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"we should mau^the^same use of a boor
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sweets prom it, but does not injure it,"
ENDOWED BY
FRANCIS HUBER, B.S., M.D., P V S '77
H IN MEMORY or
A. JACOBI, M.D., LL.D.
MEDICUS, MAOISTtR, AMfCUS
No, 7 IN THE PHYSICIANS' AND STUDENTS' READY
REFERENCE SERIES.
EPILEPSY:
ITS PATHOLOGY AND TREATMENT.
Being an Essay to which was Awaeded a Prize of Four
Thousand Francs by the Academie Royale de
Medecine le Belgique, December 31, 1889.
HOBART AMORY HARE, M.D. (^^^0, B.Sc,
Clinical Professor of the Diseases of Children and Demonstrator of Therapeutics in tlie
University of Pennsylvania; Physician to St. Agnes' Hospital and to the Children's
Dispensary of the Children's Hospital; Laureate of the Royal Academy of
Medicine in Belgium, of the Medical Society of London, etc.;
Memher of the Association uf American Physicians.
Philadelphia and London:
F. A. DAVIS, PUBLISHER,
1890.
Entered according to Act of Congress, in the year 1890, by
F. A. DAVIS,
In the Office of the Librarian of Congress at Washington, D. C, U. S. A.
Philadelphia:
The Medical Bulletin Printing House,
1231 Filbert Street.
TO
DR. THOMAS B. BRADFORD,
SURGEON TO THE DEIiAWAEE HOSPITAL
I DESIRE TO DEDICATE THIS ESSAY,
AS AN EVIDENCE OF
AFFECTION AND FRIENDSHIP.
PREFACE.
This essay upon epilepsy was considered by the
Koyal Academy of Medicine in Belgium as worthy of
a prize of four thousand francs, and this must be the
chief excuse for its publication in the face of the large
amount of literature daily accumulating concerning
this important disease.
The author believes that it is fairly representative
of the views held as most correct by the best minds
of the profession, and has endeavored to separate the
good material in literature from a vast mass of super-
stition and nonsense which persons even in our own
generation have contributed. If this book can in
any way help the physician in the present, or aid in
the discovery of remedial measures capable of curing
epilepsy in the future, its publication will not be use-
less nor a burden upon a profession notorious for
its patience with authors.
222 S. 15th; St., PHiLADBiiPHiA,
August, 1890.
EPILEPSY:
ITS PATHOLOGY AND TREATMENT,
EPILEPSY.
Synonyms. — Latin : Morbus sacer, Morbus vel sacer,
Morbus major, Morbus herculeus, Morbus comitialis,
Morbus convivialis, Morbus mensalis, Morbus inspu-
tatus, Morbus viridellus, Morbus vitriolatus, Morbus
sonticus, Morbus carducus, Morbus unaticatus, Morbus
foldus, Morbus sideratus, Morbus scelestus, Morbus
demonicus, Morbus deificus, Morbus astralis, Morbus
St. Yalentis and St. Joannis, Analepsia, Apoplexia
parva, Passio Caduca et Perditio. French : Epilepsie,
Grand mal, Haut raal, Epilepsia. German: Fallsucht,
Epilepsie. English: Epilepsy, Falling sickness. Faint-
ing sickness, Fits. Italian: Epilepsia. Scandinavian:
Epilepsin fallendsot.
Definition. — Epilepsy is to be defined as a disorder
of the nervous s^^stem characterized by sudden convul-
sive seizures of temporary duration, the muscles of the
parts affected being first in tonic spasm, then alternately
contracted and relaxed (clonic spasm), the attacks gen-
erally occurring at irregular intervals, and being always
accompanied by loss of consciousness, more or less com-
plete, in the typical disease. The movements also have
no relation with those of ordinary life. In rare instances,
however, one or more of these symptoms may be absent,
and yet the disease be epilepsy,
1 A (1)
2 Epilepsy: its Pathology and Treatment.
Before the writer goes further he must endeavor to
make clear the meaning of the terms generally employed
in discussing this disease, in order that in using a given
term his meaning may be well defined.
It is an evidence of the paucity of our knowledge in
these convulsive disorders that the nomenclature em-
ployed is at once inaccurate and inexpressive even of
the little we know. Thus, many writers divide the
disease into idiopathic epilepsy and organic epileps}'-,
because in the one case we have not been able with
the means at our disposal to discover an}'- changes from
the normal in the parts when they are examined, and
in the other we find more or less gross lesions. It is
to be hoped that before long this ignorance may be
enlightened, for it is hardly possible to imagine that a
given number of cells can evince morbid tendencies for
years and still remain organically normal. Some changes
must occur which we are not quick enough to discover.
