convulsions (grand mal) or sudden, transient loss of consciousness without convulsion (petit mal).

The importance of heredity as a causative factor of epilepsy cannot be overestimated. Innumerable influences may operate as exciting causes, but in a large proportion of cases there will be found the heritage of an unstable nervous organism, unduly responsive to irritation. It is not at all uncommon to find in the ancestry of an epileptic neurotic equivalent in the form of insanity, migraine or asthma.

It may be said briefly that the etiology of epilepsy should usually be sought in toxic or autotoxic agents acting as excitants to a poorly inhibited nervous system.

As Gowers says, "the exciting cause is only the spark which ignites the powder."

While some investigators claim to have demonstrated characteristic changes in the motor cells of the cortex and affirm that epilepsy is a diffuse lesion of the entire cortex, others attach much importance to the frequent finding of sclerosis of the cornu ammonis. As a matter of fact, there is at present no unity of opinion in regard to the minute pathology of the disease. Recent observations show that, contrary to former opinion, epilepsy occurs more frequently in men than in women.

Statistics indicate that at least sixty per cent of epileptics have their first attack before the age of twenty, and only thirteen per cent after thirty.

A description of the characteristic seizure of grand mal is too familiar to justify repetition here. There are, however, several prominent features of the attack which it may be well to review in the light of modern observation, as they serve to aid in differentiating from similar conditions or malingering.

In the first place, epileptic attacks only occasionally occur in public. Although a considerable number of cases are treated at our dispensaries an attack rarely occurs there. With a population of nearly a thousand at the Craig Colony for Epileptics of the State of New York, a seizure in the grounds is a rarity. Contrary to the prevalent idea, unusual surroundings and excitement seem to tend to repress rather than bring on an attack.

The epileptic paroxysm occurs suddenly or after a characteristic aura. The patient falls, regardless of danger; the face becomes darkly flushed; the eyes may be open or closed; the pupils are invariably dilated and do not react to light; the muscular contractions are clonic and intense; breathing is abdominal; frequently the tongue is bitten; there may be escape of urine. and fæces; the reflexes are abolished and remain so some little time after the attack has ceased; the temperature is usually increased after the attack; punctate hemorrhages may occur either in the skin or conjunctiva. An epileptic attack is of short duration, from one to ten minutes. Attacks of any

severity are generally followed by temporary mental torpor and muscular lameness.

Transient paralyses may result from exhaustion of the motor cortical centres, but if these are well marked or persistent it is probable that the case is not a genuine, but a sympathetic epilepsy.

If the patient is seen in an attack the diagnosis of epilepsy should not be difficult. Epilepsy must be distinguished from hysteria and various symptomatic and toxic convulsions. A diagnosis from uræmia and other toxic attacks can usually be made by carefully investigating concomitant symptoms. It is important in every case of convulsions to seek for signs of an organic cerebral disease; here an ophthalmoscopic examination may afford the necessary clue. The attacks of spasm observed at the beginning and during the course of dementia paralytica are generally unilateral and without loss of consciousness.

Convulsions beginning in later life are generally symptomatic and due to a cerebral tumor, cerebral syphilis, general paresis, chronic nephritis, or arterio-sclerosis.

The hysterical convulsion, which is the most difficult of differentiation, is often preceded by some form of emotional excitement; biting the tongue or other injury is rare; there are no changes in the reflexes or the pupils; the muscular movements are exaggerated and in unnatural directions; there are no involuntary evacuations; the duration of the attack is usually much longer.

In attacks of from a quarter to half an hour hysteria or an organic cerebral disease is present.

The essential characteristic of petit mal is sudden momentary loss of consciousness, almost always without convulsion, although slight twitchings may occur, especially in the face and lips. The unconsciousness is so transient that the patient does not fall as a rule, and may resume his interrupted conversation or occupation without realizing that anything unusual has happened.

Care should be taken to distinguish petit mal from the reflex phenomena (vertigoes, etc.) which so often occur in nervous children.

Its abrupt onset and transitory nature should differentiate petit mal from syncope and vertigo.

The more hopeful views at present entertained as to the prognosis of epilepsy are based largely upon its successful institutional treatment. William P. Spratling, whose large experience as superintendent of the Craig Colony, renders his opinion of especial value. says in his recent work on epilepsy: "Notwithstanding the chronicity of the affection, the results following treatment in many were such that I have no hesitancy in stating that epilepsy is not infrequently a curable disease,

irrespective of its duration, the rule being that recent cases are twice as liable to respond to treatment as chronic ones." Speaking of the influence of attacks upon the mind, he states that it is clear from his tables that the oftener the attacks occur, the less favorable is the mental condition, and he agrees with the general opinion that grand mal seizures are more amenable to treatment than petit mal or psychic attacks. He has observed that the greater the length of time between the appearance of the aura and the fit, the more readily will the case yield to treatment.

Of the medicinal treatment of epilepsy one must speak with reserve. The salts of bromide still occupy the leading place, and while it is conceded that they cannot by themselves be regarded as curative, it is probable that few severe cases of epilepsy are treated without the aid of bromide palliation. Bromide of potassium is probably most largely used. My own preference is for sodium salt, not only because of its higher percentage of bromide, but because it seems better borne by the stomach.

