Death, Dying, and Bereavement: Contemporary Perspectives, Institutions, and Practices 1st Edition, (Ebook PDF

Death, Dying, and Bereavement:
Contemporary Perspectives,
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Judith M. Stillion
Thomas Attig
Editors
Death, Dying,
and Bereavement
Contemporary Perspectives,
Institutions, and Practices
CONTENTS
Prefaceâ•…â•…xvii
Introduction: Chronology of Developments in the Movement
Thomas Attigâ•…â•… xix
Share Death, Dying, and Bereavements: Contemporary Perspectives,
Institutions, and Practices
PART I: INTELLECTUAL DEVELOPMENTS
1. Seeking Wisdom About Mortality, Dying, and Bereavementâ•…â•… 1
Thomas Attig
Personal Historyâ•…â•… 1
Philosophy as Love of Wisdomâ•…â•… 2
Existential Phenomenologyâ•…â•… 3
Facing Personal Mortalityâ•…â•… 4
Living While Dyingâ•…â•… 7
Bereavement and Grievingâ•…â•… 10
Looking to the Futureâ•…â•… 13
Referencesâ•…â•…14
2. Know Thyself: Psychology’s Contributions to Thanatologyâ•…â•… 17
Judith M. Stillion
My Entry Into the Fieldâ•…â•… 17
Early Psychologyâ•…â•… 18
The Psychoanalytic Movementâ•…â•… 18
Humanistic/Existential Psychologyâ•…â•… 21
Cognitive Psychology and Cognitive Behaviorismâ•…â•… 22
Positive Psychologyâ•…â•… 24
Eclectic Thinkersâ•…â•… 26
Facing the Futureâ•…â•… 27
3. Sociological Perspectives on Death, Dying, and Bereavementâ•…â•… 31
Tony Walter
What Draws a Sociologist to Study Death?â•…â•… 31
Foundationsâ•…â•…32
Current Themesâ•…â•… 35
Contemporary Challengesâ•…â•… 39
4. Science and Practice: Contributions of Nurses to End-of-Life
and Palliative Careâ•…â•… 45
Diana J. Wilkie and Inge B. Corless
vii
viii Contents
Palliative and End-of-Life Care Journeysâ•…â•… 45

Uncovering and Combating the Conspiracy of Silence About
Death and Dyingâ•…â•… 47
Making Meaning: Living With the Chronicity of Life-Threatening
Illnessesâ•…â•…48
Promoting Team-Based Collaborative Approaches to Careâ•…â•… 50
Managing Pain and Symptoms of Children and Adultsâ•…â•… 51
Integrating Bereavement Within Patient-Centered
and Family-Focused Dying Careâ•…â•… 52
Conducting Research With People at the End of Lifeâ•…â•… 53
Educating Nurses to Improve Care of People at the End of Lifeâ•…â•… 53
Summary: Impact of Nurses on Palliative and End-of-Life Careâ•…â•… 54
5. Legal Issues in End-of-Life Decision Makingâ•…â•… 59
James L. Werth Jr.
Backgroundâ•…â•…59
1970s and 1980sâ•…â•… 60
1990sâ•…â•…62
2000sâ•…â•…68
2010–Presentâ•…â•…71
Conclusionâ•…â•…72
6. The Ethics of Caring for the Dying and the Bereavedâ•…â•… 75
Thomas Attig
My Involvement in End-of-Life Ethicsâ•…â•… 75
The History of Medical/Health Care Ethicsâ•…â•… 76
Respect for Personsâ•…â•… 80
The Turn to Narrative Ethicsâ•…â•… 82
Looking to the Futureâ•…â•… 87
7. Theoretical Perspectives on Loss and Griefâ•…â•… 91
J. William Worden
Sigmund Freudâ•…â•… 91
Erich Lindemannâ•…â•… 91
John Bowlbyâ•…â•… 92
Colin Parkesâ•…â•… 93
Elisabeth Kübler-Rossâ•…â•… 93
William Wordenâ•…â•… 93
Therese Randoâ•…â•… 95
Simon Rubinâ•…â•… 95
Thomas Attigâ•…â•… 95
Stroebe and Colleaguesâ•…â•… 96
Continuing Bondsâ•…â•… 96
Robert Neimeyer and Janice Nadeauâ•…â•… 97
The Elephant Needs a Pedicure: Similarities, Differences,
Directions for the Futureâ•…â•… 98
Contents ix
8. The Psychologization of Grief and Its Depictions Within Mainstream

North American Mediaâ•…â•… 105
Leeat Granek
Grief as a Psychological Object of Study in a
Modernist Contextâ•…â•… 106
The Pathologization/Psychologization of Griefâ•…â•… 107
Depictions of Pathological/Psychological Grief
in Mainstream Mediaâ•…â•… 110
Discussionâ•…â•…116
Looking Aheadâ•…â•… 117
9. Developmental Perspectives on Death and Dying,
and Maturational Lossesâ•…â•… 121
Judith L. M. McCoyd and Carolyn A. Walter
Our Storiesâ•…â•… 121
Our Developmental Perspectiveâ•…â•… 122
Perinatal Period and Infancyâ•…â•… 123
Toddlerhood Through Preschool-Aged Childrenâ•…â•… 124
Elementary School-Aged Childrenâ•…â•… 125
Tweens and Teensâ•…â•… 126
Young Adultsâ•…â•… 127
Middle Adulthoodâ•…â•… 128
Retirement/Reinventionâ•…â•…129
Older Adultsâ•…â•… 130
New Directions and Developmentsâ•…â•… 131
PART II: INSTITUTIONAL DEVELOPMENTS

10. Hospice Care of the Dyingâ•…â•… 135
David Clark
Attractions of Hospiceâ•…â•… 135
Foundational Strands of Early Developmentâ•…â•… 136
Hospice Care Today: Evaluation and Controversyâ•…â•… 142
Challenges and Hopes for the Future of Hospice Care
for the Dyingâ•…â•… 148
11. Hospital-Based Palliative Careâ•…â•… 151
Bernard J. Lapointe and Dawn Allen
Where We Began and How We Have Changed—A Brief History
of Hospital-based Palliative Careâ•…â•… 153
Cornerstones and Foundations of Hospital-Based
Palliative Careâ•…â•… 157
Current Challenges in Hospital-Based Palliative Careâ•…â•… 159
Looking Ahead: Protecting the Future of Hospital-Based
Palliative Careâ•…â•… 161
x Contents
12. Palliative Care for Childrenâ•…â•… 165

Betty Davies
My Entry Into the Fieldâ•…â•… 165
Early Work in the Fieldâ•…â•… 166
The 1970s and 1980sâ•…â•… 167
The 1990sâ•…â•… 169
Definition of Pediatric Palliative Careâ•…â•… 170
Current Developments in PPC (2000–the Present)â•…â•… 172
Challengesâ•…â•…175
13. The Global Spread of Hospice and Palliative Careâ•…â•… 181
Stephen Connor
Personal Reflectionâ•…â•… 181
Foundational Work on the Global Development of Palliative Careâ•…â•… 182
Current Work on Development of Palliative Careâ•…â•… 185
Challenges and Hopes for the Futureâ•…â•… 189
14. Death and Funeral Serviceâ•…â•… 193
Vanderlyn R. Pine
Historical Antecedents to Post–World War II Funeral Directingâ•…â•… 194
The Changing Role of Funeral Directors Following World War IIâ•…â•… 195
Scholarship About Funerals, Death, Grief, and Bereavementâ•…â•… 196
Research Focused on Funeral Directingâ•…â•… 198
Criticism of Funeral Directors and Funeral Practicesâ•…â•… 202
The Impact of the Baby Boom on the Funeral Industryâ•…â•… 203
The Futureâ•…â•… 204
15. Death Education at the College and University Level
in North Americaâ•…â•… 207
Charles A. Corr
My Involvement in This Fieldâ•…â•… 207
Early Initiativesâ•…â•… 209
Early Pedagogical Resourcesâ•…â•… 210
More Recent Developments: Survey Courses on Death, Dying,
and Bereavementâ•…â•… 211
More Recent Developments: Other Death-Related Coursesâ•…â•… 214
More Recent Developments: Thanatology Programsâ•…â•… 215
What Have We Learned From and About Death Education?â•…â•… 216
16. Death Education as a Public Health Issueâ•…â•… 221
Allan Kellehear
The Case for Death Education as a Public Health Issueâ•…â•… 222
Two Current International Examplesâ•…â•… 228
Future Challengesâ•…â•… 230
Contents xi
PART III: PRACTICE DEVELOPMENTS

17. Spirituality: Quo Vadis?â•…â•…233
Kenneth J. Doka
Religion, Spirituality, Health, and Griefâ•…â•… 234
Spiritual Tasks in Life-Threatening Illnessâ•…â•… 235
Spirituality and Grief: After the Deathâ•…â•… 237
Assisting Individuals and Families at the End of Life:
Using Spiritualityâ•…â•… 237
The Power and Use of Ritualsâ•…â•… 239
The Challenge of Spiritual Supportâ•…â•… 241
Quo Vadisâ•…â•…242
18. Using the Arts and Humanities With the Dying, Bereaved, . . .
and Ourselvesâ•…â•… 245
Sandra Bertman
Where and How It All Beganâ•…â•… 245
The Equinox Institute (1969–1971)â•…â•… 247
Failproof Techniques for All Agesâ•…â•… 248
Fast Forward: From Dissection to Palliative Care—Soul Pain,
Aesthetic Distance, and the Training of Physiciansâ•…â•… 251
Changing Ideas About Health Careâ•…â•… 254
Where We Are Goingâ•…â•… 257
19. Family Support for the Dying and Bereavedâ•…â•… 261
David W. Kissane
The Development of Family-Centered Careâ•…â•… 261
The Foundations of Family-Centered Careâ•…â•… 263
Clinical Organization of Family-Centered Care Todayâ•…â•… 265
Challenges for the Future of Family-Centered Careâ•…â•… 268
20. Supporting Grieving Childrenâ•…â•… 275
Linda Goldman
My Early Years in the Fieldâ•…â•… 275
Children’s Concepts of Deathâ•…â•… 276
Resources for Childrenâ•…â•… 278
Children’s Grief and the Digital Ageâ•…â•… 280
Grief Work With Childrenâ•…â•… 282
Grief Education for Adultsâ•…â•… 284
Basic Understandings for Adultsâ•…â•… 285
Joining as a Global Grief Community for Childrenâ•…â•… 289
21. Helping Each Other: Building Communityâ•…â•… 293
Phyllis R. Silverman
Backgroundâ•…â•…293
The Widow-to-Widow Programâ•…â•… 295
xii Contents
Widows Who Accepted Helpâ•…â•… 296

