[REPRINT FROM TRANSACTIONS OF ILLINOIS STATE MEDICAL SOCIETY, 1891.] 
EPILEPSY. 
Frank P. Norbury, M. D., Jacksonville.* 
Since the time of Hippocrates epilepsy has been the sub- 
ject of much speculation, and in the earlier centuries of med- 
icine a mysticism. The progress of scientific medicine has 
now, however, uprooted these absurd and unreasonable con- 
jectures, and placed it upon a sound and rational basis, the 
theory that it is dependent upon cerebral irritation being in- 
disputable. But the definition of the disease is yet in dis- 
pute. Gowers,1 Jackson2 and others hold that the essential 
phenomena of epilepsy lies in the nervous discharge or simple 
liberation of energy of nerve elements-the convulsion, while 
Christian3 and other eminent authorities hold that the convul- 
sion is not the pathognomonic sign of epilepsy, but the essen- 
tial sign of the disease is in the loss of consciousness. We 
will not enter into the discussion of the present physiological 
theories of epilepsy, but give the following for .our definition 
of the disease, believing it will cover all the essential phe- 
nomena recognized in an epileptic attack, viz.: We may de- 
fine it as a chronic convulsive disease, characterized by almost 
invariable loss of consciousness, and special form of spasm, 
tonic or continuous, clonic or intermitting. 
Etiology.-The chief etiological factor is that of heredity, 
which we recognize as a biological law, through whose agency 
nature seeks to eliminate defects and to bring back species 
* Assistant Physician Illinois Central Hospital for Insane, Jacksonville, 
Ill. 
(1) Nervous Diseases. (2) Lumleian Lectures, 1890. 
(3) Journal of Mental Science, January, 1891, 2 
from accidental errors to the normal type. Nowhere, per- 
haps, can one be so impressed with the extent of this great 
law, with its conflict of opposites, than in the study of neuro- 
pathology. The difficulties of the investigation of heredity 
are many, and in the study of all diseases it is true that results 
obtained fall short of actual facts. The transmission may be 
direct or indirect-indirect as when one or more generations 
escape and the disease appears in the descendents. The tend- 
ency may be even more indirectly hereditary, as in cases 
where the patient's antecedents had a proclivity to nervous 
disease, declaring itself as hysteria, alcoholism, insanity, neu- 
ralgia or other nervous affections, while the interchangeable- 
ness of neuroses is shown by the appearance of epilepsy in 
the patient. The direct transmission of epilepsy is frequent. 
It is incomparably the most frequent of neurotic diseases, pro- 
ducing epilepsy in the offspring. 
Phthisis transmits a diathesis predisposing to epilepsy, in- 
sanity, imbecility and general nervous diseases. In the fam- 
ily history of epileptics phthisis is found very frequently. 
Gowers found such history in 39 per cent, of his cases, but 
thinks this not very large or conclusive as to the probability 
of phthisis producing epilepsy. He says this proportion is 
due merely to the great frequency of consumption in the 
community. Echeverria and Savage believe there is more 
than a casual relation between the two diseases. Kerlin has 
very conclusively shown that phthisis has an influence in pro- 
ducing idiocy and imbecility with associated epilepsy, which 
is astonishing. Over 50 per cent, of cases studied by him 
show a family history of consumption. Of the 16 per cent, 
who were epileptic the existence of phthisis in the antecedents 
was shown in every case. My experience, both among the 
feeble-minded and insane who have epilepsy, has convinced 
me that there exists a strong relationship between the degen- 
erate type produced by epilepsy and the enfeebled constitu- 
tions of the phthisical. Of the exciting causes of cases oc- 3 
curring early in life, to infantile convulsions can be attributed 
the most. The tendency to convulsions in the child is closely 
associated with the epileptic diathesis, and in many cases ac- 
cidental convulsions are the commencement of a life-long 
epilepsy. (Wood.)4 Infantile convulsions, says Jacobi,5 de- 
pendent upon difficult dentition, are not as frequent as is 
supposed. Other authorities, among them Sir William Jener, 
give the opinion that almost all convulsions associated with den- 
tition are really due to irritability of the nervous system, which 
accompanies the constitutional condition of retarded develop- 
ment, which we call rachitis. Rachitis is a much more preva- 
lent affection than is usually considered in the higher as well 
as in the lower walks of life, although more frequently seen 
in the latter.6 Rachitis is preventable to a certain degree, 
hence this cause leading to convulsions can be removed. This 
fact suggests the thought that a considerable number of cases 
of epilepsy are really within the range of preventable dis- 
eases. 
