than is common with other varieties.

Or the features are those of disseminated sclerosis, with nystagmus, staccato speech, and oscillations of the limbs and trunk on movement; or mixed forms, suggestive partly of one, partly of another of these three diseases, may be present.

Some special conditions of the nervous system and nutrition may be mentioned. Fits or convulsions may occur at almost any period of the case; they may be slight or severe, passing off very quickly or leaving the patient comatose for some time; the convulsions also may be scarcely noticeable, or unilateral, or general. Among the optic symptoms the pupils have been already mentioned; the optic disks are often unaffected; ptosis and strabismus are rare. The muscles seem to present no constant changes either in nutrition or electrical reactions. The bones are brittle; the skin is often pale, waxy, and especially greasy; sometimes bullæ form, and a marked capillary congestion over the malar bones is common. There is a tendency to whitlows on the fingers, and to subcutaneous hemorrhages, which sometimes lead to septicemia.

The temperature is high in acute cases, and after convulsions, when it is often accompanied by free sweating. It is also raised by much bodily exertion or mental excitement, and by complications such as bedsores and lung disease.

Duration. This is variable; there are acute and chronic cases. If the early symptoms of gradual mental change, and the early spinal symptoms, in cases beginning with locomotor ataxy or sclerosis, be excluded, the duration is rarely more than two years.

Morbid Anatomy.-The changes are very variable, but the following are found in different cases: Thickening of the calvarium, which is much marked by Pacchionian bodies; thickening of the dura mater, with false membranes (pachymeningitis); abundant subarachnoid, fluid, with thickened or adherent membranes, the adhesion, when present, being more over the frontal, parietal, and temporo-sphenoidal lobes, and more on the upper than the lower surface; wasting of the convolutions, especially the ascending parietal, paracentral, and first frontal at its base; a violet-red color of the cortex of the brain; in some cases much fluid in the lateral ventricles, with softening of the brain-tissue; in a larger number, a general hardening of the brain. In the spinal canal, the same changes may be found: pachymeningitis, or adhesion of membranes, or effusion of blood within the dura mater. The spinal cord is wasted, or presents the lesions of posterior, or of lateral, sclerosis. Microscopic examination of the brain shows increase of connective tissue, accumulation of leucocytes in the perivascular sheaths of the minute vessels, and alterations in the nerve-cells of the cortex, especially the pyramidal cells of the third layer. The nerves are also degenerated, but the sympathetic ganglia are, according to Dr. Savage, not appreciably affected.

Diagnosis.-Alcoholism may be mistaken for general paralysis, the tremor of the lips, tongue, and hands largely contributing to this; commencing peripheral neuritis might further complicate the case. But the close association of the symptoms with continued drinking, the absence of inequality of the pupils, and the improvement on prolonged abstinence would point to alcoholism. Mental failure, with definite cerebral lesions such as tumors, or the dementia following apoplexy, may give rise to difficulties. From the general physician's point of view it is important to recognize that various anomalous paralytic symptoms may be warnings of general paralysis. If a case is typically locomotor ataxy there is no special reason to anticipate mental trouble; but if the symptoms develop very rapidly or present unusual groupings, or if there are mixed symptoms not conforming to the ordinary types of the spinal-cord diseases, the mental condition should. be closely scrutinized, and the possibility of general paralysis of the insane should be kept in view.

Prognosis. In an undoubted case it is bad, death being the certain termination; but temporary improvement (remission) sometimes takes place, especially in the cases with exaltation of ideas.

Treatment. This is, of course, in the highest degree unsatisfactory, as nothing seems able to stop the progress of the very widespread changes in the nerve-tissues. If the disease is recognized early, the patient should be at once removed from all sources of worry, anxiety of business, etc.; he should get change of scene, but should be kept under observation. Excess of every

kind is to be avoided; and hitherto drugs have been found to be of little or no service except in ameliorating symptoms. Some, who believe that syphilis is the chief factor in its causation, advocate iodides and mercury; but the same line of treatment has not succeeded in the analogous case of locomotor ataxy.

FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM.

EPILEPSY.