Widows Who Refused Helpâ•…â•… 297
The Widowed Service Lineâ•…â•… 298
Other Programsâ•…â•… 298
A View of Griefâ•…â•… 299
Mutual Helpâ•…â•… 300
Current Programs and Practicesâ•…â•… 302
22. Treating Complicated Bereavement: The Development
of Grief Therapyâ•…â•… 307
Robert A. Neimeyer
A Backward Glanceâ•…â•… 307
The Contemporary Landscape of Lossâ•…â•… 309
A Scientific Codaâ•…â•… 316
Notesâ•…â•…317
23. When Trauma and Loss Collide: The Evolution of Intervention
for Traumatic Bereavementâ•…â•… 321
Therese A. Rando
Definitions and Conceptual Clarificationsâ•…â•… 323
From Two Disparate Areas to One: Pivotal Steps in the Development
of Traumatic Bereavementâ•…â•… 324
The “Classics” in the Field: Six Foundational Concepts Associated
With the Treatment of Traumatic Bereavement up to 2000â•…â•… 327
Someday to Be “Classics” in the Field: Five of the Newest, Most
Valuable Areas of Contribution to the Treatment of Traumatic
Bereavement Since 2000â•…â•… 328
Future Concerns Regarding Traumatic Bereavement
and Its Treatmentâ•…â•… 330
24. To Be or Not to Be: Suicide Then and Nowâ•…â•… 335
Judith M. Stillion
A Little Historyâ•…â•… 335
Dimensions of the Problemâ•…â•… 337
Myths About Suicideâ•…â•… 338
Understanding and Preventing Suicideâ•…â•… 338
Patterns of Suicideâ•…â•… 341
Suicide Preventionâ•…â•… 342
Society’s Role in Suicide Preventionâ•…â•… 344
Interventionâ•…â•…345
A Look Aheadâ•…â•… 346
25. Grief After Suicide: The Evolution of Suicide Postventionâ•…â•… 349
John R. Jordan
Personal Evolutionâ•…â•… 349
Evolution of the Response to a Public Health Problemâ•…â•… 350
Interventions for Survivors—Historyâ•…â•… 351
Contents xiii
Interventions for Survivors—Current Standingâ•…â•… 352

Interventions for Survivors—Future Directionsâ•…â•… 357
Notesâ•…â•…359
26. Responding to Grief and Trauma in the Aftermath of Disasterâ•…â•… 363
Colin Murray Parkes
Preparation for Disastersâ•…â•… 366
The Impact Phase—Psychological First Aidâ•…â•… 367
Recoil—Planning and Implementation—Posttraumatic Reactionsâ•…â•… 370
Aftermath—Community Care and Recoveryâ•…â•… 373
Recovery—Withdrawal of External Servicesâ•…â•… 374
Implications for Future Developmentsâ•…â•… 376
27. Care of the Caregiver: Professionals and Family Membersâ•…â•… 379
Mary L. S. Vachon
Professional Historyâ•…â•… 379
Overviewâ•…â•…380
Stress and Distressâ•…â•… 380
Burnout and Job Engagementâ•…â•… 382
Compassion Fatigue, Empathy, and Compassion Satisfactionâ•…â•… 383
What Are Caregivers Already Doing That Works?â•…â•… 383
Current Interventionsâ•…â•… 386
Major Challenges and Hopes for the Futureâ•…â•… 390
Afterwordâ•…â•…395
Judith M. Stillion and Thomas Attig
Indexâ•…â•…399
CONTRIBUTORS
Dawn Allen, PhD, Associate Director, Palliative Care McGill, McGill University,
Montreal, Quebec, Canada
Thomas Attig, PhD, Professor Emeritus, Department of Philosophy,

Bowling Green State University, Bowling Green, Ohio
Sandra Bertman, PhD, Distinguished Professor (retired), Thanatology and Arts,

National Center for Death Education, Newton, Massachusetts; Good Shepherd
Community Care Hospice & Institute, Newton, Massachusetts
David Clark, PhD, Professor of Medical Sociology, School of Interdisciplinary

Studies, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
Stephen Connor, PhD, International Palliative Care Consultant, Open Society

Foundations, New York, New York; Senior Fellow, Worldwide Hospice Palliative
Care Alliance, London, England; Senior Research Fellow, Capital Caring,
Washington, DC
Inge B. Corless, PhD, RN, FAAN, Professor, MGH Institute of Health

Professions, School of Nursing, Boston, Massachusetts
Charles A. Corr, PhD, Member, Board of Directors, Suncoast Hospice Institute,

Clearwater, Florida
Betty Davies, RN, CT, PhD, FAAN, Professor Emerita, Family Health Care
Nursing, University of California San Francisco, San Francisco, California;
Adjunct Professor and Senior Scholar, School of Nursing, University of Victoria,
Victoria, British Columbia
Kenneth J. Doka, PhD, Professor, The Graduate School, The College of New
Rochelle, New Rochelle, New York; Senior Consultant, The Hospice Foundation
of America, Washington, DC
Linda Goldman, MS, FT, LCPC, Adjunct Professor of Graduate Counseling,

School of Education, Johns Hopkins University, Baltimore, Maryland
Leeat Granek, PhD, Assistant Professor, Department of Public Health, Faculty

of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
John R. Jordan, PhD, Private Practice, Pawtucket, Rhode Island
Allan Kellehear, PhD, AcSS, Professor of Community Health, School of Health &
Education, Middlesex University, London, England
xv
xvi Contributors
David W. Kissane, MB, BS, MPM, MD, FRANZCP, FAChPM, Professor

of Psychiatry and Head of Discipline, Chairman, Department of Psychiatry,
Monash University and Monash Medical Centre, Victoria, Australia; Professor of
Psychiatry, Weill Cornell Medical College and Memorial Sloan-Kettering Cancer
Center, New York, New York
Bernard J. Lapointe, MD, Eric M. Flanders Chair in Palliative Medicine, Director,

Palliative Care McGill, McGill University, Montreal, Quebec, Canada
Judith L. M. McCoyd, PhD, LCSW (PA), QCSW, Associate Professor, Rutgers

University School of Social Work, Camden and New Brunswick, New Jersey
Robert A. Neimeyer, PhD, Professor of Psychology, Department of Psychology,

University of Memphis, Memphis, Tennessee
Colin Murray Parkes, OBE, MD, FRCPsych, DL, Consultant Psychiatrist

Emeritus, St Christopher’s Hospice, Sydenham, London, England
Vanderlyn R. Pine, PhD, Professor Emeritus, Department of Sociology, State

University of New York at New Paltz, New Paltz, New York
Therese A. Rando, PhD, BCETS, BCBT, Clinical Director, The Institute for the
Study and Treatment of Loss, Warwick, Rhode Island
Phyllis R. Silverman, PhD, Resident Scholar, Women’s Studies Research Center,

Brandeis University, Waltham, Massachusetts
Judith M. Stillion, PhD, CT, Professor Emerita, Psychology, Stillion Consulting

Services, Ormond Beach, Florida
Mary L. S. Vachon, PhD, RN, Private Practice; Professor, Department of

Psychiatry and Dalla Lana School of Public Health, University of Toronto;
Clinical Consultant, Wellspring, Toronto, Canada
Carolyn A. Walter, PhD, LCSW, Professor Emerita, Center for Social Work
Education, Widener University, Chester, Pennsylvania
Tony Walter, PhD, Professor of Death Studies, Centre for Death & Society,
University of Bath, Bath, England
James L. Werth Jr., PhD, ABPP, Director, Behavioral Health and Wellness
Services, Stone Mountain Health Services, Pennington Gap, Virginia
Diana J. Wilkie, PhD, RN, FAAN, Professor, Harriet H. Werley Endowed Chair
for Nursing Research, and Director of the Center of Excellence for End-of-Life
Transition Research, Department of Biobehavioral Health Science, College of
Nursing, University of Illinois at Chicago, Chicago, Illinois
J. William Worden, PhD, ABPP, Clinical Psychologist, Harvard Medical School,

