ABSTRACTS

DIE AFFEKTEPILEPTISCHEN ANFÄLLE DER NEUROPATHEN UND PSYCHOPATHEN (THE EPILEPTIC ATTACKS OF AFFECTIVE ORIGIN IN NEUROPATHS AND PSYCHOPATHS). By Oberarzt, Dr. Bratz. Monatschrift für Psychiatrie und Neurologie. Bd. XXIV, H. 1 und 2. January-February, 1911.

UEBER AFFEKTEPILEPTISCHE ANFÄLLE BEI PSYCHOPATHEN (AFFECTIVE EPILEPTIC ATTACKS IN PSYCHOPATHS). By Oberarzt, Dr. Stallman. Allgemeine Zeitschrift für Psychiatrie. Bd. LXVIII, H. 6. 1911.

NICHT-EPILEPTISCHE ABSENZEN IM KINDESALTER. By M. Friedmann. Abstract in Allgemeine Zeitschrift für Psychiatrie. B. LXVIII, H. 6. 1911.

The articles deal with epileptoid attacks of affective origin occurring in early criminals and unstable degenerates. These attacks are similar to true epileptic seizures, but are differentiated from them by the facts that there is no mental deterioration following, that the attacks occur as episodes and are caused by some external stimulus, especially by mental excitement. The attacks may take the form of a vertigo, unconsciousness, or psychic equivalents, but attacks of petit mal do not occur.

Convulsive seizures resembling grand mal attacks occur, but are rare. In these cases there are the symptoms of an epileptic attack, convulsions, biting of the tongue, pupillary rigidity, etc.

There is still a smaller number of psychopaths who for years suffer from episodical epileptic-like attacks. When these patients are put into a quiet environment the attacks cease. These patients are usually badly tainted hereditarily, are emotionally unstable, and when they come into contact with the environment develop an increased excitability, thus leading to the affect-epileptic attacks. Petit mal attacks, which are characteristic of true epilepsy, do not occur in these psychopaths.

Many authors have described different forms of attacks of vertigo or dizziness in the constitutionally nervous. The patients complain of a sensation of dizziness in the head, of a sensation as if they were looking through a veil, or as if everything was widely distant. The same patient may experience a great variety of such attacks.

A sharp distinction between an attack of vertigo and one of fainting is not always possible when only a single attack occurs. The author gives a summary of a case in which besides the fainting

attacks there were also so-called narcoleptic attacks. Of these latter there are two varieties: first, a true sleep coming on after mental excitement; and, secondly, abortive narcoleptic attacks. in which the patient falls asleep for a few minutes but does not lose consciousness. A patient of Friedmann's became weak in the legs after a strong emotion. A case illustrating both varieties is given. In this case one of the most severe attacks of sleep or unconsciousness occurred immediately after the patient had shot his bride. Other, light attacks occurred when he had a tooth pulled or when he saw blood.

Periods of hallucinatory confusion and twilight states are, in the author's experience, of short duration, one-half hour to a few days, among the psychopaths. The disturbance of consciousness was not deep and the patients reacted to external stimuli. Contrary to the findings in epileptic twilight states in which the attacks are most frequent, after grand or petit mal seizures, the attacks in psychopaths occur most frequently without preceding convulsive or fainting seizures. The onset was sudden, vertiginous attacks seldom preceding or accompanying them.

In the author's experience attacks of depression leading to suicidal attempts are more frequent among these psychopaths than among epileptics. About one-third of his cases have made. one or more attempts at self-destruction. On several occasions these attempts were the reason for committing the patient. Occasionally the patients have attacks of anger and excitement, which may lead to attempts at suicide.

In collecting the histories of these patients the author finds that at the bottom of all the cases there is a psychopathic constitution. They do not attend school, remain away from home, many were detected in thefts or other offenses. In the institution it is seen that the ground for these offenses is the instability. Instability and an unsettled mental state were the chief phenomena noticed. The emotional life shows a dulling and indifference with some tendency to brutality which, with the lack of self-control and an over-irritability, easily leads to explosive outbursts. In many there was a mental weakness, an intellectual deficit, but in very few cases was there a marked imbecility. On the other hand, there were quite a few who could be called normal intellectually. Homosexual practices, onanism especially, were very frequent. Intellectual deterioration was not noted in any of these cases. Neither the rapid mental decay which is seen in epileptics between the ages of fourteen and twenty, nor the gradual deterioration which occurs in chronic alcoholics occurred.

Physically the patients almost always showed the symptoms of a congenital vasomotor neurasthenia. They were pale and the best treatment in the institution, with increase in weight, did not remove the pallor. Blood examinations showed no defect in the condition of the blood. Whenever the patient was a little excited, as in an interview with the physician, the pallor was succeeded by a blush. Sometimes the blushing and paleness alternated. Profuse sweating was also noted, but seldom over the whole body.

Frequently there was hypalgesia or analgesia of the skin. Sensibility to touch was always normal. The author has never found the pain sense destroyed over half the body or over one extremity.

Spasmophilic children frequently remain neuropaths when they become older. In these children the nervous irritability may be shown by the electrical reactions or by the mechanical overexcitability of the peripheral nerves and by the so-called Chvostek phenomenon. In testing the psychopathic and epileptic children with the two latter methods the author finds a markedly increased excitability in about half of the psychopaths and in only three out of twenty-eight epileptics. This shows that the so-called spasmophilic symptoms are much more frequent in the affect-epileptic psychopaths than in epileptics of the same age.

