paresis which may last even for several days. The loss of power is
confined to the convulsed members, and may be accompanied by tingling.
{482} In the greater number of instances, however, there is some
central organic change, and the epilepsy is purely symptomatic.
Deafness, amaurosis, and other pareses of the organs of special sense
are rare sequelæ of the epileptic state.
The remote effects of the grave disease are not so decided as when the
patient has been the subject of petit mal. Slight repeated losses of
consciousness are apt to be followed by mental decay. The ultimate
result is mental enfeeblement, a progressive and very great loss of
memory, which advances to such an extent that a veritable dementia
ensues. With this there is usually a very decided perversion of the
emotions and affections, so that a good-natured, amiable child may in
a few years become everything that is bad and trying, and the acts of
mischief are almost inconceivable. Theft, incendiarism, and various
moral perversions are common in some chronic epileptics. The dementia,
it is true, is tardy in its establishment, but it comes eventually if
the individual lives long enough.
In some individuals there is a very early tendency to the development
of mania; there is a certain periodicity about the explosions, and
when established the excitement either precedes the attack by a few
days or occurs shortly afterward. The violence is characteristically
acute, and such insanity very often makes itself known in homicidal
acts rather than in those of a suicidal character. Hypochondriasis is
quite likely to follow continued epilepsy.
It is the rule for epilepsy to undergo decided modifications in the
beginning of its course. The first attack may be simply eclamptic,
without any peculiarities or definite character, and with recurrence
there is a tendency to regularity and constancy in expression.
Infantile convulsions, that may occur at any time after inconsiderable
exciting causes, may eventually be confined to the early morning or
night. So-called fainting attacks may precede petit mal, and headache
may be the precursor of ill-defined seizures. So, too, the relation of
grave and light attacks may vary. In the beginning there may be
nothing but attacks of petit mal, while later these may be
supplemented by severe fits, and even disappear entirely. So far as my
own cases go, I find that nearly two-thirds of the entire number
happen at night or in the early morning, while the others may occur in
the day or at any other time, or by day and night. Besides the terms
nocturnal and diurnal, we may use the word matutinal in relation to
the time of attack. So far as the number of attacks is concerned, we
find great irregularity. It is not always possible to count them, or
even to recognize them, for the examples are numerous where nocturnal
attacks have been undetected for years, and have finally been followed
by fits during the daytime. I have cases who have seizures but once or
twice a year, and others who have ten to forty or fifty daily. In some
cases there may be eight or ten attacks of petit mal daily, and but
two or three grave attacks during the week.
The statistics of Delasiauve and Leuret go to show that of 296 cases
of epilepsy, the cases of general epilepsy were most common—that is to
say, the attacks which occur both by day and night.
Attacks occurring occasionally by day . . . . . . . 26
" " habitually by day . . . . . . . . 30
" " only at night . . . . . . . . . . 9
" " habitually at night . . . . . . . 8 {483}
" " equally by day or night . . . . . 87
" " in larger proportion by day . . . 70
" " " " " by night . . 44
Delasiauve, Herpin, and others make delicate distinctions between the
attacks, and the former grades the seizures beginning at accesses, and
successively advancing to vertiges, accès intermédiares, and attaques
or accès compléts.[31] In fact, these are but varying degrees of
violence of the discharge, after all. We thus have light discharges
and severe discharges at different times, or, as the habit is
established, only the light or only the severe, the manifestation
depending probably upon the number of discharging cells and the
importance of the exciting cause.
[Footnote 31: _Traité de l'Épilepsie, etc._, Paris, 1845, p. 55 _et
seq._]
When the attacks occur in alarming frequency, as they sometimes do,
the condition is known as the status epilepticus. Leuret had a patient
who had eighty in two hours, and Delasiauve reports the case of a
young man fifteen years old who had twenty-five hundred in one month.
They may be so numerous as to be apparently continuous. The patient
remains in a state of coma (the status epilepticus), with very high
temperature. If he be not restored, he sinks into a deeper coma, and
all the signs of collapse manifest themselves. Bed-sores form, œdema
of the lungs ensues, and the patient dies. Happily, this condition of
affairs is rare.
