THE FLECHSIG METHOD IN THE TREATMENT OF INSANE EPILEPTICS. BY L. PIERCE CLAR K, M.D. REPRINT FRO* r American Medico=Surj;ical Bulletin, June 15, 1895. TO CC JNTRIBUTORS. Contributions of Origin; a( Thought and Experiences, on Medical and Surgical Topics, are desired by ■ tha AMERICAN MEDICO-SURGICAL BULLETIN on the following conditions: 1. -Authors of Scient ,gc papep or Clinical Reports accepted by us will receive-according to their o -Tn prefefence expressed with each communication either: a :-A number of Repi nts of their article in neat pamphlet form (pocket size); or, b :-Instead of the abov an pqUivaient value therefor in Cash. 2. -All contributions f ire received only on the express understanding: a:-That they have ' dOq been printed anywhere, nor communicated to any other journal. b:-That, if they have been read anywhere to an audience, this fact be stated in full detail by a note , on qhe manuscript. 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It heed not come in the garb of an elaborate Scientific treatise ; a simple "Letter to the Editor " will often be just as acceptable. a Not Fear, Some Rules of Order we s hould ]ihe [() have our esteemed Contributors comply with . Do not write on both sides of tn< 3 sheet. Write as legibly as you conveniei can j names especially so). Leave a liberal margin on the, sheet, or space between the lines. , Close writing is not conducive f0 correct tvpography; and That you save in writing material has to bt, expended 'a thousand-told by us in eyesight labor, and expense for pnn er>g corrections.) Address :-P O. Box, 2535 New York city. Edito r American Medico-Surgical Bulletin. THE FLECHSIG METHOD IN THE TREAT- MENT OF INSANE EPILEPTICS.* By L. PIERCE CLARK, M.D. T' HE treatment of epilepsy and its etiology are so indissolubly asso- ciated that it will be impossible for the writer to speak of the one without making occasional reference to the other. There exists but little doubt in the minds of most alienists and neurologists that the great importance hitherto given to trauma, such as scalp wounds and the nu- merous falls received in early childhood, where but little or no mental disturbance immediately followed, has been overesti- mated in the causation of all mental dis- eases, and especially in this one of epilepsy. Anxious friends, when questioned by the physician as to the cause of the fits, can very readily call to mind an accidental fall that the patient received in early infancy resulting in some slight abrasion of the scalp without any involvement of the bony wall. Now there are but few of us who can- not recall a similar accident befalling our- selves, and a similar effect should follow our mishap were it not for the fact that there is something back of all these acci- dents which must have been and is still the * Read before the Section on General Medicine, New York Academy of Medic'ne, May 21, 1S95. 1 prime factor in the etiology of this affec- tion, namely heredity. This hereditary fac- tor1 is one of great importance to recognize and to investigate. Not so much because we shall be able to cure the disease by the use of certain drugs, but because, when heredity is found and known to exist, we shall be able to ward off in some degree its evil tendency. Unhappily, many times when all these inherited factors become evi- dent, either because of their inherent nature or their strong and well-fortified position in the patient's economy, we are unable to accomplish any permanent results in the epileptic attacks. There is no question but that in many families in which epilepsy occurs it is but one of nature's methods of demonstrating her law of the survival of the fittest. This class is socially, morally, mentally, and 'In an analysis of 300 cases of the epileptic admissions to the Connecticut Hospital for In- sane, since its opening-, in 1867, it was found that 105 of them gave a positive hereditary his- tory of insanity. There were 100 cases in which no heredity was discoverable, and 95 of the 300 cases failed to give any adequate evi- dence for or against heredity. This gives us a heredity history of a little more than 50 per cent, of the epileptic admissions, as compared with those of no family history of heredity. The writer is confident that a much larger p_er cent, of heredity would obtain if the 95 cases could have been thoroughly analyzed, as these cases were mostly epileptics, who had seizures from early childhood. Many of them