and although I am not certain that, in some cases of distinct epilepsy, not included in this analysis, there were no attacks of "le petit mal," I am confident that no single case beyond the four that I have mentioned has come under my observation in which the slighter attacks were the only phenomena of the disease. Out of eighty-one cases, therefore, I have found but three in which "le petit mal" existed alone.

There is no important difference to be observed in regard of sex, in relation to the two forms of attack. The slight difference which is recorded is to the effect, that the female sex is more prone to "le petit mal" than is the male sex.

In answer to the first question, therefore, we may state:— That epilepsia gravior is nearly twice as frequent as epilepsia mitior; and that for the latter to exist alone is an excessively rare occur

rence.

Upon this point, however, somewhat conflicting statements have been made by different authors. For example, Portal says that "presque tous ces malades éprouvent des éblouissements et des vertiges."* Foville also states, "le plus ordinairement ces deux formes de l'épilepsie se développent irrégulièrement chez les mêmes malades; mais il n'est pas rare de ne voir que la première (le haut mal) d'entre elles. It est moins commun, mais cela se rencontre néanmoins que la seconde (le petit mal) constitue à elle seule toute la maladie."+ M. Delasiauve, however, differs from these authorities, stating that, "dans la section des épileptiques hommes, par exemple, 27 invidus seulement, sur 136, verraient se mêler aux grandes attaques de petits accès ou vertiges plus ou moins repétés. La coexistence des divers dégrés se montrerait plus fréquemment chez les enfants, puisqu'elle aurait eu lieu dans 18 cas sur 38."

It appears, therefore, that while in M. Delasiauve's cases "le petit mal" occurred in little more than one-fourth, in my own cases it was present in rather more than the half. It is possible, however, that this difference may be partly explained by the exclusion from my own series of all cases of simply epileptoid

* Observations sur la Nature et le Traitement de l'Épilepsie, p. 126. + Dict. de Méd. et de Chir., art. "Épilepsie," p. 413.

Traité de l'Épilepsie, p. 88.

disease, and of convulsions depending upon organic diseases of the brain.

Such, then, being the relation in regard of prevalence of the two forms of the attack, we have to inquire:

2. What is the influence of hereditary predisposition upon the form of attack?

It has been shown already (page 124), that in the cases now under examination an hereditary or family proclivity to this disease, or to nervous derangement, was discoverable in 31 per cent. This number may be regarded as representing the frequency of hereditary taint as an element in the production of "le haut mal;" for there were but three cases in which this severer form of disease did not exist : and in only one of these three was there any indication of family predisposition, and in that one it existed merely in collateral relations. We have, therefore, to examine whether an hereditary taint affects the frequency of "le petit mal." The facts may be represented in the following table :

It appears, from this table, that when hereditary taint is present, there are of those who are without "le petit mal," twice as many as there are of those who exhibit that symptom: while, on the contrary, when hereditary predisposition is absent, there are without epilepsia mitior fewer than there are with that phenomenon.

Again, there are equal numbers (14) with and without epilepsia mitior; but while of the fourteen who exhibited that symptom hereditary taint was present in only three, of the fourteen who did not there were six in whom the predisposition was discoverable.

It is, therefore, evident that an hereditary taint does not predispose to attacks of "le petit mal;" but that, on the contrary, its existence appears exclusive rather than productive of that phenomenon.

