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No. 7 IN THE PHYSICIANS' AND STUDENTS' READY
REFERENCE SERIES.
EPILEPSY:
ITS PATHOLOGY AND TREATMENT.
Being an Essay to which was Awarded a Prize of Four
Thousand Francs by the Academie Royale de
Medecine de Belgique, December 31, 1889.
HOBART AMORY HARE, M.D. (p^^iTa.), 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.;
3Iember of the Association of 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 DELAWARE HOSPITAI.
OF WIIiMINGTON,
I DESIRE TO DEDICATE THIS ESSAY,
AS AN EVIDENCE OF
AFFECTION AND FRIENDSHIP.
PREFACE.
This essay upon epilepsy was considered by the
Royal 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., Philadelphia,
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 iuspu-
tatus, Morbus viridellus, Morbus vitriolatus, Morbus
sonticus, Morbus carducus, Morbus uuaticatus, Morbus
foldus, Morbus sideratus, Morbus sceleetus, Morbus
demonicus, Morbus deificus, Morbus astralis, Morbus
St. Valentis 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 system 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.
lA (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-
ploj^ed is at once inaccurate and inexpressive even of
the little we know. Thus, many writers divide the
disease into idiopathic epilepsy and organic epilepsy,
because in the one case we have not been able with
the means at our disposal to discover any 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
Hidory. 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 observers,
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
hypothetical 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
buikling 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 entirely 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, w^hicli 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 atiection of tlie 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 w^e 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 sixteenth century the first reports of methods of cure
of a rational character appeared, and for many years
formed almost entirely 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 Scotland, Edinburgh, 1536, 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 treatmeut 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 Heurnias,^
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-
eut on the retention of semen, which, undergoing corrup-
tion, produced reflex convulsions by the irritation set up.
Yery early in the history of medicine, however, these
views were largely held, for Arethaeus* asserts that
many ph3"sicians, among them the celebrated followers
of ^sclepius, 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 physicians 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., Tournon, 1603, p. 229.
2 Opera Omnia, postrema editio, Lugduni, 1658 ; de Epilepsia, chap,
xxiii, p. 421.
2 Morb. Chron., lib. i, cap. iv.
* Opera Omnia, Morb. Chron., lib. i, cap. iv.
' Geneanthropia, Romae, 1643, p. 886. C.
6 JEpilepsy : its Pathology and Treatment.
of cure in some forms of epileps}^, but not in all forms.
Tissot,^ who wrote, comparatively speaking, much more
recently, 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 they 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 hy Democritus to a" seizure "; —
or, as Faustus has described it : —
" Turpis, et est morbi species horrenda caduco.''
The following extracts in regard to the more modern
superstitions will also be of interest to the reader, as
showing how barbarous curative measures were em-
ployed in the eighteenth century ^ : —
To Monsieur the Criminal Lieuteimnt- Ge7ieral and President of the SenesclmVs
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 agrege of the College of
* Traite de I'Epilepsie, Lausanne, 1785, p. 73.
'^ Rev. Med. et Chirurg. de Paris, November, 1855.
History, 7
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 tlm Crimbial Limtevimit-Oeneral in tJie SeneschaVs Court of
I/yons: —
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, when M. Moreau proved it to be untrue by an
8 Epilepsy: its Pathology and Treatment,
enormous collection of evidence against it. Thus, lie
saw no less than 4t,63Y 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 have
held until A^ery 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 Eckeu-
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 sj^mp-
toms of an oncoming attack of epilepsy is a peculiar
sensation felt in some portion of the body, generally
below the brain, which gradually rises up over the patient,
either rapidly or slowly, like an oncoming cloud, until,
the head having been reached, the patient is immediatel}^
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 beeu
called the '' epileptic cry," being probably due not so
much to a voluntary impulse as to a sudden expulsion
of the air from the thorax by the convulsive contraction
Symptoms, 9
of tlie alKlomiiinl miiscles^as well as those of the tliornx,
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 eases. There is, therefore, no
difference worthy of note in these numbers.
The arms are strongly 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
1 University Medical Magazine, 1889.
1*
10 Epilepsy: its FatJiology 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. Unfortunatel}- the writer finds, in the cases
collected by him, that in only 158 instances were any
remarks on this point made. In these 158 the right side
was most affected in 7Y 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 symptoms,
as it would hardly be justifiable, for in some of the cases
they may have occurred and the reporter neglected to
name any one of them.
The legs may be firmly flexed on the abdomen,
while the fingers are rigidty extended. The change in
the color of the face is very marked and almost t3q3ical
of the disease, being at first pale, then flushed, the flush-
ing deepening often into a livid purple, owing to the
asphyxia 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 b}^ 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. 11
ors give way to muscular contractions. The expression
of the face, which in the preceding stage was set and
firm, is now constantly clianged 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 by 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 body, 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 ox^^genated, 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 diflSculty.
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 i^assed away the brain is
evidently disturbed in its functions for some hours or
12 Epilepsy: its Pathology and Treatment,
perhaps cla3^s, and headache is, not rarely, 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 onl}^ recorded as occurring in 45 cases.
Having described a tj^pical attack of epilepsy, let ns
proceed to an analysis of the various S3^mptoms detailed.
Yery commonly in epilepsy we find that the patient is
covered, during or after the parox3^sm, by a profuse
sweat, which has been assigned by 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 solely 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 an 3^ sweat must
be due entirel3^ to a disordered peripheral circulation and
its nerve-supply, or to disturbances in the nerves govern-
ing the sweat-glands. Those who believe completel3^ in
V the neurotic origin of the sweat point out very forcibl3^
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-cnlled aiira^
and some diiference of opinion has arisen as to the fre-
* Diseases of the Nervous System, vol. ii, p. 681.
Arch, f. Psychiatric, 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 England 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 9T0 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
remainino- 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, 8.
Epigastric, 20. Cramp in muscles, 11. Abdominal, 3.
Headache, 16. Olfactory, 11. Aphasia, 3.
Auditory, 16. Mental, 8. Unclassified, 44.
The word au7'a is derived from the Latin, signifying
vapor ^ and its application to certain symptoms of epi-
lepsy arises from the old Greek theor^^ that the fit began
* Nervous Diseases and their Diagnosis, p. 103.
''Ibid., p. ()82.
^ 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 the 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 b}^ 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 may exist in the same part of an extremity.
Then, too, we have nothing as j^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. Every one knows how disease of the brain
may 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 periphery may cause not only cen-
tric changes but peri[)heral changes elsewhere entirely
separate trom the part primarily injured; as, for ex-
The Aura, 15
ample, the famous experiments of Brown-Seqimrd, 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 anra. 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 epileps}^ 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. Bj^ 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 aur^e 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
aurse may differ in every ease 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 anal3^sis 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,^ is twice as frequent as all the other special-
sense aurse put together. It may consist of a single or,
more commonly, many colors, floating before the e^^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 bej^ond the ability of the patient to
describe, while diplopia, blindness, or complex visions
ma}^ 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.
2 Loc. ciL, p. 684.
^ Observationum Medicarum Rariorum, Frankf urti, 1665, lib. i ; de
Epilepsia, p. 104.
A2
18 Epilepsy: its Pathology and Treatment,
a young man who always 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 pass
before the eyes, or objects seem to move toward the
patient more and more rapidly, 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 tiresome to the reader,
who, after what has been said, must have been impressed
with the idea that any vision or aberrant movement of
the apparatus vision may occur.
Auditory disturbances are also frequently present as
aurae. Thus, there 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 may 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 speedil}^
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.
Stiil one other seat may give rise to an aura, namely,
the brain. Psychical aurse, 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, lie 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 aurse vary 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 i)rolonged.
The frequenc}' 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,
Present occasionally.
Present frequently, .
20 U^
10 11
IS 11
4JIO
11^
•1j30
36 33 69 98
20 Epilepsy: its Pathology and Treatment,
When we exclude the doubtful cases, we find that
vertigo is present in It per cent., and that more females
are affected 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 aurse 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 orbicularis palpebrarum,
A ver}^ close relationship exists between the onset
of the attack itself aud the aura in these cases; that is
to say, it is difficult 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 aurje as of the
sensory variet}^, that they indicate the place in which
lies the centric trouble, if centric trouble exist, and it
is equally undeniable that these motor aurse generally
accompan}^, not the ordinary 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. Loudon.
Precursory Symptoms. 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 com])ined
aura may be present, commonly made up of a motor
and sensory aura, or of a motor and special seusory
aura, although all these may occur in a single case.
Precursory Symptoms other than Aurde. — 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 they 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. Yiolence
may be indulged for several 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 Patliology and Treatment.
as almost to amount to aphasia. The touch may be
h3^per8esthetic, or diplopia or hemiopia exist for twenty-
four or forty-eight 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 always present, he finds reason to divide
them into seven groups as follows : —
Seventy-five Gases with Precursory 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
Rotation 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, .
Feeling as of a ball in throat and chest.
Shivering with cold, ....
Pain or heat, . . .
Palpitations, spasms, ....
* Traite de I'Epilepsie, 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
Undefinable sensations, .6
Ninety-four Gases with Precursory Symptoms in the
Extremities,
Numbness, contractions, jerkings, retractions, cramps,
and formications, 36
Pain, with or without spasm, 13
Tremblings, . . . . . . . . . , 10
Aura or similar phenomena, 20
Undefinable sensations, .15
Twenty-two Gases with Precursory Symptoms of an
Undefinable Character,
General agitation and rotation of body, . . . . 8
Condition of discomfort, fainting, 6
Vague sensations, . . 7
Moroseness, 1
Five Cases with Precursory Symptoms Situated in the
Genital Organs.
Retractions of testicles or aura starting there, sensations
in the uterus, ......... 5
The seventh 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 (t5 cases), next in tlie abdomen
(32 cases), and last of all in the thorax (22 cases), the
remaining 2t cases in the sixth and seventh somewhat
artificial divisions of the author quoted being of an nn-
definable character.
Addison has also studied the relative frequenc}^ of
the symptoms of the attack itself, with somewdiat 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 Pupil. — The dilatation of the pupil, which comes
on in nearly all epileptic attacks, has connected with it
the interesting question as to whether the m^^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 physiologists that the pupil generally dilates in con-
* Addison, Journal Mental Science, vol. xii, 1807.
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 asphyxia produces similar results
b}^ its action on the centric nervous ocular apparatus. In
some cases it would seem that the 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 tlmt 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 probably 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 epileps}^ ; the best
authorities, indeed, all agree in stating that the only
changes are those brought about by the accompanying
asphyxia. 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
epileptic 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
* rEpilepsie Paralytique, 1881.
2 B
26 Ejnlepsy : its Fatliology 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 systole 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 Upilepticus. — Before passing on the writer
should speak of the condition known as the " status epi-
lepticus," in which convulsion follows convulsion so
rapidly that consciousness is never regained, but the
patient dies within a few hours as a result of exhaustion
or asphyxia.
Probabl}^ the most thorough studj^ that we liave of
this condition is that of Bourneville,^ and his results are
certainly worthy of introduction here. He details the
sj^mptoms as follows : Etat de mal epileptique is char-
acterized by —
1. Frequent repetitions of attacks so close together
as to be almost if not continuous.
2. By variable degrees of collapse, which may deepen
into coma.
3. B}' 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 noteworthy, however, that with the development
of the bed-sores the temperature rises again as high as
during the convulsions.
* Bourneville, Etat de mal Epileptique, 1873.
Time of Da\j. 2T
Time of Day. — In an analysis by Bo^^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
symptoms of an attack have been given, and the writer
would not be doing justice to the reader to let liim
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 have become
evident that almost every case is a law unto itself, and
is only surrounded by an atmosphere which stamps it as
epilepsy. In some cases only a tonic or a clonic spasm
occurs, or in others the mild sjmptoms of petit mal are
present, of which the writer will speak further on. In
the opinion of the author, as a rule, it m^y be laid down
as a positive fact that when the fit is one of the tonic t^^pe
it is generally of a less severe character than when it is
clonic; but exceptions to this rule may 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.
Total.
Per Cent.
8
23..5
17
76.4
9
28 Epilepsy : 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.
Absent, .... 7 1
Present occasionally/ . ^\ -\-\ ^^\ ^k
Present frequently, . . 5 ^ ^^ 4 ^ ^'^
18 16 34
This shows very w^ell 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 w^as found
that headache was recorded as present in 432 instances,
and as absent in only 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 suffer 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 letharg}^ 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 o\\\y
the natural reaction after the strain of the convulsion.
* Reynolds on Epilepsy. London.
Faf-alysis, 29
The writer believes that a medium view is to be taken of
this, and that both factors are at work, the exhaustion
being probabl}^ 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 paral3^sis with loss of all power
ma}^ 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 paralysis" or " hemiplegia epileptica," and the
frequency of its occurrence has been noted by Addison, ^
whose results are given in the following table.
In 31 epileptic males and 10 females paralysis was
an epileptic sequel, as follows : —
Males.
Females.
Total.
Paralysis of right side,
. 9
2
11
Paralysis of left side, .
. 7
2
9
Paralysis on both sides,
. 1
0
1
Not paralyzed, .
. 14
6
20
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 paralysis when unilateral w^as always
on the side in wdiich 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. Zeitschrif t f . Psychiatrie, Bd. XXXV, Heft 5.
2 Jour, of Mental Science, vol. xii, 1867.
30 Epilepsy : its Pathology and Treatment,
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 apoplexy,
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-
tory 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 li3q)othetical character
and entirely without foundation either phj^siologically
or otherwise, for he brings forward no support of it
save arbitrary assertion, of which he is very fond. The
majority of all neurologists believe the palsy to be the
result of exhaustion, and find no necessity to confuse
matters by advancing additional hjq^otheses concerning
which they know nothing, and which have loaded down
the boat carrying our knowledge of epilepsy in the past
until it nearly sank.
Studies have been made by Fere^ on the condition
» Loc. ciL, p. 688.
2 Compt rendus de la Socie'te de Biolog., Feb., 1888.
Rejlexes, 31
of muscular power of epileptics, both during the intervals
between the attacks and immediately after the paroxysms.
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 alwa3^s 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.
Befiexes, — A careful study of the condition of the
various reflexes after an epileptic paroxysm has been
carried out by Beevor,i who divides his cases into two
classes, namely, those seen instantly 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 :— -
Knee-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 0 2
1 0 1
43 27 70
* Brain, April, 1882.
32 Epilej^sij : 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 sjaichronously with the disappear-
ance of the clonus, and in every 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 aflected. He also records a
study of conjugate deviation of the eyes in the same
class of cases, which, as it bears npon the 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 e3^es when the fit
has passed ofi", as the writer has done when considering
the after-symptoms of the paroxysms, namely, the roll-
ing of the eyes to the opposite side and their fixation
there for some moments, followed by a rolling of the
eyes from side to side like a very much exaggerated
nystagmus. In his studies this occurred in 11 cases out
of 13.
The argument by wiiicli practical gain can be reached
by such cases is as follows : It will be remembered that
in ordinary paralysis, as, for example, hemiplegia, we
have exaggerated knee-jerk and ankle-clonus, and we also
know that after epileptic fits we may have paralysis
present of a transient or permanent character ; but we
are unable to prove its existence in every case because,
with a return of a suflflcient degree of consciousness, the
Bejiexes, 33
palsy passes away. In the one case the palsy is due to
some Injury of the nervous protoplasm; in epilepsy it
is due most frequentlj^, 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 eyes also supports this view, in all probability,
because the eyes 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 primary 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 the side to which the e3^es 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 paroxysms 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 scarcely 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 always present.
» Edin. Med. Joiirn., 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 uponbodil}^ temperature. A large number of cases
collected and examined b}^ Bourneville, in 18Y0, showed
that there is always a slight rise of temperature, some-
times amounting to 2.5 ° Fahrenheit scale. Still more
recently, the same investigator has carried his studies
farther 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 epilepticus was
capable of raising the temperature of the body to as
much as 105 ^ to lOT ° 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 Times, vol. ii, 1867.
' Berliner klin. Wochenschrif t, Nos. 43 and 44, 1886.
* Archiv f. Psychiatric und Nervenkrankheiten, vol. i.
* Le Progres Medical, February 4, 1888.
Aberrant Symjjtoms, 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
vary 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 9t.2° F., or a mean
of 98.9° F., which is virtually just normal. He noted
that the highest temperature occurred in a man who had
had an attack tha,t day, 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 paroxj^sms.
Aberrant Symptoms, — In some epileptics the conjunc-
tivae and the skin of the face are nearly always, after an
attack of epilepsy, covered by small, hsemorrhagic points,
due to the rupture of small blood-vessels. Closely
allied to this is an interparoxysmal S3^mptom that San-
dras^ has recorded a " disposition singulaire et inex-
* Journal Ment. Science, vol. xii, 1867.
^Epilepsy, London.
» Traite pratique des raalad. nerveux, t. i, p. 203.
36 Epilepsy: its Pathology and Treatment,
plicahle " 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 taches rosee without
any elevation, and which disappear rapidly 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 alw^ays 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 the patient's stomach be disordered by 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,
unfortunately, 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 stud}^ of this character has been
carried out by Addison, i who anal3^zed the urine of
patients for three days during and after the paroxysmal
period, with the following result : —
* Journal Ment. fcicience, vol. xii, 1867.
Urine,
Case I. — Paroxysmal Period,
37
DAY.
Quant,
of Urine.
Specific
Gravity.
ClNa.
Urea.
PO,.
SO3.
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
64.89
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.
Specific
Gravity.
ClNa.
Urea.
PO5.
SO3.
First,
Second, .
Third, .
Ounces.
31.0
26.5
40.5
1021
1030
1025
67.81
54.10
69.06
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
Interparoxysmal 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
152.39
226.84
111.56
45.51
27.39
34.36
Total, .
271.5
1015
133.57
2296.64
490.79
107.26
88 Epilepsy: its Pathology and Treatment,
Case III. — Paroxysmal Period.
Day.
Quant,
of Urine.
Specific
Gravity.
ClNa.
Urea.
PO5.
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
267.75
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 paroxj^sms 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 they 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 that 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 very violent.
Case I. — Urine: Specific Gravity^ l,02Jf.
Water, 931.2
Solids, 68.8 100.
Organic matter, 58.35 86.27
Fixed salts, .... . . 9.45 13.73
Phosphates precipitated by chloride of
calcium and ammonium, . . . 6.96 10.11
Case II. — Urine : Specific Gravity^ 1.02Jf.
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 15.82
Phosphates precipitated by chloride of
calcium or ammonium, . . . 2.15 5.21
1 Epilepsy, p. 288.
2 Medico-Chirurgical Transactions, p. 75, 1867.
* British Medical Journal, November 26, 1859.
40 Epilepsy: its Pathology and Treatment,
Case IY. — Urine: Specific 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}^ phospliates as well. Zapolsky found,
however, that immediately 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 sadly needed.
Albuminuria and Diabetes. — Some persons have
claimed that albumen is constantly present in the urine
of epileptics, but they are incorrect, although there are
researches which contradict this last assertion.
Saundby,^ who tested the urine twentj^-seven times
in 20 cases, with the object of detecting albumen,
using the boiling and nitric-acid tests, found it present
on twenty-two 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 contrar}^, 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.
2 Gior. internaz. d. Sc. Med., Napoli, ii, 357, 1880.
3 Medical Times and Gazette, October 14, 1882.
^ Berliner klinische Wochenschrift, October 16, 1876.
* Annales Med. Psycholog., November, 1880.
Bodily Weight. 41
paroxysm. In 1 case, which was known to have paren-
chj^matous nephritis, it was fonnd. Dowse^ also has
confirmed Mabille in this, bnt Hnppert^ agrees with
Saundby and Otto that albumen is commonly found.
When we consider the care used by Mabille and the pos-
sible carelessness of the others, and associate with 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 researcli,
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
l)y 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,^ Joll}^,^ Hammond ,^^01derogge,^^
* Practitioner, October, 1878. ^ Arch. f. Psychiatric, p. 189, 1877.
3 Berl. klin.Woch., July 5, 1875. * Arch. f. Psychol., Bd. XI, Heft 2.
^ For additional facts reached by other observers, see Briininghausen,
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, j). 5l7, 1880.
