and motion which may not amount to the dignity of an epileptic attack.
These may be so fugacious as to escape the attention of the persons in
whose company the patient may happen to be, or he himself may be
unaware of any disordered state of feeling. They may precede a severe
paroxysm, when they are known as warnings or auræ. The term aura was
originally applied to the familiar premonitory sensation which is so
often likened by the subject to the blowing of wind over the skin,
from whence it receives its name, but it has come to be applied to all
primary indications of a fit. Such auræ may be sensory or motor—in the
preponderance of cases the former, for motor precursors are quite
rare, and when they occur are most likely to be but one stage, though
a slight one, of the convulsion itself. There is no general rule about
the occurrence of an aura, but, so far as my experience goes, there is
great constancy in the character of the warning in each particular
case. The sensory disturbance may vary from a vague feeling of
confusion to a well-marked sensation. In many instances the patient
speaks of an indescribable mental disturbance, which may precede the
attack and last anywhere from a few minutes to several hours. This
confusional state or psychical aura is most protean in its expression.
It may simply be a heavy feeling, a feeling of tension, a sleepy
feeling; a restlessness which is manifested by the patient changing
his position frequently or wandering forth into the streets; an
irritability of temper which often lasts twenty-four hours or more,
and during the display of which he rebukes those who may be solicitous
about him, or wantonly destroys articles of furniture, or vents his
spleen upon inoffensive persons. I have had epileptic children under
my charge who were wont to bite their little brothers and sisters or
their nurses. A feeling of terror sometimes precedes the attack, and
very often there is a sense of impending danger which has no basis
whatever, and with it is associated a depth of depression which is
very painful. In other cases the patient manifests a strange
exhilaration, which may precede the occurrence of the attack for a
period of from one or two hours to two or three days; and this is made
manifest by great loquacity and a lively play of spirits. It is not
rare to find errors in the speech as indications of an approaching
attack. A minor degree of aphasia, slowness of speech, or anarthria
betrays occasionally the preparatory state which is the precursor of a
severe convulsion. By far the most common warnings, however, consist
of disorders of the special senses, and generally these are visual.
From an inspection of my notes I find that the patients saw colored
lights, rings of fire, bright objects, dark spots, luminous clouds, a
flood of light, sparks, stars, bright balls, lights which approached
them, lights which receded, fireworks, and all became dark. While many
were unable to define the color perceived, I found among those who
were positive that red was the color most frequently seen, while blue
came next; and this is a conclusion which I believe is accepted by
Jackson and others who have analyzed their cases.
Hemiopia and diplopia in rare cases precede the major attacks, and are
sometimes associated with distal pain and anæsthesia and with
supraorbital pain as well.[27] Among these ocular warnings we find
constriction of the visual field to be often present, especially in
cases where there is a {476} history of migraine. Vague disorders of
hearing, which may even amount to the dignity of hallucination, are
complained of by some persons. There may be simply roaring in the ears
or a sound of bells, and in one instance my patient declared that he
heard whisperings at the time of the seizure. Some patients smell
smoke or other foul odors, and in exceptional instances the odor of
some particular flower or of some aromatic substance, such as camphor,
turpentine, or tar, is perceived by the epileptic; and these are
probably psychical.[28] Sometimes there is a feeling of great
suffocation, constriction of the chest or of the throat, palpitation,
or vertigo.
[Footnote 27: See Sensory Epilepsy.]
[Footnote 28: For curious examples of this kind consult Sir Charles
Bell's _Nervous System of the Human Body_.]
