HISTORY.—There is probably no nervous disease which has been_A system of practical medicine. By American authors. Vol. 5

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, {468} 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 {469}

{470} 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_.

+------+---------------------------------------------------------

| | Paternal Ancestry.

| +----------+-----------+------------+---------+-----------

+------+----------+-----------+------------+---------+-----------

1 | F. | Died | Suicide; | Eccentric. | ... | ...

2 | M. | Alive. | Cerebral | Insane. | ... | ...

3 | F. | Alive in | Phthisis. | ... | ... | Phthisis.

| | sis. | | | |

4 | M. | Died of | Not known.| Phthisis. | ... | Epileptic.

5 | M. | Congest- | Cerebral | Insane. | ... | Migraine.

6 | M. | Alive. | Insane. | ... | ... | Insane.

7 | M. | A con- | Died of | ... | ... | Insane.

| | drunkard.| and | | |

| | | at 76. | | |

8 | M. | Phthisis.| Eccentric.| One | ... | ...

| | | | one | |

| | and | | | rhage. |

10 | M. | Most ec- | ... | ... | ... | Migraine.

+------+----------+-----------+------------+---------+-----------

+---------------------------------------------------------------

| Maternal Ancestry.

+-----------+-------------+------------+-----------+------------

+-----------+-------------+------------+-----------+------------

1 | Died of | Eccentric; | Drunkard. | ... | ...

2 | Phthisis. | ... | One died | ... | Phthisis.

| | | of | |

3 | Alive | Not known. | ... | Cerebral | ...

4 | Migraine. | Phthisis. | ... | ... | ...

5 | Phthisis. | ... | ... | ... | One died of

| | | | | one

6 | Phthisis. | ... | Phthisis. | ... | ...

7 | Phthisis. | Died in | ... | ... | Phthisis.

8 | Migraine. | ... | ... | ... |

| and | | character. | and |

10 | Epileptic.| ... | ... | ... | Migraine.

+-----------+-------------+------------+-----------+------------

+---------------------+----------------------+-------------------

| Brothers. | Sisters. | Remarks.

+---------------------+----------------------+-------------------

1 | One a dipsomaniac; | One epileptic. | A history of

| one in good health. | | criminal

| | | proclivities.

2 | One brother has | Two sisters died of | Peculiar cranium.

| infantile | organic disease of |

| paralysis. | the brain; one of |

| | cerebro-spinal |

| | sclerosis. |

3 | Younger brother | ... |

| died of tubercular | |

| meningitis. | |

4 | No brothers. | No sisters |

5 | No brothers. | No sisters. | Peculiar cranium.

6 | Eight brothers and | One died of epilepsy,|

| sisters. | and cerebral tumor |

| | was found; one |

| | paralyzed. |

7 | ... | ... | Criminal

| | | proclivities.

8 | One brother died of | ... | Child of this

| secondary | | parent was

| tubercular | | choreic.

| meningitis, the | |

| other in an asylum. | |

9 | Several brothers | No sisters. | Criminal

| unaffected. | | proclivities.

10 | 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 10 103 95 198

Between 10 and 20 171 97 268

" 20 and 30 145 92 237

" 30 and 50 81 136 217

Over 50 11 49 60

--- --- ---

511 469 980

Of 1288 cases collected by nine French authorities, in 486, or over

one-third, the disease began between the tenth and twentieth years. In

Gowers's 1450 cases we find the following showing:

Cases. | Cases.

Under 10 422 | From 40 to 49 31

From 10 to 19 665 | " 50 to 59 16

" 20 to 29 224 | " 60 to 69 4

" 30 to 39 87 | " 70 to 79 1

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.

{471} 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.

Orwin[1] 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.

[Footnote 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.

{472} 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 Baly[2] 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.

[Footnote 2: _London Med. Gazette_, 1851, xlviii. 534-540.]

[Footnote 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. Carstens[4] 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.

[Footnote 4: _Detroit Lancet_ (8), 1880, N. S. iii. 153.]

[Footnote 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 (Mitchell[6]), ergot, absinthe (Magnan[7]), 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.

[Footnote 6: _Cincinnati Lancet and Clinic_, 1881, N. S. vi. 479.]

[Footnote 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: Jacobi[8] reports a case and Payne[9]

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 {473} 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.

[Footnote 8: _Hospital Gazette_, New York, 1879, v. 41-43.]

[Footnote 9: _Indian Ann. Med. Sci._, Calcutta, 1860-61, vii. 597 _et

seq._]

Day[10] and Kerr[11] have both ascribed epilepsies seen by them to

hepatic congestion.

[Footnote 10: _Clin. Histories, etc._, London, 1866, 143-145.]

[Footnote 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 Gowers[12] (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.

[Footnote 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. Schulz[13] 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.

[Footnote 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. Simmons[14] 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 Liégey[15] 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.

[Footnote 14: _Am. Journ. Med. Sci._, 1880, N. S. lxxix. 444.]

[Footnote 15: _Gaz. méd. du Strasbourg_, 1856, xvi. 105-107.]

[Footnote 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 {474} or two others have shown that the removal

of a stone was followed by a cure of the epilepsy.

[Footnote 17: _Ed. Med. Journal_, 1868-69, xiv. 140.]

[Footnote 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

Raymond[24] 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.

[Footnote 19: _Mém. et Bull. Soc. de Méd. et Chir. de Bordeaux_, 1878,

i. 56-65.]

[Footnote 20: _Med. Essays and Observation Soc._, Edin., 1737, iv.

416.]

[Footnote 21: _Archiv f. klin. Chir._, Berlin, 1872, xiii. 379-395.]

[Footnote 22: _Union médicale de Paris_, 1872, 3d S., xiii. 656-658.]

[Footnote 23: _New York Medical Record_, 1872, vii. 472.]

[Footnote 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. Westmoreland[25] and others report such cases, but more

often the epilepsy is only symptomatic of pachymeningitis or abscess.

Some years ago I presented[26] 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.

[Footnote 25: _Atlanta Med. and Surg. Journal_, 1876-77, xiv.

717-719.]

[Footnote 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.

HISTORY.—There is probably no nervous disease which has been more