 
 '^^ I 30 
 
 Present frequently, . 
 
 7 5 
 
 36 33 69 98 
 
20 Epilepsy: its Pathology and Treatment. 
 
 When we exclude the doubtful cases, we find that 
 vertigo is present in 77 per cent., and that more females 
 are att'ected than males, in the proportion of 90 to 68.^ 
 In the cases collected by the writer vertigo is recorded 
 in 206 cases as present, and in 18 cases as absent. In 
 the remaining cases no mention of vertigo is to be 
 found. 
 
 Having now considered to a very wide extent the 
 chief characteristics of the aurae of sensation, let us 
 turn to those manifesting themselves by motor disturb- 
 ances. In some such instances contractions of the 
 muscles of one or more fingers gives the warning, or, 
 indeed, the entire limb may be moved, although this 
 is much more rare. In the same manner the attack 
 may give notice of its approach by spasm of the face, 
 particularly in the zygomatic muscles, and sometimes 
 in the orhicularis palpebrarum, 
 
 A ver}^ close relationship exists between the onset 
 of the attack itself and the aura in these cases; that is 
 to sa}^ it is difliicult to decide how far the contraction 
 of a finger partakes of the character of an aura and 
 how far it partakes of the primary movements of the 
 convulsion, for the spasmodic movements, in some cases, 
 pass from muscle to muscle until the entire body is con- 
 vulsed. It is also as true of these motor aurjB as of the 
 sensory variety, that they indicate the place in which 
 lies the centric trouble, if centric trouble exist, and it 
 is equall}^ undeniable that these motor aurae generally 
 accompan}^, not the ordinar}^ idiopathic epilepsy, so 
 called, but that dependent upon a localized Injury, or a 
 tumor of the brain. On the other hand, it is equally 
 certain that they do partake of the character of an 
 aura, since forcible extension of the fingers, flexed by 
 * Reynolds on Epilepsy. London. 
 
Precursory Symjytoms. 21 
 
 a motor aura, will in many Instances avert the attack 
 in the same manner as will a tight ligature around the 
 wrist in the case of a sensory warning. Still other 
 cases exist than those mentioned, in which a combined 
 aura may be present, commonly made up of a motor 
 and sensory aura, or of a motor and special sensory 
 aura, although all these may occur in a single case. 
 
 Precursory Symptoms other than Aiirse. — When 
 speaking of psychical aurse the writer should, perhaps, 
 have spoken of the apathy of the mental processes which 
 sometimes precedes an attack, were it not that this 
 symptom and others like it are more like the prodromata 
 of a disease than a sudden and brief warning. On the 
 other hand, in place of apathy there is sometimes for 
 several days before a fit a great increase in the rapidity 
 of thought, ideas chasing through the brain so rapidly 
 that they are lost before the}^ can be put into words. In 
 certain cases this mental condition finds itself expressed 
 in bodily restlessness, so that the man may be driven to 
 take long walks, or roam about the streets. Violence 
 may be indulged for scA^eral da3'S to such an extent as 
 in no way to separate itself from that of mania except 
 that there is generally a sane condition in regard to 
 other matters. While in this state, persons who are 
 innocent and total strangers may be attacked by the 
 patient, or furniture demolished by him. Children 
 occasionally for a few days before a parox3^sm become 
 ungovernable, often attempting to bite their playmates 
 and attendants. Great fear of an impending evil some- 
 times is present, or is supplanted by the most abject 
 melancholia. Still other cases are recorded in which 
 an extraordinary loquacity asserted itself in men of a 
 commonly morose or taciturn nature, while sometimes 
 such imperfections in speech occur for a few days 
 
22, Epilepsy: its Pathology and Treatment. 
 
 as almost to amount to aphasia. The touch may be 
 h3'per«Testhetic, or diplopia or liemiopia exist for twenty- 
 four or forty-eiglit hours beforehand. Bleeding at the 
 nose or profuse salivation, with tenderness of the gums, 
 may also be forms of prodromata, and several cases are 
 on record where the man has suddenl}^ blown his nose at 
 dinner-table, and then, springing up, dashed into the 
 street. Other men have been seized with a violent desire 
 to strip themselves of clothes, even in the street or at a 
 theatre. 
 
 Quite a number of statistics have been collected by 
 various clinicians as to the relative frequency of the 
 precursory symptoms of epileptic attacks, chief among 
 which should be mentioned those of Delasiauve,^ which 
 are here given. In 264 cases, where precursor}^ symp- 
 toms were alwa3's present, he finds reason to divide 
 them into seven groups as follows : — 
 
 Seventy-five Cases with P7^ecurso7y Symptoms in Head. 
 
 Vertigo, flashes of light, 23 
 
 Headache or feeling of weight in head, . . . .15 
 
 Heat of face, 3 
 
 Various localized sensations, 13 
 
 Indefinite, 1 
 
 Illusions, hallucinations, 9 
 
 Kotation of head and eyes, 5 
 
 Grinding of teeth, with loss of movement of tongue, . 2 
 
 Somnolence, ......... 1 
 
 Constriction of throat, 3 
 
 Twenty-two Gases with Precursory Symptoms in Thorax. 
 
 Oppression and sense of suffocation, 9 
 
 Feeling as of a ball in throat and chest, .... 2 
 
 Sliivering with cold, 5 
 
 Pain or heat, .4 
 
 Palpitations, spasms, 2 
 
 » Traite de r Epilepsia, 1854, p. 47. 
 
Precursory Symptoms. 23 
 
 Thirty-two Cases with Precursory Symptoms in 
 
 Abdomen. 
 
 Pain, eructations, and vomiting, 13 
 
 Intestinal or uterine colic, .3 
 
 Sensation of a ball, 3 
 
 Sensationof cold or vapor, 6 
 
 Stomachal heat, ......... 1 
 
 Undefinabie sensations, 6 
 
 Ninety-four Gases with Precursory Symptoms in the 
 
 Extremities. 
 
 Numbness, contractions, jerkings, retractions, cramps, 
 
 and formications, 36 
 
 Pain, wither without spasm, 13 
 
 Tremblings, 10 
 
 Aura or similar phenomena, ...... 20 
 
 Undefinabie sensations, . . . . . .. .15 
 
 Twenty-two Cases with Precursory Symptoms of an 
 
 Undefinabie Character. 
 
 General agitation and rotation of body, . . . .8 
 Condition of discomfort, fainting, . . . . .6 
 
 Vague sensations, 7 
 
 Moroseness, 1 
 
 Five Cases with Precursoyy Symptoms Situated in the 
 
 Genital Organs. 
 
 Retraction's of testicles or aura starting there, sensations 
 In the uterus, 5 
 
 The seventli series contained those rare cases where 
 there was a desire to defecate, urinate, or in which pro- 
 fuse sweating came on. 
 
 In a collection of cases made by Hammond,^ in 128 
 epileptics out of 286 persons suffering from the disease, 
 there were precursory symptoms. 
 
 When we summarize Delasiauve's results we find 
 that the largest number of the precursory symptoms 
 * Diseases of the Nervous System. 
 
24 Epilepsy: its Pathology and Treatment. 
 
 occurred in the extremities (94 cases), the next largest 
 number in the head (75 cases), next in the abdomen 
 (32 cases), and last of all in the thorax (22 cases), the 
 remaining 27 cases in the sixth and seventh somewhat 
 artificial divisions of the author quoted being of an un- 
 definable character. 
 
 Addison has also studied the relative frequenc}^ of 
 the s^'mptoms of the attack itself, witli somewhat inter- 
 esting but in no way surprising results^ : — 
 
 Loss of consciousness, 
 Muscular cramp, 
 Bit tongue in fit, 
 Uttered cry before fit, 
 Fell during fit, 
 Wet bed during fit, . 
 Wet bed at night only, . 
 Wet bed night and day, . 
 Rotated in fit, . 
 Convulsions on right side. 
 Convulsions on left side, . 
 No coma after attack. 
 
 Of course, many of these symptoms occur in a 
 single individual in many instances, but the table 
 serves to illustrate what has been said in regard to the 
 frequency of certain signs, such as the loss of conscious- 
 ness, the falling to the ground, and the frequency of 
 coma after a seizure. 
 
 The Fiqnl. — The dilatation of the pupil, which comes 
 on in nearly all epileptic attacks, has connected with it 
 the interesting question as to whether the m3'driasis is 
 produced by the convulsion directly, or indirectly by 
 the resulting asphyxia, or by both causes. The latter 
 is probably the true answer, because it is well known 
 to ph^'siologists that the pupil generally dilates in con- 
 » Addison, Journal Mental Science, vol. xii, 18li7. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 29 
 
 10 
 
 39 
 
 10 
 
 1 
 
 11 
 
 21 
 
 6 
 
 27 
 
 25 
 
 5 
 
 30 
 
 39 
 
 9 
 
 48 
 
 . 19 
 
 7 
 
 26 
 
 12 
 
 3 
 
 15 
 
 . 27 
 
 8 
 
 35 
 
 . 4 
 
 1 
 
 5 
 
 . 10 
 
 3 
 
 13 
 
 . 8 
 
 2 
 
 10 
 
 . 2 
 
 1 
 
 3 
 
The Circulation. 25 
 
 viilsions, and also that aspbj^xia produces similar results 
 hy its action on the centric nervous ocular apparatus. In 
 some cases it would seem that tlie nerve-storm continued 
 in the ocular centres after all else is quiet because of 
 the alternate contraction and dilatation of the pupil; 
 but this will be referred to further on. 
 
 The writer has already spoken of the involuntary 
 voidance of urine and faeces by epileptics, and when 
 doing so stated that it was very unusual. It is not 
 dependent, when it does occur, on the loss of conscious- 
 ness, for it never occurs in some patients whose intel- 
 lectual faculties are entirely lost, and does take place in 
 others whose minds are merely dimmed for a moment. 
 In these the spasmodic movements probabl}^ affect the 
 walls of the bladder or its sphincter, or the walls of and 
 sphincter of the lower bowel. 
 
 The Circulation. — Curiously enough, the circulatory 
 apparatus escapes almost entirely in epilepsy ; the best 
 authorities, indeed, all agree in stating that the only 
 changes are those brought about by the accompanying 
 asph3^xia. Yoisin has published a curve showing that 
 no change occurs during an aura, but Moxon, on the 
 other hand, has asserted that a stoppage of pulse occurs 
 in some instances, and, although many have denied this, 
 one can readily believe that it may occur when the in- 
 hibitory cardiac filaments of the vagus are affected. 
 Every one agrees, of course, that during the violence 
 of the muscular movements the force and rapidity of 
 the circulation is increased, and particularly the arterial 
 pressure. The latest and most elaborate studies on the 
 ei)ileptic pulse, with which the writer is acquainted, are 
 those of Mons. Y. Magnon ' who has shown that during 
 the clonic stage of the convulsion the arterial pressure 
 
 * I'Epilepsie Paialytique, 1881. 
 2 B 
 
26 Ejyilej^^y : its Fathology and Treatment. 
 
 is increased to a very great extent, as well as the 
 pulse-rate, but that during the first or tonic stage the 
 pulse-rate falls, and the rhythm is so altered that a 
 complete S3'stole and diastole may occupy six times 
 the normal period. Afterward the pulse passes to 
 the normal or into a condition of increased force and 
 frequency. 
 
 Status Ejnlepticus, — Before passing on the writer 
 should speak of the condition known as the " status epi- 
 lepticus," in which convulsion follows convulsion so 
 rapidl}^ that consciousness is never regained, but the 
 patient dies within a few hours as a result of exhaustion 
 or asph3'xia. 
 
 Probably the most thorough study that we liave of 
 this condition is that of Bourneville,^ and his results are 
 certainly worthy of introduction here. He details the 
 symptoms as follows : Etat de mal epileptique is char- 
 acterized b}^ — 
 
 1. Frequent repetitions of attacks so close together 
 as to be almost if not continuous. 
 
 2. By variable degrees of collapse, which ma}' deepen 
 into coma. 
 
 3. By more or less complete hemiplegia. 
 
 4. By increased frequency of pulse and respiration. 
 
 5. By elevation of temperature persisting even 
 between the attacks. 
 
 As the case goes on the convulsions are replaced en- 
 tirely by coma, or, in rare cases, violent attacks of mania 
 may develop. In this state the body rapidly emaciates, 
 bed-sores develop, and death ensues from exhaustion. 
 
 It is notewortliy, however, that with the development 
 of the Ijcd-sores the temperature rises again as high as 
 during the convulsions. 
 
 ^ ISourneville, Etat dc mal Epileptique, 1873. 
 
Time of Day. 27 
 
 Time of Day. — In an anah^sis by Bo3^d,^ to deter- 
 mine whether the seizures of epilepsy were more fre- 
 quently^ at night or during the day, he found that in a 
 collection of 3202 fits 1962 occurred in the day-time and 
 1240 at niglrt, showing that the waking hours are most 
 commonly interrupted. 
 
 Irregular Symptoms. — So far only the more regular 
 S3miptoms of an attack have been given, and the writer 
 would not be doing justice to the reader to let him 
 think that all cases of epilepsy are so fully accompanied 
 by a long train of constant signs as have been described. 
 Even to the most casual reader it must haA^e become 
 evident that almost every case is a law unto itself, and 
 is only surrounded b}^ an atmosphere which stamps it as 
 epilepsy. In some cases only a tonic or a clonic spasm 
 occurs, or in others the mild S3'mptoms of petit mal are 
 present, of which the writer will speak further on. In 
 the opinion of the author, as a rule, it may be laid down 
 as a positive fact that when the fit is one of the tonic ty\)Q 
 it is generally of a less severe character than when it is 
 clonic; but exceptions to this rule maj^^ occur, as is 
 evidenced by the tetanoid epilepsy of Pritchard, in 
 which rigidity of a most persistent and dangerous 
 type often is present. However, it is undoubtedly true 
 that attacks either entirely clonic or tonic are less 
 severe than those which have both varieties of muscular 
 disturbance. 
 
 After-Symptoms. — The heav}^ sleep or coma which 
 follows immediately upon the retreat of the convulsion 
 has been already spoken of, as well as the headache which 
 follows the coma, particularly if the sleep be disturbed 
 b}' the attendants of the patient. 
 
 * Quoted by Sieveking, loc. cit. 
 
28 Ejnlepsy : its Pathology and Treatment. 
 
 Headache. — The following table, showing the fre- 
 quency of the occurrence of headache may be of in- 
 terest^ : — 
 
 Headache. Males. Females. Total, Per Cent. 
 
 Absent, .... 7 1 8 28..5 
 
 Present occasionally,' . ^\\i ^^ j 15 ^'^ "^^-^ 
 
 Present frequently, . • ^S 4 ^ ' 9 
 
 18 16 34 
 
 This shows very well the constancy of headache as 
 an after-symptom, but in the writer's experience a much 
 larger portion suffer from cephalalgia. Thus, in the 
 cases of epilepsy collected by the writer, it was found 
 that headache was recorded as present in 432 instances, 
 and as absent in onl}' 34 cases. In the remaining cases 
 no record of the presence of headache was found, often 
 owing to the carelessness of the person making the report. 
 It will also be seen that females suff'er from headache 
 more commonly than males in the proportion of 93 to 
 61 per cent. 
 
 Coma and Sleep. — It has been held by some that 
 the after-symptoms of sleep and coma are identical, and, 
 while the point is well drawn, we cannot help evading it, 
 simply because in some cases the condition is neither 
 one nor the other. Thus, sleep is the state of uncon- 
 sciousness commonly found in every one, but from which 
 they can be more or less readily aroused if desired, but 
 coma is a state in which no external influences are able 
 to rouse the man from his letharg3\ In epileptics either 
 one of these conditions may assert itself. 
 
 The true relationship of this after-condition to the 
 paroxysm is also a matter of dispute, some claiming 
 that it is part of the seizure, while others think it only 
 the natural reaction after the strain of the convulsion. 
 
 * Eeynolds on Epilepsy. Loudon. 
 
Paralysis. 29 
 
 The writer believes that a medium view is to be taken of 
 this, and that both factors are at work, the exhaustion 
 being probably the chief cause of the sleep. On the other 
 hand, Siemens^ contends very strenuously that this is 
 not so, believing that the coma forms a third stage of 
 the atttack. 
 
 Paralysis. — Motor paralysis with loss of all power 
 may succeed epileptic paroxysms, and this is particularly 
 the case in those instances where the convulsive move- 
 ments are largely unilateral in character. This condition 
 has received the name from some neurologists of " post- 
 convulsive paral3'sis" or " hemiplegia epileptica,"and the 
 frequency of its occurrence has been noted by Addison ,2 
 whose results are given in the following table. 
 
 In 31 epileptic males and 10 females paralysis was 
 an epileptic sequel, as follows : — 
 
 Paralysis of right side, 
 Paralysis of left side, . 
 Paralysis on both sides, 
 Not paralyzed, .... 
 
 It will thus be seen that in 21 cases hemiplegia epi- 
 leptica followed, while in 20 cases it did not occur, — a 
 percentage which, if relied on, gives about 50 post- 
 convulsive palsies to the hundred epileptics. In these 
 cases the epileptic movements were both unilateral and 
 bilateral, and the paralj^sis when unilateral was alwaj^s 
 on the side in which the fit commenced. The question 
 at once arises, when considering this condition, as to the 
 cause of the paralysis ; or, in other words, is this tempo- 
 rary loss of power the result of exhaustion of the 
 nervous protoplasm by the forcible discharges which it 
 
 » Allgem. Zeitschrift f . Psychiatrie, Bd. XXXV, Heft 5. 
 ° Jour, of Mental Science, vol. xii, 1867. 
 
 rales. 
 
 Females, 
 
 Total. 
 
 9 
 
 2 
 
 11 
 
 7 
 
 2 
 
 9 
 
 1 
 
 
 
 1 
 
 14 
 
 6 
 
 20 
 
30 Epilepsy: its Pathology and Ty^eatment. 
 
 has put forth, or does it arise from a condition of the 
 nervous matter closely allied to actual organic change ? 
 That the loss is purely functional seems certain, for if 
 it were organic the palsy would be permanent, not tem- 
 porary as it is. Of course, where the epileptic attack is 
 the result of an embolism, or is accompanied by an 
 aneurismal dilatation of a blood-vessel, or an apoplex}'^, 
 then the paralysis is organic ; but in the simple fleeting 
 paralysis after epilepsy no such change, of course, occurs. 
 Gowers^ expresses the belief that in severe fits the loss 
 of power is purely functional and due to exhaustion, 
 while that occurring in less severe attacks is due to an 
 " inhibition of the motor centres," whatever that ma^^ be. 
 So far as the writer is aware, centres possessing an inhibi- 
 tor}^ influence over the motor cells of the cerebral cortex 
 are 3'et to be found to exist, and, while every one knows 
 of their existence in the medulla oblongata, and probably 
 in the spinal cord, no one has been bold enough to 
 attempt to prove that they possess any power except 
 over reflex phenomena. Dr. Gowers may express his 
 idea in an unfortunate manner, but, as we understand 
 him, his explanation is of a most hypothetical character 
 and entirely without foundation eitlier physiologicall}'- 
 or otherwise, for he brings forward no support of it 
 save arbitrary assertion, of which he is very fond. The 
 mnjority of all neurologists believe the palsy to be tlie 
 result of exhaustion, and find no necessit}'' to confuse 
 matters by advancing additional hypotheses concerning 
 which they know nothing, and which have loaded down 
 tlie boat carrying our knowledge of epilepsy in the past 
 until it nearly sank. 
 
 Studies have been made by Ferc^ on the condition 
 
 • Loc. cit., p. 088. 
 
 ^Compt reiidus de la Hociete de Biolug., Feb., 1888. 
 
Reflexes, 31 
 
 of muscular power of epileptics, both during the intervals 
 between the attacks and immediately after the paroxj^sms. 
 Using the ordinary dynamometer he found the general 
 strength of such persons to be from one-third to one- 
 fourth less than is normal. In his studies of the post- 
 paroxysmal state he finds the strength always markedly 
 decreased, and notes that this is more severe after noc- 
 turnal than diurnal attacks. This is not to be explained 
 by any variation in his experiments, and seems to be as 
 yet not clearly understood by any one. 
 
 The condition of the reflexes after an attack of epi- 
 lepsy is one of much interest and worthy of special 
 study. Ordinarily for the first few moments after an 
 attack all the reflexes are lost, but immediately after 
 this they are all very much increased and sometimes 
 become so excessive that " ankle-clonus " may be readily 
 elicited. 
 
 Reflexes. — A careful study of the condition of the 
 various reflexes after an epileptic paroxysm has been 
 carried out by Beevor/ who divides his cases into two 
 classes, namelj^, those seen instantl}^ after the paroxysm 
 and those in which some moments elapsed before he began 
 his tests. In all, he made observations on seventy fits 
 occurring in 31 different cases, and examined both legs in 
 each. His results are best given in a tabulated form : — . 
 
 KBee-jerk increased and clonus present, 
 " diminished and clonus absent, 
 " absent and clonus absent, 
 *' normal and clonus absent, . 
 * ' diminished and clonus present, 
 '' normal and clonus present, . 
 
 Cases Cases 
 
 Seen Seen Total. 
 
 Instantly. Shortly. 
 
 27 11 38 
 
 6 7 13 
 
 3 8 11 
 
 4 15 
 2 2 
 1 1 
 
 43 27 70 
 
 » Brain, April, 1882, 
 
32 Epilepsy: its Pathology and Treatment. 
 
 He also found that the plantar reflex was absent in- 
 stantly after the clonic stage, but returned in from three 
 to thirteen minutes, the average lapse of time before its 
 return being five minutes. In every instance the plan- 
 tar reflex occurred synchronously with the disappear- 
 ance of the clonus, and in ever}' case examined the at- 
 tacks were bilateral, though in several they were a little 
 more marked primarily on one side than on the other, 
 and in these the knee-jerk and ankle-clonus were more 
 marked on the side first affected. He also records a 
 study of conjugate deviation of the eves in the same 
 class of cases, which, as it bears upon tlie results of the 
 research just quoted, should be given here before con- 
 sidering their practical bearing. 
 
 Having first called to mind the fact that in most epi- 
 leptics the fit begins by the rotation of the eyes and head 
 to one side, generally the right, accompanied by flexion 
 of the elbow and wrist of the same side, he goes on to 
 describe the after-movements of the eyes when the fit 
 has passed off, as the writer has done when considering 
 the after-symptoms of the paroxysms, namely, the roll- 
 ing of the e3"es to the opposite side and their fixation 
 there for some moments, followed by a rolling of the 
 e3'es from side to side like a very much exaggerated 
 nj^stagmus. In his studies this occurred in 11 cases out 
 of 13. 
 
 The argument by Mdiich practical gain can be reached 
 by such cases is as follows : It will be remembered that 
 in ordinar}'' paralysis, as, for example, hemiplegia, we 
 have exaggerated knee-jerk and ankle-clonus, and we also 
 know that after epileptic fits we may have paral3^sis 
 present of a transient or permanent character ; but we 
 are unable to prove its existence in every case because, 
 with a return of a suflfiicient degree of consciousness, the 
 
Reflexes. 33 
 
 palsy passes a^vay. In the one case the palsy is due to 
 some injury of the nervous protoplasm; in epilepsy it 
 is due most frequently, according to most clinicians, to 
 exhaustion of the nerve-cells. The results are increased 
 knee-jerk and ankle-clonus in either case, and this is why 
 Beevor reached the results already given. The deviation 
 of the e3'es also supports this view, in all probability, 
 because the e3'es roll over to the opposite side from that 
 most severely affected as a result of exhaustion or palsy 
 of the centres governing them on that side, which, from 
 its primarj^ excessive action, has been more depressed 
 than its neighboring centres on the other side of the 
 brain. In other words, it would seem probable that, by 
 noting the limb in which clonus and knee-jerk are most 
 marked, and tlie side to which the eyes are secondarily 
 turned, we can decide which side of the brain is diseased, 
 particularly if the first movements of the fit are also 
 noted, even in the cases where the parox3'sms are most 
 widely and bilaterally distributed. 
 
 As a proof of the accuracy of these arguments, a 
 case may be detailed to illustrate them : A man was con- 
 vulsed on the right side (a unilateral attack) for twenty 
 minutes, and afterward, on this same side, there was 
 always diminished plantar reflex and increased knee-jerk 
 and clonus ; while on the left or unaffected side there 
 was scarcel}^ any increase in clonus or knee-jerk and re- 
 turn of plantar reflex in three minutes, but on the right 
 leg it did not return for thirty minutes. There was also 
 palsy of the right side for two hours after each attack, 
 with some aphasia. 
 
 The researches of Oliver ^ are also in accord with those 
 of Beevor, for he finds that knee-jerk is sometimes pres- 
 ent, sometimes absent, and foot-clonus is alwa^^s present. 
 
 » Edin. Med. Journ., 1886, p. 211. 
 2* 
 
34 Epilejjsy : its Pathology and Treatment. 
 
 Bodily Temperature. — Some difference of opinion 
 has existed as to the effect which the epileptic paroxysm 
 has iiponbodil}^ temperature. A large number of cases 
 collected and examined b}^ Bourneville, in 18*70, showed 
 that there is alwa3's a slight rise of temperature, some- 
 times amounting to 2.5 ° Fahrenheit scale. Still more 
 recently, the same investigator has carried his studies 
 further on 82 cases, and reached identical results with 
 his first conclusions. ^ He saw 2 cases where a fatal 
 termination occurred, the temperature being 41.4 ° C. 
 and 42.4 ^ C. 
 
 Williams^ also found that the temperature alwa} s 
 rose — sometimes as much as 3 ° F. — after a fit. 
 
 Witkowski,^ on the other hand, claimed, from a series 
 of cases examined by him, that no change took place; 
 and Westphal * thinks that elevation of temperature is 
 rare, but he has been proved incorrect by the more re- 
 cent studies of M. Bourneville and M. Georges Lemoine,^ 
 who examined no less than 200 cases of isolated attacks, 
 with the result of confirming the earlier researches of 
 Bourneville. It should be remembered, too, that this 
 earlier observer found that the status epilei)ticus was 
 capable of raising the temperature of the bods^ to as 
 much as 105° to 107° F. 
 
 Lemoine's results are perfectly in accord with those 
 of Bourneville and with physiological reasoning, for he 
 found that the temperature rises during the attack, but 
 falls rapidly afterward, so that in a quarter of an hour 
 it may have reached an almost subnormal point, but 
 after two hours is found to be normal and to remain so 
 
 » Le Progres Medical, No. 35, 1887. 
 
 ' Medical Tiiiies, vol. ii, 1867. 
 
 ' Berliner klin. Woclieiisclirift, Nos. 43 and 41, 1886. 
 
 ■• Arcliiv f. Psychiatric und Ncrvenkrankheiten, vol. i. 
 
 * Le Progres Medical, February 4, 1888. 
 
Aheri^ant Symptoms. 35 
 
 constantly. In only one case — that of an epileptic idiot, 
 with very violent attacks, and, as a rule, subnormal tem- 
 perature — was there any exception to this rule. The 
 average rise, as found by Lemoine, is about 1.2 ° F., and 
 the rectal temperature very rarely goes above 102 ° F. 
 
 The temperature in cases of epileptic insanity showed 
 considerable variation, even when there were no attacks, 
 and so did the temperature preceding different attacks 
 var}^ considerably ; so that it was somewhat difficult to 
 attain a standard for comparison. The fall after the 
 first quarter of an hour was very marked, — sometimes 
 as much as 1.4° F. in that time, — and this occurred 
 even after the most violent attacks. 
 
 In close relationship with these studies are those of 
 Addison,! undertaken with the view of discovering 
 whether the temperature of an epileptic varied from the 
 normal between the attacks. Taking the temperature 
 in the rectum in 13 men, he found the highest tempera- 
 ture to be 100.2° F. and the lowest 97.2° F., or a mean 
 of 98.9° F., wliich is virtually just normal. He noted 
 that the highest temperature occurred in a man who had 
 had an attack that da}^, while the lowest was in an idiot. 
 
 Reynolds 2 has, by a series of investigations, shown 
 that in 60.4 per cent, of the cases of epilepsy seen by 
 him the temperature was normal between the paroxysms. 
 
 Aberrant Symptoms. — In some epileptics the conjunc- 
 tivae and the skin of the face are nearly alwaj^s, after an 
 attack of epilepsy, covered by small, hsemorrhagic points, 
 due to the rupture of small blood-vessels. Closel}^ 
 allied to this is an interparoxysmal s^^mptom that San- 
 dras ^ has recorded a " disposition singulaire et ineX' 
 
 * Journal Ment. Science, vol. xii, 1867. 
 
 ^Epilepsy, London. 
 
 ' Traite pratique des malad. nerveux, t. i, p. 203. 
 
36 Epilepsy: its Pathology and Treatment. 
 
 plicable " in the skin of epileptics, for when exposed to 
 the sun they become covered on the face and even else- 
 where on the body with numerous laches rosee without 
 any elevation, and which disappear rapidlj^ when the 
 person goes into a shady spot. The writer has never 
 heard of similar cases, and gives this abstract for what it 
 is worth. 
 
 In others vomiting comes on before the coma has 
 entirely passed away, and may produce death by suffo- 
 cation, owing to the impaction of a piece of food in the 
 larynx. Hunger is alwa3^s present in the sthenic cases 
 when recovery has gone on far enough for it to be felt, 
 but in many of the weaker cases it is wanting, and is 
 often replaced by anorexia. Between the paroxysms, 
 unless tlie patient's stomach be disordered b}^ drugs, the 
 appetite is generally voracious. 
 
 Urine. — The rise of temperature, which has just been 
 considered, leads us to the question as to whether there 
 is, with the rise, a concomitant degree of tissue-waste 
 evidenced by increased solids in the urine, and this point, 
 unfortunatel3?^, is still undecided, for, although a good 
 deal of work has been done, there are many contradic- 
 tory results. 
 
 Some observers state that there are no changes in 
 the amount of solids in the urine whatever, but it 
 seems almost incredible that so much violent nervous 
 and muscular exertion can take place without being ac- 
 companied by an increase in the phosphates, urea, and 
 uric acid. 
 
 A very thorough study of this character has been 
 carried out b}^ Addison, i who anal3'zed the urine of 
 patients for three days during and after the paroxysmal 
 period, with the following result: — 
 
 ' Journal Meut. ycience, vol. xii, 1867. 
 
Urine. 
 
 Case I. — Faroxysmal Period. 
 
 37 
 
 Day. 
 
 Quant, 
 of Urine. 
 
 Specific 
 Gravity. 
 
 ClNa. 
 
 Urea. 
 
 PO5. SO3. 
 
 I 
 
 First, 
 Second, . 
 Third, . 
 
 Ounces. 
 14.5 
 17.0 
 16.5 
 
 1033 
 1031 
 1034 
 
 21.14 
 44.62 
 43.41 
 
 325.64 
 374.35 
 375.37 
 
 14.44 
 18.16 
 26.27 
 
 28.61 
 24.68 
 43.67 
 
 Total, . 
 
 48.0 
 
 1032 
 
 109.17 1075.36 
 
 58.87 
 
 93.96 
 
 Inter paroxysmal Period. 
 
 First, 
 Second, . 
 Third, . 
 
 93.5 
 99.5 
 89.0 
 
 1016 
 1014 
 1013 
 
 54.54 
 35.11 
 &4.89 
 
 572.68 
 418.70 
 414.00 
 
 29.60 
 31.50 
 31.15 
 
 29.38 
 29.78 
 26.64 
 
 Total, . 
 
 282.0 
 
 1014 
 
 154.52 
 
 1405.48 
 
 92.25 
 
 85.80 
 
 Case II. — Paroxysmal Period. 
 
 Day. 
 
 Quant, 
 of Urine. 
 
 Specifi^c 
 Gravity. 
 
 ClNa. 
 
 Urea. 
 
 PO3. 
 
 SO3. 
 
 First, 
 Second, . 
 Third, . 
 
 Ounces. 
 31.0 
 26.5 
 40.5 
 
 1021 
 1030 
 1025 
 
 67.81 
 54.10 
 59.06 
 
 379.75 
 456.02 
 472.50 
 
 22.74 
 26.07 
 10.70 
 
 21.76 
 23.80 
 26.68 
 
 Total, . 
 
 98.0 
 
 1025 
 
 189.97 
 
 1308.27 
 
 59.51 
 
 72.44 
 
 Inter paroxysmal Period. 
 
 First, . 
 Second, . 
 Third, . 
 
 95.0 
 91.5 
 85.0 
 
 1017 
 1014 
 1015 
 
 60.59 
 
 32.58 
 40.40 
 
 881.19 
 800.62 
 614.83 
 
 1.52.39 
 
 226.84 
 111.56 
 
 45.. 51 
 27.39 
 34.36 
 
 Total, . 
 
 271.5 
 
 1015 
 
 133.57 
 
 2296.64 
 
 490.79 
 
 107.26 
 
38 Epileji^i/ : its Pathology and Treatment, 
 
 Case III. — Paroxysmal Period. 
 
 Day, 
 
 Quant, 
 of Urine. 
 
 Specific 
 Gravity. 
 
 ClNa, 
 
 Urea. 
 
 PO,. 
 
 SO3. 
 
 First, 
 Second, . 
 Third, . 
 
 Ounces. 
 22.0 
 7.0 
 7.0 
 
 1030 
 1034 
 1030 
 
 77.00 
 21.41 
 20.41 
 
 385.00 
 136.79 
 147.00 
 
 31.18 
 
 8.17 
 5.37 
 
 23.00 
 11.00 
 
 7.85 
 
 Total, . 
 
 36.0 
 
 1031 
 
 117.82 
 
 668.79 
 
 44.72 
 
 41.85 
 
 Inter paroxysmal Period. 
 
 First, 
 Second, . 
 Third, . 
 
 35.0 
 73.5 
 51.0 
 
 1012 
 1006 
 1012 
 
 20.41 
 
 42.87 
 29.48 
 
 240.20 
 192.93 
 207.75 
 
 22.00 
 16.21 
 21.25 
 
 7.85 
 
 9.80 
 
 15.87 
 
 Total, . 
 
 159.5 
 
 1010 
 
 92.76 
 
 700.88 
 
 59.46 
 
 33.52 
 
 To summarize, we find in these tables that in every 
 instance the quantity of the urine was many times more 
 between the paroxysms than during them, that the 
 specific gravity was less at this time than during the 
 seizure period, and that the amount of the chlorides was 
 less in the intervals of repose than in the intervals of 
 attack, except in the first case, where this is completely 
 reversed by an unexplainable result. 
 
 The urea was considerably increased in amount dur- 
 ing the interparoxysmal periods in ever\^ case, as were 
 also the phosphates, while on the other hand sulphates 
 were decreased, except in case No. 2, where tlie}^ were 
 increased during this period of quietness. 
 
 It is worthy of note that the urine was not only in- 
 creased, during the quiet intervals, over the periods of 
 attack, but that it was increased far beyond the normal 
 amount, and, naturally, the specific gravity fell. It is 
 equally worthy of remark that the chlorides grew less 
 
Urine. 39 
 
 at this time, and tliat the quantity of urea excreted was 
 not greatest at the time of the greatest muscular action, 
 namely, the time during the attacks. The elimination 
 of phosphates, the representatives of nervous change, 
 was similarly affected. Echeverria^ found the amount 
 of urea excreted after a fit to be much greater than the 
 normal, but Gibson^ found no change in the urine. 
 
 In some researches made by Beale^ the same results 
 were reached, but were arrived at somewhat differently. 
 On analyzing the urine of four persons suffering from 
 epilepsy, he found that the phosphates were always in- 
 creased by the fits, particularly if these attacks were 
 frequently repeated or \ 
 
 Case I. — Urine 
 
 ery violent. 
 Specific Gravity^ 1.02J^. 
 
 Water, 931.2 
 
 Solids, 68.8 100. 
 
 Organic matter, 
 
 Fixed salts, 
 
 Phosphates precipitated b}^ chloride of 
 
 calcium and ammonium, . . . 6.96 10.11 
 
 58.35 86.27 
 
 9.45 13.73 
 
 Case II. — Urine: Specific Gravity^ 1.024- 
 
 Water, ....... 927.2 
 
 Solids, 72.80 100. 
 
 Organic matter, 51.01 85.18 
 
 Fixed salts, 10.79 14.82 
 
 Phosphates precipitated by chloride of 
 
 calcium and ammonium, . . . 3.92 5.38 
 
 Case III. — Urine: Specific Gravity., 1.017. 
 
 Water, 958.8 
 
 Solids, 41.20 100. 
 
 Organic matter, 34.68 84.18 
 
 Fixed salts, . . . . . . 6.52 15.83 
 
 Phosphates precipitated by chloride of 
 
 calcium or ammonium, . . . 2.15 5.21 
 
 » Epilepsy, p. 288. 
 
 ^ Medico-Chirurgical Transactions, p. 75, 1867. 
 
 * British Medical Journal, November 26, 1859. 
 
40 Upilepsij : its Pathology and Treatment. 
 
 Case I Y. — Ui-ine : Sjyecific Gravity^ 1.009. 
 
 Water, 976.7 
 
 Solids, 23.30 100. 
 
 Organic matter, 17.46 75.94 
 
 Fixed salts, 5.84 25.06 
 
 Phosphates precipitated by chloride of 
 
 calcium or ammonium, . . . 1.79 7.68 
 
 Hamilton^ states that the urine of epileptics is apt to 
 contain evidence of tissue-waste, and an increase in the 
 amount of earth}- pliosphates as well. Zapolsky found, 
 liowever, that immediatel}^ after the attack there was a 
 diminution in the quantit}^ of the phosphates, thus 
 agreeing with Addison. De Renzi^ has also published 
 an article confirmatory of these results. 
 
 A research arranged in every detail to avoid fallacy 
 is sadl}'^ needed. 
 
 Albuminuria and Diabetes. — Some persons have 
 claimed that albumen is constantl}^ present in the urine 
 of epileptics, but they are incorrect, although there are 
 researches which contradict this last assertion. 
 
 Saundby,^ who tested the urine twenty-seven times 
 in 20 cases, with the object of detecting albumen, 
 using the boiling and nitric-acid tests, found it present 
 on twent3'-tvvo occasions, as did also Otto,* who found 
 albumen in the urine in 22 cases out of 31 epileptics. 
 Indeed, Otto thinks albuminuria to be symptomatic of 
 epilepsy. On the contrarj^, Mabille,^ in a series of ex- 
 periments, most carefully carried out on 38 cases of the 
 disease, 20 of whom were men and 18 women, found not 
 a trace of albumen in the urine of any one of them, 
 although he tested for it before, during, and after the 
 
 • Loc. cit. 
 
 ^ Gior. internaz. d. So. Med., Napoli, ii, 357, 1880. 
 ' Medical Times and Gazette, October 14, 1882. 
 
 * Berliner klinische Wochenschrift, October 16, 1876. 
 ' Annales Mdd. Psycholog., Novcnibtr, 1880. 
 
Bodihj Weight. 41 
 
 paroxysm. In 1 case, which was known to have paren- 
 chymatous nephritis, it was found. Dowse^ also has 
 confirmed Mabille in this, but Huppert^ agrees with 
 Saundby and Otto that albumen is commonly found. 
 When we consider the care used b}^ Mabille and the pos- 
 sible carelessness of the others, and associate Avith this 
 the fact that Karrer^ has denied the presence of albu- 
 minuria after testing again and again by all known tests 
 the urine of 12 chronic epileptics, and tliat Kleudgen* 
 and Bunzlau agree with him, after a separate research, 
 in supporting Mabille and Dowse, one cannot fail to be 
 impressed, we think, by the fact that the condition of 
 albuminuria in epilepsy is rather a chance occurrence 
 than a regular concomitant.^ In the tests which the 
 writer has made of the urine of epileptics he has never 
 found albumen. 
 
 Sugar is probably no more frequently found in the 
 urine of epileptics than it is in that of other persons, 
 for Addison^ has tested the urine of 20 cases with 
 negative results. 
 
 Bodily Weight. — Closely associated with the question 
 of tissue-change in this disease is the assertion made 
 by Kowalewski,^ that every fit is accompanied by a loss 
 of bodily weight ranging from one to twelve pounds, 
 which, if true, shows that, either directly or indirectl}^, 
 great changes in nutrition must occur. On the other 
 hand, Lehman, Beevor,^ JoU}^,^ Hammond,^" Olderogge,^^ 
 
 * Practitioner, October, 1878. ^ Arch, f . Psychiatric, p. 189, 1877. 
 
 * Berl. klin.Woch., July 5, 1875. " Arch. f. Psychol., Bd. XI, Heft 2. 
 
 ' For additional facts reached by other observers, see Brixninghausen, 
 Allg. Med. Central. Zeitung, Berlin, 1880, xlix, p. 97; and Fiori, Osserva- 
 tore, Torino, 1880, xvi, p. 177 ; and Italia Medica, Genoa, 1881. 
 
 * Journal Nervous and Mental Disease, vol. xii, 1867. 
 
 ' Arch. f. Psychiat., Bd. XI, Heft 2. " Brit. Med. Jr., July 8, 1882. 
 
 " Berliner klin. Wochenschrift, November 26, 1881. 
 *° Journal of Nervous and Mental Diseases, p. 517, 1880. 
 »i Archiv f. Psychiatric, Bd. XII, Heft 3. 
 
 B2 
 
42 Epilepsy: its Pathology and Treatment. 
 
 Kranz, and Scliucliard assert equally positively that no 
 such change occurs, and adduce such an array of experi- 
 mental evidence that the}" cannot be mistaken. The 
 method of research carried out by the Englishman, 
 Beevor, consisted in having the patients weighed each 
 morning at the same hour and under the same con- 
 ditions in order to forma standard scale of weight. As 
 soon as an attack had passed off they were weighed 
 again to discover if any difference had taken place be- 
 tween the normal weight and that after the attack. 
 
 In 25 cases no decrease w^as noted ; in 1 it was found 
 that there was an increase in weight, but this was evi- 
 dently owing to the fact that the patient had just had 
 dinner. In 6 cases of h^^stero-epilepsy there was no 
 change. In the 30 cases examined by Lehman the re- 
 sults were perfectl}^ in accord with those of Beevor, 
 and ma}' be considered as even more accurate in that on 
 several occasions he managed to get the weight of a 
 patient immediately before and immediatel}^ after the 
 parox3'sm. Jolly's observations were apparently care- 
 fully made, and included 28 cases, while those of Ham- 
 mond were made on 6 epileptic patients. Without 
 intending to den}" the truth of Beevor's studies, it must 
 be remembered that a great element of fallacy was 
 present in them all. lie does not state whether the 
 mornino; wei<ihin2;s were before or after breakfast : so 
 that the nourishment taken, if the weighing was before 
 breakfast, might have counterbalanced the loss by 
 reason of a fit. Further, while he recognizes the in- 
 fluence which meals may have on his results, he failed to 
 take any weights in the afternoon for his normal stand- 
 ard scale, and it is manifestly incorrect to say that a 
 morning weight can be taken as a standard for the 
 entire da v. 
 
Sensory Disturbance. 43 
 
 This question has also been studied in a somewhat 
 novel manner b}^ Hallager,^ of Yiborg, and, though he 
 agrees largely with Kowalewski, some of his results are 
 interesting as pointing toward a possible solution of the 
 controYers}^ 
 
 After a large number of studies he has, by means of 
 a chart, shown that whenever there is a loss of weight 
 there is an increase in the amount of urine voided by 
 the patient. In other words, as the weight-curve falls 
 the urine-curve rises. He deduces from this that the 
 loss of weight, sometimes seen, is by loss of liquid from 
 the bod3% and that the lessening of weight is not, in 
 reality, due to tissue break-down. That it is certainly 
 not the latter is proved by the fact that nutrition is 
 usually remarkably well preserved in epileptics. Rey- 
 nolds^ finds it impaired in only 12.3 per cent., and that 
 the strength only fails in 24.4 per cent. That Hallager 
 may be correct in his explanation seems likely by the 
 measurements of urine made by Addison {loc. cit.). 
 
 Sensory Disturbance. — The amount of disturbance of 
 the sensory apparatus after epileptic attacks has been 
 studied within the last few years most carefully by sev- 
 eral observers, notably Thomsen,^ who announced that 
 cutaneous and sensory anaesthesias often exist in epi- 
 leptics permanently, and in connection with Oppen- 
 heim,* in 1884, he published an elaborate essay on the 
 subject. These investigators found that an examination 
 of 94 cases of epilepsy showed that no sensory disturb- 
 ance acutely follows an epileptic convulsion, but that in 
 old epileptics, with more or less deficienc}^ of cerebral 
 power, sensibility was greatly diminished. There are 
 
 *■ Nordisk. Med. Arkiv, 1886. 
 2 Loc, cit. 
 
 * Neurologische Centralblatt, xxiii. 
 
 * Archiv fiir Psychiatric, xv., p. 558. 
 
44 Epile}}sy : its Pathology and Treatment. 
 
 exceptions, however, to the rule that no sensory dis- 
 turbances follow acute attacks, for they found that anaes- 
 thesia of a temporar}^ form was present whenever the 
 convulsion was slightly aberrant in type, and, while 
 truly epileptic, accompanied by rare symptoms. They 
 divide such cases into tliree divisions as follows : — 
 
 1. Those in which the convulsion is followed by 
 delirium and hallucinations. 2. Those in which the 
 attack is followed by emotional or psychical phenomena 
 of a severe form, with delirium. 3. Those in which 
 the attack seemed to expend itself chiefly on the mental 
 portion of the organism. 
 
 It is at once evident, however, that these attacks are 
 liysteroid in form, and in reality ver}^ irregular. On 
 tlie other hand, it is perfectly possible that the epileptic 
 storm may exhaust the higher sensory centres jmri 
 passu with the depression of the motor area. The great 
 difficulty, too, of obtaining satisfactory answers from 
 many epileptics, for some time after an attack, surrounds 
 all such researches with some doubt. 
 
 Aphasia. — A condition wiiich may be present after 
 epileps}'-, not uucommonl}', is aj)hasia, due, in all proba- 
 bility', where it is temporary, to collateral exhaustion 
 of the gray matter containing, not the centre of speech, 
 but those centres for the muscles which practically form 
 the words as spoken. 
 
 The Eye. — It is interesting to know that the e3'e- 
 grounds of a very large number of persons have been 
 examined, in order to determine whether au}^ great 
 changes take place in persons who are epileptic. Cross ^ 
 lias examined the intra-ocular circulation of 95 cases, 
 and found that in the great majorit}^ no change was 
 noticeable. He also finds that no structural changes in 
 
 * Jour. Nervous aud Mental Diseases. 
 
The Eye. 45 
 
 tlie e3e take place. In the cases where any changes 
 wei-e noted in the intra-ocular circulation, the results 
 were so A'^arious and widely dissimilar that no conclu- 
 sions could be drawn. Gowers^ states, as a result of 
 an examination of over 1000 eye-grounds in epileptics, 
 that no chano-es at all are to be seen in the fundus oculi 
 of idiopatliic epilepsy. He states, however, that the 
 retinal arteries have seemed unduly large, while the 
 veins have not, except during an attack, when the veins 
 are distended. Allbutt, of England, has seen pallor of 
 the optic disks, as have also Hughlings-Jackson and 
 Aldridge.- Hammond^ believes, in distinction from 
 Gowers, that the fundus of the e3'e of an epileptic is 
 alwa3^s congested or pale, and evidences cerebral con- 
 gestion or anaemia, and he sees a venous pulsation in 
 all cases of plethora with epileps3\ Kostle and Nie- 
 metshek,'* of Prague, from their examinations, state 
 that the venous pulse of the fundus onl3^ occurs in those 
 cases where there is anaemia of the brain, and they go 
 so far in their theor3^ that the3^ believe all epileptic 
 brains are anaemic. Tebaldi® has also recognized pallor 
 of the papilla, increase in the venous 'circulation, and 
 immediately after an attack marked congestion of the 
 veins, with relative emptiness of the arteries. Abundo,® 
 of Naples, has studied the e3"es of this class of patients, 
 apparently with great care, and finds that after a fit 
 the ophthalmoscope reveals the vessels of the fundus con- 
 gested according to the severity of the attack, but that 
 no difference is to be seen in the two e3^es. There is 
 alwa3'S contraction of the visual field in both e3^es, but 
 
 * Medical Ophthalmoscopy, p. 157. 
 
 "^ West Riding Lunatic Asylum Reports, vol. i. 
 ^ Nervous Diseases. 
 
 * Prager Vierteljahrschrift, Heft cvi und cvii, 1870. 
 » Riv. Clin., ix, 1870. 
 
 ^ Ricerche Cliniche sui Disturb! Visivi vel I'Epilessia Napoli, 1885. 
 
46 Epilepsy: its Pathology and Treatment. 
 
 no hemianopsia, while the visual acuity is dimmed in 
 direct ratio with the violence of the parox^-sm. 
 
 Pupils. — During the coma and sleep following the 
 convulsion the pupils contract more sluggishly to light 
 than is normal, and if the mental condition of the patient 
 is one of depression the pupils are found tightly con- 
 tracted after the fit. Abundo denies, however, that rapid 
 changes occur in the pupil after an attack ; but in this 
 he is mistaken, at least in respect to some cases. Again, 
 he finds no proof of Siemen's assertion that dilatation 
 of the pupil, at the beginning of the fit, is first preceded 
 by contraction. 
 
 In 1880 Dr. Gray,^ at a meeting of the American 
 Neurological Association, read a paper in which he in- 
 sisted, very strenuousl}^, that the pupils of epileptics 
 were more widely dilated at all times than in normal in- 
 dividuals, and that they were more mobile than those 
 of healthy persons or persons suflfering from other con- 
 vulsive disorders. Indeed, he asserted that this was a 
 pathognomonic sign of e})ilepsy to be used in making 
 a differential diagnosis. In the discussion wdiich fol- 
 lowed, Spitzka^ pointed out that Gray was mistaken, be- 
 cause the dilatation spoken of was replaced by contrac- 
 tion in the epileps3^ of alcoholism. Dr. Cross^ and Dr. 
 Hammond^ supported Gra3^,not by means of any obser- 
 vations, but simply on the basis of their impressions as 
 derived in practice. Since that time, however, careful 
 observers on the other side of the Atlantic have proved, 
 by the most painstaking observations, that Gray's state- 
 ments are entirely lacking in fact. 
 
