Incoherence of speech and lack of orientation as to surroundings are more marked in epileptic insanity than in any other psychosis.

The motor symptoms vary extremely. Sometimes we note motor inhibition attaining to complete immobility and mutism, lasting for hours, days, or weeks at a time. Such quiescence is often interrupted by sudden explosive acts of violence. Again, in other cases, we observe agitation, restless wandering about, purposeless and impetuous running hither and thither, assaults, destructiveness, and, rarely, complicated acts, like theft and other petty crimes. A condition of religious ecstasy is not uncommon. The patient may feel himself wafted to heaven, where he converses with God, Christ, and the disciples.

In some rare instances epileptics are subject to dream-like states of subconsciousness, similar to somnambulism, in which complicated acts are carried out. Like the somnambulist, such patients may seem to be conscious, may comport themselves in speech and conduct in a perfectly natural manner, and in this condition, which may last for hours, days, or even weeks, commit offenses against the law, wander off as tramps, or do some extraordinary thing in following the imperative, childish, silly, or fantastic ideas which control their dream-state.

The disorders of memory incident to transitory epileptic insanity are both interesting and important. There may be, upon recovery, absolute amnesia as regards everything that has taken place. There may be remembrance of much that has occurred immediately after the insanity has passed, with subsequent amnesia. There may be complete amnesia at first, with glimpses of remembrance afterward. There is rarely any persistent recollection of the events of the psycopathic

state.

As has been stated, the rule is for these transitory epileptic insanities to exhibit a sudden onset and a sudden termination. The longer the duration, the less abrupt the cessation. The majority of these patients recover, but recurrence is, of course, frequent. Termination in a chronic condition is rare. Occasionally, death takes place from exhaustion, intercurrent maladies, or from a convulsive seizure or series of attacks during the psychosis. Recurrences tend to hasten a psychic degeneration ending in dementia.

The epileptic nature of such insanity as is here described, where the history is not known, is determined by the following characteristics : (1) Sudden onset and abrupt termination; (2) the terrifying or ecstatic nature of the hallucinations and delusions; (3) disturbance of consciousness and stuporous condition; (4) impulsive acts; (5) dream-states; (6) amnesia.

Chronic Epileptic Insanity.-Aside from epileptic dementia, the acute epileptic psychosis just described may take a chronic course, or assume a periodic form, with little improvement in the intervals between the exacerbations. There are cases which closely resemble chronic mania in their long course, and others in which melancholia is the predominating feature. The epileptic attacks to which these patients are subject are naturally the distinguishing feature, and a special color is given such cases by the epileptic psychic degeneration. Occasionally a

true circular insanity is presented, with its alternating maniacal and melancholic phases.

Treatment. Most cases of pronounced epileptic insanity require commitment to an asylum. Their proclivity to sudden accesses of rage and fury and to impulsive acts of violence necessitates this course. Where there is simply a moderate amount of psychic degeneration this course is not necessary.

The treatment should be, in the first instance, prophylactic; but, after the development of the psychosis, it consists of a combination of the treatment of ordinary epilepsy with that of the particular type of insanity presented.

Preventive therapy is concerned with the counteraction of the many elements which favor mental deterioration, with the mitigation of the epileptic's early sufferings, with the reconstruction of his environment. It may be called the moral and manual method. The moral part of it is the opportunity for education, regular occupation, and recreation. The manual and hygienic part of it, the acquisition of out-of-door trades or callings-muscular exercise, which in itself serves to reduce the number and intensity of convulsive seizures. I may be pardoned for dwelling somewhat longer on this subject of preventive therapy, and for allowing my pen to go over the same lines which it has traveled so often in past years, because I am convinced that this moral treatment marks the greatest stride in advance made for centuries in the therapeutics of epilepsy. For ages drugs have been exploited as helpful or curative; but, after all, little has been accomplished from the standpoint of materia medica. Only of late years has the moral treatment become prominent. As a rule, the epileptic patient was dismissed by his physician with a prescription of uncertain value and possibly a few general directions as to diet. It was not known to the practitioner-or, at least, he did not concern himself about the matter-that the epileptic could gain admission to no hospital of any kind; that he had no associates, occupation, or recreation; that, debarred from the schools, he grew up uneducated, and with a tendency toward retrogression rather than progress; and that, without teaching, reared in idleness, suffering from a dreadful malady, neglected in body and mind, he could find shelter at last only in the almshouses and insane asylums, these being the only institutions open to him. Yet, in by far the majority of cases of epilepsy, the attacks rob them for but brief intervals of the capacities for study, work, recreation, and social pastimes, which they possess in common with their more fortunate fellow-men. Hence the adoption of a scheme of colonization of epileptic dependents on the model of the great German colony at Bielefeld, of which the Craig Colony, in the State of New York, is an example. The Craig Colony consists of a tract of nearly nineteen hundred acres of land in the most fertile, productive, and picturesque valley of the State (the Genesee Valley). Upon this are already some sixty to eighty buildings, with accommodations at present for but 840 patients. Over eleven hundred epileptics are now on the list of patients awaiting admission. Here they are to be given an education in the various branches of learning taught in the public schools, to be

