SYMPTOMATOLOGY.

In a hundred unselected cases of epilepsy there were—

Epilepsia gravior in62 per cent.
Epilepsia mitior in10 per cent.
Epilepsia gravior and mitior in28 per cent.

1.—Epilepsia Gravior.

Premonitory Symptoms.—In the cases in which epilepsia gravior was present there were—

No premonitory symptoms in34.4 per cent.
Premonitory symptoms in65.5 per cent.

Of those cases in which there were symptoms premonitory to the attack, there were—

General premonitory symptoms in47.4 per cent.
Special Auræ in72.8 per cent.

By general premonitory symptoms are understood those morbid conditions lasting for some hours or days before each attack, and of the cases under consideration in which these were present, the following is an analysis:—

Prolonged vertigo in46.4 per cent.
Headache in21.4 per cent.
Nervousness in14.2 per cent.
Drowsiness in3.5 per cent.
Faintness in3.5 per cent.
Depression of spirits in3.5 per cent.
Cramps in3.5 per cent.
Numbness of extremities in3.5 per cent.

Of the cases in which a special aura preceded the attack, the details are as follows (the special symptom in each case being sudden):—

Loss of sight in2.3 per cent.
Loss of speech in13.9 per cent.
Loss of hearing in2.3 per cent.
General tremor in16.2 per cent.
Tremor of one foot in2.3 per cent.
Sensation in epigastrium in6.9 per cent.
Sensation in abdomen in4.6 per cent.
Sensation in throat in6.9 per cent.
Sensation in left side in2.3 per cent.
Sensation in both hands in2.3 per cent.
Sensation in one hand in2.3 per cent.
Violent pain in head in2.3 per cent.
Pain in one foot in2.3 per cent.
Sparkling sensation in eyes in6.9 per cent.
Pumping sensation in head in4.6 per cent.
Noises in ears in4.6 per cent.
Diplopia in2.3 per cent.
Contraction of one leg in2.3 per cent.
Rotation of head in2.3 per cent.
Distortion of face in2.3 per cent.
Twitching of thumb in2.3 per cent.
Spasm of eye-balls in2.3 per cent.
Disagreeable smell in2.3 per cent.

From these figures we find that in 34.4 per cent. of the cases of epilepsia gravior there are no special symptoms announcing the seizure, which takes place without warning of any kind; and it is especially in such cases that patients in falling, seriously injure themselves. In 65.5 per cent. there are premonitory symptoms of some kind, which indicate often many hours before the approach of an attack. Of these last 47.4 per cent. are of a general character, and in no less than 72.8 per cent. is there a distinct special aura, which in 25.4 per cent. alone precede the attack, the remainder being associated with the general premonitory symptoms.

Symptoms of the Attack.—In the cases of epilepsia gravior there were complete loss of consciousness with convulsions, lasting from five to ten minutes, and occurring at intervals, leaving no question as to the true nature of the disease, and all doubtful examples have been excluded from this collection. Attempts were made to form an analysis of the different symptoms constituting the paroxysm, but with indifferent success, and these are not here reproduced, because they are not sufficiently accurate for scientific purposes. The patient himself can give no account of what takes place. The friends around do not look upon the phenomena of the attack with the critical and philosophic eye of the physician; hence any information from them as to the part convulsed, the colour of the skin, the duration of the seizure, and so on, is extremely vague and untrustworthy. The number of cases personally observed actually during attacks is too limited to warrant any generalizations. There is, however, one important point which can be accurately demonstrated—namely, whether or not the tongue is bitten, and in the cases under observation

The tongue was bitten in68.8 per cent.
The tongue was not bitten in31.2 per cent.

Frequency of Attacks.—Only a general average of the number of attacks can be made; and in the present series the following gives an idea of the frequency of seizures in different individuals.

Average of one or more attacks per day in8.8 per cent.
Average of one or more attacks per week in31.1 per cent.
Average of one or more attacks per month in32.2 per cent.
Average of one or more attacks per year in15.5 per cent.
At longer or more irregular intervals in12.2 per cent.

This roughly indicates that, in the majority of cases, attacks of epilepsia gravior occur one or more times weekly or monthly. Under the last series, of attacks taking place at longer and more irregular intervals than a year, are included those cases where a few only have occurred during the lifetime of the patients.

Regularity of Attacks.—Many epileptics are attacked at regular intervals, sometimes on the same day or even hour; while others are afflicted at any time, day or night. The following indicate the proportion:—

Attacks occur at regular intervals in21.1 per cent.
Attacks occur at irregular intervals in78.8 per cent.

Time of Attack.—The following particulars alone could be definitely ascertained:—

Attacks only during sleep in8.8 per cent.
Attacks only during day while awake in8.8 per cent.
Attacks only during early morning in15.5 per cent.
Attacks at no particular time in55.4 per cent.

