patient experiences as a precursor of the attack. The so-called aura may be of mental character, in the form of an agonizing feeling of momentary duration; of sensorial character, in the form of pain in a limb or in some internal organ, such as the stomach, or morbid feeling connected with the special senses; or, further, of motorial character, in the form of contractions or trembling in some of the muscles. When such sensations affect a limb, the employment of firm compression by the hand or by a ligature occasionally succeeds in warding off an attack. The aura may be so distinct and of such duration as to enable the patient to lie down, or seek a place of safety before the fit comes on.
The seizure is usually preceded by a loud scream or cry, which is not to be ascribed, as was at one time supposed, to terror or pain, but is due to the convulsive action of the muscles of the larynx, and the expulsion of a column of air through the narrowed glottis. If the patient is standing he immediately falls, and often sustains serious injury. Unconsciousness is complete, and the muscles generally are in a state of stiffness or tonic contraction, which will usually be found to affect those of one side of the body in particular. The head is turned by a series of jerks towards one or other shoulder, the breathing is for the moment arrested, the countenance first pale then livid, the pupils dilated and the pulse rapid. This, the first stage of the fit, generally lasts for about half a minute, and is followed by the state of clonic (i.e. tumultuous) spasm of the muscles, in which the whole body is thrown into violent agitation, occasionally so great that bones may be fractured or dislocated. The eyes roll wildly, the teeth are gnashed together, and the tongue and cheeks are often severely bitten. The breathing is noisy and laborious, and foam (often tinged with blood) issues from the mouth, while the contents of the bowels and bladder are ejected. The aspect of the patient in this condition is shocking to witness, and the sight has been known to induce a similar attack in an onlooker. This stage lasts for a period varying from a few seconds to several minutes, when the convulsive movements gradually subside, and relaxation of the muscles takes place, together with partial return of consciousness, the patient looking confusedly about him and attempting to speak. This, however, is soon followed by drowsiness and stupor, which may continue for several hours, when he awakes either apparently quite recovered or fatigued and depressed, and occasionally in a state of excitement which sometimes assumes the form of mania.
Epileptic fits of this sort succeed each other with varying degrees of frequency, and occasionally, though not frequently, with regular periodicity. In some persons they only occur once in a lifetime, or once in the course of many years, while in others they return every week or two, or even are of daily occurrence, and occasionally there are numerous attacks each day. According to Sir J. R. Reynolds, there are four times as many epileptics who have their attacks more frequently than once a month as there are of those whose attacks recur at longer intervals. When the fit returns it is not uncommon for one seizure to be followed by another within a few hours or days. Occasionally there occurs a constant succession of attacks extending over many hours, and with such rapidity that the patient appears as if he had never come out of the one fit. The term status epilepticus is applied to this condition, which is sometimes followed with fatal results. In many epileptics the fits occur during the night as well as during the day, but in some instances they are entirely nocturnal, and it is well known that in such cases the disease may long exist and yet remain unrecognized either by the patient or the physician.
The second manifestation of epilepsy, to which the names epilepsia mitior or le petit mal are given, differs from that above described in the absence of the convulsive spasms. It is also termed by some authors epileptic vertigo (giddiness), and consists essentially in the sudden arrest of volition and consciousness, which is of but short duration, and may be accompanied with staggering or some alteration in position or motion, or may simply exhibit itself in a look of absence or confusion, and should the patient happen to be engaged in conversation, by an abrupt termination of the act. In general it lasts but a few seconds, and the individual resumes his occupation without perhaps being aware of anything having been the matter. In some instances there is a degree of spasmodic action in certain muscles which may cause the patient to make some unexpected movement, such as turning half round, or walking abruptly aside, or may show itself by some unusual expression of countenance, such as squinting or grinning. There may be some amount of aura preceding such attacks, and also of faintness following them. The petit mal most commonly co-exists with the grand mal, but has no necessary connexion with it, as each may exist alone. According to Armand Trousseau, the petit mal in general precedes the manifestation of the grand mal, but sometimes the reverse is the case.
The third manifestation—Jacksonian epilepsy or partial epilepsy—is distinguished by the fact that consciousness is retained or lost late. The patient is conscious throughout, and is able to watch the march of the spasm. The attacks are usually the result of lesions in the motor area of the brain, such being caused, in many instances, by depression of the vault of the skull, due to trauma.
Epilepsy appears to exert no necessarily injurious effect upon the general health, and even where it exists in an aggravated form is quite consistent with a high degree of bodily vigour. It is very different, however, with regard to its influence upon the mind; and the question of the relation of epilepsy to insanity is one of great and increasing importance. Allusion has already been made to the occasional occurrence of maniacal excitement as one of the results of the epileptic seizure. Such attacks, to which the name of furor epilepticus is applied, are generally accompanied with violent acts on the part of the patient, rendering him dangerous, and demanding prompt measures of restraint. These attacks are by no means limited to the more severe form of epilepsy, but appear to be even more frequently associated with the milder form—the epileptic vertigo—where they either replace altogether or immediately follow the short period of absence characteristic of this form of the disease. Numerous cases are on record of persons known to be epileptic being suddenly seized, either after or without apparent spasmodic attack, with some sudden impulse, in which they have used dangerous violence to those beside them, irrespective altogether of malevolent intention, as appears from their retaining no recollection whatever, after the short period of excitement, of anything that had occurred; and there is reason to believe that crimes of heinous character, for which the perpetrators have suffered punishment, have been committed in a state of mind such as that now described. The subject is obviously one of the greatest medico-legal interest and importance in regard to the question of criminal responsibility.
Apart, however, from such marked and comparatively rare instances of what is termed epileptic insanity, the general mental condition of the epileptic is in a large proportion of cases unfavourably affected by the disease. There are doubtless examples (and their number according to statistics is estimated at less than one-third) where, even among those suffering from frequent and severe attacks, no departure from the normal condition of mental integrity can be recognized. But in general there exists some peculiarity, exhibiting itself either in the form of defective memory, or diminishing intelligence, or what is perhaps as frequent, in irregularities of temper, the patient being irritable or perverse and eccentric. In not a few cases there is a steady mental decline, which ends in dementia or idiocy. It is stated by some high authorities that epileptic women suffer in regard to their mental condition more than men. It also appears to be the case that the later in life the disease shows itself the more likely is the mind to suffer. Neither the frequency nor the severity of the seizures seem to have any necessary influence in the matter; and the general opinion appears to be that the milder form of the disease is that with which mental failure is more apt to be associated. (For a consideration of the conditions of the nervous system which result in epilepsy, see the article Neuropathology.)
The influence of hereditary predisposition in epilepsy is very
