EPILEPSY.

BY ALLAN MCLANE HAMILTON, M.D.

SYNONYMS.—Epilepsia; l'Épilepsie (Fr.); Fallsücht (Ger.); Epilessia (Ital.); Epilepsin fallendsot (Scand.); Falling sickness; Fainting sickness.

DEFINITION.—According to the most recent authorities, an epileptic attack is nothing more nor less than a discharge of nervous energy from an overexcited, or what may be called a dynamo-pregnant nerve-centre, or collection of centres, and the predominance of motor or sensory phenomena determines the extent and order of the parts involved. As a rule, an epileptic paroxysm is but a symptomatic expression of a complex derangement, and it is best to formulate our nomenclature with the idea, in the first place, of location; in the second, with reference to the prominence of motor or sensory expressions; and, finally, with regard to etiology.

HISTORY.—There is probably no nervous disease which has been more extensively written upon (even in ancient times) than that under consideration. We find references to it as early as the tenth century, when it figured in the text of Avicennes. Hippocrates called it ιερόν νοσεμα, or sacred malady, and πάθοϛ παιδήιον, or malady of children, believing that the attacks had their origin always in early infancy and never later. Plato and Aretæus advanced the theory that the disease sprang from a thirst for gold, and equally absurd and unreasonable explanations are found in the writings of the fathers of medicine. The older French writers were diligent investigators, but with them prevailed the tendency to explain the origin of the disease by mysticism, and among many it was supposed to bear some connection with the coming of St. John. The popular humoral theory of the malady originated by Mercurialis was afterward opposed by Averrhoes and Fernel, but even to this day it has devoted adherents. Bouchet and Causauvieilh maintained that the disease was inflammatory—a view that was vigorously combated by Bouillaud and Delasiauve. The theory of Broussais—which was and is the basis of the conclusions of modern investigators—is that it is dependent upon cerebral irritation. It is hardly necessary to refer to the many untenable and curious attempts that have been made to explain the pathology of the malady: suffice it to say that many of them were as extravagant as that of Vepfer, who considered the pineal gland to be the locus morbi of the affection—a conclusion in which Descartes coincided. Marshall Hall was the first writer to advance the theory of reflex irritation, believing that gastro-enteric or uterine irritation acted upon the brain. In later years Schroeder Van der Kolk, Reynolds, and others have written quite fully upon the part played by the medulla, while recently numerous French and German writers—among them Bourneville, Meynert, Sommers, and Tagges—have attached much importance to the discovery of a sclerosis of parts lying at the floor of the lateral ventricles.

Perhaps our knowledge of epilepsy has received its greatest impetus from the elaborate and exact researches of Hughlings-Jackson; and his observations, taken in connection with the recent work of the numerous students of localization, open up a new field of research, and, as matters stand, the future study of epilepsy must be fruitful in the extreme.

DIVISION.—It has been the custom to divide the epilepsies into epilepsia gravior and epilepsia mitior, the haut mal and petit mal of the French. These terms are in one way misleading, and only define differences in degree. The terms general and limited would much more properly express the forms of attack, and I shall use them as far as possible in the present article. A general epilepsy is one that corresponds with haut mal, in which there is an extensive convulsion, absolute loss of consciousness, and perversion of a widespread character. Limited epilepsy includes those forms in which there is a convulsion confined to a small group of muscles, and in which loss of consciousness plays an unimportant part. Under this latter head belongs the form known as petit mal and those monospasms which depend upon a cortical irritative lesion. There are other divisions which partake of the nature of one or the other, and are unilateral and dependent upon the destructive discharge of a motor centre. Under this head may be placed the epilepsie partielle of the French or the hemi-epilepsy or Jacksonian epilepsy of the English. There are also irregular or aborted attacks—the so-called masked epilepsy—and lastly the sensory varieties.

ETIOLOGY.—It cannot be denied that heredity plays the most important part in the genesis of epilepsy. Nearly one-half of my own cases when carefully investigated were clearly traceable to some inherited predisposition. Insanity, epilepsy, and phthisis in ancestral history stamp their constitutional imprint upon the unfortunate descendant, and the history of ten cases from my notebook (see Table) will show the extent of saturation that may exist in paternal or maternal branches and the evolution of the disease in male and female subjects. The statistics of other writers, though not showing quite so large a proportion of cases with hereditary history as my own, are quite significant. Gowers found that in “1218 cases, 429, or 35 per cent., presented evidence of neurotic inheritance.” Echeverria estimated the proportion of hereditary cases at 28 per cent., while Reynolds fixes it at 31 per cent. Of 980 cases, the notes of which I have examined, many of whom have been under my personal care, 435 presented a family history of insanity, phthisis, epilepsy, cerebral apoplexy, tumor, or some lesser neurosis. So far as the history of hereditary influence is known, it appears that females are more apt to present this form of epilepsy than males, and, according to Gowers's as well as my own investigations, the transmission comes from the mother's side more frequently than the other. So far as my own inquiries have gone, I find insanity more often among the progenitors of the epileptic than any other nervous disease, and in many cases phthisis. I am inclined, therefore, to give greater weight to this relationship than Nothnagel and others. Anstie, Bastian, Savage, and other careful clinicians have pointed out not only the close connection between phthisis and epilepsy, but between the former disease and migraine; and no one who has seen much of epilepsy can fail to be impressed with the frequent association of migraine with the more serious convulsive affection of which it is quite often the precursor. Perhaps the fact that phthisis was found so often—in 230 of my 980 cases—may be due to the fact that many of the patients were of the lower classes and among the Irish, who in this country are so frequently phthisical.

Heredity in Ten Cases of Idiopathic Epilepsy, with Existing Disease or Cause of Death.

Sex. Paternal Ancestry. Maternal Ancestry. Brothers. Sisters. Remarks.
Father. Grand-
father.		 Uncles. Grand-
mother.		 Aunts. Mother. Grand-
mother.		 Uncles. Grand-
father.		 Aunts.
F. Died insane. Suicide; probably insane. Eccentric. . . . . . . Died of cerebral hemorrhage. Eccentric; died of cerebral hemorrhage. Drunkard. . . . . . . One a dipsomaniac; one in good health. One epileptic. A history of criminal proclivities.
M. Alive. Cerebral hemorrhages. Insane. . . . . . . Phthisis. . . . One died of phthisis. . . . Phthisis. One brother has infantile paralysis. Two sisters died of organic disease of the brain, one of cerebro-spinal sclerosis. Peculiar cranium.
F. Alive in third stage of post-sp. sclerosis. Phthisis. . . . . . . Phthisis. Alive. Not known. . . . Cerebral embolism. . . . One brother has infantile paralysis. . . .
M. Died of phthisis. Not known. Phthisis. . . . Epileptic. Migraine. Phthisis. . . . . . . . . . No brothers. No sisters.
M. Congestive headaches. Cerebral hemorrhage. Insane. . . . Migraine. Phthisis. . . . . . . . . . One died of phthsis; one hemiplegic. No brothers. No sisters. Peculiar cranium.
M. Alive. Insane. . . . . . . Insane. Phthisis. . . . Phthisis. . . . . . . Eight brothers and sisters. One died of epilepsy, and cerebral tumor was found; one paralyzed.
M. A confirmed drunkard. Died of embolism and softening at 76. . . . . . . Insane. Phthisis. Died in childbirth. . . . . . . Phthisis. . . . . . . Criminal proclivities.
M. Phthisis. Eccentric. One phthisis; one cerebral tumor. . . . . . . Migraine. . . . . . . . . . . . . One brother died of secondary tubercular meningitis, the other in an asylum. . . . Child of this parent was choreic.
M. A dipsomaniac and eccentric person. A genius. One died insane. Cerebral hemorrhage. None. Peculiar and eccentric. Migraine. Peculiar character. Insane and committed suicide. . . . Several brothers unaffected. No sisters. Criminal proclivities.
M. Most eccentric; a somnambulist. . . . . . . . . . Migraine. Epileptic. . . . . . . . . . Migraine. No brothers. No sisters.

In many idiopathic cases we find vices of cranial conformation, bodily asymmetry, and a history of early congenital syphilis. Laségue lays great stress upon cranial malformation, and goes so far as to say that all epilepsies not dependent upon some osseous trouble, either developmental or traumatic, are not epilepsies at all. Such epilepsy, which owes its origin to cranial asymmetry, rarely develops after the eighteenth year. The head is most often dolichocephalic or brachycephalic, and there is facial asymmetry. Laségue concludes that all the convulsions are identical; that it is not hereditary; that the attacks are always matutinal. It seems to me that Laségue's conclusions in regard to the non-existence of epilepsies from other causes are rather too arbitrary in view of the large amount of evidence to the contrary. In others, a very few, we find an apparent history of heredity explained by forceps-pressure during delivery.

So far as age and sex are concerned, and their predisposing influence, we find that by far the greatest number of cases begin before the twentieth year. This is the experience of Gowers, of Hammond, and of many others. Of my own 980 collected cases in which the beginning of the disease was known, there were—

Females.Males.Total.
Under 1010395198
Between 10 and 2017197268
Between 20 and 3014592237
Between 30 and 5081136217
Over 50 11 49 60
511469980

Of 1288 cases collected by nine French authorities, in 486, or over one-third, the disease began between the tenth and twentieth years. In Gowers's 1450 cases we find the following showing:

Cases.
Under 10422
From 10 to 19665
From 20 to 29224
From 30 to 3987
From 40 to 4931
From 50 to 5916
From 60 to 694
From 70 to 791

In 29 per cent. of these cases the disease therefore began before the tenth year.

As to sex, it appears that females are much more subject to the disease than males, but this is not true at any age. Epileptics under ten are more apt to be girls, but the proportion is nearly equal: between ten and twenty the proportion of females is undeniably greater. In adult cases we find that pure epilepsy (excluding hysteria) is much more often a disease of males than females.

In the hereditary form the disease in the great proportion of cases begins before the twentieth year; and, so far as my experience goes, this kind of the disease makes its appearance at a very early age. The part played by particular predisposing influences appears to be well defined. The children of syphilitic parents develop the disease at a more advanced age than when alcoholism is found to exist. In adult males, when the disease develops late in life, it is almost always possible to find syphilitic or coarse brain diseases, while among women the history of antecedent migraine or menstrual derangement is nearly always present, and the convulsions in a very large number of instances have a hysteroid character.

The exciting CAUSES of the disease are quite numerous. Traumatism is a frequent and important etiological factor, and the head-injuries may be recent or remote. It is quite common to find old fractures, with depressions which have existed for years without any seeming bad effects, suddenly lighting up convulsions under the influence of some new excitement. Under such circumstances the depressed bone is quite apt to give rise to symptoms suggestive of meningeal irritation and inflammation, so that the diagnosis is comparatively easy. Several observers have called attention to epilepsy which has been undoubtedly due to cicatrices not only of the scalp, but elsewhere, and these may or not be found in association with osseous lesions. The literature of the subject is replete with curious cases which go to show that epilepsy may occur from a few days to many years—even twenty—after the initial head-injury. Unsuspected cortical pressure, the inner table being alone depressed, is common; in fact, the cases in which the most serious mischief is done seem to be those where the only external evidence of violence is the contused scalp. As a consequence of such injury we may have exostoses developed.

The influence of syphilis in the production of epilepsy is one of very great importance. Not only has specific epilepsy characteristics of its own, but its origin may be distinctly traced to syphilitic infection. Cases dependent upon gross cerebral disease, such as meningitis or gumma, are excluded from consideration, but it is conceded by all syphilographers that an epilepsy may mark the second stage of the disorder, and its pathological dependence is probably a simple vascular disturbance which cannot be determined after death. So-called specific epilepsy may be congenital.

Orwin1 mentions as a cause the influence of prolonged lactation. In several cases I have seen a metrorrhagia, or a loss of blood from hemorrhoids has been followed by a readily curable epilepsy.

1 Prov. Med. and Surg. Journal, London, 1862, v. 48.

As eccentric irritating causes may be mentioned intestinal worms, but I am convinced that it is too often the fashion to ascribe convulsions in children to intestinal parasites: in very young children, however, there are frequent examples of the disease in which the attacks are precipitated by worms. The fits are usually very severe, and are not regular in their appearance, occurring at night-time more often than during the day, and, though they usually disappear when the bowels are cleared of their unpleasant occupants, may recur when once initiated, even though anthelmintics of the most powerful kind are employed. Gall-stones are mentioned by Ross as an eccentric cause of the disease, but I have never witnessed a case of this nature.