The term organic epilepsy is used as well to designate
not only direct morbid change in a given set of cells, but
to identify indirect perversion of their function produced
by the irritation or pressure or interference of nutrition
by a neighboring and demonstrable neoplasm. Of this
more will be said under the heading of Pathology.
History. — Almost as far back as we have records of
events the story of the disease called epilepsy reaches.
Long before medicine, as we know it at the present day,
took the shape which separated it from witchcraft and
sorcery, civil writings incidentally spoke of it, either
describing the disease in detail, or giving it a name
which in its meaning described the affection. Long be-
fore the time of Galen and Hippocrates we find mention
of its character, and the famous Greek just mentioned
has described it with a characteristic accuracy which
History. 3
seems as true to the disease to-day as it was hundreds
of years ago.
Almost every century since their time has borne in its
medical annals some account of its symptoms, and prob-
ably no disease has ever given rise to more discussion,
both medical and otherwise, than the one before us ; for,
unlike those diseases of an epidemic character which
from time to time swept off thousands of the human
race, epilepsy, by its constancy at all times and in all
places, fastened itself upon single individuals and left
accurate impressions on the minds of its observ^ers,
who were not disturbed by the fear of contagion and
who therefore wrote nothing hastily. The very fact
that epilepsy asserted itself in the bodies of its victims
at the most inopportune times and before all men caused
it, too, to be brought to the notice of the people more than
other affections even more wide-spread, but which by
reason of their hidden nature were less frequently seen.
It is illustrative of the true birth of medicine that epi-
lepsy is rapidly passing from the cloud of ignorance
into the light of modern science. For over twenty cen-
turies it has passed among men as a something too in-
tangible to explain, too far beyond their power of treat-
ment to yield to any one, however skillful he might
be; yet in the past twenty years, at the most, more
progress has taken place in our knowledge as to its
entire course than in all the preceding centuries. If
we glance back among the older writers we find that
they tried new remedies as frequently as they failed in
treating the disease, and one after another advanced
hjq^othetical conclusions as to its causation in almost
every case, many of which were foolish even in the light
of their own knowledge. Every form of explanation
was attempted ; the clergy, the laity, and the most
4 Epilepsy : its Pathology and Treatment.
ignorant of the common people shared the universal
privilege of inventing new theories and therapeutic
measures, and yet not one opinion has survived, and our
building of knowledge of epilepsy contains no stone
save those gathered in the last century.
One of the first efforts made by the earliest workers
of the present time was the denuding of epilepsy proper
of that enormous amount of surrounding drapery par-
taking of an epileptiform character, but at present rec-
ognized as arising from entirel}^ different causes. Spasm,
like dropsy, has come to be considered as a mere evi-
dence of some condition more or less defined, and not
as a disease itself. It is the result, not the cause. The
chief reason for all this improvement lies in the increased
desire for knowledge, which has brought about a vast
amount of original research in this field as well as in
others, and it has been well said by the famous German
physician, Nothnagel, that no affection of the human
race could be held up for which so much has been derived
of value from vivisection and experiments on the lower
animals than the disease now before us.
So much is to be said of the disease as we at present
know it that the writer cannot linger over the writings of
those of long ago, which, while interesting, are but grop-
ings in the dark and require much space, and we shall
pass over to the last few centuries, during which faint
glimmerings of light have begun to creep in. Early in
the sixteentli century the first reports of methods of cure
of a rational character appeared, and for many j^ears
formed almost entirelj^ the greater part of the literature
of epilepsy. Hector Boethius ^ in 1536 wrote of castra-
tion as a method of cure, not only directly but indirectly,
to prevent hereditary tendencies. According to this
* Cronikles Ucotlaud, Ediuburgli, 153U, lib. i.
History. 5
writer, the custom of castration with this object in
view existed for many years among the Scotch previous
to the time at which he wrote. Thus he states that,
while this treatment was accorded to epileptic males,
epileptic females were isolated, and if by chance they
conceived, both the mother and the child were to be
killed. Jean Taxil ^ also noted this means of cure as
long ago as 1603, but Platenus, Mercatus, and Heurnins,^
along with Coelius Aurelianus,^ performed the operation
many years prior to these writers, and for the same pur-
pose, namely, of curing the disease, which, in one of its
forms, was generally believed in those days to be depend-
ent on the retention of semen, which, undergoing corrup-
tion, produced reflex convulsions by the irritation set up.