were con- genital epileptics, whose parents were intem- perate in the use of alcohol. Besides, there are other family neuroses, aside from insanity, the history of which, for numerous and obvious rea- sons, cannot be obtained. Esquirol and Meynert put the hereditary element for the epileptic in- sane over 50 per cent. 2 physically unfit to propagate the race, or to cope with its environment. Either on ac- count of their vicious habits and unnatural manner of living, or because of their in- herited degenerative tendencies, Nature places her seal of doom upon one member as an habitual criminal; on another as an imbecile; on a third as a consumptive; while a fourth may have epilepsy. For us to hope to benefit one of this latter kind would be alike foolish and unsuccessful. Unfortunately, nature does not always make these existing conditions as clear as we could wish, so that in the mean time it behooves us to carefully weigh the evi- dence in all cases, and, by studying the causation, to endeavor to remove, it as far as possible. As has been pointed out by Hughlings, Jackson, Lewis, and others, the early forms of epilepsies have a well-marked influence over the mental development. This early tendency to instability of the nerve unit, and its periodical violent explosion of nerve- force, render further mental evolution im- probable, if not impossible. Eight of the ten cases to be reported presented marked physical signs or stigmata of degeneration, such as asvmmetry of the cranial vault; anomalies of the special sense organs; and maFormation of the hard and soft palate. The studies in pathology have yet to give us the keynote of the epileptic lesions upon which we can base our treatment of these idiopathic epilepsies. And until they do point out some more definite and constant lesion, we shall drift all the way from acet- anilid, borax, bromides, etc., down through 3 the whole pharmacopeia. Nevertheless, the writer believes that the extensive studies made on the nerve-cell and its functions by neuro-pathologists and physiologists in the new and more delicate technique of to-day will help to clear up this obscure lesion. Notwithstanding the fact that literature seems to point out the imperfections of the theory of vacuolation of the sensory layers in the cortex, in that vascular and proto- plasmic changes in the gray structure are not constant and not found in this disease alone, yet these conditions of cell degenera- tion portray the many forms of neuronic dissolution in the central nervous system, and they foreshadow a fruition in this de- partment which will give us a clearer know- ledge to work upon than we have hitherto possessed. An interesting clinical feature, aside from the object of this paper, presents itself as we turn to the treatment of epilepsy. This is that some patients in our hospitals for the insane contract epilepsy, although living under the best conditions possible and at such a time when their age would seem to exclude them from any great predisposition to the disease. A reference is made here to those between the ages of 50 and 60, and not to those seizures following in the track of well-marked senile, syphilitic, or hemiplegic lesions. A propos of the foregoing remarks the question arises, Why do some epilep- tics undergo a spontaneous cure as far as their seizures are concerned, either without any medication or when it has been tried in vain? These insane epileptics sometimes suddenly cease having attacks, leaving the 4 patient symptomatologically a case of chronic mania or terminal dementia.2 The one class of drugs which seems to have held sway through all of the will-o'- the-wisp plans of treatment is the bromides. While these are useful in many epilepsies of early origin, undoubtedly due to some peripheral injury or visceral disturbance, yet, in most well-established attacks and in patients eventually becoming insane, they seem only to hold back the motor dis- charges for a time*. Then the pent-up storm dashes over or breaks away the bromide barriers and there is marked mental reduc- tion. which is more or less permanent. Even in those cases where fewer seizures occur under bromide it will often be seen that this is the only favorable symptom of its use, while the mental devolution continues even more rapidly and certainly to a condition of complete dementia. Hence to-day there is given but very little bromide in the treatment of the epileptic insane with any idea of effecting