Delasiauve calls attention to the fact that the first two or three
attacks that usher in this state do not usually attract much
attention, but the succeeding ones are so violent as to immediately
suggest violent consequences. In one of my cases the attacks, when
they had once become numerous, were readily excited by the least
jarring, noise, or handling, just as we find in strychnine-poisoning
or tetanus.
Irregular Forms.—There are occasional cases of psychical or masked
epilepsy, the study of which is intensely interesting. Such forms are
characterized by perverted consciousness and a low degree of
volitional direction which may vary from automatism to the undoubted
exercise of complex functions of the mind, though badly co-ordinated.
Mesnet's soldier, when subject to a paroxysm and apparently
unconscious, would perform a number of suggested acts in a rhythmical
manner and with no subsequent knowledge of the previous event: when
started off by the word of command to march, he would blindly go on,
marking time when he met with an obstruction until stopped, or when a
paper and tobacco were placed in his hands he would proceed to roll an
unlimited number of cigarettes.
Two cases of a more complex exercise of certain intellectual powers,
while others were dormant, came under my observation some time ago.
One of them was a young man of twenty-three, who had had irregular
epileptic seizures for some years. He went to bed one evening as
usual, arose, and breakfasted with his family without creating any
suspicion that he was at all unwell. He then went down to his place of
business, and after his arrival was sent to a distant part of the city
for some tool. On his return down town he stopped at a tobacconist's
and became involved in a quarrel with one of the persons in the shop.
A policeman was called, who, more intelligent than many of his class,
immediately detected something queer about the man, arrested him, and
afterward took him to Bellevue Hospital. There he remained three days,
and suddenly {484} returned to consciousness and a knowledge of his
surroundings, but was entirely ignorant of his unfortunate experience.
It is unnecessary to say his habits were perfectly good and he was not
drunk at the time of the quarrel or arrest. His last recollection was
that of going to bed the night before the day of his arrest.
Another case of unusual interest which came under my care,
illustrating a phase of sensory epilepsy, is worthy of reproduction:
C. O——, aged twenty-two, is a reporter attached to one of the New York
afternoon papers, who received a severe injury of the head when but
three years old. He fell from the second story of an unfinished
building to the cellar, striking the upper and back part of his head
upon a beam. He was rendered unconscious, and remained so for a day or
more. He recovered from the immediate bad effect, but has suffered
from severe general headaches, which recur every week or so, with an
increase in the amount of urine excreted. About six months ago he
began to have epileptic convulsions of a violent character almost
every day, and sometimes more often. These were precipitated by
excitement, and he had a great many when worried about his wife at the
time of her delivery. Upon one occasion he fell down stairs and
injured himself quite severely. The attacks were, as a rule, preceded
by an epigastric aura of long duration, and occasionally by a visual
aura, and, according to the testimony of his associates, he became
strange and queer. When in such a dazed condition he would restlessly
wander about his office, and suddenly, without any cry, become
convulsed. After the attack he slept soundly. The bromides of sodium
and ammonium and digitalis did little or no good, but the bromide of
nickel appeared to have some influence. During the past month he has
had only two or three attacks, but these have been of a quite
irregular character. He told me that there were times when he felt
like doing himself an injury, and that he had impulses to kill some
one else. His companions said he was irritable, pugnacious, and easily
thwarted, and his brother-in-law stated that upon several occasions he
had queer turns, when he would raise his hand to strike some member of
the family—that he subsequently knew nothing of his conduct, and when
it was detailed to him he appeared greatly astonished.