Very early in the history of medicine, however, these
views were largely held, for Arethaeus * asserts that
many physicians, among them the celebrated followers
of JEsclepius, thought that venery cures the epilepsy
which begins at puberty. The same opinion was held by
Scribonius Largus, and the retention of semen was the ex-
citing cause in the belief of all. It would seem, however,
that ph3^sicians of that day were as quick to contradict one
another as they are now, for Alfarius a Cruce contended
that the epilepsy of puberty was an incident of the age
of the individual, not of the retained semen, denying
that sexual intercourse ever gave relief except in very
rare instances. Unfortunately, this writer does not seem
to have impressed this teaching on his pupils, for one of
them, Sinabaldi,^ declared coitus to be a useful means
» Traite de TEpilepsie, etc., Toumon, 1603, p. 229.
" Opera Omnia, postrema editio, Lugduni, 1658 ; de Epilepsia, chap,
xxiii, p, 421.
' Morb. Chron., lib. i, cap. iv.
* Opera Omnia. Morb. Chron., lib. i, cap. iv.
» Geueantbropia, Romae, 1643, p. 886. C.
6 Epilepmi : if^ Pnthology and Treatment.
of cure in some forms of epileps}^ but not in all forms.
Tissot,^ who wrote, comparatively speaking, much more
recentl}^, argued that this retained semen, by corruption,
produced epileptic attacks, and by so doing brought one
of the oldest superstitions down to modern times. In
justice to the older writers, however, it should be said
that the}^ did not carry out these ideas to such an ex-
treme as to lose sight of the fact that other causes might
produce the disease. Indeed, Galen and others recog-
nized that sexual excesses might have similar results
with sexual continence. It should be remembered, too,
that epilepsy and coitus were supposed to be closely
associated, for epilepsy often came on during intercourse;
so that it was compared b}^ Democritus to a" seizure ": —
or, as Faustus has described it : —
" Turpis, et est morbi species horrenda cadueo."
The following extracts in regard to the more modern
superstitions will also be of interest to the reader, as
showins: how barbarous curative measures were em-
ployed in the eighteenth century ^ : —
To Mo7meur ilie Crimiiial Lieutenant- Oefieral and Preskle^it of the SeiiescJuiVa
Court of Lyons : —
Sieur Claude Pessoneaux, mercer of that town, humbly prays and
assures you that, for eight years, he has been subject to epilepsy,
which attacks him almost daily, even several times a day, and entirely
deprives him of consciousness. And as he has been informed that
several medical authors promise a cure from the administration of a
specific remedy, composed of various roots and the skull of a man who
has died a violent death — a remedy which, when properly prepared, has
the reputation of being most efficacious, according to the certificates
which M. Hedoin, physician to the king, and agreg^ of the College of
» Traite de 1' Epilepsia, Lausanne, 1785, p. 73.
^ llev. Med. et Chirurg. de Paris, November, 1855.
Hi dory. T
Medicine at Lyons, and the Sieur Aubernon, surgeon of Lyons, have
to-day given under their seal, which certificates your petitioner shows
and sets forth to you ; and as he has been informed that a criminal,
condemned by your judgment to be hanged, is about to be executed,
may it please you. Monsieur, to permit him, after the execution of this
miserable person, to remove the skull of his head, in order to employ it
in the preparation of this remedy ; and he will consider himself bound
to continue in prayer to God for your prosperity and health.
Pessoneaux.
Let this be shown to the Procureur-General of Lyons.
80th Octobre, 1706. Claret La Tourrette,
On behalf of the king I do not forbid the concessions of the
present request [Signature illegible.]
Lyons, 30 Novembre, 1706.
Let it be done according to the decree of theProcureur-G6n6ral.
Lyons, 30 Novembre, 1706. Claret La Tourrette.
To Monsieur tfie Cnrainal Lieutenant- General in the SenescTial's Court of
Lymis : —
The sisters, rector, and governors of the General Almshouse in
Lyons humbly pray and assure you that they require in pharmacy
several skulls of persons who have died violent deaths, in order to use
them in the composition of several very necessary remedies, — among
others, of one against epilepsy, to which several persons in the above-
named house are subject.