a cure. Its principal use seems to be restricted to those cases in which its exhibition is followed by less irri- tability and greater self-control on the part 2 A case illustrating' the above peculiar circum- stances is that of W. H., male, 38 years old, sin- gle, epileptic mania. History of an ordinary case of epilepsy, with maniacal excitement. Subject to fits from childhood. Admitted to Connecticut Hospital for In-sane in June, 1873. For some time thereafter seizures occurred once a month. In 1879 the fits averaged one in two weeks. He was discharged in August, 1879. and readmitted in August, 1881, having passed the two years intervening in an almshouse. His condition as regards epileptic seizures while there was not elicited. Since his return to the hospital he has had no seizures. 5 (This photograph was kindly furnished by Dr. Coleburn.) 6 of the patient, thereby rendering these cases less a burden to those appointed for their care and maintenance. Most physicians who have to deal with the epileptic insane and their friends know how worthy an object this is when accomplished. Quite recently a plan of treatment for epilepsy has been devised by Flechsig, of Leipsic; namely, the opium-bromide treat- ment. The administration of opium in epi- lepsy is not a new idea, but the peculiar way in which it was given by Flechsig, and then followed by bromide, seems to be a new departure. This authority, after a trial in some of his own cases, reports quite fa- vorable results. Still more recently another report of cases was made by Collins,3 of New York. These cases were collected from private sources, hospitals, and alms- houses. His trial was reported to be suc- cessful in part, and especially in long-stand- ing and chronic cases. Principally to test the efficacy of the new treatment among this class, the writer selected ten cases of the epileptic insane from one hundred cases committed to the Connecticut Hospital for Insane, at Middletown. These cases had in a measure defied other forms of treatment and were considered to be even more un- manageable and difficult of control than the ordinary insane epileptic. The opium was given according to a modified form of Flechsig's method, com- mencing with one grain three times a day, and increasing one grain each day until 15 grains daily had been administered. This maximum dose (15 grains) was continued 'Medical Record, Sept. 22, 1S94. 7 (This photograph was kindly furnished by Dr. Coleburn.) for five days only, instead of four weeks, as Flechsig advises. On the appear- ance and the continuance of intestinal disturbance-a copious diarrhea and evi- dence of gastric irritation-it was thought that a further continuance of the opium could be of no value, and it was ac- cordingly withdrawn.4 A purgative was then given, and the next day bromide was ad- ministered in 15-grn. doses t.i.d. for the first week, increasing this to 30 grn. t.i.d. the second week, and to 60 gr. t.i.d. the third week. After allowing this last amount (180 grn. per day) to stand for two weeks, all were placed on 15-gr. doses t.i.d. for the remainder of the observation. The trial and resultant record cover a period of ten months. A short resume of each of the ten cases follows, and a table is appended showing the number of seizures in the dif- ferent trial periods of four months each, viz., with bromide, without bromide, bro- mide following opium, and bromide with opium, inclusive. Case I.-L. K., age 21, single female, German descent. Both her brother and mother were insane. Her seizures began about thirteen years ago, and were quite infrequent at first, but on admission her friends report that she has had five or six severe seizures monthly for the past three or four years. These attacks are followed by maniacal excitement, which has cut short 4Why Flechsig and his followers advise the continuance of opium after the system has be- come thoroughly saturated, and its direct poi- sonous effects are manifest, is not easy to com- prehend. It certainly transcends rational ther- apeutics. 9 her mental development, and she manifests the intelligence of a child of about 8 years. Bromides have been used in her case, caus- ing the seizures to be less frequent at first; but they gradually increased until now they are as frequent as before. While taking the opium treatment she suffered from epilepsy about the same as ever. If the fits were not so frequent they were more violent and severe. She was dull and very stupid under the new treat- ment. The first few weeks she showed con- siderable improvement, but at the end of five months her attacks had become as fre- quent as ever. If the new plan did her epi- lepsy no good, it did seem to benefit her general behavior, as she has been less irri- table and more manageable. Case II.