Mr. O—— came to my office in company with a friend at ten o'clock in
the morning of December 27, 1883. He had had one of his attacks at the
newspaper office, of rather more severe character than usual, at eight
o'clock, with a psychical aura, during the existence of which he was
very morose and sullen. Upon recovery he was speechless, though he
could communicate by signs. Upon his arrival at my office his manner
was composed and he appeared somewhat dazed. His pupils were dilated,
but contracted readily to light. I asked him one or more questions
regarding his inability to speak, which he perfectly understood, and
when I gave him a pencil and a piece of paper he replied without
difficulty in writing. When told to make a great effort to speak he
did so, and I thought I detected the word ‘To-day,’ but he could not
repeat it, though he tried and expressed great annoyance. He was
unable to utter any sound except a sort of groan, which could not in
any way be taken as an element of speech. I examined his larynx, but
found nothing which could explain his impaired phonation, and I sent
him to Dr. Asch, who found absolutely no abnormal appearances to
account for the speech {485} difficulty. The patient could not
phonate, and though he made attempts to enunciate the vowel-sounds,
and the vocal cords were approximated, he made no orderly sound. Asch
found a slight laryngitis of no importance.
The patient went home, and remained speechless all day, and was seen
by my associate, G. de Forrest Smith, in the evening. What occurred
during and after that gentleman's visit is contained in his notes: “I
was called to see patient about 8.15 P.M. He was lying upon the bed,
but had not slept; recognized me and motioned that he could not speak,
and I found that he could only say one or two words, and this with the
greatest effort, and so all my questions were put so that he could
answer them by nodding or shaking his head. He knew that he had had an
attack in the morning, that he had seen Hamilton and Asch, and
recalled various incidents of the day, answering intelligently my
questions in regard to them. He indicated by motions that his
inability to speak was due to a lump in his throat. When asked if he
had any trouble to think of the word he wanted, he shook his head, but
shortly afterward hesitated in an answer, and when asked if this was
due to his inability to think of the word, said ‘Yes.’ Was asked if he
had any loss of power in either side, and he motioned to his right arm
and leg, and said that he felt a numbness and pricking on that side.
On his grasping my hands with his, the right was perceptibly weaker.
“At one time he seemed confused as to which was his right or left
side, and put up both hands, and after looking at first one and then
the other in a puzzled manner, at last decided correctly, then smiled
apparently at his confusion.
“All this time he had been half lying on the bed. He now intimated
that he was tired, put his head down on the pillow and began to belch
up wind, and as he appeared about to vomit I called for a basin; but
this was only the beginning of an attack; the muscles of the neck and
right side assumed a state of tonic spasm, the extensors
predominating, so that the head was turned a little to the left and
forcibly thrust back into the pillow, and the right arm and leg were
firmly extended. He remained in this position about one minute; then,
taking two or three full inspirations, put his hand to his throat and
said plainly, ‘Something has fallen from there.’ On being asked
‘What?’ he replied, ‘A bone has fallen from my throat.’ I told him it
was well that the bone had fallen, as now he could speak. ‘Why,’ said
he, ‘I have had no difficulty in talking.’ On being asked why he had
seen Asch, he said ‘Who is Dr. Asch? I never saw any such person.’
Further questioning showed that all the occurrences of the day (except
those which had taken place immediately before the first attack) were
an absolute blank, and he thought it still morning. He asked the time,
and I told him half-past eight o'clock in the evening. At this he
seemed much surprised and said, ‘Why, I went to work this morning; how
did I come here?’ I then explained to him that he had been ill. After
further conversation he said he felt sleepy, and, after resting a few
minutes, he arose, put on his slippers, and came out into the room. He
walked with difficulty, because of the loss of power in the right
side, which he said felt numb and sore, as if it had been pounded,
also a sensation of pins and needles. After the attack his mind was
perfectly clear, and he could talk as well as ever, and all that had
happened before the attack in the morning he could remember {486}
perfectly well, but the interval between the two was a complete blank.
His inability to speak seemed due, not to lack of knowledge of what he
wanted to say, but rather to want of power to form the words, although
there was no paralysis of the vocal muscles. When he did manage to say
a word, it was invariably the correct one, but it was always done with
the greatest effort. The day after the attacks he remained at home;
the next day he went to work, but his head felt heavy and confused.