 Marie,® at the request of Charcot, in 1882 studied 
 the subject accurately, placing a candle distant from 
 
 » Jour, of Nerv. and Ment. Dis., ]S8(), = Ibid. » Ibid. * Ibid. 
 * Arch, dc Ncurolug., vol. iii, p. 12, liiS2. 
 
Refractive Anomalies. 47 
 
 each e3'e 45 centimetres, the ra^^s of light falling on the 
 cornea at an angle of 45 degrees to the visual axis. 
 Hutchinson's pupillometer was used, and studies made 
 on 53 epileptic women and 10 healthy nurses. In the 
 epileptic patients the diameter of the pupil was 5 J, in 
 the nurse 6^, which is of course just the reverse of Gray's 
 statements. Marie also found the pupil no more mobile 
 in epileptics than in others. 
 
 Musso,^ who made similar tests with TO epileptics 
 and 10 healthy persons, reached conclusions correspond- 
 ing to those of Marie, and states that the pupils of epi- 
 leptics show no difference from those of normal persons. 
 He found, however, that there was in 22.8 per cent, an 
 inequality of the pupils. 
 
 Refractive Anomalies. — Those who have read the 
 interesting essay of Dr. G. T. Stevens on " Functional 
 Nervous Diseases," which was honored by I'Academie 
 Koyale de Medecine de Belgique at the concours for 
 1881-83, must have been struck by the statistics which 
 he gives as to the ocular conditions found in 140 cases 
 of epilepsy, 85 of which were in private practice. To 
 use his own words, " The general results of these ex- 
 aminations has been to reveal the existence of refractive 
 anomalies in a considerably greater proportion than 
 has been found by Cohn in his examinations of the e3^es 
 of school-children, or by other observers in similar 
 investigations prosecuted in Germany, Kussia, and 
 America." Dr. Stevens found that in 100 consecutive 
 cases there existed : — 
 
 Hypermetropia (including hypermetropic astigmatism) in 59 
 Myopia (including myopic astigmatism) in . . .23 
 Emmetropia, or refractive errors less than one dioptric, . 18 
 
 100 
 * RiT. Sperimentale di Firenze, fasc. i and ii, 1884. 
 
48 Epilcpi^y : its ralhoJogij and Treatment. 
 
 There is one criticism which ma}^ be made in regard 
 to these statistics of Dr. Stevens, namely, that the per- 
 centage of hypermetropia is not sufficiently over and 
 above the normal percentage, as found by Cohn, to be 
 of any value in pointing to a greater frequency of this 
 error in epilepsy than elsewhere. Furthermore, the 
 writer does not believe that 100 cases give a wide enough 
 experience to justify any one in attempting to formulate 
 general rules in regard to such a disease as epileps}'. 
 The very large amount of work done b}^ Cohn on per- 
 sons presumably healthy as to their general condition 
 should be offset by an equally large series of pathologi- 
 cal examinations before conclusions are developed. 
 
 Dr. Stevens evidently sees that such a criticism may 
 be made, but does not allow it to alter his reasoning. 
 
 In the same essa^^ the fact is pointed out that 
 muscular insufficiencies in the ocular apparatus are 
 potent factors in the development of epilepsy, and a very 
 remarkable array of cases is brought forward to show 
 the correctness of this view. The truth of this as ap- 
 plied to the treatment of epilepsy in the hands of other 
 members of the profession has 3^et to be adduced, but 
 no evidence exists, so far as the author is aware, to 
 rebut it. 
 
 Mental State. — A very important question connected 
 not only with the prognosis of epilepsy but also with its 
 relation to medical jurisprudence lies in the influence 
 which the disease may exercise on the mental condition 
 of the sufferer. Russell Reynolds, ^ of London, who has 
 written very extensively on this subject, has arrived at 
 the following conclusions in regard to the effects of the 
 disease on the intellect, and, when we remember that 
 
 » Epilepsy, its Symptoms, Treatment, and Relation to Other Convul- 
 sive Disorders. London, 1862, 
 
Mental State. 49 
 
 some of tht greatest men that ever lived ^ were afflicted 
 with epilepsy, it is not difficult to agree with him, al- 
 though his conclusions cannot be accepted without some 
 qualifications. He believes : — 
 
 1. That epilepsy does not necessarily involve any 
 mental change. 
 
 2. That great mental impairment exists in some 
 cases, but this is the exception rather than the rule. 
 
 3. That females suffer (in mental vigor) more com- 
 monty than males, and also more severel}^ 
 
 4. That the commonest failure is loss of memory, 
 and that this, if regarded in all degrees, is more frequent 
 than integrity of that facult3^ 
 
 5. The apprehension is more frequently preserved 
 than lost. 
 
 6. That ulterior mental changes are rare. 
 
 7. That depression of spirits are common in males, 
 rare in females, but that excitability of temper is found 
 in both sexes. 
 
 If we think over these conclusions we are struck 
 with the nicety of the line drawn by Reynolds between 
 mental change and other conditions which we are accus- 
 tomed to associate in our minds with normal mental 
 processes. Of his first conclusions we shall speak in one 
 moment, but at present we shall consider only the fourth. 
 In the fourth he states that loss of memory is more fre- 
 quently present than retention of it, and one cannot but 
 think that in this he contradicts himself in that memory 
 is certainly a function of the brain, and its loss is 
 universally associated with impairment of its functions. 
 
 It seems certain that his first statement cannot be 
 
 ^ Napoleon Bonaparte was undoubtedly epileptic, and it is stated that 
 he had a seizure whenever he had sexual intercourse. Caesar was also a 
 sufEerer from the disease. 
 
 3 C 
 
50 Epilepsy: its Pathology and Treatment. 
 
 denied, for some cases do go on having epileptic parox- 
 ysms for long periods of time without mental involve- 
 ment, as, for example, Caesar and Napoleon ; but his 
 second conclusion is certainly open to criticism. The 
 writer is quite confident that the facts are just the re- 
 verse, and that impairment of mental jjower is the rule 
 rather than the exception. As to his fifth proposition, 
 in which he states that apprehension — by which the 
 writer supposes he means the power to grasp an idea — is 
 more frequently preserved than lost, it is almost impos- 
 sible to offer evidence, since this power varies so in 
 persons classed among us as healthy ; but in the sixth, 
 which is closely related with the first, the writer be- 
 lieves he is sadly at fault. He thinks, too, that the 
 seventh and last conclusion supports what he has al- 
 ready said in respect to the fourth, namel}^, that some 
 mental change does generally occur. Not only are the 
 remarks just made true, but it is positive that all the 
 more modern writers utterly disregard all the deduc- 
 tions drawn by Reynolds. Notable, among these, we 
 find Falret,^ in France, and no less an authority than 
 the famed Charcot, ^ while in Germany, England, and 
 America the voice of the most prominent neurologists 
 are raised in the support of this belief. 
 
 MoreF has in his writings called attention to these 
 changes, and has defined the mental condition of epilep- 
 tics as the " epileptic character." Hasse* has likewise 
 insisted that mental change occurs, and Romberg^ says 
 
 •De I'Etat Mental des epileptiques, Arch. gen. de med., Avril et 
 October, 1861. 
 
 3Lc[;ons snr les maladies du systeme nerveux, series ii. Paris, 1873-7. 
 
 'I'Etiides Cliniqno. Traite theorique ct pratique des maladies 
 mcntale, tome ii, p. 316. 
 
 * Krankhciten des Nerveuapparat. Virchow's Haudbuuli f. Spec. 
 Path. Tind Tlier. 
 
 ' liaudbuch f . Nerveukranklieitcii, voL ii. 
 
Ilental State. 51 
 
 it is characteristic to find a loss of memor}^ and diminu-. 
 tion of the distinctness of ideas, combined with great 
 irritability of temper. Esqnirol ^ stated that four-fifths 
 of all the epileptic women in the Salpetriere were insane, 
 and that the remaining one-fifth were singular in tlieirj 
 conduct, while Foville^ writes that mental failure occurs 
 in the majority of cases. Georget^ also writes that the 
 disease terminates in mental deterioration. On the 
 other hand, Maissonneuve^ details a case of severe epi- 
 lepsy in which the attacks were frequent, but in which 
 no evidence of mental failure existed. Of course, we all 
 know that these cases do occur, but they are rarely to be 
 found as compared to the others. 
 
 Gowers^ states that the interparoxysmal mental 
 state of epileptics often presents grave deterioration, 
 and that this is one of tlie most serious, and most 
 dreaded, effects of the disease. In the beginning there 
 is merely defective memory, but later the intellect gen- 
 erally suffers and there is often defective moral control. 
 In some instances, he states that actual imbecility ma^- 
 be reached. In America we find Hamilton^ stating that 
 mental decay is frequent and an ultimate result, in which 
 mental enfeeblement, with progressive and great loss of 
 memory, ending in total dementia, by no means rarely 
 occurs. Wood^ also speaks of it as a common sequel. 
 lUia-writer's own experience certainly confirms the re- 
 sults given by the others just quoted. 
 
 As so much evidence has been offered against the 
 
 * Des maladies mentales considerees sous les Rapport's medical, hy- 
 gienique et medico-legal, tome i, p. 285. 
 
 " Diction, de Med. et de Clin, pratique, art. Epilepsie, p. 416. 
 ^De la Pliysiolog. du systeme nerveux, tome ii, p. 385. 
 
 * Recherches et Oliservation, p. 58. 
 
 * Loc. cit., p. 692. 
 ^Loc. cit., p. 482. 
 ''Loc. cit. 
 
52 Epilepsy: its Pathology and Treatment. 
 
 validity of Reynolds's conclusions, it is, perhaps, but 
 just that the writer should at least place before the 
 reader the evidence hy whicli Reynolds reached them. 
 He divided his cases into four classes as follows : — 
 
 1. Those in whom no change in mental power was 
 evident to the nearest friends and relatives of the pa- 
 tient, and of these there were 16 males and eight females, 
 or a total of 24, or 38.70 per cent. 
 
 2. Those in whom the memory for recent events was 
 partlj^ clouded, but who had tlie memory for things long 
 gone b}^ well preserved, of which he found 10 males and 
 10 females, or a total of 20, or 32.25 per cent. 
 
 3. Those in whom there was diminution of a})pre- 
 liension and loss of memory'. Four males and 5 females, 
 or a total of 9, or 14.51 per cent. 
 
 4. Includes those possessing changes of the second 
 and third class, and, in addition, evidences of great 
 stupidity. Of these there were 4 males and 5 females, 
 or a total of 9, or 14.51 per cent. 
 
 He also carried his examinations still farther, as re- 
 gards the condition of memory alone, in distinction 
 from general mental impairment, witli the following 
 results from 57 cases : — 
 
 Condition of Memory. 
 Normal, .... 
 Defective only after fits, 
 Slightly defective at times, 
 Defective generally, 
 Very defective, 
 
 lies. ] 
 
 l^emal 
 
 es. 
 
 Tota 
 
 1. Per Cent, 
 
 L4 
 2 
 
 8 
 1 
 
 
 23 j 
 3< 
 
 ! 25 = 43.85 
 1 
 
 2 
 
 2 
 
 
 4- 
 
 ) 
 
 9 
 
 9 
 
 
 18] 
 
 > 32 = 56.14 
 
 6 
 
 4 
 
 
 10- 
 
 ) 
 
 33 24 57 
 
 In another table he studies the condition of " appre- 
 hension," as he terms it, or the power of grasping 
 ideas :- 
 
Mental State, 53 
 
 Condition of Apprehension. Males. Females. Total. Per Cent. 
 
 Normal, 17 12 ^^ J 30 = 62 5 
 
 Defective only after attacks, 1 1 ) 
 
 Periodically affected, . . 1 1 2 ^ 
 
 Generally defective, . . 4, 5 9 V 18 = 37.5 
 
 Extremely defective, . . 4 3 7 ) 
 
 27 21 48 
 
 It is worth}' of note that these results show epileptics 
 to be more frequently deficient in memory than in appre- 
 hension in the ratio of 56 to 3t. 
 
 Epilepsy is also closely connected with other con- 
 ditions of mental lack of power than that brought on by 
 the disease itself, and in some cases the loss of intellect 
 precedes the development of seizures. When this is not 
 the case we frequently have transient mental disorders 
 developing, which have been hinted at, and of which we 
 shall speak in a moment. Ingels, superintendent phy- 
 sician of the Hospice-Grislain in Ghent, has, in a paper 
 read in the International Congress of Psj^chiatry and 
 Neuro-Patholog3^, in 1885, attempted to show the rela- 
 tions between epilepsy and idioc3\ Out of ^79 children 
 under his care 25 were epileptics, and out of 398 chil- 
 dren received into the institution in twenty-eight ^^ears 
 125 were epileptic idiots, — nearly one-third. These he 
 divides into two classes : (1) those in whom epilepsy 
 and idiocy were congenital and (2) those in whom epi- 
 leps}^ had caused dementia. He found that in the latter 
 class the failure of mental power was always very rapid. 
 
 In some studies made by Howe ^ of 574 idiots, he 
 found that 125 had epilepsj^, but of these 92 were idiotic 
 from birth and 33 had acquired idiocj^ whether as a re- 
 sult of the epilepsy or not is not stated. Probably the 
 idiocy was not the result of the epileps}", for idiocy is 
 
 ' On the Causes of Idiocy, p. 56. London, 1856 
 
54 Epilepsy: its Pathology and Treatment. 
 
 rarely «i sequence of this disease, imbecility being gen- 
 erally the ultimate condition. The figures by Howe 
 should not, therefore, be taken as statistics on the fre- 
 quency of epilepsy and idiocy, but rather of idiocy and 
 epilepsy, — two entirely different things. An interesting 
 fact in regard to epileptic idiots is that they seem to 
 preserve some "signs of brain-power, and to be able to 
 learn simple things, which are, however, swept com- 
 pletel}'' out of their minds by the first repetition of an 
 attack. 
 
 Insanity, in distinction from idiocy or imbecilitj", 
 rarely complicates e})ilepsy, although Bucknill and 
 Tuke,^ the two well-known English psychologists, state, 
 from an analysis of many thousand cases, that the per- 
 centage of persons insane by reason of epilepsy is not 
 less than 6.5 per cent. In the " Rapport sur le Service 
 des Alienes du Departement de la Seine," for 1877, the 
 principal causes of insanity are given in 20G8 cases, of 
 which number 59 were due to epileps3\ In 864 cases, 
 where the causes of insanity were discovered, admitted 
 to tlie Lunatic Asylum at York, 23 were due to epilepsy, 
 and in the 687 cases admitted to the Northampton Asy- 
 lum, in the United States, 62 cases were supposed to be 
 due to epilepsy. It should be remembered that nisanity 
 is rarely complicated by epilepsy unless dementia para- 
 lytica exists. Epileptic insanity has a most unpromis- 
 ing outlook, and the prognosis should always be most 
 unfavorable. Cases of cure are almost unknown. 
 
 According to the studies of Echeverria,^ nocturnal 
 epilepsy is much more apt to be complicated by insanity 
 than is diurnal epilepsy, and petit mal is more apt than 
 either of the violent convulsive varieties to be followed 
 
 * Psychological Medicine. 4th ed. 
 
 ^ International tJongress of Mental Medicine. Paris, 1878. 
 
Mental State. 55 
 
 by mental overthrow. Hallucinations he also found to 
 be very common in epileptic insanity, amounting to as 
 much as 86 per cent, in 267 cases. The hallucinations 
 were divided as follows : Auditory, 62 per cent. ; sight 
 and hearing, 42 per cent. ; smell, 6 per cent. ; while 70 
 per cent, showed anaesthesia, h3^per8esthesia, or false 
 sensations. 
 
 In the careful and interesting studies of Falret, he 
 divides the mental disorders of epileps}^ into three di- 
 visions, in the first of which are those in whom mental 
 disease is between the attacks and independent of them ; 
 in the second, those in whom the mental derangement 
 takes place during the paroxysm ; and in the third class 
 he places those in whom the intellectual disorder comes 
 on in the attacks and lasts afterward. ^ 
 
 Echeverria also divides epileptic insanity into three 
 classes, namely, into intermittent, remittent, and con- 
 tinuous, all of which terms designate the conditions so 
 clearly as to require no explanation. 
 
 In the class of cases where mental disturbances are 
 merely present at or about the time of the convulsion, 
 we may have any variety of disordered function, all the 
 way from pure idiocy to homicidal mania. In this we 
 have a well-marked difference from the mental disorder 
 produced by long-standing epilepsy, which is well to 
 remember, for in the latter the alienation is one of imbe- 
 cility and harmlessness, while in the first it may be quite 
 the opposite. In some individuals there is a very early 
 tendency to the development of mania ; there is a cer- 
 tain periodicity about the explosions, and, when estab- 
 lished, the excitement either precedes the attack by a 
 few days or occurs shortly afterward. The violence is 
 
 * I have not space in which to quote this interesting research further, 
 but to those who are interested I would refer them to the original. 
 
56 Epilepsy : its Pathology and Treatment. 
 
 characteristically acute, and the mania is, while often 
 homicidal, rarely suicidal. Fortunately, this mania only 
 lasts, as a general rule, a few minutes or hours, but it 
 may, as just stated, last much longer. 
 
 When it does last, it more frequently is associated 
 with hystero-epilepsy than epilepsy, and it is also worthy 
 of note that in these cases the tits seem to produce 
 some lessening of the mania immediately after each 
 one. That permanent mania is only sometimes seen in 
 epilepsy is proved by the cases of Russell Reynolds 
 (loc. cit.)^ in which he saw only 7 maniacs in 69 cases. 
 
 Responsibility of Ejnleptics. — The responsibility of 
 such persons, so far as their acts make them amenable 
 to the law, is a question which it is impossible for the 
 writer to discuss here, simply because it hardly con- 
 cerns us in this essay, and because an enormous amount 
 of legal as well as medical writing must be cited, and 
 deep questions into the delicate subject of the dividing 
 line between responsibility and insanity are too devoid 
 of results in the court-room to be of value either to the 
 lawyer or to the physician. There are many of us who 
 are subject to harmless eccentricities which pass unno- 
 ticed in daily life, but which, if they were productive 
 of more dangerous results, might very generally be re- 
 garded as evidences of insanity or deranged mental 
 acts. 
 
 Further than this, as epilepsy and insanity go liand- 
 in-hand, without any relationship to one another, save 
 that they occur S3aichronously, in many cases a second 
 nice point of differentiation arises as to whether a 
 criminal act results from an epileptic homicidal explosion 
 of gray matter, to an insane homicidal act, or to revenge 
 actuated ])y a real but insufficient cause. It is just here 
 that the physician finds himself, when cross-questioned, 
 
Responsihility of Ej)ileptics. 57 
 
 ima,ble to give any opinion which cannot be attacked. 
 A few cases which are appended ilhistrate these difficul- 
 ties very well, and in the present state of our knowledge 
 render it Impossible for any one to elucidate them, or to 
 accurately judge as to penalties to be inflicted. Thus, 
 in a certain case of epilepsy recorded by Thorne,^ 
 there were periods in which the ordinary fits seemed 
 replaced by mental storms. Though usually a mild and 
 good-tempered man, he would during these attacks seize 
 a knife and declare he would kill his children. In 
 another case, recorded by Orange, ^ a woman subject to 
 epileptic seizures rose up from her chair with her baby 
 in her arms, and began to cut some bread for an older 
 child. While thus employed a fit came on, and she cut 
 the hand of the baby right off*, being found by the neigh- 
 bors afterward in the coma following the fit. In the 
 intervals this woman was entirely sane, but surely was 
 not responsible for the injury to her child. 
 
 The following case recorded by Hamilton ^ is inter- 
 esting in this connection : — 
 
 C. O., aged 22 3'ears, a reporter attached to a daily 
 newspaper, received an injury to his head when but 3 
 years old. He fell from the second story of an unfin- 
 ished building to the cellar, striking the upper and back 
 part of his head upon a beam. He was rendered uncon- 
 scious, and remained so for a dav or more. He recovered 
 from the immediate bad effects, but suffered from se- 
 vere general headaches, which recurred every week or so, 
 with an increase in the amount of urine excreted. About 
 six months before he was seen by the reporter he began 
 to have epileptic convulsions of a violent character 
 
 * St. Bartholomew's Hospital Rep., 1870. 
 2 Broadmoor Asylum Rep., 1877. 
 ^ Pepper's System of Medicine, vol. v. 
 3* 
 
58 Epilepsy: its Patholo(jy and Treatment. 
 
 almost every day, and sometimes more frequentl}^ They 
 were brought on by excitement, and he had a great many 
 when worried about his wife at the time of her deliver3\ 
 The attacks were, as a rule, preceded by an epigastric 
 aura of long duration, and occasionally by a visual aura. 
 At these times he was noted to be queer and strange; 
 he would restlessly wander about his office, and sud- 
 denly, without any cry, become convulsed. After the 
 attack he slept soundly. He often felt inclined to do 
 himself an injury, or to kill some one. He was irritable, 
 pugnacious, and he would often raise his hand to strike 
 some one of his family and afterward know nothing of 
 his conduct, and was greatly astonished when told that 
 he had done so. 
 
 On one particular morning he was seen at 10 o'clock, 
 liaving had a fit in his office at 8, of a more severe char- 
 acter than usual, and preceded by a ps^'chical aura, 
 during which he was \e\y morose and sullen. Upon 
 recovery he was speechless, though he could communicate 
 b}' signs. He was sensible, but dazed, with his pupils 
 strongly dilated, but mobile when the eyes were turned 
 toward the light. When asked a question he understood 
 it perfectly, and wrote an intelligible answer. He tried 
 hard to speak, and expressed annoyance at his inability 
 to do so. Laryngeal examination showed absolutely no 
 cause there for his aphonia. He remained speechless 
 all day. He was in bed later in the da}^, and able to 
 speak one or two words with great difficulty. The grasp 
 of the right hand was weaker than that of the left. He 
 now expressed himself as tired, and, turning over, began 
 to belch up wind ; the muscles of the neck and right side 
 became tonically contracted, the extensors predomi- 
 nating. He remained with the right arm and leg stiffly 
 extended for a moment, then took two or three deep 
 
Responsibility of Epilejytics. 59 
 
 inspirations, put his hand to his throat, and said that a 
 bone had fallen from his throat. He now denied ever 
 having lost his speech, and of seeing any of his physi- 
 cians before, and he had forgotten all the previous 
 occurrences of the da}'. 
 
 This, then, is another Instance of the absolute irre- 
 sponsibility of some epileptics during certain periods, 
 and if murder had been committed the man should, 
 undoubtedl}^, have been acquitted on the ground of tem- 
 porary insanitj". 
 
 Now, it is just such cases as these that lead the la3'man 
 and the judges to a wrong impression. Man}" of my 
 readers doubtless recall the famous case so often quoted 
 by Trousseau in his lectures, of a Parisian master- 
 builder who was habitually seized with attacks in which, 
 although entirely unconscious, he would run from 
 scaffold to scaffold, springing from plank to plank, but 
 never falling, and who certainl}^ was absolutely irre- 
 sponsible for his actions during that time. Again, the 
 case of a Negro has been recorded by Wood, who would 
 suddenly dash along the street uttering a scream, and 
 would keep on as hard as he could run for from half a 
 mile to a mile, when he would stop perfectly conscious, 
 although entirely ignorant of the occurrences which had 
 just taken place. If he were caught and held he was 
 instantly thrown into a furious epileptic convulsion. 
 If this man had committed a murder as he ran and been 
 tried, no one, save the experts called, would h*ve listened 
 to the idea that he was irresponsible. These last two 
 cases are, in reality, tj^pes of the disease described 
 under the head of epileps}" procursiva, which has already 
 been alluded to. 
 
 A ver}'' important point in this connection is the fact 
 that whether a man be permanently insane or temporarily 
 
60 Epilejysy : its Pathology and Treatment. 
 
 suffering from homicidal mania,, he equally requires con- 
 stant watching. Because a man is sane for twenty-nine 
 days in every month but homicidal on the thirtieth da}^ 
 is in reality a greater reason for confining him than one 
 wlio by his constant aberration of mind warns those 
 al)out him to be on their guard. The periodically epi- 
 lei)tic homicide should be imprisoned, not after he has 
 committed an outrage, but before he gets an oppor- 
 tunity. 
 
 Psychic Epilepsy. — A condition which is very inti- 
 mately connected with what hns been said on the last few 
 pages is one which Weiss ^ has recognized and named 
 " Ps^^chic Epilepsy." Indeed, it is virtually identical 
 witli the case of C. 0., which was given a moment since. 
 In the "psychic epilepsy" of Weiss he recognizes a 
 special form of the disease, running a typical course, and 
 in which the convnlsive attacks are replaced by psy- 
 clioses, which stand in no relation to convulsions and 
 liave nothing to do with them. The mental disorder is 
 characterized by a sudden onset, without incubation ; it 
 speedilj^ or in a few hours, reaches its acme, then rai)idly 
 disappears and is followed b}^ complete psychic restora- 
 tion and by a periodic recurrence without any failure of 
 mental power. Weiss has seen 4 such cases, in all of 
 which the course just given was closely pursued. In 
 the first the man suffered from frequent attacks of in- 
 sanity lasting two or three days, preceded by a well- 
 marked aura. After the attack he was perfectly sane, but 
 had absolutely no remembrance of the insane period. In 
 the second case there was a history of vertigo, pain, and 
 confusion of mind for thirt}^ j^ears previousl}^ At this 
 time spells came on associated with frantic runnings to 
 
 • Psychiatrische Studien aiis der klin.von Prof. Leidesdorf. Wicn, 
 1877. Ccntrull)!. f. d. mcd. Wisscuschaften, No. 15, 1877. 
 
Syphilitic Epilepsy. 61 
 
 and fro, find accompanied by shoutings of the word 
 " fire," which lasted from two to three days. 
 
 In the third case such attacks came on regularly two 
 or three days before each menstrual epoch, accompanied 
 by melancholia, which was followed by well-developed 
 dementia, and finally a return to perfect health. The 
 fourth instance illustrates what the writer has already 
 said. A bo3^, generally perfectly well, was occasionally 
 seized with a desire to kill somethino- which he thoug-ht 
 he saw, and which remained before him for but a minute 
 or two. According to Weiss this boy ultimately became 
 truly epileptic, and he believes that such a metamor- 
 phosis may frequently occur. 
 
 Syphilitic Epilepsy. — S3q:)hilitic epileps}^ is only one 
 of the many nervous aflfections which afflict those who 
 may be so unfortunate as to contract this disease. The 
 manner in which the nervous outcome of the disease 
 is reached will be considered under the head of Etiology. 
 There can be no doubt that S3^philis produces an enor- 
 mous amount of epilepsy, and the presence of epilepsy 
 in a person in whom the slightest chance of a specific 
 taint exists should cause him to be instantly placed 
 under antisyphilitic treatment. That this is true is evi- 
 denced by the statements of the best neurologists the 
 world has ever known, for we find no less noted a man 
 than Charcot^ stating that epilepsy is the most frequent 
 manifestation of cerebral syphilis, and the equally emi- 
 nent rournier,2 \\^q syphilographer, has insisted most 
 strongly on this point, as have also Braivais^ and M. 
 Lagneau.* In England, Hughlings- Jackson, Broadbent, 
 
 * Loc. cit. 
 
 ^ De I'Epilepsie syphilitique tertiare. Lemons professie. Paris, 1S7G. 
 =• These de Paris, No. 18, tome iv, 1827. 
 
 * Maladies syphilitique du systeme nerveux. Paris, 1860. 
 
62 Epilepsy: its Pathology and Ti^eatment. 
 
 Todd, and BuzzarcU have promulgated this doctrhie, and 
 in America Weir Mitchell, ^ Spitzka, Wood,^ and Carter 
 Gray have recorded their belief in this idea, as have also 
 Nothnagel and many equally eminent Germans. In- 
 deed, it would be hard to discover any one statement in 
 medicine which would receive more wide-spread assent 
 on all sides than does this one. 
 
 The S3'mptoms of S3'philitic epilepsy reallj^ differ in 
 no way from those of the simple idiopathic variety, but 
 some questions peculiar to this form of the affection are 
 w^ell worthy of attention. 
 
 First and foremost it is exceedingly important to 
 discover how long, after the S3'philitic poison has been 
 received, it is before the nervous outbreak results. 
 
 In some statistics collected by Echeverria* he found 
 that in 118 cases of syphilis the first epileptic spasm 
 was, in G5 males and 53 females, as follows : — 
 
 In 9 males and 15 females iu from 4 months to 1 year. 
 
 6 
 
 
 
 20 
 
 3 
 
 
 
 8 
 
 5 
 
 
 
 5 
 
 9 
 
 
 
 3 
 
 3 
 
 
 
 2 
 
 1 
 
 year 
 
 to 2 years, 
 
 2 
 
 years 
 
 to 5 " 
 
 5 
 
 (( 
 
 to 8 " 
 
 8 
 
 u 
 
 to 12 " 
 
 2 
 
 u 
 
 to 20 " 
 
 The ages of the males ranged from 19 to 30 3'cars, 
 while those of the females were from 21 to 28 3'ears. On 
 anMl3-zing this table further than its originator did, we 
 find that the average period after infection equals, as a 
 general rule, from 2 to 5 years. 
 
 The previous S3'mptoms to the epileptic attack were, 
 in the 118 cases, as follow : — 
 
 Headache in 45 males and 38 females=83 patients== 
 70.30 per cent, of tliem all. 
 
 * Aspects of Syphilitic Nervous AfTet tions. 187J. 
 
 ^ liectures on Ncrv. Diseases. ^ Nerv. Dis. and their Diagnosis. 
 
 * Journal Mental Science, July, 1880, p. 1G5. 
 
Syphilitic JEjjilejjsy. 63 
 
 Preecordial pain in 27 males and 32 females = 59 
 patients, or 50 per cent, of the whole nnmber of cases. 
 
 Of the 83 patients with cephalalgia 10 males and 16 
 females had parietal pain, and 11 males and 8 females 
 siilfered from pain in the temples, while 9 males and T 
 females suffered from occipital pain. In the remaining 
 22 cases the headache was felt all over the head. 
 
 The peculiarity of the cephalalgia of S3'philis, when 
 complicated with epileps^^ is the constancy with which 
 it annoys or agonizes the patient, alwaj^s being present 
 to some extent, and frequently exacerbated toward 
 night-fall or during the night, generally getting worse 
 until the parox3^sm breaks forth, or it may in some 
 instances relent as the storm approaches. Indeed, 
 many syphilographers believe this to be the rule rather 
 than the exception. There is certainly something very 
 tj'pical about these S3q:)hilitic headaches which, neverthe- 
 less, baffles the descriptions that one would like to give 
 of them. Once seen the}" can rarely be mistaken for 
 anything else, and even the first view of such a case 
 must impress the careful observer with several salient 
 points. The face, one notices, expresses constant suffer- 
 ing, or at least distress and weariness, and the unrelent- 
 ing character of the pain seems to crush the patient's 
 vitality of appearance and liveliness with an iron heel. 
 If spoken to, the man who has been resting the head on 
 the hands will either answer slowlj?- and painfully in 
 monosjdlables or, graduall}^ raising the face to that of 
 the questioner, give an answer and once more return to 
 liis former position. These symptoms are not, of course, 
 pathognomonic, but they are certainl}^ characteristic. 
 The pain, too, is in other ways peculiar, and Charcot^ 
 
 'Legons sur les maladies du systemo uerveux, tome ii, Deuxieme 
 editiou, p. 357. Paris, 1877. 
 
64 Epilepsy: its Pathology and Treatment. 
 
 has expressed the opinion that the crossed character of 
 the pain in this disease is of vahie, as it points to the 
 motor zone. Indeed, he regards this headache as tj'pical 
 of the disease, particularly where it is, as it generally is, 
 bilateral ; that is, in both temples or both occipital 
 regions at the same time. 
 
 In the place of the headache we ma}^ have, as pro- 
 dromal symptoms, slight loss of memory, unwonted 
 slowness of speech, general lassitude, and especially a 
 lack of willingness to make mental exertion. Somno- 
 lence may be excessive, and if any of these symptoms 
 are seen in a person whose history is syphilitic they 
 should be regarded as warnings of an approaching crisis 
 of epilepsy or of some otiier cerebral disorder. The 
 optic disks should be carefully examined, for in many, 
 but not all, cases evidence of brain disease may be 
 denoted. 
 
 This is particularly true of syphilitic epilepsy as 
 contrasted with its other forms. 
 
 There is also one s^^mptom which may occur early in 
 sjqihilitic epileptics, or sometimes only late in the 
 disease, namely, repeated partial, passing palsies, which, 
 while they may be in some cases hysterical, are, in a 
 S3'pliilitic, almost pathognomonic of brain involvement, 
 — a momentary weakness of one arm ; a slight drawing 
 of the face to one side, which disappears in a few hours ; 
 a temporary dragging of the toe ; a partial aphasia which 
 appears and disappears ; a squint which to-morrow leaves 
 no trace behind it. A symptom which has been asserted 
 as being frequent in this disease is the common occur- 
 rence of nocturnal attacks; indeed, cases have been re- 
 ported by Charcot 1 and Lagneau^ where this was the 
 
 ' Le9ons dcs maladies, etc. 
 
 3 Maladies syphiliticiuc du systcine nerveux. Paris, 1860. 
 
Syphilitic Epilepsy. 65 
 
 case, but there are similar instances, by the score, in 
 ordinary idiopathic cases. ^ 
 
 In syphilitic epilepsy there are often well-marked 
 psychical disturbances with incomplete palsies, which, 
 curiously enough, rarely involve the cranial nerves, as 
 has been particularly noted by Heubner;^ or there may 
 be an excess of psychical disturbance with a minor 
 epileptic convulsion, and with involvement of the basal 
 cranial nerves. A few writers have claimed that the 
 epilepsy of syphilis can always be distinguished, as it is 
 alwa3^s unilateral, but this is, of course, incorrect, simply 
 because, as will appear later on, unilateral epilepsj'^ of a 
 non-specific t^'pe is by no means rare. Thus it will be 
 evident that syphilitic epilepsy is not sometimes uni- 
 lateral because it is sj^philitic, but because the lesions, 
 under these circumstances, are commonly isolated and 
 in the cortex. The statistics of Echeverria, already 
 quoted a page or two back, in which the details of 118 
 cases of syphilitic epilepsy are given, also provide us 
 with interesting data concerning these points of which 
 we have just been speaking. Eight cases had fits on the 
 same side as the pain in the head, and 1 1 had fits on the 
 opposite side, while 7 were generally'' convulsed. Two 
 males, with supra-orbital neuralgic pain, had fits on the 
 same side, 4 on the opposite side, and 13 had general fits. 
 In 5 cases with occipital pain there were unilateral fits. 
 
 Lasegue^ has strongly insisted that all chronic epi- 
 leptics show some cranial deformity of a more or less 
 constant and well-marked type, and he has proven, to 
 his satisfaction, that the most common change is promi- 
 nence of the frontal bone on the right side and depres- 
 
 ^ Echeverria' s statistics contradict the assertion that syphiUtic epilepsy 
 is commonly nocturnal. In 118 cases he only found 7 instances. 
 2 Virchow's Archiv, Bd. LXXXIV, p. ^9. 
 ^ Annales Medico-psychologique, Sept., 1877. 
 
 C* 
 
Epileptic. 
 
 Non-epileptic, 
 
 57 per 
 
 cent. 
 
 51 per cent. 
 
 53 " 
 
 
 31 '' " 
 
 49 " 
 
 
 39 " '* 
 
 32 ♦' 
 
 
 23 " " 
 
 71 " 
 
 
 51 " '' 
 
 35 " 
 
 
 47 u u 
 
 66 Epilepsy: its Pathology and Treatment, 
 
 sion of the malar bone of the same side, with relative 
 prominence of the left malar bone, resulting in torsion 
 of the face and obliquity of the palatine arcli, of which 
 the axis deviates to the right side. GareP has also 
 attempted to show that such changes are present. The 
 following statistics were collected by him : — 
 
 Frontal eminence prominent, . 
 Malar prominence on left side, 
 Rotation of face, 
 Deformity of palate, 
 Flatness of one side of face, . 
 Orbit level, .... 
 
 CaiT3'ing his studies still further, Garel seems rather 
 to contradict these results, unintentionall3', for he found 
 an opportunity^ to examine the tracings of 255 measure- 
 ments of heads taken by hatters, and found that the 
 right frontal eminence was most prominent in three- 
 fourths of the cases. As this is, however, a greater 
 number than those found in epileptics, namely 57 per 
 cent., it becomes evident that the conclusions of Lasegue 
 and Garel need confirmation by further study, for in the 
 measurements made by hatters very few epileptics are 
 included, and their measurements may be taken as repre- 
 senting the shape of the normal head. Garel found the 
 Y-shaped maxilla, so common in idiots, only very rarely 
 in epileptics. Studies still more recently carried out by 
 Bourneville and Sollier ^ have confirmed the research of 
 Lesegue. 
 
 Jacksonian Epilepsy. — B}^ the term Jacksonian epi- 
 lepsy we mean an affection which separates itself from 
 true or ordinary idiopathic epilepsy by several peculi- 
 arities. By far the most important of the peculiar signs 
 
 * liyon Medicale, Jan., 1878. 
 
 ^ Le Progrcs Medical, September 22, 1888. 
 
Jacksonian Epilepsy. 67 
 
 is the character of the onset, which always begins, in the 
 typical Jacksonian disease, in some peripheral portion of 
 the body, and most frequently in the muscles of the thumb 
 or hand, so that for the moment the movements of the 
 part are localized, and may remain localized at the point 
 of origin, or immediately diffuse themselves over muscle 
 after muscle until all the arm, leg, or other groups of 
 muscles are involved. It is of the greatest importance, 
 however, that the reader should keep the aura of an at- 
 tack separated in his mind from the onset, remembering 
 that the term onset is here used by the writer to desig- 
 nate the beginning of the period following the aura, if 
 there be one. Jacksonian epilepsy miiy be of almost any 
 severity, as, in rare cases, but one muscle may suffer 
 throughout an entire attack, or in others the entire body 
 may be at last convulsed. There may or may not be 
 loss of consciousness, its presence or absence being de- 
 pendent upon the seat of the lesion in the brain and 
 the severity of the attack. In those instances where only 
 a few localized muscles are involved consciousness is 
 more commonly preserved than lost. 
 
 No better wa}^ of bringing forward the disease in a 
 clear manner to the reader's mind than to detail a typi- 
 cal case. A. E., aged 24, one year ago first noticed 
 that several times in the course of a week, which was 
 preceded by great anxiety and exhaustion of mind, he 
 had a peculiar sensation, — tingling, which passed up 
 his left arm, to be lost in the trunk, and at this mo- 
 ment, entirely without his will, his thumb was turned 
 into the palm of his hand in a spasmodic manner, and 
 that afterward the same hand felt weak and wearj^, as 
 though he had used it very severely all day. These 
 attacks were followed in the next few weeks by sev- 
 eral more, but the last one of these was only a little 
 
68 Epilepsy: its Pathology and Treatment. 
 
 more severe than the first. Six months ago, after a long 
 walk in the hot sun, he felt the sensation creeping up 
 his arm more rapicll}^ and severely than ever before, and 
 immediately afterward the thumb was once more turned 
 into the palm of the hand, the muscles of the hand, 
 wrist, and forearm were rapidly involved in a tonic 
 spasm, which soon relaxed, to be followed by clonic 
 spasm, by which all the muscles were affected, and the 
 muscles of the arm and shoulders also became involved. 
 After this attack the same feeling of uneasiness came 
 on as after the previous and less severe attacks, except 
 that the sensation of weariness involved the entire limb 
 instead of onl}* the hand, as had been the case before. 
 There was, however, no disturbance of consciousness, 
 and only a momentary giddiness at the instant that the 
 aura reached the head. Since that time he has had in 
 all six attacks, each one of which has been more severe 
 and more widespread than its predecessor, and in each 
 of which the body became more involved in the move- 
 ments. In the last two attacks there has been partial 
 loss of consciousness, and they have been followed by 
 the peculiar somnolent condition so frequently seen 
 after ordinary severe epileptic paroxysms. In the last 
 attack the whole body was equally convulsed before the 
 seizure ended, and if any one had seen the case at this 
 time it would not have been possible to have distin- 
 guished it as a case of Jacksonian epilepsy, unless the 
 history already given was known. 
 
 This, then, is a case of Jacksonian epileps}^, which 
 is typical in all its details. Tlie previous histor3'' of 
 the man is that six months before his first attack he 
 received a kick on tlie head, in the parietal region, on 
 the risrht side, which made him unconscious for some 
 hours. 
 
relit Mai GO 
 
 A ver}' interesting statement has been made by Un- 
 verreiclit, namely, tliat whatever the course of involve- 
 ment is, up or down on the side first affected, it is 
 always ascending on the side last affected. 
 
 Petit Mai. — Petit mal differs in no way in its essential 
 characters from epilepsy of a much more highly devel- 
 oped form, but in its minor characteristics it is suf- 
 ficiently at variance with haut mal or grand mal to 
 separate it in the minds of clinicians. In its most com- 
 mon form petit mal consists of a momentary loss of con- 
 sciousness, accompanied by pallor, or more rarel}' fiush- 
 ing of the face. The man who is subject to the disease 
 suddenly stops what he is doing for a moment or two, 
 and then takes up his work or subject as soon as he re- 
 covers, and at the point where he ceased, being often 
 unconscious of the break in his conversation or labor. 
 Keynolds^ has divided this minor form of the affection 
 into two divisions. In the first, he places those who are 
 attacked and have no evident spasm, and in the second 
 group are those who have evident spasm. The seizures 
 are characteristically fugacious, and if any spasm is pres- 
 ent it is nearl}^, if not quite, alwa^'s of the tonic variety. 
 Sometimes the disorder of motility' lies chiefl}'' in an in- 
 hibition of an act about to be performed. The fork in 
 a man's hand at a dinner-table ma}'^ be raised half-waj'' 
 to the mouth, then held in mid-air for a moment, and 
 then as the attack passes away continues on its journey 
 to the mouth ; or, a woman playing the piano may sud- 
 denly pause with her fingers raised from the ke3^s, miss 
 the time of three or four bars, and then go on exactly 
 where she left off, as if no interruption had occurred. ^ 
 Even lighter manifestations may exist than these. A 
 man may pass by, in conversation, a joking sa3ing of a 
 
 * Loc. cit. " For sucli a case see Georget. Malad. Nerveux, p. 3S4. 
 
TO EinJepsy : its Pathology and Treatment. 
 
 friend unconsciously, or, disregarding the repl}^ given to 
 a question, ask it a second time. To this light grade of 
 I^etit mal may be added the interesting case, recorded by 
 Hughlings-Jackson, of a man who blew his nose upon a 
 a piece of paper and gave the conductor of an omnibus 
 £2 10s. instead of two-pence half-penny. Such attacks 
 are, however, hardly to be called, strictly speaking, 
 forms of petit mal, and, notwithstanding the classifica- 
 tion given it bj^ so eminent a man as Hughlings-Jackson, 
 it seems to us to belong to what is more commonly called 
 temporarj'^ mental aberration, of which we see so many 
 instances, in the old, who certainly are not suffering from 
 petit mal. In this case, just mentioned, there was very 
 evidently no dimming of cerebral power, but a perversion 
 of its direction. 
 
 A very important matter in obtaining a patient's 
 history in cases of petit mal is to discover the presence 
 or absence of sensations described by the sufferer as 
 "faints," "losses," "times," and "giddiness," — which 
 symptoms may be all of the attack, or, at an}'' rate, all 
 to the patient who fails to recognize the succeeding 
 unconsciousness. 
 
 The writer believes it is true that well-developed 
 aurse are quite as common in petit mal as in other forms 
 of epilepsy, but this has been denied by some writers. 
 Some believe it to be more commonly present, while 
 others think it less common than in the fully-developed 
 disease. Petit mal may also affect chiefly the sensory 
 apparatus, and, in these cases, as in reality in all cases, 
 it has but a slim boundary-line between it and grand 
 mal. Thus, S. Weir Mitchell, the well-known American 
 neurologist, in his work on " Nervous Diseases," has 
 described cases in which the whole paroxysm was sen- 
 Bory. In the most pronounced of Mitchell's cases an 
 
Petit 3Ial. *ll 
 
 aura beginning at the feet passed up to the head, when 
 it was lost in the sensation of a loud sound, like that of 
 a pistol-shot, followed by a momentary sense of deadly 
 fear. It has been thought that such instances par- 
 took largely of a hysteroidal type, but there can be 
 no doubt that they eventually become truly epileptic 
 in some cases. Thus, the writer remembers a case oc- 
 curring in a lad under his charge in the Children's 
 Dispensary of the University Hospital, who was a rag- 
 picker, and who was always attacked on each da}', as he 
 sat on the floor picking rags, by a momentary uncon- 
 sciousness followed by a sensation of intense emptiness 
 of the stomach. This case eventually developed well- 
 marked epilepsy. A very well known writer and friend 
 of the author of this essay had under his charge a child 
 of eight years who would cry out of a sudden with xoain 
 in the stomach, become excessively pallid, run to his 
 mother and be held for a moment, when the whole attack 
 would be over. In some of his spells he had tonic con- 
 tractions of the feet and neck, but never unconscious- 
 ness, the paroxysms being followed by heavy sleep. 
 These cases of gastric aura frequently end in true 
 epilepsy. 
 
 A very interesting table of the chief characteristics 
 of jjetit mal has been compiled by Gowers,i ^j^^ jg 
 worthy of insertion here. The S3^mptoms are arranged 
 in the order of frequencj^ The first of the list occurs in 
 one-third of the cases and the second in a sixth, so that 
 these two are the characteristics of about half the entire 
 number of minor seisures met with : — 
 
 1. Sudden momentary unconsciousness, or fainting, 
 or sleepiness, without warning. 
 
 2. Giddiness. 
 
 * Nervous Diseases, p. 690. 
 
72 EpilepFiy : its Patliology and Treatment. 
 
 3. Jerks or starts of the limbs, trunk, or head. 
 
 4. Visual sensation or loss of vision. 
 
 5. Mental state ; sudden sensory fear. 
 
 6. Unilateral peripheral sensation or spasm. 
 
 7. Epigastric sensation. 
 
 8. Sudden tremor. 
 
 9. Sensations in both hands. 
 
 10. Pain or other sensation in the head. 
 
 11. Choking sensation in the throat. 
 
 12. Sudden scream. 
 
 13. Olfactory sensation. 
 
 14. Cardiac sensation. 
 
 15. Sensation in nose or eyeball. 
 
 16. Sudden dyspnoea. 
 
 17. General "indescribable" sensations. 
 
 The urine is very frequently passed in petit mal ; more 
 commonly than in grand mal, and more commonly in 
 females than in males. When it is passed, the accident 
 almost invariably is accompanied by loss of conscious- 
 ness.i 
 
 Under the next heading of Nocturnal Epileps}^ are 
 given the records of a case of the Vvriter's which is, t3'pi- 
 cally, one not only of petit mal and nocturnal epileps}^, 
 but also of the manner in which the minor disease may 
 rapidly become major, even in an adult well along in 
 years. 
 
 The after-symptoms of petit mal consist main 1}^, when 
 they occur, in the patient being dazed or stupid for a 
 few minutes, or by his making random remarks, or auto- 
 matic and causeless movements, which are, however, 
 purposive in their character. These movements are to 
 be separated from those constituting the true attack, 
 
 ' For a full consideration of the frequency of this and other similar 
 accidents in epilepsy, see interesting paper by Rengade and Raynaud, 
 Gazette Hebdomadaire de Med. et de Cliir. de Paris, Janvier, 1865. 
 
Nocturnal Epilepsy. 73 
 
 although very eminent neurologists have thought other- 
 wise, among them Esquirol, who called these symptoms 
 " masked epilepsy," or Morel, who named them " epilep- 
 sia larvata." The cause of these post-paroxysmal 
 phenomena is, of course, unknown, although several 
 very prominent authorities ^ have believed them to be 
 due to temporary failure of the highest centres to con- 
 trol those below them, which consequently act in an 
 automatic manner. 
 
 The relative frequency of petit mal to haut mal has 
 been placed by well-informed writers as 1 to 2.^ 
 
 Nocturnal Epilepsy. — In some cases of epileps}^ tlie 
 seizures for many months may escape notice by reason 
 of their occurring at night, while the patient is asleep. 
 As a rule, they are finally discovered eitlier by an exten- 
 sion of the attacks to waking hours or to the presence 
 of a bed-fellow, who is aroused by the movements or cries 
 of the patient. Very frequently a grown man or woman 
 will, on awaking in the morning, find that they have wet 
 their bed during the night, or, more rarely, passed out 
 the contents of the rectum. They complain on these 
 mornings of a sensation of weariness and intense lassi- 
 tude, " as if they had been beaten or bruised," and the 
 tongue is often tender and swollen from being caught 
 between the teeth. In some cases it may be difiScult to 
 rouse the man or woman sufficiently to make them get 
 out of bed, while in others an insufferable headache is 
 present. As has already been stated, nocturnal epilepsy 
 is almost always followed by diurnal attacks later on. 
 It has been asserted that incontinence of urine only 
 occurs in these cases, but this is incorrect, although I 
 believe it is more common here than elsewhere. 
 
 * Anstie, Thompson-Dickson, and Hughlings- Jackson. 
 ^ See Foville and Delasiauve, loc. cit. 
 4 D 
 
14 EpiJejisy : its Pathology and Treatment. 
 
 A very useful and valuable series of conclusions 
 in regard to nocturnal epilepsy has been reached by 
 Echeverria,^ which is now given : — 
 
 1. It is more common in females than in males, and 
 almost always is associated with diurnal vertigo, petit 
 mal or liaut mal, when it is not with insanity. 
 
 2. Its etiology is essentially encephalic, due to 
 traumatism, heredity", alcoholism, syphilis, or strong 
 emotional causes. 
 
 3. Nocturnal incontinence of urine, laceration of 
 the tongue, and petechial eruptions on the face and neck 
 are not constant, but when present are pathognomonic. 
 
 4. Sudden explosions of frantic momentary bewilder- 
 ment in the middle of the night, during sleep, or of 
 insanity on getting up in the morning, are proofs of 
 nocturnal epilepsy. 
 