Massachusetts General Hospital, Boston, Massachusetts
PREFACE
The two of us met in 1979 at one of the early conferences sponsored by the then
newly formed Forum for Death Education and Counseling, each having already
devoted several years to work in the emerging contemporary death, dying, and
bereavement movement. It was so good to gather with others from such diverse
backgrounds in teaching, research, health care, counseling professions, and volun-
teer service. We were not alone in sensing the excitement of meeting others who were
passionate about learning from one another and about changing ways of under-
standing, living with, and caring for others facing death, dying, and bereavement.
We were privileged then, and have been in the years since, to learn from,
work with, and in many cases befriend pioneers and major contributors in the
field. Two years ago, while looking back at how remarkably far the movement has
come, we realized how many leading figures and friends have died. We saw an op-
portunity to capture the collective wisdom of living pioneers, major contributors,
and participant witnesses to the founding and evolution of the movement before
more voices were lost. We would bring those voices together in a book that would
be a testament to and celebration of the work of all those who have led us to where
we are today. We are excited to have gathered together an extraordinary team of
28 authors with nearly a millennium of experience in the field to tell stories that
only they can tell about unprecedented changes that have been unfolding since the
movement began in the middle of the 20th century. We are grateful that our editor
at Springer Publishing Company, Sheri W. Sussman, endorsed our idea enthusias-
tically and helped us so ably to bring it into reality. We are also so grateful for the
opportunity to work together again on this volume, work that has deepened both
our knowledge and friendship.
We asked all of our authors to describe what drew them into the field, dis-
cuss the most important strands of early development in the area of their chapters
that they consider to be foundational and not to be forgotten, review the most
Â�valuable current work in the area, and assess major challenges and hopes for Â�future
Â�developments. Although we hope that all will live long and continue to prosper,
we wanted to harvest the insights of these seminal figures before it Â�became too late
to do so.
We are amazed and enormously grateful for the foundational and revolu-
tionary efforts of the thought leaders, institutional innovators, imaginative practi-
tioners, and concerned citizens whose stories our authors tell. As their informative
and often provocative chapters came flooding in and we began the editorial review
and polishing process, we realized how collectively they were expanding our own
understanding and appreciation of how rich and varied the contributions of the
death, dying, and bereavement movement are. Taken together, we believe these
writers have created a unique and lasting contribution to the growing body of
work that is defining a new discipline: thanatology.
xvii
xviii Preface
We bring this book to you out of the following shared convictions. First, we
pay too high a price individually and collectively in missing what matters most
in life if we persistently turn away from and remain silent about the realities of
Â�mortality that are so intimately interwoven in the fabric of our being. Everyone can
benefit from development and dissemination of better understanding the mean-
ings of death, dying, and bereavement for individuals, families, and communities
and of their implications for how we live. We do well to counter tendencies to
isolate the dying and bereaved that increase their dependence on professionals.
We believe there is a deep human need to come together as family and community
while loved ones are dying, grieving, traumatized, or contemplating suicide to hear
their stories, bear witness to their suffering, and offer support and compassion. We
endorse efforts to reach past the limitations of disease-focused medical care and
Â�pathology-focused bereavement support to recognize and respond more effectively
to the multidimensional needs of whole persons living with disease and relearn-
ing the world in grief. We affirm and call for increased understanding and support
of the resilience and capacities for overcoming suffering and finding healing that
are inherent in the human spirit. We heartily support revival of the art of medi-
cine as at least coequal with the science and value team-based and Â�volunteer-based
Â�approaches to end-of-life care. We applaud resistance to Â�professional paternalism
in favor of informed consent; respect for human dignity; attunement through dia-
logue to the particularities of individual, family, and community experiences and
needs; and affirmation of their freedom to shape their own experiences. We seek
to enable families and communities to reclaim responsibilities for death education
and care and support of those who are dying, bereaved, traumatized, or suicidal.
We eagerly await the day when death education will be integrated into schooling
at all levels to prepare citizens for those responsibilities, for scholars to deepen their
understanding, and professional caregivers to use the best of what is known wisely.
We intend this book for all who have been interested or actively engaged in
the movement through the years, and especially for those relatively new to the
field as students or practitioners who share these convictions and passions and
will carry on, extend, and creatively transform the efforts discussed here. Our au-
thors trace the development of thanatology as an interdisciplinary field of study
(in Part I) and organizational and practice developments in response to the di-
verse needs of dying, bereaved, suicidal, and traumatized individuals, families,
and communities (in Parts II and III). A unique feature of this book is a detailed
chronology that includes many, though of course not all, of the most important
milestones of the last 60 years. It is intended to serve as an overview as well as
the foundation for understanding this burgeoning field and as a guide for readers
who wish to understand in detail its short, but rich, history.
Robert Kastenbaum often casually defined the emerging academic field of
thanatology as “the study of life with death left in.” Clearly, we have in this book
stretched beyond the study of death, dying, and bereavement to encompass insti-
tutional and practice developments in response to these universal human experi-
ences. Gandhi charged us to “be the change you want to see in the world.” The
pioneers and major contributors to the movement (including our authors) have
done that and in so doing crafted better, more humane ways to conceptualize and
cope with the many faces of death, dying, and bereavement in our times. We invite
you to join them and learn from them as we move forward together.
Judith M. Stillion and Thomas Attig