Epilepsy is sometimes the result of excessive mental ex- 
citement or mental strain. It follows in the train of acute 
fevers in children; also in infectious diseases, especially 
syphilis. It may also originate from some reflex cause, such 
as phimosis, muscular error in eye strain, especially if patient 
is a young adult, and a tuberculous ancestry, intestinal worms, 
disturbances of sexual organs and intestines. Traumatism 
may occasion epilepsy by producing molecular changes in 
the central nervous system. Occasionally we find cases 
where the fits are due to imitation. I had such a case some 
two years ago. A boy aged 19 (neurotic history.) His uncle, 
an epileptic, lived with the boy's parents. The constant, 
almost daily, occurrence of fits in this man gave the boy 
much uneasiness, he thinking he was destined to become an 
(4) Nervous Diseases and their Diagnosis. (5) Keating Cyclopedia 
of the Diseases of Children. 
(6) M. J. Lewis, M. D., Cyclopedia of Diseases of Children. Keating. 4 
epileptic. Ultimately he did have several fits, always fol- 
lowing those of his uncle, until he became quite depressed, 
melancholy, and when he came under my care cataleptic 
symptoms were pronounced. The case eventually resulted in 
catalepsy when he was free from the association of his uncle. 
He made a good recovery, and is now well and stronger. 
Perhaps this case may properly be called contagious epilepsy, 
such as is related by Dr. Emil Arnsoji, of St. Petersburg, in 
May, 1891, number of American Journal of Nervous and 
Mental Diseases-a case where there were two girls, sisters, ser- 
vants, of a highly hysterical type. Previous to attack of first 
girl the sisters had had a violent quarrel, which was followed 
by a typical epileptic seizure in one of them, the other sister 
being present and attending during the attack. Several hours 
later Dr. Arnson was called to see the second girl and found 
her in a condition identical with that of her sister's seizure 
in the morning. 
Symptoms.-Brown-Sequard gives great importance to 
the recognition of the prodromata in epilepsy, the frequency 
of which is much greater than is generally known. The im- 
portance of knowing these warnings lies in our ability to otfen 
abort or mitigate the attack. The warnings of an approach- 
ing attack are quiet marked in many cases, consisting of dis- 
turbances of character, great irritability being especially no- 
ticeable. Mental disturbance, such as melancholia, with fear 
of impending danger. A state of intense restlessness, fol- 
lowed by a feeling of well-being, elation, etc., I have noticed 
in several cases. One case, now under observation, becomes 
quite joyous-sings, etc., almost incessantly until a spasm 
cuts short his hilarity and changes his condition into one of 
maniacal furor. 
Preceding attacks among the insane we notice hallu- 
cinations of sight and hearing and other sensorial disturb- 
ances. One of my patients says he hears a noise like a 5 
steam-boat whistle blowing, also at times the sweet notes of a 
bird singing. Marked aura is experienced by several of ray 
cases; one has a sensation of an ascending flood of warm 
water. Another, now dead, had spasms commencing in the 
fingers of the left hand, which continued rapidly up the left 
arm until it reached his throat, when a sensation of choking 
was experienced. He was often able to abort the attack by 
briskly rubbing his arm. Another case has the epigastric aurae, 
there being intense pain located in the epigastrium, which is 
followed by slight and frequent attacks of petit mal, and 
then comes the general convulsions. Psychical aura are fre- 
quent. I have seen several cases, one recently, the patient 
sent for me, saying he was going to die. I found him 
sitting up in bed afraid to lie down, saying as sure as his 
head touched the pillow he knew he would die. He was 
highly excited and begged me to give him something that 
would sustain life, at least until daylight came. That night 
he had several hard fits, and in the morning when I again 
saw him, he was feeling quite well. During the inter- 
paroxysmal period he is rational, but preceding an epileptic 
attack he invariably has the fear of impending danger. 