They are, therefore, obliged to have recourse to you. May it please
you. Monsieur, considering the necessity above pointed out, and for the
good of the poor, to permit the surgeon of the aforesaid house to select
and remove from the burial-place of the Penitent Sisters of Mercy such
skulls as they may find proper for the preparation of the aforesaid
remedies ; and to this end the said Penitent Sisters be invited to permit
the said memorial, and the poor of the said Almshouse will pray for
your prosperity and health. Bourg, Christin.
Let it be done as it is required.
Lyons, 13 Septembre, 1710. Claret La Tourrette.
Another old theory resembled very closely that by
which insane persons received the designation of " luna-
tic," namely, that epilepsy was always worse during the
moon's phases. This notion was held until very recent
times, wlien M. Moreau proved it to be untrue by an
8 Epilepsy: its Pathology and Treatment.
enormous collection of evidence against it. Thus, be
saw no less than 47,637 fits, of which 26,313 were be-
tween the phases of the moon and 16,324 during its
phases.
Even at the present day superstitions are very rife
among the lower classes, and all kinds of filthy decoc-
tions are employed against epilepsy. The writer is told
that in Melbourne, Australia, snakes' heads in rum haA'e
held until very lately a high reputation for the relief of
epilepsy. Even supposedly sane individuals of rank at
the present day are guilty of the most wretched super-
stitions. The following is of interest, as showing this,
taken from an address by the President of the Ecken-
foerder Shooting Club to its members: —
Her Highness, Princess Bismarck, wishes to receive, before the 18th
inst., as many magpies as possible, from the burned remains of which
to make an anti-epileptic powder. I permit myself, high and well-born
sir, to entreat you to shoot as many magpies as you can in your pre-
serves, and to forward the same to the Chief Forester, Lange, at Fried-
ricksruhe, or hither.
Symptoms. — One of the first and most marked S3'mp-
toms of an oncoming attack of epilepsy is a peculiar
sensation felt in some portion of the body, generally
below the brain, which graduallj' rises up over the patient,
either rapidl}^ or slowly, like an oncoming cloud, until,
the head having been reached, the patient is immediately
convulsed and unconscious, and almost instantly is seen
to be in the very acme of the nervous storm. Simul-
taneously with the arrival of the aura in the cervical
region the person utters a peculiar cry or scream, so
wild, so harsh, and so characteristic that it has been
called the " epileptic cry," being probably due not so
much to a voluntary impulse as to a sudden expulsion
of tlie air from the thorax by the convulsive contraction
Symptoms. 9
of the abdominal muscles, as well as those of the thorax,
and its rapid passage through the glottis narrowed by
rigid spasm of the muscles governing this opening.
Synchronously with this cry the muscles of the whole
body, in a widespread attack, become strongly con-
tracted until they are in a tonic spasm, and then, having
momentarily relaxed, pass into alternating relaxations
and contractions, which throw the sufferer now to this
side, now to that.
With the tonic spasm the muscles of the face
often produce hideous distortions of the features, in
some cases bringing about the so-called risus sardon-
icus; the head may be drawn to one side, and under
these circumstances the eyes are generally turned in
the same direction ; the jaws are locked one against
the other, and the lower jaw may also be drawn away
from the median line of the face in the same direction as
the eyeballs. Sometimes the whole body is rotated. In
the 910 cases! analyzed by the writer complete rotation
to the right is mentioned as being present in 49 persons,
and to the left in 52 cases. There is, therefore, no
difference worthy of note in these numbers.
The arms are strong^ flexed at the elbows, while the
hand is still more strongly flexed at the wrist ; the fingers
are also so bent into the palm of the hand that not unfre-
quently the skin in this region is found indented by the
nails. To speak briefly, the arms, legs, and body are
drawn and jerked in the direction of the most powerful
muscles, and, as a consequence of this, opisthotonos,
during the tonic stage, is by no means uncommon. Ex-
ceptions to this rule do, however, frequently occur, and
when present show that the paroxysm is exerting its
chief influence on the weaker muscles, while the stronger
^ University Medical Magazine, 1889.
1*
10 Epilepsy: ?7s Patholofjy and Treatment.
ones are affected at least to a less degree. As a general
rule, too, the muscles of one side suffer more than those
of the other. Unfortunately the writer finds, in the cases
collected hj him, that in only 158 instances were any
remarks on this point made. In these 158 the right side
was most affected in 77 cases, and the left side in 81 cases.
