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necessary in the chronic and acute form of a disease, known by the same name, and most of all, because the incurable nature of one form bas induced some of the ablest men to despair of success in the other. This is so well kuown of epilepsy and gout, that they have both been called the opprobria medicorum ; and tbe frequent return and long continuance of some strictures 'under every mode of treatment, is, perhaps, only less notorious as the disease is less obtrusive.
In my remarks on epilepsy, I shall, therefore, beg the reader's pery particular attention to the two forms under which it appears, because by these it will be proposed to guvern our prognosis and regulate our practice.
The acute epilepsy, on the cure of which only I have any thing to offer, is sometimes preceded by higher health than ordinary; at others, for a few days, by heaviness and an incapacity in the patient to arrange the objects of bis attention with the usual accuracy. Oftentimes these will cease a few hours before the paroxysm, and be succeeded by an hilarity which, though part of the disease, will, by the friends, be considered as the cause. The first attack is most commonly at night, immediately after or during the first sleep, rendered more inviting and profound by previous exertion or a hearty meal. The patient is altogether insensible during the paroxysm, according to the severity of which will be his subsequent feelings. The duratiou is not less uncertain; sometimes he will have a temporary tespite, during which the terrors of his mind seem beyond all description, till the paroxysin returns with the same violence as before, and with the same insensibility.
The symptoms are universal convulsions, with so preternatural a power in all the muscles, that the strength of several stout men is necessary to restrain the dangerous exertions of even a delicate subject, This muscular action is never uniform, but attended with those alternate contractions and relaxations from which the convul. sions arise. The tongue and fauces partake of it so much, thať sometimes the former is forced against the teeth with such violence as to bleed by its pressure against the sharp edges; or, if the mouth happens to be open, the tongue will be ihrust out before the teetlr are closed with such force as to produce a painful division in its substance. The muscles of the abdomen, intestines, and bladder, are so contracted in the most violent form of the disease, as to force out the contents of these viscera; and it is said that the sper, matic secretion is sometimes pressed out at the same time. The complexion of the skin, as well as the turgescence of the superficial veins, depends on the respiration of the patient, and, probably, on the irregular contraction of the heart. At one time the whole surface, more particularly the face, will have a dingy purple appearance; and the veins, especially of the neck, as is particularly remarked by Aretæus, will rise much above the skin. As the patient takes a deep respiration these subside, and the complexion recovers. In the mean while, the struggling for breath produces so strong>
pressure on the lungs and bronchiæ, that the secretion is, as it were, pumped up, and the patient is said to foam.
The number and force of the symptoms depend on the violence of the paroxysın: the same may be said of its subsequent effects. At first, the patient falls into a profound sleep, or a condition similar to it: lie awakes, and appears wild and unconscious of all that has happened. When, however, he attempts to move, he feels a stiffness in all his joints; and, if he speaks, the state of his tongue, in some cases, explains every thing to him. In proportion as he recovers his reason, the impressions on his mind are more painful. Sometimes he continues for a few days deprived of reason, without inclination or necessity for food; at others, nearly in a state of idiotey painful to the beholder, and apparently attended with most distressing horrors to himself. From these he gradually recovers, and, excepting of the events during the paroxysm, or of those immediately before and after it, his recollection is as perfect as before.
If the cause of the disease continues, however, the respite is only temporary, and the paroxysm returns sometimes with great regularity in its periods, though these may vary in different subjects. The most usual mediuin is from three to six weeks, but they have varied from a fortnight to a twelvemonth. If the returns are frequent and violent, the patient has not time to recover his reason between them. Each succeeding paroxysm leaves him worse than before, till at length he becomes idiotic or maniacal, or dies apoplectic, during a paroxysm, or suddenly, without any marked symptoms.
of such a disease, so well-marked and so formidable, there can be no difficulty in ascertaining the true character. If epilepsy is sometimes confonnded with lysteria, this can only be in its chronic form, which shall be considered hereafter.