The chief feature of this observation is that in 15.5 per cent. of cases of E. Gravior the attacks always took place immediately after the patients had wakened in the morning, and this is probably due to the sudden alteration of the cerebral circulation from the sleeping to the wakeful state.

Symptoms immediately after the Attack.—The moment the attack is over sometimes the patient is in his usual condition, and feels no ill effects from the paroxysm. More commonly, however, he suffers from various symptoms, the chief of which, and their relative frequency, is as follows:—

Return to usual condition in12.2 per cent.
Drowsy in66.6 per cent.
Confused in14.4 per cent.
Stupid in13.3 per cent.
Irritable in14.4 per cent.
Excitable in3.3 per cent.
Vertigo in13.3 per cent.
Headache in41.1 per cent.

The above conditions may last from an hour to several days.

Present condition, or state between the Attacks.—It is impossible to enter minutely into the actual physical and mental health of all the epileptic cases under notice, but the following statement gives a sketch of some of the more important conditions associated with the disease, and the frequency with which they occur. In the inter-paroxysmal state the condition of the patients were—

Healthy in every respect in17.7 per cent.
With some abnormal peculiarity in82.2 per cent.
General health good in75.5 per cent.
General health impaired in24.4 per cent.
Robust in66.6 per cent.
Not robust in33.3 per cent.
Intelligence intact in74.4 per cent.
Intelligence impaired in25.5 per cent.
Loss of memory in58.8 per cent.
No loss of memory in41.1 per cent.
Stupid in16.6 per cent.
Dull in31.1 per cent.
Irritable in25.4 per cent.
Frequent headaches in41.1 per cent.
Frequent vertigo in22.2 per cent.
Nervous in21.1 per cent.
Special diseases in21.1 per cent.

Of the 21.1 per cent. under the heading of special diseases, there were—

Hemiplegia in6.6 per cent.
Paralysis of seventh nerve in1.1 per cent.
Impediment of speech in1.1 per cent.
Cicatrix over sciatic nerve in1.1 per cent.
Idiot in1.1 per cent.
Anæmia in5.5 per cent.
Phthisis in2.2 per cent.
Confirmed dyspepsia in1.1 per cent.

From these details it is evident that epilepsy is not of necessity associated with impairment of the physical or mental health. On the contrary, we find that in 17.7 per cent. of the patients there was apparently no flaw of any kind in their constitutions, which were absolutely normal, with the exception of the periodic seizures. In no less than 75.5 per cent. was the general health good, and in 66.6 per cent. the patients were robust and vigorous. At the same time the health was markedly impaired in 24.4 per cent., and the sufferers were of delicate or weak habit in 33.3 per cent. The main fact, however, to be observed is that, in the majority of cases of epilepsy, the general health and vigour of the patient is not deteriorated. In the same way, the intellectual capacities are not of necessity affected. In 74.4 per cent. the intelligence is recorded as not seriously impaired; and in 41.1 per cent. the memory as good. On the other hand, the mental faculties were markedly deficient in 25.5 per cent.; the patients were dull and slow in 31.1 per cent.; and in more than half, or 58.8 per cent., was there evidence of loss of memory. Another frequent symptom is repeated and constant headache, which, in the present series of cases, existed in 41.1 per cent.

2.—Epilepsia Mitior.

This occurred altogether in 38 per cent. of the total number of cases. In these it occurred—

By itself in26.3 per cent.
Associated with E. Gravior in73.6 per cent.

In all, the usual characteristics of the petit mal presented themselves; there being temporary loss of consciousness, sometimes with slight spasms, but without true convulsion, biting of the tongue, &c.

Frequency of Attacks.—The rough average frequency of attacks, as estimated in the cases under consideration, was as follows:—

20 to 30 attacks per day in3.7 per cent.
10 to 20 attacks per day in7.4 per cent.
5 to 10 attacks per day in14.8 per cent.
1 to 5 attacks per day in40.7 per cent.
1 or more attacks per week in22.2 per cent.
1 or more attacks per month in7.4 per cent.
At rarer intervals in3.7 per cent.

Thus when epilepsia mitior exists, in the majority of cases the attacks are of daily occurrence.

Loss of consciousness, as ascertained in a series of cases, was

Complete in48.3 per cent.
Partial in51.6 per cent.

Premonitory Symptoms.—These are not, as a rule, so well marked in epilepsia mitior as in E. Gravior; but frequently the aura is quite as distinctly appreciated. In the 28 per cent. of cases in which E. Mitior is associated with E. Gravior, the aura was apparently the same in both. Of the 10 per cent. cases of E. Mitior occurring by itself, the following is the record:—

No aura in20 per cent.
Sensation in epigastrium in20 per cent.
Loss of speech in10 per cent.
Violent pain in head in10 per cent.
Tingling of extremities in10 per cent.
Choking sensation in10 per cent.
Hallucination in10 per cent.
Vertigo in10 per cent.

The number of cases in E. Mitior is too limited to warrant further generalization.