Medical and Physical Society. ABSTRACT of paper read by Dr. A. E. Russell on November 8th, on "The Etiology of Epileptic and other Convulsions." The paper was devoted to a consideration of the theory of cerebral anæmia as affording a reasonable explanation of the epileptic fit. This theory is an old one but has been discredited and relegated to oblivion. A perusal of the current views on epilepsy conveys the impression that while an immense amount of thought has been given to the phenomena of the fit and to the discharge from the grey matter, the cause of the discharge has been unduly neglected. Yet the intensity of the epileptic fit bespeaks a cause of marked suddenness of action and of potent influence over the grey matter. It is very difficult to conceive that such a cause should not be a very striking one, and one moreover capable of demonstration. Before the theory of cerebral anæmia could be established it must be shewn firstly that cerebral anæmia is competent to account for the various manifestations of a fit and secondly that there is evidence of the occurrence of such anæmia in the brain at the moment of Occurrence of a fit. The theory of cerebral anæmia explains the unconsciousness accompanying an epileptic fit. Excluding for the moment the aura, and it is noteworthy that it is frequently absent, the first feature in an epileptic fit is sudden loss of consciousness, so sudden that the patient may fall with the utmost violence. This loss of consciousness is not caused by the convulsion. It precedes it in point of time, and in strychnine poisoning and in tetanus the spasms may be every whit as severe as those of idiopathic epilepsy but are not attended with unconsciousness. The explanation that is submitted is that this is due to a sudden arrest of the cerebral circulation. That cerebral anæmia would be an adequate explanation of the unconsciousness is obvious. We see examples of it in fainting attacks, after severe hæmorrhage, in cases of bradycardia such as Stokes Adams Disease, etc. Sudden unilateral anæmia of the brain is also sufficient to produce sudden unconsciousness, as in embolism of a large cerebral artery. The pathology of the common fainting fit resolves itself into a cerebral anæmia due either to lowered general blood pressure from splanchnic vaso dilatation, or to actual cardiac inhibition, the former being probably by far the commoner. In those fainting fits in which the patient falls suddenly it is possible that the underlying cause is an actual temporary arrest of the heart, and transient spasms do occasionally occur in such attacks. Convulsions can also certainly be produced by cerebral anæmia as proved by the classical experiments of Kussmaul and Tenner. In the days when bleeding was a constant practice convulsion was noted by Marshall Hall to be the most familiar complication with the exception of syncope. It is clear that the most potent cause of a sudden cerebral anæmia would be a sudden arrest of the heart. There are a very large number of cases on record in which convulsive movements were associated with exceedingly slow pulse or temporary cardiac arrest, and cardiac arrest has also been noted in epilepsy. Moxon describes two cases. In one he was examining a patient's pulse when it suddenly stopped and the cessation was followed by a typical epileptic convulsion. In another case he was auscultating the heart when, to his great surprise, the sounds ceased and the was followed by convulsion. The writer has reported a similar case in which the pulse was found to be absent immediately after the onset of unconsciousness and did not return until the commencement of clonic spasms. It has been suggested by Dr. Francis Hare that epilepsy may be due to such cardiac arrest occurring as the result of a reflex vagus inhibition of the heart following upon a rapid rise of blood pressure from wide spread vaso-constriction. The circulation in epileptics is subject to rapid variations and it may be that in them the vasosystem is hyper sensitive. Irregular vaso-motor changes would afford an explanation of the aura which may precede the onset of a fit. Whatever be the immediate factor precipitating an epileptic fit, it is one which is very transient in its action and speedily recovered from. On the supposition that cerebral anæmia is the active agent in precipitating a fit, recovery is explained by the return of the circulation. If it be due to a vagus arrest of the heart it might be asked why the heart should not stop permanently. It is however a physiological fact that stimulation of the vagus nerve only produces temporary cardiac arrest and that there is a practically irresistible tendency for the heart to recommence beating even during the stimulation—the so-called vagus escape of the heart. In the case of infantile convulsions the similarity between them and those of idiopathic epilepsy is so close that the probability of a similar factor underlying the two conditions must be considerable. The vaso-motor system of the child is much more unstable than that of the adult and the ease with which emotional disturbance and shock are produced is notorious. Such a factor might be as suggested abnormally sensitive vaso-motor and cardio-motor systems with a ready liability to attacks of