eases, as it may be possible to discover some cause and remove it and so cure the disease, and the treatment should only be pursued under such guidance. Marriage of an epileptic should be absolutely forbidden.

Causes. Epilepsy begins commonly in youth. It is not infrequent that a child has convulsions between the ages of four and six, and that epilepsy appears in about the tenth year. It often begins in females at the menstrual period, and occurs thereafter more frequently at these times. Heredity is the commonest cause; about one-third of the cases show nervous disease, not usually epilepsy, in the parents, such as neuralgia, hysteria, insanity, or nervousness" in some form, but most of all, alcoholism. Disease of the lungs in the parents seems to be a predisposing factor. Among the more immediate causes of convulsions besides those mentioned above are: steady drinking, exhaustion or poor state of the blood (anæmia), injury, fevers, fright, and indigestible food, some diseases of the sexual organs, and any local cause of irritation.

66

Outcome.-Epilepsy is usually chronic, and may continue permanently. Life is apt to be shortened thereby. In early life the prospects of recovery are much brighter, but the outlook is poorer in long-continued attacks and in grown persons. Epilepsy, beginning after thirty, is apt to be merely a symptom of brain disease, and offers hope of cure. There is little probability of death in the fit, unless through the

patient's accidentally falling into fire or water, or suffering injury in the fall, and occasionally being smothered from lying on the face, as when attacks occur in bed. Epileptic subjects are often peculiar, irritable, and excitable, or dull, and generally become mentally deficient in time. There are many marked exceptions to this rule, and some of the strongest characters in all history have been epileptics, viz.: Mahomet, Napoleon, and Julius Cæsar. Some cases are entirely cured, and the greatest benefit has been obtained in colonies for epileptics which have been established in some of the States.

INSENSIBILITY

UNCONSCIOUSNESS; General Treatment. The patient's head should be moved as little and as carefully as possible. Get him to bed, or place him in a lying position. Loosen the clothing about the neck and body, or remove the clothing, if possible, and replace with nightclothes. If the breathing is of a snoring, noisy, or rattling character, turn the patient with greatest care on his side. Do not try to make the patient swallow anything until consciousness has returned, or it may choke him.

If there has been any injury of the head, or if the face is red, put ice to the head in a rubber bag, sponge bag, or bladder, and keep the feet warm by hotwater bags or bottles. The bowels may be moved by injections of soapsuds, or by five grains of calomel placed on the tongue, if an adult. If the patient does not urinate, the bladder must be emptied every six

to eight hours by passing a soft-rubber catheter which has been boiled five minutes in water and is lubricated with glycerine, the attendant's hands being thoroughly washed before using the catheter. Persons having an odor of alcohol in the breath may be suffering from conditions other than drunkenness, as head injuries and apoplexy are more apt to occur in such individuals, or some other cause of unconsciousness may be also associated. Then, too, mistaken kindness frequently results in an attempt to pour whisky down the throat of any unconscious person. The various causes which more commonly produce unconsciousness are: fainting, head injuries, alcohol, chloral and opium in poisonous doses, apoplexy, sunstroke, kidney diseases. and diabetes, epilepsy, and diseases of the brain.

Fainting. This is probably the most frequent cause of unconsciousness. It is, however, but momentary. The patient becomes suddenly very pale and, if insensibility is complete, falls, and the breathing and action of the heart stop, so that no pulse can be felt.

Fainting may be caused by general weakness and anæmia, indigestion, pain, fright, excitement, "nervousness," or heart disease. It is frequently of no serious import in the young, but in old persons its frequent occurrence may precede apoplexy. Do not raise the patient, but place him flat on his back, loosen the clothing, and raise the feet in the air. Smelling ammonia from a bottle aids recovery. Do not give anything by the mouth till the patient can swallow, and

then a tablespoonful of whisky or brandy in water may prove reviving, if you are sure there is no head injury. Mild epilepsy may be mistaken for fainting (see p. 312).

Head Injuries.-The simplest form of unconsciousness resulting from a fall or blow on the head is that accompanying concussion of the brain. Here the insensibility may be short, the patient may be pale and confused, and have nausea or vomiting on recovery. In the severer form the patient is unconscious, but may reply in monosyllables if one shouts at him. If all the limbs are moved there is no paralysis. There may be convulsions occasionally. Recovery of consciousness usually occurs within twenty-four hours, but headache, dizziness, and incapacity for mental work may persist for a considerable time. There is a possibility of abscess or brain trouble, epilepsy, or relapse into unconsciousness after a time, particularly if the patient does not have proper care. The general treatment stated is advisable, with cold to the head, employing cold cloths if ice cannot be used, and heat to the feet. The patient must lead a quiet life for some time afterwards, not returning to business for several weeks.

In the more dangerous head injuries, resulting in bleeding and clots upon or in the substance of the brain, or fracture or breaking of the bones of the skull, with pressure on the brain, there are: complete unconsciousness so that the patient does not respond to any

effort to arouse him; noisy, snoring breathing; slow pulse; and wide pupils. In fracture there is often no external sign, although there may be a depression in the skull, or the broken bones may be felt grating together when the part is manipulated. A continuous flow of blood or watery fluid from the ear is usually a sign of fracture, or the appearance of blood staining of the white of the eye or lid a day or two after the accident. A surgeon should be summoned at any cost in any case of delayed unconsciousness.

The treatment, until skilled assistance is obtained, should be that recommended for concussion.

Alcoholism. In drunkenness there may be an alcoholic breath and history of drinking. The face is apt to be flushed, and the breathing deep but not noisy and snoring as in apoplexy, and the patient will generally reply in a muttering way if roused by shouting or shaking. There may be some twitching of the muscles, but there are not real convulsions. The pulse and breathing are not noticeably slow, as in opium poisoning.

If the patient has been exposed to cold, put hotwater bottles about him and rub the surface vigorously. If he can swallow, give a dessertspoonful of mustard with a teaspoonful of salt in a glass of tepid water, to empty the stomach, and some cathartic, as five grains of calomel (see Poisons, Vol. II, p. 429). Half a teaspoonful of aromatic spirit of ammonia in water often aids recovery.