Warnings are not given in all cases, some are stricken 
without the slightest knowledge of an approaching attack. 
Frequently 1 have seen them engaged in amusements 
or work suddenly fall, seized by a spasm. I was once ex- 
amining a boy for color blindness, he was selecting the 
various shades of a color; he had reached for a skein of yarn 
when he was stricken, he fell to the floor, had a short but 
severe convulsion and then immediately arose, picked up this 
very skein of yarn for which he was reaching, and handed it 
to me, seemingly unconscious of having had the fit. 
The paroxysmal period is characteristic in most all cases 
of true epilepsy, namely, loss of consciousness with more or 
less muscular spasm. Where the symptoms are few and 
simple we distinguish it by the name of minor epilepsy or 6 
petit mal. The loss of consciousness in such a case is very 
brief and the muscular spasm is confined to the face, tongue, 
throat, eyes and neck. Pallor of the face is sometimes the 
only manifestation of the disease. If seized while standing 
the patient does not fall; if in conversation he may stop, 
appear confused, and then go on with his talk. Predomi- 
nance of mental implication may prevail, and instead of any 
marked spasm, the patient may perform some queer act, as 
for instance run or jump. This perhaps is more marked in 
epileptic children than in the adult. Kerlin in his paper on 
"Epileptic change and its appearance among feeble minded 
children" mentions several such cases. Wood maintains that 
convulsive symptoms and unconsciousness may both be 
absent. There is no uniform and regular appearance of the 
symptoms and results of epilepsy. Hughlings Jackson there- 
fore says there is, scientifically speaking, no entity to be called 
epilepsy. In the Lumleian Lectures for 1890, he views as 
epileptic, only those convulsions -which arise in the highest 
exclusively cerebral level-that is the prefrontal lobe, where 
its highest motor centers are alone affected in true epilepsy. 
To the other convulsions arising from the Rolandic zone and 
ganglia of corpus striatum, he gives the name of epi- 
leptiform convulsions. We are inclined to believe with 
Christian that it matters not what muscles may be affected or 
the extent and intensity of the convulsions, it will not be 
epilepsy unless at the same time there is loss of consciousness. 
In grand mal the intensity of the convulsions varies accord- 
ing to the number of centers secondarily affected. In grand 
mal there may or may not be an aura-patient will fall if 
standing, and in many cases utter the peculiar epileptic cry. 
Face becomes intensely pale, pupils dilate, there is conjugate 
deviation of the eyes. Tonic spasms usually more marked 
on one side than the other. Respiration is impeded. Cyanosis 
prevails-jaws firmly set, the tongue may be bitten-fingers 
firmly flexed and extremities are distorted-Veins of head 7 
and neck stand out like whip cords-carotids throb violently. 
Tonic spasm then gives way to clonic convulsions, froth tinged 
with blood oozes through the clenched teeth, muscular vibra- 
tions grow less frequent, and end in irregular shock-like jerks. 
Profuse sweatino- follows. The contents of rectum and 
bladder are often voided in this stage, and ejections of 
semen are occasionally seen in the male. 
Clonic spasms last from one-half to two minutes, then 
follows stupor and stertorous breathing. A gradual return 
to consciousness is noticed, followed by sleep, which may be 
from a few minutes to several hours duration. Patients 
generally feel dazed, have headache, and are decidedly irri- 
table after having had a spasm. The post-paroxysmal period 
may be marked by psychical changes, such as mania, melan- 
cholia or epileptic automatism. Not every form of epilepsy 
is prone to issue in mental derangement, but it is true that 
those spasms which are most destructive to mental and sen- 
sorial activity are those having the least manifestations of 
muscular spasm. 
Psychical disturbances which are noticed in many cases 
of epilepsy, sometimes before and sometimes after an attack, 
vary from slight confusion and obscuring of consciousness 
to violent hallucinations of all senses; blind reckless fury 
predominating in these maniacal outbreaks. These attacks 
may last but a few minutes or several days. Epileptic dis- 
turbances are peculiar; I have one case who during the violent 
outbreak, invariably roughly treats his bible, biting, tearing, 
and stamping it, saying it says things which are not true. 