" 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 they 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 form a 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 was 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 liystero-epilepsy there was no
change. In the 30 cases examined by Lehman the re-
sults were perfectly in accord with those of Beevor,
and may be considered as even more accurate in that on
several occasions he managed to get the weight of a
patient immediately before and immediately after the
paroxj^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 deny the truth of Beevor 's studies, it must
be remembered that a great element of fallacy was
present in them all. He does not state whether the
morning weighings 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 day.
Sensory Disturbance, 43
This question has also been studied in a somewhat
novel manner by Hallager,^ of Yiborg, and, though he
agrees largely with Kowalewski, some of his results are
interesting as pointing toward a possible solution of the
controversy.
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 body, 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 likel}^ 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 j^ears most carefully by sev-
eral observers, notably Thomsen,^ who announced that
cutaneous and sensory anesthesias often exist in epi-
leptics permanently, and in connection with Oppen-
lieim,* 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 deficiency of cerebral
power, sensibility was greatly diminished. There are
1 Nordisk. Med. Arkiv, 1886.
2 Loc. cit.
" Neurologische Centralblatt, xxiii.
* Avchiv fiir Psychiatrie, xv., p. 558.
44 Epilepsy : 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 temporary form was present whenever the
convulsion was slightly aberrant in type, and, wiiile
truly epileptic, accompanied by rare symptoms. They
divide such cases into three divisions as follows : —
1. Those in which the convulsion is followed by
delirium and hallucinations. 2. Those in w^hich 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
hy steroid in form, and in reality very irregular. On
the other hand, it is perfectly possible that the epileptic
storm may exhaust the higher sensory centres pari
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 which may be present after
epilepsy, not uncommonly, is aphasia^ due, in all proba-
bility, w^here 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 e^^e-
grounds of a very large number of persons have been
examined, in order to determine whether any great
changes take place in persons who are epileptic. Cross ^
has examined the intra-ocular circulation of 95 cases,
and found that in the great majority no change was
noticeable. He also finds that no structural clianges in
* Jour. Nervous and Mental Diseases.
The Eye. 45
the eye take place. In the cases where any changes
were noted in the intra-ocular circulation, the results
were so various and widely dissimilar that no conclu-
sions could be drawn. Gowers^ states, as a result of
an examination of over 1000 e3^e-gTounds in epileptics,
that no changes at all are to be seen in the fundus oculi
of idiopathic 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.2 Hammond^ believes, in distinction from
Gowers, that the fundus of the e3'e of an epileptic is
always congested or pale, and evidences cerebral con-
gestion or anaemia, and he sees a venous pulsation in
all cases of plethora with epileps}^ Kostle and Nie-
metsliek,^ of Prague, from their examinations, state
that the venous pulse of the fundus onl}^ occurs in those
cases where there is anaemia of the brain, and they go
so far in their theory that they 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 eyes. There is
always contraction of the visual field in both eyes, 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 paroxysm.
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 strenuously, 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 suffering from other con-
vulsive disorders. Indeed, he asserted that this was a
pathognomonic sign of epilepsy to be used in making
a differential diagnosis. In the discussion which fol-
lowed, Spitzka^ pointed out that Gray was mistaken, be-
cause the dilatation spoken of was replaced by contrac-
tion in tlie epileps}^ of alcoholism. Dr. Cross^ and Dr.
Hammond^ supported Gray, 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., 1880. ^ Ibid. = Ibid. * Ibid.
* Arch, de Neurolog., vol. iii, p. 42, 1882.
Refractive Anomalies, 47
each e3'e 45 centimetres, the rays 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|, 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 otliers.
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 PAcademie
Royale de Medecine de Belgique at the concours for
1881-83, must have been strucl^ 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 Colm in his examinations of the eyes
of school-children, or by other observers in similar
investigations prosecuted in Germany, Russia, 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
» Riv. Sperimentale di Firenze, fasc. i and ii, 1884.
48 Epilepsy : its Pathology and Ti^eatment.
There is one criticism which mn,y 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 Colin, 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 anj^ one in attempting to formulate
general rules in regard to such a disease as epilepsy.
The XQ^vj large amount of w^ork done by 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 essaj^ 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 yet 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.
Meiital State, 49
some of the 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-
monly than males, and also more severely.
4. That the commonest failure is loss of memory,
and that this, if regarded in all degrees, is more frequent
than integrity of that faculty.
6. 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
sufferer from the disease.
3 C
60 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 power 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 generall}^ occur. Not only are the
remarks just made true, but it is positive that all the
more modern writers utterl}^ disregard all the deduc-
tions drawn by Rejmolds. 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.
MoreP 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^ sa3^s
*De I'Etat Mental des epileptiques, Arch. gen. do raed., Avril et
October, 1861.
2 Lepons sur les maladies du systeme nerveux, series ii. Paris, 1873-7.
'I'Etudes Clinique. Traite theorique et pratique des maladies
men tale, tome ii, p. 316.
* Krankheiten des Nervenapparat. Vircliow's Handbuch f. Spec.
Path, und Ther.
' Handbuch f . Nervenkrankheiten, vol. ii.
Mental State, 51
it is characteristic to find a loss of memory 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 their
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 the 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 may
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.
The 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.
2 Diction, de Med. et de Clin, pratique, art. Epilepsie, p. 416.
' De la Physiolog. du systeme nerveux, tome ii, p. 385.
* Recherches et Observation, p. 58.
* Loc, cit., p. 692.
^Loc.cit., It. 482.
''Loc. cit.
52 Epilepsy : its Pathology and Tr^eatment.
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 w^hom the memory for recent events was
partly clouded, but who had the memory for things long
gone by 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 appre-
hension and loss of memor}^ Four males and 5 females,
or a total of 9, or 14.51 per cent.
4. Includes tliose 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 : —
25 = 43.85
Condition of Memory. Males. Females. Total. Per Cent.
Normal, 14 8
Defective only after fits, . 2 1
Slightly defective at times, . 2 2
Defective generally, . .9 9 18 ^ 32 = 56.14
Very defective, ... 6 4
33 24 67
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 13 ^^[so^e^.S
Defective only after attacks, 1 0 1 )
Periodically affected, . . 1 1 2 ^
Generally defective, . . 4 5 9^18 = 37.5
Extremely defective, . .4 3 7)
27 21 48
It is worthy of note that these results show epileptics
to be more frequently deticient 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 Psychiatry and
Neuro-Patholog}^, in 1885, attempted to show the rela-
tions between epilepsy and idiocy. Out of 79 children
under his care 25 were epileptics, and out of 398 chil-
dren received into the institution in twenty-eight years
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-
lepsy 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 5t4 idiots, he
found that 125 had epilepsy, but of these 92 were idiotic
from birth and 33 had acquired idiocy, whether as a re-
sult of the epilepsy or not is not stated. Probably the
idiocy was not the result of the epilepsy, for idiocy is
* On tlie Causes of Idiocy, p. 56. London, 1856
54 Epilejisy : its Pathology and Treatment,
nirely a 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 imbecility,
rarely complicates epilepsy, although Bucknill and
Tuke,^ tlie 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 18tt, the
principal causes of insanity are given in 2068 cases, of
which number 59 were due to epilepsy. In 864 cases,
where the causes of insanity were discovered, admitted
to the Lunatic Asylum at York, 23 were due to epilepsj^,
and in the 681 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 'n sanity
is rarely complicated by epilepsy unless dementia para-
lytica exists. Epileptic insanity has a most unpromis-
ing outlook, and the prognosis should alw^ays be most
unfavorable. Cases of cure are almost unknown.
According to the studies of Echeverria,^ nocturnal
epilepsy is much more apt to be complicated b}^ insanity
than is diurnal epilepsy, and petit mal is more apt than
either of the violent convulsive varieties to be followed
* Psychological Medicine. 4tli ed.
^ International Congress of Mental Medicine. Pans, 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 261 cases. The hallucinations
were divided as follows : Auditory, 62 per cent. ; sight
and hearing, 42 per cent. ; smell, 6 per cent. ; while tO
per cent, showed anaesthesia, hypersesthesia, or false
sensations.
In the careful and interesting studies of Falret, he
divides the mental disorders of epilepsy 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,
hut 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, hut 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 fits 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 Epileptics, — 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 hand-
in-hand, without any relationship to one another, save
that they occur sj^nchronously, in many cases a second
nice point of differentiation arises as to whetlier a
criminal act results from an epileptic homicidal explosion
of gray matter, to an insane homicidal act, or to revenge
actuated by a real but insufficient cause. It is just here
that the physician finds himself, when cross-questioned,
Besponsibility of Epileptics. 57
niifible 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
chikl. While thus employed a fit came on, and she cut
the hand of the baby right oft*, 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. 0., aged 22 ^^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 da}' or more. He recovered
from the immediate bad eflfects, 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.
3 Broadmoor Asylum Rep., 1877.
' Pepper's System of Medicine, vol. v.
3*
58 Epilepsy: its Pathology and Treatment.
almost every day, and sometimes more frequently. They
were brought on by excitement, and he had a great many
when worried about his wife at the time of her delivery.
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,
having had a fit in his office at 8, of a more severe char-
acter than usual, and preceded by a psychical aura,
during which he was verj^ morose and sullen. Upon
recovery he was speechless, though he could communicate
\iy 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 day, 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
Responsihilihj of Epileptics. 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 day.
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,
undoubtedly, have been acquitted on the ground of tem-
porary insanity.
Now, it is just such cases as these that lead the layman
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 v/ho certainly w^as absolutely irre-
sponsible for his actions during that time. Again, the
case of a Negro has been recorded b}^ 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 have listened
to the idea that he was irresponsible. These last two
cases are, in reality, types of the disease described
under the head of epilepsy procursiva, which has already
been alluded to.
A very important point in this connection is the fact
that whether a man be permanently insane or temporarily
60 Epilepsy: its Pathology and Treatment,
suffering from homicidal mania, he equally requires con-
stant watching. Because a man is sane for twent^Miine
days in every month but homicidal on the thirtieth day
is in reality a greater reason for confining him than one
who by his constant aberration of mind warns those
about him to be on their guard. The periodically epi-
leptic 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 has been said on the last few
pages is one which Weiss ^ has recognized and named
''• Psychic Epilepsy." Indeed, it is virtuallj^ identical
with 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 convulsive attacks are replaced by ps3 -
choses, which stand in no relation to convulsions and
have nothing to do with them. The mental disorder is
characterized by a sudden onset, without incubation ; it
speedily, or in a few hours, reaches its acme, then rapidly
disappears and is followed b}^ complete ps3^chic 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 closel}^ pursued. In
the first the man suff*ered from frequent attacks of in-
sanity lasting two or three days, preceded hy 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 w^as a history of vertigo, pain, and
confusion of mind for thirty years previously. At this
time spells, came on associated with frantic runnings to
* Psychiatrische Studien aus der klin.von Prof. Leidesdorf. Wien,
1877. CentraU)!. f. d. med. Wissenscliaften, No. 15, 1877.
Syphilitic Epilepsy. 61
and fro, and 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 boy, generally perfectly well, was occasionally
seized with a desire to kill something which lie thought
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. — Sj^^hilitic epilepsy is only one
of the many nervous affections 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 Etiolog3^
There can be no doubt that s^^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 Fournier,2 the syphilographer, has insisted most
strongly on this point, as have also Braivais^ and M.
Lagneau.^ In England, Hughlings-Jackson, Broadbent,
* Loc. cit.
2 De FEpilepsie syphilitique tertiare. Lemons professie. Paris, 1876.
3 These de Paris, No. 18, tome iv, 1827.
* Maladies syphilitique du systeme nerveux. Paris, 1860.
62 Epilepsy: its Pathology and Treatment.
Todd, and Buzzard^ 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 symptoms of syphilitic epilepsy really differ in
no way from those of the simple idiopathic variety, but
some questions peculiar to this form of the affection are
well worthy of attention.
First and foremost it is exceedingly important to
discover how long, after the s^q^hilitic poison has been
received, it is before the nervous outbreak results.
In some statistics collected hy Echeverria^ he fonnd
that in 118 cases of sj^philis the first epileptic spasm
was, in 65 males and 53 females, as follows : — •
In 9 males and 15 females in from 4 months to 1 year.
'' 16
20
1
year
to 2 years.
'' 13
8
2
years
to 5 *'
^' 15
5
5
11
to 8 ''
'' 9
3
8
u
to 12 ''
'' 3
2
12
u
to 20 "
The ages of the males ranged from 19 to 30 j-ears,
while those of the females were from 21 to 28 years. On
analyzing this table further than its originator did, we
find that the average period after infection equals, as a
general rule, from 2 to 5 3^ears.
The previous symptoms to the epileptic attack were,
in the 118 cases, as follow : —
Headache in 45 males and 38 females=83 patients=
t0.30 per cent, of them all.
* Aspects of Syphilitic Nervous Affections. 1874.
2 Lectures on Nerv. Diseases. ^ Nerv. Dis. and their Diagnosis.
* Journal Mental Science, July, 1880, p. 1G5.
Syphiliiic Epilepsy, 63
Prsecordial pain in 2*7 males and 32 females = 59
patients, or 50 per cent, of the whole number of cases.
Of the 83 patients with cephalalgia 10 males and 16
females had parietal pain, and 11 males and 8 females
s 11 tiered 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 syphilis, when
complicated with epileps}^, is the constancy with which
it annoys or agonizes the patient, always being present
to some extent, and frequently exacerbated toward
night-fall or during the night, generally getting worse
until the paroxysm breaks forth, or it may in some
instances relent as the storm approaches. Indeed,
many S3q)liilographers believe this to be the rule rather
than the exception. There is certainly something very
typical about these syphilitic headaches which, neverthe-
less, baffles the descriptions that one would like to give
of them. Once seen they 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 slowl}^ and painfully in
monosyllables or, gradually raising the face to that of
the questioner, give an answer and once more return to
his former position. These symptoms are not, of course,
pathognomonic, but they are certainly characteristic.
The pain, too, is in otlier ways peculiar, and Charcot^
^Legons sur les maladies du systeme nerveux, tome ii, Deuxieme
edition, p. 357. Paris, 1877.
64 Epilepsy: its Patliology and Treatment.
has expressed the opinion that the crossed character of
the pain in this disease is of value, as it points to the
motor zone. Indeed, he regards this headache as typical
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 other cerebral disorder. The
optic disks should be carefuU^^ examined, for in man}^,
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 symptom which may occur earlj^ in
s^^philitic 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
sj^philitic, almost pathognomonic of brain involvement,
— a momentary weakuess 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^ and Lagneau^ where this was the
^ Legons des maladies, etc.
3 Maladies sypliilitique du systeme 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, rarel3'^ involve the cranial nerves, as
has been particularly noted by Heubner;^ or there may
be an excess of psj^chical disturbance with a minor
epileptic convulsion, and with involvement of the basal
cranial nerves. A few writers have claimed that the
epilepsy of sj'philis can always be distinguished, as it is
alwa^^s unilateral, but this is, of course, incorrect, simply
because, as will appear later on, unilateral epilepsy of a
non-specific type is b^^ 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 II 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 6 cases with occipital pain there were unilateral fits.
Lasegue^ has strongly insisted that all chronic epi-
leptics show some cranial deformit}'^ 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. 269.
^ Annales Medico-psychologique, Sept., 1877.
66 Epilepsy: its Pathology and Treatment,
sion of the malar bone of tlie same side, with relative
prominence of the left malar bone, resulting in torsion
of the face and obliqnit}^ 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 : —
Epileptic,
Non-epileptic.
Frontal eminence prominent, .
. 57 per
cent.
51 per cent.
Malar prominence on left side,
. 53 "
31 *' ''
Rotation of face,
. 49 ''
39 *' ''
Deformity of palate,
. 33 ''
23 " ''
Flatness of one side of face, .
, 71 ''
51 '' ''
Orbit level, ....
. 35 ''
47 " ''
Carrying his studies still further, Garel seems rather
to contradict these results, unintentional!}^, 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 furtlier stud3^ for in the
measurements made b}^ hatters very few epileptics are
included, and their measurements may be taken as repre-
senting the shape of the normal head. Garel found the
V-shaped maxilla, so common in idiots, only very rarely
in epileptics. Studies still more recently carried out by
Boarnevilleand Sollier ^ have confirmed the research of
Lesegue.
Jacksonian Epilepsy. — By the term Jacksonian epi-
lepsy we mean an afl[ection which separates itself from
true or ordinary idiopathic epilepsy by several peculi-
arities. By far the most important of the peculiar signs
* Lyon Medicale, Jan., 1878.
2 Le Progres Me'dical, September 22, 1888.
Jacksonian Epilepsy. 6T
is the character of the onset, which always begins, in the
typical Jacksonian disease, in some peripheral portion of
the body , and most freqnently 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 may 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 way 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 weary, 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 rapidly and severely than ever before, and
immediately afterward the thumb w^as 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 only the hand, as had been the case before.
There was, however, no disturbance of consciousness,
and only a momentarj^ 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. The previous histor}^ of
the man is that six months before his first attack he
received a kick on tlie head, in the parietal region, on
the right side, which made him unconscious for some
hours.
Petit Mai. 09
A very interesting statement has been made by Un-
verreiclit, namely, that whatever the coarse 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 liaut 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 rarely flush-
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.
Reynolds 1 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 nearly, if not quite, alwaj's of the tonic variety.
Sometimes the disorder of motility lies chiefly 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-way
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 saying of a
' Loc. cit. 2 YoY such a case see Georget. Malad. Nerveux, p. 384.
'TO Epilepsy: its Pathology and Treatment,
friend unconsciously, or, disregarding the repl}^ given to
a question, ask it a second time. To this light grade of
petit 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 by 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 A^ery 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 any rate, all
to the patient who fails to recognize the succeeding
unconsciousness.
The writer believes it is true that well-developed
aurae 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-
sory. In the most pronounced of Mitchell's cases an
Petit MaL U
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 hy steroidal 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 day, 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 pain
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 petit mal has been compiled by Gowers,i and is
worthy of insertion here. The symptoms 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 Epilepsy: its Fathology and Treatment,
3. Jerks or starts of the limbs, trunk, or head.
4. Yisual 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 writer's which is, typi-
cally, one not only of petit mal and nocturnal epilepsy",
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 mainly, 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 Reynaud,
Gazette Hebdomadaire de Med. et de Chir. de Paris, Janvier, 1865.
Nocturnal Epilepsy, 73
although very eminent neurologists have tliought 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^^ the
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 either 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 difficult 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 alwaj^s 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 Hiighlings- Jackson.
* See Foville and Delasiauve, loc. cit.
4 D
74 Epilepsy: its Pathology and Treatment,
A veiy useful and valimble 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.
8. 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 epilepsy or insanit}^
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 years, 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 w^as 33 years of age, and well preserved for a
woman of her years. 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
Early in 1883 she first began to complain of attacks
of giddiness, in which 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 been away from
the city for five months every summer in a healthy
watering-place with her employer'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 history, 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 absolutely 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 chastit}^ of the woman 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 constantl^^
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 Januarj^, 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 away
from home, the family being by the sea, when the parents
were roused about 3 o'clock one morning by screams of
the little girl, who still was accustomed to sleep with the
nurse. The child had been wakened b}^ 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 77
place, as far as is known, when she again roused the
household. 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 the 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, but she remained under the
writer's care. Her e^^e-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 '' iayr 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 emplo3^ment.
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 da^^-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 tj^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.
78 Epilejisy : its Pathology and Treatment,
Epilepsie Apoplectique and Post-Hemiplegic Epilepsy.
— These convulsive conditions may 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 hsemor-
rliage 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
generally 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 differ 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 epilepsj^,
being produced by the convulsion. In a considerable
number of cases of epilepsy it will be found that the con-
vulsions succeeded an attack of paralysis, which was
sudden in onset and possessed the characteristics of vas-
cular rupture. In some i)ersons the history of this
attack is ver}" indistinct, owing to its occurrence in very
early life, while in others the paralysis 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 may leave not a trace of loss of power
behind it, but the convulsions continue, and closely re-
Post-Hemiplegic Epilepsy. 79
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-hem i-
plegic epilepsy into two classes, too, for we find that in
about one-half the cases the convulsion occurs along
with the paralj^sis, and then follows at intervals, while
in the other half the paralysis is not followed by con-
vulsive seizures for weeks, months, or years.