 6. Most sleep-walkers are persons of emotional tem- 
 perament, and ultimately arrive at epileps}^ or insanit3\ 
 
 6. The nocturnal epileptic generally forgets the fit, 
 but remembers the frightful dream that accompanied it. 
 
 The following history of petit mal passing into 
 nocturnal epilepsy and finally into the ordinary fully 
 developed diurnal attacks is of interest in connection 
 with what has been said in the last few pages. As the 
 case was not only the writer's patient for something 
 over three 3'ears, but also a life-long servant in a near 
 relative's family', the author is confident of the accuracy 
 of the account, and of the early history of the patient. 
 At the time she first really began to suffer from these 
 attacks she was 33 years of age, and well preserved for a 
 woman of her j^ears. Strong and capable of hard work, 
 although she had been for many years only a child's 
 nurse. 
 
 * Journal Nervous and Mental Diseases, January, 1879. 
 
Nocturnal Epilepsy. 75 
 
 Earl}^ in 1883 she first began to complain of attacks 
 of giddiness, in whicli she felt light-headed for a moment 
 or two, on rising from bed or the dinner-table, or stoop- 
 ing to pick things from the floor. An inquiry into the 
 state of her health gave negative results, as every func- 
 tion seemed in perfect order ; menstruation was normal, 
 as were also the intestinal and digestive organs. Her 
 food was good and plentiful, and her appetite was very 
 fair. Although 33 years of age, she had been a child's 
 nurse for over half that time, and had beeii away from 
 the city for five months every summer in a healthy 
 watering-place with her emploj^er's family; so that her 
 opportunities for good health were great for one of her 
 rank in life. So far as close-questioning, frequently 
 repeated, could go, there was no specific historj^, either 
 inherited or acquired ; nor was there any evidence of 
 hereditary tendency among her family to nervous com- 
 plaints. She said she had once heard that a distant 
 cousin was epileptic. Repeated, careful urinary analysis 
 failed absolutelj^ to show an}- abnormal condition of the 
 kidneys, although the morning urine after a night attack 
 was always thick with phosphates. The genital organs 
 were carefully examined, with negative results, and the 
 undoubted chastity of the vfoman was confirmed by the 
 finding of fairly well marked and perfect hymen. The ad- 
 ministration of iodide of potassium to remove the faintest 
 possibility of syphilis was only productive of iodism, 
 although small doses were given. The use of the bro- 
 mides held the dizziness in check for some months, so 
 that it got no worse, but did not relieve them, and it 
 was found necessary to increase their amount constantl3\ 
 She now began to complain that frequently', when sitting 
 with the other servants, perhaps at a meal, she would 
 suddenly become flushed, then pale, and simultaneously 
 
76 Epilepsy: its Pathology and Treatment. 
 
 lose consciousness to a slight extent. The voices of 
 her companions seemed afar off; she could hear them 
 speak to her, but could not answer. When the attack 
 passed off, after lasting, perhaps, thirty seconds, she 
 could reply to what they had said, but felt heavy and 
 dazed for some time afterward. These attacks became 
 gradually more severe and more frequent, but never 
 produced any true epileptic seizure. 
 
 In the month of January, 1886, the writer was roused 
 at about 1 o'clock in the morning by a messenger asking 
 him to come to the house where the woman was employed, 
 "as they could not wake her." It was the woman's 
 custom to sleep in a room with one child, while a grown 
 sister occupied an adjoining room. This sister had been 
 waked up by strange sounds issuing from the maid's 
 bed, and, finding herself unable to rouse the woman, 
 waked the rest of the household. By the time the writer 
 arrived, however, he found the patient sitting up in bed 
 perfectly conscious and receiving explanations from the 
 family, gathered in the room, as to the cause of the ex- 
 citement, of which she knew nothing. Nothing further 
 occurred of note until the following June, while awa}'- 
 from home, the family being by the sea, wlien tlie parents 
 were roused about 3 o'clock one morning by screams of 
 the little girl, who still was accustomed to sleep with the 
 nurse. Tlie child had been wakened by the seizure of 
 the woman, had tried to waken her but failed, and then, 
 becoming alarmed, had called for help. The father broke 
 open the door and, finding himself unable to waken the 
 woman, carried the child to his room. In the morning 
 the woman knew nothing of the attack, but felt tired and 
 heavy. Again another period of six months elapsed, dur- 
 ing which time she was without treatment, as the writer 
 was away from home, during which no seizure took 
 
Nocturnal Epilepsy YT 
 
 place, as far as is known, when she again roused the 
 houseliold. After this she became thoroughly alarmed, 
 as her tongue was badly bitten, which impressed her 
 greatly as a circumstantial evidence that the nocturnal 
 attacks were as severe as had been stated by tlie family. 
 No attacks ever occurred where there was relaxation of 
 the sphincters. The attacks of diurnal petit mal were 
 now so frequent and severe that they necessitated her 
 discharge from service, ])ut she remained under the 
 writer's care. Her eye-grounds were most carefully gone 
 over by a distinguished oculist of Philadelphia, who 
 found absolutely no signs of e3'e or brain disease ; 
 indeed, he said " few people have such normal eyes as 
 she has." 
 
 Under the active use of the bromides only two 
 attacks at night were suffered from in the next six 
 months, and as the attacks of petit mal were less fre- 
 quent and severe she once more sought employment. 
 All went well for some two months after this, until on a 
 certain evening the people of the house, having left her 
 as the sole occupant, came home late, could not make 
 themselves heard, broke in the front door, and found the 
 patient under the kitchen-table surrounded by all the 
 evidences of a fully developed epileptic seizure. Other 
 attacks have since occurred in the da3''-time, notwith- 
 standing the constant use of large amounts of bromides 
 and antifebrin. 
 
 It will be seen that this case, which has been given at 
 perhaps too great length, embodies a t3^pical history of 
 petit mal afterward going on to grand mal, and of noc- 
 turnal grand mal eventually becoming also diurnal. 
 The case is also of interest as regards the age of the 
 woman, as idiopathic epilepsy rarely occurs after her 
 age, and she certainly had no syphilis. 
 
T8 Ejnlepsy : its Pathology and Treatment. 
 
 Epilepsie Apoplectique and Post-Hemiplegic Epilepsy. 
 
 — These convulsive conditions nmy be divided into two 
 classes, in one of which the patient suffers from a single 
 convulsion, the result of a cerebral haemorrhage, and in 
 the other in which the changes produced by the haemor- 
 rhage result in epileptic attacks. When the convulsion 
 occurs at the time of an apoplectic effusion it is generally 
 Jacksonian in character ; that is to say, one muscle or 
 group of muscles is involved, or, if not this, the attack 
 is, at most, only unilateral. Further than this, it is 
 alwa3'S associated with the symptoms of apoplexy as 
 generall}^ seen, for there is inequality of the pupils, 
 drawing of the face to one side, and a consequent hemi- 
 plegia which lasts indefinitely. Of the attack itself it 
 may be said that, so far as the movements are concerned, 
 they dilfer in no way from those of the true epileptic 
 seizure, but it should be remembered that hemiplegia 
 often follows ordinary idiopathic epilepsies ; so that the 
 fact that the hemiplegia is permanent, and is not tem- 
 porary, is more of a sign that the attack is due to haemor- 
 rhage than the actual paralysis is. It should also be 
 remembered that apoplexy often complicates epilepsy, 
 being produced l)y the convulsion. In a considerable 
 number of cases of epileps}^ it will be found that the con- 
 vulsions succeeded an attack of paralysis, which was 
 sudden in onset aud possessed the characteristics of vas- 
 cular rupture. In some persons the history of this 
 attack is very indistinct, owing to its occurrence in very 
 early life, while in others the paral3"sis has been so 
 slight or temporary as not to bear any relation in the 
 mind of the patient with the convulsive seizures follow- 
 ing, which, in many cases, do not occur for some time 
 after. The palsy ma}' leave not a trace of loss of power 
 behind it, but the convulsions continue, and closely re- 
 
Post-Hemiplegic Epilepsy. 19 
 
 semble the so-called idiopathic form of the disease. The 
 writer also wishes to call attention to the fact that the 
 palsy and convulsions are not always due to haemorrhage, 
 but to any pathological central change. Heart disease, 
 by causing embolism, may bring it on, and rheumatism, 
 syphilis, and the puerperal state may all produce a soft- 
 ening of the cortex, with an epileptic state following 
 the paralysis. We can very readily divide post-hemi- 
 plegic epilepsy inta two classes, too, for we find that in 
 about one-half the cases the convulsion occurs along 
 with the paralysis, and then follows at intervals, while 
 in the other half the paralysis is not followed by con- 
 vulsive seizures for weeks, months, or years. 
 
 Fost-hemiplegic epilepsy may occur at any age, but 
 there can be no doubt that it far more commonly occurs 
 in infants than in adults. In at least two-thirds of the 
 cases the onset is before 5 years of age, and in nearly one- 
 half it is during the first two years of life. Very curious 
 results are reached if the statistics of the affection are 
 analyzed, — results which are quite unexplainable unless 
 by hypothesis. Indeed, they tend to overturn many of 
 our preconceived ideas. Thus, it will be found that 
 in the cases which date from infancy, females are twice 
 as numerous as males, but in cases after 5 years of age 
 there is no diff'erence between the frequency in the two 
 sexes. One of the theories of these infantile cases 
 has been that they were produced by the use of in- 
 struments during labor, and repeated post-mortem ex- 
 aminations have confirmed the possibility of this 
 occurrence. On the other hand, every obstetrician 
 knows that the birth of a boy generally means a more 
 difficult labor than that of a girl, owing to the greater 
 size of the head in the male child. A priori reasoning 
 would seem to show, therefore, that the heads of male 
 
80 Epilepsy: its Pathology and Treatment. 
 
 children would, accordingl}^, have the instruments 
 applied most frequently, and consequentl}'' that infantile 
 cerebral trouble would be the result more commonly in 
 males than in females ; but, as has been said, this conclu- 
 sion is contradicted hy the facts. Another symptom of 
 great interest is that the paralysis, in the infantile cases, 
 is more frequently on the left side than the right, but 
 after the fifth year it is equally common on both sides. 
 
 The writer has already spoken of tlie fact tliat the 
 convulsions may occur along with the first attack of 
 paral3'sis and continue, or that an interval may occur 
 between the attack and the subsequent paroxj^sm. The 
 chronic recurring fits date from the onset in about 
 one-third of the cases, and it is not uncommon for the 
 paratysis to occur in infancy and the epileps}^ to begin 
 at pubert}''. It would seem that cells injured in early 
 life laid undisturbed till the increased demands of 
 maturit.y called them out into diseased action. This 
 prolonged interval occurring so commonly in children 
 separates them from adults in this disease, for in the 
 latter class it is very rare for the epilepsy to be put off 
 for more than one j^ear. 
 
 A distinct aura is present in about five-sixths of the 
 cases, and is consequently far more frequent than in the 
 ordinary idiopathic disorder. When speaking of the 
 etiology of this affection it will be clear to the reader 
 that these conditions are virtually forms of Jacksonian 
 epilepsy so called ; at least, so far as the causative lesions 
 are concerned. 
 
 The frequency with which post-hemiplegic epilepsy 
 
 comes on in the hemiplegia of childhood has been very 
 
 recently studied, and the conclusion reached that its 
 
 occurrence is quite common.^ Thus, in Osier's cases, 
 
 ' Osier, Medical News, July, 1888. 
 
Night Terrors. 81 
 
 20 children out of 97 suffered from it. In tlie 80 cases 
 collected by Gaudard^ 11 children had hemi-epilepsy, 
 and 66 children out of 160 cases collected by Wallen- 
 burg2 were epileptic after hemiplegia. In another series 
 of cases collected by Osier 15 children out of 23 were 
 thus affected. 
 
 Night Terrors. — Night terrors may be divided into 
 two divisions, in the first of which no further nervous 
 changes occur, and in the second of which true epilepsy 
 ultimatel}^ develops. The writer is well aware that the 
 profession, at least in the raajorit}^, generally look upon 
 this condition as entirely separate, and apart from par- 
 taking of an epileptiform character ; but he is equally 
 thoroughly convinced that frequently night terrors may 
 be but an evidence of nocturnal petit mal. He has seen 
 too great a number of cases which followed out to the 
 letter all of the course usually followed by the minor 
 attacks to doubt this for a moment, and he has already 
 pointed out that in nocturnal epilepsy the patient usually 
 forgets the seizure, but remembers the frightful dream 
 which preceded it, showing that a night terror usually 
 occurs even in adults and w^ith completely dcA^eloped 
 epileps3^ There are, of course, certain children who 
 frequently have nightmare from indigestion or a fright 
 experienced during the day, but these are only occasion- 
 ally affected, and comparatively mildly so as regards the 
 concomitant mental disturbance. 
 
 When a child is brought to the phj-sician with true 
 night terrors or nocturnal petit mal, we generally find the 
 following history : The patient goes to bed apparently 
 perfectly well and as bright as usual, sleeps soundly 
 
 * Contribution 1" etude de Hemiplegia Cerebrale Infantile. Geneve, 
 1884. 
 
 ^ Ein Beitrag zur Lehre von den Cerebralen Kindeiiahmungen, Jalir- 
 bucli f iir Kiuderlieilkuude, 1686. 
 
 4* 
 
82 Epilepsy: its Pathology and Treatment. 
 
 until the night has progressed to some extent, and 
 then rises up in bed and utters a shriek of the most 
 heart-rending character, which may or may not arouse 
 the child to consciousness. The eyes are wide open 
 and staring, and show by their widely dilated pupils the 
 severity and intensity of the alarm from which the little 
 one is suffering. The face is generall^^ pale and tearless. 
 The parents as they come to the child are clutched and 
 drawn down to the bed by the frightened little one, who 
 trembles, cries, and refuses to be comforted, often cr3'ing 
 out that it sees some fearful beast, or begs that some 
 distorted image of the imagination be taken away. A 
 horrible, indefinable dread seems to blot out, as fast as 
 spoken, all the quieting, endearing terms of the parents, 
 and even the casual bystander looks about the room 
 for the fearful object to which the child points in so real- 
 istic a manner. Slowl}', amid choking sobs, the child 
 becomes pacified, and passes off into sleep by slow de- 
 grees, interrupted by frequent starts or sighs of a more 
 pronounced character than the others. The restless 
 slumber now deepens, and may last until morning, or be 
 followed by a repetition of the attack in a few hours. 
 The final history of all such cases ends in epilepsy 
 proper, preceded by lack of vivacity or momentary 
 clouding of the intellect during the day as the disease 
 extends from the night to the da3'-time. 
 
 Cardiac Epilepsy. — The possibility of epileptiform 
 convulsions coming on, due to lesions of the heart, has 
 been recognized for a number of years, and interesting 
 contributions have been made on the subject by such 
 writers as Stokes, Thornton, and Blondean, although the 
 literature of the sulyect has not by any means been 
 confined to the pen of these writers. 
 
 It will be remembered that the symptoms of cardiac 
 
Cardiac Epilepsy. 83 
 
 epilepsy are chiefly characterized by a remarkable slow- 
 ing of the pulse, so that the pulse-rate has been known 
 to drop from the normal to not more than five beats a 
 minute, and in a case reported by Thornton^ it was 
 proved by the stethoscope that in the first stage of the 
 attack the heart ceased to beat for many seconds. In 
 some cases the heart's beat can be heard over the apex, 
 but the patient becomes pulseless at the wrist. The 
 respirator}'" movements are generally at first quickened 
 and then become labored, and, perhaps, stertorous. The 
 temperature of the body falls very decidedly, not only 
 during but before the attack, so that the complaint of 
 feeling cold may be the only warning given of an ap- 
 proaching seizure, and this sensation of extreme cold 
 occurring previous to an epileptic convulsion is, in the 
 opinion of several writers, almost pathognomonic of 
 cardiac epilepsy. The color of the face resembles the 
 coloring of au ordinary idiopathic attack, being at the 
 first pale, then red and cyanotic. The convulsive move- 
 ments do not generally assert themselves during the 
 period of unconsciousness, but they may do so, and 
 biting of the tongue has been reported. In some in- 
 stances the heart has been fouiid after death in a state 
 of fatty degeneration, and this, of course, points to a 
 lack of sufficient blood-supply as being the cause of the 
 attack. That the disease is not in every case due to 
 organic failure of the heart is proved by the fact that 
 Charcot has seen such cases occur in which, after death, 
 no cardiac lesions were discoverable. 
 
 The question as to whether the nerve-storm origi- 
 nates in the brain-centres or is only secondarily pro- 
 duced by cardiac failure is one which is solved with 
 great difficulty ; since it is perfectly possible to imagine 
 
 * Trans. Clin. Soc. London, vol. vii, p 95. 
 
84 Epilepsy : its Pathology and Treatment. 
 
 that disordered nervous centres might produce not only 
 an epileptic seizure, but also exert an influence over the 
 heart, as, for example, by sending a powerful impulse 
 along the pneumogastric nerves. Every physiologist 
 knows, too, that cutting off the supply of blood from 
 the brain b}^ the partial ligation of the principal blood- 
 vessels in the neck will produce violent epileptiform con- 
 vulsions, and it has also been proved that the convulsions 
 arising in poisonings from the cardiac depressants, which 
 are epileptiform in character, are due to this cause, 
 namel}^, starvation of the nervous centres, whereby their 
 functions are perverted or set aside. Tiie true cause of 
 the epilepsies, supposabl}' due to cardiac failure, cannot 
 be considered as decided in every case, but it would 
 seem probable that such cases may arise from both the 
 causes mentioned. 
 
 The theory of the production of attacks owing to 
 deficient blood-supply has been greatly strengthened by 
 the recent reports of several observers, notably' the very 
 recent one of Lemoine,^ in wdiich he reports 5 cases of 
 cardiac epilepsy in which valvular disease of the heart 
 existed, and where great amelioration of the symptoms or 
 recovery occurred upon the use either singly or together 
 of such cardiac stimulants as digitalis and caffeine. 
 
 While the cardiac muscle was under the influence of 
 these drugs the epileptic seizures became much less fre- 
 quent, and in some cases entirel^^ disappeared, the only 
 symptoms remaining being vertigo on certain movements, 
 which, however, decreased as the condition of the heart 
 improved. Such evidence as this is of considerable 
 weight, as it strengthens very materially the belief that 
 in many instances the convulsion is due to the cardiac 
 failure. 
 
 * Kev. de Medecine, May 10, 1887. 
 
Epilepsia Frocursiva. 85 
 
 In a case reported by Lebrun^ the symptoms re- 
 sembled those of cardiac epilepsy somewhat in thai 
 there was a slowing of the pulse from TO to 32 beats, 
 with clonic spasm and syncope. After the first attack 
 the pulse never rose above 40 beats, and death followed 
 in a short time. There was no autopsy. Before the 
 attacks there was vertigo, diplopia, epigastric distress, 
 and yellow vision. 
 
 Epilepsia Ppocupsiva. — Epilepsia procursiva of the 
 older writers has within the past eighteen months been 
 studied most carefully by that accurate observer Bourne- 
 ville.2 The disease is one characterized by attacks which 
 consist in a straight or circling run of a variable dis- 
 tance, which is rarely followed by a fall or coma, but b}'' 
 facial congestion. Bourneville classes these cases into 
 those in whom the run is uncomplicated with other forms 
 of seizure, those with a progressive aura, and those in 
 whom there is epilepsy followed by running. He also 
 has studied 25 cases of procursive vertigo. The essay 
 of M. Bourneville is so exceedingly exhaustiA^e that the 
 writer can only refer the reader to the original for 
 forther information, but the following cases occurring 
 in his own practice, one of which is under his care 
 at the present time, are of great interest in this con- 
 nection. 
 
 Jesse , aged 14, is a strong and apparentl}^ liealtli}^- 
 
 boy, of healthy parents. He is a remarkably well-built 
 and manly-looking fellow, of more than the usual height 
 and weight, and well proportioned. His complexion and 
 color is good, and he is notorious at his school for his 
 brightness and acuteness in learning and understanding 
 his lessons. He is not one of those typically "bright 
 
 » BuU. de I'Acad. Roy. de Med. de Belgique, 1887. 
 " Archiv de Neurologie. 
 
86 Epilepi^y : its rathology and Treatment. 
 
 boys," who look as if highly strung, but is perfectly 
 normal so far as his appearance is concerned. 
 
 He was entirely devoid of any morbid condition 
 until just one 3'ear ago, when the first fit took place. 
 The history of his life gives no record which can be in 
 any wa}' considered as a cause of his present trouble, 
 save that when he was about 6 years of age he was struck 
 on the back of his head by another and much larger boy, 
 who had a heavy club in his hand. No unconsciousness 
 was produced, but blood fiowed freely from the wound, 
 the scar of which is still to be seen about 2 centimetres 
 downward and to the right of the occipital protuber- 
 ance. No secondary eff'ects ensued from this stroke, but 
 exactly two years ago he was once more struck while at 
 play on the head, within 2 centimetres of the former 
 scar. The blow felled him to the ground and produced 
 unconsciousness lasting for some minutes. One year 
 ago, almost on the anniversary of this last blow, he 
 was down in the cellar of his father's house, when he 
 suddenly rushed upstairs and sat on the kitchen-table, 
 muttering and moving his legs, and apparently uncon- 
 scious of his surroundings. There was no coma nor 
 headache after this attack, and he seemed perfectly well. 
 The other attacks have since occurred, either once or 
 twice a week, or even less frequently at certain times. 
 
 When they occur in the day-time thej" invariably 
 consist in a sudden run across the room, ending in a 
 fall to the fioor, but there are no spasms when he falls. 
 One week ago he V7as sent to a store for some nails. He 
 entered, asked for the nails, and then suddenly darted 
 out into the street, throwing his money away as he ran. 
 The distance traversed before he was caught was about 
 100 metres. The author of this essay had up to this 
 time never seen him in an attack ; but once, on attempt- 
 
Epilepsia Frocursiva. 8t 
 
 ing to take him before a class of students for a lecture, 
 he immediately had a parox3'sm, precipitated by fright. 
 
 The head was drawn to the left slightl}^, the right 
 shoulder thrown forward and upward, and he assumed 
 the position of one about to start on a foot-race. He 
 was instantly seized by the writer, and used the utmost 
 effort to escape, but the efforts were ineffectual, chiefly 
 because they were lacking in intelligence. The move- 
 ments of the legs, although he was held, were running 
 movements, finally deteriorating into struggles such as 
 those of an angry child trying to break Siway from a 
 parent. The entire attack was accompanied bj'' mutter- 
 ing, and at the beginning of it the saliva poured from 
 the mouth. 
 
 The aura in this case is distinctly visual, and consists 
 in total blindness. Indeed, at the first part of the attack 
 he gropes blindly about for something to clutch. There 
 is no incontinence of urine and faeces. The time of re- 
 turn to consciousness, or, rather, to intellection, is but 
 momentary, and does not last more than sixty seconds. 
 The mental clouding after tlie attack is so slight and 
 transient as to be scarcely noticeable. 
 
 He has had several nocturnal attacks, consisting in 
 turning and twisting in the bed, with muttering, but no 
 running movements. 
 
 The second case was as follows : A girl aged 8 
 years, the child of healthy parents, was brought to the 
 writer by her mother, who stated that the child would 
 occasionally suddenly give a scream, and then dart out 
 of the house into the crowded street and run one or two 
 squares, when she would return to consciousness dazed 
 and unable to find her way home, rather because of her 
 surprise at her new surroundings than an absolute lack 
 of intelligence. At the time spoken of the attacks were 
 
88 Epilepsy: its Pathology and Treatment. 
 
 so frequent that the mother could not perforin her house- 
 hold duties because of the constant watching necessary. 
 In other words, the attacks occurred several times a day. 
 If held so that escape was impossible the girl struggled 
 to get away, but there were no fits of the ordinary char- 
 acter at any time. There was never any coma after the 
 attacks ; no incontinence of urine or faeces. There was 
 no history of any cause of the disease, so far as could 
 be discovered. The mother w\as told to bring the child 
 back in one week, but failed to do so, and all trace was 
 lost of the case. 
 
 Epilepsy Nutans. — Epilepsy nutans is a limited variety 
 of the disease, and has a sudden onset wdiile the child is 
 at play, or the adult is at work. It consists simply in a 
 slight drawing of the head to one side for a moment, 
 followed by a nodding movement, repeated several times, 
 after which the child immediately resumes its play. 
 Like several other forms of epilepsy, its character indi- 
 cates its localized origin in the cortex. 
 
 Epilepsy Loquax. — Epilepsy loquax^ or muttering 
 epilepsy, has been recorded by Cheadle,^ an English 
 writer, and affects the speech-centres altogether, all the 
 rest of the cerebrum escaping. In the 4 cases seen by 
 Cheadle there was a sudden attack, during which the 
 patient simply repeated one word again and again until 
 the paroxj'^sm passed away. 
 
 Epileptiform Migraine. — An irregular and very rare 
 disorder is that known as epileptiform migraine^ several 
 cases of which have been reported. The writer is, of 
 course, aware that migraine and epilepsy are closely 
 associated, but the cases here spoken of are somewhnt 
 different. In these cases there is flexion of the fingers 
 of both hands and numbness of the feet» with violent 
 
 » Brit. Med. Journal, May 1, 1875. 
 
Toxsemic Epilepsies. 89 
 
 pain in the head of a hemicranial character. The tongue 
 feels too large for the mouth, and speech is difficult. 
 When writing is attempted (for consciousness is pre- 
 served), although words are ready to flow, only meaning- 
 less scrawls result. The e^^e-sight grows dim and the 
 pain in the temples increases in violence, these symp- 
 toms being followed by vomiting and deep sleep, from 
 which the patient awakes well. As the attacks go on 
 consciousness becomes slightl}^ dimmed, but is never 
 lost, until the disease is ver}^ far advanced.^ 
 
 Toxaemic Epilepsies. — Such convulsive disorders may 
 arise owing to the presence of a very large number of 
 toxic substances, of which the writer shall only here con- 
 sider a few, as most of them are spoken of most thor- 
 oughly in the sections on etiology and patholog3\ The 
 convulsions of fever differ from the true epileptic attack 
 very slightly indeed. It is only by the history of the 
 patient and by waiting for developments that we can 
 determine which is which, for as soon as the eruption or 
 high temperature of an exanthem occurs the character 
 of the attack is evident. 
 
 Alcoholic epilepsy consists of two distinct varieties 
 produced by overindulgence in intoxicating drinks. In 
 one of these the convulsions are symptomatic of acute 
 poisoning, and come on during a drunken orgy, or imme- 
 diately after a single large draught of liquor. In the sec- 
 ond variet}^ the couA^'ulsion does not originate while there 
 is alcohol in the blood, but in the intervals between the 
 attacks of delirium tremens resultinor from chronic 
 excessive alcoholic indulgence. Under these circum- 
 stances the paroxysms are generally accompanied by 
 hallucinations or by dementia or imbecilitj^ In the 
 alcoholic convulsion the symptoms may closely resemble 
 
 » Such a case is reported by AUbutt, in "Brain," 1883-84, p. 246. 
 
 Da 
 
90 Epilej^sy : its Pathology arid Treatment. 
 
 those of true epileps}^, and not rarely the attack is 
 ushered in by headache, gastric embarrassment, disor- 
 ders of vision, and excessive tremors, or some similar 
 prodrome which ma}^ he looked upon as partaking of 
 the nature of an aura. As a general rule these alcoholic 
 convulsions occur in parox3'sms, — two, three, four, or 
 more, one after the other, at intervals of a few minutes. 
 Not only may grand mal be closely simulated by alco- 
 holic epilepsy, but simple vertigo or true petit mal may 
 exist, either alone or associated with major convulsions. 
 Alcoholic epilepsy is often associated with hallucinations, 
 especially of terror, and not rarely is followed for days 
 by a certain degree of mental disturbance. Rather 
 curiously these cerebral disturbances result rather in 
 suicidal than homicidal tendencies, which is just the re- 
 verse of the insanity following simple epileps3\ It is 
 very important that the reader remember that alcohol- 
 ism in producing epilepsy very frequently produces a 
 permanent nerA^ous disorder which the withdrawal of 
 the poison will not remove. 
 
 The S3'mptomsof ursemic convulsions will be spoken 
 of further when studying differential diagnosis in con- 
 nection with epilepsy. 
 
 Convulaions Produced by Drugs. — As some cases of 
 sudden epileptiform convulsions are apt to result in an 
 official investigation as to their cause, and, as the char- 
 acter of the treatment of the case before death may in- 
 fluence the question of life and death for the accused 
 very greatly, it is well for the ph3'sician to bear in mind 
 that certain drugs when taken in poisonous doses pro- 
 duce very violent epileptic convulsions. This is par- 
 ticularl3^ true of the so-called cardiac sedatives, or de- 
 pressants, such as aconite, veratrum viride, sabadilla, 
 hydrocyanic acid, and one or two similar substances. 
 
Malarial Epilepsy. 91 
 
 Attention will be called to the manner in which these 
 drugs reach this result further on. Suffice it to say that 
 experimental researches have proved that they act by 
 disordering the cerebral circulation. 
 
 The symptoms of epilepsy due to chronic poisoning 
 by lead are chiefly as follow : The man, apparently in 
 his usual health, or who has had for a few days a feeling 
 of weight in the head, or headache, is suddenl}^ seized 
 with most violent convulsions, which are often fatal, and 
 which during their presence resemble ordinary epilepsy 
 so closely as not to be separated from it. They end in 
 coma, and are separated from each other by intervals of 
 nervousness and disquiet. In some cases, one convul- 
 sion follows the other so rapidl}^ that death ensues from 
 exhaustion, but in much more rare instances the attacks 
 may resemble Jacksonian epilepsy very closelj^, and 
 there may be no loss of consciousness. If such a con- 
 dition occur, it is almost sure to be followed by a more 
 violent fit. The attacks are not preceded by any aura 
 whatever, but previous to the headache, already men- 
 tioned, the patient may have had amaurosis, and oph- 
 thalmoscopic examination of the ej^es may show choked 
 disk and neuritis of the optic nerve.^ As a general rule 
 such cases are fatal, but they may recover under careful 
 treatment. 
 
 MalarHal epilepsy is an uncommon disorder, even in 
 countries and regions which are notoriously malarial, 
 but it does undoubtedly occur, particularly in the 
 southern part of the United States and in Brazil. The 
 only cases which the writer can find recorded are by 
 American or English observers, namel3^,Jacobi,2 Payne,^ 
 
 * Norris, Amer. Syst. Pract. MecT., vol. iv. 
 
 2 Hospital Gazette, New York, v, 41—13. 
 
 3 Indian Ann. Med. Sei., Calcutta, 1860-61, vii, 597. 
 
92 Epilepsy: its Pathology and Treatment. 
 
 and Hamilton.! The latter gives bnt a passing- glance 
 at the subject, and the articles of the others the author 
 has not been able to obtain ; so that he knows them solely 
 by reputation. In Hamilton's case, a young man who 
 had lived for many years in an exceedingly malarious 
 region had more or less periodic epileptic attacks, at- 
 tended by great preliminary rise of temperature and 
 intense cong-estion of the face and head. He was un- 
 usually somnolent, and in the intervals frequentl}^ suf- 
 fered from facial neuralgia. Change of the place of 
 habitation and the use of quinine removed the disease 
 entirely. 
 
 Spinal epilepsy, as it has been termed b}^ some writers, 
 really never occurs, but under this heading the writer 
 intends to place those interesting cases first recorded by 
 Charcot, 2 in which periodic epileptic attacks come on in 
 persons suffering from spinal lesions particularly due 
 to compression. Contrary to what might have been 
 expected from the well-known effects of section of the 
 spinal cord on one side in certain animals, epilepsy in 
 man from spinal lesions appears to be very rare, but it 
 does occur. Charcot has seen 10 such cases, 5 of which 
 were due to disease of the cervical part of the spinal 
 cord, produced b}^ compression. As this well-known 
 neurologist has said, these couA^ulsions are really quite 
 separate from those produced b}^ Brown-Sequard in 
 guinea-pigs, for in the latter the movements are limited 
 to the part below the injury, while in the cases recorded 
 by Charcot and others the whole body is affected.^ 
 Herewith is appended a list of several such cases for the 
 
 * Araer. Syst. Pract. Med., vol. v. 
 
 * Lemons sur les maladies du systeme nervenx, series ii. Paris, 1873-77. 
 3 It is to be remembered that this assertion is not borne out entirely 
 
 by facts. I have seen guinea-pigs with spinal hemisection suffer from 
 very wide-spread epileptic convulsions. 
 
Etiology of Epilepsy. 93 
 
 use of those interested, particular attention being paid 
 to the very remarkable case reported by Dumenil, of 
 Rouen. 1 In the following references the spinal lesions 
 were in the lumbar or dorsal cord : — 
 
 Lendet, Arch, de Med, tome i, p. 266. 1863. 
 
 Ollivier, d'Angers' 3d edition, tome ii, p. 319. 1837. 
 
 Killiet and Bartiiez, tome iii, p. 589. 1859. 
 
 Michaud, Sur la Meningitis et la Myelite, p. 50. 
 Paris, 1871. 
 
 Brown-Sequard, Recherche Epilepsie, p. 11. 
 
 Westphal, Archiv f. Psychiatric, p. 84. 1868. 
 
 Etiology of Epilepsy. — As has been said elsewhere in 
 this book, the question as to what is the cause of epi- 
 lepsy has been asked for centuries without receiving any 
 answer of a satisfactory character. Isolated cases or 
 groups of cases have of coarse been explained, as, for 
 example, to a certain extent, the traumatic and reflex 
 disorders ; but the cause of idiopathic epilepsy still re- 
 mains to be discovered, either in its original character 
 or ultimate results. We are, therefore, when dealing 
 with this brauch of the subject, forced to use great care 
 in keeping our judgment unembarrassed in order to ex- 
 clude all unimportant and extraneous points, which have 
 been so apt to retard advancement in the past. 
 
 It is a characteristic of the human brain that when- 
 ever it fails to explain a condition it begins to " beat 
 around the bush " and to invent some hypothesis which 
 has no basis at all, or by means of a species of reason- 
 ing of the post hoc procter hoc character it attemj^ts 
 to fathom unfathomable depths. Scarcel^^ a day passes 
 that the physician is not tempted to carr}" out such a 
 line of argument, often because it seems most natural, 
 and, while in some instances the result may be of a 
 
 * Quoted by Charcot, loc. cit. 
 
94 Epilepsy: its Pathology and Treatment. 
 
 true nature, in epilepsy it is very frequently at variance 
 with facts. Of course such faults are present in the dis- 
 cussion of many diseases, but the very insidiousness of 
 epilepsy not only aids in driving the physician to hypoth- 
 eses, but also renders his argument likely to fall to the 
 "•round. Both patient and physician are often persuaded 
 to accept an opinion which is surrounded by circum- 
 stantial evidence, but which otherwise has no claim upon 
 their consideration. 
 
 A point, whose importance cannot be estimated, is the 
 distinction to be made between indirect and direct etio- 
 loo-ical factors, and this is emphasized when the indirect 
 factors may at times play very important roles. This 
 may be made more clear if an example be given. It is 
 not at all uncommon to find cases of epilepsy in which 
 the patient insists most strenuously that he or she were 
 in perfect health until a certain period, when they 
 received a severe fright or were struck violently upon 
 the head. Almost invariably such persons are persuaded 
 absolutel}^ that this incident is the entire cause of all 
 their suffering, and even infuse the physician with some 
 of their belief that such is the case. 
 
 Now, it is evident that this is true sometimes, and 
 that in many others it is entirely separate from the dis- 
 ease ; it may be the direct or indirect cause, or it may 
 have no connection with the disease save that of coinci- 
 dence. The manner in which these accidents may be- 
 come the direct cause is widely recognized by every 
 writer, and it cannot be doubted that in a certain number 
 of cases organic changes in the nervous system may be 
 thus produced, for we have not only an abundance of in- 
 controvertible evidence of a clinical character, but also 
 of a pathological nature. That the change does actually 
 occur in some instances seems proved by the fact that, 
 
Etiology of Epilepsy. 95 
 
 as a general rule, the first paroxysm does not follow the 
 fright for some space of time, and the longer this is 
 deferred the more distinctly are the attacks epileptic. 
 Whenever a fit comes on immediately it is probably 
 hysterical. We see, therefore, that fright or a blow 
 may be the cause of an attack in one case and not in 
 another. Naturally if two cases have a history of cere- 
 bral injury, and both are epileptic, one is apt to think 
 that the same cause is at work in both instances, but in 
 reality no proof exists that such is the case. In one 
 individual elevation of a depressed fragment of bone may 
 result in a cure ; in the other, even though a depression 
 exists and is removed, no benefit may be reached, 
 because, in the period between the reception of the 
 injury and the first fit, the man has contracted syphilis, 
 which has produced epilepsy, under the cloak of trau- 
 matism, and which is only relieved by mercury and the 
 iodides, or he has a constitutional inherited tendency to 
 epileps}", aside from any extraneous causes. The writer 
 has seen two boys both with adherent and inflamed pre- 
 puces, and both with epilepsy : in one circumcision pro- 
 duced a cure ; in the other this operation was absolutely 
 negative in its results, and it was ultimately found that 
 this case inherited strong epileptic tendencies. 
 
 What the writer has said has not been with the 
 object of rendering any opinion hazardous, but with 
 the idea constantly before him that everything must 
 be closely looked into before it is put down as a causa- 
 tive factor. Keeping this in mind my readers will have 
 no trouble in reaching fairly definite conclusions in 
 every case. 
 
 Returning to the question as to whether fright may 
 really produce organic epilepsy, and the writer has already 
 answered this partly in the affirmative, we find that it 
 
96 Einlepsy : its Pathology and Treatment. 
 
 may do so. Thus, in one case recorded by Wood,^ a 
 child was, at the age of 2 years, taken some distance 
 in a railway train, which frightened it very much, so 
 that it kicked and screamed and finally became convulsed 
 before the destination was reached. Nothing further 
 occurred save that the child showed evidences of 
 arrested development and afterward became epileptic. 
 As it grew older it failed to talk, and died in child- 
 hood. At the post-mortem examination the region 
 of the brain where the speech-centre should have been 
 was found scooped out as if by a knife. In other words, 
 that portion of the gray matter was atrophied as a result 
 of a fright. There was no histor}^ of any character 
 whatever pointing to any other cause for the nervous 
 changes, and the child had been previously a picture of 
 health. 
 
 There can be no doubt of the influence of fright 
 in some instances, therefore ; but even here we do not 
 know but that there had been some subtle change 
 going on which only needed the mental disturbance to 
 ignite the morbid process into flame. If this is true we 
 also find that the severity of the provoking cause does 
 not of necessitj'' bear an}^ relation to the likelihood of 
 producing the disease, provided the unrest of the dis- 
 eased centres is just on the verge of an eruption. A 
 mere peristaltic wave passing suddenly along the intes- 
 tine ma}^ be the necessary spark, and, while this for the 
 moment seems unlikel}', there is good evidence that it is 
 not impossible. Such a cause may bring on a paroxysm 
 in strychnine poisoning with the greatest ease, simply 
 owing to the fact that the reflex centres are in an excited 
 state. 
 
 Passing on to the consideration of the more direct 
 
 ' JServous Diseases. 1886. 
 
Heredity. 97 
 
 causes of the disease we find that several exist, although 
 so far we have oul3^ proof of one or two. Indeed, in 
 many instances of idiopathic epilepsy no cause can he 
 determined, and we are forced to confess, ever}^ now and 
 then, that we are completely baffled and compelled to 
 make a group of cases known as the apparentlj^ causeless. 
 Heredity. — Among the causes which ma3^ be said 
 to be pregnant with epilepsy is heredity, and all ob- 
 servers are so in accord with this statement that it seems 
 almost useless to offer evidence of the truth of the asser- 
 tion. However, the following points, bearing this state- 
 ment out, are of great interest, and properly belong in 
 such an essay as this : Herpin ^ found that in 68 cases 
 seen b}^ him 10 were descended from epileptic parents, 
 and Delasiauve ^ found 33 hereditary epileptics in 300 
 cases of the disease. In Itl epileptics seen by Ham- 
 mond,^ 21 had epileptic fathers, mothers, grandparents, 
 uncles, aunts, brothers, sisters, and 24 had relatives in- 
 sane, hysterical, cataleptic, or suffering from hemicrania. 
 Echeverria,^ in his collection of 306 epileptics, found 
 that 80 had a hereditar}'' tendency, or 26 per cent. ; and 
 Hamilton,^ another American neurologist, goes so far as 
 to assert that 50 per cent, of all the 980 cases seen by him 
 were hereditar3\ In the statistics collected b}- Martin,® 
 Boucher, and Cazanveilh,'' it was found that 19 epileptic 
 parents begat t8 children, of whom 55 died yqvy young 
 and generall}^ in fits. Of the 23 remaining, 15 only were 
 healthy, and they were all ver}^ young ; and this is prob- 
 
 * Pronostic et du Traitement Curatif de I'Epilepsie, p. 325. Paris, 1852. 
 2 Traite de I'Epilepsie, 1851 
 
 * Dis. of Nervous System. 
 
 * On Epilepsy : Anatomo-Pathological and Clinical Notes. New York, 
 1870 
 
 * System of Medicine, Pepper, vol. v, p. 468. 
 
 ® Annales Med. Psycliolog., 1878 Novembre to 1879 Septcmbre. 
 ' Be rEpLlei)sie Consideree dans les Rapports avec Alienation Men tale. 
 
 5 E 
 
98 Epilepsy: its Pathology arid Treatment. 
 
 Vibly the reason why Esquirol and others have failed to 
 find, except rarel}^ a hereditary tendency in the adults 
 examined by them. 
 
 B}^ far the largest number of cases collected by any 
 one writer, so far as the author is aware, are those of 
 Gowers,^ who anal3'zed no less than 1450 cases of epi- 
 leps3% finding that an inherited tendency was indicated 
 by the presence of insanity or epilepsy in ancestors or 
 collateral relations in rather more than one-third of the 
 cases (35 per cent.), and rather less frequently in males 
 than in females, for there was this history in 33 per cent, 
 of the males and 37 per cent, of the females. There was 
 a family history of epileps}^ in two-thirds of the inherited 
 cases, of insanity in one-third, and both disorders in 
 one-tenth of the cases. In the 56 cases recorded by 
 Sieveking - heredity was the cause in 11. Re3'nolds,^ 
 in his collection of cases, found the proportion to be 31 
 per cent., while Nothnagel,* who seems to write rather 
 from memory than from actual figures, agrees with him. 
 Ilasse,® another German writer, has collected 1000 cases, 
 and has found heredity' the cause in no less numbers than 
 the others. If we take the average result of the conclu- 
 sions reached by the clinicians just named, who give 
 exact figures, we find that we have to deal with 4300 
 cases of epilepsy, of whom a little over 26 per cent, 
 were due to heredit}'. It is evident that the transmission 
 from parent to child is most frequent, and, to impress this 
 fact on my readers, let me detail a case reported by Gra}^^ 
 It is that of a married woman aged 40 3^ear8, who began 
 
 • Epilepsy and Other Chronic Convulsive Disorders. London, 1881. 
 - Kpilepsy. liondon. 
 
 ' Treatise on E])ilepsy. TiOndon. 
 
 * Zienissen's Encyclopedia, art. Epilepsie. 
 
 ^ Krankheitcu dcs Nervenapparatcs, Virchow's Handbuch f. Special 
 Patliolo<;io iind Therapie. 
 
 ^ Journal of Mental Science. 
 
Heredity. 99 
 
 at the age of 12 years to have epileptic nttacks about 
 every tliree weeks, in which she saw demons with the 
 right e^'e. She had, after marriage, nine children, who 
 all died as follows :- 
 
 First, a girl, died on the fourth da}^ of life in convul- 
 sions. 
 
 Second, a ho}^, died at 11 months in convulsions. 
 
 Third, a girl, died at 15 months in convulsions. 
 
 Fourth, a boy, died soon after birth in convulsions. 
 
 Fifth, a girl, died soon after birth in convulsions. 
 
 Sixth, a boy, died at 5 months of age in convulsions, 
 having been convulsive all his life. 
 
 Seventh, a girl, died after birth in convulsions. 
 
 Eighth, a boy, died after birth in convulsions. 
 
 Ninth, a bo}^, died after birth in coma. 
 
 Close-questioning failed to elicit ^wy other neurotic 
 family history than that given, and there was no specific 
 history. 
 
 While the writer does not desire to deny in anv way 
 that heredity is a remarkably common factor in the pro- 
 duction of epilepsy, it is his duty to point out that all 
 the writers quoted are not on the same footing as regards 
 what ma}^ be included in hereditnrj^ influences in the 
 parents. Hamilton, who, it will be remembered, found 
 50 per cent, of 980 cases to be hereditary, placed every 
 case in which there was a family history of insanity-, 
 phthisis, epilepsy, cerebral apoplexy, tumor of the brain, 
 or some lesser neurosis, in his list of hereditary cases. 
 This is manifestly wrong, since cerebral apoplexy or 
 phthisis, in reality, has ver3- little to do, as a general 
 rule, with epilepsy in any manner whatever. 
 
 That the inclusion of apoplexy in this list is entirely 
 erroneous is proved b}' the careful investigations of 
 Herpin, who found that the frequency of apoplexy 
 
100 Epilepsy: its Pathology and Treatment. 
 
 nmong the relations of epileptics was positively smaller 
 than ill the population at large. 
 
 However, there can be no doubt that other diseases 
 than epilepsy in the parent may produce hereditary 
 epilepsy. Nearly every writer states tiiis fact, and some, 
 like Hamilton, carry it absurdly far, as, for example, 
 Nothnaoel. 
 
 The ver}^ existence of other forms of nervous dis- 
 ease than those Avhicli are convulsive in character also 
 has an influence on the offspring, but not to such an 
 extent as those with which spasm is associated ; insanity 
 is probably the chief one of these. A neurosis so mild in 
 the parent as to escape notice may blossom out in the 
 offspring into epilepsy, and hysteria, hjqoochondriasis, 
 and catalepsy frequently stamp epileps}^ indelibly upon 
 the children. Migraine is a very common history in some 
 cases; that is, where tlie migraine is really migraine, and 
 not simply severe headache confined to one side of the 
 face. Nothnagel ^ gives a very interesting case, illus- 
 trating this, in which a woman suffering from this dis- 
 ease had an epileptic son and a Insterical daughter. He 
 insists that there was absolutely no other predisposing 
 cause present ; but one can hardly agree with him when 
 he speaks of simple neuralgic pains in the parents as a 
 hereditar}^ excitant of ci)ilepsy, or of mere nervousness 
 as a parental influence, except in a ver3MiKlirect manner.^ 
 
 Just here the question may be asked. What do we 
 mean by lieredity ? It is, when correctly used, a term 
 signifj'ing the transmission of a particular peculiarity, 
 or peculiarities, from parents to their children. On tiie 
 other hand, inherited predisposing factors are more in- 
 
 * Loc. cit. 
 
 ^ Wagner and Striimpel liavc both denied that any relationship exists 
 between the two. 
 
Heredity. 101 
 
 (li recti 3^ at work, and maj^ bear no relation to the pecu- 
 liarity in the child except in a general wa3^ It is to 
 the latter class that all the distant neuroses of these 
 writers should be assigned, for the^- only prepare the 
 system of the child for epilepsy. High-strung, nervous 
 races should by this argument have a larger proportion 
 of epileptics than those of a more phlegmatic character, 
 and every one knows that this is untrue by the statistics 
 which have been published of the prevalence of epilepsy 
 in various nations from time to time, and to which the 
 writer will refer more fully again. 
 
 Within the last two years, however, Marie ^ has 
 written an article strongl}^ combating the idea that 
 heredity is a strong or frequent cause of epileps3\ He 
 believes that the tendency is alwa3^s post-natal, but the 
 writer does not think that his deductions are warranted 
 1)3" his arguments, and they can hardl3" overturn the ex- 
 perience of a very large body of observers. 
 
 Some difference of opinion exists as to whether the 
 mother or the father transmits the epileptic condition to 
 the offspring the most frequentl3^ Gowers and Hamilton 
 both state that the inheritance is more frequently from 
 the mother than the father ; whereas, Nothnagel asserts 
 that there is no such difference, believing that the con- 
 dition is equally transmitted by both sexes. The first 
 of the English writers makes rather ambiguous state- 
 ments, which, owing to his eminence as an authorit3", are 
 herewith quoted, hoping that the reader will be able to 
 fathom his meaning. He sa3^s: "Where there is an 
 inherited tendenc3', the females of a family are rather 
 more likely to suffer than the males. This is due to two 
 circumstances ; the inheritance is rather more frequently 
 from the mother's side than the father's, and more 
 
 1 Le Progres Medical, 18S7. 
 
102 Epilepsy: its Pathology and Treatment. 
 
 females suffer when the heredity is maternal, more males 
 when it is paternal." He then goes on to say that "the 
 inheritance is less frequently from the mother than from 
 the father; but this is due to the fact that insanity is 
 much less common in the mother than in the father; 
 epilepsy is equally common in both." 
 
 It will be seen that this directl}^ contradicts that 
 which has been said by the same writer but a few lines 
 back. 
 
 Sex. — Another point, in connection with the question 
 as to which sex suffers from epilepsy most frequentU', 
 is still undecided, although the statements of each bod}'^ 
 of statisticians include large numbers of cases. Re}'- 
 nolds, in his collection of cases, found no difference in 
 the sexes, as did also Nothnagel and Herpin.^ On the 
 other hand, Gowers, in liis collection of 1450 cases, 
 found that there were 114 females to every 100 males. 
 
 Rather absurd deductions as to the relative frequency 
 of epilepsy among the sexes have been drawn by no less 
 noted observers than Esquirol and Moreau, who ex- 
 amined cases at Bicetre and the Salpetriere. At the 
 first there were 311 epileptic males, and at the second 
 T23 epileptic females. From these facts the}'- deduce 
 the conclusion that epilepsy is more frequent in females 
 than in males, which is incorrect in fact, and is reached 
 by erroneous methods of calculation, as tli^y do not seem 
 to have reckoned the number in each asjlum in respect 
 to their proportion to the population. The onl}'- other 
 figures which the writer has been able to find in regard to 
 tliis point have been collected by Englishmen, and in 
 each instance combat the views of Gowers, Esquirol, 
 and Moreau, placing males as the most common sufferers. 
 