There are disorders of cutaneous sensation of great diversity of
character, but those auræ which are of the most constant occurrence
are the epigastric, which consist of a vague sensation starting below
the sternum and ascending, its arrival at the throat being coincident
with the commencement of the fit, and the patient very often likens
its culmination to the violent grasp of a strong hand. So, too, we
find crawling sensations starting in the extremities and running up to
the trunk. These have been compared to the contact of insects in
motion or to the blowing of wind over the surface. There may be
tingling in one or two fingers or the whole hand, and such sensations
may be unilateral or bilateral. It is quite common for the sensory
warning to begin in the hand and foot of one side and to run up to the
knee and elbow. Sometimes the tongue becomes hyperæsthetic, and I have
frequently found that the gums became exquisitely tender just before
the attack. According to Gowers, 17 per cent. of his cases began with
unilateral peripheral auræ, but I think this is too small a
proportion, for, so far as I have observed, at least 30 per cent. of
all my cases in which any auræ at all could be ascertained presented
the history of a one-sided warning, beginning most often in the right
hand. Gowers says that in three-fourths of his cases in which the
attack began in the hand consciousness was lost before the seizure
extended beyond the arm, while in the others it extended much farther
before the actual fit was precipitated. In Gowers's cases he rarely
found that unilateral auræ were associated with other warnings; and
his experience, which is like my own, goes to prove that unilateral
sensory auræ and one-sided initial motor expressions go together, and
very often indicate gross organic disease. In some cases there may be
for several days a decided unilateral or general muscular weakness or
recurring chronic spasms which may be frequently repeated. In aborted
or irregular attacks there are also peculiar motor symptoms, to which
reference will be made later on.
In two or three patients I have found that the attack was immediately
preceded by a profuse discharge of saliva, and in one case the patient
had frequently bleeding from the nose. Several authors have called
attention to certain local vaso-motor disturbances which are expressed
by limited patches of cutaneous hyperæmia or anæmia, so that the
fingers—or, in fact, the whole hand—may either be swollen and of a
dusky-red color, or, contrariwise, there may be blanching and an
apparent diminution in size.
Sometimes the patient immediately before the attack makes more or less
automatic movements, pressing his hands to his head, clasping his
breast, {477} or clutching at some imaginary object, and after this he
loses consciousness and falls to the ground. In some irregular cases
the patient runs aimlessly for some distance or describes a circle,
and after a variable time, which rarely exceeds a minute or two, the
actual fit begins. Here are two examples:
Case I.—Boy aged fifteen, has been subject to somnambulism; attacks
began two years ago. He frequently when sitting at table rises
suddenly, and runs either around the room or out into the street if
possible. In thirty seconds or so he falls to the ground in a
convulsion. Always falls backward in opisthotonos.
Case II.—Man aged thirty-four. Attacks always begin by stage of
violent temper. While unconscious he runs about office, striking all
who try to restrain him; finally falls to the floor. Convulsions, when
they occur, are always severe. Sometimes running attack is the sole
feature.
This disposition to run is no less remarkable than another queer
prodroma I have seen in several patients, who began to take off their
clothing when first seized, no matter where they were or under what
circumstances. This is not, as has been suggested, the remains of a
half-formed idea that they must seek their beds because of their
impending trouble, but it is a much less complex mental act, and the
several patients I have seen were fully unconscious when they did
this, and were in places where there was no bed within reach. Equally
curious mental precursors of the attack have come to my notice, and
these I will detail subsequently.
SYMPTOMATOLOGY.—The Light Attack.—The epileptic attack may, as I have
said, be scarcely perceptible to those about the patient, or may
consist simply of a momentary loss of consciousness and very feeble
convulsive movements. Reynolds has described two forms: (1) That
without evident spasm; (2) that with evident spasm. Such seizures are
always fugacious, and consist merely in some transient loss of
consciousness and very little or no convulsive movement. The tonic
spasms prevail, if any, and the disorder of motility may often consist
simply in the arrest of some act in the performance of which the
patient is engaged. While playing the piano the patient's hands may
for a moment remain suspended over the keys he is about to strike; if
eating, the hand which holds the fork may be arrested between the
plate and his mouth. The attack consists sometimes in the rolling
upward of the eyeballs, or when crossing the room the patient may
stop, remaining quiet for an instant. Temporary unconsciousness, shown
by cessation of conversation, by change of color, and absence of
intelligent expression, accompanies the other trouble. In a
well-marked attack of petit mal the patient may move his lips
convulsively, and remain otherwise quiet, but bereft of consciousness,
for one or two minutes.
