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Exceptionally the absence is prolonged for hours, days or even weeks. Féré rightly includes with these absences those peculiar states of obscuration which are known as epileptic automatism, during which the patient may execute complicated acts, such as taking a journey somewhere, stopping in hotels, etc., without retaining any recollection of them after the attack. Legrande du Salle has reported a curious example of such automatism: an individual who was at Havre when his attack began, found himself on the way to Bombay when he regained consciousness, totally ignorant as to where he was or how he came there.
These states resemble states of somnambulism, with which they may, in fact, coexist.
Automatism occurs not only in connection with epilepsy. Heilbronner, Schultze and others have shown that it is met with in most diverse affections: alcoholism, manic depressive insanity, imbecility, and possibly even in neurasthenia.1
(C) Stupor following the seizures: This is a constant phenomenon which constitutes in doubtful cases an important element of diagnosis (Samt). It varies in duration from several minutes to as many hours.
(D) Delirium: This is the gravest manifestation of epilepsy. Sometimes it accompanies a convulsive seizure; at other times it precedes or follows it; still at other times it takes the place of a seizure.
It begins with an accentuation of the disorders of the
1 Heilbronner. Ueber Fugues und fugue-ähnliche Zustände. Jahrbücher f. Psychiat. und Neurol., Vol. XXIII. - Schultze. Ueber krankhaften Wandertrieb. Allg. Zeitsch. f. Psychiat., Vol. LX, No. 6.
emotions and of the character. The patient becomes irritable, anxious, and the delirium establishes itself very rapidly, often within several minutes, and never taking more than a few hours for its development.
The fundamental features in the classical form are: (a) Profound clouding of consciousness, with complete disorientation of time and place;
(B) Anxiety which is sometimes terrible; in some cases it gives rise to violent agitation;
(7) Numerous hallucinations, combined so as to constitute complete scenes, associated with delusions of a painful nature;
(d) Purely automatic and extraordinarily violent reactions; the extreme limit of this violence is known as epileptic furor. In this condition the patient often commits crimes of revolting brutality bearing the stamp of absolute unconsciousness. He kills indiscriminately strangers or his own children, riddles the corpse with thrusts of his knife, cuts off pieces and devours them. In some cases, which are rare but very important from the medicolegal point of view, the criminal act appears to be prompted by the usual sentiments of the patient.1 Suicide is sometimes observed;
(e) Amnesia, which is usually absolute, following the attack. All classical descriptions show that the patients are as a rule totally ignorant of the damage or of the crimes which they have committed. This rule, however, has some exceptions. The patient may have a recollection, most frequently very vague, of the acts accomplished by him during the attack. Three classes of cases
1 Féré. Loc. cit., p. 144.
may present themselves: (1) the subject may retain a complete or a partial recollection of the delirious period, which persists as an ordinary impression; (2) the recollection, present immediately after the attack, may be subsequently effaced, and the patient may deny facts which he previously admitted to be true; (3) inversely, the recollection, absent at the time when the patient comes to, may appear later on: the patient admits a fact which he previously denied. The recollections of epileptic delirium are thus similar to those of ordinary dreams. We may forget within a few hours a dream which we remembered very clearly at the time of awakening or, more rarely, we may, on the contrary, recollect a dream which previously seemed to have left no impression whatever upon the mind.
The following is an abstract from the record of a case of epileptic delirium.
Louis M., forty-two years old, cab driver. Father alcoholic. Patient has had epilepsy since infancy. Has typical epileptic convulsions, though not frequent, almost exclusively nocturnal, occurring about once a month. Absences of long duration: one day the patient found himself driving his carriage about eight miles from the place where he wanted to go, not knowing how he came there.
February 17, 1901, towards six o'clock in the evening, following a violent dispute with a neighbor, the patient came home sad, depressed, and told his wife that he would throw himself into the river rather than live in such a disagreeable place. He went to bed without any supper and fell asleep. About nine o'clock he stood up in his bed, seeming to be in great fear and emitting inarticulate cries, then ran with nothing on but his shirt into the next room, seized a hatchet, and came back into the bedroom, where he began to hack away at everything within his reach. His wife, terrified, ran out and called for help. Some of the neighbors came but no one dared to enter the bedroom. In the meantime they could hear the strokes of the hatchet and the cracking of the furniture.
In a few minutes the patient went at the door of the room, kicking it with his feet as though trying to break it down, but making no attempt to open it. Finally three men climbed into the room through the window without the patient hearing them. They approached him from behind, disarmed and overpowered him, and while he defended himself violently and tried to bite them, they succeeded by the greatest efforts in getting him down and tying him to his bed. The patient struggled violently to free himself, but preserved complete mutism all the time and did not seem to recognize anyone. His respiration was panting, skin covered with
perspiration, pupils widely dilated.
Towards five o'clock in the morning consciousness appeared to be returning. The patient began to look around him, noticed with astonishment the straps with which he was tied, and said a few words: "Take this off from me. What is the matter
with all these people? . ." At about six o'clock he fell into a deep sleep and woke up at noon, tired but lucid. He had some recollection of the beginning of the attack. He said he had had an impression that someone came into the room after him and his wife; it was then that he uttered the cries and ran to get the hatchet. After that he could remember nothing up to the time that he found himself tied in his bed. But what he saw even then he remembered but vaguely: he could not tell who were the people whom he had seen around his bed and said he believed that he had not recognized them at the time. Finally when shown the damage which he had done (the furniture in the room was partly destroyed), he was stupefied and refused to believe that he was the cause of all that destruction.
An attack of epileptic delirium lasts from a few minutes to several days. It may be reduced to a single automatic act. Like the other manifestations of epilepsy, it may be produced always by the same external influences and assume the same form each time. This is of course far from being always the
The termination of the delirium is either sudden, following a profound sleep, or gradual, leaving for
several hours delusions and hallucinations which persist in spite of the return of lucidity.
The above is a description of the most common, one may say classical, form of epileptic delirium. Another form is occasionally met with in which ideas of grandeur occur in place of the painful delusions; these ideas often assume a mystic character and are associated with a state of euphoria which may reach the intensity of ecstasy.
The diagnosis is very easy when these phenomena appear in an old epileptic; it becomes very difficult, however, when the epilepsy is "masked, or atypical in its course.
There is no pathognomonic sign of epileptic delirium excepting, perhaps, the stupor which follows it and the importance of which is justly insisted upon by Samt and Moeli.2 However, this stupor may be so slight as to escape the observation of those witnessing the attack. The previous history of the patient may contain nothing to aid in the diagnosis because delirium sometimes constitutes the first manifestation of epilepsy; on the other hand, epileptics may present mental disturbances which have nothing in common with their disease (alcoholic delirium, chronic delusional insanity). Only upon the entire symptom complex together with the previous history of the patient can the diagnosis of epileptic delirium or of any other epileptic manifestation be established.
We may distinguish:
Delirium tremens by the occupation delirium, by the
1 Magnan. Loc. cit., p. 2.
'Allg. Zeitsch. f. Psychiat., 1900, Nos. 2 and 3.