vagus inhibition. If this factor is brought into play only a few times we have the ordinary infantile convulsions. If however it is brought into play over and over again chronic epilepsy is the result. The convulsions met with at the onset of acute infections in childhood are worthy of discussion. Under similar conditions rigors are frequent in the adult; so much so that it is almost an aphorism that under such conditions a convulsion in a child is the equivalent of a rigor in an adult. The writer has however seen a convulsion at the onset of pneumonia in a non-epileptic adult. A rigor is associated with marked cutaneous vaso-constriction with pallor and sensation of chilliness. The sensitive cardiac and vaso-motor system of the child may not be able so readily to compensate for the rise of blood pressure thereby induced and cardiac inhibition may be produced instead, with a resulting convulsion. It is to be noted that the old established method of cutting short convulsions in infancy by means of immersion in a warm bath would cause vasodilation of the skin and thereby help to relieve the blood pressure. The influence of fright in precipitating an epileptic fit is interesting. Gowers states that "of all the immediate causes of epilepsy the most potent are psychical-fright, excitement, anxiety. Fright is effective chiefly in early life when emotion is so readily excited." When we bear in mind that fright exerts its influence on the cardiac and vaso-motor systems we see that this fact harmonises with the theory that epilepsy is due to a cerebral anæmia produced either by direct cardiac inhibition or vaso-motor spasm of the cerebral vessels. Vaso-motor spasm of the cerebral vessels has been brought forward as a cause of epilepsy and in the past has had many adherents. For a long time it was stated that the cerebral vessels did not contain nerve fibres but this has been disproved. The phenomena of Raynaud's disease find adequate explanation in extreme vaso-constriction in the affected parts. The cerebral complications which sometimes occur in this disease are explicable on the grounds that a similar constriction occurs in the cerebral vessels. Osler records the case of a woman who with three of her attacks of Raynaud's disease had transient aphasia with partial hemiplegia. Perfect recovery followed each attack. In another case severe epileptic attacks were associated with the attack of Raynaud's disease. It is quite possible that cerebral vaso-motor spasm may account for the phenomena of petit mal. Cardiac arrest is certainly not necessary for the production of such attacks, as the pulse persists during them. The pathological changes that have been described as occurring in the brains of epileptics are not so great but that they might well be secondary to the repeated attacks of cerebral anæmia followed by the extreme congestion of the cerebral vessels brought about by the convulsive movements, and the concomitant asphyxial character of the blood resulting from the spasm of the respiratory muscles. The Medical Courtship. By E. DARWIN. From the Athenæum, July, 1807. In Manhood's dawn, when first soft hairs begin Her favourite youth the blue-eyed goddess spy'd, First gentle Botany the swain address'd, Next pensive Chemia lifts the magic wand, "These are my handmaids," health-rob'd Med'cine cries, Ode in a Tavern. O Water of Neptune! Once the very gods themselves Doubt Drank you! But here Beer lies in dozens cooling on the shelves, So No H, O Thank you! Books for Review. "APPLIED BACTERIOLOGY." By C. G. Moore, M.A., Cantab. and R. T. Hewlett, M.D., F.R.C.P., London. (Baillière, Tindall & Cox) 1906. Price 12s. 6d. net. The authors intend this work to be an elementary handbook for the use of students and medical men, who require to obtain some knowledge of bacteriology, without being able to make an extensive study of this im portant subject. A short account is given of each morbid organism and of its pathogenic properties. Immunity is discussed, and about 80 pages are devoted to bacteriological technique. This is perhaps the most important chapter. While we cannot fail to praise the book taken as a whole, yet we doubt whether it will ever prove to be as useful to the student of medicine as some of the better known works, such as Muir & Ritchie's "Manual of Bacteriology." "ELEMENTS OF PRACTICAL MEDICINE." By Alfred H. Carter, M.D., F.R.C.P. Ninth edition. (H. K. Lewis, London.) Price 10s. 6d. This little book can only be regarded as an introduction to the study of medicine and is not, we imagine, intended to compete with the larger text books. The book consists of about six hundred small pages and contains a condensed system of medicine, with sections on general pathology, the diseases of the skin and a therapeutic index. Brief accounts, amounting to little more than definitions of the rarer diseases, have been included, with the result that the descriptions of the really important diseases are reduced to wholly inadequate proportions. A fuller account of the diseases, commonly met with, would, we think, have been more useful to the elementary student. The section dealing with general pathology occupies twenty-six pages, in which the author manages to give at least one sentence to every one of the important |