Sudden terror, fright of all kinds, morbid example, and other psychic causes are detailed, and undoubtedly all have more or less influence. Hysteroid attacks are notably precipitated by these mental causes, and all forms of the disease are greatly modified by abnormal exercise of the mind.

A number of writers, among them Baly2 and Booth,3 have called attention to cases of the disease dependent upon carious teeth. I have seen but one such case, where a wisdom tooth produced so much violent inflammatory action that middle-ear disease followed, and with it subsequent extension to the brain took place.

2 London Med. Gazette, 1851, xlviii. 534-540.

3 Am. Journ. of the Med. Sciences, 1870, N. S. lix. 278.

In rare cases the administration of anæsthetics is followed by epilepsy, and Gowers alludes to a case in which convulsions were due to the inhalation of nitrous oxide gas.

Concussion of the brain as the result of railroad injury or falls may give rise to a progressive epilepsy which is usually of serious character.

Reflex causes play a prominent part in many instances, though I am inclined to think that their importance has been greatly exaggerated. This is especially true of so-called uterine epilepsy. It cannot be doubted that difficult menstruation, ovarian neuralgia, etc. are found in connection with epilepsy, but whether as a cause or effect it is not always possible to say. The fact that in some women we find accès at periods identical with menstruation would point to a very close relationship. Carstens4 reports a case due undoubtedly to stenosis of the cervix; Cohen,5 an example in which there was a uterine fibroid; and others have spoken of erosion of the cervix, etc. as possible explanation of the seizure.

4 Detroit Lancet (8), 1880, N. S. iii. 153.

5 Wochenschrift f. d. ges. Heilkunde, Berlin, 1839, vii. 648, 673.

The toxic forms of epilepsy hardly need discussion in this article. Metallic poisoning, which gives rise to a veritable plumbic encephalopathy, is rather the cause of a symptomatic than generic epilepsy. Curious cases of epilepsies which have followed the use of oil of tansy (Mitchell6), ergot, absinthe (Magnan7), and various drugs show that occasionally their mode of origin may explain the convulsive seizure. Alcoholic epilepsy I do not regard as being the rare affection some authors consider it. In cases of prolonged saturation, where perhaps there are no other symptoms of chronic alcoholism, I have found it perhaps associated with the trance state (cataleptoid) or appearing in the psychic form.

6 Cincinnati Lancet and Clinic, 1881, N. S. vi. 479.

7 Recherches sur les Centres nerveux, Paris, 1876.

In old persons I have found gout to have an undoubted influence in producing the disease, there being a spasm of the cerebral vessels which usually betokens a condition of uric-acid saturation. In these cases the painful symptoms were not decided. Such epilepsies have quite often preceded serious evidence of arterial degeneration.

Malarial epilepsy is rare: Jacobi8 reports a case and Payne9 another. A young man was brought to me last year who had lived for many years in a part of Pennsylvania which was exceedingly malarious. His attacks, which were more or less periodic, were violent, and his convulsions were general and attended by very great preliminary rise of temperature and intense congestion of the face and head. The patient was unusually somnolent, and between the paroxysms frequently suffered from facial neuralgia. The influences of change of habitation and quinine determined the correctness of my diagnosis.

8 Hospital Gazette, New York, 1879, v. 41-43.

9 Indian Ann. Med. Sci., Calcutta, 1860-61, vii. 597 et seq.

Day10 and Kerr11 have both ascribed epilepsies seen by them to hepatic congestion.

10 Clin. Histories, etc., London, 1866, 143-145.

11 Med. Times and Gazette, London, 1871, i. 568.

The important etiological relation of the exanthemata to epilepsy has been the subject of much attention. The books are full of cases which owe their origin not only to scarlet fever and measles, but to whooping cough, diphtheria, and the various zymotic fevers. In 35 cases tabulated by Gowers12 (p. 28) no less than 19 were due to scarlet fever, while the first fit followed measles in 9 cases. So far as my individual experience goes, I have in 23 cases found epilepsy to be the result of scarlet fever, and this form of the disease was often associated with other manifestations of coarse brain trouble. Cerebro-spinal meningitis was the undoubted cause of epilepsy in 6 cases I examined. It is probable that just as smallpox acts upon the nervous centres, so does scarlet fever, and I agree with Gowers that the convulsions that may begin during or just after the fever are not always due to uræmia. Bright's disease may give rise to an epilepsy, but this can hardly be regarded as a distinct affection.

12 Op. cit.

There are many cases, especially in adults, which grow out of a prolonged depletion of the brain—a continued cerebral anæmia. Among these cases are some which depend upon pressure upon the great vessels of the neck, and some due to debilitating disease of a general character. Schulz13 has seen a case which followed compression of the jugular vein, and enlarged cervical glands have in other cases acted as mechanical agents. Hammond alludes to the influence of prolonged general anæmia in the production of epilepsy.

13 Cor. Bl. Deutsches Gesellsch. f. Psych., Neuwied, 1855, ii. 35.

While I do not place much reliance on the claims that have been made regarding the frequent dependence of the disease upon preputial irritation, or that it may arise from phymosis or urethral stricture, it cannot be denied that some cases have originated in difficulties of the kind, and especially the former. Simmons14 reports a case of attachment of the prepuce to the glans in which a cure followed separation. Disease of the testicles in certain cases plays a part in its genesis, and Liégey15 details an epilepsy clearly due to testicular pressure. Some years ago I saw a case in which the pressure of an improperly applied truss, I am now convinced, had much to do with the development of the convulsions. The alleged sexual causes are many, and some of them are very doubtful. A fanciful continental writer, Montmeja,16 believes that sodomy explained the appearance of the disease in one of his patients.

14 Am. Journ. Med. Sci., 1880, N. S. lxxix. 444.

15 Gaz. méd. du Strasbourg, 1856, xvi. 105-107.

16 Rev. Photo. des Hôpitaux de Paris, 1873, v. 229-232.

The existence of vesical calculi as an exciting cause cannot be disregarded, and, while rare, the observations of Duncan,17 Muscroft,18 and one or two others have shown that the removal of a stone was followed by a cure of the epilepsy.

17 Ed. Med. Journal, 1868-69, xiv. 140.

18 Arch. Sci. and Pract. Med. and Surg., 1873, 1360.

Masturbation is a popular etiological factor. I really do not believe, even in face of the numerous alleged cases that have been recorded, that the habit of self-abuse often results in genuine epilepsy. So far as my experience goes, onanism is practised by epileptics as well as by healthy boys, and when indulged in to excess is due to the congenital moral deficiency which is so common, especially in hereditary cases. In rare examples the frequently-repeated act may give rise to a form of the disease of the nature of petit mal.

Gastric disorders have attracted much attention, especially from Paget, who speaks of a gastric epilepsy and reports cases. While I do not believe in the sole etiological influence of digestive derangement, I have too often witnessed examples in which disorders of this kind markedly influenced the precipitation of attacks and the duration of the disorder.

Occasional cases of peripheral origin have been from time to time presented, and go to support in some measure the pathological views of Brown-Séquard. Among observers who have brought forward cases besides those referred to on a previous page are Lande,19 who reported a case of epilepsy dependent upon injury of the right median nerve, and Short,20 in whose case a neuroma explained the cause of the convulsions. Billroth,21 Garnier,22 Brown-Séquard,23 and Raymond24 have brought forward cases where injury of the sciatic nerve was the origin of the trouble, and in more than one instance a cure was effected by excision. It seems strange that a bone dislocation should have anything to do with the genesis of epilepsy, yet in one case reported a severe dislocation at the shoulder-joint explained the appearance of the attacks, and reduction was speedily followed by cure.

19 Mém. et Bull. Soc. de Méd. et Chir. de Bordeaux, 1878, i. 56-65.

20 Med. Essays and Observation Soc., Edin., 1737, iv. 416.

21 Archiv f. klin. Chir., Berlin, 1872, xiii. 379-395.

22 Union médicale de Paris, 1872, 3d S., xiii. 656-658.

23 New York Medical Record, 1872, vii. 472.

24 Rev. méd. de Limoges, 1869-72, iii. 102-105.

I have seen several cases where disease of the internal ear or injury of the temporal bone gave rise to the most obstinate and violent epilepsies. Westmoreland25 and others report such cases, but more often the epilepsy is only symptomatic of pachymeningitis or abscess. Some years ago I presented26 a case of genuine epilepsy in which the seizure was produced at will by irritating the meatus auditorius. By simply blowing into the ear the same effect would be produced. Since then Blake and others have related examples. Quite lately a writer in Brain has collected other cases of this species of auditory epilepsy. A year or so since I examined a patient in whom not only hemi-epilepsy, but other unilateral symptoms, followed erosion of a large part of the mastoid and petrous portion of the temporal bone as the result of a bullet wound.

25 Atlanta Med. and Surg. Journal, 1876-77, xiv. 717-719.

26 New York Medical Record, 1878, xiii. 107-109.

The influence of climate and varying barometric pressure has been considered by Delasiauve. His conclusion was that the attacks were much more common during the season of the year when the prevailing winds were from the north-west, north, or south-west.

PRODROMATA.—There are various minor disturbances of sensation and motion which may not amount to the dignity of an epileptic attack. These may be so fugacious as to escape the attention of the persons in whose company the patient may happen to be, or he himself may be unaware of any disordered state of feeling. They may precede a severe paroxysm, when they are known as warnings or auræ. The term aura was originally applied to the familiar premonitory sensation which is so often likened by the subject to the blowing of wind over the skin, from whence it receives its name, but it has come to be applied to all primary indications of a fit. Such auræ may be sensory or motor—in the preponderance of cases the former, for motor precursors are quite rare, and when they occur are most likely to be but one stage, though a slight one, of the convulsion itself. There is no general rule about the occurrence of an aura, but, so far as my experience goes, there is great constancy in the character of the warning in each particular case. The sensory disturbance may vary from a vague feeling of confusion to a well-marked sensation. In many instances the patient speaks of an indescribable mental disturbance, which may precede the attack and last anywhere from a few minutes to several hours. This confusional state or psychical aura is most protean in its expression. It may simply be a heavy feeling, a feeling of tension, a sleepy feeling; a restlessness which is manifested by the patient changing his position frequently or wandering forth into the streets; an irritability of temper which often lasts twenty-four hours or more, and during the display of which he rebukes those who may be solicitous about him, or wantonly destroys articles of furniture, or vents his spleen upon inoffensive persons. I have had epileptic children under my charge who were wont to bite their little brothers and sisters or their nurses. A feeling of terror sometimes precedes the attack, and very often there is a sense of impending danger which has no basis whatever, and with it is associated a depth of depression which is very painful. In other cases the patient manifests a strange exhilaration, which may precede the occurrence of the attack for a period of from one or two hours to two or three days; and this is made manifest by great loquacity and a lively play of spirits. It is not rare to find errors in the speech as indications of an approaching attack. A minor degree of aphasia, slowness of speech, or anarthria betrays occasionally the preparatory state which is the precursor of a severe convulsion. By far the most common warnings, however, consist of disorders of the special senses, and generally these are visual. From an inspection of my notes I find that the patients saw colored lights, rings of fire, bright objects, dark spots, luminous clouds, a flood of light, sparks, stars, bright balls, lights which approached them, lights which receded, fireworks, and all became dark. While many were unable to define the color perceived, I found among those who were positive that red was the color most frequently seen, while blue came next; and this is a conclusion which I believe is accepted by Jackson and others who have analyzed their cases.

Hemiopia and diplopia in rare cases precede the major attacks, and are sometimes associated with distal pain and anæsthesia and with supraorbital pain as well.27 Among these ocular warnings we find constriction of the visual field to be often present, especially in cases where there is a history of migraine. Vague disorders of hearing, which may even amount to the dignity of hallucination, are complained of by some persons. There may be simply roaring in the ears or a sound of bells, and in one instance my patient declared that he heard whisperings at the time of the seizure. Some patients smell smoke or other foul odors, and in exceptional instances the odor of some particular flower or of some aromatic substance, such as camphor, turpentine, or tar, is perceived by the epileptic; and these are probably psychical.28 Sometimes there is a feeling of great suffocation, constriction of the chest or of the throat, palpitation, or vertigo.