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all. We thus have light discharges and severe discharges at different times, or, as the habit is
established, only the light or only the severe, the manifestation depending probably upon the number of
discharging cells and the importance of the exciting cause.
31 Traité de l'Épilepsie, etc., Paris, 1845, p. 55 et seq.
When the attacks occur in alarming frequency, as they sometimes do, the condition is known as the
status epilepticus. Leuret had a patient who had eighty in two hours, and Delasiauve reports the case of
a young man fifteen years old who had twenty-five hundred in one month. They may be so numerous as
to be apparently continuous. The patient remains in a state of coma (the status epilepticus), with very
high temperature. If he be not restored, he sinks into a deeper coma, and all the signs of collapse
manifest themselves. Bed-sores form, œdema of the lungs ensues, and the patient dies. Happily, this
condition of affairs is rare.
Delasiauve calls attention to the fact that the first two or three attacks that usher in this state do not
usually attract much attention, but the succeeding ones are so violent as to immediately suggest violent
consequences. In one of my cases the attacks, when they had once become numerous, were readily
excited by the least jarring, noise, or handling, just as we find in strychnine-poisoning or tetanus.
Irregular Forms.—There are occasional cases of psychical or masked epilepsy, the study of which is
intensely interesting. Such forms are characterized by perverted consciousness and a low degree of
volitional direction which may vary from automatism to the undoubted exercise of complex functions of
the mind, though badly co-ordinated. Mesnet's soldier, when subject to a paroxysm and apparently
unconscious, would perform a number of suggested acts in a rhythmical manner and with no
subsequent knowledge of the previous event: when started off by the word of command to march, he
would blindly go on, marking time when he met with an obstruction until stopped, or when a paper and
tobacco were placed in his hands he would proceed to roll an unlimited number of cigarettes.
Two cases of a more complex exercise of certain intellectual powers, while others were dormant, came
under my observation some time ago. One of them was a young man of twenty-three, who had had
irregular epileptic seizures for some years. He went to bed one evening as usual, arose, and
breakfasted with his family without creating any suspicion that he was at all unwell. He then went down
to his place of business, and after his arrival was sent to a distant part of the city for some tool. On his
return down town he stopped at a tobacconist's and became involved in a quarrel with one of the
persons in the shop. A policeman was called, who, more intelligent than many of his class, immediately
detected something queer about the man, arrested him, and afterward took him to Bellevue Hospital.
There he remained three days, and suddenly returned to consciousness and a knowledge of his
surroundings, but was entirely ignorant of his unfortunate experience. It is unnecessary to say his habits
were perfectly good and he was not drunk at the time of the quarrel or arrest. His last recollection was
that of going to bed the night before the day of his arrest.
Another case of unusual interest which came under my care, illustrating a phase of sensory epilepsy, is
worthy of reproduction:
C. O——, aged twenty-two, is a reporter attached to one of the New York afternoon papers, who
received a severe injury of the head when but three years old. He fell from the second story of an
unfinished building to the cellar, striking the upper and back part of his head upon a beam. He was
rendered unconscious, and remained so for a day or more. He recovered from the immediate bad effect,
but has suffered from severe general headaches, which recur every week or so, with an increase in the
amount of urine excreted. About six months ago he began to have epileptic convulsions of a violent
character almost every day, and sometimes more often. These were precipitated by excitement, and he
had a great many when worried about his wife at the time of her delivery. Upon one occasion he fell
down stairs and injured himself quite severely. The attacks were, as a rule, preceded by an epigastric
aura of long duration, and occasionally by a visual aura, and, according to the testimony of his
associates, he became strange and queer. When in such a dazed condition he would restlessly wander
about his office, and suddenly, without any cry, become convulsed. After the attack he slept soundly.
The bromides of sodium and ammonium and digitalis did little or no good, but the bromide of nickel
appeared to have some influence. During the past month he has had only two or three attacks, but
these have been of a quite irregular character. He told me that there were times when he felt like doing
himself an injury, and that he had impulses to kill some one else. His companions said he was irritable,
pugnacious, and easily thwarted, and his brother-in-law stated that upon several occasions he had
queer turns, when he would raise his hand to strike some member of the family—that he subsequently
knew nothing of his conduct, and when it was detailed to him he appeared greatly astonished.
Mr. O—— came to my office in company with a friend at ten o'clock in the morning of December 27,
1883. He had had one of his attacks at the newspaper office, of rather more severe character than
usual, at eight o'clock, with a psychical aura, during the existence of which he was very morose and
sullen. Upon recovery he was speechless, though he could communicate by signs. Upon his arrival at
my office his manner was composed and he appeared somewhat dazed. His pupils were dilated, but
contracted readily to light. I asked him one or more questions regarding his inability to speak, which he
perfectly understood, and when I gave him a pencil and a piece of paper he replied without difficulty in
writing. When told to make a great effort to speak he did so, and I thought I detected the word ‘To day,’
but he could not repeat it, though he tried and expressed great annoyance. He was unable to utter any
sound except a sort of groan, which could not in any way be taken as an element of speech. I examined
his larynx, but found nothing which could explain his impaired phonation, and I sent him to Dr. Asch,
who found absolutely no abnormal appearances to account for the speech difficulty. The patient could
not phonate, and though he made attempts to enunciate the vowel-sounds, and the vocal cords were
approximated, he made no orderly sound. Asch found a slight laryngitis of no importance.
The patient went home, and remained speechless all day, and was seen by my associate, G. de Forrest
Smith, in the evening. What occurred during and after that gentleman's visit is contained in his notes: “I
was called to see patient about 8.15 P.M. He was lying upon the bed, but had not slept; recognized me
and motioned that he could not speak, and I found that he could only say one or two words, and this
with the greatest effort, and so all my questions were put so that he could answer them by nodding or
shaking his head. He knew that he had had an attack in the morning, that he had seen Hamilton and
Asch, and recalled various incidents of the day, answering intelligently my questions in regard to them.
He indicated by motions that his inability to speak was due to a lump in his throat. When asked if he had
any trouble to think of the word he wanted, he shook his head, but shortly afterward hesitated in an
answer, and when asked if this was due to his inability to think of the word, said ‘Yes.’ Was asked if he
had any loss of power in either side, and he motioned to his right arm and leg, and said that he felt a
numbness and pricking on that side. On his grasping my hands with his, the right was perceptibly
weaker.
“At one time he seemed confused as to which was his right or left side, and put up both hands, and after
looking at first one and then the other in a puzzled manner, at last decided correctly, then smiled
apparently at his confusion.
“All this time he had been half lying on the bed. He now intimated that he was tired, put his head down
on the pillow and began to belch up wind, and as he appeared about to vomit I called for a basin; but
this was only the beginning of an attack; the muscles of the neck and right side assumed a state of tonic
spasm, the extensors predominating, so that the head was turned a little to the left and forcibly thrust
back into the pillow, and the right arm and leg were firmly extended. He remained in this position about
one minute; then, taking two or three full inspirations, put his hand to his throat and said plainly,
‘Something has fallen from there.’ On being asked ‘What?’ he replied, ‘A bone has fallen from my
throat.’ I told him it was well that the bone had fallen, as now he could speak. ‘Why,’ said he, ‘I have had
no difficulty in talking.’ On being asked why he had seen Asch, he said ‘Who is Dr. Asch? I never saw
any such person.’ Further questioning showed that all the occurrences of the day (except those which
had taken place immediately before the first attack) were an absolute blank, and he thought it still
morning. He asked the time, and I told him half-past eight o'clock in the evening. At this he seemed
much surprised and said, ‘Why, I went to work this morning; how did I come here?’ I then explained to
him that he had been ill. After further conversation he said he felt sleepy, and, after resting a few
minutes, he arose, put on his slippers, and came out into the room. He walked with difficulty, because of
the loss of power in the right side, which he said felt numb and sore, as if it had been pounded, also a
sensation of pins and needles. After the attack his mind was perfectly clear, and he could talk as well as
ever, and all that had happened before the attack in the morning he could remember perfectly well, but
the interval between the two was a complete blank. His inability to speak seemed due, not to lack of
knowledge of what he wanted to say, but rather to want of power to form the words, although there was
no paralysis of the vocal muscles. When he did manage to say a word, it was invariably the correct one,
but it was always done with the greatest effort. The day after the attacks he remained at home; the next
day he went to work, but his head felt heavy and confused. Two days after he complained of a pressure
on the left side and back part of the head; otherwise he was all right. At this visit he said that after I had
left him on the night of the attacks he intently thought, striving to recall the incidents of the day, and after
a time concluded he could remember being at Thirty-third street, but did not know how he got there. He
thought he could recall going to see Asch, but would not know him if he should see him. I then asked
him how questions were answered by him on that day; he answered he did not know, as he had not
thought of that; then, after a few moments' reflection, said he must have written the answers. He was
then shown some of the answers he had written, which he recognized, and by an effort of memory could
recall some of the incidents of writing them. He was still unable to remember anything that occurred
after his arrival home previous to the last convulsion.”
January 27, 1885: This patient subsequently suffered from several attacks in which the psychical
element predominated. His head presented a remarkable deformity, there being a prominence
posteriorly which might be compared to a caput succedaneum, only it was entirely osseous. The upper
margin was separated from the anterior parts by a deep sulcus.
Under such circumstances we find very often that acts of great violence are committed by such
epileptics for which they are entirely irresponsible. Two or three cases of the kind occur to me now. One
of them was a boy who always bit every one and everything—his family, the domestic animals, and
inanimate objects; another, a most dignified and lady-like woman, who violently struck different
members of her family; and within the past week a woman was brought to me who hurled a kerosene
lamp at a perfect stranger with whom she was quietly talking before the seizure was precipitated.
Numerous instances are related where individuals while in the masked epileptic state have wandered
for long distances and committed a variety of purposeless acts, and undoubtedly many of the
mysterious disappearances are of this order.
SENSORY EPILEPSY.—Some years ago Hammond referred to certain peculiar epileptic attacks in which
sensory manifestations were very pronounced. To this condition he gave the name thalamic epilepsy,
believing the condition to be one of the optic thalamus. Among the large number of unclassified and
irregular cases reported by various authors there are many so much resembling each other that I think
they should be relegated to a special place.32 The notable examples of Sommers, Bergmann, Tagges,
Guislain, and others belong to this category.
32 I shortly afterward, believing the term a misnomer, invented that in use: “On Cortical Sensory Discharging Lesions or Sensory
Epilepsy,” New York Med. Journal and Obstetrical Review, June, 1882; also see “A Contribution to the Study of Several Unusual
Forms of Sensory Epilepsy which are probably Dependent upon Lesions of the Occipital Cortex,” New York Med. Record, April 4,
1885.
The features of this form of epilepsy are (1) the expression of some hallucination (prodromal stage), or
hemiopia; (2) supraorbital neuralgia; (3) aphasia, formication; (4) slight loss of consciousness, and little
if any motor disturbance.
I may present two illustrative cases:
A few months ago I was consulted by a medical gentleman in regard to a patient who had for years
presented a curious train of nervous symptoms, which afterward assumed a form leading me to think
she might have sensory epilepsy. She would, in the presence of the gentleman who consulted me, who
was a personal friend of the patient and a medical man, stop short in the midst of an animated
conversation, look fixedly ahead, appearing momentarily lost, remaining abstracted for a short period,
possibly a minute, and on recovering herself go on, finishing the sentence she had commenced before
the seizure. At this time she constantly had hallucinations of a visual character, when she saw animals,
birds, figures of men and women, who approached her, as well as a variety of other objects. A common
hallucination, which had been repeated quite frequently, consisted in visions in which green leaves and
white rabbits and other objects familiar to her in childhood figured extensively. Upon one occasion, while
sitting in the drawing-room, opposite a door which communicated with the hall, she suddenly called her
companion's attention to the hand of a man which she saw clasping the baluster rail. The hand was
seemingly disconnected from the arm. She was somewhat agitated, and it was nearly half a minute
before the vision was dismissed. Sometimes she would call attention to the hallucinations before the
attack, but more often she became transfixed, apparently lost, and then recovering she described her
visions minutely. She has apparently been able to foresee the attacks and ward them off by a strong
voluntary effort. So far as can be learned, there is no hysterical element in the case, but her seizures are
more frequent at the time of menstruation. In a private note it is stated that “the family history of the
patient is very good, and she has always seemed remarkably healthy and robust, and has shown more
than usual intellectual ability. She has appeared to persons generally to be of a contented, happy
disposition.... At night, when she closed her eyes, she suffered from these hallucinations, especially
after a day of fatigue. Her pupils are usually dilated, but her color undergoes no change during the
seizure.”
The second case is one of a more complex type:
J. B——, a bright boy aged sixteen, was sent to me by F. H. Bosworth in April, 1883. He comes of
nervous stock, his mother being subject to epilepsy, and his father is an eccentric man who manifests
his mental peculiarities chiefly in a morbid restlessness and irascibility. There is a brother who is healthy.
The attention of the parents was first called to the boy's condition by his recital of a sudden attack which
occurred during the summer of 1882. While rowing upon a river he suddenly and completely lost the
visual use of the right eye, so that in looking at a number of ducks swimming near his boat he failed to
perceive those upon one side of the flock. This condition lasted for twenty minutes, and after a brief and
severe pain over the right eye he became unconscious, the unconsciousness being preceded by a
tingling and numbness of the hand, forearm, arm, and left side of the tongue. He has subsequently had
eight or ten of these attacks, of which the following is an example: Usually without any bad feelings,
physical or mental, he, while engaged in any duty or at any time, suffers a sudden unilateral blindness.
This is never gradual, and not like the form of amblyopia in which the visual field is gradually reduced.
There is some hemichromatopsia. It would seem as if the retinal anæsthesia was unequal, for while
usually the loss is complete and universal, it sometimes happens that there is only a limited loss. Upon
one occasion, while reading, he suddenly lost the printed matter of the right lower half of the page below
a diagonal line extending from the right upper corner to the left lower corner. There is never diplopia.
This deprivation lasts anywhere from ten to twenty minutes; meanwhile, a distal anæsthesia, coming
very gradually, involves at first the fingers of the opposite hand, and successively extends to the
forearm, arm, and other parts, as I have already mentioned. There seems to be analgesia as well as
