Critical Care Nursing A Holistic

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1. A patient's physician writes a medication order to administer 20 mEq of potassium chloride to
a patient. The ICU nurse misreads the order as 200 mEq of potassium and administers this
amount of medication to the patient. As a result, the patient dies. This situation is an
example of which of the following?
A) A questionable medical order
B) Negligent supervision
C) Ordinary negligence
D) Gross negligence

2. A family member of a patient files a complaint against an ICU nurse, claiming that the nurse
improperly transferred the patient from a wheelchair to the hospital bed, resulting in a back
injury to the patient. Assuming that the nurse's due process rights are observed, which of
the following actions would be most advisable for the nurse?
A) Plan to appeal to a court if the State Board of Nursing rules against her.
B) Sue the State Board of Nursing if her license is suspended before she is found guilty.
C) Acquire legal counsel and have him or her question the board's witnesses.
D) Continue nursing practice if her license is suspended, as such a suspension violates her
constitutional rights.

3. The ex-husband of a patient asks the ICU nurse a question about the medical history of the
patient. The nurse retrieves the patient's file, opens it, and relates some of the patient's
personal information to the ex-husband. When the ex-husband asks to see the patient's file,
the nurse hands it to him, although he is not authorized by the patient to see this
information. What is the most accurate characterization of the nurse's action?
A) A criminal act against the patient
B) A breaking of the rule of personal liability
C) A violation of the HIPAA Privacy Rule
D) A case of respondeat superior

4. A nurse is accused of professional negligence because she improperly operated a ventilator,

resulting in a patient's death. The prosecution presents an expert witness to show that
operating such a ventilator is within the standard of care for a reasonable nurse. Which
aspect of negligence is the prosecution attempting to establish?
A) Duty
B) Breach of duty
C) Causation
D) Damages

5. A jury involved in a malpractice suit must decide how much to compensate a patient for the
emotional distress caused her by incomplete anesthesia during surgery. To which element
of malpractice is this decision related?
A) Duty
B) Breach of duty
C) Causation
D) Damages

6. A nurse is going to volunteer her nursing skills and time at a hospital other than the one in
which she is employed. Which of the following is true regarding potential liability related to
the nurse's actions while volunteering? Select all that apply.
A) The nurse should carry her own malpractice insurance.
B) The hospital at which she is volunteering will protect her with its own professional liability
insurance.
C) The hospital at which she is employed will protect her with its professional liability
insurance even when she is working off the job.
D) There is no liability protection available for a nurse who is volunteering on her own time.
E) The doctrine of respondeat superior does not apply in this situation.
F) The captain of the ship doctrine applies in this situation.

7. A nurse is charged with medical malpractice because she neglected to attend to a patient in
the ICU whose heart stopped and whose heart monitor alarm was clearly heard by the
nurse. The jury finds that the hospital was liable because of understaffing the ICU and that
the nurse was liable because she should have responded to the patient whose heart stopped,
regardless of the fact that she had been ordered by a physician to tend to another patient.
Which types of liability did the jury uphold? Select all that apply.
A) Captain of the ship doctrine
B) Rule of personal liability
C) Corporate liability
D) Criminal liability

8. A physician has written a medication order for a patient that includes penicillin. When the
nurse receives the order, she refuses to administer the medicine because she knows that the
patient is allergic to it. What is the most accurate way to describe this situation?
A) A questionable medication order
B) A medication error
C) A case of respondeat superior
D) A case of negligent supervision

9. A patient in the ICU dies as a result of a defective defibrillator. The nurse did not become
aware of the defect until after the patient's death. Which of the following is true in this
situation?
A) Defibrillators are not currently regulated in the United States.
B) The nurse is permitted but not required to report the malfunction to the FDA.
C) The nurse is required to report the malfunction to the FDA.
D) The nurse is likely liable in the patient's death.
10. A 10-year-old girl has been admitted to the ICU after she suffered a severe laceration on her
arm. Due to heavy hemorrhaging, the child needs a blood transfusion. Her parents,
however, who are Jehovah's Witnesses, do not believe in blood transfusions and refuse the
treatment. What would be the best action for the nurse to take?
A) Assist the physician in performing a blood transfusion for the girl, against her parents'
wishes.
B) Refuse to assist the physician in performing a blood transfusion, to respect the parents'
wishes.
C) Consult the hospital's risk management department before acting.
D) Schedule a conference with the parents to explain why an infusion is medically necessary.

11. While caring for patients, the nurse completely documents the care given. This nursing
action is defined by what kind of law?
A) Administrative
B) Civil
C) Tort
D) Criminal

12. Nursing practice is defined by the Nursing Practice Act, administered by the State Board of
Nursing. Which nursing behavior would be least likely to be addressed by the State Board
of Nursing?
A) Qualifications for licensure
B) Investigation of complaints
C) Nursing excellence awards
D) Protection of patient safety

13. The physician has ordered a medication that is contraindicated for the patient. The nurse,
after discussion with the physician and the pharmacy, refuses to administer the medication.
Upon what legal principle does the nurse base this refusal?
A) Respondeat superior
B) Captain of the ship
C) Corporate liability
D) Rule of personal liability

14. The nurse caring for a sedated patient leaves the side rails down when leaving the room and
the patient falls, breaking her hip. Why is this considered to be malpractice by negligence?
A) The patient had requested the side rails be left down.
B) The nurse assumed that the family would watch the patient.
C) This is breach of duty resulting in patient harm.
D) There will probably be a suit brought by the family.
15. A nurse has been called before the State Board of Nursing for accusations of malpractice. As
part of his defense, the nurse states that he was unaware of several provisions of the
Nursing Practice Act. Why is this defense statement valid or invalid?
A) Invalid: The nurse has a legal duty to know the contents of the Nursing Practice Act.
B) Invalid: Nursing Practice Acts vary widely in content from version to version and state to
state.
C) Valid: The nurse did not know he was violating the Nursing Practice Act at the time of his
actions.
D) Valid: The nurse was under the supervision of his charge nurse at the time of his actions

16. The nurse is caring for a critically ill patient. Which action by the nurse could most likely be
considered malpractice?
A) Assessing for allergies before administering medications
B) Consistent failure to complete adequate hand hygiene
C) Strict adherence to the visiting hours policies of the unit
D) Encouraging the patient to ask questions of the physician

17. The nurse has been accused of negligence resulting in patient harm. She was not informed
about the complaint, and her employment was terminated before a hearing before the State
Board of Nursing. What best legal recourse does the nurse have?
A) Safe harbor provision in state law
B) Fifth Amendment of the U.S. Constitution
C) Civil and tort law allows the nurse to sue the accuser.
D) Automatic dismissal of case by the State Board of Nursing

18. A nurse who commonly works on a general medical-surgical floor is asked to work briefly
in a critical care unit. The charge nurse, based on the legal principle of vicarious liability,
should give this nurse which patient assignment?
A) Admit day-of-surgery patient after open heart surgery
B) Three stable patients awaiting transfer to medical units
C) Patient with hemodynamic monitoring and unstable vital signs
D) Patient whose care requires frequent titration of vasoactive medications

19. After receiving an injury as a result of negligent care by a physician, the patient brings suit
against the hospital, the physician, and all of the members of the health care team who
participated in his care. Based on the principle of respondeat superior, the hospital is liable
for the actions of whom?
A) Nurse working in her usual assignment at hospital
B) Non-employee physician practicing in the hospital
C) Nurse on temporary assignment from an agency
D) Nurse doing volunteer work at another agency

20. A patient in CCU is critically and terminally ill. The family has made a written request that
no cardiopulmonary resuscitation (CPR) take place. The patient is well known to the
physician, who does not agree with the family's assessment of the situation. While the
physician is discussing the situation with the family and before agreement, the patient
experiences a cardiopulmonary arrest. Legally, what is the most appropriate nursing action?
A) Proceed as though a DNR order has been written, since such an order is anticipated.
B) Take no action and page the patient's physician to ask for an immediate decision over the
telephone.
C) Initiate CPR and page the patient's physician to come to the care unit.
D) Take no action and page the patient's family to return to the care unit immediately.

21. A patient has been critically ill for several weeks and a Do Not Resuscitate (DNR) order was
written several days ago. The patient's status has improved, and he is now eligible for
transfer to a general nursing unit and is awake and alert. What is the most appropriate
nursing action?
A) Initiate risk-reduction teaching to prevent recurrence of instability.
B) Ask the patient, family, and physician to review the DNR order.
C) Increase the frequency of monitoring of vital signs to ensure safety.
D) Encourage the patient to get more rest in preparation for transfer.