27 See Sensory Epilepsy.

28 For curious examples of this kind consult Sir Charles Bell's Nervous System of the Human Body.

There are disorders of cutaneous sensation of great diversity of character, but those auræ which are of the most constant occurrence are the epigastric, which consist of a vague sensation starting below the sternum and ascending, its arrival at the throat being coincident with the commencement of the fit, and the patient very often likens its culmination to the violent grasp of a strong hand. So, too, we find crawling sensations starting in the extremities and running up to the trunk. These have been compared to the contact of insects in motion or to the blowing of wind over the surface. There may be tingling in one or two fingers or the whole hand, and such sensations may be unilateral or bilateral. It is quite common for the sensory warning to begin in the hand and foot of one side and to run up to the knee and elbow. Sometimes the tongue becomes hyperæsthetic, and I have frequently found that the gums became exquisitely tender just before the attack. According to Gowers, 17 per cent. of his cases began with unilateral peripheral auræ, but I think this is too small a proportion, for, so far as I have observed, at least 30 per cent. of all my cases in which any auræ at all could be ascertained presented the history of a one-sided warning, beginning most often in the right hand. Gowers says that in three-fourths of his cases in which the attack began in the hand consciousness was lost before the seizure extended beyond the arm, while in the others it extended much farther before the actual fit was precipitated. In Gowers's cases he rarely found that unilateral auræ were associated with other warnings; and his experience, which is like my own, goes to prove that unilateral sensory auræ and one-sided initial motor expressions go together, and very often indicate gross organic disease. In some cases there may be for several days a decided unilateral or general muscular weakness or recurring chronic spasms which may be frequently repeated. In aborted or irregular attacks there are also peculiar motor symptoms, to which reference will be made later on.

In two or three patients I have found that the attack was immediately preceded by a profuse discharge of saliva, and in one case the patient had frequently bleeding from the nose. Several authors have called attention to certain local vaso-motor disturbances which are expressed by limited patches of cutaneous hyperæmia or anæmia, so that the fingers—or, in fact, the whole hand—may either be swollen and of a dusky-red color, or, contrariwise, there may be blanching and an apparent diminution in size.

Sometimes the patient immediately before the attack makes more or less automatic movements, pressing his hands to his head, clasping his breast, or clutching at some imaginary object, and after this he loses consciousness and falls to the ground. In some irregular cases the patient runs aimlessly for some distance or describes a circle, and after a variable time, which rarely exceeds a minute or two, the actual fit begins. Here are two examples:

Case I.—Boy aged fifteen, has been subject to somnambulism; attacks began two years ago. He frequently when sitting at table rises suddenly, and runs either around the room or out into the street if possible. In thirty seconds or so he falls to the ground in a convulsion. Always falls backward in opisthotonos.

Case II.—Man aged thirty-four. Attacks always begin by stage of violent temper. While unconscious he runs about office, striking all who try to restrain him; finally falls to the floor. Convulsions, when they occur, are always severe. Sometimes running attack is the sole feature.

This disposition to run is no less remarkable than another queer prodroma I have seen in several patients, who began to take off their clothing when first seized, no matter where they were or under what circumstances. This is not, as has been suggested, the remains of a half-formed idea that they must seek their beds because of their impending trouble, but it is a much less complex mental act, and the several patients I have seen were fully unconscious when they did this, and were in places where there was no bed within reach. Equally curious mental precursors of the attack have come to my notice, and these I will detail subsequently.

SYMPTOMATOLOGY.—The Light Attack.—The epileptic attack may, as I have said, be scarcely perceptible to those about the patient, or may consist simply of a momentary loss of consciousness and very feeble convulsive movements. Reynolds has described two forms: (1) That without evident spasm; (2) that with evident spasm. Such seizures are always fugacious, and consist merely in some transient loss of consciousness and very little or no convulsive movement. The tonic spasms prevail, if any, and the disorder of motility may often consist simply in the arrest of some act in the performance of which the patient is engaged. While playing the piano the patient's hands may for a moment remain suspended over the keys he is about to strike; if eating, the hand which holds the fork may be arrested between the plate and his mouth. The attack consists sometimes in the rolling upward of the eyeballs, or when crossing the room the patient may stop, remaining quiet for an instant. Temporary unconsciousness, shown by cessation of conversation, by change of color, and absence of intelligent expression, accompanies the other trouble. In a well-marked attack of petit mal the patient may move his lips convulsively, and remain otherwise quiet, but bereft of consciousness, for one or two minutes.

The patient sometimes loses himself and loses the thread of the conversation, repeating what he has just said or showing his want of appreciation of what his companion has said. To this light grade belongs the case reported by Jackson of the individual who blew his nose upon a piece of paper and gave the conductor £2 10s. instead of twopence halfpenny.

The Major Attack.—An attack of epilepsy of the familiar severe form may or not follow an aura. The first intimation to the bystander may be a noise made by the patient, which is either a loud, startling, wild cry, or a gurgling groan due to compression of the thorax and the forcible escape of wind through the vocal cords. There are three stages of the attack: (1) The stage of tonic convulsion; (2) the stage of clonic convulsion; (3) the reactionary stage.

The first stage of the attack is symptomatized by tonic spasms, which may be local or general, usually the latter. It is very often unrecognized, for its duration may be so short that it is lost in the stage of clonic spasms, which is much more protracted. There is usually unilateral seizure, the muscles of the face being primarily involved, then those of the hand and upper extremity, and then those of the lower extremity; and finally there is a general involvement, so that the patient may be in a position of opisthotonos. In some cases there is strong tonic contraction to one side, or pleurosthotonos. The notes of a case which illustrates the beginning and development of convulsion with reference to the parts involved, which I observed carefully, are the following:

Bindewald: Epileptic attack observed at hospital for paralyzed and epileptic, Sunday, Mar. 12, 1882:

1. Long, shrill cry which attracted my attention. It probably lasted five seconds. At same time patient threw up arms and became unconscious, and fell to floor. Nurses ran to him and placed him upon bed.

2. Tonic convulsions began by fine twitchings at right corner of mouth. These became gross, and were separated by succeeding long intervals. Eyes directed to left side, face pale.

3. In twenty seconds twitching began in right hand and arm, which were rigidly flexed (five seconds); then leg and foot of right side became agitated, the face meanwhile changing in color successively from red-gray to purple; lips purple, ears livid and purple, edges white; eyes still turned to the left, pupils dilated, eyes widely open; breathing stertorous and irregular.

4. General convulsions of right side.

5. Head suddenly twisted to left side; position of eyes the same. Chin drawn down, movements moderated; still livid. A fit of coughing and expectoration of much frothy mucus. Left side, with exception of head, not implicated. Whole attack lasted about one minute and thirty-five seconds. Deep sleep afterward, lasting forty-five minutes.

This attack was one of many in a confirmed epileptic, and is a fair example of those commonly met with, though not as general as we sometimes find. In most cases the attack appears to be very much longer than it usually is, and the phenomena noted above, which seemed to occupy a considerable space of time, really lasted but little more than a minute and a half. Axenfeld and Beau fix the average period of the attack as follows: “Duration of the complete attack, which Beau divides into four phases: first stage, tetanic stage, five to thirty seconds; second stage, clonic convulsions, from one to two minutes; third stage, stage of stupor, three to eight minutes; fourth stage, return of sensibility and intelligence. It is not complete until the end of from ten to thirty minutes.”

To be more explicit, the manifestation of an ordinary epileptic attack of the more severe kind is very much like this: Usually without any warning to those about the patient he utters a shrill, peculiar cry of a character never to be forgotten if once heard, and then, perhaps throwing up his hands, he falls to the ground rigid and contorted. His body may be arched laterally or antero-posteriorly, his legs are thrown out, his forearms flexed, and his fists doubled, the thumbs being beneath the other fingers. His face may be for a moment flushed, but the color recedes, and it assumes a dusky-bluish tint, the lips being ashy-gray. The eyes are usually open, and the balls are rolled up and the pupils widely dilated. The breathing may for a moment be suspended, but it soon quickens, and becomes labored and noisy, and the pulse grows hard and full. The tonic contractions are succeeded in a very short time by more or less violent clonic contractions, which increase in violence and rapidity; the jaws work and the lips are covered with foam, which is blown in and out by the rapid inspirations and expirations. It may be tinged with blood in the severe attack if the tongue is bitten, which is by no means an uncommon accident. The teeth are sometimes firmly set and the jaws locked. The head is usually drawn to one side in the first stage, but afterward may be rolled from side to side. The movements are now more or less general, and occasionally the agitation is so great that the patient throws himself from the bed on which he may be lying. The face grows more pale, or rather more livid, and toward the end of this stage there may be a puffiness and congestion such as are seen in partially asphyxiated individuals, for this alteration in color is due to dyspnœa and consequent imperfect oxidation. The patient may defecate or pass his urine unconsciously, and sometimes we find seminal emission. The movements, after a period varying from ten seconds to a minute or two, become less violent, and he may talk in a silly manner, as a person does who is recovering from profound ether unconsciousness; or deeply sigh, and he is restless. The pulse is now much weaker and more rapid, and may be irregular. The color returns to the face, the patient closes his eyes, and the body is covered with profuse perspiration. The fingers are unlocked and every evidence of spasmodic movement disappears. He falls asleep, and remains so for several hours, awaking with a confused feeling, headache, and no remembrance of the attack, and is only reminded that something has happened by his wounded tongue or lips, the bruises he has received, or by the information of friends. He looks jaded and tired, and is indisposed to exert himself for several days if the attack has been at all severe. The transition from the attack to the normal state is not always the same. Some patients do not sleep at all, but after being dazed go about their occupation. This is even true occasionally of the severe form of disease.

The usual termination of the attack is, however, by sleep preceded by a period of confusion. The patient, after coming out of the clonic stage, mutters incoherently. He is apt to pass large quantities of wind from his bowels, or vomits. This is attended by a subsidence of the spasmodic movements, and perhaps by oscillation of the eyeballs. The pulse loses its rapid, hard character, and the reaction brings with it diminished frequency of respiration and the evidence of exhaustion.

Special Symptoms.—The eyes are, as a rule, open, and, there being spasmodic movement of the ocular muscles, we find that the balls are either rolled up or directed away from the side in which the spasms begin. This is especially true in those epilepsies due to cortical disease, and the same law of conjugate deviation laid down by Bourneville may be remembered.

The pupils are dilated pretty much throughout the fit, though they may vary, and a transient contraction may occur at the commencement of the first stage. During the clonic stage, especially toward the end, they not infrequently undergo a species of oscillation. The interparoxysmal state is revealed by a very great mobility of the pupil, which has been observed by Gray and others. Gray is disposed to consider it a diagnostic indication of value, but so far I have found it only in two-thirds of my cases. Dilatation of the pupil I believe to be a very constant feature of epilepsy.

The ophthalmoscope reveals in certain cases an abnormal increase in the circulation at the fundus, in others a very decided emptiness of the retinal vessels. Jackson is disposed to consider that certain visual auræ depend upon spasm of the arterioles in this location. Loring, whose opportunities for research have been very great, is not disposed to attach much importance to the ophthalmoscopic appearances, at least during the periods between the fits.

The pulse of the epileptic between the paroxysms is small and irritable. Voisin has found the following changes: “Two or three seconds before the attack it becomes rapid, sharp, and the sphygmographic curves are higher, rounded, and nearer together. When the attack begins we see five or six little undulations in the course of the ascending line, and the curves are higher and more accentuated. Several minutes after the attack there is dicrotism, and the line of descent is very sharp, the angle with the ascending being quite acute. This form of pulse lasts an hour or half hour after the attack. There is in some cases great irregularity, with paroxysms of cardiac pain resembling angina pectoris. There is occasionally epistaxis or more marked hemorrhages.” Parrot speaks of hemorrhages from the eyes and ears, and occasionally the cerebral congestion is so great as to result in cerebral hemorrhage in old subjects.