 * It is just to say that while Plerpin uses these words his figures really 
 disagree with those of Gowers, for he found the proportion to be 110 males 
 to 1)0 females. 
 
Phthisis. 103 
 
 Bo3^cP examined 1300 cases, and found among them 
 145 epileptics, of whom one-third more were males than 
 females. 
 
 Althaus^ has also attempted to decide this question, 
 and has examined an enormous amount of statistics to 
 obtain his results. He divides the cases into periods of 
 five 3'ears, as follows, and tlie results are, I think, con- 
 clusive, notwithstanding Gowers's contradiction : — 
 
 Periods of Five Years. Males. 
 
 Per Cent. 
 
 Females. 
 
 Per Cent 
 
 1847 to 1851, 
 
 . 4,479 
 
 1.86 
 
 4,188 
 
 1.74 
 
 1852 to 1856, 
 
 . 5,441 
 
 2.10 
 
 3,998 
 
 1.55 
 
 1857 to 1861, 
 
 . 5,972 
 
 2.41 
 
 5,717 
 
 2.10 
 
 1862 to 1866, 
 
 . 6,585 
 
 2.21 
 
 5,774 
 
 1.96 
 
 1867 to 1871, 
 
 . 6,483 
 
 2.10 
 
 5,805 
 
 1.87 
 
 28,960 2.13 25,482 1.84 
 
 Phthisis. — It has been claimed by those who ought to 
 know that a family histor}^ of phthisis is a cause of epi- 
 lepsy. Among such believers ma}^ be mentioned chiefly 
 English and American writers, for the theory does not 
 seem to be generally received on the Continental side of 
 the channel.^ Hamilton, the American, in the 980 cases 
 collected by him, found 280 were phthisically inclined, 
 owing to parentage ; but he confesses that, as most of his 
 cases occurred among a very tubercular class, his results 
 may be too sweeping for general application 
 
 Even if these results are true it does not prove that 
 such a history is pregnant with epilepsy, but only that 
 he practiced among a depraved, half-starved class in a 
 great city in which consumption and epilepsy might well 
 walk hand in hand. As against these views we have 
 arrayed most of the French writers, as well as the Ger- 
 man and one or two English authors. Nothnagel and 
 
 '■ Asylum Journal of Mental Science, 1875, p. 282. 
 
 ^ Diseases of Nervous System, p. 222. 
 
 ^ Eclieverria, Anstie, Bastian, Savage, and Hamilton. 
 
104 Epilepsy: its Pathologi/ and Treatment. 
 
 Gowers both insist tbnt phthisis has no influence on the 
 disease, and the}^ point out, as the writer has just done, 
 that it is only the association of the two diseases that 
 binds them together. 
 
 Alcoholic Influences. — Another form of hereditary 
 taint in this disease is tlie alcoholic habit in the parents, 
 and here we are brought to another cause of epilepsy, 
 which may be placed under the class of predisposing 
 causes or of heredit}'. It is evident, too, that in this 
 condition epileptic children may result from the insanity 
 of rum as well as the ordinary t^pe of insanity and 
 mental disorder. Unfortunately, the relation of epilepsy 
 to alcoholism does not end here, for the drug may not 
 onl}'- produce epilepsy by inheritance, but directly in the 
 drinker himself. 
 
 As the two subjects are so inseparable they will be 
 considered together. 
 
 The alcoholic beverages which are particularly 
 eflficient in the production of epilepsy are those which 
 combine some aromatic with the alcohol, and of these 
 absinthe is certainly most remarkable in its power. 
 Horsley has found that when it is injected into the veins 
 of a dog or monkey it produces violent epileptic convul- 
 sions, wdiich are eventually followed by death. 
 
 In connection with the influence which alcohol exerts 
 in producing epilepsy directly in the drunkard, it may 
 be said that in nearly all such cases there must be lurk- 
 ing somewhere a tendency toward that form of nervous 
 disturbance which breaks forth under the influence of 
 the alcohol circulating in the blood, or is set going by 
 the depraved state of the nervous sj^stem, the result of 
 frequent debauch. 
 
 Echeverria^ has anal3'zed no less than 572 cases of 
 
 ' Journal of Mental Science, Jan., 1881. 
 
• Alcoholic Influences. 105 
 
 nlcoliolic epileps}', 307 of whom were males fnid 2G5 
 females. Divided into classes he noted that of these 
 212 belonged to the middle or upper classes, 306 to the 
 lower classes, while 108 were uneducated, and 37 w^ere 
 outcasts. Dividing all the 572 cases into three classes, 
 he finds : — 
 
 1. Two hundred and fifty-seven cases could be traced 
 directly and entirely to alcohol as cause and effect. 
 
 2. One hundred and twenty -six cases, in which there 
 was also an associated history of syphilis in 67 and 
 traumatism in 42 as an exciting cause. Of the re- 
 maining number of this group ague was given as an 
 additional cause in 2 males, sun-stroke in 9 males, and 
 the excessive use of tobacco in 1 male. Mental anxiety 
 was also an exciting additional cause in 5 cases. 
 
 3. One hundred and eighty -nine cases, 92 males and 
 97 females, in whom alcoholism w^as the result of the 
 epilepsy, quite as much as the epilepsy was the result 
 of the alcoholism. 
 
 Carrjdng his investigations still further, this observer 
 managed to get a full}^ completed famil}^ histor}^ out of 
 139 cases belonging to the first class and 86 cases be- 
 longing to the third division. Of the 139 of the first 
 class, 92 had alcoholism present, alone or with epileps}', 
 in the parents, while in the 86 cases of division No. 3 
 a tendency was inherited from insane or epileptic parents 
 or grandparents. In 5 families of persons belonging to 
 this class there were congenital idiots. From these 225 
 cases he summarizes as follows : — 
 
 In 39.33 per cent, there was a direct hereditary tend- 
 ency to epileps}'' or to alcohol and epilepsy. Parental 
 intemperance solely originated the predisposition to" 
 epilepsy in 17.30 per cent. Parental intemperance associ- 
 ated with epilepsy or insanity existed in 15.96 per cent. 
 
 6* 
 
lOG Epilepsy: its Pathology and Treatment. 
 
 of the males and 19.24 per cent, of the females, making 
 a total of 11.48 per cent, of the entire number of cases. 
 Parental epilepsy was found in 12.7 per cent, of the 
 males and 15.84 per cent, of the females. If we class 
 together the two preceding kinds of cases we have, re- 
 spectivel}^, a proportion of 20.10 per cent, in males and 
 35.47 per cent, in females. 
 
 Parental insanity and epileps}^ without any history 
 of alcoholism was met with in 4.54 per cent, of the entire 
 number of cases. The reader will note the difference 
 between the percentage of males and females. 
 
 Parental intemperance, not ingrafted into epilepsy 
 or insanitj" without any history of alcohol save in the 
 parents (not grandparents), is 2 per cent, lower in 
 females than in males. 
 
 On referring; to the ao-o;reoate number of cases of in- 
 temperance in the parents, irrespectively put together, 
 there is an increase of 15 per cent, in the males over the 
 females. A preponderance of 3.28 per cent, agaiu on 
 the female side when intemperance is associated with 
 heredity, or insanity appears as the hereditary cause ; 
 and this difference in favor of the females is almost the 
 same in relation to patients sprung from parents tainted 
 with epilepsy. 
 
 Henry Clarke^ has shown that this preponderance of 
 hereditary epilepsy among females rises to a consider- 
 ably greater extent as a predisposing cause of epilepsy 
 and crime, the rates being 66.7 per cent, among females, 
 against 38.1 per cent, among males. 
 
 Returning to the statistics which we have just left we 
 find that, of the 139 epileptics of the first division with 
 hereditar}'- taint, no less than 64 per cent, of the males 
 and 82.2 per cent, of the females suffered from con- 
 
 • Brain, January, 1880. 
 
Alcoholic Influences 107 
 
 vulsions in cliiltlhood, altliougli the}' did not become epi- 
 leptic until after 18 years of age, and then in consequence 
 of intemperance. In most of the 86 cases of the third 
 division who had hereditary taint epileps}" was developed 
 in childhood, or befoi'e 15 3'ears of age; and it is re- 
 markable that every one of these had suffered from fits 
 in childhood, while in addition 14 had left hemiplegia 
 and 3 right hemiplegia and idiocy. Four had wasting 
 paralysis of one arm, 5 palsy of one leg, 4 Pott's dis- 
 ease of the spine, and 5 facial pals3\ Five had stra- 
 bismus and 5 deafness and otorrhoaa, all dating from 
 infancy. 
 
 The chief point in the 67 cases of the second division, 
 complicated with sj'pliilis, is that in 49 of them the fits 
 were followed by palsj'. Mental disturbances were more 
 severe in these cases than in those of pure syphilitic 
 brain-lesion. 
 
 In the third division there are stiL 103 cases to be 
 accounted for, in which the cause was ascribed to head 
 injuries and climacteric change. 
 
 Echeverria states that he saw the worst cases of alco- 
 holic epilepsy amony whisky-drinkers, but he saw none 
 produced by absinthe, probably because it is rarely used 
 in America. 
 
 Drouett ^ has collected 445 cases of alcoholism in 
 males, of which 45 were epileptic from alcoholism alone, 
 while in 87 female alcoholics 9 were epileptic. As to the 
 age most common to alcoholic epilepsy, he finds that 
 below 30 years the proportion is 1 in 15 ; between 30 
 and 50 years it is 1 in 8. 
 
 Moeli 2 has studied the same question in Germany, 
 and reaches the conclusion that alcoholic epilepsy is 
 
 » Annales Med. Psycholoj^'que, 1875. 
 ^ Neurologische Ceutralblatt, 1885. 
 
108 Epilepsy: its Fathology and Treatment. 
 
 common, and that from 30 to 40 per cent, of all persons 
 with delirium tremens are ei)ileptic. 
 
 M. Hippolyte Martin ^ has also collected interesting 
 facts as to the influence of parental intemperance in the 
 production of epilepsy in children. In 150 cases of in- 
 sane epileptics at the Salpetriere he found 83 with such 
 a histor}'. He divides them into two classes, the first 
 comprising 60 cases, or over two-thirds, in which alco- 
 holism in the parents was a certaint}"^, and, second, those 
 in whom such a history was not so clearly defined. 
 
 The 60 cases belonging to the first class had 244 
 brothers and sisters, of whom no less than 48 were 
 aflfiicted with convulsions in early infanc}'. One hundred 
 and thirtj'-two were dead in 1874 and 112 still living, 
 nearly all of them 3'oung and nearly all with damaged 
 nervous organizations. Of the second class there were 
 83 brothers and sisters, of whom 10 were epileptic and 
 46 still living. These figures do not include the patients 
 themselves, and all the cases were from different families. 
 When we summarize, we find that, in 83 families with 
 410 children, 108 were epileptic, or more than one-fourth. 
 In 1874, 169 children were dead and 241 living, but 83 
 of these were epileptic, or more than one-third. Martin 
 also gives the causes of death in the parents, in a num- 
 ber of cases, to show that no hereditary tendency save 
 the alcoholism existed to produce epilepsy. They are 
 as follow : — 
 
 Apoplexy, 15. Suicides, 4. 
 
 Heart disease, 5. Hysteria, 5. 
 
 Thoracic disease, 6. Cancer, 7. 
 
 Insanity, 7. Dropsy (?), 1. 
 
 Chagrin (?), 1. 
 
 An interesting case, which, to the author's mind, 
 indicates disease followed by alcoholism rather than 
 
 • Annules Med. rsychologique, January, 1879. 
 
The Influence of Age. 109 
 
 alcoholism followed by disense, is one recorded by 
 Bourneville and Baiimg:irten ^ of fi child aged about 4 
 3' ears. Tliere was marked alcoholism, produced by large 
 quantities of wliite wine, for about one 3'ear before the 
 attack of epilepsy, but at the autopsy there was found a 
 softened condition of the brain and destruction of tlie 
 cortex, the result of meningo-encephalitis. The cunei 
 wxre ver^' small, blindness having been present for some 
 months. Microscopical examination revealed sclerosis 
 of the p^a-amidal ganglion-cells, most marked in the 
 cortex in the occipital region. 
 
 Consanguinity. — The effect of consanguinity is be- 
 lieved generally not to be a powerful one, and in this 
 connection it may not be out of place to mention the 
 statistics of Bemiss,^ who finds that in 31 children born 
 of brother and sister there was I -epileptic. Of 53 chil- 
 dren born of nncle and niece, or aunt and nephew, there 
 was 1 epileptic. Of 234 children born of cousins, them- 
 selves the offspring of kindred parents, 4 were e[)ileptic. 
 Of 154 children born of double cousins 2 were epileptic. 
 Of 2778 children born of first cousins 44 were epileptic. 
 
 The Influence of Age. — If there is one point upon 
 which all neurologists are agreed, it is the influence of 
 age upon the disease we are considering. 
 
 According to the writers whom we have just quoted, 
 when speaking of heredit3% three-fourths of all cases of 
 true idiopathic epilepsy begin under 20 years of age, 
 and nearly half of all cases between 10 and 20, the great- 
 est number being at 14, 15, and 16. One-eighth of all 
 cases begin during the first three 37ears of life, but after 
 20 the numl)er falls very low. The females in these cases 
 exceed the number of males in the first ten years b^^ 6 
 
 » Le Pro;?rf'S Med., 1887. 
 
 "^ Medico-Chiiurgical Review, July, 1860. 
 
110 Epilepsy: its Pathology and Treatment. 
 
 per cent., in the second ten 3^eavs by 18 per cent., find in 
 tiie third ten years by 12 per cent. After 30 years the 
 relation is reversed, and the excess of males gradually 
 increases, until, after 60, the malady practically occurs 
 only in males. The following are Gowers's figures in 
 1450 cases : — 
 
 Undei* 10 years, 
 
 " 10 to 19 years, 
 
 " 20 to 39 " . 
 
 " 30 to 39 " . 
 
 " 40 to 49 " . 
 
 " 50 to 59 " . 
 
 " 60 to 69 " . 
 
 " 70 to 79 " . 
 
 422 
 
 cases 
 
 655 
 
 
 224 
 
 
 87 
 
 
 31 
 
 
 16 
 
 
 4 
 
 
 1 
 
 
 In the cases reported by Hamilton the proportion to 
 each a<2:e was as follows : — 
 
 
 Females. 
 
 Males. 
 
 Total 
 
 Under 10 years, 
 
 . 103 
 
 95 
 
 198 
 
 Between 10 and 20 years. 
 
 . 171 
 
 97 
 
 268 
 
 " 20 and 30 " 
 
 . 145 
 
 92 
 
 237 
 
 " 30 and 50 " 
 
 . 81 
 
 136 
 
 217 
 
 Over 50 years, 
 
 . 11 
 
 49 
 
 60 
 
 611 469 98(' 
 
 Of 1288 cases collected by nine French authorities, 
 in 486, or over one-third, the disease began between the 
 tentli and twentieth years. Hasse,! in the 1000 cases 
 collected by hiin, found that 75 per cent, of the i)atients 
 were at the onset under 20 years of age. According to 
 the German, Nothnagel, the great mnjority of cases 
 occur between 7 and 17 years, not onl}^ in hereditary 
 epilepsy, but also in the other forms. 
 
 On analysis of the 970 cases collected from literature 
 by the writer, he found that the following results were 
 to be reached : — 
 
 * Kranklicitcn dcs Ncrvcnapparat., \'irclio\v's llandbuch f. Spec. 
 Path, und Therap. 
 
Mino7' Causes. Ill 
 
 From birth to 10 years, . 
 " 10 years to 20 years, 
 '' 20 " to 30 " 
 " 30 " to 40 " 
 " 40 " to 50 " 
 
 Above 50 years, 
 
 57 
 
 cases. 
 
 202 
 
 
 223 
 
 
 171 
 
 
 93 
 
 
 47 
 
 
 The oldest case was 81 j^ears of age. 
 
 These results place the largest number of cases be- 
 tween 20 and 30 j^ears. The real boundary of frequency 
 is from 15 to 30 years. 
 
 It has been denied that epilepsy, not due to trauma- 
 tism or brain-tumor, ever occurs in old age, and, while 
 the writer has never seen such a case, there is abun- 
 dance of clinical testimony as to the falsity of the asser- 
 tion. Gowers has seen it begin at 65 and 71 years, 
 and Reynolds at 70. Heberden also records a case at 75 
 years. In Gowers 's cases only about 2 per cent, began 
 after the fortieth year, and about 5 per cent, after the 
 thirty-fifth year. A A'er}^ well known writer on nervous 
 disease, Dr. H. C. Wood, italicizes these words : " An 
 epilepsy which develops after 35 years is not idiopathic, 
 but is due to some organic brain disease, to the abuse of 
 alcohol, reflex irritation, or other causes, which, in some 
 cases, may be so hidden as to be exceedingly difficult 
 of recognition." The same authority also states that 
 epileps}^, in his experience, after 35 years has, in 80 per 
 cent, of the cases, been due to syphilitic brain disease. 
 According to some authors the climacteric period is fer- 
 tile in the development of epileps}^, but no evidence has 
 been adduced of the proof of this. 
 
 Minor Causes. — Passing on from what may be con- 
 sidered the influential factors in all diseases, namel3', jige 
 and sex, to the various causes, both great and small, 
 which are productive of epilepsy, the writer will briefly 
 go over the minor or more anciently relied upon factors, 
 
112 EinJex)^]! : its raihology and Treatment. 
 
 and then spenk of those which at the present (\n.y are 
 more commonl}- received as really of importance. Among 
 the older observers, Ettraueller and Senac hiid grent 
 stress upon sexual excesses, but it is extremely doubtful 
 if this is often the cause unless other more powerful agents 
 assist it. In a number of cases, where it is carried to 
 great extremes, some nerve-failure may occur, particu- 
 larl}^ where there is a tendenc}^ to an epileptic condition. 
 In those instances where the sexual excesses take the 
 form of masturbation, the demoralizing influences, 
 coupled with general weakness of intellect, may also pre- 
 dispose to the atfection. It has been shown, to be sure, 
 that the first seizure has come on immediately^ after or 
 during coitus ; but this fact has, of course, no connection 
 with causation except Avhen the nervous exaltation of 
 the spinal cord excites reflexly the cranial centres. In 
 respect to the influence of masturbation, Herpin^ has 
 iwinted out that the prevalence of this A'ice must, to a 
 very large extent, prove it to be a rare causative factor 
 in producing epilepsy. NothnageP has only seen one 
 such case, and Echeverria calls attention to the fact that 
 masturbation is often resorted to after the i)erson be- 
 comes epilei)tic, although the attacks ma3'' have been so 
 long unknown, as in nocturnal epilepsy, ns to have 
 escaped attention. Contrariwise, Tissot^ and some 
 others believe that sexual continence may also result in 
 ei)ilepsy. Ilerpiu'* is also of this opinion, but limits it to 
 the female sex, while Radclifle® agrees with Tissot. The 
 writer does not think at the present time that much re- 
 liance is, or will be, placed on such opinions, and Iler- 
 
 * Du pronostic et du traitoinent cniatif dc I'epilepsie. Paris, 1852. 
 ' Ziemssen's Encycloped., art. Epilepsy. 
 
 ' Traite de I'f^pilepsie. Lausanne, 1790. 
 
 * Du i)ionostic et du traiteinent curatif de Vepilepsie. Paris, 
 
 * Ei»ilep.sy and AHied Disorders. Loudon. 
 
Minor Causes. 113 
 
 pill's argument against the tlieor3'' that masturbation is 
 a cause applies equally well here, with even greater force, 
 for the number of females Avho are not epileptic, but 
 who are sexuall}^ continent is, we hope, far be3'ond the 
 number of female epileptics from every cause. It is 
 probable that these views originally arose by reason of 
 the hysteroid convulsions which may frequently arise 
 from such causes. 
 
 Scrofalosis and rachitis have been held on high au- 
 thority as important factors in causing epilepsy b}^ the 
 celebrated English clinician, Anstie ^ who claims that 
 " active hereditary nervousness " is often so produced, 
 resulting ultimately in very much more violent disturb- 
 ances ; and Echeverria also agrees with him to a certain 
 extent, stating that if the ])arcnts are pale and badly 
 nourished the children ma}^ be epileptic. This evidence 
 is, however,., very far from receiving any general con- 
 firmation, and there is no reason for believing that epi- 
 lepsy is more frequently the result of these maladies than 
 man}^ other affections, save in the fact that, by producing 
 asj^mmetry of skull, cerebral changes may develop. It 
 should be added that Hasse,^ who was a most careful 
 investigator, also supports the views of Anstie. 
 
 Fright produces its effects in either sex probably 
 with equal frequency before puberty, biit much more fre- 
 quently in females than in males after pubert}'. This 
 becomes the more readily understood w^hen we remember 
 that, as a general rule, emotional causes are important 
 in women, less important in men, with the notable ex- 
 ception that men, being more exposed, more commonly 
 suffer from the effects of prolonged mental anxiety. 
 
 ' Journal of Mental Science, 1873. 
 
 ^ Kranklieiten des Nervenapparat., Virchow's Handbuch f . Spec. 
 Patliologie and Therapie. 
 
 E2 
 
114 Epilepsy: its Pathology and Treatment. 
 
 Indeed, where the disease occurs late in life this should 
 be remembered as a cause. 
 
 Cases, too, have been recorded by several observers 
 in which epileptic attacks developed late in life as the 
 result of operative procedures against bleeding haemor- 
 rhoids, whereby cerebral congestion resulted, 
 
 Of all diseases which may result in epilepsy, either 
 by hereditary taint or hy acquirement, syphilis, as every- 
 where, stands prominently in the foreground. This dis- 
 ease may joroduce epileps}^, of course, in two wa3's : 
 either by producing morbid brain-growths or by so in- 
 fluencing the cells of the cerebrum as to cause epileptic 
 convulsions. Under such circumstances the disease 
 very frequently bursts forth at an unexpected moment, 
 and is commonly of great severity. It is during the 
 second stage of syphilis that it commonly comes on, 
 and in such instances we generally find, on inquir3^,that 
 the ordinary eruption of syphilide has failed to appear. 
 Fer contra^ w^e seldom see nervous syphilis where tlie 
 ravages of the disease have been superficial ; that is on 
 the skin. 
 
 It is interesting to know that, while simple heredi- 
 tary epilepsy is more common than the acquired, this is 
 not so with syphilitic epileps^^, for an analysis of a series 
 of cases shows that congenital syphilis is more rarely 
 complicated by epilepsy than the acquired s\'philis. 
 Thus, in 618 S3q)hilitic epileptics Echeverria ^ saw only 
 t congenital syphilitic epileptics. 
 
 One of the curious things which we note as we look 
 back over the literature of this disease is the confidence 
 of each writer that he has discovered the great and only 
 provoking cause of cpileps}^ In some instances this 
 
 * True, liyon Meil., xlviii, 1885. 
 
 ' Journal of Mental iSciencc, July, 1880, p. 165. 
 
Mejlex Epilepsy, 115 
 
 re.ill}'- becomes amusing -were it not that tlie subject is 
 too important to be laughed at. 
 
 Thus, Lasegue^ la^'s the greatest stress upon cranial 
 malformations as a cause of this disease, going so far as 
 to assert that epilepsies not dependent on osseous 
 troubles are not epilepsies at all. Indeed, Lasegue is 
 be3^ond patience in his arbitrary method of statement, 
 for it will be remembered that, when speaking of his 
 work, and that of Garel, under the subject of symptoms, 
 *it AYas shown that such investiorations as those on which 
 he based his claim were at least open to great fallacies. 
 Lasegue, further, asserts that all the convulsions are 
 identical; that is, never hereditarj^, and that the attacks 
 are alwa^^s in the morning if the disease be t3'pical. 
 Where cranial malformations are a cause they probably 
 exert all their influence before the eighteenth 3'ear at the 
 latest. 
 
 Reflex Epilepsy. — An exceedingly important question 
 has arisen among ph3^sicians as to the character of the 
 so-called " reflex epilepsies," some claiming that they 
 are no more a part of true epilepsy than are those 
 of toxaemia or kindred conditions. Perhaps no more 
 forcible upholder of this belief can be brought forward 
 than Reynolds, 2 who vehemently denies that they are a 
 variety of the true epilepsies as recognized at the present 
 da3\ It will be remembered that the term " reflex epi- 
 lepsy " is used to signify' a convulsive condition in every 
 way similar to the ordinary epileptic convulsion, but 
 Avhich arises b}-" reason of nervous irritation occurring 
 not primarily in the higher motor centres, but in the 
 peripheral nervous apparatus, such as that caused by 
 the involvement of certain nerve-filaments in a cicatrix, 
 
 * Annales Med. Psychologique, September, 1877. 
 ^ Epilepsy. London, 1861. 
 
116 Epilepsy: its Pathology and Treatment. 
 
 either new or old, or by an inflamed prepuce or bowel. 
 lb should also be kept in mind that the term " reflex 
 epilepsy " is only used to designate a condition of the 
 nervous system in which repeated convulsive attacks 
 have occurred for a long period of time, and does not, 
 as generally emplo3ed, signify that form of nervous dis- 
 turbance shown occasionally during the eruption of a 
 tooth in a child. Russell Reynolds's^ position is defined 
 by his own words: " Epilepsy should be regarded as an 
 idiopathic disease, i.e., a morbus per se, which is to be 
 distinguished from eccentric convulsions, from toxoemic 
 convulsions, from the convulsions occurring in connec- 
 tion with organic changes in the cerebro-spinal nervous 
 system, and from every other known and recognizable 
 disease." Notwithstanding this assertiou, the same 
 author a little farther on is forced to acknowledge that 
 reflex irritations may occasionally not onl}^ produce 
 simple convulsions, but even true epileps3\ He defines 
 his position still more clearly by pointing out that in 
 ^' reflex epileps}^ " " a condition of increased irritability 
 in the reflex centre " has been set up, whereas in the true 
 disorder this morbid condition " has acquired an exist- 
 ence of its own, and the exalted irritability thenceforth 
 depends upon an altered nutrition, which continues even 
 after the removal of the original eccentric source of irri- 
 tation. It will at once be seen that the border-line be- 
 tween these two conditions is very ill defined pathologi- 
 cally, and the writer hopes elsewhere to show that a 
 peripheral lesion may cause just such central changes 
 as Reynolds believes to be necessary for the presence of 
 real epilepsy. It must constantly be borne in mind that 
 we are discussing in epilepsy a chain of symptoms, ex- 
 pressing some more or less tangible nervous change, 
 
 ' Loc. cit., p. 33. 
 
Reflex Epilepsy. 117 
 
 wliicli in some of its forms is as yet unknown to us. The 
 whole weight of Rej^nolds's opinion virtiiall}^ rests upon 
 the ability of the medical attendant to demonstrate some 
 irritation, and the diagnosis is one of epileps}^, or con- 
 vulsions of another type, according to his capability of 
 judgment. The author quite agrees with Kothnagel ^ 
 that this theory cannot be accepted simply because, in 
 the light of our present knowledge as to reflex degen- 
 erations, we cannot denj- their occurrence, at least under 
 other circumstances, although we have not as yet micro- 
 scopical knowledge in this particular instance. The laws 
 of reflex action, so ably put forth by Pfliiger, and which 
 are universally received, fully explain how these irrita- 
 tions ma}^ result. Further than this, the mere temporary 
 irritability of a cicatrix does not throw the patient into 
 convulsion after convulsion immediatel}', but the con- 
 vulsive condition having once been begun b}' such a 
 cause may be brought back even when no irritation 
 longer exists, of an acute form, by some central disturb- 
 ing mental condition entirely separated from the i:>eripli- 
 er}". The law may be laid down as an almost unvarying 
 one that every nervous act is followed by other similar 
 nervous acts, rapidly or slowly, according to the severity 
 and frequency of the first acts, and if this predisposi- 
 tion be once set up the subsequent acts may readily be 
 excited by agents which primarily would have produced 
 no effect. 
 
 This has been remarked upon by Fere,^ who states 
 that neurotic children may have an ordinary convulsive 
 attack, which, when repeated, may finally become true 
 epilepsy, and that the eclampsia of scarlet fever may 
 end in a like manner. Fere even believes that the 
 eclampsia of pregnancy may so result in some cases, 
 
 ' Loc. cit. ^ Arch, cle Xeurologle, 1885. 
 
118 Epilepaij : its Pathology and Treatment. 
 
 and he speaks of '' epilepsies eclamptiques " as a variety 
 of the disease in whicli a single convulsion comes on as 
 the result of great excitement, and which may become 
 permanent or transient. 
 
 Again, it is to be pointed out that the epileptic seiz- 
 ure often has no relation whatsoever to the degree of 
 irritation present at the time. To be sure, this binds 
 one to the doctrine that in every instance of reflex epi- 
 lepsy organic central changes take place, and if one as- 
 sents to such a belief, then it is asked why the removal of 
 the peripheral irritation in many cases cures the disease. 
 The answer is that in these cases the peripheral lesion 
 has not existed long enough or been violent enough to 
 produce such changes in the central nervous system as 
 to place it be3^ond the realm of rcover}^, and that in 
 many instances where the removal of an irritation fails 
 to produce a cure it is the lateness of the operation that 
 permits of too great central change to be remedied by 
 nature's power. Very commonly, the removal of the 
 irritation is not followed by an immediate and complete 
 remission of the seizures, but they occur at more and 
 more irregular intervals until they cease, showing that a 
 central change or tendency to convulsive explosions 
 must have been set up. The writer is exceed in gl 3^ de- 
 sirous that the fact alreadj^ stated be remembered, 
 namely, that the very occurrence of one nervous act 
 predisposes to a similar act at some future period. 
 
 It is now man}'' j^ears since the possibility of adherent 
 prepuce producing epilepsy was first brouglit forward, 
 and there can be no doubt of the truth of the assertion 
 that the removal of this redundant skin and mucous 
 membrane is accompanied by a cure in some cases. It 
 has been claimed by some writers, however, that the con- 
 vulsions in all cases have been hysterical in character, 
 
Bejlex Epilepsy. 119 
 
 and have been cured by the shock of the operation rather 
 than by the removal of a peripheral irritation. There can 
 be no doubt that in this belief there is a certain element 
 of truth, even though the convulsion be not purely hys- 
 teroid in type, but it is far more absurd to ascribe the 
 sliock as the chief means of cure than to deny entirely 
 that it has any influence. In the first place, the removal 
 of an adherent or inflamed prepuce produces benefit in 
 cases where the slightest hysterical symptoms are absent, 
 and also in cases where the entire atmosphere of the 
 case forbids such a possibility. Every one has seen cases 
 of young children of no more than a 3^ear, in whom the 
 presence of true hysteria was not to be thought of, 
 pass day by day into a greater state of nervous strain, 
 which finally ruptures into a well-defined epileptic 
 attack, and in whom the removal of the prepuce, when 
 it has been found inflamed, produces a complete cure, 
 either when tlie child has suffered till it is 2 or 3 j^ears of 
 age or as soon as the physician has been quick enough 
 to perceive the cause of the trouble. The writer has 
 himself relieved a case as early as the eleventh month 
 by such an operation. The same results are frequently 
 reached by similar operations upon persons of much 
 more advanced age, particularly if the exciting cause is 
 recognized so early that the disease has not become 
 chronic. Every one will agree that the relief obtained 
 by circumcision is in direct proportion to the j^outh of 
 the sufferer and (if one may use such an expression) the 
 youth of the disease. 
 
 It is also fortunately true that such seizures are most 
 commonly among 3^oung boys below puberty, while they 
 are exceedingly rare among men for the reasons men- 
 tioned elsewhere. In young children, also, smegma and 
 small quantities of urine frequently are allowed to re- 
 
120 EpiJc2)<^y : its Pathology and Treatment. 
 
 m;iin unnoticed behind the foreskin, which, in the adult 
 who is careless, soon call his attention to the part by 
 reason of the inflammation produced. It should be a 
 routine practice with ever}' practitioner to examine care- 
 full}^ the penis of ever}^ male child brought to him with 
 epileps}', particularly during early youth. 
 
 Closely allied to the reflex epilepsy of preputial irri- 
 tation is that supposed to arise in females from similar 
 irritation of the clitoris or vagina. Necessarily, such 
 cases are exceedingly rare among children, but become 
 more common as the period of puberty is approached, — 
 in some cases by reason of the changes occurring in the 
 parts, in others by the carrying out of pernicious prac- 
 tices whereby mechanical irritation results in a chronic 
 inflammation. It will be seen, therefore, that reflex epi- 
 lepsy from the clitoris is more common about the ages 
 of 10 to 15 than that produced in boys about the age of 
 5 or 6 by penile irritation. 
 
 It also becomes equally evident that in the girls the 
 hysterical character of the seizures may be much more 
 strongly developed, owing to the age, sex, and original 
 cause, since in masturbating girls the h3'sterical condi- 
 tion is either present as a cause or result of the self- 
 abuse, in many cases. As he writes a case comes before 
 the author of a girl of 18 j-ears, of a typical hy steroid 
 appearance, but well developed mentall}-^ and physically, 
 in whom the tendency for self-abuse was so strong that, 
 after all other measures had been tried, the operation of 
 oophorectom}" was performed with the hope of curing 
 the desire, which, in its frequent gratification, produced 
 such an increase in the hysterical seizures as to border 
 on true epileptic convulsions. The operation did not, 
 however, remedy the evil; at least, while she remained 
 under observation. 
 
Reflex Epilepsy. 121 
 
 A condition of the clitoris which is very rare, but 
 which has been supposed to produce epilepsy, is elonga- 
 tion of that organ to such an extent that it is constantly 
 in contact with the patient's clothes, and gives rise to 
 sexual desires which cannot be satisfied, or becomes 
 excoriated by the rubbing of the clothes wet with 
 vaginal discharges, even though they be of normal 
 character. For the irritation of masturbation, or that 
 last mentioned, clitoridectomy has been proposed and 
 tried to a limited extent ; at least, in this couiUry. The 
 oases have been so few that it is scarcely possible to 
 draw conclusions from the results obtained, even when 
 the cases reported from all nations are sought out. 
 
 The writer has already referred to the reflex irritation 
 caused by vaginal irritation due to the escape of the oxy- 
 uris vermicularis from the rectum into the vagina. In 
 many cases the local inflammation is so severe that atten- 
 tion is at once called to it, but in other instances the signs 
 are by no means connected with tlie seat of the disease, 
 and consequently pass hy unnoticed. It may be laid down 
 as a fact that in all cases in girls in which epileps}^ of 
 unknown cause develops the vagina should be examined, 
 and if the history is one showing the presence of worms 
 this becomes most essentially a part of the search after 
 health. 
 
 Perhaps no form of reflex peripheral irritation pro- 
 ducing epileptiform seizures has been so commonly 
 sought after and relied upon as that due to intestinal 
 indioestion or intestinal worms. The first has rather 
 been looked upon as the cause of isolated convulsions 
 occurring in nervous children ; the second has, while 
 partaking in this belief, been generally considered to 
 produce more frequent discharges of nerve-force, or, in 
 other words, repeated seizures. That indigestion may 
 
 6 F 
 
122 Epilepsy: its Pathology and Treatment, 
 
 
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Eejlex Epilepsy. 123 
 
 set up either isoliitecl or frequent attacks is without 
 doubt true, and it is even possible that thi« may give rise 
 to an epileps}^ lasting a life-time, for, as has aready been 
 said, every nervous act is followed b}^ its duphcate, if 
 sufficient cause exists. The following case from the 
 writer's note-book illustrates this very well : — 
 
 A. E., girl, aged 7 years, was brought to me by her 
 mother, who stated that she suffered from epilepsy of 
 an irregular type, which occurred seemingly without 
 cause. 
 
 During the few weeks preceding her visit convul- 
 sions had occurred as commonly as three or four times 
 a week, which, from the description of the mother, were 
 evidently epileptic in form. Previous to this no seizures 
 had occurred for some months, the first attack having 
 taken place at about the age of 4 years. The child was 
 put upon the routine treatment of bromide of potassium 
 with only slight amelioration of her symptoms. After 
 a few days the mother returned, and it was discovered 
 that the father had of late been in the habit of feeding 
 the child, giving it any of the food on his own plate that 
 the child desired. It was also discovered that corned 
 beef was frequently eaten by the father and as eommonl}^ 
 by the patient, and that the nervous disturbance gener- 
 ally followed its ingestion. For the sake of convincing 
 the parents that this was the cause of the trouble, they 
 were ordered to feed her for two weeks on only bread 
 and milk and corresponding articles of diet, and after 
 that to give her an ordinar}^ amount of corned beef. 
 The result was another convulsion. Without occupying 
 more space \)j a further account of the case, it may be 
 added that recovery with no return of the fits occurred 
 upon careful regulation of the diet and attention to the 
 digestion, the only fit following being one two months 
 
124 Epilepsy: its Pathology and Treatmeiit. 
 
 later, when, owing to the absence of tlie mother, a rela- 
 tive gave the child some indigestible food. The case 
 just cited is but an evidence of the fact that, apparentl}', 
 true epilepsy may be produced by ver}^ easily removed 
 causes. 
 
 The convulsions of 3^oung children occurring under 
 conditions of indigestion are, while epileptiform in char- 
 acter, scarcely true epileps}^, and their treatment may 
 resolve itself simply?- into the prevention of the ingestion 
 of harmful matters and the use of nervous sedatives 
 when the crisis is at hand. 
 
 Ovarian irritation has been accused of exciting true 
 epilepsy, and in a limited number of cases it is, of course, 
 a real cause, which can only be removed by a radical 
 operation. 
 
 Still another cause has recently been prominentl}'" 
 brought forward in America by Dr. Stevens, of New 
 York, and Dr. A, H. Thomas, of Philadelphia, viz., epi- 
 lepsy the result of strain and consequent reflex irritation 
 of the muscles of the eye, and they have devised an 
 operation closely allied to that ordinarily used in the 
 C(ninection of strabismus with asserted good results, 
 liather curiously, the writer has himself seen a patient 
 on the Continent who, although operated on by Dr. 
 Thomas in America, experienced relief for only a few 
 months, and is now almost as frequently and severely 
 attacked as before. 
 
 Disease of the external or middle ear may in some 
 cases be associated with reflex epilepsy, entirely inde- 
 pendent of an 3^ direct involvement of the brain itself. 
 Tlius, Moos^ reports a case of middle-ear disease resnlt- 
 ing in epileptic seizures, and traces the inflammatory 
 irritation along the tympanic plexus, and thence to the 
 • Allgem. Zeitsclirift f. Psychiatric, xxxii, 5. 
 
Eejlex Ejniejjsy. 125 
 
 brain. A large number of such instances are recorded 
 elsewhere by other writers. 
 
 Quite an elaborate research on the relation of epilepsy 
 to ear disease, when the latter acts as a causative factor, 
 has been carried out by Boucheron,^ and, while it is far 
 too long to be quoted here to an}^ extent, the results are 
 sufficiently interesting to be recorded. 
 
 1. Epileptic attacks occur in infants during the evo- 
 lution of the auricular affection which results in deaf- 
 mutism. 
 
 2. They occur in childhood during the course of 
 various affections of the ear. 
 
 3. In adult life they occur from the same causes, or 
 in other cases the trouble may reside in ^stoppage of the 
 Eustachian tube. 
 
 Boucheron also points out that epilepsy may be pro- 
 duced in dogs and cats hy the presence of foreign bodies 
 in the ears. 
 
 A research by Ormerod^ has also reached some- 
 what similar conclusions, for he tested the ears of 200 
 epileptic patients, and found that 31 of them had a 
 previous history of suppurative otitis, past or present. 
 As a counter-study he examined 100 patients with ear 
 disease for epilepsy, and found 7 cases. It will be seen 
 that this percentage is very high, for Niemeyer^ placed 
 the proportion of epileptics to the population of a country 
 at 7 per 1000, which is also absurdly high, as will be 
 shown later on. 
 
 Yery much more recently Boucheron * presented a 
 paper in which he characterizes the epilepsy of this 
 variety as consecutive to a direct action upon the auditory 
 
 ' Revue de The'r. Me'd. Chir., September 1, 1886. 
 « Brain, 1884, p. 37. 
 
 * Practische Med., art. Epilepsia. 
 
 * Societe Frangaise d'Otologie et de liaryngologle, April 27, 1888. 
 
126 Epileps]/ : its Pathology and Treatment. 
 
 nerve. He quotes Noquet, who observed a deaf-mute 
 atfected with tinnitus and epileptic attacks, who was 
 cured by Politzer's inflation of the t3^mpanum, and he 
 states that certain epilepsies can originate from com- 
 pression of the cerebral convolution where the auditory 
 nerve originates. 
 
 Galezowski ^ has reported a case of epilepsy due to 
 the reflex irritation produced by inflammation of the 
 stump of an optic nerve after the eye had been removed. 
 
 One could go on mentioning peripheral irritations 
 producing epileps}^ almost indefinite!}^, but the writer 
 will call attention to only one or two. Brubaker ^ has 
 reported 18 cases of epileps}^ purel}^ due to the presence 
 of carious teeth, and Schwartzkopff ^ has reported a 
 very interesting instance. Liebert records 3 cases of 
 this character, in every one of which the aura was re- 
 markable in that it consisted in a cramp of the muscles 
 of the tongue or involuntary movements of that organ. 
 Each case was cured by the removal of a carious tooth. 
 Baly,* Booth, ^ and Hamilton^ have done likewise. 
 
 Ross ^ reports a case where gall-stones produced the 
 disease reflexly. 
 
 Some of the other peripheral causes are stenosis of 
 the uterine cervix, uterine disease of various forms, and 
 ovarian disease. Cases have also been reported as 
 caused by stone in the bladder, ^ and a very peculiar 
 case is recorded in which the irritation of a misapplied 
 hernial truss caused epilepsy'-. 
 
 * Revue deThe'r. Med. Chir., 1886. 
 
 ^ Med. and Surg. Rep., Philadelphia, 1888. 
 
 ' Deutsches Monatshefte f. Zahiiheilk., Heft 3, September, 1885. 
 
 * London Med. Gazette, 1851, xlviii, 531. 
 
 * Araer. Jour. INIed. Sciences, 1870, n. s., lix, p 278. 
 
 ^ Loc. cit. ■• Nervous Diseases, London. 
 
 * Edinburgh Med. and Surg. Jour., 1868-69, xiv, p. liU, and Arch, Sci. 
 aud Pract, Med, and Surg., 1873, p. 1360. 
 
Be/lex Epilepsy. 127 
 
 One of the best evidences that we have of the influ- 
 ence of peripheral irritation in provoking epilepsy is 
 presented in the reports of cases where a close examina- 
 tion of a given nerve showed it to be diseased, and 
 where its removal was followed by cure. Thus, Lande^ 
 has recorded a case following injury to the right median 
 nerve, and Short^ has reported an epilepsy produced by 
 the growth of a neuroma. Not only has Brown-Sequard 
 shown, as will be pointed out farther on, that injury to 
 the sciatic nerve may produce epilepsy, but Billroth, ^ Gar- 
 nier,* and Raymond^ have shown that in similar cases 
 in man excision of the injured nerve produces relief. 
 Briand^ has also recorded a case of great interest in this 
 connection, namely, that of a man who was struck by a 
 fragment of an exploded shell across the buttocks in the 
 battle of Mans in 1871, the sciatic nerves on both sides 
 being injured. Eight months after the injury epileptic 
 fits came on, which constantly recurred. Several cases 
 of a somewhat similar tjqoe have been recorded by Bill- 
 roth^ and Shaefer^. 
 
 A form of peripheral lesion producing epilepsy, prob- 
 abl}^ not by reflex action, is that recorded by Schultz,^ 
 where prolonged compression of the jugular vein caused 
 the disease, or in those cases where enlarged cervical 
 glands bring about a similar result. 
 
 Barometric Changes. — The influence of barometric 
 changes npon epilepsy has been frequently studied, 
 
 * Mem. et Bull. Soc. de Med, et Chir. de Bordeaux, i, p. 56, 1878. 
 ' Medical Essays and Observations Soc. Edinburgh, iv, 416, 1737. 
 ' Archiv f . klin. Chirurgie, xiii, 379, 1872. 
 
 * L' Union Med. de Paris, 3 s., xiii, 65, 1872. 
 
 ' Revue Med. de Timoges, lii, p. 102, 1869-72. 
 
 * Bulletin de la Soc. d'Med. d' Angers Ann., Ixxvii, p. 121. 
 ' Langenbeck's Arch., Bd. XIII, 1871. 
 
 ' Aertzl. Intellingenzblat, 1871. 
 
 ^ Correspondensblatt Deutsclies Gesellschaft f. Psych., ii, p. 35, 1855. 
 
128 Epileps}/ : its Pathology and Treatment. 
 
 alwa3^s with very contradictory results, l)ut Delasiauve,^ 
 by a long series of studies, states that the attacks are 
 more common during the season of the year when the 
 prevailing winds are from the northwest, north, and 
 southwest, — a rather remarkable conclusion. The con- 
 clusions reached by Leuret^ are, that the season of the 
 year has little influence, and that if any such influence 
 exists it is during the autumn and winter, the fits being, 
 perhaps, a little farther apart in summer and spring. 
 
 Not onl}' are the statements of this writer not gen- 
 erally received, but an immense mass of testimony 
 shows epilepsy to be so wide-spread that no particular 
 winds can favor it. There is, probabl^^, no disease under 
 heaven which is more ubiquitous than epilepsy. It is 
 in Greenland,^ in Iceland, in India, and in Africa. In 
 Sweden and Norway it also appears."* Even the far-off 
 islands of the Pacific see the disease.^ 
 
 Toxaemic Epilepsy. — Uraemia. — Nothing particular 
 is here to be said in regard to this variety of convulsive 
 condition, for the matter will, perforce, have to be dis- 
 cussed when the subject of diagnosis is considered. 
 
 E xanthematous Fevers. — One of the causes which, in 
 a certain number of cases, certainl}^ acts in producing 
 epilepsy is that of these febrile disorders. Ever^^ writer 
 of an}^ wide experience, writing on epilepsy, mentions 
 this fact in giving the subject a general discussion, but 
 very few statistics have actual!}^ been collected in regard 
 to the frequency with which they thus act. The Eng- 
 lishman, Gowers, found that in 35 cases of epilepsy not 
 
 * Traite de I'Epilepsie. Pnris. 
 "^ Arch. gen. de med., mai, 1843. 
 
 ' Cranz, Historie von Gniiiland, Barby, i, 189, 1770; and Lange, Be- 
 niacrkn. om Gronlands Sygdomsfoihold, Kf()l)onk, p. 42, 18f)l. 
 
 * I'ontoppidan Historie von Norwegeii. Copenhagen, 1754. 
 
 * Hirsche's Haudbuch f. Geograph. und Histor. Medicine. 
 
Toxaemic Epilepsy. 129 
 
 less than 19 were due to scarlet fever and 9 measles; 
 while in America Hamilton has seen, in the 930 cases 
 collected b}^ him, but 23 cases of epileps}^ due to scarlet 
 fever and 6 due to cerebro-spinal meningitis. 
 
 As Gowers saw no less than 1450 cases, but only 
 found 35 due to exanthemata in the entire number, 
 and Hamilton only saw 29 cases of the same char- 
 acter in 980 cases, it is at once evident that these 
 causes must be very rare as compared to some of the 
 others. 
 
 These fevers ma}^ reach the result in three ways in 
 producing epileps}^: either the}'' light up into action cells 
 already slightly deranged, or produce this derangement 
 primaril}^ ; or, again, the^^ give rise to certain more gross 
 pathological changes, such as abscess or tumor. 
 
 It has been said b}^ some that the convulsions which 
 find their way out into open manifestation during or 
 after the disease has spent itself are generally due to 
 the uraemia produced by renal changes, and that this is 
 supported by the fact that scarlet fever is more com- 
 monl}^ followed by renal change and epilepsy than are 
 the other exanthemata. Aside from the fallacy of such 
 methods of reasoning, it is at once evident that where 
 the epilepsy is continued for a long time it cannot be 
 due to the accumulation of effete products in the blood, 
 and also by the fact tliat these cases show no signs of 
 renal disease during life, nor does the post-mortem ex- 
 amination discover any change from the normal state. 
 Then, too, changes are found sometimes in the brain 
 which show that the hand of the disease has been felt 
 there. Besides all this we find measles, which is rarely 
 complicated by renal trouble, standing next to scarlet 
 fever as the most common cause of epilepsy among 
 the eruptive diseases of childhood, associated with 
 
 6* 
 
130 Epilepsy: its Pathology and Treatment. 
 
 fever, and it is by no means rare to see cases of measles 
 followed ])y gross morbid lesions in the cranium. 
 
 Thus, in one case, which occurred in the practice of 
 a brother practitioner, a child in perfect health and with 
 an enviable family history, became absolutely idiotic 
 after an attack of measles, and remains so till this day 
 (2 years). Everything has been done that can be 
 attempted, and a consultation of some of the most 
 noted neurologists living has resulted in a diagnosis of 
 a large arachnoid cyst. No epileptic symptoms have 
 developed, but it is believed that this depends upon the 
 area involved rather than the smallness of the lesion. 
 
 The writer has not found any cases of epilepsy 
 directly traceable to diphtheria^ although he has seen 
 very large numbers of cases with other nervous diseases 
 from this cause, such as paralysis and kindred affections; 
 and, while he cannot deduce au}^ statistics directly on 
 this point, he is sure the fact remains that, though diph- 
 theria plaj^s havoc in the nervous protoplasm of the 
 body very frequentl}^ it rarel}- seems to cause the changes 
 necessary for the production of epileptic spasms. 
 
 The convulsions so often seen in those children about 
 to be stricken down b}^ an acute disease, and which may 
 be regarded as prodromata, are often quite as epilepti- 
 form in nature as any others with which we may come 
 in contact, but they may be only tetanic in character. 
 They are due, so far as we know, rather to functional 
 disturbance than organic change. 
 
 Lead. — A cause of epilepsy w .ch is rarely seen is 
 chronic poisoning by lead resulting in the condition 
 known as encephalopathia saturnina, or saturnine cere- 
 britis. It may be said that it is rare because its chief 
 student, the well-known Monsieur E. Tanquerel, has only 
 seen 6 cases of saturnine epilepsy in 72 cases of lead 
 
Toxsemic Epilepsy. 131 
 
 poisoning. With somo. practitioners its occurrence may 
 never be seen, for it generall}^ comes on in artisans work- 
 ing in the metal, and rarel^^, or never, does it complicate 
 the milder forms of poisoning commonly observed. Tan- 
 qaerel and others have noted that, as a general rule, the 
 period of exposure prior to the first paroxysm is one year, 
 but it varies from a few months to many years. Women 
 suffer, naturall}^, less frequently than men, owing to 
 their occupation. It has ftlso been proved that the 
 ages most commonly affected range from 20 to 50 3^ears, 
 Ijrobably due to the fact that these persons more gener- 
 ally work in lead than older or younger men. 
 
