Secondary epilepsy also reacts differently to the bromide treatment. As a rule, the disease remains practically uninfluenced by the bromides.
After these preliminary remarks, which are made partly for the purpose of orientation and partly to explain the difficulties of the ques tion, we will proceed to give a short description of the symptomatology.
The typical attack of grand mai is exactly the same in the child as in the adult. In either case the attack may come on unheralded, or may be announced by an aura of variable duration and character. To describe these things, which are found in every text book of neurology or internal medicine, seems to us superfluous.
In regard to the duration and frequency of the attacks, everything that is essential has already been stated. It should be added that in the genuine form the attacks may in the beginning be nocturnal and, if the initial cry is absent, as is so frequently the case, the attacks may not be noticed for some time, or only inferred from the evacuation of urine by which they are accompanied (compare page 374).
Pett't ?nal in its various forms is perhaps even more frequent in children than in adults. It may take the form of momentary loss of consciousness (absence), epileptic vertigo, or rudimentary, i. e., atypical convulsions.
Dazed conditions and vertigo manifest themselves as in the adult by loss of consciousness ttotal analgesia!) with slight symptoms of motor irri tation. In cases of absence the latter may be entirely absent, or consist merely in a slow, but very forcible rotation of the head, distortion of the face, or rolling of the eyes. In epileptic vertigo the patient usually falls to the ground and has a very short, tonic convulsion, often accompanied by involuntary evacuation of urine. The vertigo is often preceded by an aura.
In many children consciousness is merely clouded instead of being completely suspended during epileptic vertigo. They continue with what they are doing, and respond when spoken to, but they do not remember afterwards what happened during the attack.
Of the rudimentary and atypical attacks, the most important are: (1) localized twitchings, designated "sccousses" (Herpin) and resembling those which occur at the beginning of the cortico-cpileptic attack; (2) nodding epilepsy (epilepsia nutans); and (3) epilepsia procursiva.
The two first-named varieties, which are often unaccompanied by loss of consciousness, are always of short duration and are therefore rarely observed by the physician unless, as occasionally happens, the attacks are massed. It is difficult to identify them by the description obtained from parents. From the diagnostic standpoint it is important to remember that they may be an expression of a focal disease of the cortex (Jacksonian epilepsy) and that they also occur in genuine cases.
The attacks assume a variety of forms; sometimes they resemble the movements seen in tic; at others, a short lightning-like start with a jerking, forward movement of the trunk and head while the arms are extended, during which the child, if it happens to be sitting at the table, may strike its forehead against its plate.
Another form is the so-called nodding epilep,sy (salaam spasm), in which the same movement, not unlike a bow, is repeated with light ning-like rapidity twenty, fifty, or even a hundred times in rapid succes sion. This variety of spasm must under all circumstances, be sharply distinguished from nodding spasm (see page 322), even when it is not accompanied by loss of consciousness and disturbances of the cye movements are present also. On the other hand, there are cases which clinically resemble salaam spasm and which have nothing whatever to do with epilepsy; they must be regarded as cases of generalized tic, or as a hysterical symptom (hysterical salaam spasm).
A positive diagnosis of epilepsy demands either absolute proof that consciousness was clouded during the attack, or the presence of other positive epileptic phenomena in the same individual.
The term epilepsia procursiva has been used to describe certain peculiar epileptic attacks, consisting in forced running which begins suddenly and, after persisting for a variable time, terminates as suddenly, or ends in an attack of grand mal, thus revealing its true character of El motor aura. Consciousness is not always completely abolished during running, as appears from the fact that many of the patients avoid obsta cles or turn about face when they come to the obstacle, etc.