The temperature is usually lowered before the attack, but the surface temperature is increased during or after the second stage.

Cutaneous sensibility is often very much disturbed. Spots of hyperæsthesia and anæsthesia are sometimes left after the attack. The scalp is not infrequently exceedingly tender. The sensory troubles have been alluded to as prodromata of the ordinary motor attack. Some attacks of the sensory variety in which psychical excitement plays a part are characterized by unilateral and persistent formications.

A consequence of some epileptic paroxysms is the appearance of petechiæ, chiefly upon the face, neck, and upper extremities. The skin of old epileptics is harsh, cold, and rough, and the face is apt to be studded with spots of acne even when the patient is not taking the bromides. The hair is stiff and dry, and the ears and tip of the nose are apt to be the seats of a passive and old hyperæmia.

The urine of epileptics is apt to contain evidence of muscular waste, and an increase in the amount of earthy phosphates as well. Zapolsky found, however, that immediately after the attack there was diminution in the quantity of the phosphates. The occurrence of glycosuria has been noted by numerous clinicians. De Renzi29 has published an interesting article. I have seen no less than six well-marked cases within two years in which constant glycosuria was a feature of the disease, but in two of the patients well-marked symptoms of disease of the pons were present. After the paroxysm it is by no means uncommon to find the urine loaded with albumen. Otto, Mabille, Saundby, Bazin, and other writers speak of a transitory albuminuria. Kleudgen,30 however, does not attach much importance to this feature, believing that the albumen is often due to semen.

29 Gior. internaz. d. Sc. Med., Napoli, 1880, ii. 357-359.

30 Archiv für Psychiatrie, etc., 1880, xi. 478-506.

The tendinous reflexes are frequently abolished during the attack, but not always so, and in several cases in which I was enabled to make a test during the convulsion I found that the patellar reflex was very active, and in one case elsewhere reported it was transferred. The skin reflexes are ordinarily exaggerated.

Tongue-biting is, I think, a more common feature of the nocturnal than the other attacks. It is rare in infantile epilepsy, and is always a bad feature. The wound is sometimes very serious, and cases are mentioned where the tongue has been severed. An occasional sequel of the attack is a urinary difficulty and vesical tenderness. It is sometimes connected with great urethral irritability and spasmodic stricture, which prevents the introduction of a sound or catheter. Romberg speaks of the supervention of asthma and dysphagia.

THE IMMEDIATE AND REMOTE EFFECTS OF THE EPILEPTIC PAROXYSM.—As a result of violence we often find wounds and bruises, quite rarely fractures, but more often dislocations. Cases have been communicated to me where as a result simply of the great muscular force the humerus has been dislocated at its superior articulation. Muscular pain of great severity, and sometimes of great persistency, follows unusually severe fits, and rupture of muscular substance is not uncommon. An epiolecranon bruise in one of my cases produced a severe neuritis which was very intractable. In old cases, according to Axenfeld, there may be great muscular hypertrophy, the sterno-mastoidii attaining the size of the biceps, and in other cases there is fatty degeneration. He also calls attention to defects that may be due to frequent exercise of violence upon bones through repeated exaggerated muscular contraction. Paralysis of nerves which supply convulsed members is mentioned.

The psychical effects are various. For several days following the attack there may be simply confusion of ideas, irresolution, or drowsiness, which subsides in a short time. In not a few cases I have regarded the attack as beneficial in the sense of an explosion of relief when perverted mental states had preceded it. In such persons the discharging lesion was followed by a very conspicuous restoration of the mental equilibrium.

Occasionally the attacks are terminated by great violence or screaming or the commission of purposeless acts.

Post-epileptic aphasia has been described by Winslow, Moreau, and others, and among my own cases of the sensory variety of this disorder I have met with speech disturbance. The aphasia is of short duration, and consists either in a total incapacity for verbal expression or a transposition. It is not rare for it to be associated with the commission of a number of quasi-automatic actions.

Unilateral epilepsies are quite apt to leave behind them a species of paresis which may last even for several days. The loss of power is confined to the convulsed members, and may be accompanied by tingling. In the greater number of instances, however, there is some central organic change, and the epilepsy is purely symptomatic.

Deafness, amaurosis, and other pareses of the organs of special sense are rare sequelæ of the epileptic state.

The remote effects of the grave disease are not so decided as when the patient has been the subject of petit mal. Slight repeated losses of consciousness are apt to be followed by mental decay. The ultimate result is mental enfeeblement, a progressive and very great loss of memory, which advances to such an extent that a veritable dementia ensues. With this there is usually a very decided perversion of the emotions and affections, so that a good-natured, amiable child may in a few years become everything that is bad and trying, and the acts of mischief are almost inconceivable. Theft, incendiarism, and various moral perversions are common in some chronic epileptics. The dementia, it is true, is tardy in its establishment, but it comes eventually if the individual lives long enough.

In some individuals there is a very early tendency to the development of mania; there is a certain periodicity about the explosions, and when established the excitement either precedes the attack by a few days or occurs shortly afterward. The violence is characteristically acute, and such insanity very often makes itself known in homicidal acts rather than in those of a suicidal character. Hypochondriasis is quite likely to follow continued epilepsy.

It is the rule for epilepsy to undergo decided modifications in the beginning of its course. The first attack may be simply eclamptic, without any peculiarities or definite character, and with recurrence there is a tendency to regularity and constancy in expression. Infantile convulsions, that may occur at any time after inconsiderable exciting causes, may eventually be confined to the early morning or night. So-called fainting attacks may precede petit mal, and headache may be the precursor of ill-defined seizures. So, too, the relation of grave and light attacks may vary. In the beginning there may be nothing but attacks of petit mal, while later these may be supplemented by severe fits, and even disappear entirely. So far as my own cases go, I find that nearly two-thirds of the entire number happen at night or in the early morning, while the others may occur in the day or at any other time, or by day and night. Besides the terms nocturnal and diurnal, we may use the word matutinal in relation to the time of attack. So far as the number of attacks is concerned, we find great irregularity. It is not always possible to count them, or even to recognize them, for the examples are numerous where nocturnal attacks have been undetected for years, and have finally been followed by fits during the daytime. I have cases who have seizures but once or twice a year, and others who have ten to forty or fifty daily. In some cases there may be eight or ten attacks of petit mal daily, and but two or three grave attacks during the week.

The statistics of Delasiauve and Leuret go to show that of 296 cases of epilepsy, the cases of general epilepsy were most common—that is to say, the attacks which occur both by day and night.

Attacks occurring occasionally by day26
Attacks occurring habitually by day30
Attacks occurring only at night9
Attacks occurring habitually at night8
Attacks occurring equally by day or night87
Attacks occurring in larger proportion by day70
Attacks occurring in larger proportion by night 44

Delasiauve, Herpin, and others make delicate distinctions between the attacks, and the former grades the seizures beginning at accesses, and successively advancing to vertiges, accès intermédiares, and attaques or accès compléts.31 In fact, these are but varying degrees of violence of the discharge, after all. We thus have light discharges and severe discharges at different times, or, as the habit is established, only the light or only the severe, the manifestation depending probably upon the number of discharging cells and the importance of the exciting cause.

31 Traité de l'Épilepsie, etc., Paris, 1845, p. 55 et seq.

When the attacks occur in alarming frequency, as they sometimes do, the condition is known as the status epilepticus. Leuret had a patient who had eighty in two hours, and Delasiauve reports the case of a young man fifteen years old who had twenty-five hundred in one month. They may be so numerous as to be apparently continuous. The patient remains in a state of coma (the status epilepticus), with very high temperature. If he be not restored, he sinks into a deeper coma, and all the signs of collapse manifest themselves. Bed-sores form, œdema of the lungs ensues, and the patient dies. Happily, this condition of affairs is rare.

Delasiauve calls attention to the fact that the first two or three attacks that usher in this state do not usually attract much attention, but the succeeding ones are so violent as to immediately suggest violent consequences. In one of my cases the attacks, when they had once become numerous, were readily excited by the least jarring, noise, or handling, just as we find in strychnine-poisoning or tetanus.

Irregular Forms.—There are occasional cases of psychical or masked epilepsy, the study of which is intensely interesting. Such forms are characterized by perverted consciousness and a low degree of volitional direction which may vary from automatism to the undoubted exercise of complex functions of the mind, though badly co-ordinated. Mesnet's soldier, when subject to a paroxysm and apparently unconscious, would perform a number of suggested acts in a rhythmical manner and with no subsequent knowledge of the previous event: when started off by the word of command to march, he would blindly go on, marking time when he met with an obstruction until stopped, or when a paper and tobacco were placed in his hands he would proceed to roll an unlimited number of cigarettes.

Two cases of a more complex exercise of certain intellectual powers, while others were dormant, came under my observation some time ago. One of them was a young man of twenty-three, who had had irregular epileptic seizures for some years. He went to bed one evening as usual, arose, and breakfasted with his family without creating any suspicion that he was at all unwell. He then went down to his place of business, and after his arrival was sent to a distant part of the city for some tool. On his return down town he stopped at a tobacconist's and became involved in a quarrel with one of the persons in the shop. A policeman was called, who, more intelligent than many of his class, immediately detected something queer about the man, arrested him, and afterward took him to Bellevue Hospital. There he remained three days, and suddenly returned to consciousness and a knowledge of his surroundings, but was entirely ignorant of his unfortunate experience. It is unnecessary to say his habits were perfectly good and he was not drunk at the time of the quarrel or arrest. His last recollection was that of going to bed the night before the day of his arrest.

Another case of unusual interest which came under my care, illustrating a phase of sensory epilepsy, is worthy of reproduction:

C. O——, aged twenty-two, is a reporter attached to one of the New York afternoon papers, who received a severe injury of the head when but three years old. He fell from the second story of an unfinished building to the cellar, striking the upper and back part of his head upon a beam. He was rendered unconscious, and remained so for a day or more. He recovered from the immediate bad effect, but has suffered from severe general headaches, which recur every week or so, with an increase in the amount of urine excreted. About six months ago he began to have epileptic convulsions of a violent character almost every day, and sometimes more often. These were precipitated by excitement, and he had a great many when worried about his wife at the time of her delivery. Upon one occasion he fell down stairs and injured himself quite severely. The attacks were, as a rule, preceded by an epigastric aura of long duration, and occasionally by a visual aura, and, according to the testimony of his associates, he became strange and queer. When in such a dazed condition he would restlessly wander about his office, and suddenly, without any cry, become convulsed. After the attack he slept soundly. The bromides of sodium and ammonium and digitalis did little or no good, but the bromide of nickel appeared to have some influence. During the past month he has had only two or three attacks, but these have been of a quite irregular character. He told me that there were times when he felt like doing himself an injury, and that he had impulses to kill some one else. His companions said he was irritable, pugnacious, and easily thwarted, and his brother-in-law stated that upon several occasions he had queer turns, when he would raise his hand to strike some member of the family—that he subsequently knew nothing of his conduct, and when it was detailed to him he appeared greatly astonished.

Mr. O—— came to my office in company with a friend at ten o'clock in the morning of December 27, 1883. He had had one of his attacks at the newspaper office, of rather more severe character than usual, at eight o'clock, with a psychical aura, during the existence of which he was very morose and sullen. Upon recovery he was speechless, though he could communicate by signs. Upon his arrival at my office his manner was composed and he appeared somewhat dazed. His pupils were dilated, but contracted readily to light. I asked him one or more questions regarding his inability to speak, which he perfectly understood, and when I gave him a pencil and a piece of paper he replied without difficulty in writing. When told to make a great effort to speak he did so, and I thought I detected the word ‘To day,’ but he could not repeat it, though he tried and expressed great annoyance. He was unable to utter any sound except a sort of groan, which could not in any way be taken as an element of speech. I examined his larynx, but found nothing which could explain his impaired phonation, and I sent him to Dr. Asch, who found absolutely no abnormal appearances to account for the speech difficulty. The patient could not phonate, and though he made attempts to enunciate the vowel-sounds, and the vocal cords were approximated, he made no orderly sound. Asch found a slight laryngitis of no importance.

