In studying the peculiarities of at tacks in individual examples of the dis ease it will be found of advantage to systematize such study under four di visions or stages: the preparoxysmal, the paroxysmal, the post-paroxysmal, and the intraparoxysmal or intervalling period, as it is sometimes called. The preparoxysmal, or pre-epileptic, stage covers the period immediately preceding the attack. By far the most important symptom to be investigated here is the aura, or warning, by which is meant some peculiar and constant subjective sensation or psychical impression real ized by the patient as being premonitory of a fit. An aura is present in less than one-half of all cases, but it may be of great value and should always be care fully investigated. The aura may be referable to any of the senses. Flashes of light, sudden blindness, weird and fan tastic visions, strange noises, tinnitus, deafness, numbness or tingling or burn ing or pain in the extremities, disagree able and indefinite; but constant stom achic sensations—as fullness, oppression, or pain, constriction of the throat or of a limb or of some part of the trunk—are among the aura which have been noted.
The psychoses of epilepsy have very definite and immediate associations with other manifestations of the disease. The plea of irresponsibility for criminal acts alleged to have been committed while an individual was suffering from epileptic mental alienation should be considered invalid, unless other and irrefragable manifestations of the dis ease can be adduced. The vague and ill defined convulsions, which date hack to infancy or early childhood, do not con stitute such other manifestations. J.
W. Courtney (Med. News, June 22, 1901).
The aura is an aid sometimes in decid ing the etiological diagnosis. A sensa tion of coldness preceding an attack is said to be, especially if associated with subnormal temperature, almost diagnos tic of cardiac epilepsy. A warning of pracordial anxiety is also suggestive of this type. The aura often constitutes a guide to the location of the cerebral lesion, as, for example, in the patient re ported by Brevor and Horsley, in whom an aura of a horrible taste and smell pointed to the uncinate and hippocampal gyri, found to be the site of the causative lesion upon post-mortem examination. The interval between the aura and the attack varies. At times it is exceedingly short; in others the interval is sufficient to permit the patient to prepare for and prevent the attack.
The paroxysmal stages should always, if possible, be studied personally, or through a competent or preferably a trained observer or nurse. The state ments of the patient are obviously unre liable. The most important phenomenon to be noted in this stage is the location of the first convulsive movement, or, as it is called, the signal-symptom. This initial motor spasm, close in significance to the aura, is even more valuable at times in pointing toward the cerebral area involved by the lesion. Spasms, al
ways beginning in the right foot, for ex ample, point to the upper left Rolandic cortex, etc. The value of the signal symptom is greatest the earlier it is recognized. Epilepsy of long standing, even though dependent upon a focal lesion, tends to become general.
The post-paroxysmal period is quite as important for the determination of es sential facts as either of the other two and in much the same way. A mono plegia,—or limited sensory loss,—an aphasia, or an acute psychosis may pos sess an even more positive pathogenesis and localizing significance than the aura, or signal-symptom. The interparoxys mal period is quite interestingly filled with curious phenomena in many cases. Various states of mental alterations or abnormality, of amnesia, and morbid pro pensity may appear and may decide en tirely the question of prognosis. Evi dences of essential degeneracy, manifest in stigmata, are conveniently considered here. Asymmetry or abnormality of de velopment, especially of the skull, un due elevation of the palate-roof (Gothic arch), a deficient number of teeth, undue elongation or eversion of the coccyx,— the rudimentary tail of Fere,—are among the large number of stigmata observed.
Diagnosis.—The recognition of epi lepsy, in its typical form, is ordinarily a matter of no great difficulty. As, how ever, convulsions from urmmia, denti tion, etc., do not differ materially from epilepsy except in the matter of habitual repetition, it is necessary to consider all the collateral facts in addition to the seizure itself. A history of repeated con vulsions of abrupt onset and without im mediate assignable cause is, in itself, al most diagnostic. Even with such a his tory, however, the individual patient should always be given the benefit of a cautious differential examination, which should invariably include a careful uri nalysis. Aside from the accidental or in cidental convulsions which may accom pany other diseases, such as nephritis, diabetes, certain forms of meningitis, etc., there are only four conditions which are likely to confuse the diagnosis: tetanus, malingering, syncope, and hys teria. Tetanus differs from epilepsy in the two facts of retained consciousness and tonic spasm alone, clonic spasms be ing absent. The detection of malinger ing will at times, as in the famous case of Clegg, the "dummy chucker," prove quite difficult. It is seldom the case, how ever, that a malingerer will learn his part as well as Clegg, and few of them will have the stoicism to withstand the tests of pin-prick, hot iron, ammonia-vapor, etc., which are indicated in suspected cases. Clegg, by the way, was brought to an acknowledgment of malingering by being confronted with the fact that in his spasms he violated a physiological as well as a physical law, in that the thumb was contracted in flexion outside instead of inside the other fingers.