Two days after he complained of a pressure on the left side and back
part of the head; otherwise he was all right. At this visit he said
that after I had left him on the night of the attacks he intently
thought, striving to recall the incidents of the day, and after a time
concluded he could remember being at Thirty-third street, but did not
know how he got there. He thought he could recall going to see Asch,
but would not know him if he should see him. I then asked him how
questions were answered by him on that day; he answered he did not
know, as he had not thought of that; then, after a few moments'
reflection, said he must have written the answers. He was then shown
some of the answers he had written, which he recognized, and by an
effort of memory could recall some of the incidents of writing them.
He was still unable to remember anything that occurred after his
arrival home previous to the last convulsion.”
January 27, 1885: This patient subsequently suffered from several
attacks in which the psychical element predominated. His head
presented a remarkable deformity, there being a prominence posteriorly
which might be compared to a caput succedaneum, only it was entirely
osseous. The upper margin was separated from the anterior parts by a
deep sulcus.
Under such circumstances we find very often that acts of great
violence are committed by such epileptics for which they are entirely
irresponsible. Two or three cases of the kind occur to me now. One of
them was a boy who always bit every one and everything—his family, the
domestic animals, and inanimate objects; another, a most dignified and
lady-like woman, who violently struck different members of her family;
and within the past week a woman was brought to me who hurled a
kerosene lamp at a perfect stranger with whom she was quietly talking
before the seizure was precipitated. Numerous instances are related
where individuals while in the masked epileptic state have wandered
for long distances and committed a variety of purposeless acts, and
undoubtedly many of the mysterious disappearances are of this order.
SENSORY EPILEPSY.—Some years ago Hammond referred to certain peculiar
epileptic attacks in which sensory manifestations were very
pronounced. To this condition he gave the name thalamic epilepsy,
believing the condition to be one of the optic thalamus. Among the
large number of unclassified and irregular cases reported by various
authors there are many so much resembling each other that I think they
should be relegated to a special place.[32] The notable examples of
Sommers, Bergmann, Tagges, Guislain, and others belong to this
category.
[Footnote 32: I shortly afterward, believing the term a misnomer,
invented that in use: “On Cortical Sensory Discharging Lesions or
Sensory Epilepsy,” _New York Med. Journal and Obstetrical Review_,
June, 1882; also see “A Contribution to the Study of Several Unusual
Forms of Sensory Epilepsy which are probably Dependent upon Lesions of
the Occipital Cortex,” _New York Med. Record_, April 4, 1885.]
{487} The features of this form of epilepsy are (1) the expression of
some hallucination (prodromal stage), or hemiopia; (2) supraorbital
neuralgia; (3) aphasia, formication; (4) slight loss of consciousness,
and little if any motor disturbance.
I may present two illustrative cases:
A few months ago I was consulted by a medical gentleman in regard to a
patient who had for years presented a curious train of nervous
symptoms, which afterward assumed a form leading me to think she might
have sensory epilepsy. She would, in the presence of the gentleman who
consulted me, who was a personal friend of the patient and a medical
man, stop short in the midst of an animated conversation, look fixedly
ahead, appearing momentarily lost, remaining abstracted for a short
period, possibly a minute, and on recovering herself go on, finishing
the sentence she had commenced before the seizure. At this time she
constantly had hallucinations of a visual character, when she saw
animals, birds, figures of men and women, who approached her, as well
as a variety of other objects. A common hallucination, which had been
repeated quite frequently, consisted in visions in which green leaves
and white rabbits and other objects familiar to her in childhood
figured extensively. Upon one occasion, while sitting in the
drawing-room, opposite a door which communicated with the hall, she
suddenly called her companion's attention to the hand of a man which
she saw clasping the baluster rail. The hand was seemingly
disconnected from the arm. She was somewhat agitated, and it was
nearly half a minute before the vision was dismissed. Sometimes she
would call attention to the hallucinations before the attack, but more
often she became transfixed, apparently lost, and then recovering she
described her visions minutely. She has apparently been able to
foresee the attacks and ward them off by a strong voluntary effort. So
far as can be learned, there is no hysterical element in the case, but
her seizures are more frequent at the time of menstruation. In a
private note it is stated that “the family history of the patient is
very good, and she has always seemed remarkably healthy and robust,
and has shown more than usual intellectual ability. She has appeared
to persons generally to be of a contented, happy disposition.... At
night, when she closed her eyes, she suffered from these
hallucinations, especially after a day of fatigue. Her pupils are
usually dilated, but her color undergoes no change during the
seizure.”