The patient sometimes loses himself and loses the thread of the
conversation, repeating what he has just said or showing his want of
appreciation of what his companion has said. To this light grade
belongs the case reported by Jackson of the individual who blew his
nose upon a piece of paper and gave the conductor £2 10_s._ instead of
twopence halfpenny.
The Major Attack.—An attack of epilepsy of the familiar severe form
may or not follow an aura. The first intimation to the bystander may
be a noise made by the patient, which is either a loud, startling,
wild cry, or a gurgling groan due to compression of the thorax and the
{478} forcible escape of wind through the vocal cords. There are three
stages of the attack: (1) The stage of tonic convulsion; (2) the stage
of clonic convulsion; (3) the reactionary stage.
The first stage of the attack is symptomatized by tonic spasms, which
may be local or general, usually the latter. It is very often
unrecognized, for its duration may be so short that it is lost in the
stage of clonic spasms, which is much more protracted. There is
usually unilateral seizure, the muscles of the face being primarily
involved, then those of the hand and upper extremity, and then those
of the lower extremity; and finally there is a general involvement, so
that the patient may be in a position of opisthotonos. In some cases
there is strong tonic contraction to one side, or pleurosthotonos. The
notes of a case which illustrates the beginning and development of
convulsion with reference to the parts involved, which I observed
carefully, are the following:
Bindewald: Epileptic attack observed at hospital for paralyzed and
epileptic, Sunday, Mar. 12, 1882:
1. Long, shrill cry which attracted my attention. It probably lasted
five seconds. At same time patient threw up arms and became
unconscious, and fell to floor. Nurses ran to him and placed him upon
bed.
2. Tonic convulsions began by fine twitchings at right corner of
mouth. These became gross, and were separated by succeeding long
intervals. Eyes directed to left side, face pale.
3. In twenty seconds twitching began in right hand and arm, which were
rigidly flexed (five seconds); then leg and foot of right side became
agitated, the face meanwhile changing in color successively from
red-gray to purple; lips purple, ears livid and purple, edges white;
eyes still turned to the left, pupils dilated, eyes widely open;
breathing stertorous and irregular.
4. General convulsions of right side.
5. Head suddenly twisted to left side; position of eyes the same. Chin
drawn down, movements moderated; still livid. A fit of coughing and
expectoration of much frothy mucus. Left side, with exception of head,
not implicated. Whole attack lasted about one minute and thirty-five
seconds. Deep sleep afterward, lasting forty-five minutes.
This attack was one of many in a confirmed epileptic, and is a fair
example of those commonly met with, though not as general as we
sometimes find. In most cases the attack appears to be very much
longer than it usually is, and the phenomena noted above, which seemed
to occupy a considerable space of time, really lasted but little more
than a minute and a half. Axenfeld and Beau fix the average period of
the attack as follows: “Duration of the complete attack, which Beau
divides into four phases: first stage, tetanic stage, five to thirty
seconds; second stage, clonic convulsions, from one to two minutes;
third stage, stage of stupor, three to eight minutes; fourth stage,
return of sensibility and intelligence. It is not complete until the
end of from ten to thirty minutes.”
