The influence of climate and varying barometric pressure has been considered by Delasiauve. His conclusion was that the attacks were much more common during the season of the year when the prevailing winds were from the north-west, north, or south-west.
PRODROMATA.—There are various minor disturbances of sensation and motion which may not amount to the dignity of an epileptic attack. These may be so fugacious as to escape the attention of the persons in whose company the patient may happen to be, or he himself may be unaware of any disordered state of feeling. They may precede a severe paroxysm, when they are known as warnings or auræ. The term aura was originally applied to the familiar premonitory sensation which is so often likened by the subject to the blowing of wind over the skin, from whence it receives its name, but it has come to be applied to all primary indications of a fit. Such auræ may be sensory or motor—in the preponderance of cases the former, for motor precursors are quite rare, and when they occur are most likely to be but one stage, though a slight one, of the convulsion itself. There is no general rule about the occurrence of an aura, but, so far as my experience goes, there is great constancy in the character of the warning in each particular case. The sensory disturbance may vary from a vague feeling of confusion to a well-marked sensation. In many instances the patient speaks of an indescribable mental disturbance, which may precede the attack and last anywhere from a few minutes to several hours. This confusional state or psychical aura is most protean in its expression. It may simply be a heavy feeling, a feeling of tension, a sleepy feeling; a restlessness which is manifested by the patient changing his position frequently or wandering forth into the streets; an irritability of temper which often lasts twenty-four hours or more, and during the display of which he rebukes those who may be solicitous about him, or wantonly destroys articles of furniture, or vents his spleen upon inoffensive persons. I have had epileptic children under my charge who were wont to bite their little brothers and sisters or their nurses. A feeling of terror sometimes precedes the attack, and very often there is a sense of impending danger which has no basis whatever, and with it is associated a depth of depression which is very painful. In other cases the patient manifests a strange exhilaration, which may precede the occurrence of the attack for a period of from one or two hours to two or three days; and this is made manifest by great loquacity and a lively play of spirits. It is not rare to find errors in the speech as indications of an approaching attack. A minor degree of aphasia, slowness of speech, or anarthria betrays occasionally the preparatory state which is the precursor of a severe convulsion. By far the most common warnings, however, consist of disorders of the special senses, and generally these are visual. From an inspection of my notes I find that the patients saw colored lights, rings of fire, bright objects, dark spots, luminous clouds, a flood of light, sparks, stars, bright balls, lights which approached them, lights which receded, fireworks, and all became dark. While many were unable to define the color perceived, I found among those who were positive that red was the color most frequently seen, while blue came next; and this is a conclusion which I believe is accepted by Jackson and others who have analyzed their cases.
Hemiopia and diplopia in rare cases precede the major attacks, and are sometimes associated with distal pain and anæsthesia and with supraorbital pain as well.27 Among these ocular warnings we find constriction of the visual field to be often present, especially in cases where there is a history of migraine. Vague disorders of hearing, which may even amount to the dignity of hallucination, are complained of by some persons. There may be simply roaring in the ears or a sound of bells, and in one instance my patient declared that he heard whisperings at the time of the seizure. Some patients smell smoke or other foul odors, and in exceptional instances the odor of some particular flower or of some aromatic substance, such as camphor, turpentine, or tar, is perceived by the epileptic; and these are probably psychical.28 Sometimes there is a feeling of great suffocation, constriction of the chest or of the throat, palpitation, or vertigo.
27 See Sensory Epilepsy.
28 For curious examples of this kind consult Sir Charles Bell's Nervous System of the Human Body.
There are disorders of cutaneous sensation of great diversity of character, but those auræ which are of the most constant occurrence are the epigastric, which consist of a vague sensation starting below the sternum and ascending, its arrival at the throat being coincident with the commencement of the fit, and the patient very often likens its culmination to the violent grasp of a strong hand. So, too, we find crawling sensations starting in the extremities and running up to the trunk. These have been compared to the contact of insects in motion or to the blowing of wind over the surface. There may be tingling in one or two fingers or the whole hand, and such sensations may be unilateral or bilateral. It is quite common for the sensory warning to begin in the hand and foot of one side and to run up to the knee and elbow. Sometimes the tongue becomes hyperæsthetic, and I have frequently found that the gums became exquisitely tender just before the attack. According to Gowers, 17 per cent. of his cases began with unilateral peripheral auræ, but I think this is too small a proportion, for, so far as I have observed, at least 30 per cent. of all my cases in which any auræ at all could be ascertained presented the history of a one-sided warning, beginning most often in the right hand. Gowers says that in three-fourths of his cases in which the attack began in the hand consciousness was lost before the seizure extended beyond the arm, while in the others it extended much farther before the actual fit was precipitated. In Gowers's cases he rarely found that unilateral auræ were associated with other warnings; and his experience, which is like my own, goes to prove that unilateral sensory auræ and one-sided initial motor expressions go together, and very often indicate gross organic disease. In some cases there may be for several days a decided unilateral or general muscular weakness or recurring chronic spasms which may be frequently repeated. In aborted or irregular attacks there are also peculiar motor symptoms, to which reference will be made later on.
In two or three patients I have found that the attack was immediately preceded by a profuse discharge of saliva, and in one case the patient had frequently bleeding from the nose. Several authors have called attention to certain local vaso-motor disturbances which are expressed by limited patches of cutaneous hyperæmia or anæmia, so that the fingers—or, in fact, the whole hand—may either be swollen and of a dusky-red color, or, contrariwise, there may be blanching and an apparent diminution in size.
Sometimes the patient immediately before the attack makes more or less automatic movements, pressing his hands to his head, clasping his breast, or clutching at some imaginary object, and after this he loses consciousness and falls to the ground. In some irregular cases the patient runs aimlessly for some distance or describes a circle, and after a variable time, which rarely exceeds a minute or two, the actual fit begins. Here are two examples:
Case I.—Boy aged fifteen, has been subject to somnambulism; attacks began two years ago. He frequently when sitting at table rises suddenly, and runs either around the room or out into the street if possible. In thirty seconds or so he falls to the ground in a convulsion. Always falls backward in opisthotonos.