intact autopsychic orientation, and by the stigmata of chronic alcoholism;

States of transitory confusion encountered in chronic alcoholism, by absence of the post-epileptic stupor (Moeli);

Delirious attacks of general paresis, which may resemble epileptic delirium, by the patient's previous history and especially by the presence of the special physical signs of this affection;

Attacks of catatonic excitement by the relative conservation of lucidity.

Finally, in epilepsy one may meet with attacks of so-called epileptic mania which at times simulate closely the manic type of manic depressive insanity. However, in these attacks flight of ideas is much less pronounced, as a rule, and the morbid ideas are much more firmly fixed and much more monotonous.1

Several authors, Krafft-Ebing among them, have described under the name of transitory delirium, or transitory mania, very brief, non-recurring delirious attacks which they consider as a distinct morbid entity. The similarity between these attacks and those of epileptic delirium is such that most alienists consider them as being of epileptic origin, at least in the great majority of cases. This opinion is entertained notably by Schwartz,2 Régis,3 and Vallon. According to these authors the cases of transitory delirium which are not

4

1 Heilbronner. Ueber epileptische Manie nebst Bemerkungen über Ideenflucht. Monatsch. f. Psychiat. u. Neurol., 1902, Nos. 3 and 4. 2 Schwartz. Mania transitoria. Allg. Zeits. f. Psychiat., 1891. 3 Régis. Manuel de maladies mentales.

• Vallon.

Rapport au Congrès d'Angers, 1898.

of epileptic origin are attributable to some infectious disease, to alcoholism, or to mental degeneration. In the clinic only a close study of the antecedents of a given case enables one to decide to which of these causes the attack is due.

The etiology of epileptic delirium is that of epilepsy in general.

Treatment of epilepsy. We shall consider separately the treatment of epilepsy itself and that of its psychic complications.

The first really belongs to the domain of neurology, and I shall therefore limit myself to a mere statement of the principal indications.

(A) Hygienic measures;

(B) Medicinal treatment.

1

(A) The hygiene of an epileptic consists in: (a) A diet by which the quantity of toxines produced in the organism is reduced to the minimum: a partial milk diet combined with white meats, vegetables, eggs, is of great utility. [It has been shown by dietetic experiments 1 that epileptics have a special intolerance for proteid material in any form, and that when their diet contains more proteid than is actually needed by the organism their convulsions are more frequent and more severe and their mental condition is worse than when their diet contains no such excess. The principal dietetic indication is, therefore, to reduce the amount of proteid to the minimum that is required by the organism, replacing the proteid principle, as far as it

1 Merson.. On the Diet in Epilepsy. The West Riding Lunatic Asylum Medical Report, 1875. - Rosanoff. The Diet in Epilepsy. Journ. of Nerv. and Mental Disease, Dec., 1905.

is possible to do so,1 by fats and carbohydrates. Care must be taken, however, not to reduce the amount of proteid below the necessary minimum, for then a condition of proteid starvation is established, that is to say the patient is excreting more nitrogenous material than he is ingesting, and a general aggravation of his condition inevitably follows.] (b) The suppression of the use of all alcoholic beverages. (c) Outdoor life with moderate physical and mental labor; a mild but firm moral direction. An effort should be made to impress it upon the epileptic that he is subject to the common laws and that he is, like everybody else, responsible for his acts.

(B) Medicinal treatment. - Of all the drugs used in the treatment of epilepsy I shall mention only the bromides of the alkali metals, the efficacy of which is incontestable, and opium, which has gained considerable reputation through the recent introduction of a new method of treatment.

The bromides of sodium and of potassium are administered either separately or in a mixture of the two with bromide of ammonium, which mixture is sometimes known as the "tribromide." The doses vary according to the age, the frequency of the attacks, and the tolerance of the subject. The maximum that may be administered to an adult with benefit seems to be from 8 to 10 grams daily. Usually good results can be obtained from moderate doses-from 3 to 6 grams daily.

The action of the bromides seems to be more pro

1 Herter. Lectures on Clinical Pathology, p. 150.

nounced when the patient is allowed a "hypochlorization" diet; that is to say, a diet in which the amount of sodium chloride is reduced as far as possible (Richet and Toulouse).1

Flechsig introduced several years ago a method of treatment consisting in the administration of increasing doses of opium and finally suddenly suppressing the drug. This procedure suspends the attacks in some cases for a very long time. Unfortunately their recurrence is always to be feared.

The first question

Treatment of the mental disorders. which arises is: Should an epileptic be committed?— Yes, in two classes of cases: (1) if the seizures are accompanied by marked delirious disorders; (2) if, independently of the seizures, the patient is subject to violent impulses. Epileptic imbeciles and idiots come under the same rule.

During the delirious attacks the patient is to be constantly watched. Unfortunately rest in bed can be instituted only with great difficulty on account of the profound clouding of consciousness. Prolonged baths and the prudent use of hypnotics are here especially indicated. Refusal of food and threatening collapse are to be treated by ordinary methods.

1 Capeletti and Ormea. Le régime achloruré dans le traitement bromuré de l'épilepsie. Rev. de Psychiat., Apr., 1902.

CHAPTER III.

DEMENTIA PRÆCOX.

UNDER the name hebephrenia, Hecker, inspired by his preceptor, Kahlbaum, described a psychosis which develops by predilection at the age of puberty and which terminates in a peculiar state of intellectual enfeeblement.

Later Kraepelin extended the views of Hecker and added to this group catatonia,1 which had previously been considered an independent affection, and paranoid dementia, which includes the majority of forms of delusional insanity commonly assigned to the vast and ill-defined group of paranoias. This fusion resulted in a new morbid entity: dementia præcox.

As we shall see later on, dementia præcox cannot be defined either by the age at which it occurs or by the rapidity with which it develops. Its specific element lies exclusively in the sum of the psychic changes, affecting the emotions, the will, and association of ideas. Generally these changes are permanent and constitute the mental deterioration which is the most common outcome of the disease. In

1 Kahlbaum. Die Katatonie oder das Spannungsirresein, 1894.