-N. S., age 40, single female, United States. Has been subject to severe and frequent epileptic seizures for over twenty-two years. These generally occur at night about twice a week, followed by maniacal excitement for ten or twelve hours. This, in turn, would be followed by de- pression and stupor. There has been a steady retrograde change in patient's men- tal condition since coming to the hospital. The opium rendered her attacks less fre- quent and severe, but her stupor and de- mentia have continued to increase. The new treatment was not so effective as bro- mide when given alone, and has rather has- tened her more precipitately to a condition of complete dementia. Indeed, the patient's condition now resembles in many respects those asylum cases which, as dementia be- comes more and more pronounced, have 10 fewer and fewer seizures, until, at the time of death, there remains but little save the mental wreck to tell the unfortunate story of the violent epileptic storms. Case III.-E. F., age 34, colored female. Family history unknown. Has been intem- perate in the use of alcohol, tobacco, and opium; has had epilepsy since she was 2 years old, and has been insane for eight years. Her epileptic storms last for two or three hours, during which time she may have ten or twenty distinct fits or seizures closely approximating a condition of status. They are often preceded and invariably fol- lowed by maniacal excitement. The patient is stout to obesity and is quite demented. The peculiar feature of her history under the new treatment is that she contracted acute Bright's disease while taking the treatment. The urine was examined before opium was given, at the time of its largest dose, at the withdrawal of opium, in the in- terim, and two weeks after bromide was begun. (This was also done in the other nine cases.) Not until the last examination of urine did albumin appear in her case, but since it has been found in large quantities, together with many epithelial casts. The tests used for detecting albumin were heat and nitric acid, Heller's and Millard's. Most authorities agree upon the fact that the bromides act but little, or not at ail, upon the renal epithelium as an irritant. Although it is well known to produce stom- achic disturbances and indigestion, acting in this way as a simple mechanical irritant, yet in its passage through the circulation, to be thrown off by the kidneys, its power 11 should be considerably modified Occa- sional cases of acute suppression have been reported, but no satisfactory explanation of the physiological action in these instances has been given. It is just possible that the opium had only begun to have its effects in this case at the time of finding the albumin, but it seems more probable that the bro- mide caused the albuminuria. Case IV.-B. Me., age 48, married female; intemperate in the use of alcohol, but has good family history. She has had epilepsy for past nineteen years. The attacks are fol- lowed by excitement lasting three or four days. When bromide only is given the seiz- ures are materially lessened at first, but in a few months they return to their former fre- quency and severity. In consequence of these severe and frequent periods of mani- acal excitement she has become quite de- mented. The opium affected her unfavor- ably. Her seizures, which at no time were very frequent, but were quite severe, now also increased in number. She was violent and abusive in language at all times, and entertained well-marked delusions of perse- cution. After taking the opium for three or four days an acute attack of gastric indigestion and stomachic vertigo supervened, but on being placed in bed these disagreeable symptoms disappeared on the second day. In what degree these disagreeable condi- tions owed their origin to opium, and how far her delusions gave the initiative to them, it is impossble to state. That the latter came in for no small share of the causation the writer has no doubt, inasmuch as she began 12 the treatment with a decided prejudice against the efficacy of the "pills to cure her fits." As she had been taken away from the hospital before by friends for a short visit, her treatment was discontinued by their so- licitation, and she again returned home. At present she has been absent for nearly eight months, during which time nothing has been heard from her, and, therefore, the observations on her case under the new treatment are necessarily imperfect.5 Case V.