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Conditions in which Epileptic Phenomena Appear
After a discussion of the still obscure nature of epilepsy and a classification of varieties of epilepsies according to their cause, a precise description is given here of the most common form, essential or idiopathic epilepsy and of the associated mental and physical disorders.
This disease has been known from earliest times and described by the oldest writers in medicine. It affects all races of mankind, and at times is seen in the lower animals.
Epilepsy may be defined as a nervous affection in which there are attacks of unconsciousness, with or without muscular convulsions. When the unconsciousness is very temporary and without convulsive seizures, the condition is called minor epilepsy or petit mal; and if the loss of consciousness is more prolonged, with general convulsions, it is termed major or grand mal. Another variety, which is differentiated from the foregoing by the fact that consciousness is retained or lost late, is known as Jacksonian epilepsy, because of its association with the neurologist Hughlings Jaclcson, who described it.
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As a matter of fact epilepsy is not so much a disease in itself as a symptom or series of symptoms which may be met with in a variety of conditions, in all of which sudden and temporary attacks occur, involving disturbances of consciousness of many kinds and convulsive seizures. Thus such phenomena may be seen in the psychoneuroses (hysteria), in some psychoses, as dementia praecox, in toxic states, such as alcoholism and uraemia (kidney failure), and in organic nervous diseases such as brain tumours and general paresis.
Many Forms of Epilepsy
It would, therefore, be more correct to speak of "the epilepsies" instead of epilepsy. Where the epileptic phenomena are dependent upon some special condition the term symptomatic epilepsy is used, and when this is not discoversble, essential or idiopathic epilepsy. It must be realized that this latter designation is only a cloak for ignorance, for, though unknown, the epilepsy must be a symptom of some morbid proeess which shows itself through the central nervous system.
Though epilepsy has been regarded as a disease of the brain, in all probability in few cases is it so: It is nearer the truth to regard it as a toxic state with cerebral manifestations. It has been stated that one cannot produce epilepsy in the lower animals by injuring their nervous system, but may easily do so by introducing a convulsant poison. In the Great War, injuries to the head and brain were only followed by epilepsy in a small percentage of cases.
The different epilepsies may be grouped as follows :
1. Where the cause is obscure or unknown (idiopathic epilepsy), this being by far the largest group ;
2. Due to poisons introduc;ed externally (infectious diseases, alcohol, lead) ;
3. Due to poisons arising internally (uraemia, diabetes) ;
4. Due to gross brain disease (cerebral syphilis, arterio-sclerosis, tumour, general paralysis, cranial injuries) ;
5. Anomalous conditions, perhaps from disturbances in the internal secretions ;
6. Cardiac epilepsy (Stokes-Adams disease);
7. Convulsions from mental causes at a higher level of the nervous system (hysteria, psychasthenia, dementia praecox).
In most cases of idiopathic epilepsy the disease begins early in life. Over a third are seen before the tenth year and three-fourths before the twentieth. When seen in adult life for the first time there is probably some local disease. The sexes are affected about equally at the earliest periods, but after puberty the males are preponderant.
A great many cases of established epilepsy no doubt have their origin in infantile convulsions. There are few diseases in the production of which heredity has a greater influence, and some observers regard a family alcoholic history as predisposing. Fright is not infrequently an exciting factor.
OF late years attention has been drawn to a definite epileptic constitution, and it is concluded that there is a temperamental basis in many cases which shows itself in a defect of the personality interfering with normal social adaptation. The epileptic is apt to be irritable, suspicious, moody, hypochondriacal and evince a shallow religiosity. The interests tend to be all self-centred, and even good-tempered epileptics are often difficult to get on with.
Epilepsy tends in many cases to produce general mental deterioration, especially so if the disease manifested itself early in life. Yet, on the otber hand, cases of long standing often retain their mental vigour. Some neurologists have described an epileptic voice sign and found it in 75 per cent. of cases. This they speak of as "plateau speech," as the voice maintains an even tone instead of rising and falling.
Symptoms of an Attack
In an attack of petit mal, no matter what the person may be doing, he suddenly stops, turns pale, stares in front of him with fixed eyes, and drops anything he may have in his hand. In a moment or two he is conscious again and resumes whatever he was doing without perhaps being aware of his lapse. Sometimes some automatic action is unknowingly performed during the attack or just afterwards while in a dazed state. When such actions take place after an attack, questions of legal responsibility may be raised, as thefts or assaults may occur.
Before an attack of grand mal there is usually some warning (aura), which may consist of some bodily sensation, flashes of light or noises in the ears. Giddiness is not infrequently felt, and occasionally certain sudden movements may be made. At the onset of a fit the patient may give a loud scream, the so-called epileptic cry, and fall suddenly unconscious. Injuries are thus common. The body is flrst seen to be in a state of tonic spasm which affects all the muscles. as breathing is impeded from contraction of the chest muscles, the face becomes livid. The arms are usually bent, the hands clenched, the legs extended and the head drawn back.
