Page:Encyclopædia Britannica, Ninth Edition, v. 8.djvu/500

Rh 480 EPILEPSY to witness, and the sight has been known to induce a similar attack in an onlooker. This stage lasts for a period varying from a few seconds to several minutes, when the convulsive movements gradually subside, and relaxation of the muscles takes place, together with partial return of consciousness, the patient looking confusedly about him and attempting to speak. This, however, is soon followed by drowsiness and stupor, which may con tinue for several hours, when he awakes either apparently quite recovered, or fatigued and depressed, and occasionally in a state of excitement which sometimes assumes the form of mania. Epileptic fits of this sort succeed each other with varying degrees of frequency, and occasionally, though not frequently, with regular periodicity. In some persons they only occur once in a lifetime, or once in the course of many years, while in others they return every week or two, or even are of daily occurrence, and occasionally there are numerous attacks each day. According to Dr Reynolds, there are four times as many epileptics who have their attacks more frequently than once a month as there are of those whose attacks recur at longer intervals. When the fit returns it is not uncommon for one seizure to be followed by another within a few hours or days. Occasionally there occurs a constant succession of attacks extending over many hours, and with such rapidity that the patient appears as if he had never come out of the one fit. The term status epileplicus is applied to this condition, which is sometimes followed with fatal results. In many epileptics the fits occur during the night as well as during the day, but in some instances they are entirely nocturnal, and it is well known that in such cases the disease may long exist and yet remain un recognized either by the patient or the physician. The other manifestation of epilepsy, to which the names epilepsia mitior or le petit mal are given, differs from that above described in the absence of the convulsive spasms. It is also termed by some authors epilepti: vertigo (giddi ness), and consists essentially in the sudden arrest of volition and consciousness, which is of but short duration, and may be accompanied with staggering or some alteration in position or motion, or may simply exhibit itself in a look of absence or confusion, and, should the patient happen to be engaged in conversation, by an abrupt termin ation of the act. In general it lasts but a few seconds, and the individual resumes his occupation without perhaps being aware of anything having been the matter. In some instances there is a degree of spasmodic action in certain muscles which may cause the patient to make some unexpected movement, such as turning half round, or walking abruptly aside, or may show itself by some unusual expression of countenance, such as squinting or grinning. There may be some amount of &quot;aura&quot; pre ceding such attacks, and also of faintness following them. The petit mal most commonly co-exists with the grand mal, but has no necessary connection with it, as each may exist alone. According to Trousseau, the petit mal in general precedes the manifestation of the grand mal, but some times the reverse is the case. Although the above account represents the phenomena usually observed in the two varieties of epilepsy, it is to be noted that many cases occur exhibiting other symptoms which cannot be included in such a general description. Epilepsy appears to exert no necessarily injurious effect upon the general health, and even where it exists in an aggravated form is quite consistent with a high degree of bodily vigour. It is very different, however, with regard to its influence upon the mind ; and the question of the re lation of epilepsy to insanity is one of great and increasing importance. Allusion has already been made to the occa sional occurrence of maniacal excitement as one of the re sults of the epileptic seizure. Such attacks, to which the name of furor epilepticus is applied, are generally accom panied with violent acts on the part of the patient, render ing him dangerous, and demanding prompt measures of restraint. These attacks are by no means limited to the more severe form of epilepsy, but appear to be even more frequently associated with the milder form the epileptic vertigo where they either replace altogether or immedi ately follow the short period of absence characteristic of this form of the disease. Numerous cases are on record of persons known to be epileptic being suddenly seized, either after or without apparent spasmodic attack, with some sudden impulse, in which they have used dangerous violence to those beside them, irrespective altogether of malevolent intention, as appears from their retaining no recollection whatever, after the short period of excitement, of anything that had occurred; and there is reason to believe that crimes of heinous character, for which the perpetrators have suffered punishment, have been committed in a state of mind such as that now described. The subject is obviously one of the greatest medico-legal interest and importance in regard to the question of criminal responsi bility, and it is now justly receiving much greater attention than formerly. Apart, however, from such marked and comparatively rare instances of what is termed epileptic insanity, the general mental condition of the epileptic is in a large pro portion of cases unfavourably affected by the disease. There are doubtless examples (and their number according to statistics is estimated at less than one-third) where, even among those suffering from frequent and severe attacks, no departure from the normal ci ndition of mental integrity can be recognized. But in general there exists some peculiarity, exhibiting itself either in the form of defective memory, or diminishing intelligence, or, what is perhaps as frequent, in irregularities of temper, the patient being irritable or per verse and eccentric. In not a few cases there is a steady mental decline, which ends in dementia or idiocy. It is stated by some high authorities that epileptic women suffer in regard to their mental condition more than men. It also appears to be the case that the later in life the disease shows itself the more likely is the mind to suffer. Neither the frequency nor the severity of the seizures seem to have any necessary influence in the matter; and the general opinion appears to be that the milder form of the disease is that with which mental failure is more apt to be associated. Epilepsy has ever been regarded as one of the most formidable diseases that can afflict mankind, and much labour has been bestowed upon the investigation of its pathology. It must, however, be confessed that morbid anatomy has hitherto failed to throw any satisfactory light upon the real nature of this disease. In the very rare in stances of persons dying in the epileptic fit, the j)ost mortem appearances presented by the brain are in general either entirely negative, or of such indefinite character as cerebral congestion, while, on the other hand, in chronic cases of epilepsy, such lesions as atrophy and degeneration of brain substance or vascular disease are frequently met with, but are, as is well known, common to many other forms of ner vous disease, and are much more probably the consequences rather than the causes of the epileptic attacks. The dis ease is commonly regarded as one of functional character. It is impossible in this notice to refer in detail to the vari ous doctrines which have been held by physicians and patho- logists upon the subject of the site of the lesion in epilepsy. It is now generally admitted, as the result both of obser vation and experiment, that the upper part of the spinal cord, including the medulla oblongata, pons varolii, and other ganglia at the base of the brain, are the parts affected