anæsthesia, for a pin may be run into the muscles without producing pain, and upon one occasion the
gum was freely pricked without any discomfort to the patient. It invariably happened that the cutaneous
sensory trouble occurred upon the side opposite to the hemianopsia and neuralgia, and in the greater
number of instances the left side was that affected. The third stage of the attack consists in migrainous
headache of a very severe kind, and which sometimes lasts for an hour or more. There is a subjective
feeling as if the eye was pushed forward. This disappears with nausea and relaxation. More often he
loses consciousness when the anæsthesia reaches its limit, which seems to be the extension of the
anæsthesia to the gums. Occasionally there are slight convulsive movements upon the anæsthetic side.
While the attacks involve the left side of the body as a rule, it happens that when there is primary left
hemianopsia and right-sided anæsthesia the boy becomes very much confused in speech, and
sometimes is paraphasic, the trouble being but transitory. He is sometimes unable to speak at all,
though perfectly conscious and in possession of his faculties. No pupillary disturbance has been noticed
at any time. Upon two occasions there was a swelling of gums and tongue, which was not only
subjective, but perceived by the mother. Occasionally he sees prismatic colors and rays before the
blindness, but this has been only once or twice. During his early life he had attacks of slight numbness
of the hands and feet which were not thought much of, and he had headache as well. He has been a
somnambulist.
MORBID ANATOMY AND PATHOLOGY.—The literature of the experimental physiology of epilepsy is enriched
by the observations of a variety of careful students, among them Sir Astley Cooper, Kussmaul and
Tenner, Brown-Séquard, Nothnagel, Schroeder Van der Kolk, Pitres, Hughlings-Jackson, and the
followers of the localization school, as well as many others more or less distinguished.
The experiments of many of the early writers were directed for the purpose of ascertaining the relations
of circulatory variations to convulsive seizures, and the most notable were those of Burrows and
Kussmaul and Tenner. These latter produced compression of the carotid arteries, and instituted cerebral
anæmia by free and exhausting hemorrhages. As a consequence, the emptying of the cerebral vessels
was followed by a loss of consciousness and by epileptiform convulsions, and it was necessary to
produce the same result to compress all the great afferent vessels of the brain. The experience of
surgeons generally is, that ligation of the common carotid upon one side of the neck is sometimes very
apt to produce an alarming anæmia, with occasional convulsions, and sometimes fatal consequences.
The experiments of Hall, Landois, Hermann, and others, as well as those of the writers just mentioned,
show that carotid compression results in capilliary anæmia and venous hyperæmia, and that with
cessation of this pressure there is a sudden congestion of all vessels. The susceptibility of the brain is
greatest at its posterior part and between the optic thalami and the cord. When the bulb was subjected
to sudden changes in its nutrition—such, for instance, as followed the experiments of Hermann, who
ligated simultaneously the superior and inferior venæ cavæ of a rabbit—there were not only
convulsions, but various cardiac and other disturbances which were undoubtedly due to central
impairment of function. Kussmaul and Tenner conducted their experiments with watch-glasses luted into
the cranium—a procedure which, however, at best, is unreliable.
Brown-Séquard some years ago in part established an important pathological truth, the theory of
epileptic zones, and demonstrated in certain animals that bruising and injury of the great nerve-trunks,
especially the great sciatic, would give rise to epilepsy, and that irritation of certain tracts would
precipitate the paroxysms. He further announced that the progeny of animals in whom epilepsy had
been thus induced very frequently inherited the epilepsy of the parent. By some it was held that such
epilepsies were purely peripheral, and Brown-Séquard even believed in spinal epilepsy. His spinal
epilepsic theory has, for the most part, been explained by the anatomical researches of Hitzig and the
doctrine of interrupted spinal inhibition. In fact, many of the spinal epilepsies are examples of
exaggerated reflexes.
The epileptiginous zone theory, which, while it induced many to believe that the disease might have its
origin outside of the brain, gave rise to the false assumption that attacks with distal auræ were primarily
non-cerebral, has been discarded, and most observers have arrived at the conclusion that even in these
cases the first explosion is due to some cerebral cell-discharge.
Hughlings-Jackson's grand work has revolutionized the views held prior to his first published writings,
about twelve years ago. He believes that any part of the gray matter may, through over-excitability, give
rise to convulsive attacks.
The production of convulsions by cortical irritation is now an old story.
The experiment of Pitres and Frank33 bears upon the sensorial function of the cortex in showing that,
when the cortex is irritated, epileptiform convulsions follow, but if the exposed surface be subjected to
the ether spray the same irritation will only produce definite movements, but no convulsions.
33 Gazette des Hôpitaux, No. 38, 1883.
The investigations of Van der Kolk especially, and his followers, certainly give the medulla an important
place as the locus morbi of the malady; and it must be assumed, bearing in mind the existence of the
vaso-motor centres of Dieters and the presentation of symptoms indicative of disturbance at the floor of
the fourth ventricle, that the most important pathological changes must be looked for in this part of the
brain.
Jackson's cortical explanation is, however, fully in consonance with the medullary theory. If we study the
different stages of the attack, we shall find that there is probably a suspension of cortical inhibition—that
a derangement of the cortical cells or discharge may cause a resulting disturbance in the bulb. On the
other hand, a reflex irritation through the pneumogastric or from some distal part brings about the same
disturbance of equilibrium. There is anæmia due to irritation of the vaso-motor centre, an inhibition of the
great ganglion-cells, and a disturbance of function of the important cranial nerves. The primary anæmia
and unconsciousness are accounted for by this primary irritation of sympathetic filaments and vascular
constriction; the secondary hyperæmia is explained by the experiments of Kussmaul, which
demonstrated the succeeding congestion; or by irritation of the spinal accessory and contraction of the
muscles of the neck and compression of the large veins. The pupillary, ocular, respiratory, and other
symptoms indicate the disturbance of the nerve-nuclei in the bulb. The respiratory difficulty and the
interrupted decarbonization of the blood undoubtedly account for the secondary unconsciousness.
Van der Kolk34 in localizing the lesion in the medulla found capillary dilatations in the neighborhood of
the hypoglossal nuclei in tongue-biters. In epileptic patients who were in the habit of biting their tongues
during the fit the vessels were wider than in those who did not bite the tongue, on an average in the
course of the hypoglossus by 0.096; in the corpus olivare, which certainly here plays an important part,
by 0.098 mm.; and in the raphé by 0.055. In those who did not bite the tongue, on the contrary, the
vessels in the path of the vagus were 0.111 wider than in those in the first, Table A.35
34 “On the Minute Structure and Functions of the Spinal Cord,” by J. L. C. Schroeder Van der Kolk, New Syd. Soc. Trans.
35 TABLE.
Different Epileptics. Hypoglossus. Corpus olivare. Raphé. Vagus.
Table A—tongue biters 0.306 0.315 0.315 0.237
Table B—non biters 0.210 0.217 0.217 0.348
Difference +0.096 A. +0.098 A. +0.055 A. +0.111 B.
Nothnagel36 is of the opinion that the anæmia of the brain is not the cause of the convulsions, but that
the “excitation of the vaso-motor centre and that of the centre for the muscles are co-ordinate—that both
go on side by side, and are independent of each other.”
36 Ziemssen's Encyclopædia, vol. xiv. p. 268.
He by this theory explains the occurrence of those forms of petit mal in which there is loss of
consciousness without convulsions, and, on the other hand, twitchings before the coma.
The best argument in favor of this hypothesis is in Jacksonian epilepsy, when monospasms exist
oftentimes with a succeeding extension.
In those cases which are the outgrowth of migraine the pathological condition is probably an
exaggerated tendency to angio-spasm, the original impaired vascular tonus in the beginning giving rise
simply to pain and lesser troubles, while after repeated changes of calibre not only nutritive alterations
ensue, but hyperexcitability of the bulbar convulsion centres as well.
The labors of those who have endeavored to connect epilepsy with cerebral-tissue alterations have
been attended by nothing very definite or positive, so far as pathological explanation is concerned. The
post-mortem appearances have varied widely, and the only conclusion to be reached is that which
shows that almost any morbid gross alteration of the cerebral mass may be symptomatized by
convulsions, but such a production of paroxysmal trouble is much more likely to be the case, and in a
more definite manner, when the cortical motor-centres are subject to destructive disease or irritative
pressure. This is even not always the case, for numerous cases of injury of the paracentral lobe have
been recorded with no showing of resulting convulsions. The long list of autopsies which I will not here
consider show that an epilepsy may owe its origin to the pressure of a spicula of bone, or to the
pressure exercised by depressed fragments of the same—to tumors or adventitious products,
meningitis, cortical encephalitis, vascular degeneration, ventricular œdema, contusio-cerebri, and many
other morbid processes which result in rapid or tardy degeneration. Of course, in such cases the
genesis of the disease depends not so much upon the nature of the lesion as the location. The fruitful
collections of cases of Ogle and Jackson are full of examples of limited growth or disease involving the
cerebral cortex, while numerous cases collated by other writers show disease of the bulb or various
peripheral parts which have been closely connected with the growth and behavior of the affection.
Several able pathologists have independently and repeatedly found that sclerotic degeneration of the
hippocampal folds often existed. Delasiauve and Lébert first observed this lesion, but many modern
authorities—among them Meynert, Nothnagel, and Charcot—who have also found this appearance,
regard the change as of purely secondary, and consequently unimportant, character.
Tamburini37 reports a case of hemiplegic epilepsy with induration of the left optic thalamus and the left
cornu ammonis, in which aphasia existed. Pfleger38 and Henkes have also found the sole lesion to be
induration of the cornu ammonis. Of Pfleger's39 43 autopsies, atrophy and sclerosis of the cornu
ammonis were found twenty-five times, and it was noted that the extent of the morbid change bore
relation to the violence and frequency of the seizures.
37 Sallanzani, Modena, 1879, viii. 550-557.
38 Allg. Zeitschrift f. Psychiatrie, etc., Berlin, 1879, xxxvi. 359-365.
39 Ibid., lxxvi., and Arch. de Neurologie, No. 2, 1880, p. 299.
In many examples, especially where the disease has been found to be unilateral and associated with
more or less hemiatrophy, the autopsy disclosed a corresponding hemiatrophy of the brain. Many such
cases are reported. I have frequently found epilepsy in association with cerebral hypertrophy, and as a
symptom of cerebral tuberculosis it has long been recognized, and numerous cases are reported in
which for a long time the paroxysms were the only manifestations of the condition. In one of these
cases, reported by Luys,40 the bulb was found involved by tuberculous matter.
40 Archives gén. de Méd., 1869, ii. 641 et seq.
Convulsions have very frequently been noted in association with imperfect cerebral development, and
Echeverria laid great stress upon the hyperplastic increase in volume of certain parts of the brain.
Marie Bra41 has thus summed up her conclusions relating to the morbid anatomy of epilepsy:
“1. The mean weight of the brains of epileptics is less than the physiological mean.
“2. The cerebellum is greater than the physiological mean.
“3. There frequently exists an asymmetry between the lobes (not peculiar to epilepsy). The increase
of weight is sometimes found on the right and sometimes on the left side. Equality is the exception.
“4. In no form of mental disease (excepting perhaps general paresis, which is accompanied also by
epileptiform crises) have we met with so marked and constant a variation between the weights of
the hemispheres as exists in epilepsy.”
41 Referred to by Axenfeld.
Drasche, Green, Greenhow, Löbel, and others have detailed cases in which tuberculous deposits were
undoubtedly the causes of the disease.
Kussmaul and Tenner, Hoffman, and others have held that a stenosis of the superior part of the
vertebral canal may explain, through pressure upon the cord, the genesis of the attack, and Kroon found
asymmetry of the medulla oblongata.
The microscopical changes that have been found in brains where no gross lesion was apparent are by
no means distinctive. I have myself examined the brains of many epileptics with discouraging results.
The varying granular cell-degeneration, capillary dilatation, and exudative changes are common
enough. In several cases of cortical epilepsy I found more or less advanced degeneration of the great
cells in limited regions.
By far the most important and exact changes are those observed in the cases of sensory epilepsy. I
have elsewhere collected some continental cases. In brief, areas of occipital softening or degeneration
have been discovered in those cases with hallucination, sensory expressions, and hemiopia. In one
case attended by hallucination of smell the autopsy disclosed the following:
M. M——, was a stout Irish woman about forty years of age. She had suffered from a light form of
epilepsy dating from the tenth year, and resulting, as she stated, from a fall, when she struck her head
and was unconscious thereafter for some hours. No scar was visible, however. No satisfactory history
could be obtained regarding her early life and the first paroxysms. In the beginning these were rather
frequent, and she had as many as four or five a month. They afterward diminished in number and
severity, and for many years she had but three or four in the course of the year. They were not very
severe, and she was enabled to pursue her work as a housemaid, but did not keep her places for any
great length of time. She rarely bit her tongue, but usually frothed at the mouth and became livid and
convulsed for a short time. There was no history of one-sided spasms. As I have stated, I could gain no
accurate account of the previous attacks, except that she nearly always had an aura of a peculiar
character, which was a prominent feature of the seizure and very pronounced. She suddenly perceived
a disagreeable odor, sometimes of smoke, sometimes of a fetid character, and quite uncomplicated by
other sensory warnings; and afterward became unconscious, and remained so for two or three minutes.
She was invariably able to describe her sensations when she recovered, which she always did when I
asked her, comparing her warning to the smell of burning rags, to the smell from a match, and, as she
expressed it, it sometimes rose up in her head and choked her. She was under my observation for one
or two years, but eventually developed phthisis, and died, her attacks occurring from time to time until
her death.
Besides well-marked tuberculous lesions in the lungs, there was little of interest so far as the visceral
examination was concerned. The brain was removed and its peculiarities were carefully observed. A
great quantity of fluid was found, especially at the dependent portions of the membranes and in the
ventricles, while the dura was thickened and pearly in spots. There was a condition that might be
likened to a low grade of hemorrhagic pachymeningitis, and at the base of the brain old plastic changes
were found, there being adhesions, especially in the region of the middle lobes, but more particularly on
the right side and near the median line. The brain as a whole was small, and weighed forty-one ounces
and a fraction. The sulci were deep and gaping, and the convolutions were distinct. There was no
atrophy of the fore-brain convolutions, and no other pathological appearance was presented except that
found in the meninges, but at the lower part of the temporo-sphenoidal lobe of the right side an
appearance was found of an exceedingly interesting nature. At this point a decided shrinkage of tissue
was discovered, with depression and adhesion of the pia, the induration involving the uncinate gyrus
and parts of the adjacent convolutions, as represented in the drawing. No induration or softening of the
great motor tracts was observed, and the optic thalamus and parts adjacent were uninvolved, as was
the cord. An attempted microscopic examination, undertaken some months subsequently, was
unsatisfactory, because of the bad condition of the brain, the preserving fluid having been improperly
made. The olfactory nerves were not involved. The third frontal convolution was examined, but no
disease was found there. Consequently, it is to be inferred that no lesion of the external root of the
olfactory nerve existed.
FIG. 27.
Lower Face of Right Hemisphere.
DIAGNOSIS.—Having spoken of epilepsy as in most instances a