The patient went home, and remained speechless all day, and was seen by my associate, G. de Forrest Smith, in the evening. What occurred during and after that gentleman's visit is contained in his notes: “I was called to see patient about 8.15 P.M. He was lying upon the bed, but had not slept; recognized me and motioned that he could not speak, and I found that he could only say one or two words, and this with the greatest effort, and so all my questions were put so that he could answer them by nodding or shaking his head. He knew that he had had an attack in the morning, that he had seen Hamilton and Asch, and recalled various incidents of the day, answering intelligently my questions in regard to them. He indicated by motions that his inability to speak was due to a lump in his throat. When asked if he had any trouble to think of the word he wanted, he shook his head, but shortly afterward hesitated in an answer, and when asked if this was due to his inability to think of the word, said ‘Yes.’ Was asked if he had any loss of power in either side, and he motioned to his right arm and leg, and said that he felt a numbness and pricking on that side. On his grasping my hands with his, the right was perceptibly weaker.

“At one time he seemed confused as to which was his right or left side, and put up both hands, and after looking at first one and then the other in a puzzled manner, at last decided correctly, then smiled apparently at his confusion.

“All this time he had been half lying on the bed. He now intimated that he was tired, put his head down on the pillow and began to belch up wind, and as he appeared about to vomit I called for a basin; but this was only the beginning of an attack; the muscles of the neck and right side assumed a state of tonic spasm, the extensors predominating, so that the head was turned a little to the left and forcibly thrust back into the pillow, and the right arm and leg were firmly extended. He remained in this position about one minute; then, taking two or three full inspirations, put his hand to his throat and said plainly, ‘Something has fallen from there.’ On being asked ‘What?’ he replied, ‘A bone has fallen from my throat.’ I told him it was well that the bone had fallen, as now he could speak. ‘Why,’ said he, ‘I have had no difficulty in talking.’ On being asked why he had seen Asch, he said ‘Who is Dr. Asch? I never saw any such person.’ Further questioning showed that all the occurrences of the day (except those which had taken place immediately before the first attack) were an absolute blank, and he thought it still morning. He asked the time, and I told him half-past eight o'clock in the evening. At this he seemed much surprised and said, ‘Why, I went to work this morning; how did I come here?’ I then explained to him that he had been ill. After further conversation he said he felt sleepy, and, after resting a few minutes, he arose, put on his slippers, and came out into the room. He walked with difficulty, because of the loss of power in the right side, which he said felt numb and sore, as if it had been pounded, also a sensation of pins and needles. After the attack his mind was perfectly clear, and he could talk as well as ever, and all that had happened before the attack in the morning he could remember perfectly well, but the interval between the two was a complete blank. His inability to speak seemed due, not to lack of knowledge of what he wanted to say, but rather to want of power to form the words, although there was no paralysis of the vocal muscles. When he did manage to say a word, it was invariably the correct one, but it was always done with the greatest effort. The day after the attacks he remained at home; the next day he went to work, but his head felt heavy and confused. Two days after he complained of a pressure on the left side and back part of the head; otherwise he was all right. At this visit he said that after I had left him on the night of the attacks he intently thought, striving to recall the incidents of the day, and after a time concluded he could remember being at Thirty-third street, but did not know how he got there. He thought he could recall going to see Asch, but would not know him if he should see him. I then asked him how questions were answered by him on that day; he answered he did not know, as he had not thought of that; then, after a few moments' reflection, said he must have written the answers. He was then shown some of the answers he had written, which he recognized, and by an effort of memory could recall some of the incidents of writing them. He was still unable to remember anything that occurred after his arrival home previous to the last convulsion.”

January 27, 1885: This patient subsequently suffered from several attacks in which the psychical element predominated. His head presented a remarkable deformity, there being a prominence posteriorly which might be compared to a caput succedaneum, only it was entirely osseous. The upper margin was separated from the anterior parts by a deep sulcus.

Under such circumstances we find very often that acts of great violence are committed by such epileptics for which they are entirely irresponsible. Two or three cases of the kind occur to me now. One of them was a boy who always bit every one and everything—his family, the domestic animals, and inanimate objects; another, a most dignified and lady-like woman, who violently struck different members of her family; and within the past week a woman was brought to me who hurled a kerosene lamp at a perfect stranger with whom she was quietly talking before the seizure was precipitated. Numerous instances are related where individuals while in the masked epileptic state have wandered for long distances and committed a variety of purposeless acts, and undoubtedly many of the mysterious disappearances are of this order.

SENSORY EPILEPSY.—Some years ago Hammond referred to certain peculiar epileptic attacks in which sensory manifestations were very pronounced. To this condition he gave the name thalamic epilepsy, believing the condition to be one of the optic thalamus. Among the large number of unclassified and irregular cases reported by various authors there are many so much resembling each other that I think they should be relegated to a special place.32 The notable examples of Sommers, Bergmann, Tagges, Guislain, and others belong to this category.

32 I shortly afterward, believing the term a misnomer, invented that in use: “On Cortical Sensory Discharging Lesions or Sensory Epilepsy,” New York Med. Journal and Obstetrical Review, June, 1882; also see “A Contribution to the Study of Several Unusual Forms of Sensory Epilepsy which are probably Dependent upon Lesions of the Occipital Cortex,” New York Med. Record, April 4, 1885.

The features of this form of epilepsy are (1) the expression of some hallucination (prodromal stage), or hemiopia; (2) supraorbital neuralgia; (3) aphasia, formication; (4) slight loss of consciousness, and little if any motor disturbance.

I may present two illustrative cases:

A few months ago I was consulted by a medical gentleman in regard to a patient who had for years presented a curious train of nervous symptoms, which afterward assumed a form leading me to think she might have sensory epilepsy. She would, in the presence of the gentleman who consulted me, who was a personal friend of the patient and a medical man, stop short in the midst of an animated conversation, look fixedly ahead, appearing momentarily lost, remaining abstracted for a short period, possibly a minute, and on recovering herself go on, finishing the sentence she had commenced before the seizure. At this time she constantly had hallucinations of a visual character, when she saw animals, birds, figures of men and women, who approached her, as well as a variety of other objects. A common hallucination, which had been repeated quite frequently, consisted in visions in which green leaves and white rabbits and other objects familiar to her in childhood figured extensively. Upon one occasion, while sitting in the drawing-room, opposite a door which communicated with the hall, she suddenly called her companion's attention to the hand of a man which she saw clasping the baluster rail. The hand was seemingly disconnected from the arm. She was somewhat agitated, and it was nearly half a minute before the vision was dismissed. Sometimes she would call attention to the hallucinations before the attack, but more often she became transfixed, apparently lost, and then recovering she described her visions minutely. She has apparently been able to foresee the attacks and ward them off by a strong voluntary effort. So far as can be learned, there is no hysterical element in the case, but her seizures are more frequent at the time of menstruation. In a private note it is stated that “the family history of the patient is very good, and she has always seemed remarkably healthy and robust, and has shown more than usual intellectual ability. She has appeared to persons generally to be of a contented, happy disposition.... At night, when she closed her eyes, she suffered from these hallucinations, especially after a day of fatigue. Her pupils are usually dilated, but her color undergoes no change during the seizure.”

The second case is one of a more complex type:

J. B——, a bright boy aged sixteen, was sent to me by F. H. Bosworth in April, 1883. He comes of nervous stock, his mother being subject to epilepsy, and his father is an eccentric man who manifests his mental peculiarities chiefly in a morbid restlessness and irascibility. There is a brother who is healthy. The attention of the parents was first called to the boy's condition by his recital of a sudden attack which occurred during the summer of 1882. While rowing upon a river he suddenly and completely lost the visual use of the right eye, so that in looking at a number of ducks swimming near his boat he failed to perceive those upon one side of the flock. This condition lasted for twenty minutes, and after a brief and severe pain over the right eye he became unconscious, the unconsciousness being preceded by a tingling and numbness of the hand, forearm, arm, and left side of the tongue. He has subsequently had eight or ten of these attacks, of which the following is an example: Usually without any bad feelings, physical or mental, he, while engaged in any duty or at any time, suffers a sudden unilateral blindness. This is never gradual, and not like the form of amblyopia in which the visual field is gradually reduced. There is some hemichromatopsia. It would seem as if the retinal anæsthesia was unequal, for while usually the loss is complete and universal, it sometimes happens that there is only a limited loss. Upon one occasion, while reading, he suddenly lost the printed matter of the right lower half of the page below a diagonal line extending from the right upper corner to the left lower corner. There is never diplopia. This deprivation lasts anywhere from ten to twenty minutes; meanwhile, a distal anæsthesia, coming very gradually, involves at first the fingers of the opposite hand, and successively extends to the forearm, arm, and other parts, as I have already mentioned. There seems to be analgesia as well as anæsthesia, for a pin may be run into the muscles without producing pain, and upon one occasion the gum was freely pricked without any discomfort to the patient. It invariably happened that the cutaneous sensory trouble occurred upon the side opposite to the hemianopsia and neuralgia, and in the greater number of instances the left side was that affected. The third stage of the attack consists in migrainous headache of a very severe kind, and which sometimes lasts for an hour or more. There is a subjective feeling as if the eye was pushed forward. This disappears with nausea and relaxation. More often he loses consciousness when the anæsthesia reaches its limit, which seems to be the extension of the anæsthesia to the gums. Occasionally there are slight convulsive movements upon the anæsthetic side. While the attacks involve the left side of the body as a rule, it happens that when there is primary left hemianopsia and right-sided anæsthesia the boy becomes very much confused in speech, and sometimes is paraphasic, the trouble being but transitory. He is sometimes unable to speak at all, though perfectly conscious and in possession of his faculties. No pupillary disturbance has been noticed at any time. Upon two occasions there was a swelling of gums and tongue, which was not only subjective, but perceived by the mother. Occasionally he sees prismatic colors and rays before the blindness, but this has been only once or twice. During his early life he had attacks of slight numbness of the hands and feet which were not thought much of, and he had headache as well. He has been a somnambulist.

MORBID ANATOMY AND PATHOLOGY.—The literature of the experimental physiology of epilepsy is enriched by the observations of a variety of careful students, among them Sir Astley Cooper, Kussmaul and Tenner, Brown-Séquard, Nothnagel, Schroeder Van der Kolk, Pitres, Hughlings-Jackson, and the followers of the localization school, as well as many others more or less distinguished.

The experiments of many of the early writers were directed for the purpose of ascertaining the relations of circulatory variations to convulsive seizures, and the most notable were those of Burrows and Kussmaul and Tenner. These latter produced compression of the carotid arteries, and instituted cerebral anæmia by free and exhausting hemorrhages. As a consequence, the emptying of the cerebral vessels was followed by a loss of consciousness and by epileptiform convulsions, and it was necessary to produce the same result to compress all the great afferent vessels of the brain. The experience of surgeons generally is, that ligation of the common carotid upon one side of the neck is sometimes very apt to produce an alarming anæmia, with occasional convulsions, and sometimes fatal consequences.

The experiments of Hall, Landois, Hermann, and others, as well as those of the writers just mentioned, show that carotid compression results in capilliary anæmia and venous hyperæmia, and that with cessation of this pressure there is a sudden congestion of all vessels. The susceptibility of the brain is greatest at its posterior part and between the optic thalami and the cord. When the bulb was subjected to sudden changes in its nutrition—such, for instance, as followed the experiments of Hermann, who ligated simultaneously the superior and inferior venæ cavæ of a rabbit—there were not only convulsions, but various cardiac and other disturbances which were undoubtedly due to central impairment of function. Kussmaul and Tenner conducted their experiments with watch-glasses luted into the cranium—a procedure which, however, at best, is unreliable.

Brown-Séquard some years ago in part established an important pathological truth, the theory of epileptic zones, and demonstrated in certain animals that bruising and injury of the great nerve-trunks, especially the great sciatic, would give rise to epilepsy, and that irritation of certain tracts would precipitate the paroxysms. He further announced that the progeny of animals in whom epilepsy had been thus induced very frequently inherited the epilepsy of the parent. By some it was held that such epilepsies were purely peripheral, and Brown-Séquard even believed in spinal epilepsy. His spinal epilepsic theory has, for the most part, been explained by the anatomical researches of Hitzig and the doctrine of interrupted spinal inhibition. In fact, many of the spinal epilepsies are examples of exaggerated reflexes.