 Tlie manner in which this metallic poison produces 
 epilepsy is onl}^ known in its pathological aspect, and 
 will be spoken of more fully when considering the pa- 
 thology of the disease, only mentioning it at this point 
 lest the reader should think it had been overlooked. 
 The same may be said of arsenic and mercury, as well 
 as some other poisons of the same class. 
 
 Epileptic crises sometimes occur in rheumatic or 
 gouty persons, seemingly as a result of an excess of the 
 diathetic poison present in the blood. This cause is 
 well recognized, and the five cases reported hy Teissier^ 
 maj^ here be mentioned. 
 
 Thus far the writer has spoken of the so-called idio- 
 pathic epilepsy , Jacksonian epilepsy, reflex epilepsy, and 
 toxaemic epilepsy, and he will now call the reader's atten- 
 tion to a form of the disease which can scarcely be called 
 epilepsy without some qualification, since, while resem- 
 bling the ordinary seizure in every respect, it requires a 
 directly-acting exciting cause on each occasion. Never- 
 theless, as it is closely allied to the epilepsies due to 
 chronic peripheral irritations, this seems the most appro- 
 
 » Lyon Med., t. xlviii, 1885. 
 
132 Epilepsy: its Pathologjj and Treatment. 
 
 prijite point at which to speak of it. He refers to the 
 so-called Epilej)sie Fleuritique. 
 
 The first person to call attention to this form of con- 
 vulsive attack was Maurice Raynaud, of Paris, in 1875, 
 and since that time quite a number of well-known clin- 
 icians have seen and reported cases. The direct cause 
 is the injection into the pleural cavity of some medicinal 
 agent, such as iodine, chloral, or carbolic acid. That the 
 nervous disturbance has no'^; been due to absorption has 
 been proved again and again by direct experiment, and 
 there can be no doubt that the cause is the sudden 
 peripheral irritation which results in an impulse which, 
 being received by some centres peculiarly situated, 
 results in an epileptic seizure. The convulsions are 
 often very severe indeed, and in one or two cases have 
 resulted in death. 
 
 Cardiac epilepsy depends upon almost unknown 
 causes, and is probably due entirely to disorder of the 
 nervous apparatus governing the heart, either in the 
 liiirher centres or in the collateral anastomoses of the 
 circulatory nervous apparatus. According to both 
 Blondean^ and Stokes^ the primary lesion depends 
 rather upon a change in the heart itself, namel}'^, fatty 
 degeneration, but Halberton has seen a similar case 
 depending entirely on an injury to the neck resulting 
 in lesions in the cranial contents. It is evident, how- 
 ever, that the degenerations seen in the cardiac muscle 
 by Blondean and Stokes were not the real lesions pro- 
 ducing the disease, except perhaps indirectly and in a 
 reflex manner, and that, while the symptoms were the 
 same in each case, the lesions recorded by Halberton 
 were more probably the true ones. It is probable, too, 
 
 * Eludes cliiiiques sur le Poiils lent pennnnciit. Paris, 1879. 
 '^ Diseases of the Heart and Arteries. Loiidou. 
 
Etiology of Symptoms. 133 
 
 tliat those cases seen by Stokes had attacks separated 
 by a very narrow border-line from those of ordinary 
 syncope, for he states that one of them could always 
 abort a paroxysm by getting down npon his hands and 
 knees and placing his head downward. It should be 
 remembered, on the other hand, that the relief afforded 
 to the heart-muscle and its nerves by this saving of its 
 strength may haA^e been akin to the use of a ligature in 
 preventing the progress of an aura, or by the increased 
 supply of blood to the brain have overcome the tendency 
 to convulsive discharge. 
 
 Having gone over in a thorough manner both the 
 near and remote causes of epilepsy, let us pass on to 
 the consideration of the causes of some of the symptoms 
 individually found, to make up the entire diseased mani- 
 festations. By far the most important of these is the 
 convulsion itself, which from its character we know must 
 arise from some portion of the nervous sj^stem above 
 the spinal cord, if by no other means than the fact 
 which is universally recognized, namely, that clonic, or, 
 as they have been called, epileptiform, spasmodic move- 
 ments are alwa3^s due to a perverted cerebral action, 
 while the tonic spasm depends upon a spinal discharge 
 of impulses. It may be asked, Why is it that, if all the 
 perversion of function resides in the cerebrum, there is 
 at the first part of the fit a distinct stage in which 
 the muscles afi'ected are in a condition of tetanic con- 
 traction? Everj'' one acknowledges that the great cause 
 of all convulsions is the sudden liberation or explosion 
 of nerve-force, which sweeps everything before it. 
 
 Originating, undoubtedly, in the cerebral motor 
 centres, it passes, in epileps}^, instantly through the great 
 conducting paths in the internal capsules down to the 
 spinal cord, and from here to the muscles affected, which 
 
134 Epilepsy: its Pathology and Treatment 
 
 nre thrown into tonic contraction for the moment by the 
 suddenness and excess of the impulse which may have 
 awakened the spinal cells to their automatic action and 
 caused, in addition to the cerebral influence, an impulse 
 which may be said to be truly spinal in character. The 
 centres of the cerebrum do not send out, in all prob- 
 abiiit}^ one constant stream of nerve-force in health or 
 disease, and even those of the spinal cord produce tet- 
 anic spasm by impulses coming so rapidly one after 
 another that the muscles do not have time to relax. 
 The fact that it has been found possible to produce tetanus 
 in a muscle by rapidh' interrupted stimulation, and that 
 if the impulses are diminished in frequency a slight 
 attempt at relaxation is recorded on the revolving drum, 
 proves that this probably occurs when the impulses 
 come from the nervous centres instead of a galvanic 
 battery. 
 
 As time elapses after the first impulse has been senlj 
 out, the stream of nervous force becomes more inter- 
 rupted, and consentaneously with this the muscles find 
 time to relax more or less between each impulse. The 
 writer has already stated elsewhere that the last spasm 
 of a fit is often as severe as the first, but this in no way 
 contradicts his argument, for it is perfectly possible that 
 at first the stream flows rapidly because of a plentitude 
 of nerve-power, but later on, as this is lost, moments or 
 pauses must occur in which the cells gather strength. 
 To make this more clear, let the author use a simile^ : — 
 
 * Since the writing of these words the views here expressed have 
 received such singular confirmation that these statements are no longer in 
 any way hypothetical, for Horsley has recently found that he can lead 
 off impulses, arising in the brain, from the spinal cord, and by the aid 
 of a capillary electrometer and a photographic apparatus record the 
 impulse. Thus, on producing epileptic movements by galvanizing the 
 cortex in the leg area, he found that both the tonic contraction and 
 the clonic contractions arose in the brain, for the impulse, when led off 
 
Etiology of Symptoms. 135 
 
 If a general of an army orders several regiments to 
 charge a redoubt, and feels that he has a good reserve 
 behind him, the orders and the resulting charges may 
 follow one another in so rapid a sequence as to be vir- 
 tually a continuous stream of force, hurling itself on the 
 enemy. As the time goes b}^, the force of troops in re- 
 serve begins to diminish, and, as a consequence, it is not 
 possible for that general to send out so many impulses ; 
 but this in no way affects the severity and power in each 
 individual charge, and the force discharged by the twen- 
 tieth individual regiment may be as great as that of the 
 first, although a period may have preceded it during 
 which the remaining regiments were gathering force for 
 the charge. Indeed, the last charge may surpass in 
 severity the others, in that it may be strengthened by 
 the survivors driven back from the others. The writer 
 believes it is just so with the motor cells of the cerebral 
 cortex. The whole history of the attacks supports this 
 belief, for the first prodromal stage of restlessness so 
 often seen for some days may be said to be the evidence 
 of the massing, not of bodies of troops, but of units of 
 nerve-force, which, as they accumulate, soon run over. 
 The subsequent history of the case bears me out still 
 further ; for we often find exhaustion of the motor 
 
 from the spinal cord, gave a tracing exactly like that of ordinary epilepsy. 
 Graphically, this may be shown by the following tracing. 
 That of ordinary epilepsy is thus :— 
 
 Tonic. 
 
 Clonic. 
 That of stimulation of cortical areas is thus : — 
 
 Tonic. 
 
 Clonic. 
 The first is the muscle tracing of an epileptic fit. The second is a 
 tracing of the nerve-impulse, as shown in the capillary electrometer. 
 
136 Epilepsy: its Pathology and Treatment. 
 
 centres evidenced by paral3'sis or depression of func- 
 tion, and this lasts until sutRcient time has elapsed to 
 permit of reparative change. 
 
 That the rapid discharge of impulses is always fol- 
 lowed \>y intermittent discharges has been proved to be 
 the case by direct experimentation even wiien the subject 
 is a normal man. Thus, two American enthusiasts in 
 the study of neurology', Dercum^ and Parker, found that 
 if they stood with the tips of the fingers just touching 
 the smooth surface of a table when their arms were com- 
 pletely extended as far as possible by an effort of the 
 will, and depended on the brain-centres solely for their 
 steadiness because the surface of the table was touched 
 too lightly to afford support, they found, it is repeated, 
 that in a short time the}^ were unable to keep the arms im- 
 movable, and that, if they attempted it, jerkings of the 
 muscles came on,wdiich, when the position was persisted 
 in, eventually spread to the whole bod}- and caused them 
 to fall to the ground convulsed from head to foot, al- 
 though consciousness was preserved. That the convul- 
 sions were bona fide in character is certain, for the}^ ex- 
 hibited these phenomena before the Neurological Society 
 of Philadelphia. The writer has spoken several times 
 of the post-convulsive paral3'Sis as due to exhaustion, 
 and, aside from the fact that all living matter becomes 
 exhausted b}'' excessive action, and that certain areas of 
 the body are often paral3'zed after being most convulsed, 
 direct experimental evidence of a very simple character 
 is at hand. 
 
 In a very interesting research carried out by tho 
 ■writer's late friend and colleague. Dr. N. A. Randolph, 
 he employed a series of convicts, under his supervision, 
 in using on one day the fore-finger of the right hand to 
 
 *■ Proceedings of the Neurological Society of Philadelphia, 1884. 
 
Etiology of Symptoms. 137 
 
 depress a small key arranged on a lever so as to record 
 the number of depressions, and he found that after a 
 certain time the men were unable to go on, even though 
 bribes of luxuries were made and prizes offered to the 
 man who reached the highest number of depressions. 
 It could be seen that the will to move the finger passed 
 in the man's brain to the fore-finger centre but that 
 arriving there it found that centre too exhausted to obey. 
 It was also proved that the exhaustion of the centre 
 for the right fore-finger partially destroyed the power 
 of the centre for the left fore-finger, for my friend first 
 made a series of control experiments and determined, 
 let us say, that the maximum number of depressions 
 of the key made by a right-handed man with his right 
 fore-finger was 250, and that the maximum number made 
 by the left fore-finger was 200. If the man attempted 
 to depress the key 250 times with his right fore-finger, 
 having previously depressed the key with his left fore- 
 finger till its centre was exhausted (200 times), he was 
 unable to do more than 200 depressions instead of 250, 
 or if 250 depressions were first made with the right fore- 
 finger only 150 could be made with the left fore-finger. 
 These results, of course, prove that the two centres are 
 not absolutely independent of one another. 
 
 The causation of unilateral or monobrachial epilepsies 
 will be discussed under the question of the pathology of 
 epilepsy. 
 
 The writer has already, when describing the symp- 
 toms of an attack, stated that the cause of the dilata- 
 tion of the pupils is the asphyxia, and also that the 
 primary pallor in an attack may be due to fear or vaso- 
 motor disturbance, while the cyanosis following it is 
 from the asphyxia which results from interference with 
 the respiratory movements. 
 
138 Epilejjsy: its Pathology and Treatment. 
 
 Pathology. — The autlior has alreao}^ so often insisted 
 upon the fact that our knowledge of this disease is not 
 what it should be that he is almost ashamed to speak of 
 it here once more, but of all the sections of this essay 
 this chapter impresses one with the wisdom of offering 
 a prize for the best discussion of our present amount 
 of knowledge concerning epilepsy, since, up to the pres- 
 ent time, no essa}^ has appeared which gives the results 
 of the labors of investigators in this disease within 
 the past twent}' j^ears. 
 
 At the very beginning of the study we are forced to 
 acknowledge the impeachment that histology and anat- 
 omy fail to give us any insight whatever into the cause 
 of tlie nervous disturbances of idiopathic epilepsy. All 
 we can do is to accept the generally-received doctrine 
 tliat the convulsions are the result of an explosion of 
 nerve-force in the higher cortical or subcortical brain- 
 centres, and that the aurte and like preliminary manifes- 
 tations are in many cases of the same origin 
 
 The question of the ph3^siolog3^, or rather the 
 pathology, of epileps}- has attracted a very great array 
 of investigators ever since the dawn of the present 
 medical era, but it is only those of the last fifty 3'ears 
 who have pushed our knowledge forward to any great 
 degree, and it is probable that in the last ten years more 
 has been done than in the preceding forty. While all 
 these students have aided the subject, more or less, there 
 still remains much for them to do, though at the present 
 time the study of the functions of the nervous system, 
 particularly the brain, is being carried on with the 
 greatest vigor and accuracy, and we can have no reason 
 to doubt but that a speed}' enlightenment of our ideas 
 will soon take place. 
 
 The writer has called attention more than once to 
 
Pathology. 139 
 
 the results of Brown-Seqiiard with a passing remark, 
 but in this portion of the essay he desires to give as 
 much of his results, and those of others, as will give a 
 clear idea of the influence which experimentation has 
 had upon our knowledge of this disorder. For many 
 3'ears this world-widely known investigator has published 
 numerous papers bearing upon this matter, the refer- 
 ences to the chief of which are appended.^ He found 
 that section of one or both sciatic nerves, wounding of 
 the medulla oblongata, or of the cerebral peduncles or 
 quadrigeminal bodies, produced epileptiform paroxysms 
 at var34ng lengths of time after the infliction of the in- 
 jury. He also determined that section of one lateral 
 half of the spinal cord produced similar convulsive dis- 
 turbances. Section of the entire cord may so result, or 
 even a single puncture is often sufficient to bring on the 
 movements. It was also found that these injuries to the 
 cord were more certainly epileptogenic in some regions 
 than in others, as, for example, between the eighth dor- 
 sal and second lumbar vertebrae. After the elapse of 
 from twelve to seventy-one days it was noticed that cer- 
 tain muscles were excessively irritable, and soon a gen- 
 eral epileptic state developed. The first attack may be 
 spontaneous, but, as is well known now to every one, 
 succeeding attacks can be produced by touching or 
 pinching some portion of the skin of the animal, — a very 
 common situation for this zone beino; at the ano-le of the 
 jaw, which, therefore, received from Brown-Sequard the 
 title of the " epileptogenous zone." This zone is alwaj-s 
 on the side on which the injury is received unless that 
 
 * Researches on Epilepsy ; its Artificial Production in Animals, and its 
 Etiology, Nature, and Treatment. Boston and Philadelphia, 1857. 
 
 Journal de physiologie de I'homme, vols. 1 and iii, 1858 and 1860, and 
 in vols. 1 to iv Arch, de Physiologie normale et pathologique (Brown-Se- 
 q.uard, Charcot, and Vulpian), 1868-1872. 
 
140 Epilepsy: its Pathology and Treatment. 
 
 injury be to the cerebral cms, when it occurs on the op- 
 posite side. Even more remarliable is tlie condition of 
 this area as regards sensibility, for, while it is to some de- 
 gree lacking in sensibility, the slightest irritation of it 
 may produce the convulsion. After the epileptic par- 
 oxysms have lasted for months or for years they sub- 
 side, and the anaesthesia of the " epileptogenous zone " 
 also decreases |)a?'i passi* with the subsidence of the 
 spasms. A most extraordinary fact is, however, that 
 the young of such animals — always guinea-pigs — are 
 often spontaneousl}' epileptic, which is doubly interest- 
 ing on account of its scientific and clinical interest. 
 
 These zones have not been commonly found in man. 
 Schnee had a case of a woman who suffered from a scalp 
 wound, and pressure on the resulting cicatrix always 
 caused a fit. Neftel^ saw an epileptogenic zone develop 
 over the right eye. The writer has already called atten^ 
 tion to the case recorded by Briand,^ of injury to both 
 sciatic nerves in man followed by epileptic attacks. 
 
 These results did not only occur in the animals under 
 the care of Brown-Sequard, but many men, all over the 
 world, have i)roved their truth, notabl}^ Schiff ^ in Geneva, 
 and Westphal^ and Nothnagel,^ the latter seeing in- 
 stances in which the attacks came on, in as short a time 
 as thirty-six hours after the injur}?-, of such a severe char- 
 acter as to cause the death of a strong, health}^ animal. 
 
 Schiff obtained convulsions in from three to four 
 days. So far, convulsions have not been produced in 
 cats and dogs and rabbits with the same de2:ree of sue- 
 
 » Arch. f. Psychiatrie, Bd. VII, 1877. 
 
 "^ BuUetin de la Soc. de med. d' Angers. Ann. Ixxvii, p. 121. (Sec page 
 117 in this essay.) 
 
 ' Lelirbuch derPhysiologie, lS.58-,59. 
 
 * Berliner klin. Wochen.sclirift, 1873, No. 38. 
 
 * Ziems.sen's Encyclop., art. Epilepsy. 
 
Pathology. 141 
 
 cess fis tliG}^ have been in guinea-pigs, but Scbiff has 
 produced them in dogs without any loss of conscious- 
 ness, and the writer has tlirown guinea-pigs into such 
 conditions a number of times, and always with results 
 exactly similar to those given above. 
 
 The researches of Westphal were somewhat different 
 in method, but similar in result, with those of the other 
 observers. He found that tapping light blows on the 
 head brought about convulsions immediately, and after 
 the elapse of a few weeks epileptic convulsions of ap- 
 parently spontaneous origin came on, and that there 
 existed an " epileptogenous zone." Coma frequently 
 complicated these fits, however, and post-mortem exam- 
 ination showed small haemorrhages into the spinal cord 
 and medulla oblongata. 
 
 As is well known to all the readers of this essay, epi- 
 lepsy was at one time very generally believed to be due to 
 a disorder of the circulation at the base of the brain, and, 
 acting on this belief as long ago as 1836, Cooper,^ of 
 England, attempted to show, by some imperfect and de- 
 fective experiments on the lower animals, that this was 
 the cause. His belief was most strongly seconded by 
 two others of his countrymen, namel}^, Marshall Hall and 
 Travers,2 who pointed out the resemblance between true 
 epilepsy and the convulsions of cerebral ausemia from 
 haemorrhage. 
 
 Later than this KiissmauP and his collea2:ue. Tenner, 
 performed a very large number of similar, but more 
 careful, experiments, with the result of confirmiug the 
 assertion that epileptiform convulsions could be pro- 
 
 * Gny's Hospital Reports, vol. i. London, 1836. 
 
 ^ New Sydenham Society's Transactions, 1859. 
 
 ' Untersncliungen iiber Ursprimg und Wesen der fallsuclitigen 
 Zuchungeii bei der Verblutung so wie Fallsucht iiberhaupt. Frankfurt, 
 1857. 
 
142 Epilepsiy : its Pathology and Treatment. 
 
 duced by sudden cerebral anemia. This lias been con- 
 firmed by many other investigators, notably Wood/ of 
 America, who has found tiiat the convulsions produced 
 by most of the drugs which act as cardiac depressants, 
 when taken in toxic amounts, depend on cerebral anaemia 
 for their origin. Nothnagel as well as Kiissmaul and 
 Tenner have endeavored to produce similar results by 
 galvanization of the cervical sympathetic nerves, but 
 Nothnagel^ failed to get any convulsive result, and Kiiss- 
 maul and Tenner only succeeded once. 
 
 It is as eas}^ to explain why Nothnagel reached no 
 results as it is difficult to discover in what manner the 
 others succeeded but once, for the vasomotor sj^stem of 
 the cerebrum is not governed by the fibres of these 
 nerves at all. Nothnagel has, however, galvanized pe- 
 ripheral sensor}" nerves in order to produce vasomotor 
 sjmsm and convulsions with success, according to his 
 report, and Krauspe^ has by a very careful and excellent 
 series of experiments confirmed these results. One can- 
 not help thinking, however, that the convulsions occur- 
 ring under such circumstances were not due to the vaso- 
 motor spasm produced by the stimulation of a peripheral 
 sensory nerve, for several reasons. In the first place, 
 the writer has galvanized the sciatic nerve again and 
 again, with all degrees of strength of current, and never 
 seen any convulsive movement, but, as he did not attempt 
 to produce convulsions, but to determine the integrity of 
 the vasomotor system, he may not have continued the 
 stimulation long enough to cause spasmodic movements. 
 If the mere contraction of tlie blood-paths was the cause 
 of convulsions, they ought to come on at once, however, 
 
 * Therap. Mat. INIed. and Toxicoloojy, fith ed. 
 ' Ziomsseu's Kiuivclop., art. Ki)ilep.sy. 
 ' Petersburger Mud. Zcitschrilt, vol. xi. 
 
Pathology. 143 
 
 and not require prolonged contraction. Again, wlien a 
 peripheral sensory nerve is galvanized there is not alone 
 a vasomotor spasm of the vessels of the brain, but of the 
 entire body, and as there is no escape for the blood just 
 as much must circulate as before, although under greater 
 pressure. If, however, the blood-vessels were tightened 
 only in the brain, then the theory of Nothnagel might 
 hold good. 
 
 The writer believes the convulsions — which were un- 
 doubtedly obtained by these observers — to have been 
 due to the nervous irritation produced by the severe 
 peripheral stimulation. Every one knows that if the 
 foot be tiglitl}^ bound and the sole be tickled with a 
 feather, the sensation is not only soon unbearable, but if 
 persisted results in a typical convulsion. It is a similar 
 condition to that produced by Nothnagel and Krauspe ; 
 indeed, the convulsions obtained by these investigators 
 seem to me to support by direct exueriment the idea of 
 reflex epilepsies. 
 
 Langendorf and Zander^ have produced epileptic 
 spasms by galvanizing the peripheral ends of the vagi 
 nerves, after section, producing thereby cardiac arrest 
 and cerebral anaemia. The}^ found they could do this in 
 cliloralized rabbits, but that they failed if the chloral 
 was pushed too far. 
 
 We have now adduced most of the evidence that 
 cerebral anaemia produces convulsions, but though all 
 this work has been done it in no way proves that cere- 
 bral anaemia is the cause of epilepsy. 
 
 In the writer's belief, not onl}" is this method of ex- 
 perimentation exceedingly incorrect, but the principles 
 upon which it was carried on are entirely without sup- 
 port, notwithstanding the fact that some have thought 
 
 » Centralblatt fiir klin. Med., No. 4, 1878. 
 
144 EpiJepay: its Pathology and Treatment. 
 
 tliein as indicative of a " convalsive centre " in the 
 medulla oblongata. 
 
 Here, as in some of the recent experiments on the 
 heat-centres in fever, the author wishes to insist that the 
 production of absolutely abnormal conditions is not the 
 wa}'^ to prove the existence of a physiological centre. 
 
 One reads that such and such an investigator punc- 
 tured or removed cerebral areas and found a rise of 
 bodil3' heat, and so calls the part removed a heat-centre. 
 It is anything but a heat-centre, for if it was what its 
 name implies its removal should produce a fall of bod)- 
 heat, not a rise. The convulsions of cerebral anaemia 
 are the outward manifestations of the abuse to which 
 the cranial contents are put, and cannot be regarded as 
 scientific measures for the calling out of physiological 
 hebetude or physiological activit}'. 
 
 It having been proved, to the satisfaction of Kiiss- 
 maul and Tenner, that cerebral anaemia produces convul- 
 sions similar to epileps}^, they attempted to discover 
 whether cerebral hypersemia developed by artificial 
 means so resulted, but obtained nothing but negative 
 results. On the contrarj^ Landois^ has supported the 
 theor}' that hypersemia is similar in its results with 
 anaemia, while Escher and Hermann^ have by further 
 experiments confirmed only those of Kiissmaul and 
 Tenner. Either some fallacy underby the work of 
 Landois or else the h3'peraemia was .so intense as to pro- 
 duce absolute pathological conditions in the brain. 
 
 The whole theory that epilepsy is due to cerebral 
 anjiemia because epileptiform convulsions occur on its 
 production is a species of reasoning entirely unjusti- 
 fiable and quite absurd, and is harmful because it blinds 
 
 * Centralblatt f. die Mctl. Wissenschafteii, 1867, 
 " Pfliiger's Arcbiv, vol. iii. 
 
Pathology. 145 
 
 good investigatorg so that the}' seek no furtlier for an 
 explanation. 
 
 Some writers have held that the proof of their theor}'- 
 rests in the pallor which conies on in the face at the 
 onset of the convulsion ; which, by the bye, it does not 
 alwaj's do. These persons forget, however, that, even if 
 this were the case, the disease in reality would exist not 
 in the vasomotor condition of the brain, but in the dis- 
 charge of a sudden constricting influence from the vaso- 
 motor centre. In other words, if their reasoning were 
 carried out logically to the end thej^ would have two 
 morbid changes going on — one primarily in the vaso- 
 motor sj^stem, the other secondarily in the brain — as its 
 result. The argument, too, that pallor of the face shows 
 cerebral anaemia is foolish, for every time a person 
 blushed cerebral h^^persemia ought to result if this were 
 true. 
 
 The writer thinks, therefore, that the idea that we 
 have in cerebral anaemia the immediate cause of epilepsy 
 is absolutely untrue and quite as unlikel3\ 
 
 Quite a number of 3'ears ago it occurred to those 
 who were interested in the disease that another and 
 more logical cause was really to be sought after, and 
 that there must be some starting-point in which the 
 explosion of nerve-force originated. As a consequence 
 of this much research has been resorted to to discover 
 whether this area or convulsive spot really existed. 
 
 Kiissmaul and Tenner {loc. cit.), after much experi- 
 menting, placed this point in the nervous matter some- 
 where between the spinal cord and the crura cerebri, or, 
 in other words, in the pons Yarolii or the medulla ob- 
 longata. Brown-Sequard^ and Schiff^ have reached 
 
 * Loc.cit., p. 130. 
 2 Lelirbucli der Physiologie. 
 7 G 
 
146 Epilepsy: its Pathology and Treatment. 
 
 similar conclusions. NothnageU has also promulgated 
 a theory that there is a so-called convulsive centre in the 
 pons Varolii, and that it is from this focus that all the 
 voluntary muscles are involved. In addition to these 
 opinions, we have the conclusion of Hallopeau^ tliat 
 such a thing as spinal epilepsy, or epilepsy arising from 
 the spinal cord, may exist, and although no less an au- 
 tliority than Brown-Sequard denies this, and the whole 
 ph^'siological teaching of to-day is against such an 
 opinion, it has been thought best to mention it here. 
 
 Even if epilepsy be spinal in origin, the experiments 
 of Nothnagel and others have proved that here, at least, 
 epilepsy is not due to anaemia, for they found that 
 anaemia of tlie spinal cord is not followed by convulsive 
 movement. Kiissmaul and Tenner have also noted this. 
 One must, therefore, either believe in anremia of the cere- 
 brum as a cause and throw the spinal origin of epilepsy 
 aside, or the reverse, for both views cannot be held to- 
 gether. While the author fears that the reader may regard 
 him ere long as a universal skeptic in regard to the re- 
 sults which such notable men have obtained, he cannot 
 help drawing his attention to some points wliich are at 
 least worthy of remark, for, after all, it is our duty not 
 to accept blindly any one's results, but to put tliem to a 
 thorough mental test. According to our present knowl- 
 edge clonic spasms arise in the cerebrum, while tonic 
 spasms arise in the bulbo-spinal S3^stem. So universally 
 is this recognized that the fact that a man is suffering from 
 a tetanic spasm is proof that his spinal cord is affected, 
 either directly or indirectl}^, provided the contraction is 
 prolonged. Of course, the writer does not mean that no 
 
 • Virchow's Aroliiv, xliv. 
 
 ^ Das accidents convulsifs dans les maladies de la moelle epiniere. 
 Pawis, 1871. 
 
Pathology. 14*7 
 
 instance has ever occurred in which an exception to this 
 rule has taken place, but proof of such an instance is 
 virtually unknown. Neither does he attempt to deny that 
 the investigators named obtained convulsions, but he 
 does doubt that the convulsive movements were epilepti- 
 form in character ; at least, as we understand the term to- 
 day.^ Thus, if the reader will turn to the literature of 
 these writers he will see that they speak of tonic epilepsy 
 and clonic epileps}', using the word epilepsy to signify 
 au}^ convulsive condition. Owing to this, it is exceed- 
 ingly difficult to separate the results reall}^ bearing on 
 our subject from those which do not. We are, therefore, 
 partly in the dark, so to speak, as to whether clonic 
 movements may be generated in the pons Varolii or me- 
 dulla oblongata b}^ stimulation ; but we know that, gen- 
 erall}", if not alwaj^s, the result is tonic spasm. We 
 have, therefore, no positive proof that true epilepsy 
 finds its origin in these regions, either experimental or 
 pathological, and we have greater reasons to doubt this 
 theory than to accept it, for E.osenbach,2 working in 
 Mierzejewski's laboratory, has proved that medullary 
 stimulation results not in clonic but tonic spasms, and 
 it seems impossible that a nerve-storm of such severity 
 could originate in a portion of the nervous S3'stem so 
 pregnant with vital centres as is the medulla without 
 causing death and general cardiac and respiratory chaos. 
 Knowing the assertions of the others, whom the writer has 
 quoted, Rosenbach has been apparently most careful in 
 reaching his results, and denies their conclusions in toto. 
 Further than this, the views of Rosenbach are firmly 
 
 * It should be remembered that the medulla oblongata is but an 
 enlarged part of the spinal cord somewhat more highly specialized, and 
 although within the skull is really spinal, not cerebral, both anatomically 
 and physiologically. 
 
 ^ Vestnik kiln, ii Sudek. Psikiatrie, vol. ii, fasc. i, p. 171. 
 
148 Epilepsy: its Pathology and TreMment. 
 
 supported by the results obtained by Seppilli,^ and by 
 those of Soltmunn and Tarchanow, as well as those of 
 Albertoni. If the medullary theory is true, a skillful 
 hypothesis must be drawn up to explain the loss of con- 
 sciousness and the fact that the whole body is rarely 
 convulsed all at once, and not by degrees, as is generally 
 the case.2 Besides all this, we have, on the other hand, 
 much direct and incontrovertible evidence that epilepsy 
 is developed in the cerebrum proper. 
 
 Within the last twenty years an entirely new school 
 of experimenters has arisen, led by the celebrated 
 Englishman, Hughlings-Jackson, who may be said to be 
 the father of modern cerebral localization, and this 
 school has done very much more than all their prede- 
 cessors to decide matters positively. 
 
 Probably no one will deny that Ferrier is the chief 
 among this class of experimenters, not only because he 
 was one of the first in the field, but because his results 
 have so brilliantly been supported by his successors in 
 this line. It should not be forgotten, however, that 
 others made some attempt at similar researches before 
 him, as, for example, Nothnagel, or Bright and Todd. 
 Contemporaneously we find his co-workers to have been 
 Vulpian, Charcot, Lepine, and Landouzy, as well as 
 Pitres^ and Frank, Unverreicht^ and Schroeder von der 
 Kolk. Following these come an equally distinguished 
 band, composed of Luciani,® Scliafer, and Horsley.^ 
 
 ' Rivista Sperimentale di Frenatria, fasc. i and ii, 1884. 
 
 ^ Some results reached by Luciani may in the end dissolve the dividing 
 opinions as to tlie medullary and cortical theories, for he found that 
 extirpation of all the cortex except one leg-centre produced general 
 fits when this centre was galvanized. He therefore concludes that the 
 medulla nuist act as a distributor. 
 
 "" Trav. du Lab. de M. Marey, 1878-79, p. 413. 
 
 * Archiv f. Psychiatrie, Bd. XIV. 
 
 * Iliv. Sperimentale de Frenatria, iv, 1878, ]>. 617. 
 
 * Proceedings of the Royal Society of London. 
 
Pathology. 149 
 
 We have therefore before us at this point those who 
 have advanced oar knowledge in the past and enabled 
 those just named to complete the work which is now 
 being carried out with such ardor, and is blessed with 
 such good results. 
 
 As has already been said, the all-important question 
 to answer is, Where does the primary seat of the nerve- 
 storm exist ? From one yet undecided the answer might 
 well be: The experiments of Brown-Sequard, of Ktiss- 
 maul and Tenner, and of Notlmagel point to the medulla 
 oblongata, while those of Ferrier, Luciani, Bartholow, 
 Unverreicht, Munk, Bubnow, and Heidenhain and many 
 others, particularly those of Horsley, point to it as being 
 in the cerebral cortex. 
 
 It is impossible for me to detail at length, or even by 
 a shorter method, the labors of the investigators in cere- 
 bral localization. The writer can only point out some of 
 the salient parts with the purpose of refreshing the 
 reader's memory who is not constantly reading and 
 studying the accounts of the results as they appear in 
 print. 
 
 In the first place, it is a fact known to all ph3^siol- 
 ogists at the present time that stimulation of certain areas 
 in the cerebral cortex produces movements in given por- 
 tions of the body of greater or less extent, and now sci- 
 ence has progressed so far that parts of the cerebral sur- 
 face can be called by the name of the part they govern ; 
 as, for example, the leg-centre, the arm-centre, etc. 
 To speak roughly, the results of all experimenters, when 
 placed side by side, divide the cerebrum into three great 
 areas. The first, or frontal third, in which the x)rocesses 
 of thought are probably carried out ; the second, or middle 
 third, in which the impulses resulting in movement are 
 generated ; and the posterior third, in which the centres 
 
150 Epilepsy: its Pathology and Ti^eatment. 
 
 for the perception of sensory impulses reside. The 
 highly developed frontal lobes in the higher races of 
 mankind, and their constant decrease as the degrees of 
 intellect descend, along with the fact that stimulation 
 of these regions produces no appreciable motor effects in 
 the lower animals, are the reasons for these conclusions. 
 The functions of the middle third, or parietal regions, 
 are understood and localized to a most accurate and 
 minute extent, and this at present has gone so far that 
 galvanization of millimetre squares on the cerebral sur- 
 face is carried out with accurate results. The centres 
 not only for the various movements of a limb have been 
 found, but those which produce certain definite and 
 never-varying motions have been discovered. 
 
 A further point of interest has been noted b}^ Hors- 
 ley, who finds that the centres for various muscles are 
 arranged in such a way as to be divided from one another 
 by horizontal imaginary lines. That is to sa}-, taking 
 tlie arm-area for example, that the centres for the move- 
 ments of the muscles of the shoulder are highest, then 
 those for the lower arm and wrist come next, while those 
 governing the hand come lowest. It is generally found 
 that the centres governing large muscles are higher up 
 on the surface of the brain than those governing smaller 
 muscles, and if we stop for one moment to think this 
 seems but natural, since the ui)per centres are r.eallj' the 
 masters of the lower ones, or rather the muscles of the 
 shoulder are really the masters of those of the forearm. 
 If we seek to pick up anything we first extend the en- 
 tire arm and then the wrist. 
 
 As regards the occipital area, or the last third, the 
 results have been reached only by negative methods, if 
 one can use such a term ; tliat is, by extirpation and 
 watching the results ; for, as it is receptive, not expulsive, 
 
FathoJogij. 151 
 
 in character, galvanization produces no external signs 
 of response. This field, by reason of this indirect 
 method of reaching conchisions, is not so well mapped 
 out as is desirable, for though one experimenter may 
 attempt to extirpate the same area as his predecessor 
 the delicacy of nervous protoplasm is so great as to 
 make the slightest clumsy movement felt. This be- 
 comes even more clear wlien it is recalled that the breadth 
 of a millimetre may involve another function entirel3\ 
 
 Still further evidence has been recorded by Hitzig,^ 
 who b}" the removal of certain cortical areas governing 
 certain parts produced epileptic seizures, beginning 
 spontaneously, either on the next da}' or in a few weeks. 
 Just here, however, I must call attention to a very im- 
 portant element of fallacy' which in many wa3^s may 
 have, to a certain extent, falsified Hitzig's results. 
 
 Antiseptics being unknown and liealing b}^ first in- 
 tention being practicallj- unheard of, it is perfectl}' pos- 
 sible and probable that the convulsions noted may have 
 been due, at least in part, either to septicaemia or in- 
 flammatory causes. 
 
 Munk observed that fits could be brought about by 
 the excitation of a limited cortical area, and could be 
 stopped by the removal of that area, unless the}^ had 
 lasted for some time. Bubnow and Heidenhain^ have 
 also shown that in the early part of an attack extirpa- 
 tion of one centre quiets the tributary part, while the 
 rest of the body remains convulsed. The^' have also 
 found that in other cases, after rapid destruction of the 
 motor area on one side, cessation not only on the oppo- 
 site sides but on both sides takes place, it being indif- 
 ferent whether the area removed was the same as, or 
 
 *■ UntersTicliurigen iiber das Gehim, Berlin, 1874, p. 271. 
 2 Pfliiger's Archiv, xxvi, 137. 
 
152 Epilepsy: its Pathology and Treatment. 
 
 opposite to, that by which the outbreak originally oc- 
 curred. The}' suppose from this that each area uot only 
 governs the opposite muscles, but also that each area 
 influences the opposite area, and that, that failing, the 
 excitation is insufficient to convulse.^ In cases where 
 the extirpation failed to stop the attack Bubnow and 
 Heidenhain believe that the excitation had reached sub- 
 cortical areas untouched by the knife. These two ob- 
 servers also made an interesting observation, for they 
 remark that, while fits excited by cortical stimulation 
 always commence on the opposite side of the body, those 
 due to subcortical stimulation begin on the same side of 
 the body. These results have also been confirmed by 
 Unverreicht,^ who has also proved that section of the 
 corpus callosum does not prevent the nervous impulses 
 from crossing to the other side of the bod}^ 
 
 On the other hand, the researches of Rosenbach^ 
 differ somewhat in their results from those just quoted, 
 for he found that extirpation of a cortical centre does 
 not stop the convulsion in a tributary part. This dif- 
 ference, however, is probably not real, for we remember 
 that Bubnow and Heidenhain * found the same thino- 
 true if they did not use the knife quickly enough. 
 Rosenbach is, however, entirely in accord witli the other 
 observers in finding that cortical stimulation results in 
 convulsions. Ziehen,^ of Jena, has also determined this, 
 and has found that mechanical irritation of the corpus 
 striatum, of the middle and posterior portions of the 
 thalamus opticus, and of the anterior part of the cor- 
 
 • Note that these conclusions are virtually identical with those of 
 Dr. Randolph recorded a few pages back. 
 
 - Arch. f. Psychiatric, Bd. XIV. 
 
 ' Vestnik klin, i Hudeb. Psikhiatrie, vol. ii, part i, p. 171. 
 
 * Pfliiger's Arohiv, xxvi, 1.37. 
 
 ' Verslg. d. Siidw., Dcutsch Ncurolngen und Psychiatric, 
 
Pathology. 1 53 
 
 pora quadrigemina gives rise to energetic movements of 
 locomotion, while irritation of the posterior part of the 
 quadrigeminal bodies causes tetanic convulsions. He 
 thinks that the tonic stage of the epilepsy arises here, 
 but, we think, on very insufficient grounds. 
 
 The writer has gone into these results in some detail 
 because they bear most intimately upon what is to follow 
 as part of the evidence which he will bring forward. 
 
 When we remember tliat in nearly all cases of epilepsy 
 due to growths or injury the lesion is found after death, 
 or even during life, to be cortical in situation, we have 
 the finger of pathology to guide us ; and we maj^ also 
 state that whenever the tumor is the direct cause of the 
 disease it begins locally, provided the lesion be in the 
 cortex, or, more generally, if it be subcortical. 
 
 To one who has experimented and seen the results 
 that the writer has seen in this work, it seems scarcelj^ 
 necessary for him to adduce evidence of the epileptic 
 parox3^sm which stimulation of the cerebral cortex may 
 set up. If a moderatel}^ strong current be applied to 
 the arm-centre, or any similar point, the limb will re- 
 spond, and, if the stimulation be continued, will become 
 for the moment tonically contracted, but immediately 
 after passes into clonic movements, which become more 
 and more violent until the rest of the body is convulsed. 
 Not only is the condition exactly similar to the ordinary 
 epileptic attack in every way, but loss of power not only 
 follows temporarily in that limb, but also the centre 
 governing it refuses to respond to further stimulation 
 for the time being. 
 
 Can anything be more tj'pical ? One has only to see 
 such an experiment to be converted to the belief that 
 epilepsy is cortical. 
 
 This is indirectly indorsed by the interesting results 
 
 7* 
 
154 Epilepsy: its ratJiology and Treatment. 
 
 of Albertoni, of Soltmann, and of Tarclianoff, for they 
 found that in newly-born cats, dogs, and rabbits they 
 could not produce fits b3^ stimulating the cortex, for the 
 very evident reason that in these animals the cortex 
 was not sufficiently developed to respond, only the vital 
 centres in the lower areas being developed to carry on 
 life. 
 
 Albertoni was able to produce convulsions, however, 
 by galvanizing the cortex of a dog of 23 days. 
 
 One of the most interesting proofs of the cortical 
 origin of epilepsy lies in reports of very rare cases by 
 Oebeke and Gowers,^ in which a lesion occurring in the 
 internal capsule prevents the appearance of any more 
 nervous disturbances, — at least, on the opposite side of 
 the body from the capsular injury. In other words, the 
 pathway is blocked between the cortex and the lower 
 distributing nervous apparatus. 
 
 As has already been said, the character of the aura 
 indicates generall}^ the regi-on of the nervous S3'stem 
 which is diseased, and we ma}^ us€ this as a means of 
 localizing lesions during life. Thus, an aura consisting 
 of blindness ma}^ point to involvement of tiie centres 
 governing or connected with vision or situated near by, 
 or, if the aura is olfactor}-, it indicates cerebral disease 
 in the region of the olfactorj^ bulbs, unless the case be 
 one {)riniarily reflex. 
 
 The writer has given, so far, only the physiological evi- 
 dence of the cortical origin of epilepsy ; he will now give 
 the pathological or morbid-anatomy side of the question. 
 First, however, he must, in justice to the subject, give 
 the observations of those who look for the cause of the 
 disease in the medulla and corresponding regions. In- 
 deed, he is forced to include some rei)orts in wiiich every 
 
 * Nervous Diseases, p. (j'J8. 
 
Pathology. 165 
 
 one has his doubts at the present clay in order to present 
 all views to my readers. 
 
 In support of the theory of the medullary origin of 
 epilepsy, it is stated that lesions can be found here after 
 death. Thus, von der Kolk i found capillary dilatations 
 in the neighborhood of the hypoglossal nucleus in those 
 wlio bit their tongues during the lit, the dilatations being- 
 greater in these than in those who did not bite the tongue 
 by 0.096 millimetre, while in the corpus olivaire it was 
 0.098 millimetre and in the raphe 0.055 millimetre. When 
 the capillaries of those who did not bite their tono-ues 
 were examined in the path of the vagus, they were found 
 wider than the others by 0.111 millimetre. The follow- 
 ing table illustrates his results : — 
 
 Varieties of Hypo- Corpus -o^^i, - ^^ 
 
 Epileptics. glossus. Olivaire. ^^P^e. \ agus. 
 
 (a) Tongue-biters, . 0.306 0.315 0.315 0.237 
 
 {b) Not biters, . 0.210 0.217 0.217 0.348 
 
 Difference, . . +0.096 +0.098 a 0.055a + 0.111 & 
 
 We are prepared to accept all that is reasonable 
 in regard to pathological changes, but can any one ex- 
 plain why tongue-biters' capillaries are here dilated and 
 here contracted, or does any one believe that it is pos- 
 sible to prove that capillaries can be so accurately meas- 
 ured as the 0.111 of a millimetre, and this measurement 
 be taken as a representation of their condition in life 
 when they have submitted to a hardening fluid or, at 
 least, a section-cutter, and have lain dead in dead tissue 
 for hours or days? Such results must be entirely 
 worthless. 
 
 Much of the labor of pathologists in the past has 
 reached only contradictory results in so far as the de- 
 termination of the definite lesions is concerned, unless 
 * Minute Structures of the Spinal Cord, NewSyd. Soc. Translations. 
 
156 Epilepsy: its Pathology and Treatment. 
 
 the cause be a morbid growth or a lesion from trauma- 
 tism. Many 3'ears ago, Lebert and Dakisiauve ^ noted 
 that sclerosis of the hippocampal folds often existed in 
 epileptics, and their observations have been confirmed 
 in 20 cases by Mej-nert, Nothnagel, and Charcot, but it 
 is to be remembered that both of the latter believe the 
 changes to be secondary', not primarj^, to the epileps}'. 
 Tamburini ^ reports a case of epilepsy with hemiplegia 
 in which there was found induration of the left optic 
 thalamus and the left cornu ammonis, and in which, 
 during life, there was aphasia. 
 
 That the presence of hippocampal disease is not so 
 common as some would have us to believe seems proved 
 b}^ the results of Hemkes,^ who found in 27 epileptic 
 males and 7 females, at the Holdesheim Asylum, only 
 6 with hippocampal disease. Nothnagel* has also in- 
 jected chromic acid into the hippocampi of rabbits with- 
 out producing epileps}', and has also injured this region 
 with punctures without producing epilepsy. Besides 
 this, Hemkes has removed the hippocampi with no con- 
 vulsive results. When it is remembered, too, that this 
 portion of tlie brain of man is only rudimentar}^, while 
 in animals it is much more highly developed, it scarcely 
 seems likel}^ that hippocampal disease in man would 
 primarily produce epileps}^, as it does not do so in 
 animals. 
 
 Pfleger '^ and Hemkes have also found no lesions in 
 epileptic brains save in the cornu ammonis, the change 
 being sclerotic in character, and in a later paper 
 Pfleger ^ records 45 autopsies in which atroph}^ of the 
 
 ' Traite de I'Epilepsie. 
 
 ^ Sallanzani, Modena, 1879, viii, 550. 
 
 » Allg(>m. Zeitschrift fiir Psychiatrie, Bd. XXXIV, Heft 6. 
 
 * Viichow's Archiv, Bd. LVIII. 
 
 ' AUgem. Zeitschrift f. P.sycliiatrie, Berlin, 1879, xxxvi, p. 3591. 
 
 " Ibid., Ixxvi, and Arcliiv de Neurologic, No. 2, 1880, p. 299. 
 
Pathology. 157 
 
 cornu aramonis with sclerosis was found twenty-five 
 times. He also finds that in every instance tlie extent 
 of the lesions was in direct proportion to the severity and 
 extent of the paroxysms during life. 
 
 In a series of 90 autopsies, Sommer^ found changes 
 in the cornu aramonis in every instance, and the writer 
 believes this lesion to be present in at least 30 per cent, 
 of all fatal cases of epilepsy. ^ 
 
 In many instances, where tlie disease has existed on 
 one side in a more highly developed form tlian on the 
 other, and has been associated witli a certain amount of 
 hemiatrophy, the autopsy has disclosed corresponding 
 hemiatrophy of the brain. Baume^ states that the 
 weight of the hemispheres in epileptics is alway un- 
 equal, the lightest heniispliere being on the side oppo- 
 site the convulsed portion of the bod}^ In one series 
 of cases examined by him the smallest difference 
 between the weights of the hemispheres was 15 
 grammes ; the greatest difference was 290 grammes ; the 
 mean difference of all the cases beins; 50 orammes. In 
 another series of 20 cases the smallest difference was 
 4 grammes and the greatest difference 159 grammes, 
 making the mean 40 grammes. Hamilton* has shown 
 that hypertroi^hy of the epileptogenous side of the brain 
 often exists. 
 
 Numbers of cases of epilepsy have also been due to 
 tubercle, and Lu3"s * reports an instance in which, after 
 death, the medulla oblongata was found tuberculous. 
 Greenhow, Dresche, Grreen, and Lobel have also re- 
 ported a number of such cases. 
 
 ^ ArcMv f. Psychiatrie und Nervenkrankheiten, Bd. X, Heft 3. 
 "^ Coulbault (These de Paris, 1884) has written of the presence of this 
 lesion in epilepsy. Those interested I would refer to the original. 
 ' Annales Med. Psychologique, tome viii. 
 * Amer. System Practical Med., p. 491. 
 ' Archives gen. de med., 1869, ii, p. 541 et seq. 
 
158 Epilejjsy : its Pathology and Tr^eatment. 
 
 Imperfect cerebral development has also been insisted 
 upon as a condition commonly found after death, and 
 Echeverria ^ has laid great stress upon the hyperplastic 
 increase in volume of certain cerebral areas. A very 
 interesting study, which brings us face to face with some 
 useful conclusions, has been made by Marie Bra ^ in 
 regard to the general pathological changes seen after 
 death. The results are, perhaps, of sufficient value to 
 be given here : — 
 
 1. The mean weight of the brain of epileptics is less 
 than the physiological mean. 
 
 2. The cerebellum is greater in weight than the 
 physiological mean. 
 
 3. There is frequently an asymmetry between the 
 lobes (not peculiar to epilepsy). The increase in weight 
 is sometimes found on the right side, sometimes on the 
 left. Rarely are both sides equal. 
 
 4. In no form of brain disease (except, perhaps, gen- 
 eral paresis accompanied by epileptiform crises) have 
 we seen so marked and constant a variation between the 
 weights of the hemispheres as in epilepsy. 
 
 In the medulla oblongata Kroon has seen asj^mmetry 
 also. 
 
 Some have believed that the origin of the disease lay 
 in the closure or stenosis of the superior part of the verte- 
 bral canal. While the writer has no intention of deny- 
 ing that the observations of all these investigators are 
 correct, they form on collateral information and in 
 reality give us no clue as to the immediate lesions 
 themselves. No one would be insane enou2:h to claim 
 that either cerebral or medullar}' asymmetry caused epi- 
 lepsy. These changes form the physiological t^'pe, are 
 
 ' Epilepsy and Othci- Convulsive Disorders. 
 ^ Quoted by Axenfeld. 
 
