(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Epilepsy: its pathology and treatment. Being an essay to which was awarded a prize of four thousand francs by the Académie royale de médécine [sic] de Belgique, December 31, 1889"

.■'..-j^ •..er-T-l £CSr.r»r«;I!QE5EE£:,U;i^1 




LIBRARY 

Walter E. Fernald 
State School 




Waverley, Massachusetts 

No. .-^04--" i 




^wn^o 




^ 



Digitized by the Internet Archive 

in 2012 with funding from 

Boston Library Consortium IVIember Libraries 



http://archive.org/details/epilepsyitspatho1890hare 



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 





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 2 
1 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 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, 




'^ "^ 'O TlJ "^ 

QJ <1J CL) QJ a-> 

;_;_;_;-, ;-i 

:3 t3 p3 ;3 :3 

o o o o o 



Ti T^ T^ 'O "^ 'O "TlJ frj 



3 o 

Q P5 



C &i 
•r! 'I' 

















r/) 


OT 










;h 


;h 


CQ 






tt! 


Oj 


c3 




J- 




■— ' 


o; 


QJ 


o3 


o3 




o3 
cu 






T— 1 


Oi 


Oi 


T— 1 


y 


c5 
1— ( 



m 



CO 






a;i CD 



CO 



CO c 



rH ,-1 O 
O 



CO 



W CO 



o 

IS O 



5" 
o 



'd 


tlJ 


Ti 


'd 


'd 


0) 


o 


01 


0) 


OJ 


^-3 




Va 


^ 


-«-l 


oj 


oi 


Ti 


crt 


ci 


^ 




^ 


+^ 




CO 


CO 


CO 


ou 




-M 


.tJ 


^J 


•H-3 


+3 


O 


O 


O 


O 


o 


^ 


^ ;2; ^2; ^ 






<v 






GQ 



"d • n3 ti 'd 'd 'd • TJ 

o3rOc3o3a3o3c3rQc3 
«3-*^a2coco«2co-tJa2 

Oj-OOOOO^O 






42 o 



'd Ti 



c^ 






oj <o c3 c3 

CO 02 K_| CO OQ 



O O 



o o 



"d 'O "d 'd "d 'd "d "d "d "d 
a;a;(i;(Da)a;<D<DiiiQ:) 

o3c^c3c^c^o3oJc5c5c^ 



-4-3 -tJ -tJ ^-3 



-(-3 -»J ^J 



ooococooco 



02 



'd 

'fcjo'bJO J 
;: fd CO 



ho bJD be 

.S .S .5 
C^ C^ c» 



be 



a; oj o 
bp 'bJD 'bJD 

'S2 '^j 'a2 



•d 'd 

OJ 03 






03 -^ 



. 03 

-1-3 



^5?; : J?; 



03 

bC 



^ W IC rH tH 
m Tl^ (M CO -^ 



35 



T^C^CQC<!C<IrHi-(TtlrH 



T-^ (MCO-^OOt-OO Oi Oi-l'MCO'+iiC?C?>OOCi 



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, 



o 


« 
o 






i 


§ 


d 


0) 


u 



i 


i 

3 






d 

"§ d 




<X> 





12! 


^ 



125 




S 


d 


1 


d a 


t» 


s^^ 


o 














d 




'd 




;25 
















■^ 













^ 




.2 














m 




i 


1 

12; 




i 


1 
1 




d 



1 


K 

2 
3 


0) 

>• 


2 


1 


1 

d 

1 












2 « 










•d 








i 

o 


i 


a1 





2 '3 
S.2 


1 


^ 
2 
1 


2 


> 


1 

g 


^ 

3 


OQ 

1 

d 
-0 
d 


xn 






'2.2 




^ 






V( 








^ . 




1 


125 


Is 




:§ 






1 

123 


Xn3 






d 
1 


II 

1" 


1 

d 

02 






^ i 







^ 










-S 










"i^ 


'3 


d 


d 










-2 




in 


;2 


a5 

1 


hi 


1 

d 


d 
d 

1 


.1-1 

d 

0) 

be 


a5 
d 
be 
d 


5i 

> 

125 


u 

> 

'A 


.2 

1 

d 


d 

i 


1 


1 

CO 





.2 

o 


•id . 

lis 

til 


'3 

1 

g 


1 

_d 
'C 

d 


2:§ 

s a 

d_r,d 

Fi! 

••-1 S 


d a< 

u 


1 


u 

> 


d 
d 


d 

a> 




tl 

II 








-tj 






d 


















1 


p 

o 


d 

a> 
'tS 

d 

CO 


^3 

d 
< 


1 


6 

d 



1 
1 


>> 

'a 
1 


a? 
> 


1 

d 
d 

a 

<1 




CO 

i 
1 

d 

p< 






o 
























« 

§ 


























1 






. 