Post'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. Yery curious
results are reached if the statistics of the affection are
analyzed, — results which are quite un explainable unless
by hypothesis. Indeed, thej^ 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 difference between tlie 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}", Imve the instruments
applied most frequently, and consequently 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 by 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 equall}^ common on both sides.
The writer has already spoken of the fact that the
convulsions ma}^ occur along with the first attack of
paralysis and continue, or that an interval may occur
between the attack and the subsequent paroxysm. The
chronic recurring fits date from the onset in about
one-third of the cases, and it is not uncommon for the
paralysis to occur in infancy and the epilepsj^ to begin
at puberty. It would seem that cells injured in early
life laid undisturbed till the increased demands of
maturity 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 3^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
etiolog:y 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 Tensors, 81
20 children out of 97 suffered from it. In the 80 eases
collected by Gaiidard^ 11 children had heml-epileps}- ,
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 whicli no further nervous
changes occur, and in the second of which true epilepsy
ultimately develops. The writer is well aware that the
profession, at least in the majority, 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 nocturual petit mal. He has seen
too great a number of cases which followed out to the
letter all of the course usuall}^ followed hj the minor
attacks to doubt this for a moment, and he has already
pointed out that iu nocturnal epilepsy the patient usually
forgets the seizure, but remembers tlie frightful dream
which preceded it, showing that a night terror usually
occurs even in adults and with completely developed
epileps}^ There are, of course, certain children who
frequently have nightmare from indigestion or a fright
experienced during the daj^, but these are only occasion-
ally affected, and comparatively mildly so as regards the
concomitant mental disturbance.
When a child is brought to the physician 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 Hemiplegie Cerebrale Infantile. Geneve,
1884.
2 Ein Beitrag zur Tjehre von den Cerebralen Kindeiialimungen, Jahr-
bucli f iir Kinderheilkunde, 1886.
4*
82 Epilepsy : ■ its Pathology and Treatment,
until tlie night has progressed to some extent, and
then rises up in bed and utters a shriek of the most
heart-rending character, wliich may or may not ai^ouse
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 generally 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 crying
out that it sees some fearful beast, or beos 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 b3^stander 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 otliers. 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 daj^-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 Blondeau, although the
literature of the subject 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 b}^ 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 bodj^ 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 an 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 found 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 hy 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,
namelj^, starvation of the nervous centres, whereb}^ their
functions are perverted or set aside. TJie true cause of
the epilepsies, supposabl}' due to cardiac failure, cannot
be considered as decided in eveiy 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 which 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 evideuce 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.
* Rev. de Medecine, May 10, 1887.
Epilepsia Procursiim, 85
In a case reported by Lebrun^ the symptoms re-
sembled those of cardiac epilepsy somewhat in that
there was a slowing of the pulse from 70 to 32 beats,
w^th 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 Procursiva. — Epilepsia procursiva of the
older writers has within the past eighteen montlis 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 b}^ a fall or coma, but by
facial congestion. Bourneville classes these cases into
those in whom the run is uncomplicated w^ith other forms
of seizure, those with a progressive aura, and those in
whom there is epileps}^ followed by running. He also
has studied 25 cases of procursive vertigo. The essay
of M. Bourneville is so exceedingly exhaustive that the
writer can only refer the reader to the original for
fiirther 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 apparently healthy
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
» Bull, de r Acad. Roy. de Med. de Belgique, 1887.
" Aichiv de Neurologie.
80 Epilepsy: its Pathology 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 j^ear ago, when the first fit took place.
The histojy of his life gives no record which can be in
any way considered as a cause of his present trouble,
save that when he was about 6 3^ears of age he was struck
on the back of his head by another and much larger bo}'',
who had a heavy club in his hand. Ko unconsciousness
w^as 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 3^ear
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 the}^ 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 was 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 Procursiva» 87
iiig 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 slightly, 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 away from a
parent. The entire attack was accompanied by 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 fseces. 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 the 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 lioiise-
hold duties because of the constant watching necessary.
In other words, the attacks occurred several times a da}^
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 was told to bring the child
back in one week, but failed to do so, and all trace was
lost of the case.
Epilepsy H{A.^r\s.—Ep)ilepsy nutans is a limited variety
of the disease, and has a sudden onset while 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 paroxysm passed awa}^.
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 somewhat
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 eye-sight grows dim and the
pain in the temples increases in violence, these symp-
toms being followed b}^ vomiting and deep sleep, from
which the patient awakes well. As the attacks go on
consciousness becomes slightly dimmed, but is never
lost, until the disease is very 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 pathology. 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 variety the convulsion does not originate while there
is alcohol in the blood, but in the intervals between the
attacks of delirium tremens resulting from chronic
excessive alcoholic indulgence. Under these circum-
stances the paroxysms are generally accompanied by
hallucinations or by dementia or imbecility. In the
alcoholic convulsion the S3^mptoms may closely resemble
» Such a case is reported by AUbutt, in "Brain," 1883-84, p. 246.
90 EpiJepsij: its Pathologi/ and Treatment,
those of true epilepsy, and not rarely the attack is
ushered in by headache, gastric embarrassment, disor-
ders of vision, and excessive tremors, or spme similar
prodrome which may be 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 closelj^ simulated by alco-
holic epilepsy, but simple vertigo or true petit mal ma}'-
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. Ratlier
curiously these cerebral disturbances result rather in
suicidal than homicidal tendencies, which is just the re-
verse of the insanity following simple epilepsy. It is
very important that the reader remember that alcohol-
ism in producing epilepsy very frequently ]3roduces a
permanent nervous disorder which the withdrawal of
the poison will not remove.
The symptoms of ur^emic convulsions will be spoken
of further when studying differential diagnosis in con-
nection with epilepsy.
Convulsions 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 ma}^ in-
fluence the question of life and death for the accused
very greatly, it is well for the physician to bear in mind
that certain drugs when taken in poisonous doses pro-
duce very violent epileptic convulsions. This is par-
ticularly 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 s3aTiptoms 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 rapidlj^ that death ensues from
exhaustion, but in much more rare instances the attacks
may resemble Jacksonian epilepsy very closely, 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 e3^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.
Malarial 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. Tlie
only cases which the writer can find recorded are by
American or English observers, namel3^,Jacobi,^ Payne,^
* Norris, Amer. Syst. Pract. Med., vol. iv.
2 Hospital Gazette, New York, v, 41-43.
3 Indian Ann. Med. Sci., Calcutta, 1860-61, vii, 597.
92 Epilepsy: its Pathology and Treatment,
and Hamilton. 1 The latter gives but 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 congestion of the face and head. He was un-
usually somnolent, and in the intervals frequently 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 by some writers,
really never occurs, but under this heading the writer
intends to place those interesting cases first recorded by
Charcot,^ in which periodic epileptic attacks come on in
I)ersons suffering from spinal lesions particularly due
to compression. Contrary to what might have been
expected from the well-known eifects 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 by compression. As this well-known
neurologist has said, these convulsions are really quite
separate from those produced by 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
^ Amer. Syst. Pract. Med., vol. v.
2 Lemons sur les maladies du systeme nerveux, series ii. Paris, 1873-77.
3 It is to be remembered that this assertion is not borne ont 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. ^ 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. 183T.
Rilliet and Barthez, tome iii, p. 589. 1859.
Michaud, Siir la Meningitis et la Myelite, p. 50.
Paris, 1871.
Brown-Sequard, Recherche Epilepsie, p. 11.
Westphal, Archiv f. Psychiatrie, 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 course 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 branch 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 attempts
to fathom unfathomable depths. Scarcely a day passes
that the physician is not tempted to carr3^ 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
ground. 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-
logical 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
absolutely 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 CA^ery
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 paroxj'sm 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
hj^sterical. 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, tlie man has contracted S3q3hilis,
which has produced epilepsy, under the cloak of trau-
matism, and which is only relieved by mercury and the
iodides, or lie has a constitutional inherited tendency to
epilepsj^, aside from any extraneous causes. The writer
has seen two boys both with adherent and infiamed 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 Epileiysy : its Patliology and Treatment,
ni^y 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 history 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 friHit
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 proA^oking cause does
not of necessity bear any relation to the likelihood of
producing the disease, provided the unrest of the dis-
eased centres is jnst on the verge of an eruption. A
mere peristaltic wave passing suddenly along the intes-
tine may 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
^ Nervous Diseases. 1886.
Heredity. 97
causes of the disease we find that several exist, although
so far we have only proof of one or two. Indeed, in
many instances of idiopathic epilepsy no cause can be
determined, and we are forced to confess, every 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 may 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 by him 10 were descended from epileptic parents,
and Delasiauve ^ found 33 hereditary epileptics in 300
cases of the disease. In 171 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 hereditary 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 hereditary. In the statistics collected b}^ Martin,^
Bouctier, and Cazanveilh,^ it was found that 19 epileptic
parents begat 78 children, of whom 55 died very young
and generally in fits. Of the 23 remaining, 15 only were
healthy, and they were all very young ; and this is prob-
* Pronostie et du Traitement Curatif de I'Epilepsie, p. 325. Paris, 1852.
5 Traite de rEpilepsie, 1854.
^ Dis. of Nervous System.
* On Epilepsy : Anatomo-Pathological and Clinical Notes. New York,
1870
5 System of Medicine, Pepper, vol. v, p. 468.
^ Annales Med. Psycliolog., 1878 Novembre to 1879 Septembre.
' De I'Epilepsie Consider ee dans les Rapports avec Alienation Mentals.
5 E
98 Epilepsy: its Pathology and Treatment,
ably the reason why Esquirol and others have failed to
find, except rarel}^, a hereditary tendency in the adults
examined by them.
By far the largest number of cases collected by any
one writer, so far as the author is aware, are those of
Gowers,^ who analj^zed no less than 1450 cases of epi-
Ieps3% 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 histor3^ in 33 per cent,
of the males and 3Y per cent, of the females. There was
a family history of epilepsy 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 2 heredit}^ was the cause in 11. R03^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 epileps}^, of whom a little over 26 per cent,
were due to heredity. 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 years, who began
* Epilepsy and Other Chronic Convulsive Disorders. London, 1881.
2 Epilepsy. London.
^ Treatise on Epilepsy. London.
* Ziemssen's Encyclopedia, art. Epilepsie.
^ Krankheiten des Nervenapparates, Vircliow's Handbuch f . Special
Pathologic und Therapie.
^ Journal of Mental Science.
Heredity, 99
at the age of 12 years to have epileptic attacks about
every three weeks, in which she saw demons with the
right eye. She had, after marriage, nine children, who
all died as follows :-
First, a girl, died on the fourth day of life in convul-
sions.
Second, a boy, 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 boy, died after birth in coma.
Close-questioning failed to elicit any other neurotic
family history than that given, and there was no specific
history.
While the w^riter does not desire to deny in any way
that heredity is a remarkably common factor in the pro-
duction of epilepsy, it is his dut}^ to point out that all
the writers quoted are not on the same footing as regards
what may be included in hereditarj^ 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 insanit}',
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 ver}^ 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 by the careful investigations of
Herpin, who found that the frequency of apoplexy
100 Epilepsy: its Pathology and Treatment,
jimong tlie relations of epileptics was positively smaller
than in 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 this fact, and some,
like Hamilton, carry it absurdly far, as, for example,
Nothnagel.
The A^ery existence of other forms of nervous dis-
ease than those which 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, hypochondriasis,
and catalepsy frequently stamp epilepsy indelibly upon
the children. Migraine is a very common history in some
cases; that is, wiiere the 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 hj^sterical daughter. He
insists that there was absolutely no other predisposing
cause present ; but one can hardl}^ agree with him when
he speaks of simple neuralgic pains in the parents as a
hereditary excitant of epilepsy, or of mere nervousness
as a parental influence, except in a very indirect manner.^
Just here the question may be asked. What do we
mean by heredity? It is, when correctly used, a term
signifying the transmission of a particular peculiarit}^,
or peculiarities, from parents to their children. On the
other hand, inherited predisposing factors are more in-
* Loc. cit.
^ Wagner and Striimpel have both denied that any relationship exists
between the two.
Heredity. 101
directly at work, and may bear no relation to the pecu-
liarity in the child except in a general way. It is to
the latter class that all the distant neuroses of these
writers should be assigned, for they only prepare the
system of the child for epileps3^ 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 strongly combating the idea that
heredity is a strong or frequent cause of epilepsy. He
believes that the tendency is always post-natal, but the
writer does not think that his deductions are warranted
by his arguments, and they can hardly OA^erturn 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 frequently. Gowers and Hamilton
both state that the inheritance is more frequently from
the mother than the father ; whereas, Notlmagel 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 authority, are
herewith quoted, hoping th^it the reader will be able to
fathom his meaning. He says: ** Where there is an
inherited tendenc}^, 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
^ Le Progres Medical, 1887.
102 Epilepsy: its Pathology and Ti^eatment,
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 directly 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 frequenth^
is still undecided, although the statements of each body
of statisticians include large numbers of cases. Rey-
nolds, in his collection of cases, found no difference in
the sexes, as did also Nothnagel and Herpin.^ On the
other hand, Gowers, in his 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
123 epileptic females. From these facts they deduce
the conclusion that epilepsy is more frequent in females
than in males, w^hich is incorrect in fact, and is reached
by erroneous methods of calculation, as they do not seem
to have reckoned the number in each as^dum in respect
to their proportion to the population. The only other
figures which the writer has been able to find in regard to
this 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 Herpin uses these words his figures really
disagree with those of Gowers, for he found the proportion to be 110 males
to 96 females.
Phthisis, 103
BoycP 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 years, as follows, and the 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 history of phthisis is a cause of epi-
lepsy. Among such believers may be mentioned chiefly
English and American writers, for the theory does not
seem to be generally received on the Continental side of
the channel. 3 Hamilton, the American, in the 980 cases
collected by him, found 230 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.
2 Diseases of Nervous System, p. 222.
' Echeverria, Anstie, Bastian, Savage, and Hamilton.
104 Epilepsy: its Pathology and Treatment,
Gowers both insist that plitliisis lias no influence on the
disease, and they 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 the 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 heredity. It is evident, too, that in this
condition epileptic children may result from the insanity
of rum as well as the ordinary type 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
efficient 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, which are eventually followed by death.
In connection with the influence which alcohol exerts
in producing epilepsy directly in the drunkard, it maj^
be said that in nearly all such cases there must be lurk-
ing somewhere a tendency toAvard 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 system, the result of
frequent debauch.
Echeverria^ has anal3^zed no less than 5t2 cases of
* Journal of Mental Science, Jan., 1881.
Alcoholic Injluences, 105
alcoholic epileps}', 307 of whom were males and 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 were
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 whicli 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 eight}' -nine cases, 92 males and
97 females, in whom alcoholism was the result of the
epilepsy, quite as much as the epilepsy was the result
of the alcoholism.
Carrying his investigations still further, this observer
managed to get a fully completed family history 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 epilepsy,
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 epilepsy 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.
5*
106 Epilepsy: its Pathology and Treatment.
of the males and 19.24 per cent, of the females, making
a total of 1 7.48 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-
spectively, a proportion of 20.10 per cent, in males and
35.47 per cent, in females.
Parental insanity and epilepsy 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 insanity without any history of alcohol save in the
parents (not grandparents), is 2 per cent, lower in
females than in males.
On referrino; to the ao:oTeorate 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, again 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 6Q,^ 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
hereditary 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 Injliiences 107
vulsions in cliilclhood, filtlioiigli they did not become epi-
leptic until after 18 years of age, and tlien in consequence
of intemperance. In most of the 86 cases of the third
division who had hereditary taint epilepsy was developed
in childhood, or before 15 j^ears of age; and it is re-
markable tliat 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 palsy. Five had strar
bismus and 5 deafness and otorrhoea, 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 palsy. 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. Psycholagique, 1875.
* Neurologisclie Ceiitralblatt, 1885.
108 Epilepsy: its Pathology and Treatment.
common, and that from 30 to 40 per cent, of all persons
with delirium tremens are epileptic.
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 histor3^ He divides them into two classes, tlie first
comprising 60 cases, or over two-thirds, in which alco-
holism in the parents was a certainty, 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
afflicted with convulsions in early infanc3^ One hundred
and thirty -two were dead in 1874 and 112 still living,
nearly all of them young and nearly all with damaged
nervous ori2:anizations. 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 diflferent families.
When we summarize, we find that, in 83 families with
410 children, 108 were epileptic, or more than one-fourth.
In 1814, 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 shoAV 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
* Aunales Med. Psychologique, January, 1879.
The Influence of Age, 109
alcoholism followed by disease, is one recorded by
Bourneville and Baumgarten ^ of a child aged about 4
years. There was marked alcoholism, produced by large
quantities of white wine, for about one year before the
attack of epileps}^, but at the autopsy there was found a
softened condition of the brain and destruction of the
cortex, the result of meningo-encephalitis. The cunei
were ver}^ small, blindness having been present for some
months. Microscopical examination revealed sclerosis
of the pyramidal 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 1 epileptic. Of 53 chil-
dren born of uncle 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 epileptic.
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 heredity, 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 years of life, but after
20 the number falls very low. The females in these cases
exceed the number of males in the first ten years b}^ 6
* Le Progres Med., 1887.
2 Medico-Chirurgical Review, July, 1860.
110 Epilepsy: its Pathology and Tr^eatmenL
per cent., in the second ten ^^ears by 18 per cent., and in
the 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
onl}^ in males. The following are Gowers's figures in
1450 cases : —
422 cases.
10 to 19 years, 655
ide
r 10 years,
10 to 19 yes
20 to 39 "
30 to 39 ''
40 to 49 "
50 to 59 ''
60 to 69 "
70 to 79 ''
224
87
31
16
4
1
In the cases reported by Hamilton the proportion to
each ao^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
511
469
980
Of 1288 cases collected by nine French authorities,
in 486, or over one-third, the disease began between the
tenth and twentieth years. Hasse,^ in the 1000 cases
collected by him, found that 75 per cent, of the patients
were at the onset under 20 3 ears of age. According to
the German, Nothnagel, the great majority of cases
occur between 7 and 17 3^ears, not onl}^ in hereditary
epileps^^, but also in the other forms.
On analj^sis of the 970 cases collected from literature
by the writer, he found that the following results were
to be reached : —
* Krankheiten des Nervenapparat., Vircliow's Ilandbucli f. Spec.
Path, und Therap.
Minor Causes, 111
From birth to 10 years, 57 cases.
'' 10 years to 20 years, 202 "
'* 20 '* to30 *' . . . . . 223 "
"■ 30 " to40 '' 171 "•
'* 40 ** to50 ^' 93 ''
Above 50 years, 47 "
The oldest case was 81 years of age.
These results place the largest number of cases be-
tween 20 and 30 years. 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 ^\ years,
and Ke3aiolds at 70. Heberden also records a case at 75
years. In Gowers 's cases only about 2 per cent, began
after tlie fortieth j^ear, and about 5 per cent, after the
thirty-fifth year. A \evy 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
epilepsy, 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 epilepsy, 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, namely, age
and sex, to the various causes, botli great and small,
which are productive of epilepsy, the M^riter will briefly
go over the minor or more anciently relied upon factors,
112 Epilepsy: its Pathology and Treatment.
and then speak of those which at the present da}^ are
more commonly received as really of importance. Among
the older observers, Ettmueller and Senac laid great
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-
larly where there is a tendency 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 affection. 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 w^ien the nervous exaltation of
the spinal cord excites reflexly the cranial centres. In
respect to the influence of masturbation, Herpin^ has
pointed out that the prevalence of this vice must, to a
very large extent, prove it to be a rare causative factor
in producing e[)ilepsy. Nothnagel^ has only seen one
such case, and Echeverria calls attention to the fact that
masturbation is often resorted to after the person be-
comes epileptic, although the attacks may have been so
long unknown, as in nocturnal epilepsy, as to have
escaped attention. Contrariwise, Tissot^ and some
others believe that sexual continence may also result in
epilepsy. Herpin^ is also of this opinion, but limits it to
the female sex, while Radcliffe^ 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 Her-
* Du pronostic et du traitemeiit curatif de Tepilepsie. Paris, 1852.