Patliology. 1 59 
 
 entirely secondary to the disease, or have no connection 
 therewith whatever. The writer should also mention the 
 belief of Schroeder von der Kolk,i that the medulla is 
 always found to be in a sclerotic condition. 
 
 It is almost impossible, however, to say this change 
 is primary and this one secondarj- ; we can only call 
 those changes primar}^ where the evidence in regard to 
 them, as being such, is proved. Thus, the changes noted 
 by Greenlees ^ are evidently secondary, for he found that 
 they resembled those of prolonged cerebral congestion. 
 The muscular coat of the blood-vessels were thickened, 
 and the large ganglion-cells atrophied. 
 
 With a very few more remarks as to the morbid 
 anatomy of epilepsy, the writer will pass on to the 
 question of the changes seen in epilepsy due to syphilis, 
 embolism, and similar conditions. Within the last two 
 3'ears a very interesting paper has been published b}^ Der- 
 ciim,^ on the brains of twelve epileptics, and the author 
 does not hesitate to quote his studies here. In all of these 
 brains abnormalities of the sulci and gyri were found, 
 and in several thickening of the skull was also present. 
 In some of the brains there was overdevelopment of the 
 occipital lobe, with abnormal sulci. In several otliers, 
 the parieto-occipital and interparietal sulci were con- 
 fluent, producing an arrangement similar to that of 
 monkeys. In a number of cases the fissure of Kolando 
 opened into the Sylvian fissure. Abnormal sulci were 
 Also found in the frontal lobe. In two of the brains the 
 cuneus and in another the lobus quadratus were enor- 
 mous. In one case an entirely abnormal sulcus trav- 
 ersed the first temporal gyrus. While in nearly every 
 
 ^ Loc. cit, 
 
 ^ Joum, Ment. Science, October, 1885, p. 353. 
 
 ^ Proceedings of the Pliiladelphia Neurological Society, Dec. 26, 1886. 
 
160 Exnlepsy : its Pathology and Ty^eatment. 
 
 one of the 12 cases there was evidence of mechani- 
 cal liindrance to brain development, there were also 
 pathological changes going on. 
 
 Zohrab^ has recently published the records of an 
 examination of several brains of epileptics, in all of 
 which he fonnd necrosed and softened spots around and 
 beneath the horns of the lateral ventricles. 
 
 In syphilitic epilepsy the lesions producing the 
 trouble are much more understood than those of the 
 idiopathic t3q)e, and a very large amount of literature 
 has been written concerning them. In a series of 21 
 cases of this disease, Echeverria^ found general scattered 
 lesions all through the brain in 8 cases, in the motor 
 zone in 4 cases, in the temporo-sphenoidal in 2 cases, 
 and in the occipital area in 3 cases. In 4 other cases 
 there was disease of the base of the skull. In 10 
 instances there was atheroma of the cerebral arteries, 
 twice there was aneurism of tlie Sylvian arterj^, and once 
 of the basilar artery. In addition to these changes, 
 there were gummata in the cortex, or the snbstance of 
 the hemispheres and ganglionic centres, or there was 
 cerebral sclerosis. These changes do not, however, 
 always occur even in syphilis, for not only has clinical 
 experience shown me many cases of tlie disease where 
 no changes could be detected, but also Charcot and 
 Pitres^ have recorded the most typical Jacksonian epi- 
 lepsy without any demonstrable lesions whatever. 
 
 That gummata are quite capable of originating con- 
 vulsive seizures by their presence is proved hy daily 
 experience. They may act by so interfering with the 
 
 • Archives de Neurologie, May, 1886. 
 
 = Journ. Ment. Science, July, 1880, p. 165. 
 
 ' Nouvelle Contribution a 1' etude des Localisations motrices dans 
 I'Ecorce des Hemispheres da Uerveau. Revue Mensuelle de med. et de 
 Chir. Nov., 1879, p. 814. 
 
Pathology. 161 
 
 nutrition of cells as to render them diseased all about 
 that region, or by the irritation which thej'^ produce by 
 their presence. 
 
 Thrombi and emboli are also the primary causes of 
 convulsions, both in syphilis, in rheumatism, and in 
 cardiac disease, as well as in mauN'' other somewhat 
 similar conditions. The rule is that a tumor of the 
 brain or an embolism does not produce convulsions be- 
 cause it is a tumor or an embolism, but because it is 
 situated in an area pregnant with the possibilities of 
 convulsion. Abscess acts in the same manner, and de- 
 pressions of the skull from injury or effusions of blood 
 may so result. 
 
 The pathology of epileptiform migraine is, perhaps, 
 one of the most readily explained points in the discus- 
 sion of epileptiform disease. It will be remembered 
 that Jackson and others have considered that all cases 
 of true migraine are really evidences of disturbances in 
 the sensor}^ portion of the cortex in the ^ame manner as 
 epileps}^ may be due to irritation of the motor portion. 
 In the first place, the verj' character of typical migraine 
 is epileptic, for it is generally preceded b}^ hemianopsia 
 for a varj'ing length of time. Spasm of localized 
 muscles near the area of pain is not rare, and spasm of 
 muscles and centres elsewhere may be present, as in the 
 case quoted wlien speaking of the symptoms. 
 
 It has been held, too, that the vasomotor and pupil- 
 lary changes so often seen in migraine are due to the 
 extension of irritation into the medulla oblongata and 
 the cilio-spinal region of the cord. 
 
 The pathology of plumbic epilepsy is much more 
 simple than that of the idiopathic group, for we find 
 that there is always some more or less well-marked 
 change in the brain, consisting in a fatty degeneration 
 
 G2 
 
162 Epilepsy: its Pathology and Treatment. 
 
 of the large cells, and afterward some atrophy. The 
 blood-vessels in this state are generally atheromatous, 
 or at least thickened, and the lymph-spaces show evi- 
 dences of wide-spread change. In some instances the 
 post-mortem examination reveals very acute and very 
 severe inflammatory changes, such as acute cerebritis, 
 but in others a more subacute or chronic change only 
 seems to be present. The general sj^stem elsewhere is 
 often found even more profoundly affected than the 
 brain, and the kidneys are almost invariably diseased 
 more or less. Indeed, so common is it to find renal dis- 
 order in these cases that some have attempted to prove 
 that the epilepsy of lead was reall}^ uraemic. I have 
 shown under the head of diagnosis that this is a mistake, 
 and that they can generally be separated. We have, to 
 be sure, an epileptiform attack due to uraemia produced 
 secondarily by lead, but we also have one in which the 
 lead acts directl}^ Rosenstein^ has poisoned dogs with 
 lead in such a way that chronic poisoning resulted, and 
 lias seen epileptic fits produced in these animals in this 
 manner ; but he states positively that they were not 
 uraemic in character. He also found in these cases that 
 the lead could be recovered from the brain in large 
 quantities, and this is, as is well known, in accord with 
 hundreds of other observers who have proved that, in 
 chronic lead-poisoning, the metal is to be found in every 
 tissue of the body, even to the coats of the blood-vessels. 
 What has already been said must have enabled the 
 reader of this essay to see that epilepsy is essentially 
 a cortical disease of the cerebrum, brought about, of 
 course, in many ways. Either direct irritation of cer- 
 tain cells may so result, or indirectly by irritation of a 
 reflex character tlic}^ are perverted from their normal 
 
 ' Virchow's Arcliiv, 1867. 
 
Diagnosis. 163 
 
 function. I^o one, be he ever so wise, will be able to 
 tell the reader the ultimate cause of the nervous discharge 
 which causes the attack, until some one has discovered 
 the manner in which the remote something which causes 
 nervous protoplasm to give forth impulses acts. Above 
 all, the author desires to impress the idea that epilepsy 
 does not signify a disease, but a S3'mptom of a disease. 
 It should not, strictly speaking, be employed or applied 
 respecting the condition which is now indicated by it 
 any more than the word dropsy should be used to indi- 
 cate nephritis. Epilepsy is the manifestation of morbid 
 nervous changes, even as dropsy is of renal or cardiac 
 lesions. 
 
 Diagnosis. — When speaking of the symptoms of 
 epilepsy the writer has so thoroughly described them in 
 all their details that, under this heading, he will rather 
 devote his efforts to the question of differential diag- 
 nosis. 
 
 Undoubtedly, the most similar convulsive condition 
 that we have is that known as hj^steria, and the diagnosis 
 of one from the other is as difficult in some cases as it is 
 essential and necessary for treatment and cure. The 
 other conditions, with which it might be confused, are 
 uraemia, alcoholic epilepsy, tetanus, and syncope. On 
 the following page are arranged all these disorders in 
 a table, which briefly and succinctly shows the dif- 
 ferent points between them, although, of necessity', it is 
 somewhat arbitrary on account of the lack of space. 
 Nevertheless, it is hoped that it will be clear enough to 
 be of service, particularly in connection with what the 
 author is about to sa}^ 
 
 The A^ery irregularity of true epilepsy makes it ex- 
 tremely difficult to give clear and well-defined outlines 
 of it against another disease, particularly when we 
 
164 Epilepsy: its Pathology and Treatment. 
 
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Diagnosis. 165 
 
 remember that epilepsy and hysteria often go hand 
 in hand. 
 
 B}^ far the most important differential point between 
 tlie two disorders jnst named, when not complicated 
 with still another disease, is the character of the move- 
 ments. As already pointed out, in epilepsy they are 
 t^q^ically at variance with those of daily life, while in 
 h^'steria they are almost equally t^qncal of ordinary 
 muscular contractions, or, in other words, are more pur- 
 posive in character ; and frequently there is prolonged 
 tonic contraction of the muscles, giving rise to the as- 
 sumption of positions which bear more or less resem- 
 blance to normal attitudes. In In^steria, also, conscious- 
 ness is impaired sometimes, but never so completely as 
 in true epileps^^ Indeed, most commonl}" the individual 
 knows all that goes on around her, for, while she may 
 give no sign of consciousness by words or looks during 
 the attack, she ma}^ afterward be able to narrate all that 
 has occurred. Less commonly, however, a condition 
 known as automatic consciousness exists, iu w'hich, dur- 
 ing the paroxysm, the patient understands all that is 
 said, but forgets everything on the return to quietness. 
 
 The fact that the patient is a female cannot be re- 
 garded as affirmative evidence of hysteria in the least, 
 but the condition occurring in a male may be taken as 
 fairly positive evidence of its being epileps}^ ; and 3 et 
 it should always be remembered that males may suffer 
 from hysteroid attacks. 
 
 The movements of the hysterical patient after the 
 tonic condition has passed awa}^ are as clonic as those 
 of epilepsy, but still possess some purposive character- 
 istics, and are not so bizarre as are those of the true 
 disease. Thus, the head, arms, and legs, are struck 
 with evident endeavor against the floor or surrounding 
 
166 Epilepsy: its Pathology and Treatment. 
 
 furniture. Another point, which, when it occurs, is very 
 distinctive, is tlie onset, toward the close of a hysterical 
 convulsion, of a second stage of tonic spasm such as 
 occurred at the beginning. It will be remembered that 
 this does not occur in epilepsy, although it must be 
 borne in mind that in cases of the " status epilepticus " 
 the rapid onset of another attack ma}^ show a second 
 tonic stage. This can be separated, however, by the fact 
 that it is followed by clonic movements, whereas the 
 secondar}^ tonic stage of hysteria is usually followed by 
 relaxation and temporary recover3^ 
 
 In the secondaiy hysterical tonic contractions em- 
 prosthotonos and opistliotonos may occur, and are even 
 more rigid in their character than tliej' are in the first, 
 in some cases. Finally, too, in h3'steria, some peculiar 
 emotional position is often assumed, as of the crucifix, or 
 of intense grief, or, perhaps, immoderate laughter, with 
 corresponding movements of the trunk. If the patient is 
 quiet at this time, a smile may float across the face, while 
 the eyes, with a look of pleasure, pain, or entreaty, may 
 seem to be gazing at some object ver}^ fixr off. In some 
 very well developed cases the expression of i)leasure is 
 followed by a look of pain, with painful movements, or 
 an intense appearance of voluptuous entreat}^ with 
 sensual and venereal desire evidenced by gestures. Great 
 terror may be present, and, as the scene constantl}^ 
 changes, the woman is now jo3'ous, now mournful, now 
 scolding, now praising her attendants or herself. Such 
 is the histor}^ of a fully-developed attack of liysteria. 
 
 Hysteria is rarely seen among tlie Germans, Belgians, 
 or corresponding races, but very frequently observed by 
 French practitioners of medicine. 
 
 In France there can be no doubt that the tongue is 
 commonly bitten in hysterical convulsions, and that 
 
Diagnosis. 167 
 
 frothing of the month is freqnently present ; but in 
 the other countries which have been spoken of its pres- 
 ence may be regarded as indicative of epilepsy rather 
 than h3'Steria. Doubtless the inexperienced reader will 
 say, upon comparing these s^^mptoms with those which 
 were given as occurring in epilepsy proper, that the two 
 disorders are easily separated from one another ; but 
 the author must insist most strenuously upon the fact 
 that in both cases he has onlj' given the most t3'pical 
 characteristics of the diseases, and he repeats that all 
 cases are not b}^ any means so well defined. He would 
 also remind the reader that the chief difficulty in making 
 a diagnosis lies in the fact that frequently it must be 
 found without any previous history of the case, as when a 
 patient is brouglit into a hospital, in a fit, for treatment. 
 Where the history is obtainable, or where the diagnosis 
 can be put off until the case may be studied, the question 
 becomes more simple. 
 
 If a large number of patients suflfering from these 
 hysterical attacks be questioned in between times, it will 
 be found that the so-called globus hystei^icus becomes an 
 almost constant precursory symptom of an attack, and 
 if the relatives be questioned it will often appear that 
 they have noticed that the fall to the floor is more gentle 
 than in true epilepsy ; but this is not alwaj'S so, hy any 
 means. Again, the expression of the face in hysteria is, 
 between the attacks, often very characteristic, and the 
 surrounding atmosphere of the patient seems, even to 
 the inexperienced, to breathe hysteria. Yery commonly 
 areas of anaesthesia and 113'peraestliesia occur in these 
 patients, and are of all degrees of intensity and limita- 
 tion. Search for them generally shows their presence 
 after attacks of convulsions, but they may exist from 
 one attack to the other, or develop spontaneously. In 
 
168 Epilejy^y : its Pathology and Treatment. 
 
 nearl}^ all cases these areas are unilateral, and may ex- 
 tend entirely over one-liaif of the body, the line of de- 
 marcation of the anaisthesia or hypersesthesia, from the 
 -sound area, being clearly and abruptly defined, gcncrall}^ 
 t\t the median line of the front and back of the trunk. 
 Jt will be called to mind that such conditions are yory 
 ] are in true epilepsy. Hallucinations are far more com- 
 mon after the fit in liysteria than in epileps}^, and some- 
 times the}^ even occur during the attacks. They are 
 always associated with the mental states ; in terror, rats 
 or disgusting objects are seen , and, according to Charcot,^ 
 are generally seen on the side which, during the inter- 
 missions, is anaesthetic. The pupil is more mobile in 
 hysteria than in epilepsy', but may be contracted, normal, 
 or widely dilated. 
 
 The following ta]>le gives, in as brief a manner as 
 possible, the differential diagnosis between epilepsy and 
 lij'stero-epilepsy, nnd is founded on a lecture b3^ Pro- 
 fessor Charcot,^ delivered at the Salpetriere. Aside 
 from its conciseness the writer has inserted it here 
 because of the standing of its partial originator, whose 
 opinions on such subjects are, of course, of immense 
 value hy reason of his ability and opportunities : — 
 
 True Epilepsy. 
 Aura short. 
 Cry is violent. 
 
 Spasms first tonic, then clonic, 
 then followed by stertor. 
 
 Sometimes after fit delirium or 
 
 violent impulse or mania. 
 Mental power is lost. 
 No emotional attitudes. 
 
 Hystero-Epilepsy. 
 
 Aura extremely prolonged. 
 
 Cry is more moderate and pro- 
 longed. 
 
 Ataxic contractions, extension of 
 limbs, turning of head, clonic 
 movements, slight stertor. 
 
 Bizarre contractions, no delirium, 
 may be hallucinations. 
 
 Mental power preserved. 
 
 Emotional attitudes. 
 
 • Tief;on snr los maladies du sj'Steme nervcvix. Paris. 
 ' Gazette des Hopitaux, 1878. 
 
Diagnosis. 169 
 
 A veiy nsefiil differential point, strong!}^ insisted 
 upon l)}^ Clhircot imd Bourne ville, is that in true epilepsy 
 there is generall}^ a ver}^ considerable rise of tempera- 
 lure during an attack, wliile in h3'stero-epilepsy the 
 temperature remains normal or onl}^ slightly raised. 
 
 Some observations, made b}^ Charcot^ in " status epi- 
 lepticus," showed that the temperature in this condition 
 rises to 40° or 41° C. (104° or 106° F.), or even as 
 high as 42° C. (107.6° F.). Under these circumstances 
 death often comes on rapidly. In hystero-epilepsy, on 
 the other hand, Charcot found that the bodily tempera- 
 ture always remains at 37.5° to 38° C, and death is 
 exceedingly rare or never occurs. These observations 
 have been found true hj many other observers, and there 
 can be no doubt of their truth. 
 
 Some authors state that a continuous rise of tempera- 
 ture in hystero-epilepsy is sufficient to establish the pres- 
 ence of some other disease, or else a ver}' threatening 
 condition of the nerve-centres. Thus, in a case reported 
 by Quincke, 2 after a series of ap3'retic convulsions, con- 
 vulsions occurred with elevation of the temperature to 
 43° C, and soon ended in death. 
 
 In the diagnosis of true epileps}^ from convulsions of 
 a h3^steroid character, it is well for the ph3'sician to re- 
 member that the proportion of the two conditions in 
 frequency of occurrence is, according to Gowers {loo. 
 cit.), 815 to 185 in ever3^ 1000 cases. 
 
 The differentiation of epilepsy from uraemia is much 
 more readily carried out, for there is usuall3^ a previous 
 history of s3'mptoms pointing to renal trouble, as, for 
 example, some oedema, or somnolence, or mental apath3^, 
 for some days or hours before the attack. Of course, 
 
 * Le Progres Medical, Jan. 10, 1874. 
 3 Archiv f . HeUkunde, 1864. 
 8 H 
 
170 Epilepsy: its Pathology and Treatment. 
 
 in such cases, recourse may be had to the ordinary tests 
 for such conditions of the urinar3^ organs as are gen- 
 erally found where uraemia exists ; but it is to be re- 
 membered that epilepsy and kidney disease may exist 
 hand in hand, and that, for this reason, the prognosis 
 and diagnosis are to be carefully formed and given. If, 
 in a given case, a prolonged history of dyspepsia, of 
 frequent vomiting, occasional attacks of asthma and 
 failure of general health is found to be present, the 
 diagnosis ought probably to be ursemia. The preserva- 
 tion or loss of consciousness in ursemic convulsions is 
 variable. Generally if the convulsion is wide-spread and 
 severe the intellection is lost, but if it be only a slight 
 attack it may be preserved. So long ago as 1840 Dr. 
 Bright described cases of uraemia, on the other hand, in 
 which furious convulsions occurred without loss of con- 
 sciousness, and Roberts has reported similar instances. 
 Just here the author may remind the reader that not 
 more than thirty 3^ears ago some physicians of very high 
 standing believed epilepsj^ to be due entirely to uraemia. 
 Thus, Sievekingi firmly believed in this theory and 
 reported a case in support of his views. Fatal uraemia 
 may also occur in a patient whose urine is apparently 
 normal; and, in a large number of cases of chronic 
 contracted kidney, albumen may be absent from the 
 urine for long periods of time. The specific gravity of 
 the urine should be carefully noted, and in very doubtful 
 cases careful estimations of the urea be made. If the 
 specific gravit}^ is constantly below 1.010 the kidney 
 will nearly always be found contracted unless diabetes 
 exists. Tests of the urine passed at dilFerent times of 
 the day should always be made. Another means of 
 testing the integrit}^ of the kidney is to administer 
 
 * Brit. Med. Jour., March 20, 1858 p. 235. 
 
Diagnosis. Itl 
 
 iodide of potassium mid study its elimination. It is 
 affirmed that, after a full dose, this drug can in an hour 
 be readily recognized in the urine b}^ adding nitric acid 
 and then starch ; but when contracted kidney exists the 
 iodide fails to appear or is excreted only in ver}^ small 
 quantities. The temperature of the body may also be 
 used to differentiate between uraemia and epilepsy. In 
 1865 Kien^ called attention to the fact that even when 
 ursemic convulsions are most violent they are accom- 
 panied by a fall of temperature of as marked a character 
 as the rise noted in respect to epileps3^ Since then, this 
 has been confirmed by Roberts, Hirtz, Hutchinson, 
 Charcot, Bourneville,^ and Teinurier. 
 
 The diagnosis between puerperal eclampsia and 
 epilepsy consists chiefly in the acuteness of the attack 
 and the fact that with no previous convulsive history a 
 woman becomes suddenl}^ convulsed during t]ie puerperal 
 state. This is not a place for tlie discussion of the identity 
 of ursemia and puerperal eclampsia, although we believe 
 that this is generally supposed to cause the nervous dis- 
 turbance. If the convulsions are ursemic, the tempera- 
 ture, according to the investigators just quoted, should 
 fall, but according to Bourneville {loc. cit.) they are dis- 
 tinctly separated from those of uraemia, by reason of 
 the fact that the temperature rises with great rapidity- in 
 the very beginning of the convulsions, and there remains 
 with great steadiness. The condition of bodily tempera- 
 ture cannot, therefore, be used to differentiate puerj^eral 
 eclampsia and epileps}^ 
 
 It is important to determine whether idiopathic 
 epilepsy can be separated from that due to syphilis 
 
 * Gazette Med. de Strasbourg, 1865, p. 12. 
 
 ' Etudes Clin, et thera. sur les maladies du systeme nerveux. 
 Paris, 1873. 
 
172 Epilepsy: its Pathology and Treatment. 
 
 simply by the symptoms. Of course, this is very diffi- 
 cult to decide ; but the answer to a question of this 
 character ought to be that, so far as the convulsion itself 
 is concerned, it is not possible to separate them. If, 
 however, we can obtain any history the matter becomes 
 much more simple. It is cljaracteristic of syphilis to 
 have severe darting or aching pains in the tibiae, par- 
 ticularly at night, and it is also characteristic of syph- 
 ilitic epileps3^ to have severe frontal headache before the 
 attack, while in idiopathic epilepsy this pain generally 
 follows the seizure. 
 
 Fournier, in his lectures on epilepsy, in the Louvain, 
 in Paris, in 1875, gave a summary of his views as 
 follows : — 
 
 1. In syphilitic epilepsy there is nearl}^ alwa3's 
 absence of the shrill cry at the onset, so characteristic 
 of the idiopathic variet3^ 
 
 2. There is frequently paralysis immediately after 
 the attacks. 
 
 3. The seizure is incomplete or unilateral in char- 
 acter. 
 
 4. Attacks constantl}^ increase in severit}^ 
 
 A therapeutic point, which may be used with the 
 greatest success, is the administration of iodide of potas- 
 sium in large doses. If the epilepsy be syphilitic, it will 
 rapidly become less severe, and enormous amounts of 
 the drug will be borne with impunit3\ As much as 30 
 grammes will often do no harm in twent3^-four hours.* 
 
 It has been thought by some that the mental hebe- 
 tude, between the attacks, is greater in S3'philitics than 
 in others. This depends very largely on the area of 
 the cerebrum involved, and not upon the disease itself. 
 
 * I find on reading several papers ou the subject that Fournier has 
 also great confidence in this test. 
 
Diagnosis. 1T3 
 
 Of course, if there is a history of a chancre, or any syphi- 
 litic scars or erosions are to be seen, the diagnosis is mani- 
 fest. It is very common in syphilitic epilepsy to find 
 that the attacks are followed by prolonged attacks of 
 paralysis, not due so much to the exhaustion of the 
 centres as to the irritation produced by the gummata or 
 the inflammation which sometimes springs up around 
 them. It is also a noteworthy fact that the paralysis 
 most commonly seen involves the motor ocularis, abdu- 
 cens, and patheticus. 
 
 The diagnosis of S3'philitic epilepsy from the idio- 
 pathic form is of the utmost im[)ortance, since the 
 ultimate result must be largely governed by the cause. 
 Dowse^ has analyzed no less than 274 cases in order to 
 discover any useful points in this respect. He insists, as 
 the writer has already done, that epileptic attacks begin- 
 ning after 30 3'ears of age are almost surel}^ s^^jhilitic, 
 particularl}^ if no histor^^ of traumatism or heredity is 
 present. It is also found that, if some degree of mental 
 alienation is present between the paroxj^sms it will gener- 
 ally 3neld to specific remedies. Cyanosis is less fre- 
 quent and pallor is more common than in the ordinary 
 disease. 
 
 It is unnecessary'- for me to state once more tnat 
 petit mal is but a variety or modification of haut mal. 
 Nevertheless, it is useful to be able to separate it some 
 what from the more severe form of the disease in the 
 attempt to form a prognosis. 
 
 Some suppose that petit mal ma}^ be designated as 
 consisting of one or two of the chief symptoms of 
 epilepsy proper, and others have thought that the pres- 
 ervation of consciousness was the chief dividing-line. 
 The last idea is certainly incorrect ; but it is impossible 
 
 * Practitioner, Oct., 1878. 
 
1*T4 Epilepsy: its Pathology and Treatment. 
 
 to give any outline which will absolutely separate the 
 two conditions, so far as symptoms go. An important 
 and useful point first discovered by the celebrated neu- 
 rologist, Weir Mitchell,^ is that, whereas the inhalation 
 of amyl nitrite stops true epilepsy, the use of this drug 
 increases the severity of an attack of petit mal. 
 
 Alcoholic epileps}'^ occurring during an attack of 
 mania a potu is, of course, easily diagnosed, and the 
 general appearance of the patient, combined with his 
 history, suffices to decide the physician. The move- 
 ments are more clonic than tonic, and often are lacking 
 in force. There is, however, no constant distinction 
 between the s^^mptoms applicable to all cases. Gener- 
 ally one seizure of alcoholic epilepsy follows the other 
 every few minutes until three or four have taken place, 
 when the paroxysms cease. It is not to be forgotten 
 that alcohol may produce all degrees of epileps}^, from 
 the mildest petit mal to the most severe paroxysms ; 
 and it is also to be remembered that hallucinations of 
 terror are very commonly present. 
 
 There may be an aura in alcoholic epilepsy quite as 
 marked as in the true disease. 
 
 The separation of s^^ncope from epilepsy is one of 
 the easier tasks imposed upon us. The color of the 
 face, the weakened heart-beat, sudden loss of conscious- 
 ness, and the general appearance aid us here very much. 
 
 The separation of epilepsy from hemicrania has been 
 very well written of by Silva.^ He thinks that epilepsy 
 begins in childhood below puberty, most commonly, 
 while hemicrania comes on after puberty ; and that the 
 attacks of hemicrania decrease in violence and frequency 
 as age increases, while the contrary rule applies to 
 
 • Philadelphia Med. Times, vol. v, p. 553. 
 
 ' Giornale di Neuropatologie, fasc. i and ii, 1885. 
 
Diagnosis. 175 
 
 epilepsy. It will be seen that these views are in accord 
 with those of Striimpel and Wagner {loc. cit.). 
 
 Before closing this section of the essay the writer must 
 bring forward the points to be used in differentiating epi- 
 lepsy from those attacks simulated by malingerers. ften 
 this is most difficult ; and it is related of Fournier that, 
 after his expressing an opinion that a man could always 
 tell them apart, one of his assistants threw himself to 
 the floor on his next visit, in a pretended attack, where- 
 upon Fournier, completely misled, exclaimed, " Poor 
 
 M. , he is epileptic," upon which the assistant, 
 
 smiling, arose to his feet and confuted the statement. 
 
 Yery serious injuries are sometimes submitted to by 
 these persons to carry out their designs. Thus, the 
 famous case of a man named Clegg may be cited, who, 
 to deceive a suspicious physician, threw himself, in a pre- 
 tended fit, to the iron floor of a jail, the distance being 
 20 feet. The points to be looked into are : the condition 
 of the pupils, which, in the simulated attack, always react 
 normally, nor can the corneal reflexes be held back, the 
 color of the face is rarely changed, and the thumbs are 
 rarely flexed as they should be. Marc^ has pointed out 
 that in malingerera the by-stander can readily straighten 
 the thumbs out, and that they remain so ; whereas, in 
 epilepsy they instantly become flexed again. 
 
 Suggestions as to movements are sometimes followed 
 by malingerers, and the movements generall}^ lack the 
 bizarre character so typical of epileps}-. 
 
 If tobacco or ammonia be held to the nose of the 
 fraud, he generally is forced to disclose his true nature. 
 
 The fact that in malingerers there is no rise of tem- 
 perature may also serve as a diff*erential point. 
 
 The diagnosis of lead epilepsy from the idiopathic 
 * Diet, des Sciences Med., vol. xii, p. &i2. 
 
176 Epilepsy: its Pathology and Treatment, 
 
 varieties is somewhat difficult, if the patient is seen for 
 the first time during an attack, but the ordinary methods 
 of determining chronic lead poisoning are, of course, of 
 equal value here. Tlie blue line on the gums may be 
 present, and, if so, the diagnosis is almost certainly lead ; 
 but its absence is no proof that lead is not present. The 
 administration of iodide of potassium also will so in- 
 crease the elimination of the poison as to benefit tbe 
 case and render it more easy to recover lead from tiie 
 urine. 
 
 The history of exposure to lead in any form is, of 
 course, exceedingly valuable evidence, but it should not 
 be forgotten that in many cases this liistor3^ is wanting. 
 Thus, the poison may be due to a hair-dye, or cosmetic, 
 or to water which contains lead from pipes, or an 
 endless line of similar hidden and obscure causes. 
 Amaurosis may be present in some cases, or optic neu- 
 ritis with atrophy may occur. Where double wrist-drop 
 is present tlie diagnosis ma}- be much more easy. 
 
 It is exceedingly important to differentiate between 
 those convulsions which arise from the unemia brouirht 
 on secondarily by an action of the lead on the kidnej's 
 and those whicli are due to a direct action on the brain. 
 This may be difficult from the mere sym[)toms presented, 
 but there are some points of difference. In the first 
 place, the convulsion of ursemia is, as a general rule, not 
 so violent in its movements, nor so sudden in its onset. 
 It is generall}^ preceded by a few days of somnolence, 
 or weeks of gastric disorder and headache, while lead 
 epilepsy is generally sudden, or preceded by cephalalgia 
 by only a few days or hours. Again, examination of tlie 
 urine in ur?emic convulsions will show a decreased 
 amount of urates in proportion to the quantity of urine 
 passed, while in plumbic epilepsy just the reverse will 
 
Diagnosis. 117 
 
 be true, unless the kiclne3's ure affected pari passu with 
 the cerebrum. If albumen be present, uraemia is pointed 
 to; but if the urine has a low specific gravity, and is 
 passed in large amounts, the indications are that there is 
 chronic contracted kidne}^, which may or may not be the 
 cause of the nervous disturbance. (See diagnosis of 
 uraemia, several pages back.) 
 
 Aside from the symptoms of epilepsy which have 
 been given, one or two additional facts may be worthy of 
 record. It has been claimed by Addison^ and others 
 that epileptics have certain ph3'siognomicaI character- 
 istics, particularly if insanity also be present. Addison, 
 in 50 cases, made up of 39 males and 11 females, 
 recorded these signs as follows : — 
 
 Males. Females. Total. 
 
 Face pallid, 24 6 30 
 
 Lips thick, 20 7 2% 
 
 Eyelids puffy, 33 9 41 
 
 Pupils large, 20 5 25 
 
 " medium, 19 6 25 
 
 '' unequal, 3 2 
 
 The general aspect presented in chronic epileptics is 
 certainly as these figures represent it to be ; but it has 
 already been described so thoroughly that the writer 
 will not do so again. 
 
 If there is a history of spasms in a case coming to our 
 knowledge, in which we find asymmetry of the head and 
 face, scarred tongue, and thick, puffy, sensual, or brutish 
 lips, there should be very well founded suspicions that 
 the man is suffering from epilepsy. The skin in such 
 cases is cold and clammy, particularly about the hands, 
 and lacks its normal tone and color. Besides this, it 
 in many cases gives rise to a peculiar musty odor. 
 
 It would be out of place for the writer, at this point, 
 
 * Journal Ment. Sci., vol. xii, 1867. 
 8* 
 
178 Epilepsy: its Pathology and Treatment. 
 
 to consider the surgical diagnosis necessary before the 
 operation can be performed to relieve an epilepsy de- 
 pendent on a tumor, an abscess, or any similar condition. 
 Both the question as to the character of the lesion 
 and its seat must be settled, and not only a minute 
 study of cerebral pathology would be necessary for a 
 complete mastery of the matter in liand, but also a 
 thorough understanding of cerebral localization, which 
 it is not in the writer's power to give in an essay on 
 epilepsy. 
 
 As an illustration of the value of cerebral localization 
 in diagnosis, let the author just here give a case shown 
 to him b}^ Dr. Hughlings-Jackson during his visit to 
 London. 
 
 A man, aged 20 or 25 years, with angular curvature 
 of the spine, began to have slight evidences of the so- 
 called Jacksonian epilepsy in the muscles governing the 
 thumb of the left hand. These attacks increased in 
 force and frequency, and gradually involved the entire 
 body. At Dr. Jackson's request, Mr. Horsley cut down 
 over the region known as the thumb-centre, and found a 
 small tumor pressing on the surrounding parts. This 
 he removed, the wound healed b}^ first intention, and the 
 man has had but one or two mild attacks since, and 
 these soon after he was operated on. The left thumb is 
 now paralyzed, but the epilepsy has ceased. It may also 
 be stated, in order to show what unfavorable cases re- 
 cover, ^hat the spinal curvature is sufficient to produce a 
 paraplegia, which still remains. 
 
 Beevor* has attempted to show that there is a rela- 
 tionship between the giddiness which sometimes consti- 
 tutes the aura of epilepsy and the direction in which the 
 patient primarily rotates, using this as a means of diag- 
 
 » Brain, Jan., 1881 
 
Prognosis. ] ^9 
 
 nosis in those cases where no history can be obtained as 
 to the primary movements from the patient's friends ; 
 that is, he finds that the patient can generally recall 
 the direction of the giddy sensation felt beforehand, 
 while the friends may have overlooked the follow- 
 ing movements. The value of the point, supposing 
 it to be true, rests upon the localization of the side 
 of the brain most affected. In IT cases examined by 
 him all of them felt giddy in the direction in which 
 they ultimately moved, or, in other words, the sur- 
 rounding objects passed in a stream toward the side to 
 which the head was about to be turned. In all these 
 cases he was careful to distinguish between simple 
 giddiness and that due to ear disease or faintness, using 
 only the purer cases, where no manifest lesion was 
 apparent. 
 
 Prognosis. — The ph^^sician can always assure ^he 
 patient and friends that so far as the disease is itself con- 
 cerned there is little danger of death, since, as a general 
 rule, unless the attacks are very severe, death rarely 
 occurs, unless indirectly, b}^ the fall of the body into a 
 stream, or well, or when in some position where a steady 
 head is necessary for safet}'. Accidental asphyxia, due 
 to the burying of the face in the pillow at night, or to 
 the impaction of food in the lar3'nx, may occur, but even 
 this accident is uncommon. Some superintendents of 
 insane asylums in which epileptics are cared for have 
 resorted to shields, which, being worn over the face at 
 night, holds the mouth so far awa}^ from the pillow as to 
 prevent the supply of air being shut off. As the ten- 
 dency to turn on the face is rarely seen, this danger is 
 overestimated. 
 
 The question which the friends will alwaj-s ask is, 
 What is the prospect of ultimate recovery, or, at the 
 
180 Ejnlepfiy : its Pathology and Treatment. 
 
 least, will there be any progress toward an improve- 
 ment? Unfortunntely, the reply ought not, in any case 
 of the idiopathic form, to be favorable, even for ultimate 
 improvement, for the experience in the past of ever3'^ 
 large practitioner has been that cures rarely occur. 
 Several points which have a favorable bearing ma}'^, 
 however, be oftered in consolation, as lightening the 
 severity of the sentence; for it will be remembered that, 
 in many instances, if the disease is taken powerfully in 
 hand earl}' in its life and in the life of the patient, the 
 results are certainly fairl}^ good. This is particularly 
 true if the disease seems to be mild at the beginning. 
 Too much encouragement should not be held out from 
 the use of drugs ; but this should not be impressed upon 
 the patient's mind, since it is sure to render him careless 
 in taking the remedies prescribed. The influence which 
 sex exerts on prognosis is doubtful, although one or 
 two recent writers (Gowers, for example) think that it is 
 slightly better in males than in females. If this is true, 
 the reason of it ma}-^ lie in the greater strain placed upon 
 females at the age of puberty. 
 
 Curiously enough, hercditar}^ predisposition does not 
 seem to increase the gravity of the prognosis, but rather 
 to improve it, for Herpin^ and Gowers^ have both found 
 this true. The latter attempts to explain this by the 
 hypothesis that, as the primary tendency is present, it 
 requires only a slight cause to excite it, which cause is 
 so slight that it is readily overcome by treatment. The 
 knowledge of the frequency of attack is also very im- 
 portant to the physician in forming a prognosis, as is 
 seen b}^ the following table made by Gowers. It is 
 certainly sufficiently convincing in its figures, and for 
 
 '■ Du pronostic ct du traitoment curatif de rtpllepsie, p. 515. Paris, 1852. 
 2 Epilepsy, p. 246. London. 
 
Prognosis. 181 
 
 this reason the writer talves the liberty of inserting 
 it here. 
 
 In 100 cases the results were as follow : — 
 
 Cases. Percentage. 
 
 pYolS;. Anested. Ujj,- Arrested. 
 
 Attacks daily, ... 7 1 18 1.8 
 
 Daily or weekly, ... 11 29 29 46.7 
 
 Eight days to 1 month, . . 16 15 43 24.2 
 
 Over 1 month, ... 4 17 11 27.3 
 
 38 62 100 100.0 
 
 It has also been claimed that the presence of an aura 
 not only improves the prognosis by reason of its en- 
 abling the patient to get out of harm's, way, but also 
 seems to be associated with more remediable forms of 
 the disease. 
 
 These points are to be used in making predictions 
 for the future in idiopathic epilepsy only. Thej^ are* in 
 no wa}^ of value in other epilepsies, as will be pointed 
 out, but other things take their place. 
 
 In the first place, the very fact that idiopathic epi- 
 lepsy arises without a cause makes it unfavorable, since 
 we know not with what we have to deal ; whereas in 
 reflex epilepsy, or that dependent upon tumor, abscess, 
 or depressed bone, the ultimate result depends very 
 largely upon collateral facts, such as the situation of the 
 lesion, the safety of its removal by operation, or the 
 possibility of its removal by drugs, as in syphilis. In 
 regard to S3^philitic epilepsy, it may be asserted, with no 
 fear of contradiction, that it can, in the majority of cases, 
 be cured, and in nearly all cases improved. We find 
 that idiopathic epileps}^ has, therefore, the most gloomy 
 prognosis, while sj-philitic epilepsy has the most 
 promising. 
 
 The writer must issue a word of warning, however, 
 
182 Epilepsy: its Pathology and Treatment. 
 
 "wiiich often by its absence leads to disappointing results, 
 namely, very frequently epileptics, be the cause of tiie 
 disease what it may, improve greatly under proper treat- 
 ment for a short time, and then go no farther, or per- 
 haps move very slowly. The primary rapid improve- 
 ment deceives the physician and friends, whose en- 
 couraged thoughts should be held in check, lest they 
 be ultimatelj^ disappointed. 
 
 In post-hemiplegic epilepsy the prognosis is not 
 favorably for obvious reasons, because the lesion pro- 
 duced is one which drugs can only remedy very slightly, 
 and in which operative procedures are futile. 
 
 (For some of the other conditions influencing the 
 prognosis of epileps}^, see the section on Complications.) 
 
 Treatment. — After all, the treatment of epilepsy is, 
 to say the least, one of the most important questions 
 which come before the ph3'sician, and the only A^alue of 
 all our pathological knowledge lies in the aid which it 
 brings us in combating the disease. Unfortunately, 
 scientific physicians are too frequently inclined to study 
 morbid processes as far as they are interesting, neglect- 
 ing to use their store of facts for the good of future 
 sufferers, by attempting to argue out of them sensible 
 therapeutic measures founded on a scientific basis and 
 not on empiricism. 
 
 The autlior will not follow out in this essay the com- 
 mon custom of detailing remedies as useful or not useful, 
 and of recording cases where each remedy has produced 
 a cure ; but will endeavor not only to name the drugs 
 from which relief is obtained, but also explain why they 
 do good, whenever this is possible, in the light of our 
 present physiological and pathological knowledge. It 
 will be evident, from what follows, that the treatment 
 of epilepsy in the past has been as unwise as the treat- 
 
Treatment. 183 
 
 ment of every other disease, and the remedies have been 
 given in one case solely because they acted happily in 
 its predecessor, who had the same manifestations of tlie 
 disorder. It is just this senseless form of medication 
 which breeds the contradictory reports of the medical 
 press regarding certain remedies. 
 
 It should also be borne in mind that the treatment 
 of epilepsy is as various as the disease is variable in its 
 forms and phases, and should, in nearly all cases, resolve 
 itself into two or perhaps three divisions, consisting in 
 the removal of any exciting cause, in the checking of 
 the convulsive tendency already set up, and in the pre- 
 vention of any further attacks by suitable drugs or 
 other measures of relief. 
 
 The treatment is governed largely by the cause, and 
 is medicinal or operative, according to the etiological 
 factors at work. In the simple idiopathic epilepsy 
 medicinal means must be followed, while in a case re- 
 sulting from traumatism the depressed bone, abscess, or 
 tumor must be removed. In those due to reflex irrita- 
 tion the peripheral source of trouble must be sought 
 out and relieved. 
 
 The writer will first consider the use of drugs, merely 
 prefacing what he says b}^ remarking that, in some in- 
 stances, medicines and operative measures must go hand 
 in hand. 
 
 By far the most useful drug in use to-day for the 
 relief af epilepsy is bromide of potassium, although other 
 forms of bromide salts are to be mentioned later on. It 
 is useless for the author to attempt to give statistics as to 
 the truth of his statement, for every voice in the profes- 
 sion supports it ; and the fact has become so generally 
 recognized that very few papers, comparatively speaking, 
 appear concerning it in the medical journals of the 
 
184 Epilepny : its Pathology and Treatment. 
 
 present da}'. Tliis drug is not, however, a " cure-all," 
 even in epileps}-, and reports are constantly made of 
 cases where it has failed ; but in many cases the remedy 
 is undoubtedly responsible for a cure, when it is pushed 
 in a suitable manner, and, in the vast majority of in- 
 stances, the seizures are so decreased both in violence 
 and frequenc}' that its use may be said to be indicated 
 in ever}' case of the disease. In a very small minority, 
 however, it signally fails, and in a still smaller number 
 of cases it is useless unless combined with some other 
 drug whose power alone is very slight. Nevertheless, it 
 is to be laid down as a rule that the bromide treatment 
 of epileps}' is, jmr excellence ^ the treatment to be eni- 
 plo3'ed on every occasion. There is no other drug 
 known which can be relied upon so absolutel}', or which 
 is so powerful in its action and devoid of marked toxic 
 effect, unless given in enormous doses. Indeed, no fatal 
 case of poisoning has ever occurred from it alone, so 
 far as the author is aware, and he has searched the matter 
 thoroughly 
 
 The doses to be used vary with the salt emplo^^ed to 
 a considerable extent, and depend upon the character 
 of the disease and tem[)erament and ph3'sique of the pa- 
 tient. We have already pointed out that tlie greater the 
 duration of epilepsy is, the greater the difficulty is in 
 effecting a cure; and the length of time which the man 
 has been epileptic should therefore be most carefull}'- 
 reckoned before the treatment becfins. Further than 
 this, the frequency and severitj- of the attacks are to be i 
 looked into, and these points are really more important ' 
 than the actual duration of the ailment; since, if a man 
 has onl}'' one fit every six months for twenty 3'ears, his 
 condition is far less serious than if he has a history' of 
 three or four fits a day for one year. Again, the char- 
 
Treatment. 185 
 
 ncter of tlie attack, as to its violence, ma}- be the most 
 important fact to be regarded ; for, if tliej^ are violent 
 enough when they come on to endanger life, remedies 
 must be pushed even beyond the point of tolerance. The 
 author has heard a very celebrated physician cause much 
 amusement among his auditors by detailing au iustance 
 of an epileptic who was gettiug well, and would have re- 
 covered if he had not died. His explanation was that the 
 man was receiving moderate doses of potassium, which 
 were slowly benefiting him, and would have cured him 
 had not a single severe fit produced death in the mean- 
 while. 
 
 Another point to be calculated upon is the condition 
 of the digestion, which the bromide of potassium is 
 peculiarl}^ liable to disorder, and which is sometimes so 
 troublesome as to necessitate the administration of the 
 drug by the rectum in serious cases. Females generally 
 require smaller doses than males, and children of both 
 sexes do not require as large quantities as adults. The 
 dose to be used in the beginning of the treatment, in 
 moderate cases, is about 10 grains thrice a day; and, while 
 this may seem a ver\^ small quantity, the writer has found 
 that it can be rapidly increased in amount without caus- 
 ing the gastric distress produced by the sudden use of 
 larger doses. Every day may have an additional 10 
 grains added, until at the end of a week the patient is 
 taking 80 grains each day. There are very few cases 
 which will not become completely saturated b}^ the drug 
 if this is done ; and there are very few in which a more 
 rapid condition of bromism is needed. If, however, the 
 patient has become able to stand large amounts by the 
 prolonged use of the drug, the amount given is not to 
 be governed by grains, but physiological effects, and it 
 may be pushed almost to any amount which is borne. 
 
186 Epilepsy: its Pathology and Treatment. 
 
 It has been my experience, too, that in chronic epilepsy, 
 with regularly recurring fits, the greatest good is ob- 
 tained b}^ pushing the drug in ascending doses for one 
 week, and then, for the succeeding week, give only enough 
 to preserve the general effects of the medicament. By 
 doing this the stomach gets a rest and the appetite is 
 not so interfered with. Where the attacks occur only 
 ever}'^ two weeks this is a particular!}^ useful method, for 
 obvious reasons. As regards the time of day when the 
 drug is to be taken, there can be no variance of opinion. 
 Some writers have directed that it shall be taken alwa3^s 
 before meals ; but this is entirely lacking in advantage, 
 and decidedly fruitful of harm. Medicines to be given so 
 as to affect the general system should be taken after meals, 
 not before, and it is only when a local gastric effect is 
 desired that we use them on an empty stomach, particu- 
 larly when the substance is as irritant and depressing as 
 potassium. If taken after meals, the appetite is not de- 
 creased, but there are few who can take a dose of 10 to 
 20 grains of the bromide of potassium before breakfast 
 without suffering from anorexia. 
 
 It has been held by some that the drug should be 
 taken in minute doses, frequently repeated, in order to 
 keep the patient constant!}' under its influence. This is 
 an example of therapeutic ignorance, which will be ex- 
 plained when the author speaks of the elimination of the 
 bromide, and possesses the disadvantages of being in- 
 convenient, annoying, and apt to disorder the stomach. 
 
 If the attacks have a distinct periodicity, or can be 
 foretold for as much as two hours beforehand, the remedy 
 may be taken in a large dose at this time, and only 
 a few grains given in the intervals. If these attacks are 
 severe, no one should hesitate to use large doses by the 
 mouth and by the rectum on the day of the attack 
 
Treatment, 18t 
 
 A very important point to be borne in mind is that the 
 drug often seems to have produced a complete cure, and 
 this results in carelessness in the regularity of adminis- 
 tration. The patient should be impressed by the fact 
 that every day passed without a fit is a step forward, 
 and that every fit carries him many steps backward. He 
 should also be made to use tlie drug in moderation for 
 at least three years after all fits have ceased, and to 
 watch, after that time, for the slightest sign of their 
 return. The quantit}^ taken each day should be gradu- 
 ally decreased, not suddenly stopped short. 
 
 It is true, also, that if a recurrence of the fits take 
 place they yield to treatment very much more slowly 
 than before. 
 
 Before passing on to the discussion of the otfier 
 bromides, and tlie conditions produced by the excessive 
 use of all of them, let us first attempt to place our use of 
 these compounds in epilepsy on the scientific footing 
 already spoken of. In the section on Pathology it was 
 pointed out sufficiently clearly that the seizures known 
 as epilepsy were probably cortical in origin, and the 
 author will go upon this basis here. 
 
 There can be no doubt that the bromides act very 
 powerfully upon the cerebrum in the higher animals, 
 decreasing the irritability of the motor centres in tlie^e 
 regions to a very great extent. Not only is this pointed 
 to by clinical fact, but the well-known researches of 
 Albertoni ^ seem to prove that such is their action be- 
 yond all cavil. This investigator found that the adminis- 
 tration of a single dose of the bromide of potassium so 
 lessened the excitability of the motor cells in the cortex 
 cerebri that much stronger stimulation was necessary in 
 order to cause response in the limbs than was normal, 
 
 * Arch. f. Experimental Path, und Therapie, xv, 256. 
 
188 Epilepsy: its Pathology and Treatment. 
 
 and that it was difficult to produce epileptic attacks by 
 means of electrical stimulation of these areas, even when 
 currents were used very much stronger than those which 
 commonly so result. He also found that this lessened 
 irritability was increased still further if the drug was 
 given for several days beforehand in such doses as to 
 thoroughl}^ impress the organism. It is therefore evi- 
 dent that the bromides act directly on the cortical areas, 
 calming the tendency to explosions of nerve-force. 
 
 The results of Seppilli ^ have also confirmed those 
 of Albertoni in every way. 
 