The second case is one of a more complex type:
J. B——, a bright boy aged sixteen, was sent to me by F. H. Bosworth in
April, 1883. He comes of nervous stock, his mother being subject to
epilepsy, and his father is an eccentric man who manifests his mental
peculiarities chiefly in a morbid restlessness and irascibility. There
is a brother who is healthy. The attention of the parents was first
called to the boy's condition by his recital of a sudden attack which
occurred during the summer of 1882. While rowing upon a river he
suddenly and completely lost the visual use of the right eye, so that
in looking at a number of ducks swimming near his boat he failed to
perceive those upon one side of the flock. This condition lasted for
twenty minutes, and after a brief and severe pain over the right eye
he became unconscious, the unconsciousness being preceded by a
tingling and numbness of the hand, forearm, arm, and left side of the
tongue. He has {488} subsequently had eight or ten of these attacks,
of which the following is an example: Usually without any bad
feelings, physical or mental, he, while engaged in any duty or at any
time, suffers a sudden unilateral blindness. This is never gradual,
and not like the form of amblyopia in which the visual field is
gradually reduced. There is some hemichromatopsia. It would seem as if
the retinal anæsthesia was unequal, for while usually the loss is
complete and universal, it sometimes happens that there is only a
limited loss. Upon one occasion, while reading, he suddenly lost the
printed matter of the right lower half of the page below a diagonal
line extending from the right upper corner to the left lower corner.
There is never diplopia. This deprivation lasts anywhere from ten to
twenty minutes; meanwhile, a distal anæsthesia, coming very gradually,
involves at first the fingers of the opposite hand, and successively
extends to the forearm, arm, and other parts, as I have already
mentioned. There seems to be analgesia as well as anæsthesia, for a
pin may be run into the muscles without producing pain, and upon one
occasion the gum was freely pricked without any discomfort to the
patient. It invariably happened that the cutaneous sensory trouble
occurred upon the side opposite to the hemianopsia and neuralgia, and
in the greater number of instances the left side was that affected.
The third stage of the attack consists in migrainous headache of a
very severe kind, and which sometimes lasts for an hour or more. There
is a subjective feeling as if the eye was pushed forward. This
disappears with nausea and relaxation. More often he loses
consciousness when the anæsthesia reaches its limit, which seems to be
the extension of the anæsthesia to the gums. Occasionally there are
slight convulsive movements upon the anæsthetic side. While the
attacks involve the left side of the body as a rule, it happens that
when there is primary left hemianopsia and right-sided anæsthesia the
boy becomes very much confused in speech, and sometimes is paraphasic,
the trouble being but transitory. He is sometimes unable to speak at
all, though perfectly conscious and in possession of his faculties. No
pupillary disturbance has been noticed at any time. Upon two occasions
there was a swelling of gums and tongue, which was not only
subjective, but perceived by the mother. Occasionally he sees
prismatic colors and rays before the blindness, but this has been only
once or twice. During his early life he had attacks of slight numbness
of the hands and feet which were not thought much of, and he had
headache as well. He has been a somnambulist.
MORBID ANATOMY AND PATHOLOGY.—The literature of the experimental
physiology of epilepsy is enriched by the observations of a variety of
careful students, among them Sir Astley Cooper, Kussmaul and Tenner,
Brown-Séquard, Nothnagel, Schroeder Van der Kolk, Pitres,
Hughlings-Jackson, and the followers of the localization school, as
well as many others more or less distinguished.