To be more explicit, the manifestation of an ordinary epileptic attack
of the more severe kind is very much like this: Usually without any
warning to those about the patient he utters a shrill, peculiar cry of
a character never to be forgotten if once heard, and then, perhaps
throwing up his hands, he falls to the ground rigid and contorted. His
body may {479} be arched laterally or antero-posteriorly, his legs are
thrown out, his forearms flexed, and his fists doubled, the thumbs
being beneath the other fingers. His face may be for a moment flushed,
but the color recedes, and it assumes a dusky-bluish tint, the lips
being ashy-gray. The eyes are usually open, and the balls are rolled
up and the pupils widely dilated. The breathing may for a moment be
suspended, but it soon quickens, and becomes labored and noisy, and
the pulse grows hard and full. The tonic contractions are succeeded in
a very short time by more or less violent clonic contractions, which
increase in violence and rapidity; the jaws work and the lips are
covered with foam, which is blown in and out by the rapid inspirations
and expirations. It may be tinged with blood in the severe attack if
the tongue is bitten, which is by no means an uncommon accident. The
teeth are sometimes firmly set and the jaws locked. The head is
usually drawn to one side in the first stage, but afterward may be
rolled from side to side. The movements are now more or less general,
and occasionally the agitation is so great that the patient throws
himself from the bed on which he may be lying. The face grows more
pale, or rather more livid, and toward the end of this stage there may
be a puffiness and congestion such as are seen in partially
asphyxiated individuals, for this alteration in color is due to
dyspnœa and consequent imperfect oxidation. The patient may defecate
or pass his urine unconsciously, and sometimes we find seminal
emission. The movements, after a period varying from ten seconds to a
minute or two, become less violent, and he may talk in a silly manner,
as a person does who is recovering from profound ether
unconsciousness; or deeply sigh, and he is restless. The pulse is now
much weaker and more rapid, and may be irregular. The color returns to
the face, the patient closes his eyes, and the body is covered with
profuse perspiration. The fingers are unlocked and every evidence of
spasmodic movement disappears. He falls asleep, and remains so for
several hours, awaking with a confused feeling, headache, and no
remembrance of the attack, and is only reminded that something has
happened by his wounded tongue or lips, the bruises he has received,
or by the information of friends. He looks jaded and tired, and is
indisposed to exert himself for several days if the attack has been at
all severe. The transition from the attack to the normal state is not
always the same. Some patients do not sleep at all, but after being
dazed go about their occupation. This is even true occasionally of the
severe form of disease.
The usual termination of the attack is, however, by sleep preceded by
a period of confusion. The patient, after coming out of the clonic
stage, mutters incoherently. He is apt to pass large quantities of
wind from his bowels, or vomits. This is attended by a subsidence of
the spasmodic movements, and perhaps by oscillation of the eyeballs.
The pulse loses its rapid, hard character, and the reaction brings
with it diminished frequency of respiration and the evidence of
exhaustion.
Special Symptoms.—The eyes are, as a rule, open, and, there being
spasmodic movement of the ocular muscles, we find that the balls are
either rolled up or directed away from the side in which the spasms
begin. This is especially true in those epilepsies due to cortical
disease, and the same law of conjugate deviation laid down by
Bourneville may be remembered.
{480} The pupils are dilated pretty much throughout the fit, though
they may vary, and a transient contraction may occur at the
commencement of the first stage. During the clonic stage, especially
toward the end, they not infrequently undergo a species of
oscillation. The interparoxysmal state is revealed by a very great
mobility of the pupil, which has been observed by Gray and others.
Gray is disposed to consider it a diagnostic indication of value, but
so far I have found it only in two-thirds of my cases. Dilatation of
the pupil I believe to be a very constant feature of epilepsy.
The ophthalmoscope reveals in certain cases an abnormal increase in
the circulation at the fundus, in others a very decided emptiness of
the retinal vessels. Jackson is disposed to consider that certain
visual auræ depend upon spasm of the arterioles in this location.
Loring, whose opportunities for research have been very great, is not
disposed to attach much importance to the ophthalmoscopic appearances,
at least during the periods between the fits.
The pulse of the epileptic between the paroxysms is small and
irritable. Voisin has found the following changes: “Two or three
seconds before the attack it becomes rapid, sharp, and the
sphygmographic curves are higher, rounded, and nearer together. When
the attack begins we see five or six little undulations in the course
of the ascending line, and the curves are higher and more accentuated.
Several minutes after the attack there is dicrotism, and the line of
descent is very sharp, the angle with the ascending being quite acute.
This form of pulse lasts an hour or half hour after the attack. There
is in some cases great irregularity, with paroxysms of cardiac pain
resembling angina pectoris. There is occasionally epistaxis or more
marked hemorrhages.” Parrot speaks of hemorrhages from the eyes and
ears, and occasionally the cerebral congestion is so great as to
result in cerebral hemorrhage in old subjects.
The temperature is usually lowered before the attack, but the surface
temperature is increased during or after the second stage.