 An enormous amount of research has proved also 
 that the drug may be doubly useful in reflex epilepsies, 
 not only by its action on the motor cortex, but b}'^ its 
 influence on the afferent portion of the nervous system. 
 
 The experiments of Eulenberg and Guttmann ^ prove 
 that the sensor}^ paths in the spiual cord feel more power- 
 fully than any other portion of the bod^^ the effects of 
 the drug, for they found that if they tied the blood- 
 vessels supplying one limb of au animal, and then in- 
 jected the bromide into the body, reflex action was 
 abolished equally on both sides, proving that the loss of 
 reflex action does not depend upon the action of the 
 drug on the sensory nerve-trunks. That the loss of reflex 
 action is not due to an action on the motor portion of 
 the cord is proved by the fact that voluntary motion is 
 completely preserved. As these experiments have been 
 confirmed by Lewisky,^ Bartholow,* Purser,^ and La- 
 borde,^ there can be no doubt of their truth, and we can 
 
 * Rivista Sperimentale di Frenatria, fasc. i and ii, 1884. 
 - Virchow's Arcliiv, xli, 1867. 
 
 » Ibid., xlv, p. 191. 
 
 * Bromides : their Physiological Effects. Providence, 1871. 
 " Dublin Journ. Med. Sci., xlvii, 324, 18(,9. 
 
 ^ Archivs de Physiol. Norm, et Pathol., t. i, p. 423, 1868, and Comptes 
 Rendus, t. Ixv, 1867. 
 
Treatment. 189 
 
 rest assured that not only does the drng prevent nerv- 
 ous disturbance in the cerebrum, but that it also pre- 
 vents the peripheral irritation from traveling up to the 
 brain, there to produce morbid excitement. 
 
 Apropos of the theory that epilepsy is due to vaso- 
 motor disturbance, which has been shown to be un- 
 founded, it ma}^ also be added that the bromide of 
 potassium was, and is, believed by some to effect a cure 
 l)y producing a vasomotor spasm at the base of the brain. 
 There is not one atom of reason in this idea, even if the 
 disease were due to vasomotor changes. 
 
 Hammond and Amor3^^ have seen the circulation in 
 the brain slowed by the drug, and it has been claimed 
 by Lewisky that if the toes be cut off the blood flows 
 from them more slowly in the poisoned animal thah in 
 the normal frog. None of these facts prove vasomotor 
 action, but rather that there is a lessened circulation by 
 reason of the cardiac depression produced b}' the potas- 
 sium, which is well known to occur. 
 
 An important therapeutic point is to know how 
 rapidly bromide of potassium is eliminated, so that we 
 may know how frequently to give the drug. That it is 
 passed out with only moderate speed is certain, for Ra- 
 buteau^ has seen its presence in the urine one month after 
 the last dose, and Bill ^ has found it two weeks after the 
 use of the drug had ceased. Amory* recovered, on the 
 other hand, one-half the amount ingested in the first 
 succeeding twentj^-four hours and one-tiiird in the second 
 twenty-four hours. It is evident, however, that it is 
 
 ^ The Physiological Effects of Bromide of Potassium, part ii, i>. 147. 
 Boston, 1872. 
 
 " I only know this paper by reputation, and have been unable to find 
 the reference to it. There has been very little work done on this subject 
 on the other side of the Atlantic. 
 
 ^ American Journ. Med. Sci., July, 18G8. 
 
 * Loc, cit. 
 
190 Epilepsy: its Pathology and Treatment. 
 
 eliminated so slowly that doses given three times a day 
 make the patient ingest more than he passes out. That 
 it remains long in the S3'stem is proved by the fact that, 
 after repeated doses given to a healthy man, marked 
 somnolence persists for days. 
 
 There is one more point to which attention must bo 
 called, and that is the fact that when the bromides are 
 taken for any length of time they produce bromism, 
 which, in its moderate or severe forms, produces a mental 
 condition very closely allied to that seen in old chronic 
 epileptics. This condition of the mind should never be 
 overlooked, and the writer believes that the mental 
 changes of epilepsy are greatly increased by its constant 
 and careless administration. 
 
 Bromism, or chronic poisoning by any one of the 
 bromides, is often a very troublesome sjmptom, wiiich 
 has to be dealt with carefully, for if the drug is with- 
 drawn the attacks return. The first signs of this gen- 
 erally are shown by an acne of the face, which may soon 
 involve the whole surface of the body, and, if not re- 
 lieved, give rise to a condition in which the face and 
 neck become a mass of sores covered with pus. Even 
 when the drug has only been used thus for two or three 
 days, this milder form may occur in those who have an 
 idios3mcrasy to the bromides; and, if the patient be in 
 the higher walks of life, or a woman, it may be impossible 
 to overcome his or her dislike of the drug on this 
 account. It is my custom to give a small quantity of 
 arsenic along with each dose in such patients, or, indeed, 
 in all cases where the drug must be pushed to extremes. 
 The influence which the arsenic exercises elsewhere than 
 on the skin is unknown, but the author is confident thnt 
 it very strongly acts in protecting the sexual apparatus, 
 and that it also aids the digestion and appetite for food. 
 
Treatment. 191 
 
 It has already been said that the bromide probably aids 
 the disease in producing mental hebetude in some cases, 
 and this S3^mptom very early comes on in bromism. There 
 is often failure of memory, somnolence, loss of spirits, 
 and loss of sexual desire and power. If the drug is 
 used after this, all the powers fail, and the man dies from 
 total extinguishment of all vital action. 
 
 The salts of iron, sodium, lithium, nickel, and am- 
 monium have all been used in epilepsy with good results, 
 but, except in certain instances, they fail to act as well 
 as that of potassium, unless given in larger doses. There 
 are several occasions in which, however, each one pos- 
 sesses marked advantages, and may succeed where potas- 
 sium has failed. In all cases of epilepsy complicated with 
 anaemia the bromide of iron should be employed, but 
 where there is plethora it will generally increase the dis- 
 ease or do no good. Where it acts after potassium fails, 
 the iron is necessary because of its tonic and food 
 effect. 
 
 Bromide of sodium, while somewhat less powerful 
 than potassium, is not by any means so apt to disorder 
 the stomach, and is preferable in some cases on this 
 account. It possesses no other advantages.^ 
 
 The bromide of lithium has been highly recom- 
 mended in intractable cases by Weir Mitchell, ^ who 
 even states that it maj^ be given in one-half the dose of 
 the potassium salt with equally good effects. 
 
 The bromide of nickel cures some cases where all 
 other remedies fail, but this is rare. In a series of 
 physiological experiments made by the author some j'ears 
 since, he found it virtually identical with the potassium 
 
 * Decaisne, as a result of a number of trials, thinks it identical with 
 the potassium salt, save that in large doses it produces constipation, not 
 diarrhoea. 
 
 * Am. Journal Med. Sciences, October, 1870. 
 
192 Epilepsy: its Pathology and Treatment. 
 
 salt in its action, and be lias found it useful in about 
 tlie same doses as bromide of potassium. 
 
 The bromide of ammonium is very irritant, and dis- 
 orders the stomach quite readily. It ought alwa3S to be 
 used, when used at all, witk some other drug, the ammo- 
 nium only acting as an adjuvant. 
 
 Several authors have tried hydrobromic acid, but it 
 is very much more apt to derange digestion and to pro- 
 duce vomiting than any of the salts. Tlie dose of the 
 dilute acid is J to 1 ounce in a tumblerful of sweetened 
 water. 
 
 The bromate of potash has been used by Mitchell in 
 not more than 5- to 10- grain doses with good results, 
 but is more dangerous, and scarcely of greater value. 
 
 There can be no doubt that in some instances what 
 is known as the mixed treatment is successful where all 
 else fails. This consists most commonly of a prescrij)- 
 tion in which the bromides of potassium, sodium, and 
 ammonium take part. Why this combination acts better 
 than any one of the salts alone no one knows, but it is 
 certainly a clinical fact.^ 
 
 In other cases still, digitalis, when used along with 
 one of the bromides, seems to carry out favorable 
 results. Indeed, digitalis has for j^ears been used alone 
 in epilepsy with fairly good results, and should nlways 
 be used in obstinate cases. In petit mal, where bromide 
 of potassium alone so often fails, it is useful, and several 
 English writers, notably Gowers,^ assert that its best 
 effects are in cases of nocturnal epileps3\ Why this 
 should be the case no one is able to decide, and it would 
 seem doubtful whether it does any more good in nocturnal 
 
 * As one example of such experience, see article by Erlenmeyer iu 
 Ce)itrall)latt f. Nervciiheilkuiide ixnd Psychiatric, etc., No. 18, 1884. 
 
 * Nervous Diseases. London. 
 
Treatment. 193 
 
 attacks than in the others. The writer is also unable to 
 exphiin why it shoukl influence epilepsy at all, for its 
 action on the nervous system is slight, save in toxic 
 amounts, when it lessens reflex action very markedly, 
 first, by stimulation of Setschenow's reflex inhibitory 
 centre, and later by paral3'sis of the spinal cord. This 
 latter action never occurs, of course, in its medicinal 
 use; but in medicinal doses it may, by acting on the 
 inhibitor}'- centre, allay convulsive tendencies. Probably 
 its chief action is through its circulatory effects, and 
 further study may show it to be efficacious only in those 
 cases where a heart tonic is required. 
 
 Another combination very much employed and lauded 
 is the bromide with belladonna, the mydriatic being alone 
 almost useless, but of great antiquity in its use in 
 epilepsy. 
 
 Like digitalis and bromide, it succeeds very frequently 
 in petit mal, and indeed seems to be much more success- 
 ful than the digitalis, but its mode of action is exceedingly 
 doubtful. As the drug acts even more powerfully upon 
 the nervous S3'stem than upon the circulatory apparatus, 
 it has been thought that its influences for good depended 
 upon this effect, but the experiments of Seppilli^ con- 
 tradict this belief; for he found that, if atropine was 
 given to an animal, the surface of the cortex cerebri 
 responded more readily than is normal to stimulation. 
 Professor Albertoni^ has also made a series of experi- 
 ments to determine whether it inhibits the motor powers 
 of the cortex. In his hands, repeated small doses, or 
 one large dose, in no way retard the convulsions pro- 
 duced b}^ stimulation of the brain. Both these investi- 
 gators are therefore in accord. 
 
 * Ri vista Sperimentale di FFenatria, fasc. i and ii, 1884. 
 ^ Arch, f . Exp. Path, und Pharm., xv, p. 26.5, 
 9 I 
 
194 Epilepsy: its Pathology and Treatment. 
 
 At one time it was held that belladonna acted on the 
 spinal cord and peripheral nerves under such circum- 
 stances, but it should be remembered that we know now 
 that atropine is only of value in relaxing spasm when 
 given in full dose, and oftentimes hypodermically, and 
 that under tliese circumstances it affects rather the 
 motor-nerve endings than the central nervous apparatus. 
 At the present time those who believe the origin of 
 epilepsy to be dependent on cerebral vasomotor spasm 
 rest the occasional good results from the use of this 
 drug on its vasomotor influence ; but there is a good 
 reason for throwing this idea aside, even if the morbid 
 process was really present, namely, that the drug in 
 ordinary medicinal doses raises arterial tension by 
 stimulation of the vasomotor centre, while it only 
 lowers blood-pressure when given in toxic amounts, and 
 then by an action on the blood-vessel walls. 
 
 As long ago as the early part of this centur}^, can- 
 nabis indica came into notice in the treatment of epi- 
 lepsy, and is probably of much more value alone than 
 with any other drug. Although it is at present rarely 
 so used, from the writer's own studies he thinks it of 
 value, for he finds that it distinctly lessens reflex action 
 and acts powerfully upon the higher nervous centres in 
 the brain. Its use and value in migraine is undeniably 
 of the greatest importance, and attention has already 
 been called to the fact that several eminent neurologists 
 believe epilepsy and migraine to be ver}^ closely allied. 
 The effect on the circulation is almost m/, and its influ- 
 ence is solely expended on the nervous system. The 
 deep sleep x^roduced by it, even in moderate medicinal 
 doses, is not onl}^ deep but prolonged, and it undoubt- 
 edly quiets the sensory nerve-trunks all over the body, 
 as well as the sensory side of the cord. Indeed, it seems 
 
Treatment. 195 
 
 ■to resemble the bromides in its action quite closely. It 
 should be given in doses oi \ io \ grain of the solid 
 extract or 20 minims of the fluid extract. Like the 
 bromides, too, it is very rarely capable of producing 
 serious results, and there are no cases of a fatal char- 
 acter reported from its overuse. To illustrate its slight 
 lethal power, it may be stated that the author has in- 
 jected into the jugular vein of a dog not less than 35 
 cubic centimetres of a fluid extract, the dose of which 
 was physiologically active at 8 minims in man before 
 producing death. 
 
 Gelsemium sempervirens is an American plant whose 
 praises, in almost every disease, have been wiilely 
 heard. Its influence alone is almost worthless, for 
 it possesses no power over the cerebral centres wiiat- 
 ever ; but in combination with cannabis indica it makes 
 a very useful agent, as it quiets any excitement in the 
 spinal cord and depresses its conducting power, while 
 the cannabis indica, in its turn, quiets the cerebrum. 
 The dose of the tincture is 20 drops, but it should be 
 remembered that it is as poisonous as the other is 
 innocuous. 
 
 Owing to the soporific influences exercised by opium 
 it has been very frequently tried, with success and fail- 
 ure as a result. It certainly has not taken any rank in 
 the list of remedies, and this is a deserved withdrawal 
 of professional favor. It increases reflex activity very 
 commonly, and seems to affect the intellectual areas of 
 the cerebrum rather than tiie motor portions, although 
 Seppilli's experiments show it to exercise a decided de- 
 pressant influence over these areas. Combined with 
 gelsemium it may, perhaps, be emploj^ed, but only when 
 nothing else is at hand or all other remedies have failed. 
 If it is so employed great care is to be used, and it 
 
196 Epilepsy: its Pathology and Treatment. 
 
 should not be forgotten that both drugs kill by respira- 
 tory failure. When used in " status epilepticus " it often 
 does the most good in relieving the spasm, but it must 
 be employed in large doses, and if the succeeding coma 
 of epilepsy has added to it that of large doses of opium 
 death may ensue. 
 
 The employment of zinc has been very greatly rec- 
 ommended for many years, but has found little favor of 
 late among the profession generally. It has been stated 
 that it quiets the cerebral cortex, the medulla oblongata, 
 and spinal cord, and in this wa}^ cures the attacks. This 
 is, however, merely clinical evidence, and has no experi- 
 mental proof to support it. 
 
 Even its most sanguine supporters confess that its 
 range of usefulness is generally in those cases where the 
 bromides succeed, and agree that its powers are much 
 inferior to these compounds. The dose of the oxide is 
 3 to 7 grains twice or thrice a day, and even in this 
 amount may cause nausea and vomiting. The citrate is 
 more soluble, and is better borne b}' the digestive appa- 
 ratus. Its influence over the disease is probably the 
 same, as is also true of the lactate, which was so largely 
 used by Herpin {loc. cit.), and which is, so far as my 
 reading goes, the best salt of zinc to use. 
 
 Nitrate of silver was brought into use long before 
 the value of more recent drugs was known. Every 
 one is agreed as to its lack of curative power, and 
 no one has ever claimed good results from it save 
 when it was used constantly for a long time. As the 
 drug is eliminated very slowly, it rapidly accumulates, 
 and argyria soon comes on. It may be used, after all 
 else fails, in doses of ^ to :| grain, tlirice a da}^, after 
 meals, and the mucous membrane of the inside of the 
 lips and the conjunctiva should be carefully watched for 
 
Treatment. 197 
 
 the early signs of chronic silver poisoning. We cer- 
 tainly have no knowledge as to its influence on the ner- 
 vous system, and, if it acts at all, it must be by some 
 alterative influences rather than by any other means. 
 
 Nitro-glycerin is to be employed rather in petit mal 
 than in haut mal, in the dose of 1 drop of a 1-per-cent. 
 solution once, twice, or thrice a dixy. Our knowledge of 
 its effects, so far as its curative influences are concerned, 
 is ver}^ slight, but it really seems to benefit some cases. 
 Its action is very fleeting, and one is inclined to believe 
 that it influences the brain very little except it be taken 
 just before an attack is expected, or where the cardiac 
 action is defective. Its great lethal power should ilever 
 be forgotten. 
 
 The use of the nitrite of amyl is not for the purpose 
 of directly curing the disease, but of warding off im- 
 pending attacks, the warning of which is given by an aura 
 of slow progression. Tlie author has pointed out already 
 that it increases the severit}^ of petit mal. In epileptics 
 who have a prolonged aura we may use nitrite-of-amjd 
 pearls, which consist in small glass bulbs containing a 
 few drops of the drug. As the aura comes on, tlie pa- 
 tient should break one of these in his handkerchief and 
 inhale the drug, tliereb^^ putting aside the attack. 
 
 The influence which the drug exerts upon the brain 
 is secondary rather than primary, and is probably de- 
 X)endent on its action on the blood or circulation. Its 
 influence on the spinal cord and nerves is much more 
 marked and direct, and it is most certainly a \QYy power- 
 ful spinal depressant. As its influence over unstriated 
 muscular fibre is very great, it affects the vasomotor 
 S3^stem very powerfully, and those who think that epi- 
 lepsy is due to vasomotor spasm at the base of the brain 
 point to the effects of this drug as a proof of their 
 
198 E^nlepsy: its Pathology and Treatment. 
 
 hypothesis. Such reasoning is not, however, necessarily 
 correct. Tlie writer is inclined to believe that the nitrite 
 of amyl j^iits aside an attack by a sudden shock to the 
 nerve-centres, which diverts them, so to speak, from 
 their intended discharge, very much as a ligature stops 
 an aura. When we remember that the drug acts in- 
 stantly, and converts nearly all the oxj-genating blood 
 of the body into a non-ox^^gen-carrying fluid by reason 
 of the nitrite-ox^dia^moglobin produced, the sudden 
 change in the cerebral nutrition and life is most marked. 
 In the " status epilepticus " it is of great value in stop- 
 ping the seizures, and ma}^ be used under these circum- 
 stances in heroic amounts applied at intervals to the 
 nostrils. In the tonic spasm, if it be severe enough to 
 stop respiration, it should be remembered that, as the 
 drug is not inhaled, it is absolutel}^ worthless. It is only 
 when a moment of relaxation occurs that it does its work. 
 
 As a general rule, the nitrite of ammonium or sodium, 
 whicli are more prolonged in their effects, should be used 
 to supplement the amyl salt. 
 
 Gowers states that nitrite of amyl does good by 
 flooding the brain with arterial blood. How such a 
 statement can be made b}^ any one is amazing. Of all 
 the drugs in the world nitrite of amyl produces exactlj^ 
 the opposite cliange, as Gow^ers should be aware froni 
 his own use of the sul^stance. 
 
 The use of anaesthetics in epileps}^ is virtually use- 
 less, and, in some cases, dangerous, for ether is too slow 
 in its effects, and may, by its irritant vapors, increase 
 the tendency to lar3^ngeal spasm or cause lung compli- 
 cations. Further than this, if umemia is the cause of 
 tlie fit, and this fact is unknown in everj^ case until it is 
 examined, the ether may increase the inflammation of 
 the kidney very seriously. 
 
Treatment. 199 
 
 Chloroform, tliough it acts much more rapidly, may 
 cause sudden cardiac failure, and both drugs may increase 
 the post-convulsive coma very greatly. 
 
 In "status epilepticus " they may be used, as, in 
 such cases, the convulsion must be stopped at all hazards, 
 and the preference should always be for amyl nitrite. 
 
 The iodide of potassium is entirely useless in epi- 
 lepsy, unless it is due to syphilis, when it is of the 
 greatest service. Indeed, the bromide and all other 
 drugs should be set aside, while it is pushed to the 
 utmost. As is well known, syphilitics usually bear the 
 drug extremely well, and the writer knows of one in- 
 stance where no less than 800 grains were taken every 
 twentj^-four hours, with rapid improvement as a result. 
 
 This point is strongly insisted upon by all therapeu- 
 tists and syphilographers, notably among whom stands 
 Fournier. ^ 
 
 Where the convulsions are due to a gumma the iodide 
 of potassium is, however, too slow in its action, and 
 should be replaced by mercury in order to break down 
 the growth without delay, lest a seizure end the scene 
 by asphyxia or some similar accident. 
 
 Some difference of opinion exists as to the usefulness 
 of iron in epilepsy. Several ver}'- eminent clinicians have 
 asserted that it always makes the attacks worse and, 
 therefore, does more harm than good. 
 
 The writer thinks that, like ever3"thing else, iron is no 
 more to be given in every case than is a dose of oil, but 
 that where there is plethora it is harmful and where there 
 is malnutrition and anaemia it does good. Over the dis- 
 ease itself it really has no effect at all, except through 
 its action on the general s^'stem. 
 
 Chloral h3Tlrate is a remedy which has been only 
 
 * li'Union Medicale, 1875, et Annales de Dermatol, et Sypliilog., 1880. 
 
200 Epilepsy: its Pathology and Treatment. 
 
 partly tried in epileps}^, and its usefulness is not as 3^et 
 determined. It possesses the marked disadvantage, as 
 compared to tlie bromides, of being a very fatal poison, 
 which is an important fact to be borne in mind by tlie 
 ph^'sician when giving it to a patient, whose mind, 
 already weakened by the disease or naturally stupid, may 
 forget and take too much. Its physiological action in- 
 dicates, much more fully tlmn many other much more 
 lauded remedies, that it may be of value, since it exerts 
 its chief influence on the motor pathwa3's of the spinal 
 cord and quiets the motor portion of the cerebral cortex, 
 and also produces sleep. Seppilli ^ has proved this, too, 
 by direct experimentation after the method employed by 
 Albertoni. Its use, combined with one of the bromides, 
 is often accompanied by the most desirable results, and 
 should be tried at all times unless some cardiac compli- 
 cation forbids it. It may disorder the stomach, and 
 should, like the bromides, always be given well diluted 
 and after meals. 
 
 Of the more recent remedies, antifehrin certainly 
 stands in the foremost rank, and bids fair, in some in- 
 stances, to rival the bromides. Prof. Germain See and 
 the writer have reported cases which obtained very 
 marked relief from it, and more recent investigators 
 have done likewise. The author's experience with the 
 drusr has been that it exerts its chief benefits in chronic 
 epilepsy. At least, if a child were brought to the writer 
 with a beginning epileps}^, he would use the bromides, 
 but, if the disease was chronic, the antifebrin. In the 
 cases seen by the writer the patients were adults, and 
 liad very marked mental failure, one of them being vir- 
 tuall}'' idiotic and a sufferer from two to six attacks 
 every day Bromides had lost power over them, and 
 
 ' Ilivista Si)eriineiitale di Frenatwia, fasc. i and ii, 1881. 
 
Treatment. 201 
 
 antifebrin certfiinly acted most marvelously. Thus, in 
 one case the fits fell from twent3^-one to four a week, 
 when the patient was lost sight of. It should be used 
 in the form of powder, on the tongue, in the dose of 8 
 grains thrice a da}', with a little sugar. 
 
 Mabille and Ramadier ^ have found acetanilide A'ery 
 useful, also, as has Leid}^,^ who found benefit produced 
 by the drug in 14 cases out of 26, and alsothat the drug 
 influenced more favorably still petit mal. 
 
 Bowsnyoi ^ treated 9 epileptics in this manner, using 
 doses ranoino; from 3 to 30 orains. He believes the druo- 
 to be inferior to the bromides, both in its control of the 
 disease and in the depressant effects which it sometimes 
 produces. He found, however, that large doses gener- 
 ally controlled the attacks. 
 
 On the other hand, Salm,* in Joll3^'s clinic in Stras- 
 burg, gave the drug in doses of from 1 to 3 grammes a 
 da}^, and not only saw no benefit, but some of the cases 
 became worse. 
 
 Antipyrin has also been pushed forward as a remed}', 
 and, as the physiological action on the nervous S3'stem 
 is virtuall}^ identical with antifebrin. They will be 
 spoken of together. 
 
 Antipyrin vv-as recommended by Lemoine,® in 188T, 
 in certain forms of epilepsy, but condemned in most 
 cases. 
 
 In those who suff'er from menstrual epileps}^, so called, 
 or in those in whom the attack is produced reflexly by 
 the presence of intestinal parasites, the drug does good. 
 
 Lemoine also found it very useful in those cases 
 
 » Soc, Med. Psycholog. Seance, Juin 27, 1887. 
 
 3 N. Y. Med. Journal, vol. i, 1888. 
 
 ^ Centialbl. f. d. Gesammte Therapie, March, 1888. 
 
 * Neurol. Centralblatt, 1887. 
 
 * Gazette Med. de Paris, December 24, 1887. 
 
 9* 
 
202 Einlepsy : its Pathology and Treatment. 
 
 associated with migraine. In these cases the results 
 were better than with the bromides, but in the idio- 
 pathic, simple varieties it was useless. Mairet and Com- 
 bemale ^ have used the drug in epileptiform mania with 
 very satisfactory results. 
 
 In children suffering from freqnentl}^ recurring epi- 
 leptic attacks the presence of worms should alwa3's be 
 looked for, and, when found, the}^ should be expelled as 
 rapidly as ])ossible. If they are the Oxyuris vermicu- 
 laris, the best remedy, by far, is the injection of a strong 
 infusion of quassia of such a strength that there is 1 to 
 2 ounces of quassia to each pint of water. 
 
 In girls, where tlie removal of the worms from the 
 rectum is not followed by relief, a careful examination 
 of the vagina should be made and quassia employed in 
 somewhat weaker solution as a vaginal wash, as, A^ery 
 commonl3% intense inflammation is here present, pro- 
 duced by migratory movements of rectal parasites. If 
 the quassia is unobtainable in an}'- case, a saturated solu- 
 tion of chloride of sodium ma}- be emplo^'ed. 
 
 To complete the consideration of the treatment of 
 epileps}', the writer must add the information which we 
 possess in regard to remedies which, while highl}'' rec- 
 ommended by one person, have ])een wholly or jmrtly 
 found useless by the majority of the profession. 
 
 Foremost among such agents stands curare, a sub- 
 stance whose ph3'siological action makes it about as fit 
 for the treatment of this disease as so much sawdust or 
 equally valuable matter. Every one knows that this 
 drug paral3'zes the peripheral motor nerves in the muscles 
 long before it affects, to any extent, the rest of tlie or- 
 ganism, and it is evident that its anticonvulsive action 
 can only rest on tlie theor}^ that it blocks the pathway 
 
 * Gazette Hebdoraadaire, December 23, 1887. 
 
Treatment. 203 
 
 to the muscles in such a way that the impulses cause uo 
 contractions in them. Even supposing that curare could 
 be given in large enough dose to obtain a full phj'sio- 
 logical effect, it could in no way prevent an^-thing more 
 than the outward evidence of an attack ; and, as the in- 
 jury lies not in the muscular contractions, but in the 
 central nervous storm, its uselessness is apparent. Even 
 its most vehement supporters are unable to adduce any 
 remarkable results from its use. 
 
 Kunz ^ has used it in 80 cases, and seen, so he says, 
 6 radical cures and several cases of partial relief.* Thier- 
 celin, in 1861, found it of value when combined with 
 other drugs, or, in other words, it was useless in itself; 
 and Benedikt, in 18G6, reported that it lessened the fre- 
 quency of attacks, but did not cure. In the same year 
 Mundt declared it useless, and the year before (1865) 
 Yoisin made a like assertion. Still more recently, 
 BourncA^lle and Bricon ^ have tried its anti-epileptic 
 virtues. They administered curare h3^podermically to 
 33 epileptics, but obtained only one cure (?), although in 
 some instances it was o-iven for as lono- as six months at 
 a time, and they therefore believe curare virtual!}^ use- 
 less for such purposes. Further, it is hard to imagine a 
 more lethal drug with less medicinal power for good. 
 
 Apomorphia has been used by Yallender ^ hypo- 
 dermically with some good results, ])ut it has certainly 
 not obtained general favor in the profession. 
 
 Cocculus indicus, in the form of a tincture, has been 
 employed by Hamhusin * in the dose of 10 drops witli 
 asserted good results, but its value certainly needs much 
 more thorough tests than any one observer can employ, 
 
 ' Ber. d. 51 Verhandlung deutsch. Natiirf. und Aerzte in Cassel. 
 ^ Arch, de Neurologle, March, April, and May, 1886. 
 ^ Berliner klin. Woclienschrift, 1877, xiv, 185. 
 * Bull, de I'Acad. de Med. de Belgique, 1880. 
 
204 Ejnlepsy : its Pathology and Treatment. 
 
 aiul its use is still suh judice in consequence. He found, 
 however, that the system became rapidly accustomed to 
 the drug, and tliat it could be increased day by daj'^ until 
 150 drops at a dose could be borne. 
 
 Picrotoxine is also, in all probability, a useless rem- 
 edy, but has been recommended by Planat, Conyba,^ 
 and Hamhursin. 
 
 Osmic acid has been quite thoroughly tried b}" Wil- 
 dermuth,^ either in the form of the acid in water or, 
 more latterlj^, as the osmate of potassium, the dose be- 
 ing in twentj^-four hours about \ grain. In 10 old and 
 chronic cases he reached no result in Y of them ; in 2 
 the attacks became less frequent, and one previously 
 desperate case recovered. Three later cases gave in two 
 instances quite marked amelioration and in one case no 
 benefit. 
 
 The treatment of epileps}^ by borax has not received 
 very wide recognition. Perhaps the most thorough 
 studies of its effects have been those of Gowers,^ in 
 England, and Folsom,* in America. It would seem that 
 some cases which are obstinate under ordinary treatment 
 are benefited hy it, but it certainly is not to be com- 
 monly employed. The doses are generally about 15 
 grains ter die. 
 
 Several clinicians have proposed the use of electricity 
 in the treatment of epileps}', and have attempted to gal- 
 vanize the brain by placing a pole on each side of the 
 temples or on the forehead and occiput. Still others 
 liave tried it by placing a pole on the spine and one on 
 tlie vertex. Rockwell professes to have benefited cases 
 by this means, but it is extremely doubtful if his results 
 
 ' Jonv. de Med. et de (.'hirnrgie prat., 1880, 214. 
 
 ' Bulletin Gen. de Therai)eutique, October 25, 1884. 
 
 ' Epilepsy. London. 
 
 * Boston Med. and Surg. Joum., February 18, 1886. 
 
Treatment. 205 
 
 were not due to coincidence or imagination. Electricity 
 resembles water in the law that it always travels in tlie 
 direction of least resistance, and, this being the case, it 
 is evident that the current passes through the integu- 
 ment over the skull, and not through the bone and cere- 
 brum inside of the cranium. 
 
 A practical proof of the failure of the attempt is 
 that the slightest current applied, in reality, to the brain 
 elicits a response, while in the method just mentioned 
 this never occurs. 
 
 Having spoken of the drugs which may be gfven to 
 epileptics, let the writer draw the attention of the reader 
 to those which may not be used. There is a very large 
 amount of reliable evidence, both experimental and clini- 
 cal, that quinine should never be employed where it can 
 be avoided. Thus, Seppilli,^ in his researches, found that 
 it increased the irritability of the cerebral cortex, and 
 Briquet ^ has asserted that it is a direct cerebral stimu- 
 lant. That toxic doses of quinine may provoke epilep- 
 tiform convulsions has been proved by Jakowbowich,^ 
 who has seen them in dogs and in other animals, and 
 Brown-Sequard and Albertoni * have noted that cinchoni- 
 dine and quinine alwa3^s increase the number of attacks 
 in epileptics. 
 
 Salicylic acid, too, has an effect upon the brain very 
 closely allied to that of quinine, and should alwaj^s be 
 used with care in epilepsy. Prof. Germain See ^ has 
 pointed out also that large doses produce violent epilep- 
 tiform convulsions in the lower animals. 
 
 Strychnia, while its chief effect is to heighten the 
 
 * Rivista Sperimeiitale de Frenatiia, fasc. i and ii, 1884. 
 ^ Traite Therapeutique de Quinquina. Paris, 1855. 
 
 ^ Rev. des Sciences Med., 187.3. 
 
 * Archiv f. Experimental Path, und Pharm., xv, 278. 
 
 * Bulletin de Tx^^cad. de Me'd., 1877. 
 
206 Einlepsy : its Pathology and Treatment. 
 
 activity of the spinal cord, also, according to Seppilli, 
 increases the irritability of the cortex, and should be 
 emplo^'ed only in particular cases. The same writer also 
 found that absinthe and picrotoxine acted detrimentally 
 in increasing the excitability of the motor zone. 
 
 Bleeding the patient in epilepsy, unless there is par- 
 ticular evidence of cerebral congestion, which is exceed- 
 ingly rare, is harmful rather than of value. Orschansky ^ 
 found that removal of one-seventh of all the blood in 
 the body by the femoral vein did not lessen the irrita- 
 bility of the cortex, and Minksowsky ^ ligatured all the 
 blood-vessels going to the brain without decreasing its 
 excitability. We know also tliat cerebral anaemia pro- 
 duces epileptic attacks. 
 
 A very important point which is constantly brought 
 before the physician who is treating epileps}^ is that of 
 diet. Nearly every patient inquires what he shall eat, 
 when he suffers from this disease. So far as the writer 
 is aware, very few researches of a thorough character 
 have ever been carried out on a large scale to determine 
 the foods which may or may not be ingested. Of course, 
 nearly every one of us know from our personal experi- 
 ence that red meats are hurtful, particularl}' in children. 
 Curiously enough, tlie influence of diet, in one research 
 covering a number of cases of chronic epileps}-, seemed 
 to be of little moment. Thus, Merson^ examined 24 
 such cases, putting 12 of them on a purelj^ vegetable 
 and 12 on a purely nitrogenous diet. The result, after 
 this had been continued for two months, was tliat the 
 vegetarians had had a few less fits than the others, but 
 the ditference was so slight as to be almost of no weight 
 in determining the question. Some authors at the present 
 
 * Quoted by SeppiUi. "^ Ibid. 
 
 ' West Ridiiif; Lunatic Asylum Reports, 1875. 
 
Treatment. 207 
 
 day believe this opinion as to tlie liarmfnlness of meats 
 to be erroneous. 1 
 
 The operative treatment of epilepsy divides itself 
 into two classes, — that concerned with the removal of 
 lesions in the brain, and that which deals with the re- 
 moval of peripheral irritations, such as adherent prepuce 
 or growths and nerves. The writer will first speak of 
 those forms of epilepsy due to centric causes among the 
 cells themselves, such as abscess, tumor, pressure, em- 
 bolism, and thrombus. He has elsewhere pointed out 
 that these changes are productive of epilepsy, and it is 
 unnecessary for him to go over them again in this respect. 
 
 Notwithstanding the antivivisection laws of Eng- 
 land, curiously enough she stands pre-eminent in cerebral 
 surgery ; and, so far as is known, the first successful 
 operations for abscess and tumor of the brain were there 
 performed in 1884, by Mr. Godlee. In much the same 
 manner as abdominal surger}^ suddenly stepped to the 
 front and became a very popular means of relief, so this 
 new field has been largely gone over by surgeons in all 
 parts of the world, and, it may be said, has been re- 
 markably successful, considering the limited diffusion 
 of the knowledge of cerebral localization which has 
 heretofore existed. Indeed, the failures, in the majority 
 of cases w^hich have failed, have depended on the lack of 
 experience in the operator rather than on the gravity of 
 the operation itself. Probably no one in the world is at 
 present so widely known in this branch of surgery as 
 Victor Horsley, of London, both because of his skill 
 and his researches. On a recent visit to England, where 
 he was good enough to let the author see something of 
 his work, the wa*iter was greatly impressed by the fact 
 that his experimental investigations were always used 
 * Gowers, in his book on Epilepsy, is one of tliese. 
 
208 Upilepsi/ : its Pathology and Treatment. 
 
 for the fartherimce of his professional work, aiul that 
 he represented, par excellence^ the logical j^hysician and 
 physiologist. 
 
 None who have seen men familiar with brain localiza- 
 tion operate can do so without being impressed with the 
 fact that the present centur}^ has given birth to still an- 
 other medical triumph. According to the most success- 
 ful operators of the day, the most strict and careful anti- 
 sepsis is preserved during the operation, which consists 
 in first shaving the entire head, and then bathing it with 
 a solution of the bichloride of mercury or soap. Horsley 
 uses carbolic-acid solution. The area of the cortex in- 
 volved is now traced out on the skin, and the operation 
 then consists in forming the flap and trephining as usual. 
 The majority of surgeons do not use the carbolic-acid 
 spray, but Horsley insists that it is absolutely necessary, 
 informing me that in every case wiiere he has operated 
 on monke3's without the spray death has occurred, 
 wliereas where it has been used the}'' invariabl}^ recoA'^er. 
 The dura is next laid aside in the form of a flap in much 
 the same way as the scalp, but the greatest possible care 
 is exercised, lest, in the movements of the operation, 
 any pressure be made on the cortex, as this is very often 
 followed b}^ paral^^sis of the limb supi)lied by that area, 
 at least for a time. Care is also to be shown tliat no 
 part of the cortex at any time becomes dry, and if tiie 
 operation is prolonged the flaps should be now and 
 again laid over tlie part to moisten it. In some instances 
 the tumor or abscess is subcortical, rather than cortical, 
 and it becomes necessar^^ for tlie operator to make either 
 exploratory incisions or digital examinations for it. The 
 haemorrhage from the ])rain is not so violent as might be 
 supposed, and can be controlled by com[)resses, or, where 
 large surface-vessels appear, by torsion or ligature. 
 
Treatment. 209 
 
 The most troublesome oozing is from the diploea,a,nd 
 this may be stopped by a mixture of bees-wax and gum- 
 beuzoin, which is melted in a test-tube and boiled, in 
 order to sterilize it before it is used. When it hardens 
 again, it is rubbed over the bleeding spot, and checks 
 all haemorrhage ; nor does it influence the recovery of 
 the patient in any way whatever. The following suc- 
 cessful case, operated on by Dr. W. W. Keen, is of in- 
 terest, as showing the value of cerebral localization as a 
 scientific fact, and its use in relieving humanity^ as well 
 as the enormous size of the growth : — 
 
 A man, aged 26 j'ears, was injured by a fall from a 
 window at the age of 3, his head striking against a brick. 
 A superficial wound was made in the scalp, but no 
 trouble was experienced from the injury until twenty 
 years had elapsed, when e[)ilepsy developed itself. At 
 the same time there was aphasia and paralysis of the 
 right arm and leg ; these last symptoms, however, soon 
 passed away. 
 
 The operation was performed December 15, 1887, 
 and the tumor removed measured 2| inches in its long 
 axis and 2|- inches in its short axis. It was IJ inches 
 thick. It extended from the fissure of Sylvius into the 
 first frontal convolution, and from near the fissure of 
 Rolando into the bases of the three frontal convolutions. 
 The weight of the tumor was 3 ounces and 49 grains. 
 
 The patient did remarkablj^ well for two daj^s after 
 the operation. On the third da}'- marked symptoms of 
 pressure showed themselves, and this was ascertained to 
 be due to the presence of a large clot of greater size 
 than the tumor itself. This was carefully removed, and 
 all went well for ten days, when pressure symptoms 
 were aorain observed. There was also severe diarrhoea 
 and a temperature of 104^° F. The presence of pus 
 
210 Epilepsy: its Pathology and Treatment, 
 
 was suspected, and the wound was accordingly re-opened. 
 This resulted in a hernia cerebri. Later there were sev- 
 eral less severe attacks of diarrhoea, accompanied by 
 more or less rise of temperature. The hernia was some- 
 what persistent, and, in order to facilitate the process of 
 healing, skin-grafts were made from the arm. The 
 wound was dressed with bichloride gauze for eight 
 weeks, but there was no evidence of absorption, nor was 
 the diarrhoea attributable to it. The spray was not used, 
 but all other antiseptic measures were employed. The 
 wound healed completely, and the man recovered not 
 only from the operation, but from the epilepsy. 
 
 The operation of trephining for any traumatic con- 
 dition of the skull in epilepsy has now, as has already 
 been said, reached a point of acknowledged value. 
 
 Briggs ^ has recorded 30 cases of this character, of 
 whom 25 were cured, 3 were relieved, 1 was not benefited, 
 and 1 died. Again, the statistics of Walsham,^ giving 
 130 such cases, though the}^ are not quite so favorable 
 as those of Briggs, are of great value, for Y5 of them 
 were completely cured, 18 were improved, and 30 died. 
 Seven were not benefited. It will be seen that out of 
 160 cases there were 100 cures, 21 improvements, 7 
 failures, and 31 deaths. It is evident, therefore, that 
 operative procedures in such cases are more fruitful 
 (62,5 percent.) than any form of medication in any form 
 of the disease. The necessity for operating becomes 
 ver}' evident if we can rely on the assertion of Garmany^ 
 that 50 per cent, of all cases of frontal traumatism be- 
 come epileptic. 
 
 A method of treatment which is quite heroic is that 
 
 * American Practitioner, July, 1884, 
 
 ^ St. Bartholomew's Hosp. Rep., vol. xix. 
 
 3 Trans, Ninth. Intemat. Med. Congress, 1887. 
 
Treatment. 211 
 
 fidopted by Alexander,^ an Eiiglishnmn, namely, ligation 
 of the vertebral arteries. The operation consists in 
 making a linear incision opposite the lower end and 
 outer side of the external jugular vein "for 3 inches," 
 eroinof down throu2:h the fascia between tlie anterior 
 scalenus and longus colli muscles, and in t^'ing one 
 or both vertebral arteries at the sixth cervical verte- 
 brae. His results in 21 cases are, in his opinion, suffici- 
 ently good to decide the value of this line of treatment, 
 but we cannot agree with him. In 9 of the cases, up 
 to the time of his report, no fits have occurred for a 
 very long time and in 8 cases they are becoming less 
 frequent ; in the remaining 4 not much change has been 
 noted, — indeed, one died in a parox3^sm. He is careful to 
 state that he has little confidence in the operation if the 
 attacks are chronic, but denies any serious after-effects. 
 Practically, however, the surgeon would hardly feel jus- 
 tified in performing such an operation until the disease 
 had been treated by all other means and so had become 
 chronic, and even then might hesitate for a considerable 
 time, simply because the risks to be run seem about 
 equal with the chances of relief. The reasoning by 
 which the procedure is arrived at is that the convulsions 
 depend chiefly upon alteration in the nutrition of the 
 medulla oblongata, and by this operation the circulation 
 is changed sufficiently to produce a cure. It is hard to 
 see why it should not make a case worse rather than 
 better. 
 
 There are several cases on record in which removal 
 of the testicles has resulted in the cure of epilepsy. As 
 long ago as 1855, Dr. McKinley, an American, reported 
 several such instances, ^ in 2 of which disease of the 
 
 » Brain, 1882-83, p. 170. 
 
 ' American Med. Gazette, July, 1855. 
 
212 Epilepsy: its Pathology and Treatment. 
 
 testes occurred in epileptics who were cured when the 
 glands were removed. In the other cases the operation 
 was performed with the cure of the epilepsy in view, 
 there being no disease of the testicles. Two of these 
 occurred in the practice of Dr. White, of Tennessee, 2 
 in the practice of Dr. Talbot, in Missouri, and 1 in the 
 experience of Dr. Hacher, of Louisiana. Another case 
 is that performed b}^ Holz at the request of Frank. ^ 
 All the American cases are recorded in McKinlej-'s 
 paper, and in all of them the cure was accomplished. 
 
 Bacon^ has also A^ery much more recentl3'^ revived 
 castration as a means of cure, particularly in insane 
 males who were masturbators. 
 
 Operative surgery has even interfered with idiopathic 
 epileps^^, for we find the records of several cases where 
 nerve-stretching has been performed with more or less 
 satisfactory results. Thus, Gillette^ reports an instance 
 of a woman with congenital epilei^sy, in whom he 
 stretched the median and ulnar nerves in the upper third 
 of the arm, with the effect of decreasing the attacks from 
 90 to but 18 per month in the course of less than three 
 weeks. 
 
 Much has been written and spoken by able men as to 
 the wonderful relief afforded in some cases of epilepsy 
 by the removal of peripheral irritation, which, in many 
 instances, was very obscure and ill defined. Like every 
 other measure of relief, it is probable that a greater use- 
 fulness was claimed for it than was deserved, and prob- 
 ably many persons are lacking foreskins, ovaries, or 
 clitoris b}^ reason of the search for peripheral enemies of 
 health. No one can den}^, however, that cases of reflex 
 
 • Praxes Medical Universal Preceptor, vol. ii, chap. xi. 
 
 "Journal of Mental Science, Oct., 1880, p. 470. 
 ^ Le Progres Medical, February 5, 1881. 
 
Treatment. 213 
 
 character do exist, and that very frequently their re- 
 moval results in recover3^ In the case of adherent or 
 inflamed prepuce, particularly in children, this should 
 be removed or every care taken that all foreign matter, 
 such as urine and smegma, is kept out where the opera- 
 tion is not permitted. Circumcision is an operation 
 which is not only simple in its performance but lacking 
 in danger, and is always justifiable, if only for the sake 
 of the attempt at cure. Very frequently, as has al- 
 ready been said elsewhere in this essay, masturbation is 
 thus done away with and an element of nervous relief 
 gained. Where masturbation occurs in epileptic girls, 
 clitoridectomy may be performed with success, or even 
 the ovaries extirpated, as has already been detailed in 
 one case. 
 
 Closely allied to this is the influence which Charcot 
 has shown to be i^ossessed by pressure on the ovaries 
 in some cases of epilepsy. Certain epileptics immedi- 
 ately become convulsed if pressure is made, and in these 
 there is generally very marked ovarian tenderness. If 
 the tenderness does not pass away b}'' ordinary means, 
 the ovaries should be removed by the ordinar}^ operation. 
 
 Sometimes, after amputations of the fingers or an 
 extremity, neuromata form on the ends of the severed 
 nerves, and they become entangled in the cicatrix, giving 
 not only much pain, but also producing epilepsy. The 
 surgeon should here remove the growths or free the 
 nerves from the scar. In some manner epileptogenic 
 zones sometimes develop, and should be excised. 
 
 For many years the operation of trephining areas 
 where depression seemed to exist has been customary in 
 very obstinate cases of epileps}^, and some surgeons 
 have gone so far as to trephine in any case, hoping in 
 some indirect waj^ to relieve the morbid process. 
 
214 Epilepsy: its Pathology and Treatment. 
 
 The writer does not, however, see that this comes 
 within the confines of modern surgery, bold though it 
 be ; for, unless some real reason for trephining exists, 
 the operation is too severe to be performed in the dark. 
 
 One ma3" also mention here the treatment suggested 
 by Marshall Hall, namelj^ tracheotom}^ Of course the 
 absolute uselessness of this operation as a cure for 
 epilepsy is known to-da3'',but Hall believed that the con- 
 vulsion was due to "carbonized blood," produced by the 
 asphyxia brought on by closure of the glottis. 
 
 Duration and Number of Epileptic Fits and Mortality. — 
 Epilepsy is absolutely unlimited, except by death, in the 
 length of its existence in a given case. No age which 
 the patient may attain rids him of his Nemesis, which 
 follows him to the grave whether he be in the prime of 
 life or broken down with years. Of course any given 
 attack may cause death, as has been shown under the 
 head of prognosis, but otherwise no change may occur 
 in the vitality of the patient, unless the fits are violent 
 or frequent enough to cause exhaustion. 
 
 An exceedingly interesting case of this character has 
 been recorded by Prichard^ of a man of 71 years, who 
 had been a confirmed epileptic for fift3'-seven 3^ears. He 
 worked at baskets for a living, and would often have as 
 man}^ as four or five fits a day, interrupting his work. 
 On several occasions he suffered from as many as thirty 
 in one day; indeed, it was estimated that in all he had 
 in his life no less than sixty-five thousand (65,000) fits. 
 He seemed but slightly" dulled by them, and would goon 
 working till another came on. His wife and himself 
 became so accustomed to their occurrence that they 
 came to be regarded as part of their daily life. On one 
 occasion, in his seventy-first year, however, the man 
 
 » British Med. Journ., April 28, 1860, p. 319. 
 
Duration and Number of Epileptic Fits ; Mortality. 215 
 
 failed to return to consciousness, and upon examining 
 him he was found to have suffered from an apoplexy, 
 from which he died. At the autopsy the dura mater 
 was natural, but the arachnoid was opaque. The ven- 
 tricles were filled with blood from the rupture of the 
 artery. In the falx major anteriorly was a considerable 
 plate of bone, IJ inches long, tolerably thick, and flat on 
 the side toward the membrane, while on the other side 
 it was markedly indented by the convolutions. In the 
 upper part of the convexity of the left hemisphere were 
 two round deposits of bone, as large as nuts, under the 
 arachnoid and in the pia mater, pressing down into the 
 substance of the brain, which was much softened about 
 them. There was a single, much larger deposit of the 
 same shape below, and another was attached to the 
 petrous portion of the temporal bone by a pedicle, and 
 occupied a cavity in the substance of the middle lobe. 
 
 An extraordinary number of fits may occur in a 
 brief space of time without causing death, or even very 
 great exhaustion ; at least, in some cases. A very good 
 example of this fact is that of a case reported by New- 
 ington,^ which is as follows : On the twentieth day of 
 the month, at 9 a.m., the fits began in the woman under 
 his care. By 9 p.m. the same day she had had 274 fits, 
 and by 9 a.m. on the 21st she had 384 more, or 622 fits 
 in twenty-four hours. This makes a rate of 1 nearly 
 every minute. By 9 a.m. on the 22d she had 400 more, 
 by 9 a.m. on the 23d 525, by 9 a.m. on the 24th 895, 
 and from 9 a.m. on this day to 9 a.m. on the 25tli she had 
 214 fits. 
 
 Altogether, she had 2156 fits in five days, and yet 
 survived, being fed by the rectum. This seems almost 
 incredible, but the reporter is evidently reliable. 
 
 * Journal of Mental Science, 1877, p. 89. 
 
21 G Epilepsy: its PatJiology and Treatment. 
 
 Delasiaiive^ has seen a single patient have 2500 fits 
 a month, and Altliaus^ records the case of a bo}' who 
 had 1350 in the same space of time. Leszynsky^ also 
 reports the case of a woman, aged 46, "who had 688 con- 
 vulsions in seventy-five hours, ending in death. In a 
 case of etat de mal epileptique recorded by Bourneville* 
 the convulsions occurred as follows : — 
 
 1st day, 20 fits ; 2d day, 45 fits ; 3d day, 22 fits; 4th 
 day, 27 fits ; 5th day, 12 fits. 
 