During the inter-paroxysmal period he is an incessant reader 
of this book. Many epileptics are kleptomaniacs, they steal 
and hoard up everything they can get hold of. Some three 
years ago I had an epileptic boy patient who would steal 
spoons from the table, break off the handles and store them 
away in a cigar box. 8 
During the inter-paroxysmal period many cases are en- 
tirely normal, or the mental faculties are affected but slightly. 
Bevan Lewis7 says it is a well recognized fact, that certain 
forms of epilepsy with frequent fits may last for many years, 
and the mental faculties remain in the interval between suc- 
cessive seizures perfectly intact. You all, no doubt, can 
recall such cases in your own practice where your patients 
have had fits for years with no marked mental impairment. 
It is most probable that some feebleness of mind will be noticed. 
A large class of these unfortunate beings have gradual in- 
creasing mental aberration, eventually ending in dementia. 
None of the insane, unless it is the general paretic, 
arrive at a more degraded level than the epileptic. A class 
of epilepsy, named procursive epilepsy, has lately received 
considerable attention. Bourneville, Ladarne and Mairet 
have given considerable time to the study of this class. The 
patient does not have an ordinary convulsion, but suddenly 
runs forward or in a circle. The attacks are brief and are 
not followed by somnolence or coma. The patient does not 
fall, as a rule. Ladarne says procursive epilepsy may be 
present for years before merging into ordinary epilepsy; 
transition from one to the other form may occur. It is not pos- 
sible to localize the disease anatomically, but no doubt it is of 
organic cerebral origin. Mairet thinks the organic lesion 
one of sclerosis, either trophic or hypertrophic. The cere- 
bellum is always affected. I have a male procursive patient 
under my care whose attacks are characterized first by 
throwing down his book, then getting up, giving a shrill cry 
and throwing his hands up, runs forward describing the 
arc of a circle, then a complete small circle, then again a 
large arc; when he falls he is slightly somnolent, but soon gets 
up and resumes his reading. We frequently observe in epi- 
leptics the condition called status epilepticus, characterized 
by a rapid succession of attacks without return of conscious- 
(7) Mental Diseases, 1889, 9 
ness during the slight remission. Coma follows; there is 
absence of reflex except during periods of temporary in- 
crease. Continued elevation of temperature, rapid pulse 
and respiration; temperature ranges from 105 to 107 ° F., 
and may continue high even after death. This condition is 
evidently due to vaso motor paralysis; the heat production 
still continues while its elimination is inhibited. The re- 
searches of Wood, Ott, Radnitz and others have shown the 
possible existence of a heat centre, which may in status 
epilepticus become exhausted and the balance of heat forming 
and heat elimination be disturbed. Rosenthal says it has not 
yet been proven that this condition could not be due to cir- 
culatory changes. Death is due to exhaustion or meningitis. 
During the past year I have seen four such cases prove 
fatal. In one the temperature reached 107| and remained 
high for several hours after death. 
Epileptics as a rule are religiously inclined, and many 
spend their time reading the bible, and are otherwise re- 
ligiously devout. You are, perhaps, aware that the religious 
history of the world has been influenced by this disease 
greatly. Mohamedanism owes its popularity and great in- 
fluence to it.8 It was epilepsy which held before Mohamed's 
eyes and made to sound in his ears the hallucination which 
led him to believe that he had a message from God. 
Political history has also been influenced by epilepsy. 
The career of Napoleon the Great, whose dogged persistence, 
brute-like cruelty and lack of human justice no doubt had 
epilepsy for a basis. In reading the history of his memor- 
able campaigns, in which the word impossible never entered, 
Talleyrand in bis memoirs and others speak of his spasms, 
his madness, his distorted judgment. At the famous battle 
of Waterloo, during a critical period in its progress, not a 
word of command or advice could be obtained from him, for 
he sat mute, somnolent and utterly regardless of his surround- 
(8) Blot on the Brain,-Ireland. 10 
ings, and it was only by his forcible removal from the battle- 
field by one of his generals that his life was saved. What 
would have been the political aspect of Europe to-day had it 
not been for Napoleon's epilepsy? 
