sensory irritation. Although atropin causes dilatation of the pupil, this will be slighter than upon the healthy side. Trophic disorders may gradually arise, as, for instance, atrophy of one side of the face.

Etiology. The causative factors for paralysis of the sympathetic are generally of traumatic nature, for instance, punctured, gunshot and operative wounds of the neck, compression by enlarged lymphatic glands, inflammatory processes involving the connective tissue of the neck, enlarged thyroid gland, fracture and luxation of the cervical vertebræ, disease of the cervical cord or of the lower portion of the brachial plexus (Vol. I., p. 499), and pulmonary tuberculosis if adhesions exist between the apex of the diseased lung and the cervical sympathetic.

The prognosis depends upon the removability of the causative factors.

Treatment.-Galvanization of the cervical sympathetic has been recommended in treatment. In addition, operative intervention must be taken into consideration.

IRRITATION OF THE CERVICAL SYMPATHETIC.

Symptoms.-Irritation of the cervical sympathetic is primarily attended with dilatation of the pupils-spastic mydriasis. Often the power of accommodation also is impaired. Occasionally protrusion of the eyeballs and widening of the palpebral fissure occur in consequence of irritation of the muscle of Müller. As a result of vasomotor spasm the carotid and temporal arteries at times are contracted, and the side of the face and the neck are pale and cool; and sweating may be absent. Trophic disorders may develop within a short time, and give rise to disfiguring unilateral atrophy

of the face.

Etiology. The same causative factors that are responsible for paralysis of the cervical sympathetic may give rise also to irritation, and occasionally irritative and paralytic states alternate with each other.

With regard to prognosis and treatment the same statements are applicable as were made concerning paralysis of the sympathetic.

VI. CENTRAL NEUROSES.

THOSE nervous disorders are designated neuroses for which hitherto it has not been possible to demonstrate anatomic alterations. They are, therefore, designated also functional nervous disorders. Central neuroses include those nervous disorders whose

seat is suspected to be in the central nervous system. It is the object of medical investigation to limit progressively the number of central neuroses.

CENTRAL NEUROSES IN WHICH MOTOR DISTURBANCES PREDOMINATE.

EPILEPSY.

Etiology. In typical cases epilepsy is attended with attacks of unconsciousness and general clonic muscular spasm, which in all probability are dependent upon transitory hyperemia in the motor and purely psychic areas of the cerebral cortex. The condition is therefore designated also idiopathic or true epilepsy. The designation symptomatic epilepsy has been applied to cases in which neoplasms, hemorrhage, abscesses, parasites, detached splinters of bone, and the like, cause irritation of the motor centers in the central convolutions of the cerebral cortex, and as a result induce general, but frequently also localized clonic muscular spasm. Under the latter condition the disorder is designated also cortical or Jacksonian epilepsy. The characteristic feature of the latter is the fact that in many cases consciousness is preserved during the convulsive attacks, and that if general convulsions occur these always appear first in the same extremity. The remarks that follow apply only to idiopathic epilepsy.

True epilepsy is an extremely common disease that occurs rather more frequently in women than in men. Not rarely it is transmitted by heredity, as manifested by the occurrence of epilepsy in successive generations or by its alternation with hysteria, neurasthenia, psychopathies, or other central neuroses. Occasionally the predisposition to epilepsy is congenital. Alcoholism in the parents, particularly conception during a debauch, not rarely gives rise to epilepsy in the children. Occasionally difficulty in labor is responsible for the development of epilepsy, as, for instance, protracted labor and delivery with forceps. At times epilepsy occurs in the sequence of infectious diseases. Syphilis particularly is properly considered a frequent cause of the disease. Toxic epilepsy is worthy of especial consideration. Alcoholic excess is a frequent cause for this condition. Chronic lead-poisoning also may cause epilepsy. Some cases of epilepsy are dependent upon injuries to the skull and general concussion of the body. Psychic influences may also be operative. Thus, epilepsy may occur in the sequence of fright, fear, or joy, and after excessive mental activity. Some persons are attacked by epilepsy after having witnessed epileptic attacks in others, and having been deeply moved by the occurrence. Epilepsy has been observed also to develop in persons who, for one reason or another, have

attempted to imitate an epileptic seizure. Reflex epilepsy is of considerable practical importance. This occurs in connection with diseases of organs at times far removed from the brain, an irritative influence being exerted from this point upon the brain. It is especially well known that nerves imprisoned in cicatrices may give rise to reflex epilepsy, and that the attacks can be induced by pressure upon such cicatrices, and also that cure can occasionally be effected by their removal. Polypi in the nose, the pharynx, and the ear, or foreign bodies in the nose or the ear, coprostasis, intestinal worms, phimosis, preputial calculi, uterine displacements, pregnancy, disease of the heart, and the like, may also give rise to reflex epilepsy.

Symptoms. As a rule, epilepsy sets in between the seventh and the twentieth year of life. Should the first symptoms appear in adults it will be found often that special causes are operative, particularly traumatism, alcoholism, syphilis, or reflex influences. The designation late epilepsy has been applied to cases in which the disease begins after the fortieth year of life. Epilepsy may appear in three varieties, namely, grave or major epilepsy, mild or minor epilepsy, and the epileptic equivalent.