Examination of the head, post mortem, never fails to shew the cause of the aciite symptoms, by exhibiting the effects of the actions which produced them. If a patient dies of any other complaint, after several acute epileptic attacks, the only difference perceived is in the texture of the brain, which is firmer and more elastic than usual; with the cavities somewhat larger. If he dies from the effect of a paroxysm, a considerable quantity of fluid is found in the ventricles of the brain, which is still firmer, with adhesions of the pia mater, and frequently considerable layers of coagulated lymph, more transparent or jelly-like than usual. If he lives sometime after a paroxysm, without perfectly recovering his reason, or with an evident alteration in his temper or character, yet, in other respects, reasonable, we usually find suppuration in the brain, either in different small abscesses, the matter of which has made its way into the cavities and to the basis; or with a whole hemisphere so much altered as, in many places, to render it difficult to distinguish between pus and brain, or with one or more distinct abscesses contained in very thin capsules.
Such is the history of this dreadful disease, which has acquired, in different countries, names according to the impressions it has NO. 221.
produced on the minds of the spectators. In the days of Hippecrates it was imputed, like many others, to supernatural causes. If the work slegt Noor lege is really as old as that physician, it must be admitted that be refutes such an opinion by arguments which would not disgrace a much more modern writer. However, the impression of somewhat sacred attached to the disease seems to have been prevalent among the Greeks till their conversion to Christianity. The pythoness, in the Acts, was, probably, an epileptic female, similar to the sybil described by Virgil. Even the Jews, who had the benefit of a purer religion, could not divest themselves of supernatural agency, and, in one instance, the term lunatic* is added to dæmoniac, probably from the periodical returns of the paroxysms. As epileptics recover from their convulsions, and ac
power of speaking before the full return of their reason, they utter many incoherencies, some of which must be true, and the rest might be interpreted according to the events which followed. Aretæus, however, adopts a name not necessarily connected with supernatural agency, and the etymology of which is too simple to require notice.
Celsus, on this occasion, satisfies himself with the vernacular language of his
country, morbus comitialis vel major nominatur. The late Dr. Heberden very justly ascribes the former of these names to the ill omen attached to the disease, and the consequent dissolution of a national assembly, if any person was seized with it.t Among the moderns, the Spaniards and Portuguese, besides the Greek term, have also gota coral. A very ingenious Portuguese gentleman assures me, that this is a corruption of gota incuravel, or incurable gout; but the Spanish and French Dictionary of Cormon, published at Lyons, derives the word coral from the Latin cor. The Italians have for their vernacular term morbo maestro, or the master disease; the French have a somewhat similar expression, le mal haut; and the Germans call it schwere noth, or the lieavy calamity. All these languages have, besides the above, the medical term epilepsy, and in most of them are expressions analogous to our falling sickness, (as mal caduc, malo caduco, fallende sucht.) This might lead one to suspect, that, in this, as in many other instances, the vulgar have been more correct than the learned, and that they distinguished the chronic disease merely by the sudden falling, whilst the acute form was viewed with so much terror as gave rise to expressions they seemed fearful of defining.
The proximate cause of acute epilepsy does not appear to have been sufficiently sought for in the only way in which it could be discovered, by comparing the symptoms with the appearances after
Etanusa gouevos, Matt. ch. iv. v. 24, and ch. xvii. v. 15. + See bis learned Commentaries, article Epilepsy. Aulus Gellius speaks of a certain day appointed for soldiers to be sworn in, nisi (inter alia) morbus sonticus auspiciumve quod sine piaculo preterire non liceat.--N. A. lib. xvi, cap, iv.
death. Hippocrates imputes the whole to a redundance of pituita. This opinion, venial in his days, seems to have revived in our own times; at least, it is difficult any other way to account for some late remarks on the pituitary gland, published on the coutinent, and transcribed into some of our English journals.
On a review of all the symptoms of acute epilepsy, and of the appearances after death, I have no scruple in referring the whole to inflammation in the substance of the brain. No one is ignorant that in many epileptic subjects no change has been observed in the appearance of that organ; there are, however, many authorities on the contrary side. It does not, therefore, seem unfair to impute this difference to the different forms of a disease, too often included under one general terin.