-N. P., single female, age 47, no hereditary history of neurotic character found. On her twelfth birthday she had her first epileptic fit, since which time she has continued to have attacks at shorter or longer intervals. The mental evolution of the patient was put at an end by the seiz- ures, and the psychical development which she had acquired at that age has gradually but continually undergone devolution, until at the present time she is in a condition of stuporous dementia. Bromide has been given in the Brown- Sequard mixture, and also alone; but at all times it has affected her unfavorably, both physically and mentally. The action of bro- mide rendered her so stupid that even vege- tative life could not obtain without serious physical impairment. The seizures always come on very suddenly, without any warn- ing to any one, not even to herself. These result in her falling on her face and bruis- ing it severely. Her countenance bears but little resemblance to that of a human physi- "Since reporting this case, the patient has re- turned to the hospital. The friends report that the fits have been about as frequent and severe as ever. 13 ognomy because of these numerous falls and their resultant injuries. It was thought that opium might modify her attacks somewhat, and she was there- fore included in the number for trial treat- ment. In the table it will be seen that she never was under bromide for so long a pe- riod as four months, and, consequently, the relative action of bromide alone and that of opium and bromide is not known in hei case. The opium had but little or no power over her seizures and its attendant insanity. Case VI.-J. L., 27 years old, male, single, no occupation. Family history very poor. His uncle was insane, and his brother died from convulsions in infancy. His attacks have played a prominent part in his daily life for the past twenty years. He has been insane for ten years. His seizures are im- mediate and sudden in their onset; patient generally falls on his face in the most vio- lent manner, bruising himself severely. He received no benefit from the opium treatment whatsoever. His epilepsy had probably become so permanently a part of his functional activity that nothing could be of benefit in preventing these periodical motor discharges along such well-worn nervous paths. Case VII.-J. C., male, single, no occu- pation. He is said to have had epileptic at- tacks for twenty-two years. The causation was probably hemiplegia. He had an insane uncle. His hemiplegia, which affected the left side, and from which he has recovered somewhat, occurred in infancy. His leg and his arm, especially the latter, are undevel- oped and atrophied. The facial muscles and 14 tongue are also involved. The patient has subjective sensations of heat and cold on the surface of the left side, and these are particularly annoying directly after the seiz- ures. The aura connected with the seizures is a combined one of vision and olfaction. It begins by his seeing yellow, blue, and black streaks in the air. The yellow and blue gradually blend and gyrate until they change into a dark brown or black, at which time they join with the black streak. After the blending is complete, they all make fig- ure-of-eight movements. Many times the changes in the aura will proceed no farther than the blending of the blue and yellow, especially when taking bromide or after opium-bromide treatment. At all times the visual aura is followed by a smell of smoke. When the patient was taking the bromide following the opium treatment it was found that he required just 30 grains of bromide to dam back his seizures. If it was less- ened 5 grains for two or three days he would complain of the woodwork chan- ging to the blue, yellow, and black colors. This sensation would also be attended by a feeling of constriction of the scalp, dizziness, and nausea. While under the opium treat- ment he always expressed himself as feeling well, although during the seventeen days in which he took the opium he had ten fits, more than he ever had before in the same length of time. After starting on the bro- mide he had very few convulsions, and out of the whole number of cases reported he alone gave unmistakable signs of mental and physical improvement under the opium- bromide treatment. It is a well-recognized 15 fact that bromide alone has but little effect in the treatment of insane epileptics whose attacks are nocturnal, and in most of these cases in which benefit was obtained the fits were diurnal. Case VIII.