symptomatic disorder, it would be proper to confine this section to
the differentiation of the simpler and more classical form of the
idiopathic disorder from certain purely eclamptic attacks or those due
to cerebral tumor or coarse degeneration. The epileptic attack itself
is to be considered from its time of happening, its duration, the
element of unconsciousness, its associations, and the antecedent
history of the individual. It may be confounded with the similar
phenomenon dependent upon cardiac weakness, uræmic poisoning,
toxic or alcoholic saturation, etc.
Of course, when we find recurring seizures with a certain amount of

what Carter-Gray calls quasi-periodicity, preferring perhaps the night,
the early morning, or only the daytime, we are almost sure of
epilepsy. This supposition is strengthened by the association with
attacks of petit mal. The duration of an attack, which may be from a
few seconds to several minutes, is also a guide, for in certain toxic
and other paroxysms the rule is for a succession of attacks to occur.
The question of consciousness is one that has drawn forth a great

deal of discussion, especially with reference to medico-legal cases. I
think the majority of clinicians are agreed that loss of consciousness
is an absolute belonging of epilepsy, yet there are cases in which the
lapse is scarcely perceptible. It is a dangerous precedent to
establish, for the convulsive symptoms in such cases are taken from
the epileptoid category. It is quite true that there are many hemi-
epilepsies in which the intellectual condition is one that may easily
be mistaken. I have seen numerous cases in which an apparent
conservation of consciousness remained throughout a slight
monospasm, but I do not feel at all sure of this; and in cases of
aborted or masked epilepsy there is a dual mental state which would
readily deceive the lay observer. The case of Mrs. S—— is an
example of this kind. After the obvious subsidence of the dramatic
and conspicuous feature of the fit she remained for hours and days
in a state of undoubted transposition, performing acts which required
something more than a high degree of automatism—going to the
table, talking about certain subjects which were suggested, with
apparent ease, but not connecting them intelligently with her
surroundings, as she would before and after the epileptoid state.
After a time she apparently resumed her normal state, but was
entirely unconscious of the happenings of her previous hours or
days, not even recollecting her simplest actions. Julian Hawthorne's
hero in Archibald Malmaison, though not drawn by a physician's pen,
suggests the state of which I speak, and it has the merit of being
based upon one of the elder Forbes Winslow's interesting cases.
When we find paroxysmal attacks occurring in individuals with

atypical heads, thick swollen lips, scarred tongues, and irregular
teeth, we may strongly suspect the patient to be epileptic. To these
we may add the appearance of the eyes, the fishy, lack-lustre
expression which betokens old epilepsy. The hands are clammy and
the skin mud-colored; the hair is dry and coarse; and the body often
has a death-like odor.
In children, certain mental peculiarities are to be inquired into.

Unnatural brightness or dulness—what may be called the clumsy
organization—is often present, and the muscular use is often
imperfect. We find that there is often but little nicety in walking, in
using the hands, in speaking, or after learning to write there is an
incapacity, with ever so much teaching, to develop a character or
style. Such children can never become ambidextrous. These little
points may seem trifling, but to the physician who carefully studies
his cases they may prove of great help. The history of the nights may
often lead to the discovery perhaps of a long-existing nocturnal
epilepsy. Incontinence of urine, blood upon the pillow, nightmares,
morning headache, and petechiæ betoken unsuspected night
attacks; and Le Grand du Saulk mentions the case of a young
Englishman who committed a purposeless crime and was
discovered to be epileptic, the diagnosis being confirmed by an
antecedent history of nocturnal seizures, and subsequent watching
resulted in the discovery of many night attacks.
As to special conditions with which the epilepsy may be confounded,

I may refer to cardiac weakness. It not rarely happens that simple
fainting attacks are confounded with those of an epileptic nature.
Such is the case more often in heat-prostration, when some rigidity
attends the loss of consciousness. The duration of such a state, the
condition of the pulse and color, however, will easily clear up any
doubts upon the part of the observer. The existence of a cause
should also be considered, and the fact that usually the epileptic
paroxysm is sudden, while a feeling of depression and feebleness
precedes the fainting attack, should be remembered. I may present
in tabular form the points of difference:
EPILEPSY. SYNCOPE.
Loss of consciousness Loss of consciousness follows
sudden. feeling of faintness.
Period of complete Unconscious throughout, no
unconsciousness usually convulsions.
short.
The existence of auræ of a The existence of preliminary vague
well-defined type. prostration, nausea, and irregular
heart action.
Often involuntary discharge Quite rare or never.
from bowels and bladder.
Patient usually falls into heavy After slight weakness patient is
sleep or is indifferent after anxious and worried, and quickly
convulsion. seeks relief.
The difficulty of diagnosis, however, is only in cases of petit mal.

