A delirious confusion with hallucinations and delusions often develops. Some cases have a very strong religious coloring and believe themselves to be in heaven or hell—hear the voice of God, angels, etc. Grandiose ideas may appear and wonderful adventures are narrated. The mood is variable and may be either anxious, cheerful or erotic. There is a marked tendency to violence and the patients may be very restless and agitated. Delusions are common and often lead to suicidal attempts. Some exhibit an anxious delirium accompanied by numerous hallucinations. The patient is clouded as well as disoriented and delusions develop early. Fabrications sometimes appear in this condition. These deliria may last a few hours or several weeks. Profound and more or less long continued epileptic stupors may complicate the situation.
A "conscious delirium" of longer duration is observed in some instances. The sensorium is not so much clouded, and the patient appears quite clear. Hallucinations and illusions usually develop early in the attack. Pleasurable, grandiose ideas often appear. The attitude in a general way resembles that of a confused disorientation. Anxious moods may develop, or rarely cheerful tendencies. Consciousness becomes dreamy, with hallucinations of a religious coloring. Patients with an apparently clear sensorium may commit numerous foolish or even criminal acts without any apparent insight into their significance. Such conditions as this may last weeks or months. Self-accusation may occur between attacks. These individuals are quite likely to start on absolutely aimless journeys which may be the outcome of an alcoholic debauch. The dream state in such cases may have a decided alcoholic coloring with characteristic hallucinations or humorous tendencies. This may be mixed with religious ecstatic manifestations. Dream states only occur once or twice during the lifetime of an epileptic or may be comparatively frequent. Many patients never have them.
Aschaffenburg found fainting attacks in seventy-four per cent, convulsions in forty-two per cent, stupors in forty-four, petit mal in fifty-eight, dream states in thirty-six, and ill-humor in from sixty-four to seventy per cent of his cases. In his Munich clinic Kraepelin studied 515 epileptics. Eighty-six and eight-tenths per cent of them had attacks of unconsciousness, probably often reported as convulsions, 23.3 per cent had dizzy spells, 9.7 per cent stupors, 15.1 per cent petit mal, 3.3 per cent attacks of various kinds without unconsciousness, 16.5 per cent dream states, 1.9 per cent somnambulisms, 36.9 per cent ill-humor, 13.8 per cent excitements, mostly alcoholic complications, and 2.5 per cent had status epilepticus.
An epileptic weakmindedness develops in many cases. The field of thought is contracted and egocentric in character with delayed associations as shown by Jung. The patient is egotistical, interested in petty details, and strongly inclined to religious tendencies. He always minimizes the severity of the disease which, in his opinion, is improving rapidly. He is likely to develop mild paranoid ideas and feels that he has been mistreated or that others are prejudiced against him. These individuals are usually moody, irritable, dull, emotionally unstable and excitable. They are often overactive but not industrious. Many show a persistent "wanderlust." Werther reported that between seven and eight per cent of his cases were tramps or beggars. Quite a few show criminal tendencies. They nearly always have a marked susceptibility to alcohol which greatly aggravates their symptoms. Kraepelin is inclined to look upon the epileptic personality as a result of the disease and not the soil in which it develops.
In the more advanced deteriorations or epileptic dementias there is a marked mental dulness with poverty of thought, loss of memory, irascibility and occasional violence. Kraepelin refers to a genuine "epileptic physiognomy" which is often observed. Strabismus, nystagmus, ptosis, tremors and many other neurological symptoms are frequently found. Clark and Scripture have described a characteristic "voice" in epilepsy. Besta found a subnormal temperature in sixty-six per cent of his cases. Very elaborate studies of the blood have been reported from time to time. The secretions and excretions have been made the subject of exhaustive research and the changes in metabolism have been gone into thoroughly.
The pathology of epilepsy has been given careful consideration by Alzheimer. In cases of status epilepticus he found extensive acute alterations, more particularly in the Betz cells, with swelling of the neurones, crumbling of the Nissl bodies, and dislocation of the nucleus to the apex. Here and there the ganglion cells were entirely destroyed and others showed regressive changes. Karyokinetic figures are seen in the glia cells, which are usually swollen, show ameboid changes and contain degenerative products. Accumulations of broken down cell products are found around the vessels. A sclerosis of the cornu ammonis, usually unilateral, was reported by Bourneville in 14.8 per cent, by Pfleger in fifty-eight per cent, and by Alzheimer in from fifty to sixty per cent of the cases of epilepsy examined. This consists of an atrophy of the cells in a well defined area and their replacement by a network of fibres. The cells are shrunken or entirely gone, while there is a great increase in the neuroglia elements with many free nuclei. The walls of the vessels are thickened and "stäbchenzellen" appear. The significance of these findings is not known. Nissl looks upon them as only a part of a general involvement of the cortex. Widespread cell changes were frequently reported by both Nissl and Alzheimer. A marked increase in the neuroglia has been found particularly in the superficial layers of the cortex,—the so-called "marginal gliosis" of Chaslin. The vessels show an intimal proliferation and a thickening of the walls, with occasional mast-cells in the lymph spaces. Ranke has called attention to the presence or persistence of "Cajal" cells in the ordinarily cell free layers of the cortex. These are large transversely placed ganglion cells, common in the superficial layers of the cortex of the newborn but not found in the normal adult brain. This condition is looked upon as a cortical development defect. These so-called "Cajal" cells are also found in some of the mental deficiencies. Nevertheless it must be conceded that there are no definitely characteristic pathological changes so constant as to render certain the differentiation of this disease postmortem.
No forms of insanity perhaps are clinically so difficult and unsatisfactory from the standpoint of classification as are the epileptic psychoses. The various mental manifestations of the disease may very logically be described as: 1. Pre-paroxysmal episodes, 2. Paroxysmal states, 3. Post-paroxysmal episodes, 4. Inter-paroxysmal conditions to be specified, as excitements, depressions, anxieties, confusion, stupor, dream states, paranoid conditions, etc., and 5. Epileptic deterioration. There is some question as to whether the various psychic epilepsies, so called, are sufficiently clear-cut to constitute clinical entities.
The delimitation of these psychoses for statistical purposes is described in the Association's manual as follows:—
"In addition to the epileptic deterioration, transitory psychoses may occur which are usually characterized by a clouded mental state followed by an amnesia for external occurrences during the attack. (The hallucinatory and dream-like experiences of the patient during the attack may be vividly recalled.) Various automatic and secondary states of consciousness may occur.
"According to the most prominent clinical features the epileptic mental disorders should therefore be specified as follows:—