The epileptiginous zone theory, which, while it induced many to believe that the disease might have its origin outside of the brain, gave rise to the false assumption that attacks with distal auræ were primarily non-cerebral, has been discarded, and most observers have arrived at the conclusion that even in these cases the first explosion is due to some cerebral cell-discharge.

Hughlings-Jackson's grand work has revolutionized the views held prior to his first published writings, about twelve years ago. He believes that any part of the gray matter may, through over-excitability, give rise to convulsive attacks.

The production of convulsions by cortical irritation is now an old story.

The experiment of Pitres and Frank33 bears upon the sensorial function of the cortex in showing that, when the cortex is irritated, epileptiform convulsions follow, but if the exposed surface be subjected to the ether spray the same irritation will only produce definite movements, but no convulsions.

33 Gazette des Hôpitaux, No. 38, 1883.

The investigations of Van der Kolk especially, and his followers, certainly give the medulla an important place as the locus morbi of the malady; and it must be assumed, bearing in mind the existence of the vaso-motor centres of Dieters and the presentation of symptoms indicative of disturbance at the floor of the fourth ventricle, that the most important pathological changes must be looked for in this part of the brain.

Jackson's cortical explanation is, however, fully in consonance with the medullary theory. If we study the different stages of the attack, we shall find that there is probably a suspension of cortical inhibition—that a derangement of the cortical cells or discharge may cause a resulting disturbance in the bulb. On the other hand, a reflex irritation through the pneumogastric or from some distal part brings about the same disturbance of equilibrium. There is anæmia due to irritation of the vaso-motor centre, an inhibition of the great ganglion-cells, and a disturbance of function of the important cranial nerves. The primary anæmia and unconsciousness are accounted for by this primary irritation of sympathetic filaments and vascular constriction; the secondary hyperæmia is explained by the experiments of Kussmaul, which demonstrated the succeeding congestion; or by irritation of the spinal accessory and contraction of the muscles of the neck and compression of the large veins. The pupillary, ocular, respiratory, and other symptoms indicate the disturbance of the nerve-nuclei in the bulb. The respiratory difficulty and the interrupted decarbonization of the blood undoubtedly account for the secondary unconsciousness.

Van der Kolk34 in localizing the lesion in the medulla found capillary dilatations in the neighborhood of the hypoglossal nuclei in tongue-biters. In epileptic patients who were in the habit of biting their tongues during the fit the vessels were wider than in those who did not bite the tongue, on an average in the course of the hypoglossus by 0.096; in the corpus olivare, which certainly here plays an important part, by 0.098 mm.; and in the raphé by 0.055. In those who did not bite the tongue, on the contrary, the vessels in the path of the vagus were 0.111 wider than in those in the first, Table A.35

34 “On the Minute Structure and Functions of the Spinal Cord,” by J. L. C. Schroeder Van der Kolk, New Syd. Soc. Trans.

35 TABLE.

Different Epileptics.Hypoglossus.Corpus olivare.Raphé.Vagus.
Table A—tongue biters0.3060.3150.3150.237
Table B—non biters0.2100.2170.2170.348
Difference +0.096 A. +0.098 A. +0.055 A. +0.111 B.

Nothnagel36 is of the opinion that the anæmia of the brain is not the cause of the convulsions, but that the “excitation of the vaso-motor centre and that of the centre for the muscles are co-ordinate—that both go on side by side, and are independent of each other.”

36 Ziemssen's Encyclopædia, vol. xiv. p. 268.

He by this theory explains the occurrence of those forms of petit mal in which there is loss of consciousness without convulsions, and, on the other hand, twitchings before the coma.

The best argument in favor of this hypothesis is in Jacksonian epilepsy, when monospasms exist oftentimes with a succeeding extension.

In those cases which are the outgrowth of migraine the pathological condition is probably an exaggerated tendency to angio-spasm, the original impaired vascular tonus in the beginning giving rise simply to pain and lesser troubles, while after repeated changes of calibre not only nutritive alterations ensue, but hyperexcitability of the bulbar convulsion centres as well.

The labors of those who have endeavored to connect epilepsy with cerebral-tissue alterations have been attended by nothing very definite or positive, so far as pathological explanation is concerned. The post-mortem appearances have varied widely, and the only conclusion to be reached is that which shows that almost any morbid gross alteration of the cerebral mass may be symptomatized by convulsions, but such a production of paroxysmal trouble is much more likely to be the case, and in a more definite manner, when the cortical motor-centres are subject to destructive disease or irritative pressure. This is even not always the case, for numerous cases of injury of the paracentral lobe have been recorded with no showing of resulting convulsions. The long list of autopsies which I will not here consider show that an epilepsy may owe its origin to the pressure of a spicula of bone, or to the pressure exercised by depressed fragments of the same—to tumors or adventitious products, meningitis, cortical encephalitis, vascular degeneration, ventricular œdema, contusio-cerebri, and many other morbid processes which result in rapid or tardy degeneration. Of course, in such cases the genesis of the disease depends not so much upon the nature of the lesion as the location. The fruitful collections of cases of Ogle and Jackson are full of examples of limited growth or disease involving the cerebral cortex, while numerous cases collated by other writers show disease of the bulb or various peripheral parts which have been closely connected with the growth and behavior of the affection.

Several able pathologists have independently and repeatedly found that sclerotic degeneration of the hippocampal folds often existed. Delasiauve and Lébert first observed this lesion, but many modern authorities—among them Meynert, Nothnagel, and Charcot—who have also found this appearance, regard the change as of purely secondary, and consequently unimportant, character.

Tamburini37 reports a case of hemiplegic epilepsy with induration of the left optic thalamus and the left cornu ammonis, in which aphasia existed. Pfleger38 and Henkes have also found the sole lesion to be induration of the cornu ammonis. Of Pfleger's39 43 autopsies, atrophy and sclerosis of the cornu ammonis were found twenty-five times, and it was noted that the extent of the morbid change bore relation to the violence and frequency of the seizures.

37 Sallanzani, Modena, 1879, viii. 550-557.

38 Allg. Zeitschrift f. Psychiatrie, etc., Berlin, 1879, xxxvi. 359-365.

39 Ibid., lxxvi., and Arch. de Neurologie, No. 2, 1880, p. 299.

In many examples, especially where the disease has been found to be unilateral and associated with more or less hemiatrophy, the autopsy disclosed a corresponding hemiatrophy of the brain. Many such cases are reported. I have frequently found epilepsy in association with cerebral hypertrophy, and as a symptom of cerebral tuberculosis it has long been recognized, and numerous cases are reported in which for a long time the paroxysms were the only manifestations of the condition. In one of these cases, reported by Luys,40 the bulb was found involved by tuberculous matter.

40 Archives gén. de Méd., 1869, ii. 641 et seq.

Convulsions have very frequently been noted in association with imperfect cerebral development, and Echeverria laid great stress upon the hyperplastic increase in volume of certain parts of the brain.

Marie Bra41 has thus summed up her conclusions relating to the morbid anatomy of epilepsy:

“1. The mean weight of the brains of epileptics is less than the physiological mean.

“2. The cerebellum is greater than the physiological mean.

“3. There frequently exists an asymmetry between the lobes (not peculiar to epilepsy). The increase of weight is sometimes found on the right and sometimes on the left side. Equality is the exception.

“4. In no form of mental disease (excepting perhaps general paresis, which is accompanied also by epileptiform crises) have we met with so marked and constant a variation between the weights of the hemispheres as exists in epilepsy.”

41 Referred to by Axenfeld.

Drasche, Green, Greenhow, Löbel, and others have detailed cases in which tuberculous deposits were undoubtedly the causes of the disease.

Kussmaul and Tenner, Hoffman, and others have held that a stenosis of the superior part of the vertebral canal may explain, through pressure upon the cord, the genesis of the attack, and Kroon found asymmetry of the medulla oblongata.

The microscopical changes that have been found in brains where no gross lesion was apparent are by no means distinctive. I have myself examined the brains of many epileptics with discouraging results. The varying granular cell-degeneration, capillary dilatation, and exudative changes are common enough. In several cases of cortical epilepsy I found more or less advanced degeneration of the great cells in limited regions.

By far the most important and exact changes are those observed in the cases of sensory epilepsy. I have elsewhere collected some continental cases. In brief, areas of occipital softening or degeneration have been discovered in those cases with hallucination, sensory expressions, and hemiopia. In one case attended by hallucination of smell the autopsy disclosed the following:

M. M——, was a stout Irish woman about forty years of age. She had suffered from a light form of epilepsy dating from the tenth year, and resulting, as she stated, from a fall, when she struck her head and was unconscious thereafter for some hours. No scar was visible, however. No satisfactory history could be obtained regarding her early life and the first paroxysms. In the beginning these were rather frequent, and she had as many as four or five a month. They afterward diminished in number and severity, and for many years she had but three or four in the course of the year. They were not very severe, and she was enabled to pursue her work as a housemaid, but did not keep her places for any great length of time. She rarely bit her tongue, but usually frothed at the mouth and became livid and convulsed for a short time. There was no history of one-sided spasms. As I have stated, I could gain no accurate account of the previous attacks, except that she nearly always had an aura of a peculiar character, which was a prominent feature of the seizure and very pronounced. She suddenly perceived a disagreeable odor, sometimes of smoke, sometimes of a fetid character, and quite uncomplicated by other sensory warnings; and afterward became unconscious, and remained so for two or three minutes. She was invariably able to describe her sensations when she recovered, which she always did when I asked her, comparing her warning to the smell of burning rags, to the smell from a match, and, as she expressed it, it sometimes rose up in her head and choked her. She was under my observation for one or two years, but eventually developed phthisis, and died, her attacks occurring from time to time until her death.

Besides well-marked tuberculous lesions in the lungs, there was little of interest so far as the visceral examination was concerned. The brain was removed and its peculiarities were carefully observed. A great quantity of fluid was found, especially at the dependent portions of the membranes and in the ventricles, while the dura was thickened and pearly in spots. There was a condition that might be likened to a low grade of hemorrhagic pachymeningitis, and at the base of the brain old plastic changes were found, there being adhesions, especially in the region of the middle lobes, but more particularly on the right side and near the median line. The brain as a whole was small, and weighed forty-one ounces and a fraction. The sulci were deep and gaping, and the convolutions were distinct. There was no atrophy of the fore-brain convolutions, and no other pathological appearance was presented except that found in the meninges, but at the lower part of the temporo-sphenoidal lobe of the right side an appearance was found of an exceedingly interesting nature. At this point a decided shrinkage of tissue was discovered, with depression and adhesion of the pia, the induration involving the uncinate gyrus and parts of the adjacent convolutions, as represented in the drawing. No induration or softening of the great motor tracts was observed, and the optic thalamus and parts adjacent were uninvolved, as was the cord. An attempted microscopic examination, undertaken some months subsequently, was unsatisfactory, because of the bad condition of the brain, the preserving fluid having been improperly made. The olfactory nerves were not involved. The third frontal convolution was examined, but no disease was found there. Consequently, it is to be inferred that no lesion of the external root of the olfactory nerve existed.

FIG. 27.

Lower Face of Right Hemisphere.

DIAGNOSIS.—Having spoken of epilepsy as in most instances a symptomatic disorder, it would be proper to confine this section to the differentiation of the simpler and more classical form of the idiopathic disorder from certain purely eclamptic attacks or those due to cerebral tumor or coarse degeneration. The epileptic attack itself is to be considered from its time of happening, its duration, the element of unconsciousness, its associations, and the antecedent history of the individual. It may be confounded with the similar phenomenon dependent upon cardiac weakness, uræmic poisoning, toxic or alcoholic saturation, etc.

Of course, when we find recurring seizures with a certain amount of what Carter-Gray calls quasi-periodicity, preferring perhaps the night, the early morning, or only the daytime, we are almost sure of epilepsy. This supposition is strengthened by the association with attacks of petit mal. The duration of an attack, which may be from a few seconds to several minutes, is also a guide, for in certain toxic and other paroxysms the rule is for a succession of attacks to occur.