An inference which will very probably be drawn upon this question, is that the hereditary taint is such as to develop speedily the worst form of the disease; and that, therefore, when it is present, "le haut," rather than "le petit mal," will be produced: but, in order to prevent such conjecture from leading the reader astray, it may be stated now that "le petit mal" does not take the place of the severer seizures; but that it is an additional phenomenon, present in those cases where the frequency of epilepsia gravior is at its highest. therefore, of "le petit mal" is, cæteris paribus, a sign of greater severity of disease than its absence; but it is the absence of this sign of severity which is associated with hereditary predisposition.†

The presence,

With regard to the difference of sex, this only is worthy of observation, that, whereas in the male sex the absence of hereditary taint appears a predisposition to epilepsia mitior, such is not the case in the female sex; the numbers, in regard of the latter sex, being equal. Where hereditary taint is present, the tendency to escape attacks of "le petit mal" is equal for the two sexes; being for each as 2:1. The numbers, however, are too small to establish any positive proposition in respect of sexual relationships; they are, however, quite sufficiently large to show the general relation of hereditary taint, and "le petit mal." For taking the whole number, 28, we find 9 in whom hereditary predisposition existed; this being equal to 32 per cent., and almost identical with the number found already (page 124), in the general estimate of that causative condition; whereas, of equal numbers, 14, with and without epilepsia mitior, the hereditary taint varies from 21 per cent. in the former series, to 42 per cent. in the latter.

We may conclude, therefore, that hereditary taint is not without influence upon the character of the attacks; but that the influence

* See p. 154.

+ By comparing the remarks upon hereditary taint in relation to the mental state of the patient, with those in respect of the influence exerted by "le petit mal" upon the same state, further evidence will be obtained that epilepsia mitior is of the greatest importance in regard of the effects of the disease; and this being, as I think, placed beyond doubt, it is of very curious interest to know that hereditary predisposition prevents the individual from suffering the worst effects of his malady, rather than predisposes him to their development.

it exerts is favourable to the development of epilepsia gravior rather than of epilepsia mitior.

The next question which we have to consider is in regard of the influence which may be exerted upon the character of the epileptic paroxysms by the age at which the disease first makes its appearance. It may be asked, 3. Is the form of attack determined by the age of the patient? or, if not so determined, is it influenced by age, and to what degree?

The relationship of age, to epilepsy generally, has been considered in the sub-section Etiology, at page 126; so that it is now necessary to examine the subject with especial reference to epilepsia mitior. In the following table, therefore, the cases are divided into three series :-in the first, there are those who presented only attacks of epilepsia gravior; in the second, there are those cases which were complicated with epilepsia mitior; and in the third, there are the few in whom the latter form of paroxysm existed alone. The ages at commencement are divided into quinquennial periods; and the numbers placed in the lines of the several periods, represent, of course, the number of individuals in whom the disease commenced within those periods.

Males Females Both Males Females Both Males Females Both Males Females Both

The first obvious inference from the above table is, that age is not the sole determining cause of the form of paroxysm; for

both epilepsia mitior and epilepsia gravior have commenced at nearly all quinquennial periods up to the fortieth year. It is obvious further, that the influence exerted by age is comparatively trivial; for the cases in the first and second series are distributed upon the same general principle in each, and with no marked difference of detail.

There is, however, this to be observed, that whereas when the disease commenced under five years of age, half of the cases exhibited only the severer form of attack, and the other half exhibited either the milder form alone, or "le petit mal" in combination with "le haut mal;" when the disease began in the second quinquennial period, there were twice as many with epilepsia mitior as without it; when in the third, there were half as many again with "le petit mal" as with "le haut mal" only; when in the fourth, there were one-third as many again; when in the fifth, twice as many; but when commencing after twenty-five years of age, as in all the subsequent groups, there was only one-fourth of the number presenting "le petit mal."

We may conclude, therefore, that an early commencement does not predispose to one or the other form of attack; but that when the disease begins between the sixth and twentieth years, there is a stronger predisposition to the development of epilepsia mitior than there is at either an earlier or a later age and also that when disease commences during that period, it is more likely to be displayed by both forms of attack than by one only.

A similar conclusion is warranted if, instead of representing the prevailing numbers commencing at particular ages, we compare the mean age at commencement of those cases where only epilepsia gravior was present, with that of the individuals in whom the two forms co-existed.

The cases were so few in which epilepsia mitior existed alone, that although I have placed them in the above list, I attach no value to the numbers they furnish. For example, there was