Case II.—Man aged thirty-four. Attacks always begin by stage of violent temper. While unconscious he runs about office, striking all who try to restrain him; finally falls to the floor. Convulsions, when they occur, are always severe. Sometimes running attack is the sole feature.
This disposition to run is no less remarkable than another queer prodroma I have seen in several patients, who began to take off their clothing when first seized, no matter where they were or under what circumstances. This is not, as has been suggested, the remains of a half-formed idea that they must seek their beds because of their impending trouble, but it is a much less complex mental act, and the several patients I have seen were fully unconscious when they did this, and were in places where there was no bed within reach. Equally curious mental precursors of the attack have come to my notice, and these I will detail subsequently.
SYMPTOMATOLOGY.—The Light Attack.—The epileptic attack may, as I have said, be scarcely perceptible to those about the patient, or may consist simply of a momentary loss of consciousness and very feeble convulsive movements. Reynolds has described two forms: (1) That without evident spasm; (2) that with evident spasm. Such seizures are always fugacious, and consist merely in some transient loss of consciousness and very little or no convulsive movement. The tonic spasms prevail, if any, and the disorder of motility may often consist simply in the arrest of some act in the performance of which the patient is engaged. While playing the piano the patient's hands may for a moment remain suspended over the keys he is about to strike; if eating, the hand which holds the fork may be arrested between the plate and his mouth. The attack consists sometimes in the rolling upward of the eyeballs, or when crossing the room the patient may stop, remaining quiet for an instant. Temporary unconsciousness, shown by cessation of conversation, by change of color, and absence of intelligent expression, accompanies the other trouble. In a well-marked attack of petit mal the patient may move his lips convulsively, and remain otherwise quiet, but bereft of consciousness, for one or two minutes.
The patient sometimes loses himself and loses the thread of the conversation, repeating what he has just said or showing his want of appreciation of what his companion has said. To this light grade belongs the case reported by Jackson of the individual who blew his nose upon a piece of paper and gave the conductor £2 10s. instead of twopence halfpenny.
The Major Attack.—An attack of epilepsy of the familiar severe form may or not follow an aura. The first intimation to the bystander may be a noise made by the patient, which is either a loud, startling, wild cry, or a gurgling groan due to compression of the thorax and the forcible escape of wind through the vocal cords. There are three stages of the attack: (1) The stage of tonic convulsion; (2) the stage of clonic convulsion; (3) the reactionary stage.
The first stage of the attack is symptomatized by tonic spasms, which may be local or general, usually the latter. It is very often unrecognized, for its duration may be so short that it is lost in the stage of clonic spasms, which is much more protracted. There is usually unilateral seizure, the muscles of the face being primarily involved, then those of the hand and upper extremity, and then those of the lower extremity; and finally there is a general involvement, so that the patient may be in a position of opisthotonos. In some cases there is strong tonic contraction to one side, or pleurosthotonos. The notes of a case which illustrates the beginning and development of convulsion with reference to the parts involved, which I observed carefully, are the following:
Bindewald: Epileptic attack observed at hospital for paralyzed and epileptic, Sunday, Mar. 12, 1882:
1. Long, shrill cry which attracted my attention. It probably lasted five seconds. At same time patient threw up arms and became unconscious, and fell to floor. Nurses ran to him and placed him upon bed.
2. Tonic convulsions began by fine twitchings at right corner of mouth. These became gross, and were separated by succeeding long intervals. Eyes directed to left side, face pale.
3. In twenty seconds twitching began in right hand and arm, which were rigidly flexed (five seconds); then leg and foot of right side became agitated, the face meanwhile changing in color successively from red-gray to purple; lips purple, ears livid and purple, edges white; eyes still turned to the left, pupils dilated, eyes widely open; breathing stertorous and irregular.