-T. B., 36, male, single, hat- ter by trade. About fourteen years ago, after a "severe injury to spine and head," he be- gan having epileptic seizures, which in- creased in severity until he became mani- acal and difficult of control, and, finally, was brought to the hospital in 1890. His seiz- ures, which at first were generally nocturnal are now mostly diurnal. On admission, physical examination revealed no injury to spine or head save a slight scalp wound, which patient states was received in a bar- room fight long before his epilepsy began. It was necessary to give bromide in such large doses before his seizures could be con- trolled at all that the patient's health materi- ally suffered and the treatment was finally discontinued. He was placed on opium treatment July 1, 1894. His former dull and stupid condition has now reached that of al- most complete dementia, yet his seizures have been lessened nearly one-half of their former frequency and violence by the new treatment. He is at present much reduced in bodily health, which does not seem to be so much on account of the opium treatment as to his delusions and steady refusal to eat. Whether the apparent improvement in his case will continue any longer than that due to the other forms of treatment, which have been beneficial for a time, it is impossible to state.6 " e This case has been removed from hospital, and is suffering from phthisis pulmonalis. 16 Case IX.-T. W., 39, male, single, com- mon laborer. He had epilepsy for twenty years prior to admission to the hospital. Has been insane for nine years. His friends un- consciously gave a history pointing strongly to the idea of his early mental weakness. He is considerably demented at present and hardly understands the very simplest lan guage addressed to him. The new treatment did not modify or change his condition to any appreciable ex- tent. The attendant writes the following note in the wardbook while he was under the opium treatment: "Patient enjoys the drowsy feelings produced by such large doses of opium." Case X.-E. D., aged 36, male, single, ad- mitted to the hospital in 1890. Never had an occupation, as his epilepsy began when he was 19 years old. This case gives an un- doubted family history of degeneracy, al- though friends state it to be due to an unus- ually severe attack of rubeola, which oc- curred in early infancy. His seizures gen- erally take place at night, the ratio of the night attacks to those during the day being 100 to 3. These are all followed by profound de- pression, lasting many times for hours. In the interim he is extremely irritable and de- structive. The aura connected with his epi- lepsy he describes as a fine threadlike silk starting from the epigastrium and graduallv rising until it reaches a point about the level of the third rib, when he feels a sud- den and rapid accumulation of saliva in the mouth. While this salivation may be a spe- cial feature of the aura, yet its significance 17 may be modified by the fact that he has for years habitually allowed more or less saliva to collect in his mouth and throat. When- ever he replies to a question his speech has a bubbling sound as if coming through water. Some of these severe seizures come on very suddenly, the aura lasting only for a few seconds, followed by severe convulsions and loss of consciousness. This latter con- dition of unconsciousness is quickly recov- ered from only to be lost many times in three or four minutes. This aura of saliva- tion, or "attacks of water brash," as he terms it, sometimes takes the place entirely of the seizures, or the fit is aborted at the comple- tion of the aura. This feature remains the only thing for many days to tell of his epilepsy. As in the other cases of nocturnal epilepsy, bromide had in this one failed to be of much benefit to the patient. He has had 413 seizures during the year, 398 by night, and 13 by day. For the first few months he appeared to gain under the new treatment, but eventually came back to his old number of seizures per month. What power in controlling