22. A terminally ill patient is admitted to the CCU for stabilization and palliative procedures.
The nurse encourages this awake and alert patient to complete paperwork for advance
directives. What is the best rationale for this nursing action?
A) Required by the admission protocol for the hospital and the unit
B) Allows the patient to express his or her choices for some treatment decisions
C) Prevents estranged family from interfering with competent patient decisions
D) Allows the physician to apply his or her best judgment for care decisions

23. A critical care nurse has administered an intravenous sedative in an excessive dose to a
patient. The patient experiences a cardiopulmonary arrest, and the family complains to the
State Board of Nursing. After investigation and a hearing, the Board finds that the nurse
was guilty of malpractice and disciplines the nurse. This situation is an example of what?
A) Medication errors are the most common reason for State Board of Nursing action.
B) An unusual and rare incidence of lack of judgment by a nurse in a stressful situation
C) Absence of the application of due process for the nurse by the State Board of Nursing
D) A family looking for an opportunity for litigation

Answer Key - Chapter 8- Legal Issues in Critical Care Nursing

1. C
2. C
3. C
4. A
5. D
6. A, E
7. B, C
8. A
9. C
10. C
11. A
12. C
13. D
14. C
15. A
16. B
17. B
18. B
19. A
20. C
21. B
22. B
23. A
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sensation. In the bilateral type the movements exist in all of the limbs, and are unaccompanied by
weakness or disorder of sensation. The degree of movement varies in different cases. In some it is very
slight, and can be controlled by extreme effort on the part of the patient. In other cases the movements
are violent and uncontrollable. The muscles of the affected limbs become hypertrophied from the
constant exercise.

The following case of athetosis has come under my care:

Case II.—W. A——, aged thirteen years, male. He had good health until 1877, when at the age of six
years he had diphtheria. The attack was not severe, and he was up most of the time. About ten days
after apparent convalescence he was suddenly seized with left hemiplegia. The paralysis was complete,
involving the left arm and leg, the left side of the face, and the muscles of deglutition. There was also
aphonia. In two weeks he began to talk, but indistinctly. In a month he could move the arm, but the
movements were inco-ordinate. At about the same time he began to walk, but dragged the leg. The arm
never regained power of voluntary motion, but instead there came on a spasmodic condition of the
muscles which fixed the arm in various positions, and at the same time there were kept up constant but
irregular movements of the hand and fingers. No spasmodic action of the leg-muscles occurred until a
year later. He has never walked well since the attack of hemiplegia. The positions which the arm has
assumed have varied at different times, but it usually retains one attitude for several months at a time.
Sometimes the arm has been held in extension; at another time it has been flexed; indeed, the positions
have been numerous. His general health improved and the speech became perfect.

Condition on examination Aug. 14, 1884: General health good, well grown for age. The nutrition of the
affected side is good, but the left side of the face is markedly smaller than the right, although there is no
paralysis. The position of the arm attracts immediate attention. The arm, hand, and fingers are in
extreme extension, as shown in the cut, which is made from a photograph. The arm-muscles are tense
and rigid. The fingers are continually in motion, sometimes flexed, sometimes extremely extended; then
in a few moments they will be widely separated or distorted in some other way. The favorite position,
however, seems to be with the fingers extended until bent backward, separated from each other, and
the thumb adducted slightly. The patient is unable to bring the arm down by a voluntary effort, but when
asked to put it by his side he pulls it down with the right hand, and keeps it down by sitting upon the
hand. The muscles of the arm are hypertrophied, especially those of the upper arm and shoulder. The
circumference of the left arm around the biceps is almost an inch greater than that of the right. The leg is
stiff and the foot is usually inverted. Here also the position changes at different times. When he walks
the stiffness increases and the foot is dragged. The speech is clear and distinct, and the intellect perfect.
He goes to school, and is fully equal to or more advanced than boys of his age. There is no evidence of
cardiac disease.

FIG. 26.
 Case of Athetosis.

The patient's condition in Oct., 1885, had changed somewhat. The arm is in a different attitude. It is still
extended, but is held down by the side or away from the body. At times the forearm is strongly
supinated. There are still constant but slowly-changing movements of the fingers. One plan which the
patient has of keeping the arm flexed is to put the forearm behind the back with the right hand, and it
becomes locked there by the action of the extensors. By a strong effort of will he can slowly and with
great difficulty open and shut the fingers, and can flex the forearm. The leg is in the same condition as
before.

The resemblance between athetosis and post-paralytic chorea is very close. Most of the cases of the
former disorder which have been reported have been of the hemiplegic type. In Case I. the disease
came on after an attack of delirium tremens, which was followed by six weeks of unconsciousness. The
first symptom the patient was capable of noticing was numbness of the right arm and leg. The
involuntary movements came on later. This would look as if there had been some lesion involving the
left hemisphere of the brain. It is stated that no paralysis existed when the case was examined by
Hammond, but there may have been a slight hemiplegia which had passed away. In another case
reported by the same author the peculiar movements were preceded by hemiplegia and aphasia.

Oulmont has written a complete essay on athetosis, and has collected therein all the literature of the
subject.3 He sustains the view of the close connection between athetosis and post-paralytic chorea, but
he considers that, although nearly allied, a difference does exist between the two affections. He believes
this is most marked in the bilateral form of athetosis, for here the disorder is usually not preceded by
paralysis, and it is not accompanied by disturbances of sensation.
3 Étude clinique sur l'Athétose, Paris, 1878.

Gowers4 has also collected a number of cases, some of which came under his own observation, and
has written a valuable treatise on the subject.
4 Medico-Chirurgical Transactions, 2d Series, vol. xli.

PATHOLOGY.—The symptoms point to a brain lesion, probably in the gray matter, and a perverted
condition of the nerve-cells which leads to over-action, either spontaneously or under the influence of a
motor impulse. In most of the cases reported by Claye Shaw there was imbecility. Charcot found in three
post-mortem examinations lesions in each instance in the posterior portion of the optic thalamus, the
most posterior part of the caudate nucleus, and the most posterior part of the corona radiata. Gowers
has made an autopsy in one case in which there was post-hemiplegic inco-ordination affecting the arm
only, without the spasmodic fixation of the limb. In the brain was found but one lesion, and that was a
cicatricial induration of the optic thalamus, extending across its centre beneath its upper surface, and
approaching at its outer part, but not involving, the ascending white fibres of the crus. No secondary
degeneration was found in the cord.

PROGNOSIS.—This is almost always unfavorable. In some cases the inco-ordination decreases and the
spasm becomes less violent, but it seldom disappears altogether. One of Gowers's cases was benefited
by treatment, and two of those related by Hammond were relieved.

TREATMENT.—Many remedies have been given without marked benefit. In Gowers's case there is no
doubt that the decided improvement which took place was due to galvanism. The treatment lasted three
months, and a descending galvanic current was used. The positive pole was put upon the nucha, and
the negative on the over-acting muscles and on the hand and foot. One of Hammond's cases, as related
above, was apparently cured by stretching the median nerve. A prolonged course of galvanism and
some alterative, like mercury or chloride of gold and sodium, would seem to offer the best prospect of
benefit.

LOCAL CONVULSIVE DISORDERS.

BY ALLAN MCLANE HAMILTON, M.D.

Thomsen's Disease.

SYNONYMS.—Rigidité musculaire avec impuissance de la volonté; Rigidité et hypertrophie musculaire;

Myotomé congenitale.
In the year 1876, Thomsen,1 the medical officer of Kappeln, described a curious form of nervous
disease which affected several members of his own family, himself included. It consisted of a tendency
to cramp and limited spasm when a voluntary act was attempted, and a seeming and sudden loss of
power. This condition disappeared after the performance of the act and its repetition. An attempt at
walking would be attended by spastic rigidity of the flexor muscles of the lower extremities, by flexion of
the thighs and legs at an angle of 120°, so that the patient often fell forward upon his knees. An attempt
to arise from the chair was attended by the same difficulty, the person becoming utterly helpless. The
arms and legs were most frequently affected, the trunk-muscles being usually exempt. In some cases
the muscles supplied by cranial nerves were the seat of spasm, so that the patient could not close his
mouth nor shut his eyes. Westphal, Erb, Peters, Schönfeld, Engel, and others have reported about eight
cases in all, and in addition to the symptoms above referred to it was found that mental excitement and
cold chiefly precipitated the seizure. The sphincters were never affected, and the general nervous
functions were not impaired. The patients talked stiffly, and this was probably due to a spasmodic
affection of the lips, tongue, and other articulating organs. The tendinous reflexes were normal, but
irritation of the soles produced a peculiar cramp of the leg-flexors and bending of the knees. There is a
species of muscular increase which resembles pseudo-hypertrophic paralysis.
1 Berliner klin. Woch., Mar. 12, 1883.

The malady seems to be of an hereditary nature, if we are to judge by Thomsen's cases. It begins early
in life, and does not materially shorten the same. I have seen one case, a young child, which presented
the main symptoms of, and was first mistaken for, pseudo-hypertrophic paralysis.

Westphal regards the affection as an “anomaly of muscular tonus;” others have shed no light upon its
pathology.

I believe the condition to be an occasional feature of certain organic disorders, notably posterior spinal
sclerosis, and there is a variety of paralysis agitans where there is no tremor which presents all the
symptoms. The very rare nature of the malady and its peculiar expression render diagnosis easy. It
possibly may be mistaken for pseudo-hypertrophic paralysis in young subjects, but in this latter disease
we find electrical change in the muscles, and an absence of the tendon reflex. An examination of the
enlarged muscles will not reveal fatty increase.

Painless Facial Spasm.