Various degenerative signs were found more frequently in the unstable psychopaths than in epileptics. General hypalgesia, which may be classed among the degenerative signs, was often seen. Hereditary taints were found in about eighty per cent of early epileptics as contrasted to ninety-six per cent of psychopaths. In many of these latter cases it was found that the father was psychopathic and alcoholic, or the father was alcoholic and the mother imbecile.

In the greater number of cases the only external cause was a long lasting emotional strain which was more effective in causing the attacks than fright or sudden anger. In a lesser number of cases physical disability may also cause an attack of affectepilepsy, such as infectious diseases, heat, and even acute alcoholic intoxication.

The convulsive seizures of the psychopaths cannot be differentiated from genuine epileptic attacks. In both there is loss of consciousness, pupillary rigidity, jerking of all the limbs, biting of the tongue, and enuresis. But there are several distinguishing features. The seizures of the psychopaths are not so severe as in epileptics. Injuries are less frequent. The seizures are always single and status affect-epilepticus never occurs. Death has never

been noted in these cases. Enuresis and auræ occur less frequently than in true epilepsy. Petit mal attacks do not occur. The attacks of vertigo are easily distinguished from petit mal attacks. When they increase to loss of consciousness we speak of fainting attacks. The majority of these attacks are of short duration. The last point of differentiation is their episodicity and the fact that they are dependent on some external cause. In many of the less severe cases the external causes are not so prominent as to be useful as differential points when used alone, but in all these cases the author was able to demonstrate the external

cause.

The author does not attempt to prove that the affect-epileptic attacks occur only in the neuropaths and psychopaths, but quotes from the literature many articles dealing with similar phenomena occurring in other constitutional conditions, such as psychasthenia. Agoraphobia and obsessions as described by Westphal and the tics, anxiety states, phobias as described by Janet and Raymond, are examples. Oppenheim has described the affect-epileptic attacks as occurring in the neurasthenics or psychasthenics who suffer from phobias and obsessions, a different group than the unstable degenerates.

Alzheimer has noted the episodical character of the epileptic seizures in psychopathic children, especially at puberty, and remarks that the trouble has no relationship to genuine epilepsy, but stands nearer hysteria, from which, however, it can be differentiated. Spiller has noted that seizures occur in conditions other than epilepsy and hysteria.

From a review of the literature one may conclude that many writers have seen convulsive seizures of a typical epileptic character in neurasthenics, which are not epileptic and not hysterical. In the majority of cases, as far as one can tell from a history, there was an underlying psychopathic constitution.

There are several theories as to the causation of these attacks. Liebermeister says that swooning attacks occur in circulatory disorders from fright, anxiety, or similar mental shocks due to a contraction of the cerebral vessels or to an overfilling of the splanchnic vessels leading to a cerebral anæmia. Weber found. that there was a constriction of the vessels of the brain following unpleasant affective experiences, which is related to a dilatation. of the abdominal vessels.

In congenital neuropathic conditions this relation is disturbed, often reversed. From this the author concludes that the seizures in psychopaths have a definite relationship to the circulatory system and come from some disturbance of the circulation.

In conclusion one may say:

Episodical attacks occur in hereditarily tainted neuropaths or psychopaths of different kinds, in unstable psychopaths, in psychasthenics with obsessions, in hereditarily tainted, nervous children and in a number of cases of endogenous nervosity. These attacks occur usually in the first decade, are rare in the third decade, and are practically never present at the end of the fourth decade. The seizures are episodical, can occur singly or may persist for years and disappear without any deterioration noticeable in the patient.

Mental excitement, such as anger, sight of blood, etc., as well as physical causes, as infectious diseases, great heat, alcoholic excess; and in children, anæmia and autointoxication may cause these affect-epileptic attacks.

The attacks may be of very different kinds, such as, (1) grand mal, (2) attacks of dizziness (=vertigo), (3) fainting attacks, (4) severe narcoleptic attacks, (5) conditions with failure of the motor musculature (slight narcoleptic attacks), (6) psychic attacks (equivalents). The attacks differ from epilepsy in that the grand mal attacks do not lead to status epilepticus and death, petit mal attacks never occur, attacks of vertigo are frequent. The differential diagnosis from hysteria can only be made by long observation and through the absence of the physical and mental phenomena of hysteria. The affect-epileptic attacks stand nearer to hysterical than to epileptic seizures.

Stallman reports six cases in which there were typical epileptic seizures which were caused by some external stimulus, such as frustrated suicidal attempts or anger at being kept in the institution. In none of these cases was there any intellectual decay. The patients all lacked the physical and mental signs of hysteria, and the author thinks that in every case there was a more or less high grade vasomotor neurasthenia.

Friedmann found short "absences" in children, in which consciousness persists, but there is a momentary pause, an inability to move. The attacks occur after some excitement, such as a painful operation, the child stands motionless, gazes steadily upward. This lasts about ten to twenty seconds and the children know everything that passes about them. The attacks are repeated often, sometimes ten to forty times. The trouble is characterized by very short attacks, consciousness is retained, the duration of the whole trouble is rather long, but the development of the child is not hindered. Bromides have no effect on the frequency of the attacks.

The basis of the trouble is not yet clearly demonstrated. In adults the relationship of the attacks to neurasthenia is fairly well