the fits the bromide possessed after the administration of opium was entirely lost after the first five months. The patient is as active as ever, and is cheerful and companionable to those about him in the ward, in marked contrast to his former condition of irritability. The saliva which he emitted during one of his seizures was carefully examined, but proved to be of the same composition as normal salivary secretions. Many authorities speak of the conspicuous role which the salivary secretions take in an epileptic attack, but 18 Female Cases. No. of Seizures under No Bromide for 4 mos. 4 mos. of Bromide only. 17 days of Opium only. 123 days or 4 mos. Bromide only, directly after Opium. 140 days 4 mos. of Bromide following Opium, inclusive of 17 days of Opium. 4 mos. of Opium and Bromide, July 1st to Nov. 1st. Last 4 mos. of Opium- Bromide Treatment. S' a .bfi z Q S' Q X 0 p S' Q .bp Z O H S' Q .bp K *3 0 H $ a * 3 0 H 5 ,b£ Z 3 0 B. McDf.... e.f 3 21 24 11 14 6 6 3 57 22 9 27 27 68 36 0 6 12 0 3 3 2 7 3 9 14 7 0 1 2 4 2 0 4 3 1 0 5 5 i5 3 I 8 6 1 11 2 II 4 40 16 3 19 TO 41 27 11 9 8 5 13 2 15 7 5» 17 13 24 X5 56 30 1 7 5 1 IO 2 9 4 F 13 3 16 9 38 23 26 19 19 24 L. K N. S N.P Total.. 73 94 167 18 15 33 9 19 28 27 73 IOO 46 92 138 24 65 89 88 Table No. 1. Showing the Number of Seizures under Bromide, No Bromide, and Opium-Bromide. t B. McD. Discharged after 56 days. 19 Male Cases. No. of Seiz- ures for 4 mos. under No Bromide. 4 mos. of Bromide only. 17 days of Opium only. 123 Days of Bromide only directly after Opium. 4 mos. of Opium and Bromide Treatment. 140 days of Opium and Bromide Treatment. No. of Seizures in 3 Yrs- Average or Series of 4 mos. for 3 yrs. (9 in all). Nov. 1/94, to Meh. 1, '95. Last 4 mos. D. N. Tot D. N. Tot n. N. Tot D. N. Tot D. N. Tot D. N. Tot D.& N. J. L 21 36 57 13 22 35 2 6 8 9 27 36 II 33 44 11 33 44 376 41.8 82 J. C. .. 4° 2& bb 15 14 29 8 2 IO 2 I 3 IO 3 13 IO 3 13 461 51.2 O T. B 5° 20 70 3° 11 41 7 1 8 5 5 IO 12 7 19 12 6 18 382 42.4 I E. S i 127 128 15 7 22 4 9 13 11 25 36 15 34 49 15 34 49 800 88.8 204 T. W 48 28 76 IO 0 IO 3 9 12 II 1 12 >4 10 24 >4 IO 24 480 53-3 5 Total 160 237 397 83 54 >37 24 27 5> 38 '59 97 62 86 148 62 86 148 2499 277-5 302 Table No. 2. Showing the Number of Seizures under Bromide, No Bromide, and Opium-Bromide. 20 July ist, 1894. ist. 2d. 3d- 4th. 5th. 6th. 7th. 8th. 9th. 10th. nth. 12th. 13th. 14th. 15th. 16th. 17th. D. N D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. D. N. J.c 0 0 O 0 O O O 0 O 0 O O O 0 O O O O I 0 I O I I O O I O 2 O I 0 I I Table No. 3. Record of Seizures for the 17 Days under Opium. Total 10 ; 8 by day, and 2 by night. 21 few have recorded instances where the ex- pulsion of saliva plays so important a part as to entirely take the place of the seizure. Examination of the urine in all cases proved nothing of interest or importance in the treatment, save the case above men- tioned of acute Bright's. After a careful survey of the treatment in all the cases, one is forced to the conclusion that the opium plan is a little less of value in the epileptic insane than the simple bromide treatment. The three cases of J. C., E. D., and J. B., in which improvement was noticeable, were the ones least expected to be benefited at the outset. The first was a hemiplegic; the second, one of undoubted hereditary neurotic his- tory; while the third presented more men- tal peculiarities due to his insanity than to the primary disease of epilepsy. Therefore, no law seems deducible whereby we may be able to gauge its applications in the epileptic insane or to predict its beneficial use with any degree of certainty. Notwith- standing this, we should always bear in mind that the treatment of epilepsy is as various as the disease is variable in its many forms and phases, the nature of which we are only just beginning to know. That this treatment by opium gives us no hard and fast lines for its use is only what might be expected when we take into account that most other forms of treatment in this grave disease are used empirically. Tn this plan of opium treatment, as in the many others which have gone before it, the primary rapid improvement found in some cases deceives many whose encouraged 22 thoughts should be held in abeyance lest they be ultimately disappointed in such plans of treatment, and rush to the other ex- treme to denounce its utter failure. Although epilepsy is a disease of mental degeneration, yet that fact