The question of consciousness is one that has drawn forth a great deal of discussion, especially with reference to medico-legal cases. I think the majority of clinicians are agreed that loss of consciousness is an absolute belonging of epilepsy, yet there are cases in which the lapse is scarcely perceptible. It is a dangerous precedent to establish, for the convulsive symptoms in such cases are taken from the epileptoid category. It is quite true that there are many hemi-epilepsies in which the intellectual condition is one that may easily be mistaken. I have seen numerous cases in which an apparent conservation of consciousness remained throughout a slight monospasm, but I do not feel at all sure of this; and in cases of aborted or masked epilepsy there is a dual mental state which would readily deceive the lay observer. The case of Mrs. S—— is an example of this kind. After the obvious subsidence of the dramatic and conspicuous feature of the fit she remained for hours and days in a state of undoubted transposition, performing acts which required something more than a high degree of automatism—going to the table, talking about certain subjects which were suggested, with apparent ease, but not connecting them intelligently with her surroundings, as she would before and after the epileptoid state. After a time she apparently resumed her normal state, but was entirely unconscious of the happenings of her previous hours or days, not even recollecting her simplest actions. Julian Hawthorne's hero in Archibald Malmaison, though not drawn by a physician's pen, suggests the state of which I speak, and it has the merit of being based upon one of the elder Forbes Winslow's interesting cases.

When we find paroxysmal attacks occurring in individuals with atypical heads, thick swollen lips, scarred tongues, and irregular teeth, we may strongly suspect the patient to be epileptic. To these we may add the appearance of the eyes, the fishy, lack-lustre expression which betokens old epilepsy. The hands are clammy and the skin mud-colored; the hair is dry and coarse; and the body often has a death-like odor.

In children, certain mental peculiarities are to be inquired into. Unnatural brightness or dulness—what may be called the clumsy organization—is often present, and the muscular use is often imperfect. We find that there is often but little nicety in walking, in using the hands, in speaking, or after learning to write there is an incapacity, with ever so much teaching, to develop a character or style. Such children can never become ambidextrous. These little points may seem trifling, but to the physician who carefully studies his cases they may prove of great help. The history of the nights may often lead to the discovery perhaps of a long-existing nocturnal epilepsy. Incontinence of urine, blood upon the pillow, nightmares, morning headache, and petechiæ betoken unsuspected night attacks; and Le Grand du Saulk mentions the case of a young Englishman who committed a purposeless crime and was discovered to be epileptic, the diagnosis being confirmed by an antecedent history of nocturnal seizures, and subsequent watching resulted in the discovery of many night attacks.

As to special conditions with which the epilepsy may be confounded, I may refer to cardiac weakness. It not rarely happens that simple fainting attacks are confounded with those of an epileptic nature. Such is the case more often in heat-prostration, when some rigidity attends the loss of consciousness. The duration of such a state, the condition of the pulse and color, however, will easily clear up any doubts upon the part of the observer. The existence of a cause should also be considered, and the fact that usually the epileptic paroxysm is sudden, while a feeling of depression and feebleness precedes the fainting attack, should be remembered. I may present in tabular form the points of difference:

EPILEPSY.SYNCOPE.
Loss of consciousness sudden.Loss of consciousness follows feeling of faintness.
Period of complete unconsciousness usually short.Unconscious throughout, no convulsions.
The existence of auræ of a well-defined type.The existence of preliminary vague prostration, nausea, and irregular heart action.
Often involuntary discharge from bowels and bladder.Quite rare or never.
Patient usually falls into heavy sleep or is indifferent after convulsion.After slight weakness patient is anxious and worried, and quickly seeks relief.

The difficulty of diagnosis, however, is only in cases of petit mal.

There are light forms of auditory vertigo that may resemble vertiginous epilepsy. In the former there is never loss of consciousness, and the patient refers to the rotary character of the vertigo. A history of antecedent attacks, tinnitus, aural disease, and a certain constancy which is not a feature of petit mal, may be mentioned.

There are cases, however, which are puzzling, and come under the head of auditory epilepsy rather than auditory vertigo; and in these there is a multiplicity of expressions, the auditory symptoms predominating.

Of uræmic convulsions it is hardly necessary to speak. There is a previous history of renal disease which the microscope and less delicate tests will reveal, and clinically there is antecedent headache, some stupidity, and not unrarely thickness of speech and somnolence. There are some cases, however, which are obscure. I have known patients with chronic renal disease—such as waxy kidney, for instance—to develop a species of epilepsy, the paroxysms recurring from time to time and behaving very much as the idiopathic disease would; and their occurrence would mark some imprudence in diet or exposure, and their disappearance an improvement in the patient's general condition. The attacks were not classical, inasmuch as there seemed to be but one stage of violent clonic convulsion, preceded by intellectual dulness, and followed by a semi-comatose condition which was far mere profound than the somnolent stage of epilepsy. The movements were not accompanied by a great degree of opisthotonos or pleurosthotonos.

Alcoholic and absinthic epilepsies are usually preceded and followed by symptoms indicative of profound saturation.

The consideration of hysterical epilepsy may be found elsewhere, but it may do to briefly refer to some cases which do not present the phenomenon first described by Charcot and Bourneville. The ordinary hysterical attack is never attended by loss of consciousness, by any of the pupillary changes so constant in epilepsy, by the mobility of the pupil between the attacks which is present in a large number of true epileptic individuals. There are never the succeeding changes of color, and the seizures are commonly produced or attended by some emotional disturbance, or are associated with ovarian disturbance.

Epilepsy is occasionally simulated by malingerers, and sometimes the skill of the subject is so great as to even deceive the practised eye. Prisoners, soldiers, and litigants may counterfeit an epilepsy, and go through with great personal suffering to accomplish their purpose. “Clegg, the dummy-chucker,” whose remarkable case has figured in the medical journals, upon one occasion threw himself from an iron platform to the stone floor of the jail, nearly twenty feet below, to convince a suspicious physician of his honesty. The simulator rarely bears close watching. The dilatation and contraction of the pupil cannot be simulated, nor can the corneal or pupillary insensibility. The fraud cannot voluntarily change his color, as is the case in true epilepsy, and as a rule the thumbs of the impostor are never flexed, as they should be. Suggestions for a purpose are readily heard, and sometimes adopted, by the apparently unconscious man. Gottardi42 lays great stress upon the use of the ophthalmoscope as a means of detecting simulated epilepsy. He calls attention to the frequency of retinal changes with facial asymmetry and other evidences that suggest cerebral disease or non-development. Gottardi has found that the pulse in true epilepsy is always lower after an attack, but it soon reaches its normal standard.

42 Abstract in Journal of N. and M. Dis., Oct., 1881, p. 843.

The differentiation of idiopathic epilepsy from that due to syphilis is possible when we consider the element of pain. Besides the tibial pains of syphilis, the epilepsy thus produced is often preceded by intense frontal headache, while that of ordinary epilepsy follows the attack. The syphilitic epilepsy is not attended by so great or continued a loss of consciousness as the non-specific form, and the movements are apt to be most violent on one side or the other. The association of the attacks with various bodily signs, such as nodes, old scars, alopecia, erosions, etc., and in connection with possible cranial nerve-paralyses, will throw light upon its true character. The paralyses referred to seem most frequently to involve the motor ocularis, abducens, and patheticus. Syphilitic epilepsy, too, is quite irregular in its time of manifestation, and is not unrarely followed by aphasia; but the interparoxysmal mental state is one of extreme dulness, memory being blunted and there being a peculiar hebetude.

PROGNOSIS.—Within the past quarter of a century the ideas of the medical profession regarding the curability of epilepsy have certainly undergone a change. The statistics of Bennett and others show that since the introduction of the bromic salts the proportion of cures has been decidedly increased. Nevertheless, the disease is a most discouraging and troublesome one to manage, and especially is this the case when it assumes the form of petit mal. The rapid recurrence of light attacks is, as has already been said, very apt to lead not only to mental enfeeblement, but is very often followed by very severe paroxysms.

Epilepsy of a more or less constant form, in which the seizures resemble each other, is far more incurable than that of variable type; for example, we find that unilateral seizures are much more apt to be associated with established cortical disease than when they are general and simply explosive manifestations. It has been held that a tendency to permanency is marked by a diminution in the extent of the interval. This is by no means true. I have had cases under observation for ten or twelve years in which attacks separated by intervals of six months or one year marked the course of the disease, in which frequent initial attacks were present. These cases I regard as very bad so far as prognosis is concerned. I much prefer a history of irregular and comparatively disorderly attacks. In female subjects the menstrual influence is not always a bad factor. When we are enabled to remove some production of an exciting cause in connection with the catamenia the prognosis is more hopeful; but an opinion must be expressed with great caution, especially in those cases beginning at an early age and not after the establishment of the menses. Traumatic cases are not always bad, but those in which the element of heredity plays a part most certainly are, Herpin and Gowers to the contrary; and though these cases for a time do well under treatment, its good effects are not constant. Individuals with misshapen heads, whose deformity suggests premature sutural ossification, are not susceptible to the influence of treatment, and all other osseous changes, such as exostosis, plaques in the dura, and bony growths, whose existence can only be guessed at or inferred from suggestive appearances elsewhere, give rise to a variety of epilepsy which is beyond the reach of drugs. With symptomatic epilepsies the case is sometimes different, for while the seizures which arise from the irritation of a cerebral tumor are almost as hopeless as the form I have just mentioned, we know from experience that the epilepsy of syphilis and other allied diseases, and those of toxic origin, with the exception sometimes of those occasionally due to alcohol or lead, are curable. The meningeal thickening of alcoholic origin or the encephalopathy of lead may be the pathological bases of very intractable paroxysms.

So far as age is concerned, it may be stated that many eclamptic seizures of young children which are due to well-recognized irritable causes are promptly cured if there be no hydrops ventriculi or preossification of the coronal sutures, and if the epileptic habit is not established. The epilepsies of six or eight years' standing are not encouraging from a therapeutic point of view, and those of advanced life developing in aged persons are equally unfavorable.

The treatment of epilepsy due to heat-stroke is by no means satisfactory, and, though the attacks are often separated by long periods, they are apt to recur in spite of drugs.

Gowers has prepared several valuable tables which show the influence of age upon recovery. He says: “The following table shows that age has a distinct influence on prognosis. The percentage of the unimproved cases to the whole is 30 (43:143::30:100). The percentage of the cases commencing at each age arrested and unimproved is stated, and between brackets is indicated the excess of the arrested or unimproved cases at each period of life over the proportion for the whole 30 and 70 per cent. respectively:

———Cases.——— ———Percentage.———
Unimproved. Arrested. Unimproved. Arrested.
Under 10 14 29 32.5 (+2.5) 67.5
From 10-19 23 45 34 (+4) 66
20 and over 6 26 19 81 (+11)
43 100 30 70

Thus, the proportion of the cases commencing under twenty in which arrest was obtained is considerably less than the proportion of cases commencing over twenty, the difference amounting to about 13 per cent. The period of the first twenty years of life at which the disease commences has little influence, but the prognosis is little better in the cases which commence under ten than in those which commence between ten and twenty: arrest is more frequently obtained. The cases which commence in women at the second climacteric period are also obstinate, although not sufficiently numerous to be separately given.”

He also finds, from an analysis of the same cases, the fact noted by others, that the prognosis is favorable in inverse proportion to the duration of the disease.

Attacks which chiefly occur in the daytime are much more amenable to treatment than the nocturnal seizures, and especially is this the case in the tongue-biting form. Sudden blows upon the head or falls have been known in isolated cases to effect an amelioration in the patient's disease, but these examples are rare.

The existence of an aura is much better than if none existed.

Death from the attack itself is rare, yet in the large pauper institution with which I was connected for many years I have known of several cases. More often the death results from asphyxia resulting from a bolus of food which chokes the patient or from a fall in some dangerous place—into the fire or elsewhere. Accidental death from drowning is more common than any other form.

The status epileptica into which patients sometimes pass who have had many convulsions is occasionally a fatal termination of the malady, and is always a serious feature.