 Doxwell records the case of a male, aged 20 years, 
 who frequently had 200 to 300 fits per diem, and in the 
 last year of his life 21,800 fits. 
 
 The interval between the fits is A'ery variable, but 
 all statisticians agree that the most common interval is 
 from one day to one week. 
 
 A German observer,^ Snell, has studied the mor- 
 tality of insane ej^ileptics in order to compare the death- 
 rate in this class with that of pure insanit3^, and he finds 
 that insane epileptics have a higher death-rate, generally 
 dying at or before the age of 33 j^ears. The causes of 
 these deaths, as enumerated b}^ him, show that the 
 greater mortality depends on the accidents of the fit 
 than the disease itself, for coma due to asphyxia is very 
 commonly assigned as the cause. Out of 100 cases ex- 
 amined Snell found death due to phthisis in 31 cases 
 besides the causes just mentioned. 
 
 Chapman^ has made studies from the records of 
 asylums to determine the difference in mortality between 
 epileptics in whom the disease had been acquired and ' 
 
 ' Traits de I'Epilepsie, Lausanne. 
 ' Epilepsy, Hysteria, and Ataxia, Tjondon, 1866. 
 » N. Y. Medical Journal, Mar. 21, 1885, p. 321. 
 * Houmeville, Etat de mal Kpileptiqiio, 1873. 
 ' Snell, Zeitscrift f. Fsycliiatrie for 1875. 
 "Jour. Mental Sci., Apr. 1880, p. 15. 
 
Duration and Number of Epileptic Fits ; Mortality 217 
 
 those in whom it was congenital. He finds that the 
 acquired form is miicli more fatal than the latter, and 
 much more so in females than in males, — twice as much 
 so in the congenital form, but three or four times as 
 much in the acquired disease. In the researches of 
 Martin,^ of Boucher and Cazanvielh,^ the first-named 
 observer working in the Salpetriere, and whose labors 
 have been quoted when speaking of the influence of 
 heredity in producing epilepsy, it was found that virtu- 
 all}^ all children born of epileptic parents are epileptic 
 or dead before puberty. 
 
 These results in France have been duplicated in 
 England by Althaus,^ who has collected statistics of six 
 periods of five years, as follows : — 
 
 Deaths. 
 
 1838-42, 
 1843-44, 
 1845-51, 
 1852-56, 
 1857-61, 
 1862-66, 
 1867-71, 
 
 Periods. 
 
 jrer v^enL. oi 
 Nerv. Dis. 
 
 of All ] 
 
 5,585 
 
 2.66 
 
 .32 
 
 8,667 
 
 3.62 
 
 .42 
 
 10,339 
 
 4.01 
 
 .49 
 
 11,689 
 
 4.31 
 
 .54 
 
 12,359 
 
 4.21 
 
 .51 
 
 12,290 
 
 3.98 
 
 .49 
 
 60,929 
 
 3.86 
 
 .47 
 
 30 years. 
 
 He also found that the mortality of males to females 
 in epilepsy is as 2.13 to 1.84. 
 
 The statements of most writers that the mortality 
 of epilepsy is very low, and which have been given in 
 this essa}^ as the writer's own belief in the matter, have 
 recently received strong contradiction at the hands of 
 Worcester,* an American investigator. He examined 
 
 * Annales Med. Psych ologique, Nov., 1S78, to Sept., 1879. 
 
 ' De I'EpilepsJe conslderee dans ses Rapports avec 1' Alienation mentale. 
 ' Nervous Diseases, p. 222. London. 
 
 * Med. Record, 1888, 33, 4C7 ; also see Abstract in Amer. Jour. 'Med. 
 Sciences, July, 1888. 
 
 10 K 
 
218 Epilepsy: its Pathology and Treatment. 
 
 the statistics of the Michigan Insane Asylum for the past 
 twent3'-eight years, as well as those of fifty-five other asy- 
 lums, fifteen of which give statistics for their entire period 
 of operation. The results show that 20 per cent, to 30 per 
 cent, of the epileptic inmates die of epilepsy, the rate 
 being often much nearer the hitter figure. This is a 
 much laro^er number than the total death-rate of the in- 
 dividual asylums, and shows, therefore, that not only is 
 epilepsj^ a very fatal disease, but that many more epi- 
 leptics die from it than from all other causes put 
 together. Worcester admits that the inmates of asjdums 
 are generally cases of unusual severity, but on the other 
 hand points out that they are better taken care of, and 
 have greater security from accidents, so that he believes 
 these figures really do represent the death-rate. On the 
 other hand, if it were true that epilepsy is so fatal, it is 
 remarkable that so few deaths occur in the ordinary 
 practice of the average ph3^sician and neurologist. 
 
 The cause most commonly producing death, other 
 than traumatisms, is, according to Leszynsk}',^ in every 
 sixteen deaths of epileptics out of twenty due to status 
 epilepticus. 
 
 Proportion of Epileptics to Population and the General 
 Distribution of the Disease. — The number of epileptics 
 to the population of a country forms a very interesting 
 study. Lunier* has investigated the subject in France 
 and Tigges^ in Germany, in one province, that of Meck- 
 lenberg-Schwerin. Further studies are those of the 
 census of the Rhine provinces,* and those of Mejmne^ 
 in Belgium. Lunier draws his results from the men 
 
 » N. Y. Med. Journal, 1885, Mar. 21, p.321. 
 
 ^ Annales Med. Psychologique, March to November, 1881. 
 
 3 Zeitschrift f. Psychiatric, Bd. XI, Heft. 4. 
 
 * Centralblatt f. Nervenheilkunde, Septcmbor 5, 1882. 
 
 * Topographic Med. de la Belgiquc, Bruxclle, 1865, p. 101. 
 
Proportion of Epileptics to Population. 219 
 
 examined for the conscription, of whom there were 
 1,458,740, between 1873 and 1877. In this number 
 there were found 2398 epileptics, which would give the 
 proportion among the inhabitants of France as 16.44 to 
 every 10,000. The objection to these figures is that the 
 cases were all between 20 and 21 years of age ; so Lunier 
 has endeavored to eliminate this source of error, and as 
 a result puts the proportion at 16.44 in every 10,000 
 between the ages of 10 and 40 years. 
 
 The census made b}^ Tigges showed that the propor- 
 tion of epileptics in the town of Schwerin was 1 to every 
 855 persons, showing the disease to be quite prevalent, 
 comparatively speaking. The studies made in the Rhine 
 provinces were to discover the proportion of mentally 
 unsound epileptics to those who were mentally sound. ^ 
 It was found that those who had mental failure num- 
 bered 807, or 23.3 per cent. ; while those sound equalled 
 2653, or 76.7 per cent. 
 
 In Mecklenburg-Schwerin the number of epileptics 
 and idiots is virtually the same, for there were found to 
 be 639 epileptics and 658 idiots. Out of 639 epileptics 
 there were 167 idiots, or 25 per cent. 
 
 In Wurtemberg the proportion of epileptics to 
 healthy persons is 0.93 per 1000, and in Belgium ac- 
 cording to Meynne^ it is 0.9 per 1000, which is virtually 
 the same. 
 
 Hirsch^^ states that the proportion for Southern 
 Europe is 1.5 for 1000, while in France it is 1.6 per 1000. 
 The same authority places the number in Italy at 2.4 
 per 1000. 
 
 Complications. — The various complications which 
 may arise in epilepsy really belong to two separate 
 
 * Mentally unsound equals insane or idiotic. 
 
 " Topographic Med. de la Belgique, Bruxelle, 1865. 
 
 ^ Handbuch f. Geograpli. und Historisclie Pathologic. 
 
220 Epilepsy: its Pathology and Treatment. 
 
 classes, namely, those which come on directly or indi- 
 rectly as the result of the disease, and those which arise 
 during its course as they arise in ordinary life. 
 
 Naturally enough, a very common variet^^ of compli- 
 cation is some traumatism, severe or mild, and which is 
 suffered as the result of the fall accompanying the fit, 
 whereby the head is struck against some hard or sharp 
 object. Of course the severity of the injury is never the 
 same and cannot be described, for it may be anything 
 from fracture to a slight abrasion or bruise. When 
 such an accident does happen, it pursues the same 
 course as in healthy persons, but it should not be for- 
 gotten that the coma of the fit may be dangerously 
 deepened by the concussion, and also that the coma may 
 mislead the physician so tliat it be regarded not as the 
 natural sequence of an attack, but as produced by the 
 injury. Fractures of the clavicle are very common in 
 these persons, owing to the fact that in falling this bone 
 is suddenly strained by the shoulder striking on the 
 ground or surrounding bodies. In the same manner 
 various dislocations may ensue. The presence of a 
 fracture in an epileptic is a very much more serious 
 matter tlian would appear at first glance, for even if the 
 fits are not ver}^ frequent they are almost sure to cause 
 a fresh solution of continuit}^, or even to convert a 
 simple into a compound fracture by the jerkings of the 
 muscles. Splints are, of course, of value, and the limb 
 may be wrapped in a pillow, but still disturbance of the 
 part may occur. Careful watching with quiet rest in 
 bed must always be insisted upon, since, under these 
 circumstances, no second fall takes place on the advent 
 of a new attack. A watcher may sometimes be appointed 
 who will use nitrite of amyl wlienever a fit seems immi- 
 nent, but this is hardly practicable in most cases. It is 
 
Complications. 221 
 
 unnecessaiy for me to remark that all the secondary 
 changes, produced by injuries in the brain and elsewhere, 
 are to be looked for. 
 
 In other cases apoplexy ma}' occur, due to the 
 sudden strain upon the cerebral blood-vessels during the 
 fit, and if the coma following an attaek is prolonged or 
 peculiar this fact should be called to mind. Tiie 
 inequalit}'' of the pupil, the stertorous respiration, the 
 fact that the tongue cannot be protruded straight from 
 the mouth, all point to cerebral trouble ; but the rise of 
 temperature, the coma, and, last of all, the hemiplegia, 
 are characteristic of both states, and cannot be used for 
 differential diagnosis. 
 
 Meningitis may also arise, particularly in the cases 
 where the fits have been prolonged and frequent, or it 
 may be caused by the injury received in the fall or 
 tossings. 
 
 The frequency of paralysis lias alread}^ been dis- 
 cussed, under the heading of After-S3anptoms. It may 
 be mentioned here, however, that Reynolds has only 
 seen it as a continuous condition in 3 out of 81 cases of 
 epilepsy. 
 
 The influence of pregnane}^ on epilepsy is another 
 point of interest and dispute, some claiming that the fits 
 are increased while others say they are diminished in 
 frequency. Tyler Smith^ has seen only 2 cases of 
 epilepsy occur during labor in 53 deliveries of 15 
 epileptic women. 
 
 The susceptibility of epileptics to infectious diseases 
 is very slight, according to the best authorities. Rom- 
 berg states it to be very much decreased, and many 
 others agree with him. On the other hand, Esquirol 
 believed epileptics to be singularly open to such diseases. 
 ' Lancet, xxiv, p. 644, 1849. 
 
222 Epilepsy: its Pathology and Treatment. 
 
 The influence of acute diseases on epilepsy has been 
 quite recently studied by Bourneville and Bonnaire^ 
 during an epidemic of measles in the epileptics and 
 idiots at the Bicetre, and they find that during the 
 course of the intercurrent malady the fits are much 
 decreased in force and frequency. Seglas^ has also 
 made a series of observations at the Salpetriere and the 
 Bicetre, and he reaches the following conclusions : — 
 
 1. Intercurrent diseases have in the greater number 
 of cases a favorable influence on epileps}^ 
 
 2. In some cases this is only during the intercurrent 
 disease. 
 
 3. Febrile disorders modify it most commonly. 
 
 » Le Progres Med., 1883. 
 
 2 Compt. rendu Service Bicetre from Farmee. Paris, 1883. 
 
INDEX. 
 
 PAGE 
 
 Abdominal aura 16 
 
 Aberrant after-symptoms 35 
 
 After-symptom, albuminuria and diabetes as an 40 
 
 aphasia as an 44 
 
 change in bodily temperature as an * 34 
 
 urine as an 36 
 
 weight as an 41 
 
 coma and sleep as an 28 
 
 disorders of eye as an 44 
 
 of mind as an 53 
 
 of pupil as an 46 
 
 paralysis as an 29 
 
 reflexes as an 81 
 
 refractive anomalies as an 47 
 
 sensory disturbance as an 43 
 
 After-symptoms of petit mal 73 
 
 Alcoholic epilepsy 89-104 
 
 influences 104 
 
 Anaesthetics, uses of 198 
 
 Analysis of symptoms 12 
 
 Antifebrin, uses of 200 
 
 Antipyrin, uses of 201 
 
 Apomorphine, uses of 203 
 
 Apprehension of epileptics 52 
 
 Auditory aurae 18 
 
 Aura 12 
 
 characters of 13 
 
 of abdomen 16 
 
 of brain 19 
 
 of motion 20 
 
 of sight 17 
 
 of smell 18 
 
 of stomach 71 
 
 of taste 19 
 
 origin of 14 
 
 sensations of . . 16 
 
 Barbarous curative measures 6 
 
 Bleeding, indications for 206 
 
 Borax, uses of 204 
 
 Bromide of iron, uses of 191 
 
 of lithium 191 
 
 of nickel, uses of 191 
 
 of potassium, uses of 183 
 
 (223) 
 
224 Index. 
 
 PAGE 
 
 Cardiac epilepsy 82-132 
 
 Castration as a cure for epilepsy 4-211 
 
 Causes of epilepsy 93 
 
 of symptoms 133 
 
 Cephalic aura 19 
 
 Cerebral anaemia as a cause for epilepsy 142 
 
 hypersemia as a cause for epilepsy 144 
 
 Cerebral localization 149 
 
 Characteristics of petit mal 71 
 
 Characters of aura 13 
 
 Chloral hydrate, uses of 199 
 
 Chloroform, uses of 199 
 
 Circulation during attack 25 
 
 Circumcision 213 
 
 Clltoridectomy 121, 122-213 
 
 Cocculus indicus, uses of 203 
 
 Complications of epilepsy 219 
 
 Consanguinity as a cause for epilepsy 109 
 
 Continuous epileptic insanity 55 
 
 Contra-indications for certain drugs 205 
 
 Convulsions produced by drugs 90-205 
 
 Convulsive centre 144, 145 
 
 Curare, uses of 202 
 
 Definition of epilepsy 1 
 
 Diagnosis of epilepsy 163 
 
 Differential diagnosisoftrueepilepsyfromalcoliolicepilepsy 174 
 
 from attacks of malingerers 175 
 
 from hemicrania 174 
 
 from hystero-epilepsy 1C5 
 
 from petit mal . 173 
 
 from puerperal eclampsia 171 
 
 from syncope 174 
 
 from syphilitic epilepsy 172 
 
 from ursemic convulsions 169 
 
 Diet 206 
 
 Drugs contra-indicated 205 
 
 Duration of epileptic fits 214 
 
 Electricity, uses of 204 
 
 Epilepsia larvata 73 
 
 procursiva 85 
 
 Epilepsie apoplectique 78 
 
 eclamptique 118 
 
 pleuritiquc 132 
 
 Epilepsy, alcoholic 89 
 
 cardiac 83 
 
 definition of 1 
 
 diagnosis of 163 
 
Index. 225 
 
 PAGE 
 
 Epilepsy, etiology of 93 
 
 history of 2 
 
 idiopathic 2 
 
 Jacksonian 66 
 
 lead 130 
 
 loquax 88 
 
 malarial 91 
 
 masked 73 
 
 nocturnal "^ 
 
 nutans 88 
 
 organic 2 
 
 pathology of 138 
 
 physiology of. 138 
 
 post-hemiplegic 79 
 
 prognosis of 179 
 
 psychic 60 
 
 reflex 115 
 
 saturnine 130 
 
 spinal 92-146 
 
 symptoms of 8 
 
 synonyms of 1 
 
 syphilitic 61 
 
 topsemic 89-128 
 
 treatment of 182 
 
 ursemic 128 
 
 Epileptic character 50 
 
 crises . 131 
 
 cry 8 
 
 insanity 54 
 
 continuous , . 55 
 
 intermittent 55 
 
 remittent. 55 
 
 mania 55 
 
 Epileptics, general distribution of 219 
 
 responsibilities of 56 
 
 Epileptiform migraine 88 
 
 pathology of 161 
 
 Epileptogenous zone 139 
 
 removal of . . 213 
 
 Etiology of epilepsy 93 
 
 of symptoms 133 
 
 Encephalopathia saturnina 130 
 
 Exanthematous fevers as a cause for epilepsy 128 
 
 Facial expression during attack 10, 11 
 
 Gastric aura 71 
 
 General distribution of epilepsy 219 
 
 Globus hystericus 167 
 
 Greek theory of aura 13 
 
 10* 
 
226 Index. 
 
 PAGE 
 
 Hemiplegia epileptica ^. 29 
 
 Heredity 97 
 
 History 2 
 
 Hysterical convulsions 165 
 
 Idiopathic epilepsy 2 
 
 Incontinence of urine and feeces during attack 12-72 
 
 Influence of acute disease on epilepsy 222 
 
 of age on epilepsy 109 
 
 of barometric changes on epilepsy 127 
 
 of consanguinity on epilepsy 109 
 
 of pregnancy on epilepsy 221 
 
 of sex on epilepsy 221 
 
 Insanity, epileptic .... 54 
 
 Intermittent epileptic insanity 55 
 
 Interparoxysmal symptom 35 
 
 Iodide of potassium, uses of 199 
 
 Iron, uses of 199 
 
 Irregular symptoms 27 
 
 Isolation of female epileptics 5 
 
 Jacksonian epilepsy . 66 
 
 Laws of reflex action 117 
 
 Lead epilepsy 130 
 
 patliology of. ... 101 
 
 symptoms of 91 
 
 Ligation of vertebral arteries 211 
 
 Malarial epilepsy 91 
 
 Mania of epileptics 55 
 
 Masked epilepsy 73 
 
 Mental state of epileptics 48 
 
 Migraine, epileptiform 88 
 
 Minor causes of epilepsy : — 
 
 congenital syphilis . 114 
 
 cranial malformations 115 
 
 fright 113 
 
 masturbation 112 
 
 rachitis 113 
 
 scrofulosis 113 
 
 sexual continence 112 
 
 excesses . 112 
 
 surgical operations 114 
 
 Mortality of epileptics 216 
 
 Motor aura 20 
 
 Muscular power of epileptics 31 
 
 Muttering epilepsy 88 
 
Index. 227 
 
 PAGE 
 
 Nerve-stretcliing as a cure for epilepsy 212 
 
 Nervous irritation as a cause for epilepsy 14d 
 
 Night terrors °^ 
 
 Nitrate of amyl, uses of ^A^ 
 
 of silver, uses of |^^ 
 
 Nitro-glycerin, uses of ^^l 
 
 Nocturnal epilepsy _J^ 
 
 Number of epileptic fits .Jit) 
 
 Olfactory aurse J^ 
 
 Oophorectomy as a cure for epilepsy ^lo 
 
 Operative treatment ^^ 
 
 Optical aurse ^" 
 
 Organic epilepsy 2 
 
 Origin of aura 14 
 
 Osmic acid, uses of . '^^^ 
 
 Paralysis following convulsion 29 
 
 Pathology of epilepsy |^o 
 
 of epileptiform migraine l»| 
 
 of plumbic epilepsy 161 
 
 of syphilitic epilepsy 1«0 
 
 Petit mal • ^^ 
 
 after-symptoms of |^^ 
 
 table of characteristics of J^l 
 
 Phthisis as a cause of epilepsy 103 
 
 Physiology of epilepsy jjo 
 
 Physiognomy of epileptics l^o 
 
 Picrotoxine, uses of . 204 
 
 Post-convulsive paralysis 29 
 
 Post-hemiplegic epilepsy "^ 
 
 Precursory symptoms other than aurse ^1 
 
 tables of ^J 
 
 Prognosis of epilepsy 1|^ 
 
 Proportion of epileptics to population 219 
 
 Psychic epilepsy . • • • ^ 
 
 Psychical aura 1^ 
 
 Pupil during attack 24 
 
 Quassia, uses of 202 
 
 Reflex epilepsy 11^ 
 
 from adherent prepuce IJ^ 
 
 from carious teeth 1'^" 
 
 from cicatrix • 11^ 
 
 from ear-diseases 1~^ 
 
 from eye-strain ^24 
 
 from gall-stones 126 
 
 from hernial truss Ipy 
 
 from indigestion 121 
 
 from inflamed bowels 116 
 
228 Index. 
 
 PAGE 
 
 Reflex epilepsy, from inflamed prepuce 116-118 
 
 from irritated clitoris 120-121 
 
 from nerve injury 127 
 
 from ovarian irritation 124 
 
 from stenosis of uterine cervix 126 
 
 from vesical calculus 126 
 
 from worms 121 
 
 Relative frequency of petit mal to liaut mal 73 
 
 Remittent epileptic insanity 55 
 
 Responsibility of epileptics 56 
 
 Risus sardonicus « 9 
 
 Saturnine cerubritis 130 
 
 epilepsy 130 
 
 Sensations of aura 16 
 
 Sex, influence of, upon epilepsy 102 
 
 Spinal epilepsj'^ 92-146 
 
 Status epilepticus 26 
 
 Susceptibility of epileptics to infectious diseases 221 
 
 Symptoms of epilepsy 8 
 
 Synonyms of epilepsy 1 
 
 Syphilitic epilepsy 61 
 
 pathology of .... 160 
 
 symptoms of 62 
 
 cranial deformity. 65 
 
 headache 62 
 
 lassitude 64 
 
 loss of memory 64 
 
 palsy . 44 
 
 praecordial pain 63 
 
 psychical disturbances 65 
 
 somnolence 64 
 
 Table of characters of aurse 13 
 
 of diff"erential diagnosis of epilepsy from other con- 
 vulsions 164 
 
 of epilepsy from liystero-epilepsy 168 
 
 of precursory symi)toms 22 
 
 Time of attack 27 
 
 Toxemic epilepsy 89-128 
 
 Tracheotomy 214 
 
 Treatment of epilepsy 182 
 
 Trephining 210-213 
 
 Urajmic epilepsy 128 
 
 Urinary incontinence in petit mal 72 
 
 Venery as a cure for epilepsy 5 
 
 Voluminous state 19 
 
 Zinc, uses of 196 
 
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 Great Britain, 8s. 6d. ; France, 13 fr. 40. 
 
 The constantly increasing demand for this work attests its thor- 
 ough reliability audits popularity with the profession, and points to 
 the fact that it is already the standard work on this very important 
 subject. The part on Physical Electricity, written by Dr. Liebig, one 
 of the recognized authorities on the science in the United States, treats 
 fully such topics of interest as Storage Batteries, Dynamos, the Elec- 
 tric Light, and the Principles and Practice of Electrical Measurement 
 in their Relations to Medical Practice. Professor Rohe, Avho writes on 
 Electro-Therapeutics, discusses at length the recent developments of 
 Electricity in the treatment of stricture, enlarged prostate, uterine 
 fibroids, pelvic cellulitis, and other diseases of the male and female 
 genito-urinary organs. 
 
 M ANTON — Childbed ; its Manag-ement ; Diseases and 
 their Treatment. 
 
 By Walter P. Maxton, M.D., Visiting Physician to the Detroit 
 Woman's Hospital ; Consulting Gynaecologist to the Eastern Michigan 
 Asylum ; President of the Detroit Gynaecological Society ; Fellow of 
 the American Society of Obstetricians and Gynaecologists, and of the 
 British Gynaecological Society ; Member of Michigan State Medical 
 Society, etc. In one neat 12mo volume. No. 10 in the Physicians^ and 
 Stridmts' Beady-Reference Series. Ix Preparation . 
 
 MASSBY — Electricity in the Diseases of "Women : with 
 Special Reference to the Application of Strong Currents. 
 
 By G. Bettox Maspey, M.D., Physician to the Gynaecological 
 Department of Howard IIos])ital ; late Electro-Tlierapeutist to the 
 Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases; 
 Member of the American Neurological Association,of the Philadelphia 
 Neurological Society, of the Franklin Institute, etc. No. 5 in the Phy- 
 sicians' and Shtdints' Ready-Rrference Serirs. Second Edition, Re- 
 vised and Enlarged. Witli IS^cw and Original Wood-Engravings. 
 Handsomely bound in Dark-Blue Cloth. 240 pages, 12mo. 
 
 Price, post-paid, in ITnited States and Canada, 91.50, net; 
 Great Britain. 6s. Cd. ; France, 9 Cr. 35. 
 
F. A. Davis, Philadelphia, Pa. 
 
 MEARS — Practical Surgery. 
 
 By J. EwixG Mears, M.D., Lecturer on Practical Surgery and 
 Demonstrator of Surgery in Jefferson Medical College ; Professor of 
 Anatomy and Clinical Surger}^ in the Pennsylvania College of Dental 
 Surgery, etc. With 490 Illustrations. Second Edition, Revised and 
 Enlarged. 79-i pages. 12mo. Cloth. 
 
 Price, in United States and Canada, Cloth, S3.00. Discount^ 
 20 per cent., making it, net, S3.40 ; Postage, 30 Cents Extra. 
 Great Britain, 13s. France, 18 fr. 75. 
 
 Medical Bulletin Visiting List, or Physicians' Call 
 
 Record. Areanged upon an Original and Convenient 
 
 Monthly and AVeekly Plan for the Daily Eecording 
 
 OF Professional Visits. 
 
 This is, beyond question, the best and most convenient time- and 
 labor- saving physicians' pocket record-book ever published. Phy- 
 sicians of many years' standing and with large practices pronounce 
 this the best list they have ever seen. It is handsomely bound in fine, 
 strong leather, with flap, including a pocket for loose memoranda, etc., 
 and is furnished with a Dixon lead-pencil of excellent quality and 
 finish. It is compact and convenient for carrying in the pocket. Size, 
 4x6^ inches. In three st3des. 
 
 Net Price, post-paid : Xo. 1, Regular Size, for 70 patients 
 daily each month for one year, United States and Canada, 
 Sil.35 ; Great Britain, 5s. 3d. ; France, 7 fr, 75. No. 3, JLarge 
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 States and Canada, §1.50 ; Great Britain, 6s. 6d. ; France, 
 9 fr. 35. No. 3, in which "The Blanks for Recording Visits 
 in " are in removable sections, United States and Canada, 
 SI. 75 ; Great Britain, 7s. 3d. ; France, 13 fr. 30. 
 
 MICHBNETl — Hand-Book of Eclampsia ; or, Notes and 
 Cases of Puerperal Convulsions. 
 
 By E. MiCHENER, M.D.; J. H. Stubbs, M.D. ; E. B. Ewing, 
 M.D. ; B. Thompson, M.D. ; S. Stebbins, M.D. 16mo. Cloth. 
 
 Net Price, 75 Cents ; Great Britain, 3s. ; France, 4 fr. 30. 
 
 NISSBN — A Manual of Instruction for Giving- Sv^edish 
 Movement and Massage Treatment. 
 
 By Prof. Hartvig Nissen, Director of the Swedish Health Insti- 
 tute, Washington, D.C. ; late Instructor in Physical Culture and Gym- 
 nastics at the Johns Hopkins University, Baltimore, Md. ; Author of 
 "Health by Exercise without Apparatus." Illustrated with 29 Original 
 Wood-Engravings. In one 12mo volume of 128 pages. Neatly bound 
 in Cloth. 
 
 Price, post-paid, in United States and Canada, SI. 00, net; 
 Great Britain, 4s. 6d. ; France, 6 fr. 30. 
 
8 Catalogue of 3Iedical Publications. 
 
 Physicians' All-Requisite Time- and Labor- Saving 
 Account-Book. Being a Ledgee and Account-Book 
 FOR Physicians' Use, Meeting All the Eequirements of 
 THE Laav and Courts. 
 
 Designed by William A. Seibert, M.D., of Easton, Pa. There 
 is no exaggeration in stating that this Account-Book and Ledger re- 
 duces the labor of keeping j-our accounts more than one-half, and at 
 the same time secures the greatest degree of accuracy. 
 
 To all physicians desiring a quick, accurate, and comprehensive 
 method of keeping their accounts, we can safely say that no book as 
 suitable as this one has ever been devised. 
 
 Net Price, Shipping Expenses Prepaid : No. 1, 300 Pages, 
 for 900 Accounts per Year, Size 10 x 13, Bound in ^-Russia, 
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 Canada (duty paid), SS.SO ; Great Britain, 31s.; Fi'ance, 
 30 fr. 30. No. 2, 600 Pages, for 1800 Accounts per Year, 
 Size 10 X 12, Bound in ^-Russia, Raised Back-Bands, Clotli 
 Sides, in United States, »8.00 ; Canada (duty paid), S$8.80 : 
 Great Britain, 1.13s. ; France, 49 fr. 40. 
 
 A circular showing the plan of the book will be sent free to any 
 address on application. 
 
 Physicians' Interpreter : In Four Languages (English, 
 French, German, and Italian). 
 
 Specially arranged for diagnosis by M. von V. The object of this 
 little work is to meet a need often keenly felt by the busy physician, 
 namely, the need of some quick and reliable method of communicat- 
 ing intelligibly with patients of those nationalities and languages un- 
 familiar to the practitioner. The plan of the book is a systematic 
 arrangement of questions upon the various branches of Practical 
 Medicine, and each question is so worded that the only answer re- 
 quired of the patient is merely Yes or No. The questions are all 
 numbered, and a complete Index renders them always available for 
 quick reference. The book is written by one who is well versed in 
 English, French, German, and Italian, Ijeiug an excellent teacher in 
 those languages, and who has also had considerable hospital experi- 
 ence. Bound in full Russia Leather, for carrying in the pocket. Size, 
 5x2^ inches. 206 pages. 
 
 Price, post-paid, in United States and Canada, $1.00, net; 
 Great Britain, 4s. 6d. ; France, 6 fr. 30. 
 
 PURDY — Diabetes: its Cause, Symptoms, and Treat- 
 ment. 
 
 By CiiAS. W. PuKDY, M.D. (Queen's University), Honorary 
 Fellow of the Royal College of Physicians and Surgeons of King- 
 ston ; Member of the College of Physicians and Surgeons of Ontario ; 
 Author of " Bright's Disease and Allied AjBTectious of the Kidneys ^'' 
 
F. A. Davis, Philadelphia, Pa. 
 
 Member of the Association of American Physicians ; Member of the 
 American Medical Association ; Member of the Chicago Academy of 
 Sciences, etc., etc. With Clinical Illustrations. In one neat 12mo 
 volume. No. 8 in the Physidans' and Stzcdents' Heady- Reference Scries. 
 Handsomely bound in Dark-Blue Cloth. Ready October, 1890. 
 
 Net Price, United States and Canada, $1.35 ; Great Britain 
 5s. 3d. ; France, 7 fr. 75 ; post-paid. 
 
 PRICE AND EAGLETON— Three Charts of the Nervo- 
 Vascular System. Part I. — The Nerves. Part II. — 
 The Arteries. Part III. — The Veixs. 
 
 Arranged by W. Henry Price, A.M., M.D., and S. Potts 
 Eagletox, M.D. Endorsed by leading anatomists. '' The Nervo- 
 Vascular System of Charts'' far excels every other system in their 
 completeness, compactness, and accuracy. 
 
 Price, United States and Canada, 50 cents, net, complete ; 
 Great Britain, 2s. 6d. ; France, 3 fr. 60. 
 
 ROHE — Text-book of Hygiene : A Comprehensive Trea- 
 tise ou" the PriiiJ'ciples axd Practice or Preventive Medi- 
 cine FROM an American Stand-point. 
 
 By George H. Rohe, M.D., Professor of Obstetrics and Hygiene 
 in the College of Physicians and Surgeons, Baltimore; Director of the 
 Maryland Maternite ; Member of the American Public Health Asso- 
 ciation ; Foreign Associate of the Societe Francaise d'Hygiene, of the 
 Societe des Chevaliers-Sauveteurs des Alpes Maritimes, etc. Second 
 Edition, thoroughly Revised and Largely Rewritten, with many Illus- 
 trations and valuable Tables. Rohe's Hygiene is the Standard Text- 
 book in many Medical Colleges in the iTnited States and Canada. 
 It is a sound guide to the most modern and approved practice in Ap- 
 plied Hygiene. In one handsome Octavo volume of about 400 pages, 
 bound in Extra Cloth. 
 
 Net Price, United States and Canada, S3.50 ; Great Britain, 
 lis. 6d. ; France, 16 fr. 20. 
 
 SAJOUS — Hay Fever and its Successful Treatment by 
 Superficial Org-anio Alteration of the Nasal 
 Mucous Membrane. 
 
 By Charles E. Sajous, M.D., Lectnrer on Rhinology and Laryn- 
 gology in Jefl'erson Medical College ; Vice-President of the American 
 Laryngological Association ; OflBcer of the Academy of France and 
 of Public Instruction of Venezuela ; Corresponding Member of the 
 Royal Society of Belgium, of the Medical Society of Warsaw (Poland) , 
 and of the Society of Hygiene of France ; Member of the American 
 Philosophical Society, etc., etc. With 13 Engravings on Wood. 12mo. 
 Bound in Cloth. Beveled edges. 
 
 Price, United States and Canada, Xet, S>1.00 ; Great Britain, 
 4s. 6d. ; France, 6 fr. 30. 
 
10 Catalogue of Medical Publications. 
 
 SANNE — Diphtlieria, Croup : Tracheotomy and Intu- 
 batioD. 
 
 From the French of A. Saxxe. Translated and Enlarged by 
 Henry Z. Gill, M.D., LL.D. Diphtheria having become such a 
 prevalent, wide-spread, and fatal disease, no general practitioner can 
 afford to be without this work. It Avill aid in preventive measures, 
 stimulate promptness in the application of and efficiency in treatment, 
 and moderate tlie extravagant views wliich have been entertained re- 
 garding certain specifics in the disease Dii)htheria. 
 
 A full Index accompanies the enlarged volume, also a list of 
 authors, making, altogether, a very handsome illustrated volume of 
 over 680 pages. 
 
 Net Price, post-paid, United States, Cloth, ^4.00; L.eatlier, 
 So.OO. Canada (duty paid), Cloth, 84.40; Leather, JS5.50. 
 Great Britain, Cloth, 17s. ; Leather, £1 Is. France, Cloth, 
 24 fr. 60 ; Leather, 30 fr. 30. 
 
 SENN — Principles of Surgery. 
 
 By N. Senx, M.D.. Pli.D., IMilwaukee, Wis. ; Professor Principles 
 of Surgery and Surgical Pathology in Rush Medical College, Chicago, 
 111.; Professor of Surgery in the Chicago Polj'clinic ; Attending Sur- 
 geon to the Milwaukee Hospital ; Consulting Surgeon to the Mil- 
 waukee County Hospital and to the I>Iilwaukee County Insane Asylum ; 
 Honorary Fellow College of Physicians in Philadelphia, Pa. ; Perma- 
 nent Member of the German Congress of Surgeons ; Member of La 
 Academie deMedicina de Mexico, of the D. Hayes Agnew Surgical So- 
 ciety in Philadelphia, Pa., of the Ohio State Medical Society, and of the 
 Minnesota State Medical Society ; Member of the American Surgical As- 
 sociation, of the American ]\[edical Association, of the British Medical 
 Association, of the Wisconsin State Medical Society, and of the 
 Bi-ainard Medical Society, etc. In one handsome Royal Octavo volume, 
 with over 100 illustrations. Ix Press. Will be issued in October, 
 1890. 
 
 SHOEMAKER — Ointments and Oleates, Especially in 
 Diseases of the Skin. 
 
 By Joiix V. Shoemaker, A.M., M.D., Professor of Materia 
 Medica, Pharmacology, Thei-apcutics, and Clinical Medicine, and 
 Clinioal Professor of Diseases of the Skin in the Medico-Chirurgical 
 College of Philadelphia; Physician to the Medico-Chirurgical Hos- 
 ])ital ; Member of the American Medical Association, of the Pennsyl- 
 vania and Minnesota State Medical Societies, the American Academy 
 of Medicine, the British Medical Association ; Fellow of the Medical 
 Society of London, etc. Secoxd Editiox, Revised and Enlarged. 
 No. 6 in the P/nj.sicians' and Studoits* Ready-Reference Se)'ies. 12rao. 
 Neatly bound in Cloth. 
 
 Price, in United States and Canada, net, $1.,'>0, post-paid ; 
 Great Britain, 6s. 6d. ; France, 9 fr. 35. 
 
F. A. Davis, Philadelj)hia, Pa. 11 
 
 The accompanying Table of Contents Avill give a general idea of 
 the work : — 
 
 Contents. — Part I. History and Oiigin, Part II. Process of 
 Manufacture. Part III. Physiological Action of the Oleates. Part 
 IV. Therapeutic Effect of the Oleates. Part Y. Ointments: Local 
 Medication of Skin Diseases. Antiquity of Ointments. Different 
 Indications for Ointments, Powders, Lotions, etc. Information about 
 Ointments : Scanty, Scattered, and Insufficient. Fats and Oils : Ani- 
 mal and Vegetable. Their Chemical C(jmposition. Comparative 
 Permeability of Oils into the Skin ; of Animal, of Vegetable. Incor- 
 poration of Medicinal Substances into Fats : (1) Mode of Prepara- 
 tion, (2) Vegetable Powders and Extracts, (3) Alkaloids, (4) Mineral 
 Substances, (5) Petroleum Fats : Chemical Composition : Uses and 
 Disadvantages. List of Officinal Ointments. Indications. Substances 
 often Prescribed Extemporaneously in Ointment Form. Indications. 
 A full index renders the book convenient for quick reference. 
 
 SHOEMAKER AND AULDE— Materia Medica, Phar- 
 macology, and Therapeutics. 
 
 By John V. Shoemaker, A.M., M.D., Professor of Materia 
 Medica, Pharmacology, and Therapeutics in the Medico-Chirurgical 
 College of Philadelphia, and Member American Medical Association, 
 and John Aulde, M.D., Demonstrator of Clinical Medicine and of 
 Physical Diagnosis in the Medico-Chirurgical College of Philadelphia, 
 and Member American Medical Association. Royal Octavo. Vol. I 
 Now Ready. 
 
 Net Price, per volume, in United States and. Canada, Cloth, 
 S2.o0 ; Sheep, §3.35. Great Britain, Cloth, 10s. 6d. ; Sheep, 
 14s. 6d. France, Cloth, 16 fr. 30 ; Sheep, 30 fr. 30. 
 
 Several blank sheets of closely-ruled letter-paper are inserted at 
 convenient places in the work, thus rendering it available for the stu- 
 dent and physician to add valuable notes concerning new remedies 
 and other important matters. Part I embraces three subdivisions, as 
 follows : — 
 
 First. A brief synopsis upon the subject of Pharmacy. Second. 
 A Classification of Medicines is presented under the head of General 
 Pharmacology and Therapeutics, with a view to indicate more espe- 
 cially the methods by which the econonu" is affected. Third. A sum- 
 mary has been prepared upon Therapeutics, covering methods of 
 Administration, Absorption and Elimination, Incompatibility, Pre- 
 scription-Writing, and Dietary for the Sick. This section of the work 
 embraces nearly one hundred and fifty pages. 
 
 Part II is devoted to Remedies aitd Remedial Agents not Properly 
 Classed with Drugs, and includes elaborate articles upon Electro- 
 Therapy, Hydro-Therapy, Masso-Therapy, Heat and Cold, Oxygen, 
 Mineral-Waters, and other subjects, such as Climatology, H^'pnotism 
 and Suggestion, Metallo-Therapy, Transfusion, and Baunscheidtismus, 
 have received a due share of attention. 
 
12 Catalogue of Medical Publications. 
 
 SHOEMAKER— Heredity, Health, and Personal 
 Beauty. 
 
 By John V. Shoemaker, A.M., M.D., Professor of Materia 
 Medica, Pharmacolog-y, Therapeutics and Clinical Medicine, and 
 Clinical Professor of Diseases of the Skin in the Medico-Chirurgical 
 College of Philadelphia, etc. In one Royal Octavo volume. In 
 Press. Ready in Autumn, 1890. 
 
 SMITH— The Physiology of the Domestic Animals : A 
 
 Text- Book for Veterinary and Medical Students and 
 Practitioners. 
 
 By Robert Meade Smith, A.M., M.D., Professor of Compara- 
 tive Ph3^siology in University of Pennsylvania; Fellow of the College 
 of Physicians and Academy of the Natural Sciences, Philadelphia; of 
 the American Physiological Society ; of the American Society of 
 Naturalists; Associe Etranger de la Societe Francaise d'H3'^giene, etc. 
 In one handsome Royal Octavo volume of over 950 pages. Profusely 
 Illustrated with more than 400 fine Wood-Engravings and many 
 Colored Plates. 
 
 Net Price, in United States, Cloth, So.OO ; Sheep, $6.00. 
 Canada (duty paid), Clotli, 8§5.50 ; Sheep, $6.60. Great 
 Britain, Cloth, 31s. ; Sheep, 34s. France, Cloth, 30 fr. 30 ; 
 Sheep, 36 fr. 30. 
 
 This new and important work, the most thoroughly complete in 
 the English language on this subject, has just been issued. In it the 
 physiology of the domestic animals is treated in a most comprehensive 
 manner, especial prominence being given to the subject of foods and 
 fodders, and the character of the diet for the herbivora under different 
 conditions, with a full consideration of their digestive peculiarities. 
 Without being overburdened with details, it forms a complete text- 
 book of physiology, adapted to the use of students and practitioners 
 of both veterinary and human medicine. This work has already been 
 adopted as the Text-Book on Physiology in the Veterinary Colleges of 
 the United States, Great Britain, and Canada. 
 
 STEWART— Obstetric Synopsis. 
 
 By John S. Stewart, M.D., Demonstrator of Obstetrics and 
 Chief Assistant in the Gynpecological Clinic of the Medico-Chirurgical 
 College of Philadelphia. With an Introductory Note by William S. 
 Stewart, A.M., M.D., Professor of Obstetrics and Gynaecology in the 
 Medico-Chirurgical College of Philadelphia. Forty-two Illustrations ; 
 202 pages. 12mo. Handsomely bound in Dark-Blue Cloth. Ho. 1 in 
 the Physicians' and Students' Ready -Bcfei'ence iSeries. 
 
 Price, post-paid, in United States and Canada, net, SI. 00 ; 
 Great Britain, 4s. 6d. ; France, 6 fr. 20. 
 
F. A. Davis, Philadelphia, Pa. 13 
 
 ULiTZMANN— The Neuroses of the Genito Urinary 
 System in the Male : with Sterility and Impo- 
 tence. 
 
 By Dr. R. Ultzmaxx, Professor of Genito-Urinary Diseases in 
 the University of Vienna. Translated, with, the author's permission, 
 by Gardjter W. Allen, M.D., Surgeon in the Genito-Urinary De- 
 partment Boston Dispensary. Just Issued. Xo. 4intlie PhysicianH^ 
 and Students^ Beady -Reference Series. Illustrated. 12mo. Handsomely 
 bound in Dark-blue Cloth. 
 
 Net Price, in United States and Canada, SI. 00, post-paid ; 
 Great Britain, 4s. 6d. ; France, 6 fr. 30. 
 
 Syixopsis of Contexts. — First Part.— I. Chemical Changes in 
 the Urine in Cases of Neuroses. II. The Neuroses of the Urinary and 
 of the Sexual Organs, classified as : 1, Sensory Neuroses ; 2, Motor 
 Neuroses ; 3, Secretory Neuroses. Second Part. — Sterility and Impo- 
 tence. 
 
 The Treatment in all Cases is described Clearly and Minutely. 
 
 WITHERSTINE— International Pocket Medical For- 
 mulary. Aeeak-ged Therapeutically. 
 
 By C. Sumner Witherstine, M.S., M.D., Associate Editor of 
 the " Annual of the Universal Medical Sciences ;" Visiting Physician 
 of the Home for the Aged, Germantown, Philadelphia; late House- 
 Surgeon Charity Hospital, New York. More than 1800 formulse from 
 several hundred well-known authorities. With an Appendix contain- 
 ing a Posological Table, the newer remedies included ; Important In- 
 compatibles ; Tables on Dentition and the Pulse ; Table of Drops in a 
 Fluidrachm and Doses of Laudanum graduated for age ; Formulae and 
 Doses of Hypodermic Medication, including the newer remedies; Uses 
 of the Hypodermic Syringe ; Formulae and Doses for Inhalations, 
 Nasal Douches, Gargles, and Eye-washes ; Formulae for Suppositories; 
 Use of the Thermometer in Disease ; Poisons, Antidotes, and Treat- 
 ment ; Directions for Post-Mortem and Medico-Legal Examinations ; 
 Treatment of Asphyxia, Sun-stroke, etc. ; Anti-emetic Kemedies and 
 Disinfectants ; Obsteti-ical Table ; Directions for Ligation of Arteries ; 
 Urinary Analysis ; Table of Eruptive Fevers ; Motor Points for Elec- 
 trical Treatment, etc. This work, the best and most complete of its 
 kind, contains about 275 printed pages, besides extra blank leaves. 
 Elegantly printed, with red lines, edges, and borders ; with illustra- 
 tions. Bound in Leather, with Side-Flap. It contains more than 1800 
 Formulae, exclusive of the large amount of other very valuable matter. 
 
 Price, post-paid, in United States and Canada, ®3.00, net. 
 Great Britain, 8s. 6d. France, 13 fr. 40. 
 
 YOUNG — Synopsis of Human Anatomy : Being a Com- 
 plete CoMPEND OF Anatomy, including the Anatomy of 
 the Viscera, and Numerous Tables. 
 
 By James K. Young, M.D., Instructor in Orthopaedic Surgery 
 and Assistant Demonstrator of Surgery, University of Pennsylvania; 
 
14 Catalogue of Medical Publications. 
 
 Attending Orthopedic Surgeon, Out-Patient Department, University- 
 Hospital, etc, JVo. 3 in the Physicians^ and Stiident^s' Beady-Reference 
 Series. Illustrated with 76 Wood-Engravings ; 390 pages. 13mo. 
 Handsomely bound in Dark-Blue Cloth. 
 
 Price, post-paid, in United States and Canada, S1.40, net. 
 Great Britain, Gs. 6d. France, 9 fr. 35. 
 
 THE FOLLOWING BOOKS ARE SOLD ONLY BY 
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 Annual of the Universal Medical Sciences : A Yearly 
 Bepoet of the Progress of the General Sanitary Sciences 
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 Edited by Charles E. Sajous,M.D., Lecturer on Laryngology and 
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 Associate Editors, Assisted by over Two Hundred Corresponding 
 Editors and Collaborators. In Five Royal Octavo Volumes of about 
 500 pages each, bound in Cloth and Half-Russia, Magnificently Illus- 
 trated with Chromo-Lithographs, Engi-avings, Maps, Charts, and 
 Diagrams. Being intended to enable any physician to possess, at a 
 moderate cost, a complete Contemporary History of Universal Medicine, 
 edited by many of America's ablest teachers, and superior in every 
 detail of print, paper, binding, etc., a befitting continuation of siich 
 great works as " Pepper's System of Medicine," " Ashhurst's Interna- 
 tional Encyclopaedia of Surgery," " Buck's Reference Hank-Book of 
 the Medical Sciences." 
 
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 The Satellite of the * ' Annual of the Universal Medical Sciences. " 
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 branches of medicine appearing in the medical press at large, edited 
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 connection with the Annual, and for Subscribers Only. 
 
F. A. Davis J Philadelphia^ Pa. 15 
 
 Lectures on Nervous Diseases, from the Stand-poixt of 
 ^ Ceeebeal and Spinal Localization, and the Later 
 Methods Employed in the Diagnosis and Treatment 
 OF these Affections. 
 
 By Ambrose L. Eanney, A.M., M.D., Professor of the Anatomy 
 and Physiology of the Nei-yous System in the New York Post-Graduat« 
 Medical School and Hospital ; Professor of Nervous and Mental 
 Diseases in the Medical Der^artment of the University of Vermont, etc.; 
 Author of "The Applied Anatomy of the Nervous System," "Prac- 
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 Wood-Engravings, and Reproduced Photographs of Typical Cases. 
 One handsome Royal Octavo volume of 780 pages. 
 
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 Sheep, 28s.; Half-Russia, 30s. France, Cloth, 34 fr. TO ; 
 Sheep, 40 fr. 45 ; Half-Kussia, 43 fr. 30. 
 
 Lectures on the Diseases of the Nose and Throat. 
 
 Delivered at the Jefferson Medical College, Phila- 
 delphia. 
 
 By Charles E. Sajous, M.D., Lecturer on Rhinology and 
 Laryngology in Jefferson Medical College ; Vice-President of the 
 American Laryngological Association ; Officer of the Academy of 
 France and of Public Instruction of Venezuela ; Corresponding Mem- 
 ber of the Royal Society of Belgium, of the Medical Society of Warsaw 
 (Poland), and of the Society of Hygiene of France; Member of the 
 American Philosophical Society, etc., etc. Illustrated with 100 
 Chromo-Lithographs, from Oil-Paintings by the author, and 93 En- 
 gravings on Wood. One handsome Royal Octavo volume. 
 
 Price, in United States, Cloth, Koyal Octavo, 8S4.00; Half- 
 Kussia, Koyal Octavo, S5.00. Canada (duty paid). Cloth, 
 S4.40 ; Half-Kussia, S5.50. Great Britain, Cloth, ITs. ; 
 Half-Russia, JSl Is. France, Cloth, 24 fr. 60 ; Half-Kussia, 
 30 fr. 30. 
 
 Stanton's Practical and Scientific Physiognomy; or 
 How to Read Faces. 
 
 By Mart Olmsted Stanton. Copiously Illustrated. Two large 
 Octavo volumes. 
 
 The author, Mrs. Mart 0. Stanton, has given over twenty years 
 
16 Catalogue of Medical Publications. 
 
 to the preparation of this work. Her style is easy, and, by her happy 
 method of illustration of every point, the book reads like a novel and 
 memorizes itself. To physicians the diagnostic information conveyed 
 is invaluable. To the general reader each page opens a new train of 
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