It is evident, therefore, that both sides suffer about
equally. The author has not attempted to analyze these
cases as to relative frequency of the general S3'mptoms,
as it would hardly be justifiable, for in some of the cases
the^' may have occurred and the reporter neglected to
name any one of them.
The legs may be firml}^ flexed on the abdomen,
while the fingers are rigidly extended. The change in
the color of the face is very marked and almost typical
of the disease, being at first pale, then flushed, the flush-
ing deepening often into a livid purple, owing to the
asphj^xia produced by the convulsive contraction of the
thorax. In some cases the eyelids are widely drawn
apart so that the eye, owing to its fixation, has a staring
appearance ; in others they are so tightly closed that the
fingers of the on-looker can scarcely force the lids apart.
The staring but blank expression of the eyes is also
increased by the slow dilatation of the pupils, which
always accompanies the asphyxia.
The duration of these tonic contractions rarely ex-
ceeds two minutes, and in most cases is limited to but a
few seconds. It is followed by clonic spasms, already
described, which are ushered in by more or less violent
tossings, but whose onset is forewarned by peculiar vi-
bratory thrills, which run through all the affected muscles.
The eyelids tremble, the body changes its position ever
so slightly, and then, as if the vibrations gained greater
and greater power with each moment the fibrillary trem-
Symptoms. 1 1
ors give wfij" to miisciilar contractions. The expression
of the face, which in the preceding stage was set and
firm, is now constantl}^ changed by the movements of the
facial muscles; the jaws, no longer locked together, are
gnashed and crunched one upon the other ; the tongue is
alternately protruded and drawn back, and, as a conse-
quence, is often caught between the teeth and bitten and
lacerated. The excessive movements of the muscles of
mastication force the increased quantities of liquid
secreted b}^ the salivary glands from the mouth in the
form of froth, which is often stained with blood by reason
of the injuries to the tongue. The constancy of the
convulsive movements now becomes less and less marked ;
well-developed remissions occur between each toss of
the bod}^, until the movements cease entirely ; but it
should be constantly borne in mind that the prolonga-
tion of the remissions does not produce any decrease in
the severity of the intervening spasm, the final spasm
often being even more violent than the first.
The intense discoloration of the face begins to pass
away as soon as the remissions, by their length, permit
the blood to be oxygenated, its disappearance being
temporarily arrested by each paroxysm. Finally, the
spasms having ceased, the patient lies before us relaxed,
unconscious, and exhausted, and passes into a deep sleep
or coma, which lasts a variable length of time, and from
which he cannot be aroused except very rarely, and then
with great difficulty.
Absolute coma was recorded in the writer's collec-
tion of cases as present in 104 cases, in 12 others it was
marked as absent, and in the remaining cases the person
keeping the record failed to report concerning it.
Even when the sleep has passed away the brain is
evidently disturbed in its functions for some hours or
12 Ejnlepsy : its Pathology and Treatment.
perhaps days, and headache is, not rarel}^, complained
of after the patient seems like himself in other respects.
The sphincters are very rarel}^ relaxed, although the
urine ma^^ be voided, as may also the faeces. According
to Gowers^ this relaxation is more commonly associated
with nocturnal epilepsy, and this opinion coincides with
the writer's experience.
That urinary incontinence is extremely rare is shown
by the fact that in the cases collected b}^ the writer (970)
it was only recorded as occurring in 45 cases.
Having described a typical attack of epilepsy, let us
proceed to an analysis of the various symptoms detailed.
Very commonly in epilepsy we find that the patient is
covered, during or after the paroxysm, by a profuse
sweat, which has been assigned b}^ some to the excess-
ive muscular movements and by others to vasomotor
changes which they think occur. Emminghaus^ has made
reports and studied this matter in order to determine
which of these theories is the true one, and inclines to the
belief that it is due solel}'' to vasomotor disturbance, but
it is probable that both the muscular movement and the
changes in the circulatory system are at fault. In some
cases the muscular movements may amount to almost
nothing, and under these circumstances any sweat must
be due entirel}^ to a disordered peripheral circulation and
its nerve-supply, or to disturbances in the nerves govern-
ing the sweat-glands. Those who believe completel}' in
the neurotic origin of the sweat point out very forcibly
that often in the most severe fits no sweating takes place.
The Aura. — One of the most interesting and impor-
tant of all the symptoms described is the so-called aura,