Cutaneous sensibility is often very much disturbed. Spots of
hyperæsthesia and anæsthesia are sometimes left after the attack. The
scalp is not infrequently exceedingly tender. The sensory troubles
have been alluded to as prodromata of the ordinary motor attack. Some
attacks of the sensory variety in which psychical excitement plays a
part are characterized by unilateral and persistent formications.
A consequence of some epileptic paroxysms is the appearance of
petechiæ, chiefly upon the face, neck, and upper extremities. The skin
of old epileptics is harsh, cold, and rough, and the face is apt to be
studded with spots of acne even when the patient is not taking the
bromides. The hair is stiff and dry, and the ears and tip of the nose
are apt to be the seats of a passive and old hyperæmia.
The urine of epileptics is apt to contain evidence of muscular waste,
and an increase in the amount of earthy phosphates as well. Zapolsky
found, however, that immediately after the attack there was diminution
in the quantity of the phosphates. The occurrence of glycosuria has
been noted by numerous clinicians. De Renzi[29] has published an
interesting article. I have seen no less than six well-marked cases
within two years in which constant glycosuria was a feature of the
disease, but in two of {481} the patients well-marked symptoms of
disease of the pons were present. After the paroxysm it is by no means
uncommon to find the urine loaded with albumen. Otto, Mabille,
Saundby, Bazin, and other writers speak of a transitory albuminuria.
Kleudgen,[30] however, does not attach much importance to this
feature, believing that the albumen is often due to semen.
[Footnote 29: _Gior. internaz. d. Sc. Med._, Napoli, 1880, ii.
357-359.]
[Footnote 30: _Archiv für Psychiatrie, etc._, 1880, xi. 478-506.]
The tendinous reflexes are frequently abolished during the attack, but
not always so, and in several cases in which I was enabled to make a
test during the convulsion I found that the patellar reflex was very
active, and in one case elsewhere reported it was transferred. The
skin reflexes are ordinarily exaggerated.
Tongue-biting is, I think, a more common feature of the nocturnal than
the other attacks. It is rare in infantile epilepsy, and is always a
bad feature. The wound is sometimes very serious, and cases are
mentioned where the tongue has been severed. An occasional sequel of
the attack is a urinary difficulty and vesical tenderness. It is
sometimes connected with great urethral irritability and spasmodic
stricture, which prevents the introduction of a sound or catheter.
Romberg speaks of the supervention of asthma and dysphagia.
THE IMMEDIATE AND REMOTE EFFECTS OF THE EPILEPTIC PAROXYSM.—As a
result of violence we often find wounds and bruises, quite rarely
fractures, but more often dislocations. Cases have been communicated
to me where as a result simply of the great muscular force the humerus
has been dislocated at its superior articulation. Muscular pain of
great severity, and sometimes of great persistency, follows unusually
severe fits, and rupture of muscular substance is not uncommon. An
epiolecranon bruise in one of my cases produced a severe neuritis
which was very intractable. In old cases, according to Axenfeld, there
may be great muscular hypertrophy, the sterno-mastoidii attaining the
size of the biceps, and in other cases there is fatty degeneration. He
also calls attention to defects that may be due to frequent exercise
of violence upon bones through repeated exaggerated muscular
contraction. Paralysis of nerves which supply convulsed members is
mentioned.
The psychical effects are various. For several days following the
attack there may be simply confusion of ideas, irresolution, or
drowsiness, which subsides in a short time. In not a few cases I have
regarded the attack as beneficial in the sense of an explosion of
relief when perverted mental states had preceded it. In such persons
the discharging lesion was followed by a very conspicuous restoration
of the mental equilibrium.
Occasionally the attacks are terminated by great violence or screaming
or the commission of purposeless acts.
Post-epileptic aphasia has been described by Winslow, Moreau, and
others, and among my own cases of the sensory variety of this disorder
I have met with speech disturbance. The aphasia is of short duration,
and consists either in a total incapacity for verbal expression or a
transposition. It is not rare for it to be associated with the
commission of a number of quasi-automatic actions.