ment of this subject, is in the negative, viz., The presence or absence of intellectual failure cannot be referred to the existence or non-existence of hereditary predisposition.

The next question to be considered is the following:

2. Can the mental condition of the epileptic be shown to depend upon the age at which the disease commenced?

There are two modes in which the materials for answering this question may be represented. In the first, having divided the epileptics into four classes, we may give the number of individuals in whom epilepsy commenced at each quinquennial period of life; we may then divide at any point we choose, say twenty or fifteen years of age, and extract in the several classes the numbers in whom the disease commenced above and below those ages. A second method is to compare the mean age at which, in each of the classes, the disease made its appearance. The first method is exemplified in the following table :

:

229

First class.

Second class.

Males. Females. Total.

Males. Females. Total.

2

4

2

4

11,

5

0

16,

5

2

3

These relations may be represented pictorially in the following diagram:

Under 5. 6 to 10. 11 to 15. 16 to 20. 21 to 25. 26 to 30. 31 to 35. 36 to 40. Above 45. Number of Patients. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

The facts which are apparent from the preceding table and diagram are of considerable interest. It is evident that in regard of each class there is this general law-that the number of patients whose epilepsy commenced at ages varying from eleven years to twenty was greater than of those in whom it commenced at any other age. This increased frequency of commencement, therefore, during that decennial period, is a property of epilepsy per se, and is not specially related to the presence or degree of mental failure.

There is no other general principle in which the four groups agree, except this very wide one, that the number of cases is less for each group at advanced than at early periods of life.

If the four classes are considered differentially in regard of age at commencement, we have the following facts:

That early commencement is more common in the first group than in the second, and in the second than in the third and

fourth; and that late commencement is more frequent in the first and second than in the third and fourth.

If we divide the patients into two series, placing in the first those whose epilepsy began before, and in the second those in whom it commenced after, twenty years of age, we have the following numbers, when reduced to per-centage:

With the exception, therefore, of the third class, in which the number in whom epilepsy commenced early in life is relatively much smaller than in the others, there is but little difference to be detected; all of the groups agreeing in this, that it is much more common for epilepsy to begin before than after twenty years of age.

It is apparent that the mind is not specially affected in those whose epilepsy begins early, neither is it in those whose disease is late in its development.

If we form another two series of the patients, dividing them at ten years of age, and combining the second, third, and fourth classes together, in order to contrast them with the first, we see that of 24 individuals forming the first class, 9, or 37.50 per cent., exhibited the disease when under ten years of age; but of those in whom the mind was more or less seriously damaged, only 7 of 36, or 19.44 per cent., were affected at that early period of life. An early commencement of epilepsy does not therefore entail, but seems rather to prevent, the mental failure which is often one of the concomitants of that disease.

Romberg has said, that "when epilepsy occurs at the earlier periods of life, and before puberty, it is generally followed by idiocy, and is frequently complicated with paralysis of single members."* The preceding statements show that, so far as my own observation has extended, such is not the case with regard to the earlier periods of life. As to the frequency of paralysis, I may say, that in simple epilepsy I have never met with paralysis except in three instances, and that in those it

* Manual of Nervous Diseases, Vol. II., p. 209.

was of simply accidental occurrence, and presented itself very early in the history of the case.

The interesting question here raised by Romberg, and previously by Esquirol,* is with regard to the influence of puberty upon the mental condition of epileptics. It has been already shown that a large number of cases date their origin during that transition period of the organism (see page 126); but it has also been shown that in but few cases can the attacks be referred, at their commencement, to sexual conditions. (See page 136.) Granting, therefore, that the general organic changes attendant upon puberty may be regarded as predisposing conditions to epileptic disease, and that there is yet wanting any evidence to prove that special derangements of the genital functions possess any notable causative influence; we return to this question-whether the commencement of epilepsy before or after puberty has any special effect upon the subsequent mental condition of the patient? Romberg states that it has, and that the effect is prejudicial; but the cases which have come under my own care would appear to warrant a different conclusion.

It being impossible to ascertain, in regard of time, the exact relationship of many cases to the development of puberty, I have divided the cases generally at the age of sixteen years, and have so placed, that they may be compared, the numbers of males and females in each mental class. I have chosen the age sixteen, it being generally understood that puberty is about fully established at that age in the majority.†

* Des Maladies Mentales, Tome I., p. 288.

+ Carpenter's Principles of Human Physiology, pp. 992 and 996.

From this table it is evident, 1. That commencement before puberty does not necessarily or prominently entail mental failure upon either sex; for out of twenty-four cases in which no intellectual impairment could be detected, no less than fourteen had suffered from the disease before they were sixteen years of age.

It appears, 2. That the commencement of epilepsy after the sixteenth year is completed does not prevent the occurrence of serious mental failure; for, out of fifteen cases exhibiting great defect of mind, no less than ten were free from the disease until after puberty.

We may conclude, 3. That the chances of mental impairment are precisely the reverse of those which Romberg has stated them to be; for, throwing together the first and second, and the third and fourth classes, we find that whereas of those in whom there was little or no intellectual deterioration, there were so many as 61 per cent. who suffered before reaching their sixteenth year; on the contrary, of those in whom there was considerable defect of mind, there were but 33 per cent. who dated their disease from so early a period of life. Early commencement of epilepsy, or commencement before puberty, is of favourable omen, therefore, in the prognosis of an individual's intellectual chances.

The second method by which we may reply to the question on page 164, is a calculation and comparison of the several mean ages at which epilepsy commenced in those individuals who formed the four classes respectively.

By considering the two sexes together, and combining the first two and the last two groups, we arrive at the widest difference which the above table exhibits, and learn that, when there was little or no mental impairment, epilepsy began one