There is a form of spasm of the muscles supplied by the facial nerves which differs from ordinary tic
douloureux by the fact that there is no pain in the former. The trouble may be one of a very limited
nature, consisting of the involvement of a few fibres, or of limited groups of muscles, or of all the
muscles of the side of the face. I never have seen a case of double spasm, though such undoubtedly
exist.

The nature of the paroxysm is cumulative, and, as a rule, the attack increases until it reaches an acme
of intensity, then quite suddenly ceases. It often begins by a slight drawing of the corner of the mouth,
the levator anguli oris and other muscles in the neighborhood being the seat of chronic spasms. This
limited spasmodic action is followed by further facial contractions. The orbicularis palpebrarum is often
the sole seat of the convulsive movement, and this is common in excessive smokers.

As a rule, the trouble is peripheral and due to some reflex cause, such as cold, injury, bad teeth, which
produces reflected irritation through the branches of the fifth nerve, or in rare cases it may be central or
due to some bony or other pressure upon the nerve in its passage through the skull. In a recent case
the trouble was of evident central origin, and I obtained a history of lightning pains in the lower
extremities, some inco-ordination of muscles in both upper and lower extremities, and some paresis of
the facial muscles. In this case the spasms involved all the muscles of the right side of the face, and
recurred every few minutes. They had first appeared five or six years before I saw the patient, and had
gained in frequency from two or three daily until within the past four months they occurred, as I have
said, every few minutes. The other symptoms were of insignificant character compared to the spasms.

Of the large number of cases I have seen, many impressed me as being the result of a simple bad habit,
yet moral or other measures did not avail much.

It is important to diagnose certain unusual forms of facial spasm from the petit mal of epilepsy, and
careful observation will detect a transitory loss of consciousness in the latter. It is equally important to
find a cause if any exists, and a careful examination of the state of the teeth, the integrity of vision, and
the possible existence of aural disease should be made in all cases. In some cases over-use of the
eyes, which may be defective in their power of accommodation, may precipitate blepharospasm. In
other cases the act of masticating hard substances or taking very hot or cold fluids into the mouth may
give rise to the spasm.

Hyoscyamine in repeated doses of from 1/200 to 1/25 grain of Merck's crystals does more in the way of
relieving the spasms than any other drug of which I know. If this does no good, gelsemium cautiously
used is often of great service. Local galvanic applications with currents of great intensity will form a
valuable adjuvant. So far, I have never tried nerve-section or stretching in these cases, but recommend
them as a dernier ressort.

Torticollis.

SYNONYMS.—Wry neck, Rheumatismus colli, Obstipite, Cephaloxia.

Wry neck or torticollis consists essentially of a spasm of the sterno-cleido-mastoideus, though other
muscles are nearly always involved: the result is a peculiar and striking distortion which is quite familiar.
It consists in the drawing downward and backward of the head on the affected side, while the chin is
pointed forward and upward to the other. The disease is presented in several forms. It may be a
temporary disorder as the result of a rheumatic condition, disappearing rapidly, or occurs as an
hysterical affection, or it may be a chronic and intractable nervous disease. We must also consider it
from the standpoint of the form of distorted motility. In some cases there is simple tonic contraction,
which may eventually result in tense contracture, shrinking, and tendinous hardness; and in others the
attention of the physician is attracted by a species of tremor and agitation. Unlike the tremor of sclerosis,
this is uninfluenced by the attempts of control upon the part of the patient, but is aggravated by fatigue
and excitement. It rarely happens that both muscles are affected so that the head is drawn backward.
Most of the cases are single, chronic, and progressive, and, though very slow in the onward march, are
usually beyond the reach of remedies. The patient becomes greatly annoyed by his infirmity, and seeks
every measure to overcome his unfortunate deformity. He commonly tries to hold his head or chin,
pressing the latter downward, or, holding his cane against his head upon the dependent side, strives to
keep it up. As a result, there is a sagging or drooping of the affected side of the body, so that one
shoulder is lower than the other.

The disease, as a rule, begins in adult life, yet there are many young cases.2 Wilks calls attention to the
fact that in these latter there is apt to be some facial asymmetry on the contracted side. One side of the
head is smaller than the other, and one eye seems to be lower.
2 Diseases of the Nervous System, p. 454.

Most of the cases I have seen have been men, though I have met with many hysterical examples in
young girls. The double torticollis (Newnham's salaam convulsion) usually affects children, and it is the
rule to find associated strabismus and intellectual disturbance. In the adult cases there has usually been
a history of hereditary neurotic influence and overwork.

Electrically, we find a susceptibility to both currents, and the reaction of degeneration may be detected in
the affected muscles in old cases. The opposing muscles are usually the seat of diminished electrical
excitability.

Torticollis may be due to peripheral or deep causes. Cold, reflex irritation, forced and uncomfortable
positions, are to be mentioned among the former, and intracranial or vertebral disease as examples of
the latter. The pathological explanation lies in a disorder of the motor fibres of the spinal accessory
nerve. Any affection of the external branch will result in the condition above described.

In young cases the PROGNOSIS is good as a rule, though this is by no means invariably so, for sometimes
the special symptoms are but forerunners of others of a more grave character. Hysterical torticollis is
often instantly, or at least very readily, cured by electro-therapeutics and cauterization. A well-
established adult case is almost hopeless and resists all ordinary treatment.

Many forms of TREATMENT have been recommended from time to time, and such drugs as the bromides,
chloroform, conium, and hyoscyamine are suggested. The latter I believe to be the most serviceable
remedy. Electricity has done good in either form, and vigorous faradization with the electric brush is
earnestly recommended in hysterical, rheumatic, or functional cases. Some years ago I devised a
method which in a number of cases has been of great service. I allude to the combined and
simultaneous use of the galvanic and induced currents. A double electrode is applied to the back of the
neck. This contains the anodal pole of the galvanic current and the cathodal of the faradic. The two
other poles are placed—one, the galvanic cathode, over the origin of the affected muscle, the induced
anodal pole over the weakened muscle which is not in spasm. I suppose in old cases the most valuable
treatment is that of a surgical nature. I have twice seen the spinal accessory exsected with the result of
a complete cure; and I think this is the only sure measure. H. B. Sands of this city has performed the
operation quite successfully in other instances. Care should be taken not to operate in cases presenting
other symptoms which suggest the remotest suspicion of organic cerebral disease, and the existence of
unilaterally increased tendinous reflexes or tremor should be carefully looked for as contraindications.

Braces and apparatus are often worse than useless, increasing not only the patient's discomfort, but
aggravating the malady.

Eclampsia.

(Εχλαμψις and λαμβω, “I shine,” brilliancy, flashes of light from the eyes.—Dunglison.)

DEFINITION.—A term used to express certain irregular convulsive attacks, as a rule due to eccentric
irritation, uræmic poisoning, or like causes, and chiefly used in connection with the convulsions of
infants.

This term has gradually been dropped in scientific medical literature, and many authors think it useless,
believing the condition to be usually epileptoid. Nothnagel,3 who is more liberal than many other
clinicians, says: “What is there now remaining of what was formerly eclampsia? Are we altogether
justified in still retaining the name? We believe so, and are of the opinion that the title eclampsia should
be reserved as the name of an independent affection, which, it is true, can at present be defined only by
its clinical symptoms. We propose that the designation eclampsia should be made use of for those
cases of epileptiform spasms which, independent of positive organic diseases, present themselves as
an independent acute malady, and in which, so far as our present knowledge allows us to judge, the
same processes arise generally in the way of reflex excitements, and the same mechanism in the
establishment of the paroxysms comes into play, as in the epileptic seizure itself.”
3 Cyclopædia of the Practice of Med., Von Ziemssen, Am. ed., vol. xiv. pp. 301, 302.

If any distinction at all be made, it should be one founded upon the fact that epilepsy itself is usually an
organic disease, or, more precisely, a disease which when established is dependent upon some
disorganization, while eclampsia is used to express those seizures of a purely functional nature.
By far the greater number of eclamptic seizures are found among young children. There is no uniformity
in their expression or return. Any eccentric irritation is apt to precipitate one or more attacks, and those
forms of irritation dependent upon sensory disturbances of the mucous membrane are commonly
present. The convulsions of teething belong to this class, as well as those in which gastric disorder plays
a part; and in the first instance the cutting of the large teeth, and in the latter the presence of indigestion
with diarrhœa, are quite commonly associated with the convulsion.

The high degree of irritability of the nervous system of children renders them peculiarly susceptible to
causes which in after years would effect little or no disturbance; and this is especially true before the fifth
year. West and Reynolds are of the opinion that convulsions occur in children as delirium in adults; in
other words, they are the most common expression of neurotic instability.

Infantile convulsions are usually general, and neuro-spasms are not common, except when they are
dependent upon neoplasm, ventricular dilatation, or local meningitis. It evidently takes very limited
peripheral excitement to precipitate a general convulsion in the child, and a familiar example is the
disturbance which may involve the peripheral branches of the fifth nerve in difficult dentition.