Within a few seconds the second, or clonic, stage of the fit begins. Gradually the muscles, instead of being fixed, begin to jerk more and more forcibly and rapidly. The eyes open and shut. the eyeballs roil from side to side, and all the muscles of the face are in constant movement. As the mouth opens and shuts the tongue may be caught between the teeth and bitten. The limbs. too, are thrown about violently. Frothy saliva issues from the mouth and this may be blood-stained. Control over the bladder and rectum is lost, so that urine involuntarily escapes and faeces may also be voided. In a minute or two the natural colour of the face returns, the movements become less and less violent, and the epileptic is in the next stage, that of coma. Here the face is congested, perhaps through exertion, the whole body is relaxed and the breathing deep and noisy. After a short time the patient regains full consciousness, though For a period he may be dazed. A deep sleep often follows followed by some headache.
No attempt should be made to prevent the movements in a fit, but their violence may be gently restra:ned to prevent the patient from injuring himself. A cork or other gag inserted between the back teeth prevents biting of the tongue. Tight clothing is loosened.
Attacks of grand mal may occur at any time, even during sleep, and some only have them at this time (nocturnal epilepsy). Their number may vary from several a day to only a few during a year. When they occur one after the other without an interval of consciousness, a serious and often fatal condition called the status epilepticus arises.
Consequences of Epileptic Attacks
After minor or major attacks curious apparently purposive actions of an irrelevant nature may be performed without any awreness on the part of the main personal consciousness. Sometimes similar states of automatism may occur independently of any attack. They are then regarded as substitutes for the fits and are known as "epileptic equivalents." These may be quite transient or protracted, and nearly always are characterised by a subsequent loss of memory of the events which have taken place during the attack.
Thus there may be sudden violent assaults, even of a murderous nature or there may result theft or indecent behaviour. When of long duration this psychic epilepsy may involve long journeys and may show the various phenomena of double consciousness described under the heading Dual Personality. Recovery may be gradual or sudden, and . sometimes takes place after a prolonged sleep.
Following epileptic attacks other morbid states are occasionally noted. There may be great depression with suicidal feelings; great excitement (epileptic furor) in which frenzied assaults are made; much confusion, even amounting to stupor for a lengthy: period; epileptic delirium with terrifying hallucinations; ecstasy (q.v.) with hallucinations.
Thus epilepsy is liable to be associated with mental disorders which frequently necessitate institutional control. In time there is a tendency to a progressive dementia.
In Jacksonian epilepsy, in which consciousness is usually retained, the attacks are commonly the result of irritation in the motor region of the brain cortex. The spasm may begin in some of the muscles of the leg, arm or face, and then estend to all the muscles of the part involved. These spasms may continue localised for years but may at any time become general.
When typical, the diagnosis of epilepsy is not difficult, though that of the underlying cause may be. The greatest interest has usually centred in its differentiation from hysteria. In the latter the attack is not so likely to occur with such lightning suddenness and does not take place during the night or when the patient is alone; the epileptic cry is absent; the face becomes red and not livid; the struggling tends to be more purposive and becomes more manifest when restrained; unconsciousness is not so profound, the eyes are usually shut or half closed; falling is not so sudden and therefore injuries are not so commonly sustained and tongue biting or loss of sphincter control is frequently absent. Probably, however, no hard and fast line can be drawn between these types of attack and it may be impossible to tell from the fit itself whether it is epileptic or hysterical.
It is now realized that the epochs of physiological stress which might be provocative of epilepsy were also periods of psychic stress and that the latter might be of great import. There is, moreover, definite evidence of a psychic instablity which in all probability has an intimate relationship with the factors productive of much epilepsy.
The outlook in idiopathic epilepsy is not good. The earlier in life the fits appear, the poorer are the chances of cure. The more frequent the attacks and the longer the symptoms show themselves the smaller is the probability of any adequate betterment and the greater the likelihood of mental deterioration setting in. If the attacks are arrested for some years the chances of subsequent freedom from fits are fairly good. Very occasionally fits cease spontaneously. It is rare for death to occur in a fit except in the condition of status epilepticus.
Notwithstanding what has been said about the chances of recovery, treatment should be persevered with. In dealing with symptomatic epilepsy the treatment, of course, is directed to the underlying cause. The possibility of there being a psychic element must be borne in mind and investigated. If signs of mental conflict are found, suitable psychotherapy whether it be hypnotism, suggestion or psycho-analysis, should be employed.
The treatment of so-called idiopathic epilepsy will be dealt with as it is applied to the attack itself, to the status epilepticus, and lastly to the patient at other times.
When an epileptic falls in an attack, the main point is the prevention of an injury to the patient. Something soft should be placed beneath his head in a recumbent position, and simple measures taken to obviate his limbs being injured through their movements. No restraint of these should be attempted. A cork or bit of rubber should be put between the teeth to prevent laceration of the tongue, and all clothing should be loosened around the neck and chest so that there may be free chest expansion. Any wound received in falling must, of course, receive immediate attention. Should vomiting occur during the fit, the body should be rolled to one side to prevent the vomit being aspirated into the lungs.
As soon as consciousness is regained no further care is usually needed, but if the patient is dazed and sleepy he should be given the opportunity of resting in a suitable environment. If any abnormal mental excitement occurs subsequently, restraint may be needed and the patient will then have to be removed in an ambulance.
During the status epilepticus the same precautions must be used, but a doctor should at once he sent, for, because of the danger to life and the necessity for special treatment, which cannot be given by a layman.