Epilepsy is a disease in which there are attacks of sudden loss of consciousness with or without convulsions, independent, as far as our present knowledge goes, of any demonstrable lesion of the brain, or peripheral irritation, or blood poisoning. Although the name is commonly associated with the idea of convulsions, and these indeed occur in the most typical and severe forms of attack, still it is important to note that coma is almost invariably present with the convulsions, and in many slighter attacks there is no convulsion at all. The second part of the definition excludes those convulsions which may arise from organic cerebral lesions, such as tumor, or in the course of Bright's

disease, or from anæmia. These are often called epileptiform to indicate their close relation to the epileptic convulsions now under consideration.

Epilepsy, then, is a functional disorder of the brain, a functional neurosis, or spasmodic neurosis, as it has been named by some; and its recognition, to a certain extent, depends on the absence of any other symptom from which the existence of structural lesions or diseases likely to cause convulsive phenomena could be inferred.

Etiology. It is slightly more frequent in females than in males, and very much more often begins in early life (Dr. Gowers says 75 per cent.) than in middle or advanced age, though it may be common enough in the latter class, simply because it is in a great majority of cases incurable, yet not fatal. Thus, beginning at an early age, it may continue throughout the life of the individual, who eventually dies from other causes. Among the predisposing causes, inheritance has the greatest importance; and this shows. itself partly by the appearance of epilepsy in the children of epileptics, but very largely by its occurrence in the offspring or other blood-relations of those who have suffered, not from epilepsy, but from some other serious disorder of the nervous system, such as insanity, hypochondriasis, hysteria, and marked neurotic weakness, or nervousness. Dipsomania in the parents may occasionally be a contributing cause. When epilepsy is not inherited, but acquired, alcoholic indulgence, sexual excesses, and possibly masturbation, may be the predisposing causes. The first two causes are not so likely to be in operation at the period of life when epilepsy generally begins, and the last more often leads to hysterical conditions simulating epilepsy-hysteroid epilepsy. The more immediate causes of a first epileptic attack, which may be the beginning of a life-long series, are fright, mental anxiety or excitement, injuries to the head, fevers such as scarlet or enteric, and the presence of worms in the intestines.

Epilepsy occurs in two well-marked forms, described as major and minor attacks-epilepsia major and epilepsia minor, or, in the terms of French writers, haut mal and petit mal. The major attack consists of the fully developed fit, with coma and violent convulsion, which will be immediately described. The minor attack consists of a momentary loss of consciousness, with either no convulsion at all, or at most a little twitching or some other slight sensory or motor disturbance; or rarely, motor disturbance without unconsciousness.

Major Epilepsy.-This occurs in several stages-(1) aura; (2) unconsciousness and tonic contraction; (3) clonic convulsion; (4) recovery. The aura (or breath, from the sensation of air passing up the limb to the head, which constitutes one form of this symptom) is any sensation or motion experienced by the patient while he is yet conscious, mostly of very short duration, and terminating abruptly in loss of consciousness and convulsion. 1. There is a great variety of auræ, which may be felt in almost every

part of the body-in the limbs, face, and head, in the viscera, and the organs of the special senses. They have been classified into sensory, motor, vasomotor, and psychical. The following may be mentioned: tingling and numbness in the arm, leg, face, or tongue; twitching or spasm in the same parts; loss of vision, or visual hallucinations, such as flashes of light, or colors, or definite objects; hallucinations of sound, noises, etc.; unpleasant odors or tastes; sensation of choking, nausea, vertigo, epigastric pain; flushes of heat, coldness, palpitation of the heart; an indefinite sense of fear or anxiety; running and jumping, or other coördinated movement. of sensation and motion are mostly unilateral, but may be bilateral; the arm is more often affected than the leg, and facial auræ mostly consist of spasm. Visual auræ are much more common than auræ of the other special senses. Sometimes a vague sense of fear may last some time before the occurrence of the actual fit; but, as a rule, the aura is of momentary duration. In about half the cases it is entirely absent.