instructed in every kind of industry, to be treated each and every one for epilepsy, and to be offered a home in a sort of village life, where they will no longer have the feeling of social ostracism, or be debarred from the privileges of intellectual and moral development enjoyed by the rest of mankind.

The out-of-door life in a farming community has already had wonderful results, which may be learned from the annual reports of the colony. It will suffice to say here that the average reduction in frequency of attacks among all the patients has been fully fifty per cent., and that the mental and moral regeneration of the beneficiaries has been truly remarkable. What the effect of such change of environment must be as a prophylactic against psychic degeneration and insanity can not be estimated. We may now briefly touch upon the medicinal and surgical treatment of epilepsy. The old drugs-borax, nitrate of silver, belladonna, and the bromids-have their uses. One is valuable in one case and not in the other; and each patient, where the disease is idiopathic, and no etiological indication exists for the preferment of an especial agent, must be experimented upon with one drug after another for two or three months at a time, until a satisfactory remedy is discovered. Upon the whole, the bromids are most effective as a general antispasmodic for all cases. While the bromids are, perhaps, the most useful remedy we can employ as an antispasmodic in many cases of epilepsy, their exhibition in every case is not advisable. With a considerable number of patients the bromids are entirely ineffectual; with no small number, too, very serious symptoms, such as acute bromism, increase of seizures, and even insanity, supervene upon their use. many of the cases where actual good is done by the bromids in reducing the frequency and severity of the attacks, the concomitant symptoms are such that it becomes questionable whether the remedy be not, after all, worse than the disease. The writer makes it a practice, therefore, to exhibit the bromids with caution, and never to employ them until the series of less harmful, but often quite as efficacious, remedies for epilepsy have been tried in vain.

In

There are some new drugs and remedial methods that have come into vogue of late which are worthy of attention. In the first place, there is simulo, a South American plant of the hyssop family, the tineture of which is given in doses of one to two or three drams three times daily. After an experience in many cases for several years, I would say of simulo that it deserves trial in most cases; that it is perfectly harmless, which can not be said of the bromids, borax, belladonna, and some other drugs; that in a few cases it has been extremely beneficial in my hands, and that in most cases it has no effect at all. Simulo combined with small doses of bromid acts very well. The so-called opium-bromid treatment of Flechsig is of value for many patients, especially in old and obstinate cases where all other agents have proved ineffectual. This treatment consists of the administration of opium for some six weeks, beginning with one-half to one grain three times daily, and increasing gradually until ten to fifteen grains a day are taken, when the use of opium is suddenly stopped, and bromids in large and grad

ually reduced doses are given (thirty grains four times daily, to begin with). I had used in certain cases of epilepsy for some years codein with considerable success, but this combination of the opiate with bromids is still more satisfactory.

Adonis vernalis conjoined with the bromids, as recently suggested by Bechterew, is an efficient method of treatment, from which, in several instances, I have had gratifying results. Digitalis, which has properties similar to Adonis vernalis, was formerly frequently given in epilepsy, but the new combination seems to be much more efficacious.

