That the cause of mental failure is not identical with that which induces the attacks is evident from the perfect intellectual integrity of some who suffer severely from the paroxysms;* and also from the absence of all direct proportion between the degree of impairment and that of exalted motility. That its cause is, however, closely associated with that of the attacks is to be inferred from the fact that the degree of failure does bear direct proportion to the frequency of the latter. And we may further gather, that its relation is more close to that element in the causation of attacks which induces loss of consciousness, than to that which causes the convulsion; since it is with "le petit mal" that intellectual deterioration is associated more notably than with the violent paroxysms.§ The precise nature of the cerebral change upon which the mental failure depends we cannot positively describe; but the evidence from pathological anatomy is that the nutrition of the cerebral lobes does, in some epileptics, become impaired; and the inference from symptoms would be to the same effect. This impairment, although not necessarily induced by the epileptic conditions, as I have just shown, is, however, in all probability, due to the changes which these induce upon nutrition through the vaso-motor nerves. The circulation in the brain proper is under the control of that portion of the reflective centre and its appendages in which epilepsy has its seat; and through changes in the latter the former becomes deranged. Anæmia of the brain is the essential phenomenon of "le petit mal;" and this, followed by the toxic effect of venous blood, is also present in "le haut mal;"** yet persistent mental impairment does not result from these paroxysmal changes. But the conditions which cause these are to be regarded as the sources of that failure, operating slowly and progressively as the disease goes on; but in some instances commencing with its commencement, and in others producing most marked deterioration even before any paroxysmal phenomena have been observed.++ The phenomena to be discovered during the interparoxysmal + See p. 177. * See p. 186. § See p. 191. Bouchet et Cazauvieilh, De l'Épilepsie considérée dans ses Rapports avec l'Aliénation Mentale. See p. 243. + See p. 182. period in the region of motility afford evidence which has been already discussed in regard of the primary or essential facts in epilepsy.* The condition of the general health has been shown to be so various and so often unimpeachable, that positively no relation can be demonstrated to exist between it and the disease. It is absolutely good in the majority;† and when impaired its relations are such as to show that its deterioration is neither cause nor effect of the attacks; and further, that it determines neither the existence nor degree of mental incapacity. All that does appear is, that the paroxysms are less frequent when the health and strength are impaired than when they are normal and robust,§ and that the mind is more frequently damaged in the physically strong than in the weak.|| P. 72. + See p. 176. § See p. 158. || See p. 177. CHAPTER VI. DIAGNOSIS. "In our daily visits to the sick our first duty is to establish an accurate diagnosis. Diagnosis in these diseases is, unfortunately, not of the physical kind, as in diseases of the thorax, but the interpretation of symptoms. In this manner it is that the physiology of the nervous system and the diagnosis of its diseases meet and coalesce."-MARSHALL HALL. TRUE epilepsy is to be distinguished from feigned convulsions, and from divers diseases. We have to establish its dia gnosis from I. Simulated epilepsy. II. Syncope. III. Hysteria. IV. Catalepsy. V. Eccentric convulsions. VI. Convulsions that are the expression of diathetic diseases. VII. Organic lesions of the cerebral and spinal centres. Some of these resemble epilepsy in many points, others in but few; and it is by an examination of the general clinical history of a case, rather than of its convulsive paroxysms, that the diagnosis may be established. I. Epilepsy is less frequently SIMULATED now than it appears to have been in past times. The diagnosis depends upon the absence or presence of certain symptoms which cannot be feigned. Choice of locality for falling is not to be depended on, as Georget* and others have insisted; for I have known epileptics who were able to exert this faculty; as, for example, a youth who could dismount from his saddle, tie his horse to a tree, get * De la Physiologie du Système Nerveux, &c., Tome I., p. 347. over a hedge and lie down on the other side, or go into a cottage to have his fits. I have known others who could walk out of one room into another, and lie down on a sofa. Similar facts are related by Portal. Choice of locality does not prove that epilepsy is feigned; the absence of choice, on the other hand, is presumptive evidence that it is genuine; and this in proportion to the danger, or the privacy of the locality in which the fall occurs. It has been said that if the thumbs are forcibly unbent they remain open in true epilepsy, whereas the simulator closes them again. This test cannot be relied upon either way; but the manner in which the re-closure takes place might afford hints of insincerity. Dr. Watson mentions the great strength of the true epileptic, his cool skin, and the short duration of the attacks as points likely to be feigned with difficulty or error. But athletes can exert enormous force; the skin of the epileptic is not necessarily cool until asphyxia has occurred, and there is, as well, undue evaporation from its surface; and again the clonic stage of convulsions is sometimes of long duration, whereas a clever impostor might shorten the period of his performance. These characters, though not decisive, are, nevertheless, of use, in combination with others. The dusky and pallid tint of skin cannot be assumed, nor can the condition of the pupil -"pupillæ semper dilata ;"§ and upon the presence or absence of these the diagnosis may be established, with or without the aid of other corroborative proofs. II. SYNCOPE could only be mistaken for attacks of "le petit mal," or vice versa. There are not the clonic convulsive movements of epilepsia gravior. The loss of consciousness is not absolute, nor is it so sudden in syncope as in epilepsy. Volition, rather than perception, is in abeyance; the patient feels, sees, hears, but cannot do anything; in extreme cases he "loses himself" altogether. But this Observations, p. 127. + Marc. Épil. Simulée, Dict. de Sc. et Méd., Vol. XII., p. 542. § Millar, Dissertatio de Epilepsia, p. 4. takes place, as a more or less gradual change; he feels "faint," and exhibits embarrassment of both respiration and circulation. There is usually some immediate cause of the sensation, such as change of posture, &c.; and the horizontal position affords speedy relief. The fainting patients slide downwards, and this with some gentleness; epileptics seem to be thrown down-" cum impetu prosternuntur."* Of syncope the sufferer retains some recollection; of epilepsy, i. e. of "le petit mal," he usually has none; and the fatigue felt after the former is greater than that following the latter.t III. Epileptic attacks sometimes occur in those who are the subjects of HYSTERIA, and there are to be witnessed paroxysms which partake of the features of both maladies. As a rule, however, they are distinct, and we have to point out the diagnosis of typical cases of the two. In the epileptic, during the interparoxysmal period, there are none of the special features of hysteria. The latter is more common in the female sex. It rarely commences earlier than the fifteenth year, or later than the thirtieth-although when once established it may persist until a later period. It is more common in the unmarried, or continent; and in those of luxurious and lazy habits. It is frequently associated with uterine irregularities, such as amenorrhoea, dysmenorrhoea, menorrhagia, &c. The mental condition differs from that of epilepsy. There is great want of belief in volitional power, leading to the assertion that this thing and the other cannot be done; and this, in combination with excess of emotion, produces most characteristic features. The epileptic is more or less listless, careless, indifferent, or stolid; the hysterical patient, as a rule, exhibits the very reverse of these conditions. Sensation and emotion are preternaturally active; every kind of pain is "agonizing," every trouble "overwhelming," every joy "excessive;" and, under the influence of these, various actions may be performed which a few seconds before were said and believed to be impos * Tatai, Hercules vere Cognitus, p. 53. |