2. The fit itself commences with sudden unconsciousness; if standing or walking, the patient often falls suddenly forward, or seems to be thrown violently to the ground, sometimes with an involuntary cry, shriek, or groan -the epileptic cry. He is then found to be in a state of tonic convulsion, the back rigid and slightly arched, the legs extended, and the head drawn backward or rotated to one side. The face is often pale at first; the pulse is quick, but sometimes it cannot be felt, and this is attributed by Dr. Fagge to compression of the artery by muscular contraction. The general tonic contraction fixes the chest, and respiration is stopped, so that gradually the face becomes more and more dusky, and eventually quite cyanosed. The tonic stage lasts from three to thirty or forty seconds, and then passes into the stage of clonic convulsions.

3. Twitchings begin in the face, the eyelids, and the side of the neck, and quickly extend to all the muscles of the body and limbs. There is a rapid succession of to-and-fro movements, of alternate flexion and extension in the limbs, of opening and shutting of the eyelids and of the jaws, lateral deviation of the eyeballs, and perhaps of the head; the tongue is pushed forward, and may be caught between the teeth; saliva is freely secreted, frothed in the mouth, and escapes from the lips mixed with blood from the bitten tongue. The face becomes livid, or almost black, and the lips and features are swollen. Urine, fæces, and, in men, semen may escape during this stage, and the violent contraction of the muscles may even cause dislocation of the shoulder. The patient is, of course, quite insensible; the conjunctivæ do not respond to a touch, the pupils are dilated or oscillate.

4. The clonic stage lasts a few minutes, rarely more than five or six, and then the convulsions gradually subside-they become less frequent, and interrupted by pauses of some seconds; the breathing becomes easier, the frothing at the mouth ceases, and the face gradually assumes a more normal

color. Finally, the patient remains simply comatose, and the coma passes into natural sleep, or consciousness is recovered rather suddenly soon after the cessation of the convulsions.

The reflexes are mostly absent for a short time after the attack, and then for a time the deep reflexes may be increased (Gowers). The urine may contain a trace of albumin or of sugar; petechiæ may be seen under the skin from rupture of blood-vessels during the stage of venous congestion; sometimes there is a transient hemiplegia; or vomiting; or serious mental disturbances, such as delirium, which is often of a maniacal kind.

The mechanical injuries from which the epileptic suffers will, of course, remain after the fit, and may give valuable indications in cases where the fit has not been seen—for instance, in nocturnal epilepsy. These are the bitten tongue, petechiæ on the skin, a dislocated shoulder, and, in other cases, various cuts, wounds, or bruises from the falling of the patient upon the ground or against unyielding objects.

Minor Epilepsy.-This consists, in a large number of instances, of little more than a sudden unconsciousness: in the midst of talking, perhaps, the eyes become fixed, the pupils dilated, the speech becomes incoherent, the patient is obviously unconscious of what is going on around him; he may, if at meals, put his fingers in his plate or his cup, or commit some other irregularity that he would not do if conscious. The condition lasts a few seconds, and then he becomes conscious, and goes on with what he was doing, or perhaps recognizes that there has been a blank, or feels giddy, or has headache, and is glad to lie down for some little time. Sometimes giddiness is the most marked feature of the attack, and in other cases a sensation in one or other part of the body, or a spasmodic movement, which may be quickly followed by temporary unconsciousness, though the former will seem to the patient the chief feature of the attack. These have a close resemblance to the auræ of the major attacks, and Dr. Gowers enumerates sensations in the epigastrium, hands, head, nose, eyeball, and cardiac region, olfactory and visual sensations, jerks in the limbs, head, or trunk, sudden tremor, sudden screaming, sudden dyspnoea, mental conditions, such as a sudden state of fear, etc.

Post-epileptic Conditions.-The petit mal, even more than the major attacks, is liable to be followed by certain post-epileptic conditions.

One

of these consists of various automatic actions, of which the patient is then and afterward entirely unconscious. He may thus commit acts of violence, rushing about and striking all that he comes near, or a woman may kill her child, or one may appropriate things that do not belong to him. Trousseau. records the case of the judge who relieved his bladder in the corner of the room, without any consciousness of the act. These cases have great medicolegal importance, since the occurrence of epileptic fits may be entirely unknown, and the criminal acts may be attributed to willful and conscious