There are a few cases of epilepsy in which careful investigation indicates self-intoxication as a factor. In these an excess of ethereal sulphates (indican) in the urine, together with periodical or constant attacks of gaseous diarrhea, are almost positive manifestations of putrefactive or fermentative changes taking place in the alimentary tract. It is remarkable how much benefit may be obtained in such patients by the regulation of the diet (milk and its modifications, koumiss, matzoon, somal, rare or raw beef, eggs, green vegetables, and special breadstuffs, like Zweiback, Huntley & Palmer's breakfast biscuits, and Voebt's biscotte de legumine), by the frequent drinking of hot water and the occasional flushing out of the large intestine by hot water, and by the use of certain intestinal antiseptics, given two hours after eating, with plenty of water (beta-naphtol or salol, gr. v).

The remarkable effect of the thyroid extract upon general nutrition would naturally suggest the advisability of its administration for experimental purposes in some of the nervous diseases which we are accustomed to look upon as due to nutritional disturbances in the nervous system. With this idea in view, I have employed it in a good many cases of epilepsy, in a number with very good effect. Especially noteworthy was mental improvement in several cases of epilepsy with apparently considerable dementia. It is worthy of more extended trial.

Aside from the remedies for the epilepsy just described, we need occasionally to employ certain other drugs for particular conditions, such as status epilepticus, maniacal outbreaks, pronounced melancholic states of terror, etc. In status epilepticus rectal injections of chloral, gr. xx, with an ounce of starch-water, repeated at intervals of two or three hours if needed, give the most satisfaction. In great ideomotor excitement we should use hyoscin, hyoscyamin, or duboisin hypodermatically, in doses of to 5 of a grain. In anxious melancholic conditions morphin hypodermatically is, perhaps, the best alleviating agent to exhibit.

The question of trephining must naturally come up in certain cases of epileptic psychoses where trauma to the head is evidently the cause of the epilepsy and psychic degeneration. The following points are to be taken into consideration as a guide in this matter:

1. In the very small number of cases having injury to the head as a cause the epileptic habit is so strong, and the changes in the brain. are usually so old and deep-seated, that an operation, as a rule, does not cure, and seldom permanently diminishes the frequency of the attacks.

2. Of miscellaneous traumatic cases, where a surgical procedure seems justifiable and is undertaken, a cure of the epilepsy may be reasonably expected in, perhaps, four out of every hundred cases operated upon.

3. The removal of a cicatrix from the cortex, supposed to be the epileptogenic nidus, will naturally be followed by the formation of a new cicatrix in the surgical wound-the creation, therefore, of a new epileptogenic center.

4. The more recent the injury, the greater will be the promise of lasting benefit.

5. In cases of traumatic epilepsy with marked epileptic psychoses (recurrent attacks of rage, fury, violence, destructiveness, etc.) trephining would be justifiable as a possible means of diminishing the severity, danger, and frequency of the maniacal attacks, even though the epilepsy itself or the psychic degeneration might not be improved.

CHAPTER X.

DEMENTIA.

Secondary; Senile; Primary.

Definition." Dementia" is a term employed to designate simply a general enfeeblement of all the mental faculties. It is often used improperly by the laity as synonymous with insanity. But in medicine it signifies only a general weakening of a mind once normal. Hence it is not applied to congenital mental weakness. The term "idiocy," with its various degrees, includes all of these congenital psychic defects. There are innumerable gradations comprised in dementia, from the merest dullness to profound deficiency or complete loss of all the intellectual faculties. Such enfeeblement of the mind may be the result of serious cerebral diseases or disorders, such as epilepsy, alcoholism, syphilis, etc., when the dementia is qualified as epileptic, alcoholic, syphilitic dementia, etc. It is often a sequel to acute insanities, like mania and melancholia, and to chronic psychoses, like circular insanity and paranoia, and hence the distinctive term secondary dementia applied to such examples. It takes the chief part in the syndrome of paresis, so that that disorder is often entitled "paralytic dementia." Progressive mental enfeeblement not infrequently accompanies senile involution and organic changes in the brain incident to that epoch of life; hence the well-known disorder called senile dementia. Finally, there is a form of mental disease characterized in the main from the very beginning by extraordinary psychic enfeeblement, and this malady is classified as an acute or primary

dementia.