Eclamptic seizures occur at any time, and may be very slight: a trifling twitching may be all, or, on the
other hand, the attack may consist of violent opisthotonos. There is great difficulty, of course, in getting
anything from a young child as to its feelings before an attack, and I hardly think we are authorized in
saying that there is any aura or ascertainable precursor. The history of a previous nervous state is,
however, usually ascertainable, which is expressed by crying fits, peevishness, and great restlessness.
Sometimes there is a disposition to sleep which almost amounts to stupor. The behavior of a child is
often likened to that which marks the commencement of acute tubercular meningitis—night-terrors,
grinding of the teeth, and flushing of the face. The first convulsions may be only partial, but in a short
time their character becomes general, and they become exceedingly violent, and are sometimes fatal.
The clinical features of an eclamptic seizure may in every respect resemble one of epilepsy, making
allowance for the age of our patient.

The stage of pallor is perhaps more extended in the child.

Handfield Jones speaks of a form of eclampsia of hyperæmic causation in association with certain
exanthemata. In children convalescing from scarlatina he observed the development of attacks which
were relieved by carotid pressure and bleeding in subjects who presented anasarca and other
indications of renal disease.

We are familiar enough with the convulsions of puerperal women, which, as a rule, though not always,
are presented by subjects whose urine is albuminous. It can sometimes distinctly be traced to what must
be regarded as uterine excitement. Just as chorea is often a feature of the pregnant state, so may
convulsive seizures arise. The peculiarities of the epilepsy of pregnancy will, however, be elsewhere
considered.

I shall purposely refrain from the consideration of those forms of symptomatic infantile convulsions
which mark the occurrence of cerebral accidents or grave disease.

EPILEPSY.
 BY ALLAN MCLANE HAMILTON, M.D.

SYNONYMS.—Epilepsia; l'Épilepsie (Fr.); Fallsücht (Ger.); Epilessia (Ital.); Epilepsin fallendsot (Scand.);
Falling sickness; Fainting sickness.

DEFINITION.—According to the most recent authorities, an epileptic attack is nothing more nor less than a
discharge of nervous energy from an overexcited, or what may be called a dynamo-pregnant nerve-
centre, or collection of centres, and the predominance of motor or sensory phenomena determines the
extent and order of the parts involved. As a rule, an epileptic paroxysm is but a symptomatic expression
of a complex derangement, and it is best to formulate our nomenclature with the idea, in the first place,
of location; in the second, with reference to the prominence of motor or sensory expressions; and,
finally, with regard to etiology.

HISTORY.—There is probably no nervous disease which has been more extensively written upon (even in
ancient times) than that under consideration. We find references to it as early as the tenth century, when
it figured in the text of Avicennes. Hippocrates called it ιερόν νοσεμα, or sacred malady, and πάθοϛ
παιδήιον, or malady of children, believing that the attacks had their origin always in early infancy and
never later. Plato and Aretæus advanced the theory that the disease sprang from a thirst for gold, and
equally absurd and unreasonable explanations are found in the writings of the fathers of medicine. The
older French writers were diligent investigators, but with them prevailed the tendency to explain the
origin of the disease by mysticism, and among many it was supposed to bear some connection with the
coming of St. John. The popular humoral theory of the malady originated by Mercurialis was afterward
opposed by Averrhoes and Fernel, but even to this day it has devoted adherents. Bouchet and
Causauvieilh maintained that the disease was inflammatory—a view that was vigorously combated by
Bouillaud and Delasiauve. The theory of Broussais—which was and is the basis of the conclusions of
modern investigators—is that it is dependent upon cerebral irritation. It is hardly necessary to refer to the
many untenable and curious attempts that have been made to explain the pathology of the malady:
suffice it to say that many of them were as extravagant as that of Vepfer, who considered the pineal
gland to be the locus morbi of the affection—a conclusion in which Descartes coincided. Marshall Hall
was the first writer to advance the theory of reflex irritation, believing that gastro-enteric or uterine
irritation acted upon the brain. In later years Schroeder Van der Kolk, Reynolds, and others have written
quite fully upon the part played by the medulla, while recently numerous French and German writers—
among them Bourneville, Meynert, Sommers, and Tagges—have attached much importance to the
discovery of a sclerosis of parts lying at the floor of the lateral ventricles.

Perhaps our knowledge of epilepsy has received its greatest impetus from the elaborate and exact
researches of Hughlings-Jackson; and his observations, taken in connection with the recent work of the
numerous students of localization, open up a new field of research, and, as matters stand, the future
study of epilepsy must be fruitful in the extreme.

DIVISION.—It has been the custom to divide the epilepsies into epilepsia gravior and epilepsia mitior, the
haut mal and petit mal of the French. These terms are in one way misleading, and only define
differences in degree. The terms general and limited would much more properly express the forms of
attack, and I shall use them as far as possible in the present article. A general epilepsy is one that
corresponds with haut mal, in which there is an extensive convulsion, absolute loss of consciousness,
and perversion of a widespread character. Limited epilepsy includes those forms in which there is a
convulsion confined to a small group of muscles, and in which loss of consciousness plays an
unimportant part. Under this latter head belongs the form known as petit mal and those monospasms
which depend upon a cortical irritative lesion. There are other divisions which partake of the nature of
one or the other, and are unilateral and dependent upon the destructive discharge of a motor centre.
Under this head may be placed the epilepsie partielle of the French or the hemi-epilepsy or Jacksonian
epilepsy of the English. There are also irregular or aborted attacks—the so-called masked epilepsy—
and lastly the sensory varieties.

ETIOLOGY.—It cannot be denied that heredity plays the most important part in the genesis of epilepsy.
Nearly one-half of my own cases when carefully investigated were clearly traceable to some inherited
predisposition. Insanity, epilepsy, and phthisis in ancestral history stamp their constitutional imprint upon
the unfortunate descendant, and the history of ten cases from my notebook (see Table) will show the
extent of saturation that may exist in paternal or maternal branches and the evolution of the disease in
male and female subjects. The statistics of other writers, though not showing quite so large a proportion
of cases with hereditary history as my own, are quite significant. Gowers found that in “1218 cases, 429,
or 35 per cent., presented evidence of neurotic inheritance.” Echeverria estimated the proportion of
hereditary cases at 28 per cent., while Reynolds fixes it at 31 per cent. Of 980 cases, the notes of which
I have examined, many of whom have been under my personal care, 435 presented a family history of
insanity, phthisis, epilepsy, cerebral apoplexy, tumor, or some lesser neurosis. So far as the history of
hereditary influence is known, it appears that females are more apt to present this form of epilepsy than
males, and, according to Gowers's as well as my own investigations, the transmission comes from the
mother's side more frequently than the other. So far as my own inquiries have gone, I find insanity more
often among the progenitors of the epileptic than any other nervous disease, and in many cases
phthisis. I am inclined, therefore, to give greater weight to this relationship than Nothnagel and others.
Anstie, Bastian, Savage, and other careful clinicians have pointed out not only the close connection
between phthisis and epilepsy, but between the former disease and migraine; and no one who has seen
much of epilepsy can fail to be impressed with the frequent association of migraine with the more
serious convulsive affection of which it is quite often the precursor. Perhaps the fact that phthisis was
found so often—in 230 of my 980 cases—may be due to the fact that many of the patients were of the
lower classes and among the Irish, who in this country are so frequently phthisical.

Heredity in Ten Cases of Idiopathic Epilepsy, with Existing Disease or Cause of Death.
Paternal Ancestry. Maternal Ancestry.
Sex. Grand- Grand- Grand- Grand- Brothers.
Father. Uncles. Aunts. Mother. Uncles. Aunts.
father. mother. mother. father.
F. Died insane. Suicide; Eccentric. ... ... Died of Eccentric; Drunkard. ... ... One a
probably cerebral died of dipsomaniac
insane. hemorrhage. cerebral one in good
hemorrhage. health.
M. Alive. Cerebral Insane. ... ... Phthisis. ... One died ... Phthisis. One brothe
hemorrhages. of has infantile
phthisis. paralysis.

F. Alive in third Phthisis. ... ... Phthisis. Alive. Not known. ... Cerebral ... One brothe
stage of post- embolism. has infantile
sp. sclerosis. paralysis.
M. Died of Not known. Phthisis. ... Epileptic. Migraine. Phthisis. ... ... ... No brothers.
phthisis.
M. Congestive Cerebral Insane. ... Migraine. Phthisis. ... ... ... One died No brothers.
headaches. hemorrhage. of phthsis;
one
hemiplegic.
M. Alive. Insane. ... ... Insane. Phthisis. ... Phthisis. ... ... Eight
brothers and
 sisters.

M. A confirmed Died of ... ... Insane. Phthisis. Died in ... ... Phthisis. ...
drunkard. embolism childbirth.
and softening
at 76.
M. Phthisis. Eccentric. One ... ... Migraine. ... ... ... ... One brothe
phthisis; died o
one secondary
cerebral tubercular
tumor. meningitis,
the other in
an asylum.
M. A A genius. One died Cerebral None. Peculiar and Migraine. Peculiar Insane ... Several
dipsomaniac insane. hemorrhage. eccentric. character. and brothers
and eccentric committed unaffected.
person. suicide.
M. Most ... ... ... Migraine. Epileptic. ... ... ... Migraine. No brothers.
eccentric; a
somnambulist.

