When we find paroxysmal attacks occurring in individuals with atypical heads, thick swollen lips, scarred tongues, and irregular teeth, we may strongly suspect the patient to be epileptic. To these we may add the appearance of the eyes, the fishy, lack-lustre expression which betokens old epilepsy. The hands are clammy and the skin mud-colored; the hair is dry and coarse; and the body often has a death-like odor.
In children, certain mental peculiarities are to be inquired into. Unnatural brightness or dulness—what may be called the clumsy organization—is often present, and the muscular use is often imperfect. We find that there is often but little nicety in walking, in using the hands, in speaking, or after learning to write there is an incapacity, with ever so much teaching, to develop a character or style. Such children can never become ambidextrous. These little points may seem trifling, but to the physician who carefully studies his cases they may prove of great help. The history of the nights may often lead to the discovery perhaps of a long-existing nocturnal epilepsy. Incontinence of urine, blood upon the pillow, nightmares, morning headache, and petechiæ betoken unsuspected night attacks; and Le Grand du Saulk mentions the case of a young Englishman who committed a purposeless crime and was discovered to be epileptic, the diagnosis being confirmed by an antecedent history of nocturnal seizures, and subsequent watching resulted in the discovery of many night attacks.
As to special conditions with which the epilepsy may be confounded, I may refer to cardiac weakness. It not rarely happens that simple fainting attacks are confounded with those of an epileptic nature. Such is the case more often in heat-prostration, when some rigidity attends the loss of consciousness. The duration of such a state, the condition of the pulse and color, however, will easily clear up any doubts upon the part of the observer. The existence of a cause should also be considered, and the fact that usually the epileptic paroxysm is sudden, while a feeling of depression and feebleness precedes the fainting attack, should be remembered. I may present in tabular form the points of difference:
| EPILEPSY. | SYNCOPE. |
| Loss of consciousness sudden. | Loss of consciousness follows feeling of faintness. |
| Period of complete unconsciousness usually short. | Unconscious throughout, no convulsions. |
| The existence of auræ of a well-defined type. | The existence of preliminary vague prostration, nausea, and irregular heart action. |
| Often involuntary discharge from bowels and bladder. | Quite rare or never. |
| Patient usually falls into heavy sleep or is indifferent after convulsion. | After slight weakness patient is anxious and worried, and quickly seeks relief. |
The difficulty of diagnosis, however, is only in cases of petit mal.
There are light forms of auditory vertigo that may resemble vertiginous epilepsy. In the former there is never loss of consciousness, and the patient refers to the rotary character of the vertigo. A history of antecedent attacks, tinnitus, aural disease, and a certain constancy which is not a feature of petit mal, may be mentioned.
There are cases, however, which are puzzling, and come under the head of auditory epilepsy rather than auditory vertigo; and in these there is a multiplicity of expressions, the auditory symptoms predominating.
Of uræmic convulsions it is hardly necessary to speak. There is a previous history of renal disease which the microscope and less delicate tests will reveal, and clinically there is antecedent headache, some stupidity, and not unrarely thickness of speech and somnolence. There are some cases, however, which are obscure. I have known patients with chronic renal disease—such as waxy kidney, for instance—to develop a species of epilepsy, the paroxysms recurring from time to time and behaving very much as the idiopathic disease would; and their occurrence would mark some imprudence in diet or exposure, and their disappearance an improvement in the patient's general condition. The attacks were not classical, inasmuch as there seemed to be but one stage of violent clonic convulsion, preceded by intellectual dulness, and followed by a semi-comatose condition which was far mere profound than the somnolent stage of epilepsy. The movements were not accompanied by a great degree of opisthotonos or pleurosthotonos.
Alcoholic and absinthic epilepsies are usually preceded and followed by symptoms indicative of profound saturation.
The consideration of hysterical epilepsy may be found elsewhere, but it may do to briefly refer to some cases which do not present the phenomenon first described by Charcot and Bourneville. The ordinary hysterical attack is never attended by loss of consciousness, by any of the pupillary changes so constant in epilepsy, by the mobility of the pupil between the attacks which is present in a large number of true epileptic individuals. There are never the succeeding changes of color, and the seizures are commonly produced or attended by some emotional disturbance, or are associated with ovarian disturbance.