There are light forms of auditory vertigo that may resemble
vertiginous epilepsy. In the former there is never loss of
consciousness, and the patient refers to the rotary character of the
vertigo. A history of antecedent attacks, tinnitus, aural disease, and a
certain constancy which is not a feature of petit mal, may be
mentioned.
There are cases, however, which are puzzling, and come under the
head of auditory epilepsy rather than auditory vertigo; and in these
there is a multiplicity of expressions, the auditory symptoms
predominating.
Of uræmic convulsions it is hardly necessary to speak. There is a

previous history of renal disease which the microscope and less
delicate tests will reveal, and clinically there is antecedent headache,
some stupidity, and not unrarely thickness of speech and
somnolence. There are some cases, however, which are obscure. I
have known patients with chronic renal disease—such as waxy
kidney, for instance—to develop a species of epilepsy, the
paroxysms recurring from time to time and behaving very much as
the idiopathic disease would; and their occurrence would mark some
imprudence in diet or exposure, and their disappearance an
improvement in the patient's general condition. The attacks were not
classical, inasmuch as there seemed to be but one stage of violent
clonic convulsion, preceded by intellectual dulness, and followed by
a semi-comatose condition which was far mere profound than the
somnolent stage of epilepsy. The movements were not accompanied
by a great degree of opisthotonos or pleurosthotonos.
Alcoholic and absinthic epilepsies are usually preceded and followed

by symptoms indicative of profound saturation.
The consideration of hysterical epilepsy may be found elsewhere,

but it may do to briefly refer to some cases which do not present the
phenomenon first described by Charcot and Bourneville. The
ordinary hysterical attack is never attended by loss of
consciousness, by any of the pupillary changes so constant in
epilepsy, by the mobility of the pupil between the attacks which is
present in a large number of true epileptic individuals. There are
never the succeeding changes of color, and the seizures are
commonly produced or attended by some emotional disturbance, or
are associated with ovarian disturbance.
Epilepsy is occasionally simulated by malingerers, and sometimes

the skill of the subject is so great as to even deceive the practised
eye. Prisoners, soldiers, and litigants may counterfeit an epilepsy,
and go through with great personal suffering to accomplish their
purpose. “Clegg, the dummy-chucker,” whose remarkable case has
figured in the medical journals, upon one occasion threw himself
from an iron platform to the stone floor of the jail, nearly twenty feet
below, to convince a suspicious physician of his honesty. The
simulator rarely bears close watching. The dilatation and contraction
of the pupil cannot be simulated, nor can the corneal or pupillary
insensibility. The fraud cannot voluntarily change his color, as is the
case in true epilepsy, and as a rule the thumbs of the impostor are
never flexed, as they should be. Suggestions for a purpose are
readily heard, and sometimes adopted, by the apparently
unconscious man. Gottardi42 lays great stress upon the use of the
ophthalmoscope as a means of detecting simulated epilepsy. He
calls attention to the frequency of retinal changes with facial
asymmetry and other evidences that suggest cerebral disease or
non-development. Gottardi has found that the pulse in true epilepsy
is always lower after an attack, but it soon reaches its normal
standard.
42 Abstract in Journal of N. and M. Dis., Oct., 1881, p. 843.
The differentiation of idiopathic epilepsy from that due to syphilis is

possible when we consider the element of pain. Besides the tibial
pains of syphilis, the epilepsy thus produced is often preceded by
intense frontal headache, while that of ordinary epilepsy follows the
attack. The syphilitic epilepsy is not attended by so great or
continued a loss of consciousness as the non-specific form, and the
movements are apt to be most violent on one side or the other. The
association of the attacks with various bodily signs, such as nodes,
old scars, alopecia, erosions, etc., and in connection with possible
cranial nerve-paralyses, will throw light upon its true character. The
paralyses referred to seem most frequently to involve the motor
ocularis, abducens, and patheticus. Syphilitic epilepsy, too, is quite
irregular in its time of manifestation, and is not unrarely followed by
aphasia; but the interparoxysmal mental state is one of extreme
dulness, memory being blunted and there being a peculiar hebetude.
PROGNOSIS.—Within the past quarter of a century the ideas of the

medical profession regarding the curability of epilepsy have certainly
undergone a change. The statistics of Bennett and others show that
since the introduction of the bromic salts the proportion of cures has
been decidedly increased. Nevertheless, the disease is a most
discouraging and troublesome one to manage, and especially is this
the case when it assumes the form of petit mal. The rapid recurrence
of light attacks is, as has already been said, very apt to lead not only
to mental enfeeblement, but is very often followed by very severe
paroxysms.
Epilepsy of a more or less constant form, in which the seizures

resemble each other, is far more incurable than that of variable type;
for example, we find that unilateral seizures are much more apt to be
associated with established cortical disease than when they are
general and simply explosive manifestations. It has been held that a
tendency to permanency is marked by a diminution in the extent of
the interval. This is by no means true. I have had cases under
observation for ten or twelve years in which attacks separated by
intervals of six months or one year marked the course of the
disease, in which frequent initial attacks were present. These cases I
regard as very bad so far as prognosis is concerned. I much prefer a
history of irregular and comparatively disorderly attacks. In female
subjects the menstrual influence is not always a bad factor. When we
are enabled to remove some production of an exciting cause in
connection with the catamenia the prognosis is more hopeful; but an
opinion must be expressed with great caution, especially in those
cases beginning at an early age and not after the establishment of
the menses. Traumatic cases are not always bad, but those in which
the element of heredity plays a part most certainly are, Herpin and
Gowers to the contrary; and though these cases for a time do well
under treatment, its good effects are not constant. Individuals with
misshapen heads, whose deformity suggests premature sutural
ossification, are not susceptible to the influence of treatment, and all
other osseous changes, such as exostosis, plaques in the dura, and
bony growths, whose existence can only be guessed at or inferred
from suggestive appearances elsewhere, give rise to a variety of
epilepsy which is beyond the reach of drugs. With symptomatic
epilepsies the case is sometimes different, for while the seizures
which arise from the irritation of a cerebral tumor are almost as
hopeless as the form I have just mentioned, we know from
experience that the epilepsy of syphilis and other allied diseases,
and those of toxic origin, with the exception sometimes of those
occasionally due to alcohol or lead, are curable. The meningeal
thickening of alcoholic origin or the encephalopathy of lead may be
the pathological bases of very intractable paroxysms.
So far as age is concerned, it may be stated that many eclamptic

seizures of young children which are due to well-recognized irritable
causes are promptly cured if there be no hydrops ventriculi or
preossification of the coronal sutures, and if the epileptic habit is not
established. The epilepsies of six or eight years' standing are not
encouraging from a therapeutic point of view, and those of advanced
life developing in aged persons are equally unfavorable.
The treatment of epilepsy due to heat-stroke is by no means

satisfactory, and, though the attacks are often separated by long
periods, they are apt to recur in spite of drugs.
Gowers has prepared several valuable tables which show the

influence of age upon recovery. He says: “The following table shows
that age has a distinct influence on prognosis. The percentage of the
unimproved cases to the whole is 30 (43:143::30:100). The
percentage of the cases commencing at each age arrested and
unimproved is stated, and between brackets is indicated the excess
of the arrested or unimproved cases at each period of life over the
proportion for the whole 30 and 70 per cent. respectively:
———Cases.——— ———Percentage.———
Unimproved. Arrested. Unimproved. Arrested.
Under 10 14 29 32.5(+2.5) 67.5
From 10-19 23 45 34 (+4) 66
20 and over 6 26 19 81 (+11)
43 100 30 70
Thus, the proportion of the cases commencing under twenty in which

arrest was obtained is considerably less than the proportion of cases
commencing over twenty, the difference amounting to about 13 per
cent. The period of the first twenty years of life at which the disease
commences has little influence, but the prognosis is little better in the
cases which commence under ten than in those which commence
between ten and twenty: arrest is more frequently obtained. The
cases which commence in women at the second climacteric period
are also obstinate, although not sufficiently numerous to be
separately given.”
He also finds, from an analysis of the same cases, the fact noted by
others, that the prognosis is favorable in inverse proportion to the
duration of the disease.
Attacks which chiefly occur in the daytime are much more amenable
to treatment than the nocturnal seizures, and especially is this the
case in the tongue-biting form. Sudden blows upon the head or falls
have been known in isolated cases to effect an amelioration in the
patient's disease, but these examples are rare.
The existence of an aura is much better than if none existed.
Death from the attack itself is rare, yet in the large pauper institution
with which I was connected for many years I have known of several
cases. More often the death results from asphyxia resulting from a
bolus of food which chokes the patient or from a fall in some
dangerous place—into the fire or elsewhere. Accidental death from
drowning is more common than any other form.
The status epileptica into which patients sometimes pass who have
had many convulsions is occasionally a fatal termination of the
malady, and is always a serious feature.
The influence of different epochs in life is worthy of consideration: of

menstruation, of marriage, of pregnancy, and of the menopause
there is much to be said. I have sufficiently spoken of the
establishment of the menstrual flow, and I would only add another
word of caution against giving a too favorable prognosis except in
those cases of very recent origin. Marriage appears to have very
little to do with changing the attacks, unless they be of an hysteroid
character. I have never known epilepsy to influence the course of a
pregnancy in any unfavorable way, and I think this has been the
observation of others. Gowers refers to cases in which the attacks
ceased during the time the mother was carrying the child.
The occasional bad influence of the pregnant state has been

illustrated by a case reported by Terrillon.43 This example was a
woman who had been the victim of epilepsy of hereditary origin since
her seventh year. At the commencement of menstruation her attacks
became periodic, and recurred every two months, and she had
several two or three days before the flow. Two pregnancies followed
several years afterward. During the periods they were increased in
number and severity, and occurred several times daily. She had
more attacks at this period than in all the time after delivery.
43 Annales de Gynécologie, June, 1881, p. 401.
I have found that the relief of uterine flexion or the establishment of