In many idiopathic cases we find vices of cranial conformation, bodily asymmetry, and a history of early
congenital syphilis. Laségue lays great stress upon cranial malformation, and goes so far as to say that
all epilepsies not dependent upon some osseous trouble, either developmental or traumatic, are not
epilepsies at all. Such epilepsy, which owes its origin to cranial asymmetry, rarely develops after the
eighteenth year. The head is most often dolichocephalic or brachycephalic, and there is facial
asymmetry. Laségue concludes that all the convulsions are identical; that it is not hereditary; that the
attacks are always matutinal. It seems to me that Laségue's conclusions in regard to the non-existence
of epilepsies from other causes are rather too arbitrary in view of the large amount of evidence to the
contrary. In others, a very few, we find an apparent history of heredity explained by forceps-pressure
during delivery.

So far as age and sex are concerned, and their predisposing influence, we find that by far the greatest
number of cases begin before the twentieth year. This is the experience of Gowers, of Hammond, and of
many others. Of my own 980 collected cases in which the beginning of the disease was known, there
were—

Females. Males. Total.

Under 10 103 95 198
Between 10 and 20 171 97 268
Between 20 and 30 145 92 237
Between 30 and 50 81 136 217
Over 50 11 49 60
511 469 980

Of 1288 cases collected by nine French authorities, in 486, or over one-third, the disease began
between the tenth and twentieth years. In Gowers's 1450 cases we find the following showing:

Cases.
Under 10 422
 From 10 to 19 665
From 20 to 29 224
From 30 to 39 87
From 40 to 49 31
From 50 to 59 16
From 60 to 69 4
From 70 to 79 1

In 29 per cent. of these cases the disease therefore began before the tenth year.

As to sex, it appears that females are much more subject to the disease than males, but this is not true
at any age. Epileptics under ten are more apt to be girls, but the proportion is nearly equal: between ten
and twenty the proportion of females is undeniably greater. In adult cases we find that pure epilepsy
(excluding hysteria) is much more often a disease of males than females.

In the hereditary form the disease in the great proportion of cases begins before the twentieth year; and,
so far as my experience goes, this kind of the disease makes its appearance at a very early age. The
part played by particular predisposing influences appears to be well defined. The children of syphilitic
parents develop the disease at a more advanced age than when alcoholism is found to exist. In adult
males, when the disease develops late in life, it is almost always possible to find syphilitic or coarse
brain diseases, while among women the history of antecedent migraine or menstrual derangement is
nearly always present, and the convulsions in a very large number of instances have a hysteroid
character.

The exciting CAUSES of the disease are quite numerous. Traumatism is a frequent and important
etiological factor, and the head-injuries may be recent or remote. It is quite common to find old fractures,
with depressions which have existed for years without any seeming bad effects, suddenly lighting up
convulsions under the influence of some new excitement. Under such circumstances the depressed
bone is quite apt to give rise to symptoms suggestive of meningeal irritation and inflammation, so that
the diagnosis is comparatively easy. Several observers have called attention to epilepsy which has been
undoubtedly due to cicatrices not only of the scalp, but elsewhere, and these may or not be found in
association with osseous lesions. The literature of the subject is replete with curious cases which go to
show that epilepsy may occur from a few days to many years—even twenty—after the initial head-injury.
Unsuspected cortical pressure, the inner table being alone depressed, is common; in fact, the cases in
which the most serious mischief is done seem to be those where the only external evidence of violence
is the contused scalp. As a consequence of such injury we may have exostoses developed.

The influence of syphilis in the production of epilepsy is one of very great importance. Not only has
specific epilepsy characteristics of its own, but its origin may be distinctly traced to syphilitic infection.
Cases dependent upon gross cerebral disease, such as meningitis or gumma, are excluded from
consideration, but it is conceded by all syphilographers that an epilepsy may mark the second stage of
the disorder, and its pathological dependence is probably a simple vascular disturbance which cannot
be determined after death. So-called specific epilepsy may be congenital.

Orwin1 mentions as a cause the influence of prolonged lactation. In several cases I have seen a
metrorrhagia, or a loss of blood from hemorrhoids has been followed by a readily curable epilepsy.
1 Prov. Med. and Surg. Journal, London, 1862, v. 48.

As eccentric irritating causes may be mentioned intestinal worms, but I am convinced that it is too often
the fashion to ascribe convulsions in children to intestinal parasites: in very young children, however,
there are frequent examples of the disease in which the attacks are precipitated by worms. The fits are
usually very severe, and are not regular in their appearance, occurring at night-time more often than
during the day, and, though they usually disappear when the bowels are cleared of their unpleasant
occupants, may recur when once initiated, even though anthelmintics of the most powerful kind are
employed. Gall-stones are mentioned by Ross as an eccentric cause of the disease, but I have never
witnessed a case of this nature.

Sudden terror, fright of all kinds, morbid example, and other psychic causes are detailed, and
undoubtedly all have more or less influence. Hysteroid attacks are notably precipitated by these mental
causes, and all forms of the disease are greatly modified by abnormal exercise of the mind.

A number of writers, among them Baly2 and Booth,3 have called attention to cases of the disease
dependent upon carious teeth. I have seen but one such case, where a wisdom tooth produced so
much violent inflammatory action that middle-ear disease followed, and with it subsequent extension to
the brain took place.
2 London Med. Gazette, 1851, xlviii. 534-540.

3 Am. Journ. of the Med. Sciences, 1870, N. S. lix. 278.

In rare cases the administration of anæsthetics is followed by epilepsy, and Gowers alludes to a case in
which convulsions were due to the inhalation of nitrous oxide gas.

Concussion of the brain as the result of railroad injury or falls may give rise to a progressive epilepsy
which is usually of serious character.

Reflex causes play a prominent part in many instances, though I am inclined to think that their
importance has been greatly exaggerated. This is especially true of so-called uterine epilepsy. It cannot
be doubted that difficult menstruation, ovarian neuralgia, etc. are found in connection with epilepsy, but
whether as a cause or effect it is not always possible to say. The fact that in some women we find accès
at periods identical with menstruation would point to a very close relationship. Carstens4 reports a case
due undoubtedly to stenosis of the cervix; Cohen,5 an example in which there was a uterine fibroid; and
others have spoken of erosion of the cervix, etc. as possible explanation of the seizure.
4 Detroit Lancet (8), 1880, N. S. iii. 153.

5 Wochenschrift f. d. ges. Heilkunde, Berlin, 1839, vii. 648, 673.

The toxic forms of epilepsy hardly need discussion in this article. Metallic poisoning, which gives rise to
a veritable plumbic encephalopathy, is rather the cause of a symptomatic than generic epilepsy. Curious
cases of epilepsies which have followed the use of oil of tansy (Mitchell6), ergot, absinthe (Magnan7),
and various drugs show that occasionally their mode of origin may explain the convulsive seizure.
Alcoholic epilepsy I do not regard as being the rare affection some authors consider it. In cases of
prolonged saturation, where perhaps there are no other symptoms of chronic alcoholism, I have found it
perhaps associated with the trance state (cataleptoid) or appearing in the psychic form.
6 Cincinnati Lancet and Clinic, 1881, N. S. vi. 479.

7 Recherches sur les Centres nerveux, Paris, 1876.

In old persons I have found gout to have an undoubted influence in producing the disease, there being a
spasm of the cerebral vessels which usually betokens a condition of uric-acid saturation. In these cases
the painful symptoms were not decided. Such epilepsies have quite often preceded serious evidence of
arterial degeneration.

Malarial epilepsy is rare: Jacobi8 reports a case and Payne9 another. A young man was brought to me
last year who had lived for many years in a part of Pennsylvania which was exceedingly malarious. His
attacks, which were more or less periodic, were violent, and his convulsions were general and attended
by very great preliminary rise of temperature and intense congestion of the face and head. The patient
was unusually somnolent, and between the paroxysms frequently suffered from facial neuralgia. The
influences of change of habitation and quinine determined the correctness of my diagnosis.
 8 Hospital Gazette, New York, 1879, v. 41-43.

9 Indian Ann. Med. Sci., Calcutta, 1860-61, vii. 597 et seq.

Day10 and Kerr11 have both ascribed epilepsies seen by them to hepatic congestion.
10 Clin. Histories, etc., London, 1866, 143-145.

11 Med. Times and Gazette, London, 1871, i. 568.

The important etiological relation of the exanthemata to epilepsy has been the subject of much attention.
The books are full of cases which owe their origin not only to scarlet fever and measles, but to whooping
cough, diphtheria, and the various zymotic fevers. In 35 cases tabulated by Gowers12 (p. 28) no less
than 19 were due to scarlet fever, while the first fit followed measles in 9 cases. So far as my individual
experience goes, I have in 23 cases found epilepsy to be the result of scarlet fever, and this form of the
disease was often associated with other manifestations of coarse brain trouble. Cerebro-spinal
meningitis was the undoubted cause of epilepsy in 6 cases I examined. It is probable that just as
smallpox acts upon the nervous centres, so does scarlet fever, and I agree with Gowers that the
convulsions that may begin during or just after the fever are not always due to uræmia. Bright's disease
may give rise to an epilepsy, but this can hardly be regarded as a distinct affection.
12 Op. cit.