seems to have but little influence on the good bodily con- dition that epileptics generally possess. Even when the seizures are very severe and frequent, as in E. S.'s case, they enjoy ex- ceptionally good health, and only when medication sets up some irritation of the alimentary tract do they have any loss of appetite; perhaps in such cases the abnor- mal functional activity of the muscular sys- tem aids in keeping them in good physical health, notwithstanding that such muscular movement appears to be extreme and exces- sive. All the trial cases had their diet regulated as regards vegetables and meats, which seemed to have but little effect on their seizures. Their stomachic and intestinal digestion has been carefully looked into, but with the same futile results as were had from the diet regulation. In such cases, where the chronicity has become permanent- ly established, the question presents itself: Which shall we accept, the periodical out- burst of violent nervous discharge leading slowly down that broad pathway to de- mentia, or shall we meet this tendency to discharge on the part of the higher nervous centers by stronger and still stronger re- sistance? The pursuance of this latter idea, it seems to the writer, must inevitably ,hasten them on that downward path from which there 23 will be no possible return. In other words, shall we give drugs in these chronic insane epileptics? In conclusion, therefore, it would seem that in the report of these few selected cases among the chronic insane epileptic, the in- ference to be drawn is that the results ob- tainable from the opium treatment do not justify its use, except in those cases where the other forms of treatment have been tried and found to be entirely inefficient. At least, the writer sees no reason why in theory or practical observation this plan of treatment should be exalted above the many other plans of drug giving. For obvious reasons it can be seen that as the result of the trial was unsatisfac- tory a further delayed report would not be more favorable. It would, indeed, probably militate still further against its efficacy. The writer cannot but think that if previous re- ports of its success on sane epileptics had been withheld for a longer period, they, too, would have been less hopeful. In closing, I wish to express my sincere thanks to Drs. Keniston and Stanlely for their kind assist- ance in preparing the tables presented with these cases. Middletown, Conn. 24 EIGHTH YEAR. American Med ico=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the ist and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N.Y. $3.00 per year. • The BULLETIN is the only journal that publishes regularly complete reports of all the meetings of the New York Academy of Medicine and its ten Special Sections. The BULLETIN is also the Official Organ of the Sections on Orthopedic Surgery, and on Laryngology and Rhinology. WILLIAM HENRY PORTER, M.D., Chief Editor. WILLIAM C. GUTH, M.D., Pathology and General Medicine. SAMUEL LLOYD, M.D., Surgery. ADOLPH ZF.H, M.D., Pathology and General Medicine. GEORGE G. VAN SCHAICK, M.D., Pathology and Clinical Medicine. W. TRAVIS GIBB, M.D., Gynecology. WILLIAM OLIVER MOORE, M.D., Ophthalmology and Otology. ADOLPH BARON, M.D., Diseases of Children. WILLIAM VISSMAN, M.D., Pathology and Bacteriology. T. HALSTED MYERS, M.D., Orthopedic Surgery. GEORGE THOM AS JACKSON, M.D., Dermatology, WILLIAM B. COLEY, M.D., Genera] Surgery. JAMES E. NEWCOMB, M.D., Laryngology. GEORGE K. SWINBURNE, M.D., Genito-Urinaty Surgery. HENRY T. BROOKS, M.D., Bacteriology. JOHN WINTERS BRANNAN, M.D., Neurology and Psychiatry. IRA VAN GIESON. M.D., Pathology of Nervous System. Editorial Staff. FREDERICK PETERSON, M.D., Associate Editor. T.S.SOUTHWORTH, M.D., Obstetrics, Gynecology, Pediatrics. WILLIAM FANKHAUSER, M.D., Materia Medica and Therapeutics. LEWIS A. CONNER, M.D., Neurology. ALBERT WARREN FERRIS, M.D., Neurology. PEARCE BAILEY, M.D., Neurology. MORTON R. PECK, M.D., Neurology. LOUIS HF.ITZMANN, M.D., General Medicine and Paihology. DANIEL B. HARDENBERGH, M.D., Obstetrics and Gynecology. OT TO H. SCHULTZE, M.D., Obstetrics and Gynecology. JOHN HOCH, ALD., General Medicine. HOWELL T. PERSHING, M.D., Neurology. THOMAS PECK PROUT, M.D., Psychiatry. B. FARQUHAR CURTIS, M.D., Surgery. CHARLES HENRY WALKER, M.D., General Medicine. ALBERT H. ELY, M.D., Gynecology. GEORGE G. WARD, M.D., Obstetrics. WALTER A. DUNCKEL, M.D., Diseases of Children.