The most satisfactory preparation I have found to be a watery solution of some definite strength say twenty-five or fifty per cent. The administration of this solution in vichy or apollinaris water seems to enhance its effect. No definite dosage of bromide can be prescribed for all cases. If the drug is called for at all it should be given in whatever dosage controls the attacks, and the quantity necessary for this result varies greatly in different individuals.

In using the bromides Spratling believes in restricting the ingestion of salt and keeping the doses as low as is consistent with a reasonable control of the epileptic phenomena. He finds that under the withdrawal of salt from the diet ten grains of bromide is as effective as twenty grains in the ordinary way.

Opium as an adjuvant of the bromides in the treatment of epilepsy, has been highly lauded in rare cases which fail to respond to bromide treatment alone. This plan of treatment necessitates the administration of large doses of opium, and its popularity has greatly waned.

Innumerable drugs have been praised and hailed as cures of epilepsy, but, unfortunately, very few of them are worthy of even mention. The reported results from the use of Enanthe crocata, cotyledon, solanum caroliensis, and others have been conflicting and the conclusion is that their rare successes have been in symptomatic convulsions rather than in true epilepsy. No treatment of epilepsy can be successful which is not based upon attention primarily to the individual rather than to the disease. In order to overcome hereditary tendencies, irritable nerve centres must be trained to a condition of stability. This can be done only by the enforcement of a carefully arranged

schedule of living, including occupation, exercise, rest, and recreation modified in accordance with the special needs and limitations of each case.

Faulty metabolism and autotoxæmia should be corrected by compelling the patient to follow a thoroughly detailed plan of diet. Free elimination should be secured by daily graded baths, deep breathing, and the promotion of renal and intestinal activity. The more absolute and persistent the submission to such regulation, the greater the hope of amelioration or cure. In a letter recently received from Dr. Hartstein W. Page, superintendent of the Hospital Cottages for Children, he says: "We have no secret, peculiar, or special remedies, prescriptions or methods. We rely largely upon regulation of diet, functions and habits. I believe that discipline, firm, steady, kindly, is of great importance and value in these cases. We do not exclude bromides from our treatment, and after a somewhat wide observation, I do not believe the bromides are responsible for so much mental deterioration as has been claimed by some and feared by many. Of the epileptics now with us, about twenty per cent have ceased to have attacks and have had none for periods ranging from one to five or six years. I believe many of them would go on indefinitely without attacks if they were to remain under these conditions, but that many, if not most of them, would relapse upon returning to the ordinary conditions of the homes from which they come. I do not include in apparently cured, cases which are being carried along without attacks by anti-spasmodic treatment. Some of our best apparent cures have been in cases where no anti-spasmodic treatment has been given."

In the last report of the Massachusetts Hospital for Epileptics, the superintendent, Dr. Everett Flood, dwells upon the value of routine life, and calls attention to the desirability of having patients partake of their food with moderation, at regular intervals, and with thorough insalivation.

These views are in perfect accord with the opinions of the most experienced observers who agree that in the cure for epileptics the chief reliance must be upon hygienic and moral regulation.

In the administration of such treatment the general practitioner is greatly handicapped because of his difficulty in controlling patients, and it is for this reason that institutional or colonization treatment affords the best results.

We are fortunate in having in Massachusetts two institutions to which we can send epileptics with full confidence that they will receive careful individualization, and treatment by the best therapeutic methods.

The Massachusetts Hospital for Epileptics, located at Monson, Mass., (Post Office and Railroad station, Palmer) accommodates about five hundred patients.

Epileptics over fourteen years old are admitted to this hospital as follows:

1. The regular insane commitment, such as is used at the insane hospitals.

2. The same indigent; in this case the approval of a judge is required, in addition to the physicians' certificates and the notification of the town authorities.

3. The same private, in which two sureties are required to sign the patient's application.

Each patient is required to work as much as he is able. Patients are not allowed to go to town alone, nor to walk out alone. They are expected to live on plain diet, and to go to bed early. These restrictions are not irksome when they are fully understood, and can be complied with easily.

The Hospital Cottages for Children, at Baldwinville, care for about one hundred and fifty children. This institution is supported largely by endowments and private charity.

The noble work it has accomplished and the excellent results obtained surely entitle it to an annual State appropriation. The class of cases cared for at this Hospital are:

First. Children under fourteen years of age, suffering from epileptic or epileptiform seizures.

Second. Children suffering from other nervous disorders, not feeble-minded.

Third. Children with deformities, with disease of the hip, knee, and other joints, spinal disease, infantile paralysis, and other affections where the disorder is likely to require a long residence in a hospital,

Fourth. Children needing operation or fitting of supports. These return to their homes as soon as the appliances are well fitted, usually in a few days, and may be brought to the Hospital at short intervals for observation.

Children are supported in the following ways:

First. There are a few free beds. Those who maintain them may nominate children to occupy them. There are not nearly enough free beds to provide for all who apply for them.

Second. The Children's League assists in the support of a few cases, but the League beds are also in great demand and are rarely vacant. For information relating to the League write to Mrs. J. K. Dexter, 27 High Street, Springfield, Mass.

Third. In many cases the town where the child is settled is willing to pay the charity rate, $3.25 per week, which is below cost and is offered in these cases in consideration of the assistance this institution has received from public and charity funds. Those desiring this aid should arrange with the overseers of the poor of their city or town.

Fourth. In some cases where the child has no town settlement, the state authorities are willing to pay the charity rate