A system of practical medicine. By American authors. Vol. 5

by Unknown

4. General convulsions of right side.

5. Head suddenly twisted to left side; position of eyes the same. Chin drawn down, movements moderated; still livid. A fit of coughing and expectoration of much frothy mucus. Left side, with exception of head, not implicated. Whole attack lasted about one minute and thirty-five seconds. Deep sleep afterward, lasting forty-five minutes.

This attack was one of many in a confirmed epileptic, and is a fair example of those commonly met with, though not as general as we sometimes find. In most cases the attack appears to be very much longer than it usually is, and the phenomena noted above, which seemed to occupy a considerable space of time, really lasted but little more than a minute and a half. Axenfeld and Beau fix the average period of the attack as follows: “Duration of the complete attack, which Beau divides into four phases: first stage, tetanic stage, five to thirty seconds; second stage, clonic convulsions, from one to two minutes; third stage, stage of stupor, three to eight minutes; fourth stage, return of sensibility and intelligence. It is not complete until the end of from ten to thirty minutes.”

To be more explicit, the manifestation of an ordinary epileptic attack of the more severe kind is very much like this: Usually without any warning to those about the patient he utters a shrill, peculiar cry of a character never to be forgotten if once heard, and then, perhaps throwing up his hands, he falls to the ground rigid and contorted. His body may be arched laterally or antero-posteriorly, his legs are thrown out, his forearms flexed, and his fists doubled, the thumbs being beneath the other fingers. His face may be for a moment flushed, but the color recedes, and it assumes a dusky-bluish tint, the lips being ashy-gray. The eyes are usually open, and the balls are rolled up and the pupils widely dilated. The breathing may for a moment be suspended, but it soon quickens, and becomes labored and noisy, and the pulse grows hard and full. The tonic contractions are succeeded in a very short time by more or less violent clonic contractions, which increase in violence and rapidity; the jaws work and the lips are covered with foam, which is blown in and out by the rapid inspirations and expirations. It may be tinged with blood in the severe attack if the tongue is bitten, which is by no means an uncommon accident. The teeth are sometimes firmly set and the jaws locked. The head is usually drawn to one side in the first stage, but afterward may be rolled from side to side. The movements are now more or less general, and occasionally the agitation is so great that the patient throws himself from the bed on which he may be lying. The face grows more pale, or rather more livid, and toward the end of this stage there may be a puffiness and congestion such as are seen in partially asphyxiated individuals, for this alteration in color is due to dyspnœa and consequent imperfect oxidation. The patient may defecate or pass his urine unconsciously, and sometimes we find seminal emission. The movements, after a period varying from ten seconds to a minute or two, become less violent, and he may talk in a silly manner, as a person does who is recovering from profound ether unconsciousness; or deeply sigh, and he is restless. The pulse is now much weaker and more rapid, and may be irregular. The color returns to the face, the patient closes his eyes, and the body is covered with profuse perspiration. The fingers are unlocked and every evidence of spasmodic movement disappears. He falls asleep, and remains so for several hours, awaking with a confused feeling, headache, and no remembrance of the attack, and is only reminded that something has happened by his wounded tongue or lips, the bruises he has received, or by the information of friends. He looks jaded and tired, and is indisposed to exert himself for several days if the attack has been at all severe. The transition from the attack to the normal state is not always the same. Some patients do not sleep at all, but after being dazed go about their occupation. This is even true occasionally of the severe form of disease.

The usual termination of the attack is, however, by sleep preceded by a period of confusion. The patient, after coming out of the clonic stage, mutters incoherently. He is apt to pass large quantities of wind from his bowels, or vomits. This is attended by a subsidence of the spasmodic movements, and perhaps by oscillation of the eyeballs. The pulse loses its rapid, hard character, and the reaction brings with it diminished frequency of respiration and the evidence of exhaustion.

Special Symptoms.—The eyes are, as a rule, open, and, there being spasmodic movement of the ocular muscles, we find that the balls are either rolled up or directed away from the side in which the spasms begin. This is especially true in those epilepsies due to cortical disease, and the same law of conjugate deviation laid down by Bourneville may be remembered.

The pupils are dilated pretty much throughout the fit, though they may vary, and a transient contraction may occur at the commencement of the first stage. During the clonic stage, especially toward the end, they not infrequently undergo a species of oscillation. The interparoxysmal state is revealed by a very great mobility of the pupil, which has been observed by Gray and others. Gray is disposed to consider it a diagnostic indication of value, but so far I have found it only in two-thirds of my cases. Dilatation of the pupil I believe to be a very constant feature of epilepsy.

The ophthalmoscope reveals in certain cases an abnormal increase in the circulation at the fundus, in others a very decided emptiness of the retinal vessels. Jackson is disposed to consider that certain visual auræ depend upon spasm of the arterioles in this location. Loring, whose opportunities for research have been very great, is not disposed to attach much importance to the ophthalmoscopic appearances, at least during the periods between the fits.

The pulse of the epileptic between the paroxysms is small and irritable. Voisin has found the following changes: “Two or three seconds before the attack it becomes rapid, sharp, and the sphygmographic curves are higher, rounded, and nearer together. When the attack begins we see five or six little undulations in the course of the ascending line, and the curves are higher and more accentuated. Several minutes after the attack there is dicrotism, and the line of descent is very sharp, the angle with the ascending being quite acute. This form of pulse lasts an hour or half hour after the attack. There is in some cases great irregularity, with paroxysms of cardiac pain resembling angina pectoris. There is occasionally epistaxis or more marked hemorrhages.” Parrot speaks of hemorrhages from the eyes and ears, and occasionally the cerebral congestion is so great as to result in cerebral hemorrhage in old subjects.