There are many cases, especially in adults, which grow out of a prolonged depletion of the brain—a
continued cerebral anæmia. Among these cases are some which depend upon pressure upon the great
vessels of the neck, and some due to debilitating disease of a general character. Schulz13 has seen a
case which followed compression of the jugular vein, and enlarged cervical glands have in other cases
acted as mechanical agents. Hammond alludes to the influence of prolonged general anæmia in the
production of epilepsy.
13 Cor. Bl. Deutsches Gesellsch. f. Psych., Neuwied, 1855, ii. 35.

While I do not place much reliance on the claims that have been made regarding the frequent
dependence of the disease upon preputial irritation, or that it may arise from phymosis or urethral
stricture, it cannot be denied that some cases have originated in difficulties of the kind, and especially
the former. Simmons14 reports a case of attachment of the prepuce to the glans in which a cure followed
separation. Disease of the testicles in certain cases plays a part in its genesis, and Liégey15 details an
epilepsy clearly due to testicular pressure. Some years ago I saw a case in which the pressure of an
improperly applied truss, I am now convinced, had much to do with the development of the convulsions.
The alleged sexual causes are many, and some of them are very doubtful. A fanciful continental writer,
Montmeja,16 believes that sodomy explained the appearance of the disease in one of his patients.
14 Am. Journ. Med. Sci., 1880, N. S. lxxix. 444.

15 Gaz. méd. du Strasbourg, 1856, xvi. 105-107.

16 Rev. Photo. des Hôpitaux de Paris, 1873, v. 229-232.

The existence of vesical calculi as an exciting cause cannot be disregarded, and, while rare, the
observations of Duncan,17 Muscroft,18 and one or two others have shown that the removal of a stone
was followed by a cure of the epilepsy.
17 Ed. Med. Journal, 1868-69, xiv. 140.

18 Arch. Sci. and Pract. Med. and Surg., 1873, 1360.

Masturbation is a popular etiological factor. I really do not believe, even in face of the numerous alleged
cases that have been recorded, that the habit of self-abuse often results in genuine epilepsy. So far as
my experience goes, onanism is practised by epileptics as well as by healthy boys, and when indulged
in to excess is due to the congenital moral deficiency which is so common, especially in hereditary
cases. In rare examples the frequently-repeated act may give rise to a form of the disease of the nature
of petit mal.

Gastric disorders have attracted much attention, especially from Paget, who speaks of a gastric epilepsy
and reports cases. While I do not believe in the sole etiological influence of digestive derangement, I
have too often witnessed examples in which disorders of this kind markedly influenced the precipitation
of attacks and the duration of the disorder.

Occasional cases of peripheral origin have been from time to time presented, and go to support in some
measure the pathological views of Brown-Séquard. Among observers who have brought forward cases
besides those referred to on a previous page are Lande,19 who reported a case of epilepsy dependent
upon injury of the right median nerve, and Short,20 in whose case a neuroma explained the cause of the
convulsions. Billroth,21 Garnier,22 Brown-Séquard,23 and Raymond24 have brought forward cases where
injury of the sciatic nerve was the origin of the trouble, and in more than one instance a cure was
effected by excision. It seems strange that a bone dislocation should have anything to do with the
genesis of epilepsy, yet in one case reported a severe dislocation at the shoulder-joint explained the
appearance of the attacks, and reduction was speedily followed by cure.
19 Mém. et Bull. Soc. de Méd. et Chir. de Bordeaux, 1878, i. 56-65.

20 Med. Essays and Observation Soc., Edin., 1737, iv. 416.

21 Archiv f. klin. Chir., Berlin, 1872, xiii. 379-395.

22 Union médicale de Paris, 1872, 3d S., xiii. 656-658.

23 New York Medical Record, 1872, vii. 472.

24 Rev. méd. de Limoges, 1869-72, iii. 102-105.

I have seen several cases where disease of the internal ear or injury of the temporal bone gave rise to
the most obstinate and violent epilepsies. Westmoreland25 and others report such cases, but more often
the epilepsy is only symptomatic of pachymeningitis or abscess. Some years ago I presented26 a case
of genuine epilepsy in which the seizure was produced at will by irritating the meatus auditorius. By
simply blowing into the ear the same effect would be produced. Since then Blake and others have
related examples. Quite lately a writer in Brain has collected other cases of this species of auditory
epilepsy. A year or so since I examined a patient in whom not only hemi-epilepsy, but other unilateral
symptoms, followed erosion of a large part of the mastoid and petrous portion of the temporal bone as
the result of a bullet wound.
25 Atlanta Med. and Surg. Journal, 1876-77, xiv. 717-719.

26 New York Medical Record, 1878, xiii. 107-109.

The influence of climate and varying barometric pressure has been considered by Delasiauve. His
conclusion was that the attacks were much more common during the season of the year when the
prevailing winds were from the north-west, north, or south-west.

PRODROMATA.—There are various minor disturbances of sensation and motion which may not amount to
the dignity of an epileptic attack. These may be so fugacious as to escape the attention of the persons
in whose company the patient may happen to be, or he himself may be unaware of any disordered state
of feeling. They may precede a severe paroxysm, when they are known as warnings or auræ. The term
aura was originally applied to the familiar premonitory sensation which is so often likened by the subject
to the blowing of wind over the skin, from whence it receives its name, but it has come to be applied to
all primary indications of a fit. Such auræ may be sensory or motor—in the preponderance of cases the
former, for motor precursors are quite rare, and when they occur are most likely to be but one stage,
though a slight one, of the convulsion itself. There is no general rule about the occurrence of an aura,
but, so far as my experience goes, there is great constancy in the character of the warning in each
particular case. The sensory disturbance may vary from a vague feeling of confusion to a well-marked
sensation. In many instances the patient speaks of an indescribable mental disturbance, which may
precede the attack and last anywhere from a few minutes to several hours. This confusional state or
psychical aura is most protean in its expression. It may simply be a heavy feeling, a feeling of tension, a
sleepy feeling; a restlessness which is manifested by the patient changing his position frequently or
wandering forth into the streets; an irritability of temper which often lasts twenty-four hours or more, and
during the display of which he rebukes those who may be solicitous about him, or wantonly destroys
articles of furniture, or vents his spleen upon inoffensive persons. I have had epileptic children under my
charge who were wont to bite their little brothers and sisters or their nurses. A feeling of terror
sometimes precedes the attack, and very often there is a sense of impending danger which has no
basis whatever, and with it is associated a depth of depression which is very painful. In other cases the
patient manifests a strange exhilaration, which may precede the occurrence of the attack for a period of
from one or two hours to two or three days; and this is made manifest by great loquacity and a lively
play of spirits. It is not rare to find errors in the speech as indications of an approaching attack. A minor
degree of aphasia, slowness of speech, or anarthria betrays occasionally the preparatory state which is
the precursor of a severe convulsion. By far the most common warnings, however, consist of disorders
of the special senses, and generally these are visual. From an inspection of my notes I find that the
patients saw colored lights, rings of fire, bright objects, dark spots, luminous clouds, a flood of light,
sparks, stars, bright balls, lights which approached them, lights which receded, fireworks, and all
became dark. While many were unable to define the color perceived, I found among those who were
positive that red was the color most frequently seen, while blue came next; and this is a conclusion
which I believe is accepted by Jackson and others who have analyzed their cases.

Hemiopia and diplopia in rare cases precede the major attacks, and are sometimes associated with
distal pain and anæsthesia and with supraorbital pain as well.27 Among these ocular warnings we find
constriction of the visual field to be often present, especially in cases where there is a history of
migraine. Vague disorders of hearing, which may even amount to the dignity of hallucination, are
complained of by some persons. There may be simply roaring in the ears or a sound of bells, and in one
instance my patient declared that he heard whisperings at the time of the seizure. Some patients smell
smoke or other foul odors, and in exceptional instances the odor of some particular flower or of some
aromatic substance, such as camphor, turpentine, or tar, is perceived by the epileptic; and these are
probably psychical.28 Sometimes there is a feeling of great suffocation, constriction of the chest or of the
throat, palpitation, or vertigo.
27 See Sensory Epilepsy.

28 For curious examples of this kind consult Sir Charles Bell's Nervous System of the Human Body.

There are disorders of cutaneous sensation of great diversity of character, but those auræ which are of
the most constant occurrence are the epigastric, which consist of a vague sensation starting below the
sternum and ascending, its arrival at the throat being coincident with the commencement of the fit, and
the patient very often likens its culmination to the violent grasp of a strong hand. So, too, we find
crawling sensations starting in the extremities and running up to the trunk. These have been compared
to the contact of insects in motion or to the blowing of wind over the surface. There may be tingling in
one or two fingers or the whole hand, and such sensations may be unilateral or bilateral. It is quite
common for the sensory warning to begin in the hand and foot of one side and to run up to the knee and
elbow. Sometimes the tongue becomes hyperæsthetic, and I have frequently found that the gums
became exquisitely tender just before the attack. According to Gowers, 17 per cent. of his cases began
with unilateral peripheral auræ, but I think this is too small a proportion, for, so far as I have observed, at
least 30 per cent. of all my cases in which any auræ at all could be ascertained presented the history of
a one-sided warning, beginning most often in the right hand. Gowers says that in three-fourths of his
cases in which the attack began in the hand consciousness was lost before the seizure extended
beyond the arm, while in the others it extended much farther before the actual fit was precipitated. In
Gowers's cases he rarely found that unilateral auræ were associated with other warnings; and his
experience, which is like my own, goes to prove that unilateral sensory auræ and one-sided initial motor
expressions go together, and very often indicate gross organic disease. In some cases there may be for
several days a decided unilateral or general muscular weakness or recurring chronic spasms which may
be frequently repeated. In aborted or irregular attacks there are also peculiar motor symptoms, to which
reference will be made later on.