^ Ziemssen's Encycloped., art. Epilepsy.
^ Traite de I'Epilepsie. Lausanne, 1790.
* Du pronostic et du traitement curatif de Tepilepsie. Paris.
* Epilepsy and Allied Disorders. London.
3Iinor Causes, 113
pin's argument against the theory that masturbation is
a cause applies equall^^ well here, with even greater force,
for the number of females who are not epileptic, but
who are sexually continent is, we hope, far beyond 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.
Scrofidosis and rachitis have been held on high au-
thority as important factors in causing epilepsy by 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 parents are pale and badly
nourished the children may 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
many other affections, save in the fact that, by producing
asymmetry 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, but much more fre-
quently in females than in males after puberty. This
becomes the more readily understood when 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.
2 Krankheiten des Nervenapparat., Virchow's Handbuch f . Spec.
Patliologie and Therapie.
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 by acquirement, syphilis, as everj^-
where, stands prominently in the foreground. This dis-
ease may produce epilepsy, of course, in two ways :
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 inquiry, that
the ordinary eruption of syphilide has failed to appear.
Per contra^ we seldom see nervous S3q3hilis where the
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 syphilis.
Thus, in 618 s^q^hilitic epileptics Echeverria ^ saw only
Y 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 epileps}^ In some instances this
^ True, Lyon Med., xlviii, 1885.
2 Journal of Mental Science, July, 1880, p. 165.
Eejlex Epilepsy. 115
really becomes fimiising were it not that the subject is
too important to be laughed at.
Thus, Lasegue^ la3'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
beyond 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 sj'mptoms,
it was shown that such investigations 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 always in the morning if the disease be typical.
Where cranial malformations are a cause tli^y probably
exert all their influence before the eighteenth year at the
latest.
Reflex Epilepsy. — An exceedingly important question
has arisen among physicians 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
day. 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
which arises by 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.
It should also be kept in mind that the term " reflex
epilepsy " is only used to designate a condition of the
nervous sj^stem in which repeated convulsive attacks
have occurred for a long period of time, and does not,
as generally emplo^^ed, 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, ^.e., a morbus per se, which is to be
distinguished from eccentric convulsions, from toxsemic
convulsions, from the convulsions occurring in connec-
tion with organic changes in the cerebro-spinal nervous
sj^stem, and from every other known and recognizable
disease." Notwithstanding this assertion, the same
author a little farther on is forced to acknowledge that
reflex irritations may occasionally not only produce
simple convulsions, but even true epileps3^ He defines
his position still more clearly by pointing out that in
*' reflex epilepsy " '' 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 orioinal 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
w^e are discussing in epilepsy a chain of sjaiiptoms, ex-
pressing some more or less tangible nervous change,
* Loc. cit., p. 33.
Bejiex Epilepsy, 117
"wliicli in some of its forms is as yet unknown to us. The
whole w^eight of Reynolds's opinion virtually rests upon
the ability of the medical attendant to demonstrate some
irritation, and the diagnosis is one of epilepsy, or con-
vulsions of another t3q)e, according to his capability of
judgment. The author quite agrees with Nothnagel ^
that this theory cannot be accepted simply because, in
the light of our present knowledge as to reflex degen-
erations, we cannot deny their occurrence, at least under
other circumstances, although we haA^e 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 may 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 by 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 periph-
/^rj. 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, 2 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. ^ Arcli. de Neurologle, 1885.
118 Epilepsy: its Pathology and Treatment,
and he speaks of *' epilepsies eclaraptiqiies " as a variety
of the disease in which 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. Yery common!}^, 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 already stated be remembered,
namely, that the very occurrence of one nervous act
predisposes to a similar act at some future period.
It is now many years since the possibility of adherent
prepuce producing epilepsy was first brought 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 b}^ 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,
Reflex Epilepsy, 119
and have been cured by the shock of the operation rather
than b}^ 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,
whicli 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 the child has suffered till it is 2 or 3 years 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 3routh of
the sufferer and (if one may use such an expression) the
3^outh of the disease.
It is also fortunately true that such seizures are most
commonly among young 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 Epilepsy: its Pathology and Treatment,
main 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 every practitioner to examine care-
fully the penis of every male child brought to him with
epilepsy, particularly during early j^outh.
Closely allied to the reflex epilepsy of i^reputial 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
inflammartion. 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 hysterical 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 years, of a typical h^^steroid
appearance, but well developed mentally and phj^sically,
in whom the tendency for self-abuse was so strong that,
after all other measures had been tried, the operation of
oophorectomy 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 hns 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 country. The
cases 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 vaccina. 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 the seat of the disease,
and consequently pass by unnoticed. It may be laid down
as a fact that in all cases in girls in which epilepsy 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
indigestion 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 Eijilepsy : its Pathology and Treatment,
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Reflex Epilepsy, 123
set np either isolated or frequent attacks is without
doubt true, and it is even possible that this may give rise
to an epileps}^ lasting a life-time, for, as has aready been
said, every nervous act is followed by its duplicate, 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 t3^pe, 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
thnt the father had of late been in the habit of feeding
the child, giving it an^^ 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 common 1}^
b}^ 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 ordinarj^ amount of corned beef.
The result was another convulsion. Without occupying
more space by a further account of the case, it may be
added that recover}^ 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 Treatment.
later, when, owing to the absence of the mother, a rela-
tive gave the child some indigestible food. The case
just cited is but an evidence of the fact that, apparently,
true epilepsy may be produced by very easily removed
causes.
The convulsions of young children occurring under
conditions of indigestion are, while epileptiform in char-
acter, scarcely true epilepsy, 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 prominently
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 e^^e, and they have devised an
operation closely allied to that ordinarily used in the
connection of strabismus with asserted good results.
Rather 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 any direct involvement of the brain itself.
Thus, Moos^ reports a case of middle-ear disease result-
ing in epileptic seizures, and traces the inflammatory
irritation along the tympanic plexus, and thence to the
* Allgem. Zeitsclirift f . Psychiatrie, xxxii, 5.
Beflex Epilepsy, 125
brain. A large number of such instances are recorded
elsewhere by other writers.
Quite an elaborate research on the relation of epileps}^
to ear disease, when the latter acts as a causative factor,
has been carried out b^^ 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 T 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 Ther. Med. Cliir., September 1, 1886.
2 Brain, 1884, p. 37.
» Practische Med., art. Epilepsie.
* Societe Frangaise d'Otologie et de liaryngologie, April 27, 1888.
126 Epilepsy: its Pathology and Treatment,
nerve. He quotes Noqiiet, who observed a deaf-mute
atfected with tinnitus and epileptic attacks, who was
cured by Politzer's inflation of the t} 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
tlie 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 indefinitely, but the writer
will call attention to only one or two. Brubaker ^ has
reported 18 cases of epilepsy 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 de Ther. Med. Chir., 1886.
2 Med. and Surg. Rep., Philadelphia, 1888.
' Deutsches Monatshefte f. Zahnheilk., Heft 3, September, 1885.
* London Med. Gazette, 1851, xlviii, 534.
' Amer. Jour. Med. Sciences, 1870, n. s., lix, p 278.
* Loc. cit. ' Nervous Diseases, London.
' Edinburgh Med. and Surg. Jour., 1868-69, xiv, p. 110, and Arch. Sci.
and Pract. Med. and Surg., 1873, p. 1360.
Rejlex 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 injurj^ 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 1811, the sciatic nerves on both sides
being injured. Eight months after the injury epileptic
fits came on, which constantl}^ recurred. Several cases
of a somewhat similar type have been recorded by Bill-
roth^ and Shaefer^.
A form of peripheral lesion producing epilepsy, prob-
ably 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 upon 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, iii, 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 Deutsches Gesellschaft f. Psych., ii, p. 35, 1855.
128 Epilepi^y : its Pathology and Treatment,
ulwa^'S with very contradictory results, but DelasiauA^e,^
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, certainly acts in producing
epilepsy is that of these febrile disorders. Every writer
of any wide experience, writing on epilepsy, mentions
this fact in giving the subject a general discussion, but
very few statistics have actuall}^ 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. Paris.
^ Arch. gen. de med., mai, 1843.
' Cranz, Historie von Gronland, Barby, i, 189, 1770 ; and Lange, Be-
maerkn. om Gronlands Sygdomsforliold, Kfobenk, p. 42, 1864.
* Pontoppidan Historie von Norwegen. Copenhagen, 1754.
^ Hirsche's Handhuch f. Geograph. und Histor. INIedicine.
Toxdemic Epilepsy, 129
less than 19 were due to scarlet fever and 9 measles;
while in America Hamilton has seen, in the 930 cases
collected hy 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 may reach the result in three ways in
prodncing epilepsy: either they 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 by some that the convulsions which
find their way out into open manifestation during or
after the disease has spent itself are generall}^ 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 that these cases show no signs of
renal disease during life, nor does the post-mortem ex-
amination discover au}^ change from the normal state.
Then, too, changes are found sometimes in the brain
w^iicli 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 IVeatment,
fever, and it is by no means rare to see cases of measles
followed by 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 plays havoc in the nervous protoplasm of the
body very frequentl}^, it rarely 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 by an acute disease, and which ma}^
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 some practitioners its occurrence may
never be seen, for it generally comes on in artisans work-
ing in the metal, and rarely, or never, does it complicate
the milder forms of poisoning commonly observed. Tan-
querel 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 ^ears. Women
suffer, naturallj^, less frequently than men, owing to
their occupation. It has also been proved that the
ages most commonly affected range from 20 to 50 3^ears,
probably due to the fact that these persons more gener-
ally work in lead than older or younger men.
The manner in which this metallic poison produces
epilepsy is only 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 mercurj^, 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 epileps}^, and
toxsemic 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 Pathology and Treatment.
priate point at which to speak of it. He refers to the
so-called Epilepsie Fleuritique.
The first person to call attention to this form of con-
vulsive attack was Maurice Raynaud, of Paris, in 1815,
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 not 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 receiA^ed 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
liigher 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, namely, 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 indirectl}^ 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,
* Etuflcs cliniques sur le Pouls lent permanent. Paris, 1879.
2 Diseases of the Heart and Arteries. London.
Etiology of Symptoms. 133
that 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 upon 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 have 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 system 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 always 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 affected are in a condition of tetanic con-
traction ? Every one acknowledges that the great cause
of all convulsions is the sudden liberation or explosion
of nerve-force, which sw^eeps everything before it.
Originating, undoubtedly, in the cerebral motor
centres, it passes, in epilepsy, 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
are thrown into tonic contraction for the moment b}^ 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-
ability, one constant stream of nerve-force in healtli or
disease, and even those of tlie 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 rapidl\" 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 sent
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,
60
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 hy^ 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 b}^ 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 tliat 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 :—
x
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 b}^ paralysis or depression of func-
tion, and this lasts until sufficient time has elapsed to
permit of reparative change.
That the rapid discharge of impulses is always fol-
lowed b}^ intermittent discharges has been proved to be
the case by direct experimentation even when the subject
is a normal man. Thus, two American enthusiasts in
the study of neurology, Dercum^ and Parker, found that
if they stood with tlie 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 the}^ attempted it, jerkings of the
muscles came on, which, when the position was persisted
in, eventually spread to the whole body 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 paralysis as due to exhaustion,
and, aside from the fact that all living matter becomes
exhausted by excessive action, and that certain areas of
the body are often paralyzed after being most convulsed,
direct experimental evidence of a very simple character
is at hand.
In a very interesting research carried out by the
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 lie 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 destroj^ed 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 ke}^ 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.
1.38 Epilepsy: its Pathology and Treatment,
Pathology. — The author lias alreaaj^ 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 epileps}^, since, up to the pres-
ent time, no essay has appeared which gives the results
of the labors of investigators in this disease within
the past twent}^ years.
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 the nervous disturbances of idiopathic epitepsy. All
w^e can do is to accept the generally-received doctrine
that the convulsions are the result of an explosion of
nerve-force in the higher cortical or subcortical brain-
centres, and that the aurae and like preliminary manifes-
tations are in many cases of the same origin
The question of the physiology, or rather the
pathology, of epileps3^ 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 j-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 fort3^ 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 speedy enlightenment of our ideas
will soon take place.
The writer has called attention more than once to
Pathologij, 139
the results of Brown-Seqnard 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
years 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 paroxj^sms
at varying 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 being at the angle of the
jaw, which, therefore, received from Brown-Sequard the
title of the " epileptogenous zone." This zone is always
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 physiologic de I'homme, vols, i and iii, 1858 and 1860, and
in vols, i to iv Arch, de Physiologie normale at pathologlque (Brown-Se-
quard, 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 remarkable is the 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 ansesthesia of the " epileptogenous zone "
also decreases pari passu with the subsidence of the
spasms. A most extraordinary fact is, however, that
the young of such animals — always guinea-pigs — are
often spontaneously 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 proved their truth, notably 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 injury, of sucli a severe char-
acter as to cause the death of a strong, healthy 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 degree of suc-
» Arch. f. Psychiatrie, Bd. VII, 1877.
2 Bulletin de la Soc. de med. d' Angers. Ann. Ixxvii, p. 121. (See pasje
117 in this essay.)
^ Lehrbnch der Physiol ogie, 1858-59.
* Berliner klin. Wochenschrift, 1873, No. 38.
* Ziemssen's Encyclop., art. Epilepsy.
Pathology, 141
cess as tliey have been in guinea-pigs, but Sob iff has
produced them in dogs without any loss of conscious-
ness, and the writer has thrown 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, namely, Marshall Hall and
Travers,2 who pointed out the resemblance between true
epilepsy and the convulsions of cerebral anaemia from
li8emorrha2:e.
Later than this KiissmauP and his colleague, Tenner,
performed a very large number of similar, but more
careful, experiments, with the result of confirming the
assertion that epileptiform convulsions could be pro-
* Guy's Hospital Reports, vol. i. London, 1836.
2 New Sydenham Society's Transactions, 1859.
' Untersuchungen iiber Ursprung und Wesen der fallsuchtigen
Zuchungen bei der Verblutung so wie Fallsuclit iiberliaupt. Frankfurt,
1857.
142 Epilepsy: its Pathology and Treatment,
diiced by sudden cerebral anaemia. This has been con-
firmed by many other investigators, notably Wood,^ of
America, who has found that 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 haA^e 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 system of
the cerebrum is not governed by the fibres of these
nerves at all. Nothnagel has, however, galvanized pe-
ripheral sensory nerves in order to produce vasomotor
spasm 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 the blood-paths was the cause
of convulsions, they ought to come on at once, how^ever,
* Therap. Mat. Med. and Toxicoloi^y, 6tli eel.
2 Ziemssen's Encyclop., art. Epilepsy.
^ Petersburger Med. Zeitseliiift, vol. xi.
Pathology. 143
and not require prolonged contraction. Again, when 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 Notlmagel 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 tightly bound and the sole be tickled with a
feather, the sensation is not onlj^ soon unbearable, but if
persisted results in a typical convulsion. It is a simihir
condition to that produced b}^ 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. They found the}^ 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 only 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 haA^e thought
* Centralblatt fiir klin. Med., No. 4, 1878.
144 Epilepsy: its Fathologij and Treatment,
them as indicative of a '^ convulsive 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
way to prove the existence of a physiological centre.
One reads that such and such an investigator i:)unc-
tured or removed cerebral areas and found a rise of
bodily 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 body-
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 ph3^siological
hebetude or physiological activit3^
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 hyperaemia developed by artificial
means so resulted, but obtained nothing but negative
results. On the contrary", Landois^ has supported the
theor}^ that hyperaemia is similar in its results with
anaemia, wiiile Escher and Hermann^ have by further
experiments confirmed only those of Kiissmaul and
Tenner. Either some fallacy underlaj^ the work of
Landois or else the hyperaemia was so intense as to pro-
duce absolute pathological conditions in the brain.
The whole theory that epilepsy is due to cerebral
anaemia 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 Med. Wissenschaften, 1867.
2 Pfliiger's Arcliiv, vol, iii.
Pathology. 145
good investigators so tliat they seek no further for an
explanation.
Some writers have held that the proof of their theory
rests in the pallor which comes on in the face at the
onset of the convulsion ; which, by the bye, it does not
always 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 they would have two
morbid changes going on — one primarily in the vaso-
motor system, 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 hjqoeraemia 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 unlikely.
Quite a number of years 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 Lehrbuch 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^ that
sucli a thing as spinal epilepsy, or epilepsy arising from
the spinal cord, may exist, and although no less an au-
thority than Brown-Sequard denies this, and the whole
physiological 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
angemia of the spinal cord is not followed by convulsive
movement. Kiissmaul and Tenner have also noted this.
One must, therefore, either believe in anaemia 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 liaA^e obtained, he cannot
help drawing his attention to some points which are at
least worthy of remark, for, after all, it is our duty not
to accept blindly any one's results, but to put them 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 sj^stem. So universally
is this recoonized that the fact that a man is sufferinsf from
\a tetanic spasm is proof that his spinal cord is affected,
either directly or indirectly, provided the contraction is
prolonged. Of course, the writer does not mean that no
* Virchow's Arcliiv, xllv.
^ Das accidents convulsifs dans les maladies de la moelle epiniere.
Paris, 1871.
Pathology, 147
instance lias 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 wall see that they speak of tonic epilepsy
and clonic epilepsy, using the word epilepsy to signify
any convulsive condition. Owing to this, it is exceed-
ingly difficult to separate the results really 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 Yarolii or me-
dulla oblongata by stimulation ; but we know that, gen-
erally, if not always, 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 Rosenbach,^ working in
Mi erzejew ski'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 sj^stem so
pregnant with vital centres as is the medulla without
causing death and general cardiac and respiratory cliaos.
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.
2 Vestnik klin. u Sudek. Psikiatrie, vol. ii, fasc. 1, p. 171.
148 Epilepsy : its Pathology and Treatment,
supported bj the results obtained b}^ Seppilli,^ and by
those of Soltmann and Tarchanow, as well as those of
Albertoni. If the medullary theory is true, a skillful
liypothesis 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.^ 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
Englisliman, 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 Terrier 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
Yulpian, 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,^ Schafer, and Horsle3\^
* Rivista Sperimentale di Frenatria, f asc. i and ii, 1884.
2 Some results reached by Luciani may in the end dissolve the dividing
opinions as to the 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 tlierefore concludes tliat tlie
medulla must act as a distributor.
3 Trav. du Lab. de M. Marey, 1878-79, p. 413.
* Archiv f . Psychiatric, Bd. XIV.
* Riv. Sperimentale de Frenatria, iv, 1878, p. 617.
® Proceedings of the Royal Society of London.
Patliology. 149
We lifive 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 Kiiss-
maul and Tenner, and of Nothnagel 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 iliQj 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 processes
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 Ejnlepsy : its Pathology and Treatment,
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
the 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 reall}^ 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 ; that is, by extirpation and
watching the results ; for, as it is receptive, not expulsive,
Pathology, 151
ill character, galvanization produces no external signs
of response. Tliis field, by reason of this indirect
method of reaching conclusions, 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 when it is recalled that the breadtli
of a millimetre may involve another function entirely.
Still further evidence has been recorded by Hitzig,^
who by the removal of certain cortical areas governing
certain parts produced epileptic seizures, beginning
spontaneously, either on the next day or in a few weeks.
Just here, however, I must call attention to a very im-
portant element of fallacy which in many ways may
have, to a certain extent, falsified Hitzig's results.
Antiseptics being unknown and healing by first in-
tention being practically unheard of, it is perfectly 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 they 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. They 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
* Untersn Chun gen iiber das Gehirn, 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. They suppose from this that each area not 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 thing-
true if they did not use the knife quickly enough.
Kosenbach is, however, entirely in accord with 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.
2 Arch. f. Psychiatric, Bd. XIV.
' Vestnik klin. i Sudeb. Psikhlatrie, vol. ii, part i, p. 171.
* Pfluger's Archiv, xxvi, 137.
^ Verslg. d. Sildw., Deutsch Neurologen und Psychiatric.
Pathology. 153
pora qimdrigemina gives rise to energetic movements of
locomotion, while irritation of the posterior part of the
quadrigeminal bodies causes tetanic convulsions. He
thinks tliat 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 wiiat is to follow
as part of the evidence which he will bring forward.