menstruation has exercised a decidedly modifying influence for the
better in several cases.
Sometimes the disease is interrupted by the menopause, but very

often in my experience it has changed in type and been followed by
mental degeneration.
The prognosis of the epileptoid mental state is serious in the
extreme, and even when in early life the attacks are aborted or
changed to perversion of the intellect or emotions existing as a
complication, the hope of cure dwindles almost to nothing.
The spontaneous cure of epilepsy is rare. Its course, however, is

more often interrupted by some intercurrent disease. Of 33 cases
observed by Delasiauve in which there was some complicating
disease, such as erysipelas, pneumonia, pleurisy, acute articular
rheumatism, burns and contusions, scarlatina, erythema, or the
condition of pregnancy, it was found that in 25 cases there was a
decided improvement (une heureuse influence), and in 8 only was
there no modification of the attacks. Axenfeld is disposed to believe
that acute and febrile disorders more decidedly influence the course
of epilepsy than those of a chronic nature. The influence of either
may be small or may diminish the number of attacks without curing
the disease.
TREATMENT.—The treatment of epilepsy depends so much upon the

form of the disease that no arbitrary rule can be laid down upon
general principles, and we must bear in mind the necessity for
removing the exciting causes if possible, the preservation of the
balance of cerebral blood-pressure and cell-equilibrium, and the
nutrition of the cerebral mass. It may be our purpose to remove
various toxæmic or cachectic states as well. As a minor division of
treatment we must consider the abortion of the attack when auræ
are detected. It has been the custom, I think among too many, to
manage the disease in an empirical manner, depending upon some
routine course of treatment, such as the indiscriminate use of the
bromides, for example. I am convinced that the intractable character
of the disease has come to be greatly exaggerated through failures
attendant upon the wholesale use of the bromic salts, without regard
to the indication in each particular case. It behooves us first to select
a reliable bromide, and then to give it with relation to the time of the
fit, its severity, and the condition of the individual. The importance of
this has impressed me very often. An equally divided daily dose will
not do a patient who has matutinal attacks the same good as will a
large dose at night, and in certain anæmic individuals the bromides
very often increase the attack. Then, too, the cases in which
seizures of petit mal predominate are not benefited to the extent that
those are in which the repetition of severe attacks is the feature. The
bromide should always be well diluted and given when the stomach
is empty or nearly so. The bromide of sodium is, to my mind, the
most serviceable salt, and when given alone or combined with the
bromide of ammonium is better than the potassic salt or the various
others. It should be carefully kept in solution or in waxed-paper
powders in a tight preserve-jar. As to its method of administration, I
much prefer the use of a solution which shall combine other
adjuvants which I will presently mention, and separate powders as
well, which may be used to reinforce the dose. The latter are to be
employed by the patient in the event of an unlooked-for series of
attacks, and are to be used to the point of producing mild bromism at
the time. In certain cases it is all-important to take into consideration
the condition of the heart. In some cases where there is manifest
and continued cerebral congestion, with full vessels and hard pulse, I
have found that the combination with chloral or aconite was
desirable. In other cases where the heart's action was irregular and
weak my experience with digitalis and nitro-glycerin or with
strychnine was most happy. In those cases that passed large
quantities of clear urine of low specific gravity the action of nitro-
glycerin and digitalis has been most prompt, and the same has been
true of epilepsies of migrainous origin.
There have been various methods of using the bromide suggested

which are more or less practical. The writers of a few years ago
suggested the prompt production of bromism—a state in which the
patient should be kept for a long time. This I strongly disapprove of,
not only because the mental and physical depression is a very
disagreeable and sometimes permanent condition, but because I
have found that the attacks are often increased after a time, though
at first they may have been suppressed. Others believe in giving the
bromides at intervals, with periods when no medicine at all is
administered.
For my own part, I am in favor of the establishment of a mild
bromism which does not extend beyond a slight anæsthesia of the
fauces or the appearance of slight acne. If I find it necessary to
increase the dose, I give cod-liver oil, iron, and bark or some of the
many preparations of the hypophosphites for a time; and they do not
diminish the specific effects of the drug to any great extent. In the
event of a series of attacks I direct the patient to take an extra dose
at such time as will anticipate the seizure.
This treatment should be kept up for at least two or three years after
the attacks have disappeared, and it may be even necessary to
continue a bromide course in a small way for an unlimited period.
If there be an hysterical element, or if ovarian excitement is

supposed to have anything to do with the attacks, the combination of
cannabis indica is strongly recommended. This suggestion holds
good in the cases where migraine is associated with the epilepsy, or
the latter is an outgrowth of the former.
Next to the bromides of potassium and sodium I have been very

successful with the nickel bromide. I find that it is retained with little
trouble, producing no gastric derangement if taken after eating. A
syrup prepared by most of the good pharmacists is preferable to any
other method of administering the salt. Quite recently Leaman44 has
reported two cases of severe epilepsy which were greatly benefited.
His conclusion is that it does most good in the form of the disease
when the attacks are separated by long intervals.
44 Med. News, Apr. 18, 1885.
The bromate of potassium, which has been used by Weir Mitchell45

and Hinsdale, may be worthy of a trial. It should never be given,
however, in larger doses than five or ten grains thrice daily. These
investigators found that thirty grains slowed the heart very
considerably, and forty grains produced watery discharges from the
bowels and drowsiness. In their hands, notwithstanding these
disagreeable effects, it controlled the seizures. The hydrobromate of
conia is a comparatively new remedy which has been

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Death, Dying, and Bereavement:

Palliative and End-of-Life Care Journeysâ•…â•… 45

8. The Psychologization of Grief and Its Depictions Within Mainstream

PART II: INSTITUTIONAL DEVELOPMENTS

12. Palliative Care for Childrenâ•…â•… 165

PART III: PRACTICE DEVELOPMENTS

Widows Who Accepted Helpâ•…â•… 296

Interventions for Survivors—Current Standingâ•…â•… 352

Thomas Attig, PhD, Professor Emeritus, Department of Philosophy,

Sandra Bertman, PhD, Distinguished Professor (retired), Thanatology and Arts,

David Clark, PhD, Professor of Medical Sociology, School of Interdisciplinary

Stephen Connor, PhD, International Palliative Care Consultant, Open Society

Inge B. Corless, PhD, RN, FAAN, Professor, MGH Institute of Health

Charles A. Corr, PhD, Member, Board of Directors, Suncoast Hospice Institute,

Linda Goldman, MS, FT, LCPC, Adjunct Professor of Graduate Counseling,

Leeat Granek, PhD, Assistant Professor, Department of Public Health, Faculty

John R. Jordan, PhD, Private Practice, Pawtucket, Rhode Island

David W. Kissane, MB, BS, MPM, MD, FRANZCP, FAChPM, Professor

Bernard J. Lapointe, MD, Eric M. Flanders Chair in Palliative Medicine, Director,

Judith L. M. McCoyd, PhD, LCSW (PA), QCSW, Associate Professor, Rutgers

Robert A. Neimeyer, PhD, Professor of Psychology, Department of Psychology,

Colin Murray Parkes, OBE, MD, FRCPsych, DL, Consultant Psychiatrist

Vanderlyn R. Pine, PhD, Professor Emeritus, Department of Sociology, State

Phyllis R. Silverman, PhD, Resident Scholar, Women’s Studies Research Center,

Judith M. Stillion, PhD, CT, Professor Emerita, Psychology, Stillion Consulting

Mary L. S. Vachon, PhD, RN, Private Practice; Professor, Department of

J. William Worden, PhD, ABPP, Clinical Psychologist, Harvard Medical School,

Judith M. Stillion and Thomas Attig

I may present two illustrative cases:

The second case is one of a more complex type:

The production of convulsions by cortical irritation is now an old story.

38 Allg. Zeitschrift f. Psychiatrie, etc., Berlin, 1879, xxxvi. 359-365.

39 Ibid., lxxvi., and Arch. de Neurologie, No. 2, 1880, p. 299.

“2. The cerebellum is greater than the physiological mean.

Lower Face of Right Hemisphere.

DIAGNOSIS.—Having spoken of epilepsy as in most instances a

Of course, when we find recurring seizures with a certain amount of

The question of consciousness is one that has drawn forth a great

When we find paroxysmal attacks occurring in individuals with

In children, certain mental peculiarities are to be inquired into.

As to special conditions with which the epilepsy may be confounded,

The difficulty of diagnosis, however, is only in cases of petit mal.

Of uræmic convulsions it is hardly necessary to speak. There is a

Alcoholic and absinthic epilepsies are usually preceded and followed

The consideration of hysterical epilepsy may be found elsewhere,

Epilepsy is occasionally simulated by malingerers, and sometimes

The differentiation of idiopathic epilepsy from that due to syphilis is

PROGNOSIS.—Within the past quarter of a century the ideas of the

Epilepsy of a more or less constant form, in which the seizures

So far as age is concerned, it may be stated that many eclamptic

The treatment of epilepsy due to heat-stroke is by no means

Gowers has prepared several valuable tables which show the

Thus, the proportion of the cases commencing under twenty in which

The existence of an aura is much better than if none existed.

The influence of different epochs in life is worthy of consideration: of

The occasional bad influence of the pregnant state has been

I have found that the relief of uterine flexion or the establishment of

Sometimes the disease is interrupted by the menopause, but very

The spontaneous cure of epilepsy is rare. Its course, however, is

TREATMENT.—The treatment of epilepsy depends so much upon the

There have been various methods of using the bromide suggested

If there be an hysterical element, or if ovarian excitement is

Next to the bromides of potassium and sodium I have been very