In two or three patients I have found that the attack was immediately preceded by a profuse discharge
of saliva, and in one case the patient had frequently bleeding from the nose. Several authors have
called attention to certain local vaso-motor disturbances which are expressed by limited patches of
cutaneous hyperæmia or anæmia, so that the fingers—or, in fact, the whole hand—may either be
swollen and of a dusky-red color, or, contrariwise, there may be blanching and an apparent diminution in
size.

Sometimes the patient immediately before the attack makes more or less automatic movements,
pressing his hands to his head, clasping his breast, or clutching at some imaginary object, and after this
he loses consciousness and falls to the ground. In some irregular cases the patient runs aimlessly for
some distance or describes a circle, and after a variable time, which rarely exceeds a minute or two, the
actual fit begins. Here are two examples:

Case I.—Boy aged fifteen, has been subject to somnambulism; attacks began two years ago. He
frequently when sitting at table rises suddenly, and runs either around the room or out into the street if
possible. In thirty seconds or so he falls to the ground in a convulsion. Always falls backward in
opisthotonos.

Case II.—Man aged thirty-four. Attacks always begin by stage of violent temper. While unconscious he
runs about office, striking all who try to restrain him; finally falls to the floor. Convulsions, when they
occur, are always severe. Sometimes running attack is the sole feature.

This disposition to run is no less remarkable than another queer prodroma I have seen in several
patients, who began to take off their clothing when first seized, no matter where they were or under what
circumstances. This is not, as has been suggested, the remains of a half-formed idea that they must
seek their beds because of their impending trouble, but it is a much less complex mental act, and the
several patients I have seen were fully unconscious when they did this, and were in places where there
was no bed within reach. Equally curious mental precursors of the attack have come to my notice, and
these I will detail subsequently.

SYMPTOMATOLOGY.—The Light Attack.—The epileptic attack may, as I have said, be scarcely perceptible
to those about the patient, or may consist simply of a momentary loss of consciousness and very feeble
convulsive movements. Reynolds has described two forms: (1) That without evident spasm; (2) that with
evident spasm. Such seizures are always fugacious, and consist merely in some transient loss of
consciousness and very little or no convulsive movement. The tonic spasms prevail, if any, and the
disorder of motility may often consist simply in the arrest of some act in the performance of which the
patient is engaged. While playing the piano the patient's hands may for a moment remain suspended
over the keys he is about to strike; if eating, the hand which holds the fork may be arrested between the
plate and his mouth. The attack consists sometimes in the rolling upward of the eyeballs, or when
crossing the room the patient may stop, remaining quiet for an instant. Temporary unconsciousness,
shown by cessation of conversation, by change of color, and absence of intelligent expression,
accompanies the other trouble. In a well-marked attack of petit mal the patient may move his lips
convulsively, and remain otherwise quiet, but bereft of consciousness, for one or two minutes.

The patient sometimes loses himself and loses the thread of the conversation, repeating what he has
just said or showing his want of appreciation of what his companion has said. To this light grade belongs
the case reported by Jackson of the individual who blew his nose upon a piece of paper and gave the
conductor £2 10s. instead of twopence halfpenny.

The Major Attack.—An attack of epilepsy of the familiar severe form may or not follow an aura. The first
intimation to the bystander may be a noise made by the patient, which is either a loud, startling, wild cry,
or a gurgling groan due to compression of the thorax and the forcible escape of wind through the vocal
cords. There are three stages of the attack: (1) The stage of tonic convulsion; (2) the stage of clonic
convulsion; (3) the reactionary stage.

The first stage of the attack is symptomatized by tonic spasms, which may be local or general, usually
the latter. It is very often unrecognized, for its duration may be so short that it is lost in the stage of clonic
spasms, which is much more protracted. There is usually unilateral seizure, the muscles of the face
being primarily involved, then those of the hand and upper extremity, and then those of the lower
extremity; and finally there is a general involvement, so that the patient may be in a position of
opisthotonos. In some cases there is strong tonic contraction to one side, or pleurosthotonos. The notes
of a case which illustrates the beginning and development of convulsion with reference to the parts
involved, which I observed carefully, are the following:

Bindewald: Epileptic attack observed at hospital for paralyzed and epileptic, Sunday, Mar. 12, 1882:

1. Long, shrill cry which attracted my attention. It probably lasted five seconds. At same time patient
threw up arms and became unconscious, and fell to floor. Nurses ran to him and placed him upon
bed.

2. Tonic convulsions began by fine twitchings at right corner of mouth. These became gross, and
were separated by succeeding long intervals. Eyes directed to left side, face pale.

3. In twenty seconds twitching began in right hand and arm, which were rigidly flexed (five
seconds); then leg and foot of right side became agitated, the face meanwhile changing in color
successively from red-gray to purple; lips purple, ears livid and purple, edges white; eyes still turned
to the left, pupils dilated, eyes widely open; breathing stertorous and irregular.

4. General convulsions of right side.

5. Head suddenly twisted to left side; position of eyes the same. Chin drawn down, movements
moderated; still livid. A fit of coughing and expectoration of much frothy mucus. Left side, with
exception of head, not implicated. Whole attack lasted about one minute and thirty-five seconds.
Deep sleep afterward, lasting forty-five minutes.

This attack was one of many in a confirmed epileptic, and is a fair example of those commonly met with,
though not as general as we sometimes find. In most cases the attack appears to be very much longer
than it usually is, and the phenomena noted above, which seemed to occupy a considerable space of
time, really lasted but little more than a minute and a half. Axenfeld and Beau fix the average period of
the attack as follows: “Duration of the complete attack, which Beau divides into four phases: first stage,
tetanic stage, five to thirty seconds; second stage, clonic convulsions, from one to two minutes; third
stage, stage of stupor, three to eight minutes; fourth stage, return of sensibility and intelligence. It is not
complete until the end of from ten to thirty minutes.”

To be more explicit, the manifestation of an ordinary epileptic attack of the more severe kind is very
much like this: Usually without any warning to those about the patient he utters a shrill, peculiar cry of a
character never to be forgotten if once heard, and then, perhaps throwing up his hands, he falls to the
ground rigid and contorted. His body may be arched laterally or antero-posteriorly, his legs are thrown
out, his forearms flexed, and his fists doubled, the thumbs being beneath the other fingers. His face may
be for a moment flushed, but the color recedes, and it assumes a dusky-bluish tint, the lips being ashy-
gray. The eyes are usually open, and the balls are rolled up and the pupils widely dilated. The breathing
may for a moment be suspended, but it soon quickens, and becomes labored and noisy, and the pulse
grows hard and full. The tonic contractions are succeeded in a very short time by more or less violent
clonic contractions, which increase in violence and rapidity; the jaws work and the lips are covered with
foam, which is blown in and out by the rapid inspirations and expirations. It may be tinged with blood in
the severe attack if the tongue is bitten, which is by no means an uncommon accident. The teeth are
sometimes firmly set and the jaws locked. The head is usually drawn to one side in the first stage, but
afterward may be rolled from side to side. The movements are now more or less general, and
occasionally the agitation is so great that the patient throws himself from the bed on which he may be
lying. The face grows more pale, or rather more livid, and toward the end of this stage there may be a
puffiness and congestion such as are seen in partially asphyxiated individuals, for this alteration in color
is due to dyspnœa and consequent imperfect oxidation. The patient may defecate or pass his urine
unconsciously, and sometimes we find seminal emission. The movements, after a period varying from
ten seconds to a minute or two, become less violent, and he may talk in a silly manner, as a person
does who is recovering from profound ether unconsciousness; or deeply sigh, and he is restless. The
pulse is now much weaker and more rapid, and may be irregular. The color returns to the face, the
patient closes his eyes, and the body is covered with profuse perspiration. The fingers are unlocked and
every evidence of spasmodic movement disappears. He falls asleep, and remains so for several hours,
awaking with a confused feeling, headache, and no remembrance of the attack, and is only reminded
that something has happened by his wounded tongue or lips, the bruises he has received, or by the
information of friends. He looks jaded and tired, and is indisposed to exert himself for several days if the
attack has been at all severe. The transition from the attack to the normal state is not always the same.
Some patients do not sleep at all, but after being dazed go about their occupation. This is even true
occasionally of the severe form of disease.

The usual termination of the attack is, however, by sleep preceded by a period of confusion. The patient,
after coming out of the clonic stage, mutters incoherently. He is apt to pass large quantities of wind from
his bowels, or vomits. This is attended by a subsidence of the spasmodic movements, and perhaps by
oscillation of the eyeballs. The pulse loses its rapid, hard character, and the reaction brings with it
diminished frequency of respiration and the evidence of exhaustion.