Grave or major epilepsy is characterized by the occurrence of typical epileptic attacks. These set in without demonstrable exciting cause, or they are induced by excessive psychic or physical activity, alcoholic and venereal excesses, or the like. Not rarely the occurrence of an epileptic attack is preceded by prodromes, among which remote and immediate must be differentiated. The remote prodromes frequently appear several days before the occurrence of the epileptic attack, and consist in change in character, peevishness, irritability, a tendency to anger, disturbed sleep, frequent dreams, apathy, and allied disturbances. The immediate prodromes are known also as the epileptic aura, and generally precede the epileptic attack by only a few seconds. The aura is described as sensory, motor, vasomotor, or sensorial, in accordance with the nerve-path involved in its development. The sensory aura may give rise to complaint of various paræsthesiæ; at times, though on the whole rarely, of a sensation as if a breath of air had been blown upon the surface, whence the designation anra (breath of air). A motor aura may consist in contracture, twitching, or paralysis, which not rarely begins always in the same extremity, and which in accordance with the relations of the motor cortical centers extends in regular manner and in the same order to the remaining extremities. The vasomotor aura is attended with states of in the musculature of the vessels, and gives rise to pallor and coldness of the skin, while the sensorial aura is attended at times with roaring or ringing in the ears, the hearing of voices, at other times with disorders of smell or taste, generally of a disagreeable character, and at still other times with visual

spasm

disturbances. In the last-named event the patient may see colors, and red with especial frequency; or he is frightened by hideous figures, which overwhelm him. Occasionally the patient is thereby impelled to acts of violence, and even to murder, and many a crime owes its commission to such processes, of which the patient has no knowledge on emerging from the epileptic attack. Such conditions are designated pre-epileptic (preparoxysmal) insanity.

The actual epileptic attack generally begins with a loud, piercing cry. The patient suddenly loses consciousness, and falls helplessly to the ground. Injuries are often incurred thereby. The unconsciousness is so profound that the patient may fall into the fire, and one or more members be burned or charred, without any perception on his part of the occurrence during the attack. At first the face and the surface of the entire body become pale, and all of the muscles of the body are thrown into tonie spasm. Within a few seconds, however, this is replaced by clonic muscular spasm, which, by reason of its wild and violent nature, gives the epileptic attack its horrible aspect. The eyeballs are rolled to and fro, and eventually are rotated inward and upward. The muscles of the face are greatly distorted. The jaws are held tightly together, and are displaced laterally, and from behind forward, and the reverse, so that not rarely the grinding of the teeth can be heard at a considerable distance. The tongue is lashed to and fro in the mouth, not rarely being caught between the teeth and becoming imprisoned there, so that it is bitten, and blood-streaked sputum escapes from the mouth. Generally, frothy saliva escapes from between the lips, probably because in consequence of clonic spasm of the muscles of deglutition the saliva cannot be swallowed. Clonic spasm of the muscles of the trunk gives rise to violent agitation of the entire body, and the patients often throw themselves about from side to side. Respiration is irregular, intermittent, and frequently accompanied by groaning, gurgling, and snoring sounds. The extremities also exhibit the most varied displacements and movements. The fingers are held flexed, and the thumbs drawn beneath the fingers, so that the thumbs can be secured and extended only with difficulty and at times only with luxation or even fracture. The force of the muscular contraction is very considerable, so that occasionally teeth are broken and bones dislocated or fractured. Marked spasm of the muscles of the neck causes stagnation of blood in the jugular veins, so that the external jugular veins often become converted into blue strands as thick as a finger. In addition, there may be present acute protrusion of the eyeballs of progressive intensity, marked conjunctival injection, and evanosis of the face. Subeùtaneous hemorrhages also readily occur. The pupils, which were dilated at the commencement of the attack and during the short

period of tonic spasm, become contracted with the onset of the clonic muscular spasm. It is of especial diagnostic importance that the pupils exhibit no reaction to light and to sensory irritation of the skin, thus no alteration in size. Often during the attack involuntary discharge of urine and also ejaculation of seminal fluid take place.

The duration of an epileptic attack generally varies from ten seconds to five minutes. The muscular contractions succeed one another with progressively lessening frequency and intensity, cease gradually, and the patient gradually emerges from his coma without knowing what has happened. Some patients are speedily restored to consciousness, and feel fresher and better after the attack than before. Others become fretful, peevish, capricious, irritable, and ill-tempered. In still others hallucinations and illusions appear. They become violent, destroy articles about them, set fire to inflammable articles, attempt to strangle or to kill their attendants-in short, commit crimes without consciousness thereof or without any recollection thereof after emerging from the epileptic attack. These phenomena are grouped together under the designation of post-epileptic (post-paroxysmal) states. Further, this condition persists at times for days. Naturally, its recognition is of importance for the comprehension of some otherwise inexplicable crimes.

Epileptic attacks occur at times only by day, in other instances, however, exclusively at night, and, accordingly, a distinction can be made between diurnal epilepsy and nocturnal epilepsy. Cases of the latter variety are at times surrounded by diagnostic difficulty. Attention should be directed especially to the discovery of whether injury of the tongue, subcutaneous hemorrhage, or involuntary discharge of urine has taken place during the night. The urine at times contains albumin or spermatozoids after an epileptic attack. Occasionally polyuria, glycosuria, and paralysis develop in the sequence of an epileptic attack, the last-named disappearing generally in the course of a few days.

The number of epileptic attacks is quite variable. Some patients have perhaps a small number of attacks in the course of a year, while others have an attack or more than one daily. It also frequently happens that periods with few attacks alternate with periods in which numerous attacks occur. Occasionally the attacks occur in such rapid succession that one has not terminated before the other sets in. The patients do not return to consciousSuch a condition is designated status epilepticus. It is not unattended with danger. A rising temperature (up to 42° C.— 107.6° F.) particularly is not a favorable sign, and death may be threatened from exhaustion of the central nervous system.

ness.

The individual epileptic attack is not rarely followed by complications. Bite-wounds of the tongue, subcutaneous hemorrhage,