The brain is, if possible, more guarded against injury and spontaneous disease than any other part. Its great importance, and its extreme delicacy, point out the necessity as the cause of these provisions. Against the first, its bony case is admired by every pathologist; against the second, the whole structure and arrangement of its blood vessels seem particularly directed. The principal means by which the functions of any organ in the living body are impeded, besides external injury, are hæmorrhage and inflammation. Hæmorrhage, in the substance of the brain, seldom fails to produce apoplexy or partial palsy. Inflammation, if continued, destroys the patient by effusion of fluid into its cavities; or by suppuration, the frequent iermination of, and a means of reljef in, inflammation of other parts; or by action excited and continued beyond what the powers of life can support.
To preserve the brain from hæmorrhage, the veins are not only more numerous and capacious than the arteries, but the sinuses are a most important provision. Hence, whenever the head is too full of blood, either from a plethora or any niechanical obstruction, the capaciousness of the sinuses admits a considerable delay in its return, without injury to the structure of the brain. It would appear, also as if the internal juguiar vein, besides its large area, were capable of greater extension than other veins, if Winslow's remark is just, that, “though the largest of all that go to the head, it is not so large as it seems when injected.”
By these salutary provisious, the brain may sometimes be loaded with blood for many hours and days with no other inconvenience tban a heaviness or drowsiness, of which the patient is very sensible, and the cause of which he often discovers. But, if this fulness is greater than the vessels can support, a rupture of one of them must follow, with the consequences already mentioned. To prevent this, a further provision is made by the process of inflammation. The dangerous effects of inflammation, beyond a certain degree, have been pointed out; it now remains to be shewn in what manner inflamination, when necessary to prevent worse mischief, is conducted, so as to produce its salutary effects witbout irreparable injury to
나? Such is the progress of infammation in that form which Mr. G 2
Hunter first called the adhesive state, -a term wow so general, that po apology can be necessary for its adoption. It may not, however, be amiss to say a few words concerning its progress, particularly in the brain. The adhesive, then, is that kind of inflammation in which lymph is thrown out without any rupture of a vessel. This lymph, by its adhesive property, unites, with great rapidity, parts previously only in contact. It produces these effects, according to the structure of parts. When the vessels of the brain are so turgid as to endanger a rupture, the provision made is to strengthen their sides by the coagulated part of the lymph, wbich, by its adhesions, enables them to resist the effects of increased pressure. Hence the brain is firnier and more elastic; an increased quantity of fluid is also found in the cavities, which are readily enlarged according to the capacity required of them. The danger from plethora is thus provided against; and, if not very considerable, the pleibora ceases, by the effusion, by the violent actions which follow, and by the generally dejected state of the patient for a few days after; but the brain has undergone the adhesive inflammation, that is, its substance is hardened by the coagulum, and its ventricles are enlarged by the increased quantity of Auid. This lymph and fluid, therefore, “must be absorbed before the brain is restored to its healthy state.
Having thus gone through the bistory of all the symptoms attending an acute epileptic paroxysm, and also those changes which take place in the brain, so as to become what is called the proximate cause of these symptoms, it may not be a loss of time to compare the presumed căuse and its effect.
The previous heaviness of the patient is the effect of plethora, which has rendered the vessels of the brain so full as to require the adhesive infiammation to support them. Inflammation is encreased action. It is, therefore, attended with encreased powers, or a greater capacity of bringing original powers into action; hence, the encreased vigour and hilarity which sometimes immediately precedes a paroxysm. The same bas been remarked by Sydenham, immediately previous to a gouty paroxysm, and is among the first aphorisms of Hippocrates relative to disease in general, But, when inflammation is very considerable in any organ, the customary functions of that organ are suspended. This is well known in the intestinal canal, and in the kidneys. Even the muscles cease to act under violeot infiammation, an effect extended to the muscles of the heart itself. From the cessation of the usual functions of the brain, we should expect a total insensibility to every impression on the organs
of sense, and an entire extinction of memory; and such is actually the case as long as the high inflammation or epileptic paroxysm continues. But the muscles are put in action by stimuli and sympathy, without any consciousness of the mind. Hence, the great irregularity of their convulsive contractions, when they are no longer influenced by the mind and their encreased violence, in contracting, probably, from the strong impressions conveyed through the nerves from parts of the brain under the enereased action of