'^ 


Gs 


1* 


■^ 








1 


•2 




1 







1 


1 






1 


^ 

s 







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, 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 



CATALOGUE OF THE PUBLICATIONS 



OF 



K. A. DAVIS, 

1231 FILBERT STREET, PHILADELPHIA. 



BRANCH OFFICES 



NEW YORK CITY : 
117 TV. Forty-second Street. 

CHICAGO : 
24 Xakeside Building, 314-330 

S. Clark St. 



ATLANTA: 

35 Old Capitol. 

LONDON, ENG. : 

40 Berners Street, Oxford 
Street, W. 



ORDER FROM NEAREST OFFICE. 

FOR SALE BY ALL BOOKSELLERS. 



Prices of books, as given in our catalogue or circu- 
lars, include full prepaj^ment of postage, freight, or 
express charges. Customers in Canada and Mexico 
must pay the cost of duty, in addition, at point of 
destination. 

N. B.— Kemittances should toe made toy Express Money-Order, 
Post-Office Money-Order, Registered Letter, or Draft on New York 
City, Philadelphia, Boston, or Chicago. 

We do not hold ourselves responsible for books sent 
by mail ; to insure safe arrival of books sent to distant 
parts, the package should be registered. Charges for 
registering (at purchaser's expense), 10 cents for every 
four pounds or less. 



Catalogue of Medical Publications, 



BASHO RE— Improved Clinical Chart. For the Separate 
Plotting of Temperature^ Pulse, and Respiration. 

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 ; 
Great Britain, 3s. 6d. ; France, 3 fr. 60. 

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- 
erence Series. 

Price, in United States and Canada, post-paid, $11.40, net ; 
Great Britain, 8s. 6d. ; France, 9 fr. 35. 

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. 

Price, in United States and Canada, post-paid, Cloth, ^2.00, 
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 ; 
Great Britain, 10s.; France, 13 fr. J30. 



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 
labor- saving physicians' pocket record-book ever published. Phy- 
sicians of many years' standing and with large practices pronounce 
this the best list they have ever seen. It is handsomely bound in fine, 
strong leather, with flap, including a pocket for loose memoranda, etc., 
and is furnished with a Dixon lead-pencil of excellent quality and 
finish. It is compact and convenient for carrying in the pocket. Size, 
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, 
Kaised Back-Bands, Clotli Sides, in United States, ^5.00 ; 
Canada (duty paid), ^5.50, net; Great Britain, 38s.; 
France, 30 fr. 30. No. 3, 600 Pages, for 1800 Accounts 
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- 
EITE" for one year) : in United States, Cloth, 5 Vols., 
Royal Octavo, $15.00, Half-Russia, 5 Vols., Royal Oc- 
tavo, $20.00. Canada (duty paid). Cloth, $16.50; Half- 
Russia, $33.00. Great Britain, Cloth, «4 7s ; Half-Rus- 
sia, £5 15s. France, Cloth, 93 fr. 95; Half-Russia, 134 
fr. 35. 

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, 
$7.15; Half-Russia, $7.70. Great Britain, Cloth, 32s,; 
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.) 

Price, in United States, Cloth, ^9.00; Sheep, Sll.OO; Half- 
Kussia, SS13.00. Canada (duty paid). Cloth, ^10.00; 
Sheep, JS12.10; Half-Russia, ^14.30. Great Britain, 
Cloth, 56s. ; Sheep, 68s. ; Half-Russia, 80s. France, 
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. 
Baron, Hunter Mackenzie, and Sir Morell Mackenzie. Besides 
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 
of their respective countries. 

Price, 13s. or ^3.00 per annum (inclusive of Postage). 
For single copies, however, a cliarge of Is. 3d. (30 
Cents) will toe made. Sample Copy, 35 Cents. 

The Medical Bulletin. 

Edited by John V. Shoemaker, A.M., M.D. Monthly; |1.00a 
year. Bright, Original, and Keadable. Articles by the best practical 
writers procurable. Every article as brief as is consistent with the 
preservation of its scientific value. Therapeutic notes by the leaders 
of the medical profession throughout the world. These and many 
other unique features help to keep The Medical Bulletin m its 
present position as the leading low-priced Medical Monthly of the 
world. Subscribe now! 

TERMS, Sl.OO A YEAR IN ADVANCE 

In United States, Canada, and Mexico. 

Foreign Subscription Terms. 

ENGI.AND, 5 Shillings. JAPAN, 1 Yen. 

AUSTRALIA, 5 Shillings. GERMANY, 5 Marks. 

FRANCE, 6 Francs. HOLLAND, 3 Florins.