When we remember that 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 may 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 scarcely
necessary for him to adduce evidence of the epileptic
jmroxysm which stimulation of the cerebral cortex may
set up. If a moderately 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 beinsf.
Can anything be more typical ? 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 Pathology and Treatment,
of Albertoni, of Soltmaim, and of Tarchanoff, for they
found that in newly-born cats, dogs, and rabbits they
could not produce fits by 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
pathwaj^ is blocked between the cortex and the lower
distributing nervous apparatus.
As has already been said, the character of the aura
indicates generally the region of the nervous s^^stem
which is diseased, and we may us-e this as a means of
localizing lesions during life. Thus, an aura consisting
of blindness may point to involvement of the centres
governing or connected w^ith vision or situated near by,
or, if the aura is olfactor}', it indicates cerebral disease
in the region of the olfactory bulbs, unless the case be
one primarily reflex.
The w^riter 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 reports in which every
* Nervous Diseases, p. 698.
Pathology. 155
one has his doubts at the present day 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 ^ found capillary dilatations
in the neighborhood of the hypoglossal nucleus in those
who bit their tongues during the fit, 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 tongues
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 -pa^iip' Vao-im
Epileptics. glossus. Olivaire. -t^^P'^e. vagus.
(«) Tongue-biters, . 0.306 0.315 0.315 0.237
(p) Not biters, . 0.210 0.217 0.217 0.348
Difference, . . +0.096 +0.098a -0.055a -t-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 the}'^ 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, New Syd, Soc. Translations.
156 Epilepsy: its Pathology and Treatment.
the cause be a morbid growth or a lesion from trauma-
tism. Manj^ 3^ears ago, Lebert and Dalasiauve ^ noted
tliat sclerosis of the hippocampal folds often existed in
epileptics, and their observations have been confirmed
in 20 cases by Meynert, Nothnagel, and Charcot, but it
is to be remembered that both of the latter believe the
changes to be secondary, not primary, to the epileps3\
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
by the results of Hemkes,^ w4io found in 21 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 epilei)sy. Besides
this, Hemkes has removed the hippocampi with no con-
vulsive results. When it is remembered, too, that this
portion of the brain of man is only rudimentary, while
in animals it is much more highly developed, it scarcely
seems likelj^ 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 atrophy of the
* Traite de I'Epilepsie.
2 Sallanzani, Modena, 1879, viii, 550.
"" Allgem. Zeitschrif t f iir Psycliiatrie, Bd. XXXIV, Heft 6.
* Virchow's Archiv, Bd. LVIII.
' Allgem. Zeitschrift f . Psycliiatrie, Berlin, 1879, xxxvi, p. 359.
^ Ibid., Ixxvi, and Archiv de Neurologie, No. 2, 1880, p. 299.
Pathology. 157
cornu ammonis 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 daring life.
In a series of 90 autopsies, Sommer^ found changes
in the cornu ammonis 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 the disease has existed on
one side in a more highly developed form than on the
other, and has been associated with a certain amount of
hemiatrophy, the autopsy has disclosed corresponding
hemiatroph}^ of the brain. Baume^ states that the
weight of the hemispheres in epileptics is alway un-
equal, the lightest hemisphere being on the side oppo-
site the convulsed portion of the body. 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 being 50 grammes. 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 hypertrophy of the epileptogenous side of the brain
often exists.
Numbers of cases of epilepsy have also been due to
tubercle, and Luys ^ reports an instance in which, after
death, the medulla oblongata was found tuberculous.
Greenhow, Dresche, Green, and Lobel have also re-
ported a number of such cases.
* Archiv f. Psychiatric 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. Psych ologique, tome viii.
* Amer. System Practical Med., p. 491.
' Archives gen. de med., 1869, ii, p. 541 et seq.
158 Epilepsy: its Pathology and Treatment,
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 2 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, perliaps, gen-
eral paresis accompanied by epileptiform crises) have
we seen so marked and constant a variation between the
w^eights of the hemispheres as in epileps}^
In the medulla oblongata Kroon has seen asymmetry
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 enough to claim
that either cerebral or medullary asymmetry caused epi-
lepsy. These changes form the plij'siological t^^pe, are
^ Epilepsy and Other Convulsive Disorders.
^ Quoted by Axenf eld.
Pathology. 159
entirely secondary to the disease, or have no connection
therewith whatever. The writer should also mention the
belief of Schroeder von der Kolk,^ 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 primary 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
years a very interesting paper has been published by Der-
cum,^ 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 others,
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 Rolando
opened into the Sylvian fissure. Abnormal sulci were
jxIso 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.
2 Journ. Ment. Science, October, 1885, p. 353.
' Proceedings of the Philadelphia Neurological Society, Dec. 26, 1886.
160 Epilepsy: its Faihology and Treatment
one of the 12 cases there was evidence of mechani-
cal hindrance 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 found 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 type, and a very large amount of literature
has been written concernino- 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 the Sylvian artery, and once
of the basilar artery. In addition to these changes,
there were gummata in the cortex, or the substance 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 b}^ daily
experience. They may act by so interfering with the
* Archives de Neurologie, May, 1886.
2 Journ. Ment. Science, July, 1880, p. 165.
" Nouvelle Contribution a r etude des Localisations motrices dans
I'Ecorce des Hemispheres du Cerveau. 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 they 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 many 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 sensory portion of the cortex in the same manner as
epilepsy may be due to irritation of the motor portion.
In the first place, the very character of typical migraine
is epileptic, for it is generally preceded by hemianopsia
for a varying 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 when 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 S3^stem elsewhere is
often found even more profoimdly 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}^ ursemic. 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 directly. Rosenstein^ has poisoned dogs with
lead in such a way that chronic poisoning resulted, and
has seen epileptic fits produced in these animals in this
manner ; but he states positively that they were not
ursemic 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 epileps}^ is essentially
a cortical disease of the cerebrum, brought about, of
course, in many wa3"S. Either direct irritation of cer-
tain cells may so result, or indirectly by irritation of a
reflex character they are perverted from their normal
lyircliow's Archiv, 1867.
Diagnosis, 163
function. IN'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 hysteria, 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 say.
The very 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
the 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
typically at variance with those of daily life, while in
hysteria they are almost equally t3^pical 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 hysteria, also, conscious-
ness is impaired sometimes, but never so completely as
in true epilepsj^ Indeed, most commonly 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 may afterward be able to narrate all that
has occurred. Less commonly, however, a condition
known as automatic consciousness exists, in which, dur-
ing the paroxysm, the patient understands all that is
said, but forgets everj^thing 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 epilepsy ; and yet
it should always be remembered that males may suffer
from hysteroid attacks.
The movements of the hysterical patient after the
tonic condition has passed away 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 the 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 may show a second
tonic stage. This can be separated, however, by the fact
that it is followed by clonic movements, whereas the
secondary tonic stage of In^steria is usually followed by
relaxation and teniporarj^ recover3\
In the secondary hysterical tonic contractions em-
prosthotonos and opisthotonos may occur, and are even
more rigid in their character than they are in the first,
in some cases, Finall}^, too, in hj^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 very far off. In some
very well developed cases the expression of pleasure is
followed by a look of pain, with painful movements, or
an intense appearance of voluptuous entreaty, with
sensual and venereal desire evidenced hy gestures. Great
terror may be present, and, as the scene constantly
changes, the woman is now joyous, now mournful, now
scolding, now praising her attendants or herself Such
is the history of a fully-developed attack of hysteria.
Hysteria is rarely seen among the 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 mouth is frequently present ; but in
the other countries which have been spoken of its pres-
ence may be regarded as indicative of epilepsy rather
than hysteria. Doubtless the inexperienced reader will
say, upon comparing these symptoms 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 strenuousl}^ upon the fact
that in both cases he has only given the most tj^pical
characteristics of the diseases, and he repeats that all
cases are not hy 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 historj^ of the case, as when a
patient is brought 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 suffering from these
hysterical attacks be questioned in between times, it will
be found that the so-called globus hystericus 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, by any
means. Again, the expression of the face in hj^steria 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 hypersesthesia 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 Epilepsy: its Pathology und Treatment.
nearly all cases these areas are unilateral, and may ex-
tend entirely over one-half of the body, the line of de-
marcation of the anaesthesia or hypersesthesia, from the
sound area, being clearly and abruptly defined, gcnerall}^
:it the median line of the front and back of the trunk.
]t will be called to mind that such conditions are A^ery
rare in true epilepsy. Hallucinations are far more com-
mon after the fit in hysteria than in epilepsy, and some-
times i\\Qj even occur duriBg the attacks. They are
always associated with tlie 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 wideh^ dilated.
Tlie following table gives, in as brief a manner as
possible, the difierential diagnosis between epilepsy and
hystero-epilepsy, and is founded on a lecture by Pro-
fessor Charcot, 2 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 b}^ 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,
m9,y be hallucinations.
Mental power preserved.
Emotional attitudes.
* Legon sur les maladies du syst^me nerveux. Paris,
* Gazette des IlOpitaux, 1878,
Diagnosis. 169
A yer}^ useful differential point, strongly insisted
upon by Charcot and Bourne ville, is that in true epilepsy
there is generally a very considerable rise of tempera-
ture during an attack, while in hystero-epilepsy the
temperature remains normal or only slightly raised.
Some observations, made by 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 by 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 very threatening
condition of the nerve-centres. Thus, in a case reported
by Quincke, 2 after a series of apyretic convulsions, con-
vulsions occurred with elevation of the temperature to
43^ C, and soon ended in death.
In the diagnosis of true epilepsy from convvdsions of
a hysteroid character, it is well for the physician to re-
member that the proportion of the two conditions in
frequency of occurrence is, according to Gowers {loc.
cit.), 815 to 185 in every 1000 cases.
The differentiation of epilepsy from uraemia is much
more readil}^ carried out, for there is usually a previous
history of symptoms pointing to renal trouble, as, for
example, some oedema, or somnolence, or mental apathy,
for some da} s or hours before the attack. Of course,
* Le Progres Medical, Jan. 10, 1874.
3 Arcbiv f. Heilkunde, 1864.
8 H
170 Epilepsy: its Fatlwlogy and Ti^eatment,
in such cases, recourse may be had to the ordinary tests
for such conditions of the urinaiy 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 uraemia. 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 epileps}^ to be due entirely to uraemia.
Thus, Sieveking^ 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 carefull}^ noted, and in very doubtful
cases careful estimations of the urea be made. If the
specific gravity is constantly below 1.010 the kidne^^
will nearly always be found contracted unless diabetes
exists. Tests of the urine passed at difierent times of
the day should always be made. Another means of
testing the integrit}^ of the kidne}^ is to administer
* Brit. Med. Jour., March 20, 1858 p. 235.
Diagnosis. 171
iodide of potassium and 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 very small
quantities. The temperature of the body may also be
used to differentiate between uraemia and epileps}^ In
1865 Kien^ called attention to the fact that even when
nrsemic 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 epilepsy. 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 suddenly convulsed during the puerperal
state. This is not a place for tlie discussion of the identity
of uraemia and puerperal eclampsia, although we believe
that this is generally supposed to cause the nervous dis-
turbance. If the convulsions are nraemic, the tempera-
ture, according to the investigators just quoted, should
fiiU, but according to Bourneville {loc. cit,) tliey 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 epileps3\
It is important to determine whether idiopathic
epilepsy can be separated from that due to syphilis
* Gazette Med. de Strasbourg, 1865, p. 12.
2 Etudes Clin, et thera. sur les maladies du systeme nerveux,
Paris, 1873.
172 Epilepsy: its Pathology and T?'eatment,
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 concerued, it is not possible to separate them. If,
however, we can obtain auy history the matter becomes
much more simple. It is characteristic of syphilis to
liave severe darting or aching pains in the tibiae, par-
ticularly at night, and it is also characteristic of syph-
ilitic epileps}^ 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 nearly always
absence of the shrill cry at the onset, so characteristic
of the idiopathic variet}^
2. There is frequently paralysis immediately after
the attacks.
3. The seizure is incomplete or unilateral in char-
acter.
4. Attacks constantly increase in severity.
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 impunity. As much as 30
grammes will often do no harm in twenty-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 on the subject that Fournier has
also great confidence in this test.
Diagnosis. 113
Of course, if there is a iiistory 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 pathetic us.
The diagnosis of syphilitic epilepsy from the idio-
pathic form is of the utmost importance, since the
ultimate result must be largely governed by the cause.
Dowse^ has analyzed no less than 2Y4 cases in order to
discover any useful points in this respect. He insists, as
tlie writer has already done, that epileptic attacks begin-
ning after 30 ^^ears of age are almost surel}^ syphilitic,
particularly if no histor}^ of traumatism or heredity is
present. It is also found that, if some degree of mental
alienation is present between the paroxysms it will gener-
ally yield 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 may 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*74 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, 1 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 epilepsy 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 symptoms 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 epilepsy, 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 syncope 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 commonl}^,
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. 1 and ii, 1885.
Diagnosis. ITS
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. Often
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.
Very 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 malingerers 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 epileps3^
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 differential point.
The diagnosis of lead epilepsy from the idiopathic
* Diet, des Sciences Med., vol. xii, p. 542.
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 the
case and render it more easy to recover lead from the
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 history 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 may be much more easy.
It is exceedingly important to differentiate between
those convulsions which arise from the uraemia brought
on secondarily by an action of the lead on the kidneys
and those which are due to a direct action on the brain.
This may be difficult from the mere symptoms presented,
but there are some points of diflerence. In the first
place, the convulsion of uraemia is, as a general rule, not
so violent in its movements, nor so sudden in its onset.
It is generally 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 the
urine in uraemic 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. 11T
be true, unless the kidne3'S are 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 kidney, which may or ma^^ not be the
cause of the nervous disturbance. (See diagnosis of
uraemia, several pages back.)
Aside from the s^miptoms 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'siognomical 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 27
Eyelids pufTy, 33 9 41
Pupils large, 20 5 25
" medium, 19 6 25
" unequal, 0 2 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 veiy 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 hand, 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 by 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, that 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., 1884.
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 17 cases examined by
him all of them felt giddy in the direction in which
they ultimxately moved, or, in other words, the sur-
rounding objects passed in a stream toward the side to
which the head w^as 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 phj^sician can always assure the
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, by 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 larynx, 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 away 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 alwa}^ ask is,
What is the prospect of ultimate recovery, or, at the
180 Epilepsy: its Pathology and Treatment.
least, will there be any progress toward an improve-
ment? Unfortunately, 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 ever}^
large practitioner has been that cures rarely occur.
Several points which have a favorable bearing ma}^,
however, be offered 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 early in its life and in the life of the patient, the
results are certainly fairly 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 may lie in the greater strain placed upon
females at the age of puberty.
Curiousl}^ enough, hereditar}' 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 readilj' 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 by the following table made by Gowers. It is
certainly sufficiently convincing in its figures, and for
* Du pronostic et du traitemeiit curatif de I'epilepsie, p. 615. Paris, 1852.
2 Epilepsy, p. 246. London.
Prognosis, 181
this reason the writer takes the liberty of inserting
it here.
In 100 eases the results were as follow : —
Cases. Percentage.
™!!!; Arrested. ™«^; Arrested.
proved. ^
^rresLe
* proved. '
(!^lTeSt(
Attacks daily,
. 7
1
18
1.8
Daily or weekly,
. 11
29
29
46.7
Eight days to 1 month, .
. 16
15
42
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. They 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 maj^ 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 epilepsy has, therefore, the most gloomy
prognosis, while S3^philitic epilepsy has the most
promising.
The writer must issue a word of warning, however,
182 Epilepsy: its Pathology and Treatment,
which often by its absence leads to disappointing results,
namely, very frequently epileptics, be the cause of the
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 ultimatel}^ 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 epilepsy, 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 physician, and the only value 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 author 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 ph3^siological 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 the
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 by 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 Epilepsy: its Pathology and Treatment,
present day. This 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 frequency that its use may be said to be indicated
in every case of the disease. In a very small minorit}^,
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 epilepsy is, par excellence^ the treatment to be em-
ployed on every occasion. There is no other drug
known which can be relied upon so absolutely, 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 employed to
a considerable extent, and depend upon the character
of the disease and temperament and physique of the pa-
tient. We have already pointed out that the 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 carefully
reckoned l)efore the treatment begins. Further than
this, the frequency and severity 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 only 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 3^ear. Again, the char-
Treatment, 185
acter of the attack, as to its violence, ma}^ be the most
important fact to be regarded; for, if they 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 an instance
of an epileptic who was getting 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
peculiarly 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 very 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 by 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 an 3^ amount which is borne.
112
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 by 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 onl}^
ever}^ two weeks this is a particularly 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 alwa^^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 sj^stem 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, frequentlj" repeated, in order to
keep the patient constantly 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 the drug in moderation for
at least three 3^ears 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 other
bromides, and the 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 thase
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,
* Arcli. 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, lie also found that this lessened
irritability was increased still further if the drug was
given for several da3^s beforehand in such doses as to
thoroughly 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 doubl}^ useful in reflex epilepsies,
not only by its action on the motor cortex, but by its
influence on the aflTerent ]3ortion of the nervous sj^stem.
The experiments of Eulenberg and Guttmann ^ prove
that the sensory paths in the spinal cord feel more power-
fully than any other portion of the body the eflTects of
the drug, for they found that if they tied the blood-
vessels supplying one limb of an 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.
2 Virchow's Archiv, xli, 1867.
3 Ibid., xlv, p. 191.
* Bromides : their Physiological Effects. Providence, 1871.
* Dublin Journ. Med. Sci., xlvii, 324, ISfiO.
« 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 drug prevent nerv-
ous disturbance in the cerebrum, ])ut 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 may also be added that the bromide of
potassium was, and is, believed by some to effect a cure
by 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 Amory^ 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 than in
the normal frog. None of these ftxcts prove vasomotor
action, but rather that there is a lessened circulation by
reason of the cardiac depression produced by 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 twenty-four hours and one-third in the second
twenty-four hours. It is evident, however, that it is
* The Physiological Effects of Bromide of Potassium, part ii, p. 147.
Boston, 1872.
2 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.
* hoc. 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 system 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 symptom, which
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
da3^s, this milder form may occur in those who have an
idiosyncrasy 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 that
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 symptom 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
ansemia 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 ad vantages. ^
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 years
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.
2 Am, Journal Med. Sciences, October, 1870.
192 Epilepsy: its Pathology and Treatment.
Sfilt in its fiction, and he has found it useful in about
the same doses as bromide of potassium.
The bromide of ammonium is very irritant, and dis-
orders the stomach quite readily. It ought always to be
used, when used at all, witk some other drug, the ammo-
nium only acting as an adjuvant.
Several authors have tried h3^drobromic a^^id, but it
is A^ery much more apt to derange digestion and to pro-
duce A^omiting than any of the salts. The dose of the
dilute acid is ^ 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 prescrip-
tion in w^liich 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 years been used alone
in epilepsy with fairly good results, and should always
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 epile[)sy. Whj^ 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 sucli experience, see article by Erlenmeyer in
Centralblatt f. Nervenheilkunde und Psychiatrie, etc., No. 18, 1884.
* Nervous Diseases. London.
^ Treatment. 193
attacks than in the others. The writer is also unable to
explain why it should 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 paralysis 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
inhibitory 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 system 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 by stimulation of the brain. Both these investi-
gators are therefore in accord.
* Rivista Sperimentale di Frenatria, fasc. i and ii, 1884,
^ Arch, f . Exp. Path, und Phariii., xv, p. 265.
9 1
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 these 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 century, 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 very closely allied.
The effect on the circulation is almost mZ, and its influ-
ence is solely expended on the nervous system. The
deep sleep produced by it, even in moderate medicinal
doses, is not only 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 of :^ to ^ grain of tlie 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.
Oelsemiuni semper vir ens is an American plant whose
praises, in almost every disease, have been widely
heard. Its influence alone is almost worthless, for
it possesses no power over the cerebral centres what-
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 the 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 employed, 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 way 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, aud is better borne by 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 slowl}^, it rapidly accumulates,
and argyria soon comes on. It may be used, after all
else fails, in doses of |^ to ^ grain, thrice a day, 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 da}^ Our knowledge of
its effects, so far as its curative influences are concerned,
is very slight, but it really seems to benefit some cases.