Special Symptoms.—The eyes are, as a rule, open, and, there being spasmodic movement of the ocular
muscles, we find that the balls are either rolled up or directed away from the side in which the spasms
begin. This is especially true in those epilepsies due to cortical disease, and the same law of conjugate
deviation laid down by Bourneville may be remembered.

The pupils are dilated pretty much throughout the fit, though they may vary, and a transient contraction
may occur at the commencement of the first stage. During the clonic stage, especially toward the end,
they not infrequently undergo a species of oscillation. The interparoxysmal state is revealed by a very
great mobility of the pupil, which has been observed by Gray and others. Gray is disposed to consider it
a diagnostic indication of value, but so far I have found it only in two-thirds of my cases. Dilatation of the
pupil I believe to be a very constant feature of epilepsy.

The ophthalmoscope reveals in certain cases an abnormal increase in the circulation at the fundus, in
others a very decided emptiness of the retinal vessels. Jackson is disposed to consider that certain
visual auræ depend upon spasm of the arterioles in this location. Loring, whose opportunities for
research have been very great, is not disposed to attach much importance to the ophthalmoscopic
appearances, at least during the periods between the fits.

The pulse of the epileptic between the paroxysms is small and irritable. Voisin has found the following
changes: “Two or three seconds before the attack it becomes rapid, sharp, and the sphygmographic
curves are higher, rounded, and nearer together. When the attack begins we see five or six little
undulations in the course of the ascending line, and the curves are higher and more accentuated.
Several minutes after the attack there is dicrotism, and the line of descent is very sharp, the angle with
the ascending being quite acute. This form of pulse lasts an hour or half hour after the attack. There is in
some cases great irregularity, with paroxysms of cardiac pain resembling angina pectoris. There is
occasionally epistaxis or more marked hemorrhages.” Parrot speaks of hemorrhages from the eyes and
ears, and occasionally the cerebral congestion is so great as to result in cerebral hemorrhage in old
subjects.

The temperature is usually lowered before the attack, but the surface temperature is increased during or
after the second stage.

Cutaneous sensibility is often very much disturbed. Spots of hyperæsthesia and anæsthesia are
sometimes left after the attack. The scalp is not infrequently exceedingly tender. The sensory troubles
have been alluded to as prodromata of the ordinary motor attack. Some attacks of the sensory variety in
which psychical excitement plays a part are characterized by unilateral and persistent formications.

A consequence of some epileptic paroxysms is the appearance of petechiæ, chiefly upon the face,
neck, and upper extremities. The skin of old epileptics is harsh, cold, and rough, and the face is apt to
be studded with spots of acne even when the patient is not taking the bromides. The hair is stiff and dry,
and the ears and tip of the nose are apt to be the seats of a passive and old hyperæmia.

The urine of epileptics is apt to contain evidence of muscular waste, and an increase in the amount of
earthy phosphates as well. Zapolsky found, however, that immediately after the attack there was
diminution in the quantity of the phosphates. The occurrence of glycosuria has been noted by numerous
clinicians. De Renzi29 has published an interesting article. I have seen no less than six well-marked
cases within two years in which constant glycosuria was a feature of the disease, but in two of the
patients well-marked symptoms of disease of the pons were present. After the paroxysm it is by no
means uncommon to find the urine loaded with albumen. Otto, Mabille, Saundby, Bazin, and other
writers speak of a transitory albuminuria. Kleudgen,30 however, does not attach much importance to this
feature, believing that the albumen is often due to semen.
29 Gior. internaz. d. Sc. Med., Napoli, 1880, ii. 357-359.

30 Archiv für Psychiatrie, etc., 1880, xi. 478-506.

The tendinous reflexes are frequently abolished during the attack, but not always so, and in several
cases in which I was enabled to make a test during the convulsion I found that the patellar reflex was
very active, and in one case elsewhere reported it was transferred. The skin reflexes are ordinarily
exaggerated.

Tongue-biting is, I think, a more common feature of the nocturnal than the other attacks. It is rare in
infantile epilepsy, and is always a bad feature. The wound is sometimes very serious, and cases are
mentioned where the tongue has been severed. An occasional sequel of the attack is a urinary difficulty
and vesical tenderness. It is sometimes connected with great urethral irritability and spasmodic stricture,
which prevents the introduction of a sound or catheter. Romberg speaks of the supervention of asthma
and dysphagia.

THE IMMEDIATE AND REMOTE EFFECTS OF THE EPILEPTIC PAROXYSM.—As a result of violence we often find
wounds and bruises, quite rarely fractures, but more often dislocations. Cases have been
communicated to me where as a result simply of the great muscular force the humerus has been
dislocated at its superior articulation. Muscular pain of great severity, and sometimes of great
persistency, follows unusually severe fits, and rupture of muscular substance is not uncommon. An
epiolecranon bruise in one of my cases produced a severe neuritis which was very intractable. In old
cases, according to Axenfeld, there may be great muscular hypertrophy, the sterno-mastoidii attaining
the size of the biceps, and in other cases there is fatty degeneration. He also calls attention to defects
that may be due to frequent exercise of violence upon bones through repeated exaggerated muscular
contraction. Paralysis of nerves which supply convulsed members is mentioned.

The psychical effects are various. For several days following the attack there may be simply confusion
of ideas, irresolution, or drowsiness, which subsides in a short time. In not a few cases I have regarded
the attack as beneficial in the sense of an explosion of relief when perverted mental states had
preceded it. In such persons the discharging lesion was followed by a very conspicuous restoration of
the mental equilibrium.

Occasionally the attacks are terminated by great violence or screaming or the commission of
purposeless acts.

Post-epileptic aphasia has been described by Winslow, Moreau, and others, and among my own cases
of the sensory variety of this disorder I have met with speech disturbance. The aphasia is of short
duration, and consists either in a total incapacity for verbal expression or a transposition. It is not rare for
it to be associated with the commission of a number of quasi-automatic actions.

Unilateral epilepsies are quite apt to leave behind them a species of paresis which may last even for
several days. The loss of power is confined to the convulsed members, and may be accompanied by
tingling. In the greater number of instances, however, there is some central organic change, and the
epilepsy is purely symptomatic.

Deafness, amaurosis, and other pareses of the organs of special sense are rare sequelæ of the
epileptic state.

The remote effects of the grave disease are not so decided as when the patient has been the subject of
petit mal. Slight repeated losses of consciousness are apt to be followed by mental decay. The ultimate
result is mental enfeeblement, a progressive and very great loss of memory, which advances to such an
extent that a veritable dementia ensues. With this there is usually a very decided perversion of the
emotions and affections, so that a good-natured, amiable child may in a few years become everything
that is bad and trying, and the acts of mischief are almost inconceivable. Theft, incendiarism, and
various moral perversions are common in some chronic epileptics. The dementia, it is true, is tardy in its
establishment, but it comes eventually if the individual lives long enough.

In some individuals there is a very early tendency to the development of mania; there is a certain
periodicity about the explosions, and when established the excitement either precedes the attack by a
few days or occurs shortly afterward. The violence is characteristically acute, and such insanity very
often makes itself known in homicidal acts rather than in those of a suicidal character. Hypochondriasis
is quite likely to follow continued epilepsy.

It is the rule for epilepsy to undergo decided modifications in the beginning of its course. The first attack
may be simply eclamptic, without any peculiarities or definite character, and with recurrence there is a
tendency to regularity and constancy in expression. Infantile convulsions, that may occur at any time
after inconsiderable exciting causes, may eventually be confined to the early morning or night. So-called
fainting attacks may precede petit mal, and headache may be the precursor of ill-defined seizures. So,
too, the relation of grave and light attacks may vary. In the beginning there may be nothing but attacks of
petit mal, while later these may be supplemented by severe fits, and even disappear entirely. So far as
my own cases go, I find that nearly two-thirds of the entire number happen at night or in the early
morning, while the others may occur in the day or at any other time, or by day and night. Besides the
terms nocturnal and diurnal, we may use the word matutinal in relation to the time of attack. So far as
the number of attacks is concerned, we find great irregularity. It is not always possible to count them, or
even to recognize them, for the examples are numerous where nocturnal attacks have been undetected
for years, and have finally been followed by fits during the daytime. I have cases who have seizures but
once or twice a year, and others who have ten to forty or fifty daily. In some cases there may be eight or
ten attacks of petit mal daily, and but two or three grave attacks during the week.

The statistics of Delasiauve and Leuret go to show that of 296 cases of epilepsy, the cases of general
epilepsy were most common—that is to say, the attacks which occur both by day and night.

Attacks occurring occasionally by day 26

Attacks occurring habitually by day 30
Attacks occurring only at night 9
Attacks occurring habitually at night 8
Attacks occurring equally by day or night 87
Attacks occurring in larger proportion by day 70
Attacks occurring in larger proportion by night 44

Delasiauve, Herpin, and others make delicate distinctions between the attacks, and the former grades
the seizures beginning at accesses, and successively advancing to vertiges, accès intermédiares, and
attaques or accès compléts.31 In fact, these are but varying degrees of violence of the discharge, after