Diagnosis.-To find out in all cases whether the patient 
has epilepsy or not is by means an easy task. In those mild 
forms attended with complicated symptoms it requires con- 
siderable time and observation to render a diagnosis. It is 
important especially to alienists that this form be recognized. 
From a medico-legal standpoint it is well to watch closely 
for those cases of simulated attacks which are rare but yet do 
occur. 
Hystero-epilepsy is differentiated from true epilepsy, first, 
by a partial retention of consciousness; second, by the vio- 
lent hysterical manifestions, such as distortion, peculiar 
changes of position, etc. I have a case of hystero-epilepsy 
under my care who only has fits in the presence of others, and 
then has from three to six following in quick succession. He 
is nervous, excitable, and at times apathetic. True epilepsy 
is easily and readily recognized by the loss of consciousness 
and more or less muscular spasm. 
Pathology.-Epilepsy is a disease of the brain, but what 
part of the organ is affected or the nature of the lesion which 
produces the disease we do not know; there being no perma- 
nent lesion there is no definite pathology. Starr regards the 
gross changes as described by Alexander, Meynert and others 
as not the direct cause of the disease, and says it is inconsistent 
with our clinical knowledge of the disease to seek for visible 
pathological changes. We find grave organic lesions, such as 
tumors, abscess, meningitis, sclerosis, brain softening, etc., 
in the post-mortem examinations of epileptics, such lesions 
having been diagnosed before death, but their connection 
with the epilepsy being doubtful. They are all capable of 
producing it. In idiopathic epilepsy there are no pathologi- 
cal changes. Jackson's explanation of such an attack is a 11 
chemical one, being explained as follows: Phosphorous is a 
striking constituent of nervous matter. It is a triad-in the 
abnormal nutritive process producing unstable nervous mat- 
ter the phosphorous is replaced by nitrogen, which is much 
more explosive, the replacement occurring in different de- 
grees, as evidenced by epilepsy major and minor. The 
change is a change of quality not quantity. 
Brown Sequard asserts that in epilepsy, as in natural 
sleep, it is beyond doubt that cerebral anaemia is not the 
cause of the loss of consciousness, but that it is extremely 
probable that the cessation of the activity of the brain in sleep, 
either hypnotic or normal, in petit mal, in a well-developed 
epileptic convulsion, certain cases of syncope in asphyxia 
and in poisoning depends upon an inhibitory action upon the 
base of the encephalon and cervical marrow without the 
quantity of blood being diminished in the brain. He has 
shown this inhibitory action by experiment upon dogs and 
other mammals.9 
Prognosis.-Inherited epilepsy is rarely if ever cured. 
The longer the disease has lasted the greater improbability of 
its recovery. When the attacks can be directly traced to 
peripheral irritation, and this can be removed, the case is 
more hopeful. Mental impairment indicates permanency of 
the disease. Epilepsy itself is a rare cause of death. 
Treatment.-All we can do generally in the treatment of 
this disease is to render less frequent and less severe the at- 
tacks. The removal of peripheral irritation, as before stated, 
makes the case more hopeful, but statistics are not encourag- 
ing as to complete recovery, probably due to the establish- 
ment of the epileptic habit, which is due to the adjacent brain 
centers having become irritable and unstable. 
Where focal epilepsy exists and operation is undertaken, 
the complete excision of the focal irritation is important, but 
even this may not cause cessation of the fits, for in these 
(9) Archives de Physiologic, January, 1891. 12 
cases also the epileptiform habit may have become estab- 
lished. The correction of eye strain as a source of peripheral 
irritation has received considerable attention from Ranney, 
Stevens and others with more or less success. In gynecological 
practice, removal of ovaries has been done for the same reason. 
I have a case in mind where ovariotomy was performed, 
with cessation of fits following, as is the result after almost 
any surgical operation, but in due time the fits recurred with 
increased frequency and severity. Our treatment must be a 
general one, hygienic and dietary, with much attention to 
having the digestion good and bowels regular. Regarding 
hygienic care, it is advisable to give them as much open air 
exercise as possible, and if children, allow them to play and 
enjoy themselves. While engaged in play or in attendance 
upon an amusement, epileptic children rarely if ever have an 
attack. The diet of epileptics should be nutritious but not 
too stimulating. Epileptics should as far as possible be free 
from care and responsibility. 