Its action is \Qvy 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 never
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 hy an aura
of slow progression. The author has pointed out already
that it increases the severity of petit mal. In epileptics
who have a prolonged aura we may use nitrite-of-amyl
pearls, which consist in small glass bulbs containing a
few drops of the drug. As the aura comes on, the pa-
tient should break one of these in his handkerchief and
inhale the drug, thereb}^ putting aside the attack.
The influence which the drug exerts upon th0 brain
is secondary rather than primary, and is probably de-
pendent 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 very power-
ful spinal depressant. As its influence over unstriated
muscular fibre is very great, it affects the vasomotor
system 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 Epilepsy: its Pathology and Treatment,
hypothesis. Such reasoning is not, however, necessarily
correct. The writer is inclined to believe that the nitrite
of amyl puts 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 oxygenating blood
of the body into a non-oxygen-carrying fluid b^^ reason
of the nitrite-oxyhsemogiobin 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 may 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 absolutely 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 am^d does good by
flooding the brain with arterial blood. How such a
statement can be made by any one is amazing. Of all
the drugs in the world nitrite of amyl produces exactlj^
the opposite change, as Gowers should be aware from
his own use of the substance.
The use of anaesthetics in epilepsy 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 laryngeal spasm or cause lung compli-
cations. Further than this, if uraemia is the cause of
the fit, and this fact is unknown in every case until it is
examined, the ether may increase the inflammation of
the kidney very seriousl3\
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 s^^philis, when it is of the
greatest service. Indeed, the bromide and all other
drugs should be set aside, while it is pushed to tlie
utmost. As is well known, syphilitics usually bear the
drug extremel}^ well, and the writer knows of one in-
stance where no less than 800 grains were taken every
twenty-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 dow^n
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 everj^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 system.
Chloral hj^drate is a remedy which has been only
» L'Union Medicale, 1875, et Annales de Dermatol, et Sypliilog., 1880.
200 Epilepsy: its Pathology and Treatment.
parti}' tried in epileps}^, and its usefulness is not as yet
determined. It possesses the marked disadvantage, as
compared to the bromides, of being a very fatal poison,
w hich is an important fact to be borne in mind by the
physician 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 than manj^ other much more
lauded remedies, that it may be of value, since it exerts
its chief influence on the motor pathways 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, alwaj^s 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 liave reported cases which obtained very
marked relief from it, and more recent investigators
have done likewise. The author's experience with the
drug 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
had very marked mental failure, one of them being vir-
tually idiotic and a sufferer from two to six attacks
every day Bromides had lost power over them, and
' Rivista Sperimentale di Frenatria, fasc. i and ii, 1884.
Treatment. 201
antifebrin certainly acted most marvelousl}^ 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 very
useful, also, as has Leid}^,^ who found benefit produced
by the drug in 14 cases out of 26, and also that the drug
influenced more favorably still petit mal.
Bowsnyoi ^ treated 9 epileptics in this manner, using
doses ranging from 3 to 30 grains. He believes the drug
to be inferior to the bromides, both in its control of the
disease and in the depressant effects whicli it sometimes
produces. He found, however, that large doses gener-
ally controlled the attacks.
On the other hand, Salm,^ in Jolly's clinic in Stras-
burg, gave the drug in doses of from 1 to 3 grammes a
day, 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 system
is virtually identical with antifebrin. They will be
spoken of together.
Antipyrin was recommended by Lemoine,® in 1887,
in certain forms of epilepsy, but condemned in most
cases.
In those who suffer from menstrual epilepsy, 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.
2 N. Y. Med. Journal, vol. i, 1888.
^ Centralbl. f. d. Gesammte Therapie, March, 1888.
* Neurol. Centralblatt, 1887.
* Gazette Med. de Paris, December 24, 1887.
9*
202 Epilepsy : 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 frequently recurring epi-
leptic attacks the presence of worms should always be
looked for, and, when found, they should be expelled as
rapidly as possible. If they are the Oxyuris vei^micu-
lariSj 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 the 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, very
commonly, intense inflammation is here present, pro-
duced by migratory movements of rectal parasites. If
the quassia is unobtainable in any case, a saturated solu-
tion of chloride of sodium may be employed.
To complete the consideration of the treatment of
epilepsy, the writer must add the information which we
possess in regard to remedies which, while highl}^ rec-
ommended by one person, have been wholly or partly
found useless by the majority of the profession.
Foremost among such agents stands curare, a sub-
stance whose physiological 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 paralyzes the peripheral motor nerves in the muscles
long before it affects, to any extent, the rest of the or-
ganism, and it is evident that its anticonvulsive action
can only rest on the theory that it blocks the pathway
* Gazette Hebdomadaire, December 23, 1887.
Treatment, 203
to the muscles in such a way that the impulses cause no
contractions in them. Even supposing that curare could
be given in large enough dose to obtain a full physio-
logical effect, it could in no vv^ay prevent anything 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 A^ehement 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 1866, 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)
Voisin made a like assertion. Still more recently,
Bourneville and Bricon ^ have tried its anti-epileptic
virtues. They administered curare li3'podermically to
33 epileptics, but obtained only one cure (?), although in
some instances it was given for as long as six months at
a time, and they therefore believe curare virtually 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 ^ h}- po-
dermically with some good results, but 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 deutscli. Naturf. und Aerzte in Cassel.
2 Arch, de Neurologie, March, April, and May, 1886.
3 Berliner kiln. Wochenschrift, 1877, xiv, 185.
* Bull, de r Acad, de Med. de Belgique, 1880.
204 Ujnlepsy : its Pathology and Treatment.
and its use is still siibjudice in consequence. He found,
however, that the system became rapidly accustomed to
the drug, and that it could be increased day by day 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 by Wil-
dermuth,2 either in the form of the acid in water or,
more latterly, as the osmate of potassium, the dose be-
ing in twenty -four hours about ^ grain. In 10 old and
chronic cases he reached no result in 7 of them ; in 2
the attacks became less frequent, and one previousl}^
desperate case recovered. Three later cases gave in two
instances quite marked amelioration and in one case no
benefit.
The treatment of epilepsy 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 by 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 epilepsj^, 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
have tried it by placing a pole on the spine and one on
the vertex. Rockwell professes to have benefited cases
by this means, but it is extremely doubtful if his results
» Jour, de Med. et de Chirurgie prat., 1880, 214.
2 Bulletin Gen. de Therapeutique, October 25, 1884.
3 Epilepsy. London.
* Boston Med. and Surg. Journ., February 18,
Treatment. 205
were not due to coincidence or imagination. Electricity
resembles water in the law that it always travels in the
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 given 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 always 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 Sperimentale de Frenatria, f asc. i and ii, 1884.
^ Traite Therapeutique de Quinquina. Paris, 1855.
" Rev. des Sciences Med., 1873.
* Archiv f. Experimental Path, und Pliarm., xv, 278.
' Bulletin de 1' Acad, de Med., 1877.
206 Epilepsij : its Pathology and Treatment.
activity of the spinal cord, also, according to Seppilli,
increases the irritability of the cortex, and should be
employed 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 i
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 that cerebral anaemia pro-
duces epileptic attacks.
A very important point which is constantly brought
before the physician who is treating epilepsy 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, particularly in children.
Curiously enough, the influence of diet, in one research
covering a number of cases of chronic epilepsj^, seemed
to be of little moment. Thus, Merson^ examined 24
such cases, putting 12 of them on a purely vegetable
and 12 on a purely nitrogenous diet. The result, after
this had been continued for two months, was that the
vegetarians had had a few less fits than the others, but
the difference was so slight as to be almost of no weight
in determining the question. Some authors at the present
» Quoted by SeppiUi. ^ ji^i^^
' West Riding Lunatic Asylum Reports, 1875.
Treatment, 207
day believe this opinion as to the harmfulness of meats
to be erroneous.^
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 surgery 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 which 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 writer was greatly impressed by the fact
that his experimental investigations were ahvaj^s used
* Gowers, in his book on Epilepsy, is one of these.
208 Ujnlepsy: its Patlwlogy and Treatment.
for the furtherance of his professional work, and that
he represented, par excellence^ the logical ph^^sician 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 centurj^ 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 shaAdng the entire head, and tlien 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 where he has operated
on monke3'S without the spray death has occurred,
whereas where it has been used they invariably recover.
The dura is next laid aside in the form of a flap in mucli
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 by paralj^sis of the limb supi)lied by that area,
at least for a time. Care is also to be shown that no
part of the cortex at any time becomes dry, and if the
operation is prolonged the flaps should be now and
again laid over the part to moisten it. In some instances
the tumor or abscess is subcortical, rather than cortical,
and it becomes necessary for the operator to make either
exploratory incisions or digital examinations for it. The
haemorrhage from the brain is not so violent as might be
supposed, and can be controlled by compresses, or, where
large surface-vessels appear, by torsion or ligature.
Treatment. 209
The most troublesome oozing is from the cliploea, and
this may be stopped hy a mixture of bees-wax and gum-
benzoin, 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 3'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 epilepsy 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 If 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 remarkably well for two daj^s after
the operation. On the third day 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 again observed. There was also severe diarrhoea
and a temperature of 1041° y. The presence of pus
I*
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 tlie 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 they 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 svich cases are more fruitful
(62.5 per cent.) 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.
3 St. Bartholomew's Hosp. Rep., vol. xix.
3 Trans. Ninth. Internat. Med. Congress, 1887.
Treatment, 211
adopted by Alexander,^ an Englishman, 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,"
going down through the fascia between the anterior
scalenus and longus colli muscles, and in tying one
or both vertebral arteries at the sixth cervical verte-
brse. 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 paroxysm. 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.
2 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. Haclier, of Louisiana. Another case
is that performed by Holz at the request of Frank. *
All the American cases are recorded in McKinley's
paper, and in all of them the cure was accomplished.
Bacon^ has also very much more recently 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 epilepsy, in w^hom 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 by reason of the search for peripheral enemies of
health. No one can deny, however, that cases of reflex
* Praxes Medical Universal Preceptor, vol. ii, chap. xi.
2 Journal of Mental Science, Oct., 1880, p. 470.
8 Le Progres Medical, February 5, 1881.
Treatment. 213
character do exist, and that very frequently their re-
moval results in recover}^ 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. Yery 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 possessed 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 ordinary 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 epilepsy, and some surgeons
have gone so fo,r as to trephine in any case, hoping in
some indirect way 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 snrgery, bold thougli it
be ; for, unless some real reason for trephining exists,
the operation is too severe to be performed in the dark.
One ma}^ also mention here the treatment suggested
by Marshall Hall, namelj^, tracheotomy. Of course the
absolute uselessness of this operation as a cure for
epileps}^ is known to-day, 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 11 years, who
had been a confirmed epileptic for fifty-seven j^ears. He
worked at baskets for a living, and would often have as
many 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 go on
working till another came on. His w-ife 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 lie 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, 1^ 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 396,
and from 9 a.m. on this day to 9 a.m. on the 25th 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.
216 Epilepsy: its Pathology and Treatment,
Delasiauve^ has seen a single patient have 2500 fits
a month, and Althaus^ records the case of a bo}' who
had 1350 in the same space of time. Leszynskj^ 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; Uh
day, 21 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 very 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 epileptics in order to compare the death-
rate in this class with that of pure insanit}^, and he finds
that insane epileptics have a higher death rate, generally
dying at or before the age of 33 years. The causes of
these deaths, as enumerated by him, show that the
greater mortality depends on the accidents of the fit
than the disease itself, for coma due to asph^^xia 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 diflference in mortality between
epileptics in whom the disease had been acquired and '
* Traite de TEpilepsie, Lausanne.
2 Epilepsy, Hysteria, and Ataxia. London, 1866.
3 N. Y. Medical Journal, Mar. 21, 188.5, p. 321.
* Bourneville, Etat de mal Epileptique, 1873.
* Snell, Zeitscrift f. Psycliiatrie 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 much 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.
Periods.
Nerv. Dis.
of All ]
1838-42,
5,585
2.66
.32
1843-44,
....
1845-51,
8,667
3.62
.42
1852-56,
10,339
4.01
.49
1857-61,
11,689
4.31
.54
1862-66,
12,359
4.21
.51
1867-71,
12,290
3.98
.49
3.86
.47
30 years. 60,929
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 A^ery low, and which have been given in
this essay 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., 1H78, to Sept., 1879.
*De I'Epilepsie consideree dans ses Rapports avec 1' Alienation mentale.
' Nervous Diseases, p. 222. London.
* Med. Record, 1888, 33, 4G7 ; also see Ahstract 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
twenty-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 latter figure. This is a
much larger number than the total death-rate of the in-
dividual as3dums, and shows, therefore, that not only is
epilepsy 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 as^dums
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 liand, if it were true that epilepsy is so fatal, it is
remarkable that so few deaths occur in the ordinary
practice of the average physician and neurologist.
The cause most commonly producing death, other
than traumatisms, is, according to Leszynskj^,^ 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 Meynne^
in Belgium. Lunier draws his results from the men
» N. Y. Med. Journal, 1885, Mar. 21, p.321.
2 Annales Med. Psychologique, March to November, 1881.
3 Zeitschrif t f . Psychiatrie, Bd. XI, Heft. 4.
* Centralblatt f. Nervenheilkunde, September 5, 1882.
^ Topographie Med. de la Belgique, Bruxelle, 1865, p. 101.
Proportion of Epileptics to Population. 219
examined for the conscription, of wliom 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 j^ears of age ; so Lunier
has endeavored to eliminate this source of error, and as
a result puts the jjroportion at 16.44 in every 10,000
between the ages of 10 and 40 years.
The census made by 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
ma}^ arise in epilepsy really belong to two separate
* Mentally unsound equals insane or idiotic.
' Topographic Med. de la Belgique, Bruxelle, 1865.
* Handbuch f. Geograph. und Historisclie Pathologie.
220 Epilepsy: its Pathology and Treatment,
classes, immely, 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 variety 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 an3^thing
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 that 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 than would appear at first glance, for even if the
fits are not very frequent they are almost sure to cause
a fresh solution of continuity, 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 vf hen ever a fit seems immi-
nent, but this is hardly practicable in most cases. It is
Complications, 221
unnecessary 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 may occur, due to the
sudden strain upon the cerebral blood-vessels during the
fit, and if the coma following an attack is prolonged or
peculiar this fact should be called to mind. The
inequality 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 paralj^sis lias already been dis-
cussed, under the heading of After-Symptoms. 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 pregnancy 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 Salpetri^re and the
Bicetre, and he reaches the following conclusions : —
1. Intercurrent diseases have in the greater number
of cases a favorable influence on epilepsy.
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 Tarmee. 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 84
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 31
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 aurse 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
Clitoridectomy 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 diagnosis oftrue epilepsy fromalcoholic epilepsy 174
from attacks of malingerers 175
from hemicrania 174
from hystero-epilepsy 165
from petit mal . 173
from puerperal eclampsia 171
from syncope 174
from syphilitic epilepsy 172
from uraemic 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
pleuritique 132
Epilepsy, alcoholic 89
cardiac * 82
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 73
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
uraemic 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 faeces during attack 12-72
Influence of acute disease on epilepsy 222
of age on epilepsy 109
of barometric changes on epilepsy • . . 137
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
pathology of . . 161
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-stretching as a cure for epilepsy 212
Nervous irritation as a cause for epilepsy 143
Night terrors 81
Nitrate of amyl, uses of 197
of silver, uses of 196
Nitro-glycerin, uses of ... 197
Nocturnal epilepsy 73
Number of epileptic fits 215
Olfactory aurse 18
Oophorectomy as a cure for epilepsy 213
Operative treatment 207
Optical aursB 17
Organic epilepsy . 2
Origin of aura 14
Osmic acid, uses of 204
Paralysis following convulsion 29
Pathology of epilepsy . 138
of epileptiform migraine 161
of plumbic epilepsy ; 161
of syphilitic epilepsy 160
Petit mal 69
after-symptoms of 72
table of characteristics of 71
Phthisis as a cause of epilepsy 103
Physiology of epilepsy 138
Physiognomy of epileptics 138
Picrotoxine, uses of . 204
Post-convulsive paralysis 29
Post-hemiplegic epilepsy 79
Precursory symptoms other than aurae 21
tables of 22
Prognosis of epilepsy 179
Proportion of epileptics to population 219
Psychic epilepsy , 60
Psychical aura 19
Pupil during attack 24
Quassia, uses of 202
Reflex epilepsy 115
from adherent prepuce 118
from carious teeth 126
from cicatrix 115
from ear-diseases 124
from eye-strain 124
from gall-stones 126
from hernial truss 126
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 epilepsy 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
prsecordial 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 hystero-epilepsy 168
of precursory symptoms 22
Time of attack 27
Toxsemic epilepsy 89-128
Tracheotomy 214
Treatment of epilepsy 182
Trephining 210-213
Ursemic epilepsy 128
Urinary incontinence in petit mal . 72
Yenery as a cure for epilepsy 5
Voluminous state 19
Zinc, uses of 196
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But one color of ink necessaiy. Designed for the Convenient,
Accurate, and Permanent Daily Recording of Cases in Hospital and
Private Practice. By Harvey B. Bashore, M.D. Fifty Charts, in
Tablet Form. Size, 8x12 inches.
Price, in United States and Canada, post-paid, 50 cents, net ;
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BOWEN— Hand-Book of Materia Medica, Pharmacy,
and Therapeutics.
By CuTHBERT BowEN, M.D., B.A., Editor of "Notes on
Practice/^ One 12mo volume of 370 pages. Handsomely Bound in
Dark-Blue Cloth. No. 2 m the Physicians^ and Students^ Beady-Bef-
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Price, in United States and Canada, post-paid, $11.40, net ;
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BURET— Syphilis: To-Day and in Antiquity.
By Dr. F. Buret (Paris). Translated from the French, with the
author^s permission, by A. H. Ohmann-Dxjmesnil, A.M., M.D., Pro-
fessor of Dermatology and Syphilology in the St. Louis College of
Physicians and Surgeons. To be completed in three 12mo. volumes.
Volume I, Syphilis in Antiquity. In Press.
CAPP — The Daughter. Her Health, Education, and
Wedlock. Homely Suggestions to Mothers and
Daughters.
By William M. Capp, M.D., Philadelphia. This is just such a
book as a family physician would advise his lady patients to obtain
and read. It answers many questions which every busy practitioner
of medicine has put to him in the sick-room at a time when it is
neither expedient nor wise to impart the information sought.
It will not mar the most proper womanly modesty or refined
feelings, and may wisely be put into the hands of any woman or girl ;
is a book for the family ; will bear repeated readings, and will be useful
to refer to in emergencies. In one beautifully printed (large, clear
type) 12mo volume of 150 pages. Attractively bound in Extra Cloth.
Price, in United States and Canada, post-paid, ^1.00, net ;
Great Britain, 5s. 6d. ; France, 6 fr. ao.
CATHELL — Book on the Physician Himself, and Things
that Concern His Reputation and Success.
By D. W. Cathell, M.D., Baltimore, Md. Being the Ninth
Edition (enlarged and thoroughly revised) of "The Physician Him-
jP. a, Davis^ Philadelphia^ Pa.
self, and What He Should Add to His Scientific Acquirements in Order
to Secure Success/' In one handsome Octavo volume of 29S pages,
bound in Extra Cloth.
Price, in United States and Canada, post-paid, $3.00, net;
Great Britain, lis. 6d. ; France, 13 fr. 40.
This remarkable book has passed through eight (8) editions in
less than five years, has met with the unanimous and hearty approval
of the profession, and is practically indispensable to every young
graduate who aims at success in his chosen profession. It has just
undergone a thorough revision by the author, who has added much
new matter, covering many points and elucidating many excellent
ideas not included in former editions.
