EPILEPSY Even if We exclude all eases characterized by symptomatic convul sions, which are interpreted as "acute epilepNy," and restrict the use of the term "epilepsy" to desig,nate a distinctly chronic disease "mani festing itself either in frequently recurring convulsions with loss of consciousness, or in concomitant symptoms of such attacks, or in psy chopathic concomitant or sequential phenomena" \A"C shall still lack a clear insight into the true nature of these conditions. Especially are we unable in the present state of our knowledge to deter mine whether we are justified in classifying epilepsy among the functional nervous diseases, or whether We must include it among the organic diseases.
We are also at the present time unable to give a final answer to the question whether so-called primary or genuine epilepsy is identical with the symptomatic or secondary form, as Binswanger believes in contra diction to the old Nothnagel classification. Whereas in genuine epilepsy the somatic or psychic attacks with their coneomitant or sequential phenomena for years constituted the entire clinical picture; in symptom atic epilepsy they merely form part of an extensive impairment of the cerebral function (idiocy, infantile cerebral palsies), which depends on organic changes.
It is quite natural to adnlit, in the case of these large groups of so-called symptomatic epilepsies, that the convulsions are due not to perverted function, but to lesions of the brain that are susceptible of histologic den]onstration.
It is not necessary to go into this matter any further, and we refer the reader to Zappert's discussion of tlae question in the preceding section.
Both forms of epilepsy are observed in childhood, and the necessity or desirability, of distinguishing between the two depends on whether there is any marked clinical difference. Although in many eases it is impossible, as Binswanger emphatically points out, to say (luting life whether one is dealing with an anatomieally normal brain, or at least one presenting only a secondary atrophy (genuine epilepsy), or with SCWIT diffuse or focal changes (symptomatic epilepsy), it is nevertheless possible in the great majority of eases to make this distinction, and in our opinion, such a distinction is desirable for many' reasons.
In the first place, the age at which epilepsy begins, and accord ingly the frequency at the various periods of life, is different. A study
of the literature reveals in this respect the greatest contradictions, which appear to be difficult to reconcile. Whereas, according to Chaslin, epilepsy most frequently begins between the ages of 7 and 15; or, according to Bouchet and Cazauvielh, between 10 and 15; or 12 and 16 (Beau), H. Neumann finds that epilepsy commences most frequently between the second and fifth year; a little more rarely during the sixth to the tenth; and still more rarely between the tenth and fourteenth year of life. This statement of the statistical discrepancies which, brief as it is, suffices for our purpose, shows that we are dealing with differences that cannot be attributed to chance. It may be suggested that they are due to the difference in the material, the first series of statistics being derived from patients in epileptic or other homes; while Neumann's statistics are based on a children's clinic. This may be admitted, but it also implies a difference as regards diagnosis and prognosis. The cases in which the disease develops early are for the most part cases of secondary epilepsy, and the majority of these patients do not attain the age at which they are sent to institutions because they succumb to the progressive eerebral disease; it is from those who are attacked later in life that the inmates of institutious arc mainly drawn.
There is a difference in thc clinical type of the first attacks, as well as in the time of their first appearance. In genuine epilepsy thc first attack is like the succeeding ones, and is of characteristically short duration. In the secondary epilepsies, the first attack, which often represents the onset of the infectious or toxic cerebral affection, is not infrequently much longer in duration. It may last hours, or even half a day or night. Later in the course of the disease the attacks usually become shorter and more like those of genuine epilepsy. Again, in the symptomatic form the first protracted attack at the beginning or the disease is often replaced by a series of short attacks occurring together during a period of days or weeks; while, on the other hand, in primary epilepsy the occurrence of isolated attacks, separated by more or less regular intervals of weeks or months, is practically the rule.