has been erroneously ascribed as the cause of the latter rather than an incident and coincident of it.

Finally, the modern pathology of epilepsy gives sufficient ground for the present broad but empirical treatment of the disease, which consists largely in overcoming hereditary tendencies as far as possible, and excluding toxic and autoxic agents and administering a carefully detailed plan of living plus such degrees of sedation as may be necessary in individual cases. In the light of the pathogenesis (although as yet it but foreshadows its fruition) and the histo-pathologic changes already known, with their certain results in impairment of normal cerebral functions if not checked, the importance of the most comprehensive and early treatment is obvious.

The missing links in our knowledge of epilepsy are its pathogenetic agents and the organic anomaly of the cortex which constitutes its predisposition; these two factors still hold the mystery of frequent relapses. The gap between its terminal gliosis and the toxic and autoxic agents has been narrowed by recent knowledge of the initial cortical cell changes, which particularly concern the nucleus.

We are warranted in drawing the following conclusions regarding the pathology of epilepsy:

1. Epilepsy is a cerebral disease attended and followed by profound and diffuse cortical degeneration.

2. The morbid changes concern chiefly the destruction of the nuclei of the cells of the sensory type from which the primary departure of the disease originates. Its terminal pathology is a progressive gliosis more or less marked and diffuse.

3. Epilepsy is essentially a sensory phenomenon with a motor manifestation.

4. Its etio-pathology rests with a variety of toxic or autotoxic agents not as yet definitely isolated or determined.

5. The disease is engrafted upon a cortical organic cellular anomaly which is induced largely by a faulty heredity, the exact anatomic nature of which is not known.

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ADAMI: "British Med. Journal," March 16, 1901.

AGOSTINI: "Rev. Sper. di Freniatria," 1896.

ALZHEIMER: "Monatschr. f. Psychiatrie und Neurologie," 1898, IV.

v. BECHTEREW: "Neurol. Centralblatt," 1895, XIV.

BISCHOFF: "Wiener klin. Woch.," 1899, XXXIX. "Jahrbuch f. Psych.," 1901.

BINSWANGER: "Specielle Path. u. Therapie" (Nothnagel), Bd. XII, 1899. BLEULER: "Münch. med. Woch.," 1895, XLII, 33.

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CHAPTER XIII.

THE GENERAL TREATMENT OF EPILEPSY.

Control of Patient of First Importance. Regulation of the Patient's Habits and Diet. The Value of Proper Exercise. The Purpose and Scope of Medico-pedagogic Treatment. The Young Epileptic's Especial Demand for Education and Training. The Mental, Moral, and Physical Failure of the Epileptic without Care.

THE treatment of epilepsy lies along three distinctive lines: General, Medical, and Surgical, and we will consider them in the order named.

In speaking of the general treatment of epilepsy, we refer more particularly to the treatment of the epileptic himself than to the treatment of his disease. The importance of the former has been steadily increasing since the epileptic first came under especial care in this country in institutions designed for his needs, twelve or fifteen years ago. Up to that time the medical treatment of the disease was held to be of paramount importance, since, indeed, it was the only one then known to be at the physician's command. But now, while drugs play a conspicuous and valuable part, they are regarded by the best among those whose familiarity with epilepsy is greatest, as often falling short of fully meeting the requirements in all cases, so that the aid of other agencies must be evoked. These will be described in detail in the present chapter, for their value is clearly beyond dispute, while the knowledge of their use, variously modified as they must be to meet changing types of cases, is not nearly so universal as it ought to be.

To be sure, the physician in general practice is often handicapped by his inability to control the

patient in the manner desired, as is fully possible only in special institutions; but this apparent disadvantage is not nearly so great as it seems at first glance, for, as a rule, the general practitioner has a more intelligent class to deal with than the institution physician. To the latter, patients are often sent only after their control has largely been lost at home.

Barring this single difference, the valuable features of treatment now so greatly in vogue in colonies of different kinds are fully as valuable to the epileptic treated at home as to the epileptic whose constant atmosphere is some form of colony life.

The Control of the Patient most Essential. We may start with the following proposition, applicable without exception to every case alike: The more absolutely the physician is permitted to control the patient in every respect, the more promising the hope of amelioration or

cure.

This may be accomplished in one of three ways, depending largely upon the age, general intelligence, and character of the patient. It may be accomplished first by securing the aid of the patient himself, having him fully understand what he must do in order to get well, and at the same time show a perfect willingness in literally carrying out every direction imposed upon him. Such patients will be quite frequently encountered, though they do not constitute the majority, for the reasons that epilepsy being essentially a disease of early life and so often causing mental impairment in a few years' time, the patient lacks the judgment and discretion of maturer years, and mental faculties unclouded by disease.

But there still remains a very considerable number whose disease does not appear until after puberty, whose general development and education up to that time were good, and whose attacks are of a type to permit the retention of a comparatively sound mind,