Medically, every form of drug in therapeutics has been 
used at one time or another. Now, however, we have 
learned that the most successful anti-epileptic drug is that 
which gives steadiness to the nervous system by lessening its 
activity, and so diminishing the tendency to give forth dis- 
charges of high tension. The bromide answers such a need 
better than any other drug. Fothergill says they have 
changed the entire aspect of epilepsy. The bromide of 
potassium is most used, but other preparations are highly ser- 
viceable, especially bromide of sodium in cases subject to 
digestive disturbances, the bromide of camphor in associated 
vertigo. For general usage, the bromide of potassium is the 
best preparation. It may be given for years without any 
serious effects. The only contra-indications being pulmonary 
tuberculosis, severe cutaneous lesions or grave disturbances 
of nutrition. 13 
Involvement of intelligence or emaciation are not indica- 
tions for its withdrawal.10 Because of its transient influence 
it should be given often; that is, at least three times a day. 
In children it is well to commence with five grains and in- 
crease gradually until sufficient is being given to control the 
paroxysms. It is well to bear in mind the fact that if small 
doses have no effect larger ones will be of no avail, and 
broinism may result. Seguin recommends that we should 
aim to keep the patient at the point of bromism, avoiding 
toxic effects. I am not an advocate of this method, for when 
we give enough of the bromide to control spasm, that is all 
that is necessary, and why should we saturate the patient 
with the drug when it is not necessary. 
I have had fair success with biborate of soda in the treat- 
ment of a number of cases of epilepsy,where bromide of potas- 
sium has failed. One case, who formerly had from one to six 
severe convulsions a day, followed by homicidal tendencies, 
has by the use of biborate of soda improved greatly. He has 
not had a spasm for six months. He receives thirty grains three 
times a day. Another case, a boy aged 13, with nocturnal 
spasms, has on ten grains three times a day, gained greatly 
physically, and has not had a spasm for over a month. In 
several cases I have had to discontinue the use of this drug 
owing to its producing gastric disturbances, nausea and vom- 
iting, and in one case decided vertigo. Emaciation spoken 
of by Risien and Russel resulted in the first case mentioned; 
but when I combined syr. hypophosphites he rapidly re- 
gained flesh and is now as heavy as before. Stewart recom- 
mends combination of bromide of potassium with biborate of 
soda when nocturnal and diurnal spasms occur; the biborate 
of soda being peculiarly adapted to nocturnal spasms. 
Where migraine is associated I combine Cannabis Indica 
with the anti-epileptic remedy. Where heart lesion or feeble- 
ness of circulation, give digitalis. If tonic treatment is in- 
(10) Medical Record, Jan., 1890. 14 
dicated, which is in almost every case, iron, cod liver oil, 
hypophosphites, etc., should be given. To arrest paroxysms 
inhalation of chloroform or amyl nitrate should be used. 
And in the condition of status epilepticus chloral hydrate per 
rectum, in doses of not less than forty grains, is indicated. 
Antipyrine, antifebrine, nitro-glycerine and numerous other 
remedies have been tried alone or associated with the bro- 
mides. None however have given much satisfaction except 
in special cases, when some of them have by some unexplained 
manner had almost specific action. I recall one case treated 
wholly for several months with the Elix-Pyrophosphate of 
Iron. Where acne results it is well to combine arsenic with 
the bromides. In cases of syphilitic origin the anti-syphilitic 
treatment should be pushed. Epilepsy due to hereditary 
syphilis is oftentimes worse when such treatment is pursued. 
I had such a case and I finally was compelled to discontinue 
the use of iodide of potassium and other treatment because 
the healing up of the ulcers always caused increased spasms. 
He had to have a vent, so to speak, for the elimination of 
syphilitic poison. In traumatic epilepsy trephining is justi- 
fiable and recommended in all cases. The operation as now 
performed is free from danger, and the patient should at 
least have the chance for recovery which it may give. It 
should be done early and before organic changes and the 
epileptic habit are established. Carious teeth in epileptics 
should be removed. The observations of Brubaker11 show 
that they are the source of irritation in many cases. 
(11) Therapeutic Gazette, January, 1888,