CLEVENGER — Spinal Concussion- Surgically Consid-
ered as a Cause of Spinal Injury^ and Neurologi-
cally Restricted to a Certain Symptom Group, for
which is Suggested the Designation ''Erichsen^s
Disease, ^^ as One Form of the Traumatic Neuroses,
By S. V. Clevenger, M.D., Consulting Physician, Reese and
Alexian Hospitals; Late Pathologist, County Insane Asylum, Chicago;
Member of numerous American Scientific and Medical Societies; Col-
laborator American Naturalist, Alienist, and Neurologist, Journal of
Neurology and Psychiatry, Journal of Nervous and Mental Diseases;
Author of '^ Comparative Physiology and Psychology, '' etc.
For more than twenty years this subject has occasioned bitter con-
tention in law courts between physicians as well as attorneys, and in that
time no work has appeared that reviewed the entire field judicially
until Dr. Clevenger's book was written. It is the outcome of five
years' special study and experience in legal circles, clinics, hospital
and private practice, in addition to twenty years' labor as a scientific
student, writer, and teacher. Every Physician and Lawyer should own
this work. In one handsome Royal Octavo volume of nearly 400 pages,
with 30 Wood-Engravings.
Price, in United States and Canada, post-paid, $S.50, net;
Great Britain, 14s. ; France, 15 fr.
DAVIS— Consumption : How to Prevent it, and How to
* Live with it. Its Nature, Causes, Prevention, and
the Mode of Life, Climate, Exercise, Food and
Clothing Necessary for its Cure,
By N. S. Davis, Jr., A.M , M.D., Professor of Principles and
Practice of Medicine in Chicago Medical College ; Physician to Mercy
Hospital; Member of the American Medical Association, Illinois
State Medical Society, etc., etc. 12mo, In Press.
Catalogue of Medical Publications.
DAVIS— Diseases of the Heart, Lungs, and Kidneys.
By N. S. Davis, Jr., A.M.,M.D., Professor of Principles and
Practice of Medicine in the Cbicago Medical College, Chicago, 111.,
etc. In one neat 12mo volume. Ko. ■ in the Physicians^ and Students^
Beadij-Beference Series. In Preparation.
DEMARQU AY— Essay on Medical Pneumatology and
Aerotherapy. A Practical Investigation of the Clini-
cal and Therapeutic Value of the Gases in Medical
and Surgical Practice^ ivith JEJ special Reference to
the Value and Availability of Oxygen^ Nitrogen.,
Hydrogen^ and Nitrogen Monoxide,
By J. N. Demarquay, Surgeon to the Municipal Hospital, Paris,
and of the Council of State; Member of the Imperial Society of Sur-
gery; Correspondent of the Academies of Belgium, Turin, Munich,
etc. ; Officer of the Legion of Honor ; Chevalier of the Orders of Isa-
bella-the-Catholic and of the Conception, of Portugal, etc. Translated,
with notes, additions, and omissions, by Samuel S. Wallian, A.M.,
M.D., Member of the American Medical Association ; Ex-President of
the Medical Association of Northern New York ; Member of the New
York County Medical Society, etc. In one handsome Octavo volume
of 316 pages, printed on fine paper, in the Best Style of the Printer's
Art, and Illustrated with 21 Wood-Cuts.
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net; Half-Russia, ^3.00, net. Great Britain, Clotli, lis.
6d. ; Half-Russia, 17s. France, Cloth, 13 fr. 40; Half-
Russia, 18 fr. 60.
EDINGER—Twelve Lectures on the Structure of the
Central Nervous System. For Physicians and
Students.
By Dr. Ludwig- Edingee, Frankfort-on-the-Main . Second Re-
vised Edition. With 133 illustrations. Translated by Willis Hall
ViTTUM, M.D., St. Paul, Minn. Edited by C. Eugene Riggs, A.M.,
M.D., Professor of Mental and Nervous Diseases, University of Minne-
sota ; Member of the American Neurological Association. The illus-
trations are exactly the same as those used in the latest German
edition (with the German names translated into English), and are.
very satisfactory to the Physician and Student using the book. The
work is complete in one Royal- Octavo volume of about 250 pages,
bound in Extra Cloth.
Price, in tJnited States and Canada, post-paid, S1.T5, net ;
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F, A, Davis^ Philadelphia^ Fa,
EISENBERG— Bacteriological Diagnosis. Tabular Aids
for Use in Practical Work.
By James Eisenberg, Ph.D., M.D., Vienna. Translated and
augmented, with the permission of the author, from the latest Grerman
Edition, by Norval H. Pierce, M.D., Surgeon to the Out-Door
Department of Michael Reese Hospital ; Assistant to Surgical Clinic,
College of Physicians and Surgeons, Chicago, 111, In one Octavo
volume, handsomely bound in Cloth. In Press.
GOODELL — Lessons in Gynaecology.
By William Goodell, A.M., M.D., etc.. Professor of Clinical
Gynaecology in the University of Pennsylvania. With 112 illustra-
tions. Third Edition, thoroughly revised and greatly enlarged. One
volume, large Octavo, 578 pages.
Price, in United States and Canada, Cloth, S5.00 ; Full
Sheep, S&6.00. Discount, 30 per cent., makings it, net,
Cloth, ^4.00; Sheep, ^4.80. Postage, 27 cents extra.
Oreat Britain, Cloth, 22s, 6d. ; Sheep, 38s. France, 30
fr. 80.
This exceedingly valuable work, from one of the most eminent
specialists and teachers in gynaecology in the United States, is now
offered to the profession in a much more complete condition than
either of the previous editions. It embraces all the more important
diseases and the principal operations in the field of gynaecology, and
brings to bear upon them all the extensive practical experience and
wide reading of the author. It is an indispensable guide to every
practitioner who has to do with the diseases peculiar to women.
GUERNSEY— Plain Talks on Avoided Subjects.
By Henry N. Guernsey, M.D., formerly Professor of Materia
Medica and Institutes in the Hahnemann Medical College of Philadel-
phia; Author of Guernsey's "Obstetrics,'' including the Disorders
Peculiar to Women and Young Children ; Lectures on Materia Medica,
etc. The following Table of Contents shows the scope of the book : —
Contents.— Chapter I. Introductory. II. The Infant. III.
Childhood. IV. Adolescence of the Male. V. Adolescence of the
Female. VI. Marriage: The Husband. VII. The Wife. VIII. Hus-
band and Wife. IX. To the Unfortunate. X. Origin of the Sex. In
one neat 16mo volume, bound in Extra Cloth.
Price, in United States and Canada, post-paid, $1.00 ; Great
Britain, 6s. 6d. ; France, 6 fr. 30.
HARE — Epilepsy : its Pathology and Treatment. Being
an Essay to which was Awarded a Prize of Four
Thousand Francs by the Academic Royal de Mede-
cine de Belgique, December 81^ 1889.
By HoBART Amort Hare, M.D. (University of Pennsylva-
nia), B.Sc, Clinical Professor of the Diseases of Children, and
Demonstrator of Therapeutics in the University of Pennsylvania;
Catalogue of Medical Publications.
Laureate of the Royal Academy of Medicine in Belgium, of the
Medical Society of London, etc. 12mo. 228 pages. Neatly bound in
Dark-blue Cloth. No. 7 in the Physicians^ and Students^ Beady-Befer-
ence Seiies.
Price, in United States and Canada, post-paid, $1.^5, net;
Great Britain, 6s. 6d. ; France, 7 fr. 75.
''This little work is an admirably con-
densed statement of the clearest authen-
ticated facts on this subject known. The
author is evidently a rnaster in the art
of clear, condensed statements of what
is known, and he could do a great ser-
vice to science by 'boiling down* some
of the thousand-page volumes that are
coming from the press. This work is
of great value to all physicians who
wish to have the facts concerning epi-
lepsy in the most available form." —
Quarterly jfournal of Inebriety.
" It is representative of the most ad-
vanced views of the profession, and the
subject is pruned of the vast amount of
superstition and nonsense that generally
obtains in connection with epilepsy." —
Medical Age.
HARE — Fever : its Pathology and Treatment. Being
the BoyUton Prize Essay of Harvard Univey^-
sity for 1890 ; containing Directions and the Latest
Information Concerning the Use of the So- Called
Antipyretics in Fever and Pain, ■»
By HoBART Amory Hare, M.D. (University of Pennsyl-
vania), B.Sc, Clinical Professor of the Diseases of Children and
Demonstrator of Therapeutics in the 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; Member of the Asso-
ciation of American Physicians, etc. Illustrated with more than 25
new plates of tracings of various fever cases, showing beautifully and
accurately the action of the antipyretics. The work also contains
85 carefully-prepared statistical tables of 249 cases, showing the un-
toward effects of the antipyretics. 12mo. Neatly bound in Dark-
Blue Cloth. No. 10 in the Fhysicians^ and Students^ Beady -Beference
Series.
Price, in United States and Canada, post-paid, $1.35, net;
Great Britain, 6s. 6d. ; France, 7 fr. 75.
JAMES — American Resorts, with Notes upon Their
Climate.
By BusHROD W. James, A.M., M.D. , Member of the American
Association for the Advancement of Science, the American Public
Health Association, the Pennsylvania Historical Society, the Franklin
Institute, and the Academy of Natural Sciences, Philadelphia; the
Society of Alaskan Natural History and Ethnology, Sitka, Alaska,
etc. With a translation from the German, by Mr. S. Kauffmann,
of those chapters of "Die Klimate der Erde," written by Dr. A. Woe-
IKOF, of St. Petersburg, Russia, that relate to North and South Ameri-
ca, and the islands and oceans contiguous thereto. In one Octavo
volume, handsomely bound in Cloth. Nearly 300 pages.
Price, in United States and Canada, post-paid, $2.00, net;
Great Britain, lis. 6. ; France, 18 fr. 40.
F, A, Davis^ Philadelphia^ Pa, 7
KEATING— Record-Book of Medical Examinations for
Life-insurance.
Designed by John M. Keating, M.D. This record-book is small,
neat, and complete, and embraces all the principal points that are
required by the different companies. It is made in two sizes, viz. :
No. 1, covering: one hundred (100) examinations, and No. 2, covering
two hundred (200) examinations. The size of the book is 7 x ^%
inches, and can be conveniently carried in the pocket.
Prices, post-paid: No. 1, for 100 Examinations, bound in
Cloth, United States and Canada, 50 Cents, net ; Oreat
Britain, 3s. 6d. ; France, 3 fr. 60. No. 2, for »00 Ex-
aminations, bound in Full liCatlier, with Side-Flap,
United States and Canada, .**1.00, net; Great Britain,
6s. 6d.; France, 6 fr 20.
KEATING AND EDWARDS -Diseases of the Heart
and Circulation in Infancy and Adolescence. With
an Appendix entitled ''^ Clinic at Studies on the
Pulse in Childhood,''''
By John M. Keating, M.D., Obstetrician to the Philadelphia
Hospital and Lecturer on Diseases of Women and Children ; Surgeon
to the Maternity Hospital ; Physician to St. Joseph's Hospital; Fellow
of the College of Physicians of Philadelphia, etc. ; and William A.
Edwards, M.D., formerly Instructor in Clinical Medicine and Physi-
cian to the Medical Dispensary in the University of Pennsylvania;
Physician to St. Joseph's Hospital ; Fellow of the College of Physi-
cians ; formerly Assistant Pathologist to the Philadelphia Hospital, etc.
Blustrated by Photographs and Wood-Engravings. About 225 pages.
8vo. Bound in Cloth.
Price, in United States and Canada, post-paid, $1.50, net ;
Great Britain, 8s. 6d. ; France, 9 fr. 35.
KELLER— Perpetual Clinical Index to Materia Medica,
Chemistry, and Pharmacy Charts.
By A. H. Keller, Ph.G., M.D., consisting of (1) the " Perpetual
Clinical Index, ^^ an oblong volume, 9x6 inches, neatly bound in Extra
Cloth ; (2) a Chart of " Materia Medica,'^ 32 x 44 inches, mounted on
muslin, with rollers; (3) a Chart of " Chemistry and Pharmacy,''
32 x 44 inches, mounted on muslin, with rollers.
Price for the Complete "Work, United States, ^5.00 net ; Canada
(duty paid) $5.50, net ; Great Britain, 38s. ; France, 30 fr. 30.
LIEBIG and ROME— Practical Electricity in Medicine
and Surgery.
By G. A. LiEBia, Jr., Ph.D., Assistant in Electricity, Johns Hop-
kins University; Lecturer on Medical Electricity, College of Phy-
sicians and Surgeons, Baltimore ; Member of the American Institute
Catalogue of Medical Fublications.
of Electrical Engineers, etc. ; and George H, Rohe, M.D., Professor
of Obstetrics and Hygiene, College of Physicians a*nd Surgeons, Balti-
more ; Visiting Physician to Bay View and City Hospitals; Director
of the Maryland Maternite; Associate Editor "Annual of the Uni-
versal Medical Sciences,'^ etc. Profusely Hlustrated by Wood-Engrav-
ings and Original Diagrams, and published in one handsome Royal
Octavo volume of 383 pages, bound in Extra Cloth.
Price, in United States and Canada, post-paid, S^.OO, net;
Great Britain, lis. 6d. ; France, 13 fr. 40.
The constantly increasing demand for this work attests its thorough
reliability and its popularity with the profession, and points to the
fact that it is already the standard work on this very impoi'tant sub-
ject. 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 Pi-inciples and Practice of Electrical Measurement
in their Relations to Medical Practice. Professor Rohe, who 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, etc., etc.
MANTON— Childbed ; its Management; Diseases and
their Treatment.
By Walter P. Manton, M.D., Visiting Physician to the De-
troit 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. Ao. m the Phy-
sicians^ and Students^ Beady-Reference Series. In Preparation.
MASSEY — Electri3ity in the Diseases of Women. With
Special Reference to the Application of Strong
Currents.
By G. Betton Massey, M.D.,- Physician to the Gynaecological
Department of the Howard Hospital; Late Electro-Therapeutist to the
Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases;
Member of the American Neurological Association, of the Philadel-
phia Neurological Society, of the Franklin Institute, etc. Second
Edition. Revised and enlarged. With New and Original Wood-
Engravins^s. Handsomely bound in Dark-Blue Cloth. 2^1:0 pages.
12mo. No. 5 in the Physicians' and Students' Beady- Reference Series.
Price, in United States and Canada, post-paid, SI. 50, net;
Great Britain, 8s. 6d. ; France, 9 fr. 35.
F. A. Davis, Philadelphia, Pa.
9
" A new edition of this practical
manual attests the utility of its exist-
ence and the recognition of its merit.
The directions are simple, easy to fol-
low and to put into practice, the ground
is well covered, and nothing is assumed,
the entire book being the record of ex-
perience."— Journal of Nervous and
Mental Diseases.
"It is only a few months since we
noticed the first edition of this little
book ; and it is only necessary to add
now that we consider it the best treatise
on this subject we have seen, and that
the improvements introduced into this
edition make it more valuable still." —
Boston Medical and Surgical jfourn.
"The style is clear, but condensed.
Useless details are omitted, the reports
of cases being pruned of all irrelevant
material. The book is an exceedingly
valuable one, and represents an amount
of study and experience which is only
appreciated after a careful reading." —
Medical Record,
MEARS — Practical Surgery.
By J. EwiNa Mea«s, M.D., Lecturer on Practical Surgery and
Demonstrator of Surgery in Jefferson Medical College; Professor of
Anatomy and Clinical Surgery in the Pennsylvania College of Dental
Surgery, etc. Third Edition. Revised and Enlarged. In Prep-
aration.
Medical Bulletin Visiting List, op Physicians' Call
Record, Arranged upon an Original and Con-
venient Monthly and Weekly Plan for the Daily
Recording of Professional Visits,
This is, beyond question, the best and most convenient time- and
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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,
4 X 6X inches. In three styles. Send for Descriptive Circular.
Net Price, post-paid ; No. 1, Regular Size, for 70 patients
daily each month for one year, United States and Canada,
^1,25; France, 7 fr. 75. No. 2, Large Size, for 105
patients daily each month for one year. United States and
Canada, $1.50; France, 9 fr. 35. No. 3, in which "The
Blanks for Recording Visits in" are in six (6) removahle
sections, United States and Canada, $1.75 ; France, 12
fr. 80.
Special Edition for Great Britain only, 4s, 6d,
MICHENER— Hand-Book of Eclampsia; or, Notes and
Gases of Puerperal Convulsions,
By E. MiCHENEE, M.D. ; J. H. Stubbs, M.D. ; R. B. Ewing,
M.D.; B. Thompson, M.D.; S. Stebbins, M.D. 16mo. Cloth.
Price, 60 cents* net ; Great Britain, 4s« 6d. ; France* 4 fr. 20,
10 Catalogue of Medical Fublications,
NISSEN— A Manual of Instruction for Giving Swedish
Movement and Massage Treatment.
By Prof. Hartvig Nissen, Director of the Swedish Health In-
stitute, Washington, D.C. ; late Instructor in Physical Culture and
Gymnastics 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, in United States and Canada, post-paid, $1.00, net;
Great Britain, 6s. ; France, 6 fr. 20.
Physicians' All-Requisite Time- and Labor- Saving
Account- Book. Being a Ledger and Account-Book
for Physicians^ Use, Meeting all the Requirements
of the Law 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 your 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.
Prices, Shipping Expenses Prepaid : No. 1, 300 Pages, for
900 Accounts per Year, Size 10 x 13, Bound in ^-Kussia,
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per Year, Size 10 x 13, Bound in sJ-Kussia, Baised Back-
Bands, Clotli Sides, in United States, ^8.00 ; Canada (duty
paid), ^8.80^ net; Oreat Britain, 43s.; 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, being an excellent teacher in
those languages, and who has also had considerable hospital experience.
Bound in full Russia Leather, for carrying in the pocket. Size, 5 x 2^
inches. 206 pages.
Price, in United States and Canada, post-paid, $1.00, net ;
Great Britain, 6s. ; France, 6 fr. 30.
F A. Davis, Philadelphia, Pa. 11
PRICE AND EAGLETON— Three Charts of the Nervo-
Vascular System. Part I. — The Nerves, Part II,
— The Arteries, Part III, — The Veins,
A New edition, Revised and Perfected. Arranged by W. Henry
Price, M.D., and S. Potts Eagleton, M.D. Endorsed by leading
Anatomists. *' The Nervo- Vascular System of Charts'' far excels
every other system in their completeness, compactness, and accuracy.
Clearly and beautifully printed upon extra-durable paper. Each chart
measures 19 x 24 inches.
Price, in the United States and Canada, post-paid, 50 cents, net.
Complete ; Great Britain, 3s. 6d. ; France, 3 fr. 60.
PURDY — Diabetes: its Cause, Symptoms, and Treat-
ment.
By Chas. W. Purdt, M.D. (Queen's University), Honorary
Fellow of the Koyal College of Physicians and Surgeons of Kingston ;
Member of the College of Physicians and Surgeons of Ontario ; Author
of " Bright's Disease and Allied Affections of the Kidneys ; '^ 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.
Handsomely bound in Dark-Blue Cloth. No. 8 in the Physicians' and
Shcde7its' Ready -Reference series.
Price, United States and Canada, 851.35, net ; Great Britain,
6s. 6d. ; France, 7 fr. T5 ; post-paid.
REJVIONDIIMO— Circumcision: its History, Modes of
Operation, etc. From the Earliest Times to the
Present ; with a History of Eunuchism, Hermaphro-
dism, etc,, as Observed Among All Races and Nations ;
also a Description of the Different Operative Methods
. of Modern Surgery Practiced upon the Prepuce,
By P. C. Remondino, M.D. (Jefferson) ; Member of the Ameri-
can Medical Association ; Member of the American Public Health
Association; Member of the State Medical Society of California, and
of the Southern California Medical Society. In Press. Nearly
Ready. No. 11 in the Physicians' and Students' Ready-Reference Series,
ROHE — Text-Book of Hygiene. A Comprehensive
Treatise on the Principles and Practice of Pre-
ventive Medicine from an American Stand-point.
By George H. Rohe, M.D., Professor of Obstetrics and Hygiene
in the College of Physicians and Surgeons, Baltimore ; Member of the
American Public Health Association, etc.
12 Catalogue of Medical Publications,
Secot^d Edition, thoroughly revised and largely rewritten, with
many illustrations and valuable tables. In one handsome Royal
Octavo volume of over 400 pages, bound in Extra Cloth.
