They deduce from their studies that the missing links of our knowledge epilepsy consist in the fact that its pathogenic agents and the organic anom aly of the whioh constitute its predisposition, still hold the mystery of frequent relapses. By this study, how ever, we claim to have narrowed the gap between the terminal gliosis and the toxic and antotoxic agents in the dis ease pathogenesis, and they believe this is largely comprised in cell-changes and those particularly of the nucleus. L. P.
Clark and T. L'. Trout (Boston Med. and Surg. Jour., April 23, 1903).
The lesion is a general one affecting the entire cortex; it involves most ex tensively the cells of the second, or so called pyramidal, layer type,—the cells which present a relatively larger surface exposure to the circulating poison in pro portion to their volume than the larger pyramids; the presence of a marked neuroglia proliferation. The changes in the cell are quite analogous to those definitely known to be caused by toxic agents, as furfurol, alcohol, and the tet anus bacillus and its toxins. Regarding the nature of the lesion, the authors have examined the cortex in twenty-one cases from the Craig colony. The same lesions were uniformly found present in all. The evidences of cortical degenera tions were general. The expression of acute and chronic exhaustion Was shown in a diffuse ehromatolysis and other characteristic protoplasmic changes. The manifestation of a vital intoxica tion of the cell was presented in a swollen nucleus, a destruction of the nu clear membrane and intranuclear net work, and, finally, an abstraction of the nucleolus was rendered easily possible by the knife, it behaving as a loose body in the nucleus. Contributory evidence of the ultimate disappearance of the cell from the cortex was manifest in an in filtration of the cortex with leucocytes and a progressive gliosis. From the na ture of the lesion they infer that epi lepsy is a highly sensory motor reflex phenomenon. L. P. Clark and T. P. Trout (Med. Record, Feb. 14, 1903).
Our knowledge as to the pathogeny of epilepsy is scarcely less obscure and no more satisfactory. Anemia or hyper aamia in extreme degree may, either of them, excite a convulsion. This is a fact of experimental demonstration as well as of common clinical experience. Me chanical irritation—as from trauma, neoplasm, or foreign bodies—is an agency capable of inducing convulsive attacks, as is well known.
Transmitted irritation from the pe riphery, through the medium of some local condition of disease—as, for exam ple, an injured nerve—may excite a con vulsive explosion of the corresponding cortical centre. Carious teeth, stenosis of the uterine os, volvulus of the intes tine, adherent prepuce, and many other conditions of local disease may, through the medium of transmitted irritation along the afferent nerve-trunks, provoke an explosion of the related cells of the cortex. Such eases constitute the much questioned, but undeniably existent, class of reflex epilepsies. Finally, we have as a factor in the pathogenesis of epilepsy certain states of toxmnia, some of them autogenous in origin, others depending upon the introduction from external sources of poisons with a relative affinity for the cortex.
Facts point rather to a toxfemie origin than to any pathological change in the brain or spinal cord. Percy Bryant (State Hospital Bull., Oct., '9(3.
The attack is due to an antemia of the cerebral cortex, brought on by an arterial constriction due to either hyper irritability of vasomotor centres or of the cortical motor centres, or (and this is true in a majority of the cases) of both. Such hyperirritability may be congenital or acquired, and the im mediate cause acting on these centres is a poison or ptomaine generated within the body of the patient himself. A. M. Bleile (Med. Times, July, '98).
The toxic epilepsies—those which are as yet positively determinable as such— are not numerous. There is reason to believe, however, that much more infor mation remains to be gained as to the true pathogeny of epilepsy from the cru cible and the chemist than from the scal pel and the anatomist.
Prognosis.—The prognosis in epilepsy may be said to be progressively bad in a direct ratio with the number of attacks or the duration of the disease in the pa tient affected. If of long standing, the prognosis is bad, regardless of the cause. One convulsion, even though it be acci dental, invites another, and, if repeated a few times, the convulsive habit is es tablished and is curable only in rare in stances. Organic epilepsy dependent upon focal disease of even circumscribed limits is no exception to this rule, unless recognized promptly and treated prop erly by surgical procedure at once. Epi lepsy due to syphilis, if promptly treated, can be cured; if treatment is delayed, it quickly becomes as intractable as any other form of the disease. This is true also of the toxic and reflex varieties. The element of heredity is of sinister sig nificance in proportion to the intensity with which it may appear in the indi vidual family history. The age of onset is of importance in prognosis, both as regards the curability of the disease and the development of serious complica tions. In epilepsy beginning in early childhood the tendency to the develop ment of status epileplieus, a condition dangerous to life, is increased. I have seen this condition in seven cases, and in every one of them the disease began be fore the age of ten years. The develop ment of dementia is more probable the earlier the onset of epilepsy. Mania as a complication is more likely to be found in cases developing at puberty or later in life. Epilepsy developing without as signable cause at middle age (the eptilep sie lardive of Forel) seems more amen able to treatment and the prognosis is rather better. In one such case, how ever, observed by the writer, the disease having developed after the age of thirty, there being a history of parental syphilis, the patient died in an epileptic attack, the disease having persisted for several years. Death from or during an epilep tic seizure is not uncommon. The status epilepticus is especially dangerous to life.