The influence of different epochs in life is worthy of consideration: of menstruation, of marriage, of pregnancy, and of the menopause there is much to be said. I have sufficiently spoken of the establishment of the menstrual flow, and I would only add another word of caution against giving a too favorable prognosis except in those cases of very recent origin. Marriage appears to have very little to do with changing the attacks, unless they be of an hysteroid character. I have never known epilepsy to influence the course of a pregnancy in any unfavorable way, and I think this has been the observation of others. Gowers refers to cases in which the attacks ceased during the time the mother was carrying the child.

The occasional bad influence of the pregnant state has been illustrated by a case reported by Terrillon.43 This example was a woman who had been the victim of epilepsy of hereditary origin since her seventh year. At the commencement of menstruation her attacks became periodic, and recurred every two months, and she had several two or three days before the flow. Two pregnancies followed several years afterward. During the periods they were increased in number and severity, and occurred several times daily. She had more attacks at this period than in all the time after delivery.

43 Annales de Gynécologie, June, 1881, p. 401.

I have found that the relief of uterine flexion or the establishment of menstruation has exercised a decidedly modifying influence for the better in several cases.

Sometimes the disease is interrupted by the menopause, but very often in my experience it has changed in type and been followed by mental degeneration.

The prognosis of the epileptoid mental state is serious in the extreme, and even when in early life the attacks are aborted or changed to perversion of the intellect or emotions existing as a complication, the hope of cure dwindles almost to nothing.

The spontaneous cure of epilepsy is rare. Its course, however, is more often interrupted by some intercurrent disease. Of 33 cases observed by Delasiauve in which there was some complicating disease, such as erysipelas, pneumonia, pleurisy, acute articular rheumatism, burns and contusions, scarlatina, erythema, or the condition of pregnancy, it was found that in 25 cases there was a decided improvement (une heureuse influence), and in 8 only was there no modification of the attacks. Axenfeld is disposed to believe that acute and febrile disorders more decidedly influence the course of epilepsy than those of a chronic nature. The influence of either may be small or may diminish the number of attacks without curing the disease.

TREATMENT.—The treatment of epilepsy depends so much upon the form of the disease that no arbitrary rule can be laid down upon general principles, and we must bear in mind the necessity for removing the exciting causes if possible, the preservation of the balance of cerebral blood-pressure and cell-equilibrium, and the nutrition of the cerebral mass. It may be our purpose to remove various toxæmic or cachectic states as well. As a minor division of treatment we must consider the abortion of the attack when auræ are detected. It has been the custom, I think among too many, to manage the disease in an empirical manner, depending upon some routine course of treatment, such as the indiscriminate use of the bromides, for example. I am convinced that the intractable character of the disease has come to be greatly exaggerated through failures attendant upon the wholesale use of the bromic salts, without regard to the indication in each particular case. It behooves us first to select a reliable bromide, and then to give it with relation to the time of the fit, its severity, and the condition of the individual. The importance of this has impressed me very often. An equally divided daily dose will not do a patient who has matutinal attacks the same good as will a large dose at night, and in certain anæmic individuals the bromides very often increase the attack. Then, too, the cases in which seizures of petit mal predominate are not benefited to the extent that those are in which the repetition of severe attacks is the feature. The bromide should always be well diluted and given when the stomach is empty or nearly so. The bromide of sodium is, to my mind, the most serviceable salt, and when given alone or combined with the bromide of ammonium is better than the potassic salt or the various others. It should be carefully kept in solution or in waxed-paper powders in a tight preserve-jar. As to its method of administration, I much prefer the use of a solution which shall combine other adjuvants which I will presently mention, and separate powders as well, which may be used to reinforce the dose. The latter are to be employed by the patient in the event of an unlooked-for series of attacks, and are to be used to the point of producing mild bromism at the time. In certain cases it is all-important to take into consideration the condition of the heart. In some cases where there is manifest and continued cerebral congestion, with full vessels and hard pulse, I have found that the combination with chloral or aconite was desirable. In other cases where the heart's action was irregular and weak my experience with digitalis and nitro-glycerin or with strychnine was most happy. In those cases that passed large quantities of clear urine of low specific gravity the action of nitro-glycerin and digitalis has been most prompt, and the same has been true of epilepsies of migrainous origin.

There have been various methods of using the bromide suggested which are more or less practical. The writers of a few years ago suggested the prompt production of bromism—a state in which the patient should be kept for a long time. This I strongly disapprove of, not only because the mental and physical depression is a very disagreeable and sometimes permanent condition, but because I have found that the attacks are often increased after a time, though at first they may have been suppressed. Others believe in giving the bromides at intervals, with periods when no medicine at all is administered.

For my own part, I am in favor of the establishment of a mild bromism which does not extend beyond a slight anæsthesia of the fauces or the appearance of slight acne. If I find it necessary to increase the dose, I give cod-liver oil, iron, and bark or some of the many preparations of the hypophosphites for a time; and they do not diminish the specific effects of the drug to any great extent. In the event of a series of attacks I direct the patient to take an extra dose at such time as will anticipate the seizure.

This treatment should be kept up for at least two or three years after the attacks have disappeared, and it may be even necessary to continue a bromide course in a small way for an unlimited period.

If there be an hysterical element, or if ovarian excitement is supposed to have anything to do with the attacks, the combination of cannabis indica is strongly recommended. This suggestion holds good in the cases where migraine is associated with the epilepsy, or the latter is an outgrowth of the former.

Next to the bromides of potassium and sodium I have been very successful with the nickel bromide. I find that it is retained with little trouble, producing no gastric derangement if taken after eating. A syrup prepared by most of the good pharmacists is preferable to any other method of administering the salt. Quite recently Leaman44 has reported two cases of severe epilepsy which were greatly benefited. His conclusion is that it does most good in the form of the disease when the attacks are separated by long intervals.

44 Med. News, Apr. 18, 1885.

The bromate of potassium, which has been used by Weir Mitchell45 and Hinsdale, may be worthy of a trial. It should never be given, however, in larger doses than five or ten grains thrice daily. These investigators found that thirty grains slowed the heart very considerably, and forty grains produced watery discharges from the bowels and drowsiness. In their hands, notwithstanding these disagreeable effects, it controlled the seizures. The hydrobromate of conia is a comparatively new remedy which has been recommended. My own experience does not support that of Wolfenden.46 Severe cases were treated by him with benefit. The dose he recommends is half a grain, and not more than four and a half grains are to be given in twenty-four hours. Headache and dizziness attended its use.

45 Med. News, Dec. 27, 1884, p. 718.

46 Practitioner, June, 1884.

Erlenmeyer47 is an advocate of the mixed treatment, and his best results have been obtained by combining the bromides of potassium, sodium, and ammonium in the proportion of 1:1:½. He thinks much greater permanency of effect follows such a combination. A curious result witnessed by this author is the fact that the acne produced by one salt given alone is apt to disappear when the combination is administered.

47 Centralblatt für Nervenheilkunde, Psychiatrie, etc., No. 18, 1884.

A solution of hydrobromic acid, prepared after Fothergill and Wade's formula, is recommended by H. C. Wood of Philadelphia,48 who presented the record of its use in twelve cases of obstinate epilepsy. It seems that in his hands large doses acted much better than when the bromides were given alone. He recommends ounce iij per diem. My own experience, which I detailed some years ago, was to the effect that it possessed no virtues whatever in ordinary doses. The solution is so difficult to take, and so disagreeable in every way, that many patients prefer almost any other treatment. It cannot be doubted that some cases of epilepsy are benefited by a change of treatment, no matter what, and possibly Wood's cases belong to this class.

48 Med. News, Feb. 23, 1884.

Belladonna and ergot are remedies that have had many advocates, Trousseau being the most pronounced champion of the former. Their use in the lighter attacks is attended sometimes by the most happy results, but they cannot be said to have any permanent effect. The first is advantageous because of its power to diminish reflex excitement, and in those undeveloped infantile convulsions which are often grouped under the head of eclampsia its virtues are decided. Belladonna or its alkaloid may be given in combination with the bromides. Ergot or ergotin, in spite of its undeservedly bad reputation, may be given in large doses, one to two drachms of the tincture thrice daily, or five grains of the aqueous extract in the course of the day. Of chloral there is not much to be said. At one time it was thought to possess great virtues, especially in combination with the bromides, but subsequent experience has taught me that its use has many drawbacks, and only in exceptional cases is it to be recommended—viz. in those in which there is a disposition to excitement—either as a substitute for the attack or as a sequel.

The use of the iodide of potassium in combination with the bromides is of great service in symptomatic epilepsies or those of syphilitic origin. The iodide should be pushed, so that the patient may take three or four drachms daily, and its injurious gastric action and unpleasant taste may be done away with by administering it in large quantities of milk or some mild alkaline water, such as Vichy. Among the other remedies used and advocated by various writers are hyoscyamine, the salts of zinc, chloral, the ammonio-sulphate of copper, picrotoxin, strychnine, curare,—all of which have little or no effect in permanently changing the course of the disease. Cerebral galvanism, if properly employed, is certainly worthy of a trial as an adjuvant.

As abortants we may resort to diffusible stimulants—ammonia, alcohol, or some carminative. If the aura be perceived, a drachm of the aromatic spirits of ammonia or a glass of sherry will often prevent subsequent developments, and the inhalation of ten or fifteen drops of nitrite of amyl will avert the attack. Nitrite of amyl may be conveniently used in the form of pearls, which may be first crushed in the handkerchief. The nitrite of soda, which has been recommended as a substitute, is an unstable and dangerous drug, and is not to be recommended.

I called attention some years ago to the virtues of nitro-glycerin as an abortant in epilepsy. It may be given in alcoholic solution or tablets from 1/50–1/25 of a grain at a dose, to be perhaps repeated. Great care should be taken to procure a reliable preparation.

When a sensory aura proceeds from a particular locality in preference, the application of some local form of irritant is strongly recommended. A blister or light touch of the button of the actual cautery will do, and if the point of origin be one of the extremities a circular blister or cautery-line, after the method recommended by Buzzard, will be serviceable in the treatment of the case.

Buzzard has observed the fact, in several of his patients who complained of a sensory aura in the biceps, that when an encircling blister was applied just above this spot the attacks were aborted. In more than one of his cases of partial epilepsy the extraordinary result of a transfer of the convulsion to the other extremity is noted. He found that the circle should be complete, for a blister which half encircled the arm did no good. I have used the same treatment in cases of writer's cramp with marked benefit.

Brown-Séquard has pointed out the good effects of forcible and painful extension of one finger or toe if the aura is of sufficient duration to enable the individual to resort to this procedure.

The condition known as the status epilepticus is best treated by amyl nitrite, which can be administered frequently. Repeated doses of nitro-glycerin, so that its full effects are produced, do more good than chloroform or any of the well-known anæsthetics.

Of setons I have very little to say. At best, they are a barbarous and painful mode of treatment, and, although cures have been effected, I have never been much encouraged by their so-called influence.

Certain intractable cases are helped by surgical procedure, and trephining has sometimes resulted in a cure. I know of one brilliant result obtained by Leo of this city in an old epileptic, in which the use of the instrument over the occipital region resulted in a complete removal of the disease. It is especially recommended in cases in which the form of the attacks bears some relation to the probable disturbance of the cortical motor-centres; and even in such cases there must be constancy in the method of expression of the convulsion. So often do we find meningeal thickening of an extensive district that it is manifest that trephining would do little or no good. The statistics of the operation are unsatisfactory, for in the large mass of testimony there is great want of exactness as to the pathological suggestions of the attack, and a great deal about the method of procedure and recovery from the operation itself, and very little about the phenomena of the disease.

The diet of the epileptic should be of the most simple kind. Merson,49 whose carefully-prepared paper is full of valuable statistics, is strongly in favor of vegetable diet, and his results are encouraging. I am convinced that many children never would have become hysterical or epileptic but for injudicious indulgence in animal food. Whenever possible, I confine my patient to a diet of fish, poultry, and fresh vegetables, with fruit. As an exciting cause the overloading of the stomach has so often precipitated attacks as to lead Paget and others to invent the term gastric epilepsy for this form of the disease. The greatest care must be paid not only to diet, but to the general habits of the patient—over-exercise, especially after eating, the avoidance of hot places and high altitudes. A residence by the seashore is preferable to mountainous places; and excitement, over-study, and all agencies favoring cerebral congestion are to be avoided.

49 West Riding Reports, vol. v. p. 1.