Price, United States^ post-paid, S2.50, net ; Canada (duty paid)
8g3.75, net ; Great Britain, 14s. ; France, 16 fr. 30,
Every Sanitarian should have Rohe^s " Text-Book of Hygiene ^' as
a work of reference. Of this new (second) edition, one of the best
qualified judges, namely, Albert L. Gihon, M.D., Medical Director of
U. S. Navy, in charge of U. S. Naval Hospital, Brooklyn, N. Y., and
ex-President of the American Public Health Association, writes : " It
is the most admirable, concise rhumk of the facts of Hygiene with
which I am acquainted. Professor Rohe^s attractive style makes the
book so readable that no better presentation of the important place of
Preventive Medicine, among their studies, can be desired for the
younger members, especially ^ of our profession/'
SAJOUS— Hay Fever and its Successful Treatment by
Superficial Organic Alteration of the Nasal Mucous
Membrane.
By Charles E. Sajous, M.D., formerly Lecturer on Rhinology
and Laryngology in Jefl[erson Medical College ; Vice-President of the
American Laryngological Association ; Officer 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, in United States and Canada, Sl.OO, net; Great
Britain, 6s. ; France, 6 fr. 30.
SANNE— Diphtheria, Croup: Tracheotomy and Intuba-
tion.
From the French of A. Sanne. 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 will aid in preventive measures,
stimulate promptness in the application of and efficiency in treatment,
and moderate the extravagant views which have been entertained re-
garding certain specifics in the disease diphtheria.
A full Index accompanies the enlarged volume, also a list of
authors, making, altogether, a very handsome Illustrated volume
of over 680 pages.
Price, United States, post-paid. Cloth, $4.00 , 1/eather, $5.00.
Canada (duty paid). Cloth, $4.40 ; I^eather, $5.50, net.
Great Britain, Cloth, 33s. 6d. ; L.eather, 38s. France,
Cloth, 34 fr. 60 ; Leather, 30 fr. 30.
F. A, Davis ^ Philadelphia^ Pa, 13
SENN— Principles of Surgery.
By N. Senn, M.D. , Ph.D., Professor of Principles of Surgery and
Surgical Pathology in Rush Medical College, Chicago. 111.; Professor
of Surgery in the Chicago Polyclinic; Attending Surgeon to the Mil-
waukee Hospital ; Consulting Surgeon to the Milwaukee County Hos-
pital and to the Milwaukee County Insane Asylum.
In one handsome Royal Octavo volume, with 109 fine Wood-En-
gravings and 624 pages.
Price, in United States, Cloth, §84. 50 ; Sheep or Half-Russia,
JS5.50, net. Canada (duty paid). Cloth, ^5.00; Sheep or
Half-Kussia, 886.10, net; Great Britain, Cloth, 34s. 6d. ;
Sheep or Half-Kussia, 30s. France, Cloth, 37 fr. 30;
Sheep or Halt-Russia, 33 fr. 10.
This work, by one of America's greatest surgeons, is thoroughly
COMPLETE ; its clearness and brevity of statement are among its con-
spicuous merits. The author's long, able, and conscientious researches
in every direction in this important field are a guarantee of unusual
trustworthiness, that every branch of the subject is treated authorita-
tively and in such a manner as to bring the greatest gain in knowledge
to the Practitioner and Student. Physicians and Surgeons alike should
not deprive themselves of this very important work.
A critical examination of the Wood-Engravings (109 in oiumber) loill
reveal the fact that they are thoroughly accurate and produced by the best
artistic ability.
Stephen Smith, M.D., Professor of
Ch'nical Surgery in Medical Department
of University of the City of New York,
writes: "I have examined the work
with great satisfaction, and regard it as
a most valuable addition to American
Surgical literature. There has long
been great need of a work on the prin-
ciples of Surgery which would fully
illustrate the present advanced state of
knowledge of the various subjects em-
braced in this volume. The work seems
to me to meet this want admirably."
'' The achievements of Modern Sur-
gery are akin to the marvelous, and Dr.
Senn has set forth the principles of the
science with a completeness that seems
to leave nothing further to be said until
new discoveries are made. The work
is systematic and compact, without a
fact omitted or a sentence too much,
and it not only makes instructive but
fascinating reading. A conspicuous
merit of Senn's work is his method, his
persistent and tireless search through
original investigations for additions to
knowledge, and the practical character
of his discoveries. This combination
of the discoverer and the practical man
gives a special value to all his work,
and is one of the secrets of his fame.
No physician, in any line of practice,
can afford to be without Senn's ' Prin-
ciples of Surgery.' " — T/ie Review of
Insanity and Nervous Diseases.
SHOEMAKER— Heredity, Health, and Personal Beauty.
Including the Selection of the Best Cosmetics for
the Skin J Hair^ Nails .^ and All Parts Belating to the
Body,
By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and
Clinical Professor of Diseases of the Skin in the Medico-Chirurgical
College of Philadelphia; Physician to the Medico-Chirurgical Hos-
pital, etc., etc. This is just the book to place en the ivaiting-room table
of every physician J and a work that will prove useful in tlie hands of your
patiefits.
14 Catalogue of Medical Publications,
The health of the skin and hair, and how to promote them, are
discussed ; the treatment of the nails ; the subjects of ventilation,
food, clothing, warmth, bathing; the circulation of the blood, diges-
tion, ventilation ; in fact, all that in daily life conduces to the well-
being of the body and refinement is duly enlarged upon. To these
stores of popular information is added a list of the best medicated
soaps and toilet soaps, and a whole chapter of the work is devoted to
household remedies.
The work is largely suggestive, and gives wise and timely advice
as to when a physician should be consulted.
Complete in one handsome Royal Octavo volume of 425 pages,
beautifully and clearly printed, and bound in Extra Cloth, Beveled
Edges, with side and back gilt stamps and Half-Morocco Gilt Top.
Price, in United States, post-paid, Cloth, $S.50 ; Half-
Morocco, ^3.50 net. Canada (duty paid), Clotli, «3.75;
Half-Morocco, $3.90, net. Great Britain, Cloth, 14s.;
Half-Morocco, 19s. 6d. France, Cloth, 15 fr. ; Half-
Morocco, 33 fr.
SHOEMIAKER— Materia Medica and Therapeutics. With
Especial Beference to the Clinical Application of
Drugs,
Being the second and last volume of a treatise on Materia Medica,
Pharmacology, and Therapeutics, and an independent volume upon
drugs.
By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and
Clinical Professor of Diseases of the Skin in the Medico Chirurgical
College of Philadelphia ; Physician to the Medico-Chirurgical Hos-
pital, etc. ,etc.
This is the long-looked-for second volume of Shoemaker's Materia
Medica, Pharmacology, and Therapeutics. It is wholly taken up with
the consideration of drugs, each remedy being studied from three
points of view, viz. : the Preparations, or Materia Medica; the
Physiology and Toxicology, or Pharmacology ; and, lastly , its Therapy.
Dr. Shoemaker has finally brought the work to completion, and now
this second volume is ready for delivery. It Is thoroughly abreast of
the progress of Therapeutic Science, and is really an indispensable
book to every student and practitioner of medicine. Royal Octavo,
about 675 pages. Thoroughly and carefully indexed.
Price, in United States, post-paid, Cloth, ^3.50; Sheep, $4.50,
net. Canada (duty paid). Cloth, S4.00 ; Sheep, $5.00,
net. Great Britain, Cloth, 30s.; Sheep, 36s. France,
Cloth, 33 fr. 40 ; Sheep, 38 fr. 60.
The first volume of this work is devoted to Pharmacy, General
Pharmacology, and Therapeutics, and remedial agents not properly
classed with drugs. Royal Octavo, 353 pages. Price of Volume I,
post-paid, in United States, Cloth, $2.50,' net; Sheep, $3.25, net.
Canada, duty paid. Cloth, $2.75, net ; Sheep, $3.60, net. Great Britain,
Cloth, 14s., Sheep, 18s. France, Cloth, 16 fr. 20; Sheep, 20 fr. 20.
The volumes are sold separately.
F, A, Davis ^ Philadelphia^ Pa,
15
SHOEMAKER— Ointments and Oleates, Especially In
Diseases of the Skin.
By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and
Clinical Professor of Diseases of the Skin in the Medico-Chirurgical
College of Philadelphia, etc., etc. Second Edition, revised and en-
larged. 298 pages. 12mo. Neatly bound in Dark-Blue Cloth. No. 6
in the Physicians^ and Students^ Beady-Reference Series.
Price, in United States and Canada, post-paid, $1.50, net ;
Great Britain, 8s. 6d. ; France, 9 fr. 35.
The author concisely concludes his preface as follows: "The
reader may thus obtain a conspectus of the whole subject of inunction
as it exists to-day in the civilized world. In all cases the mode of
preparation is given, and the therapeutical application described
seriatim^ in so far as may be done without needless repetition.''
It !s invaluable as a ready reference
when ointments or oleates are to be
used, and is serviceable to both druggist
and physician, — Canada Medical Rec-
ord.
To the physician who feels uncertain
as to the best form in which to prescribe
medicines by way of the skin the book
will prove valuable, owing to the many
prescriptions and formulae which dot
its pages, while the copious index at the
back materially aids in making the book
a useful one. — Medical News,
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 Comparative
Physiology 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 Natural-
ists; Associe Etranger de la Societe Fran^aised'Hygiene, etc. In one
handsome Royal Octavo volume of over 950 pages. Profusely illus-
trated with more than 400 fine Wood-Engravings and many Colored
Plates.
Price, in United States, Cloth, ^5.00; Sheep, $6.00, net.
Canada (duty paid). Cloth, ^5.50; Sheep, $6.60, net.
Great Britain, Cloth, 28s.; Sheep, 33s. France, Cloth,
30 fr. 30 ; Sheep, 36 fr. 20.
This new and important work is the most thoroughly complete in
the English language on the subject. 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.
16 Catalogue of Medical Publications.
SOZINSKEY— Medical Symbolism. Historical Studies
in the Arts of Healing and Hygiene,
By Thomas S. Sozinskey, M.D., Ph.D., Author of "The
Culture of Beauty,-^ "The Care and Culture of Children," etc.
12mo. Nearly 200 pages. Neatly bound in Dark-Blue Cloth. Appro-
priately illustrated with upward of thirty (30) new Wood-Engravings.
No. 9 in the Fhysicians' and Students^ Ready -Reference Series.
Price, in United States and Canada, post-paid, S^l.OO, net;
Great Britain, 6s. ; France, 6 fr. 80.
STEWART— Obstetric Synopsis.
By John S. Stewart, M.D., Demonstrator of Obstetrics and
Chief Assistant in the Gynaecological 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. 42 Illustrations. '202
pages. 12mo. Handsomely bound in Dark-Blue Cloth. No. 1 in the
Physicians^ and Students^ Ready -Reference Series.
Price, in United States and Canada, post-paid, J^l.OO net ;
Great Britain, 6s. 6d. ; France, 6 fr. 30.
ULTZMANN— The Neuroses of the Genito-Urinary Sys-
tem in the Male. With Sterility and Impotence,
By Dr. R. Ultzmann, Professor of Grenito-Urinary Diseases in
the University of Vienna. Translated, with the author's permission,
by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary De-
partment, Boston Dispensary. Illustrated. 12mo. Handsomely bound
in Dark-Blue Cloth. No. 4 *^ ^^^ Fhysicians^ and Stude^its^ Ready-
Reference Series.
Price, in United States and Canada, post-paid, ^1.00, net;
Great Britain, 6s. ; France, 6 fr. 20,
Synopsis oe Contents. — First Part — I. Chemical Changes in
the Urine in Cases of Neuroses. II. Neuroses of the Urinary and of
the Sexual Organs, classified as: (1) Sensory Neuroses ; (2) Motor Neu-
roses ; (3) Secretory Neuroses. Second Part — Sterility and Impotence.
The treatment in all cases is described clearly and minutely.
WHEELER — Abstracts of Pharmacology.
By H. A. Wheeler, M.D. (Registered Pharmacist, No. 3468,
Iowa). Prepared for the use of Physicians and Pharmacists, and
especially for the use of Students of Medicine and Pharmacy, who
are preparing for Examination in Colleges and before State Boards of
Examiners.
This book does not contain questions and answers, but solid pages
of abstract information. It will be an almost indispensable companion
to the practicing Pharmacist and a very useful reference-book to the
F, A. Davis, Philadelphia, Pa. 17
Physician. It contains a brief but thorough explanation of all terms
and processes used iif practical pharmacy, an abstract of all that is
essential to be known of each officinal drug, its preparations and
therapeutic action, with doses; in Chemistry and Botany, much that
is useful to the Phj^sician and Pharmacist ; a general working formula
for each class and an abstract formula for each officinal preparation,
and many of the more popular unofflcinal ones, together with tlielr
doses; also many symbolic formulas; a list of abbreviations used in
prescription writing ; rules governing incompatibilities ; a list of
Solvents ; tests for the more common drugs ; the habitat and best time
for gathering plants to secure their medical properties.
The book contains 180 pages, 5)^ x 8 inches, closely printed and
on the best paper, nicely and durably bound, containing a greater
amount of information on the above topics than any other work for the
money.
Price, in United States and Canada, post-paid, $1.50, net;
Great Britain, 8s. 6d. ; France, 9 fr. 35.
WITHERSTINE— International Pocket Medical Formu-
lary. Ai^ranged '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 to
Charity Hospital, New York. Including more than 1800 formulae from
sevei-al hundred well-known authorities. With an Appendix containing
a Posological Table, the newer remedies included; Important. Incom-
patibles; Tables on Dentition and the Pulse; Table of Drops in a
Fluidrachm and Doses of Laudanum graduated for age; Formulae and
Doses of Hypodermatic Medication , including the newer remedies; Uses
of the Hypodermatic Syringe; Formulae and Doses for Inhalations, Nasal
Douches, Gargles, and Eye-washes; Formulae for Suppositories; Useof
the Thermometer in Disease ; Poisons, Antidotes, and Treatment; Direc-
tions for Post-Mortem and Medico-Legal Examinations; Treatment of
Asphyxia, Sun-stroke, etc.; Anti-emetic Remedies and Disinfectants;
Obstetrical Table; Directions for Ligation of Arteries; Urinary Analy-
sis; Table of Eruptive Fevers; Motor Points for Electrical 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 illustrations. Bound in leather,
with Side-Flap.
Price, in United States and Canada, post-paid, S3.00, net;
Great Britain, lis. 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 Pennsylvaniaj
18 ' Catalogue of Medical Publications.
Attending Orthopaedic Surgeon, Out-Patient Department, University
Hospital, etc. Illustrated with 76 Wood-Engravifigs. 390 pages. 12mo.
No. 8 in the Physicians^ and Studeiits^ Ready -Be ference Series.
Price, in United States and Canada, post-paid, 9^1.40, net ;
Great Britain, 8s. 6d. ; France, 9 fr. 35.
While the author has prepared this work especially for students,
sufficient descriptive matter has been added to render it extremely
valuable to the busy practitioner, particularly the sections on the
Viscera, Special Senses, and Surgical Anatomy.
The work includes a complete account of Osteology, Articulations
and Ligaments, Muscles, Fascias, Vascular and Nervous Systems,
Alimentary, Vocal, and Respiratory and Genito-Urinary Apparatus,
the Organs of Special Sense, and Surgical Anatomj^
In addition to a most carefully and accurately prepared text,
wherever possible, the value of the work has been enhanced by tables
to facilitate and minimize the labor of students in acquiring a thorough
knowledge of this important subject. The section on the teeth has
also been especially prepared to meet the requirements of students
of dentistry.
In its preparation, Gray's ''Anatomy'' (last edition), edited by
Keen, being the anatomical work most used, has been taken as the
standard.
The following Publications sold only by Subscription,
or Sent Direct on Receipt of Price, Shipping
Expenses Prepaid.
Annual of the Universal Medical Sciences. A Yearly
Report of the Process of the General Sanitai^y
Sciences Throughout the World,
Edited by Chakles E. Sajous, M.D., formerly Lecturer on Laryn-
gology and Rhinology in Jefferson Medical College, Philadelphia, etc.,
and Seventy Associate Editors, assisted by over Two hundred Corre-
sponding Editors and Collaborators. In Five Royal Octavo Volumes of
about 500 pages each, bound in Cloth and Half-Russia, Magnificently
Illustrated with Chromo-Lithographs, Engravings, Maps, Charts, and
Diagrams. Being intended to enable any physician to possess, at a
moderate cost, a complete Contemporary History of Universal Medi-
cine, edited by many of America's ablest teachers, and superior in
every detail of print, paper, binding, etc., a befitting continuation of
such great works as " Pepper's System of Medicine," " Ashhurst's In-
ternational Encyclopsedia of Surgery," "Buck's Reference Hand-
Book of the Medical Sciences,"
F, A, Davis ^ Philadelphia , Pa, • 19
SUBSCRIPTION PRICE Per Year (Including the « S ATEL-
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The Satellite of the *' Annual of the Universal Medical
Sciences.'' A Monthly Review of the most important articles upon
the practical branches of Medicine appearing in the medical press at
large, edited by the Chief Editor of the Annual and an able staff.
Published in connection with the Annual, and for its Subscribers Only.
Lectures on Nervous Diseases. From the Stand-point of
Cerebral and Spinal Localization^ and the Later
Methods Fmployed in the Diagnosis and Treatment
of these Affections,
By Ambrose L. Ranney, A.M., M.D., Professor of the Anatomy
and Physiology of the Nervous System in the New York Post-Graduate
Medical School and Hospital ; Professor of Nervous and Mental
Diseases in the Medical Department of the University of Vermont, etc. ;
Author of '' The Applied Anatomy of the Nervous System," " Prac-
tical Medical Anatomy," etc., etc. Profusely Illustrated with Original
Diagrams and Sketches in Color by the author, carefully selected
Wood-En graving!, and Reproduced Photographs of Typical Cases.
One handsome Royal Octavo volume of 780 pages.
Price, in United States, Cloth, $5.50; Sheep, $6.50; Half-
Russia, $7.00. Canada (duty paid), Cloth, $6.05 ; Sheep,
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Sheep, 37s. 6d.; Half-Russia, 40s. France, Cloth, 34
fr. 70 ; Sheep, 40 fr. 45 ; Half-Russia, 43 fr. 30.
Lectures on the Diseases of the Nose and Throat. De-
livered at the Jefferson Medical College^ Philadel-
phia,
By Charles E. Sajous, M.D., formerly 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 War-
saw (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, Royal Octavo, $4.00; Half-
Russia, Royal Octavo, ^5. 00. Canada (duty paid), Clotli,
$4.40; Half- Russia, $5.50. Great Britain, Cloth, 32s. 6d ;
Sheep or Half- Russia, 88s. France, Cloth, 34 fr. 60;
Half-Russia, 30 fr. 30.
20 Catalogue of Medical Public atioyis,
Stanton's Practical and Scientific Physiognomy; or How
to Read Faces.
By Mary Olmsted Stanton. Copiously Illustrated. Two large
Octavo volumes.
The author, Mrs. Mary 0. Stanton, has given over twenty years
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
ideas. (This book has no reference whatever to Phrenology.)
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Cloth, 30 fr. 30 ; Sheep, 36 fr. 40 ; Half-Russia, 43 fr. 30.
Sold only by Subscription, or sent direct on receipt of price, ship-
ping expenses prepaid.
Journal of Laryngology and Rhinology.
Issued on the First of Each Month. Edited by Dr. Norris
WoLFENDEN, of London, and Dr. John Macintyre, of Glasgow, with
the active aid and co-operation of Drs. Dundas Grant, Barclay J.
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those specialists in Europe and America who have so ably assisted in
the collaboration of the Journal, a number of new correspondents
have undertaken to assist the Editors in keeping the Journal up to
date, and furnishing it with matters of interest. Amongst these are :
Drs. Sajous, of Philadelphia; Middlemass Hunt, of Liverpool;
Mellow^, of Rio Janeiro; Sedziak, of Warsaw; Draispul, of St.
Petersburg, etc. Drs. Michael, Joal, Holger Mygind, Prof.
Massei, and Dr. Valerius Idelson will still collaborate the literature
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