This chapter will be devoted to sensations
and bodily changes that seem to be related to
the viscera. These are phenomena that may be
called visceral seizures, both sensory and
motor.
The visceral auras were extensively
described by Gowers (1901). He related them to
the innervation of the pneumogastric nerve but
made no attempt to consider these phenomena as
anything more than auras. Wilson (1929) has
referred to what he called vasovagal attacks of
Gowers, and reported certain cases in which
visceral phenomena were well described.
In Chapter III a section was devoted to
autonomic responses and this section should
serve as an introduction to the following
discussion. The major concentration of
functional representation of autonomie systems
is to be found in the diencephalon and there is
well-known control in the medulla oblongata as
well. But some of these functions are found to
have representation in the cerebral cortex.
Autonomic specializations in the cerebral
cortex. In the cortex the representation is apt
to be related to various motor specializations.
For example, to name only a few of the
delegations of autonomie control to the cortex:
respiration is controlled, for the purposes of
vocalization, in each of the four vocalization
areas (supplementary motor and lower Rolandic
motor, right and left hemisphere). Respiration
is inhibited when the activity of the swallowing
is produced in the lower Rolandic motor area.
Respiration is influenced likewise by
stimulation of the olfactory cortex and the
anterior inferior portion of the cingulate
gyrus.
Pupillary change may be produced by
discharge in, or stimulation of, the occipital
visual areas and also in the precentral area
from which conjugate eye turning is produced,
also in the supplementary motor area when
contraversive looking movements are produced.
Pupillary change occurs when certain psychical
states are produced, such as the emotion of
fear, by discharge in the temporal cortex.
It is obvious that no useful purpose would
be served by an attempt to separate these
phenomena from the motor or sensory or psychical
specialization of which they form a part. It is
also idle to inquire as to whether vision,
hearing, equilibration, tasting, and smelling,
which have been treated as somatic, should have
been classed as visceral.
In most cases there can be no complete
segregation of autonomic phenomena from somatic
phenomena. But there are rare examples of
exclusive autonomic seizures. In such cases
there seems to be a diencephalic localization as
exclusive as the cortical localization of a
simple Jacksonian motor seizure.
The sense of taste has already been
considered with the somatic sensations and
salivation, likewise, because of its
representation in the lower sensorimotor cortex.
Salivation is also represented in the
diencephalon, as indicated by the report of CASE
J.HL. to follow.
Priapism is a rare occurrence during a
seizure. We have had one adult, whose attacks
were due to a large meningeal fibroblastoma
underneath one frontal lobe, who had priapism
during major attacks. There was also one child
of 19 months, C.Gn., who had a very large cyst
of the right hemisphere. His attacks during
status epilepticus were first on one side, then
on the other. At one time they were chiefly
truncal, and priapism appeared for about half an
hour. There appeared with it flushing of the
face in a blotchy manner. We have never produced
erection by stimulation and have no conception
as to its relationship to cerebral
hemispheres.
DIENCEPHALIC AUTONOMIC SEIZURES
Complicated seizures in which all the
manifestations are autonomic are rare, but they
do occur and are of great anatomical importance.
Such an example was described by Penfield
(1929b). This case1 may now be summarized:
pupillary control, and at least certain of the
mechanisms for discharging gland
secretions-tears, sweat, saliva. It is
interesting that evidence of gastrointestinal
activity was absent. There was no vomiting, no
borborygmus, no defecation, although there may
well have been gastrointestinal activity of
which no evidence was seen. It is obvious that
the term "vasovagal" is hardly descriptive of
such a case as this. There was micturition only
on one occasion.
When the attacks became more severe there
was loss of consciousness and this occurred
without somatomotor involvement. The discharge
seems to have spread directly to include the
neural mechanisms essential to consciousness,
just as it does in an otherwise exclusively
somatomotor discharge as soon as the intensity
becomes great enough.
Since observing this case, we have had
numerous opportunities to verify the existence
of visceromotor representation in this
area.
In CASE H.C. (Case Index), stimulation close
to the infundibulum produced flushing of face
and neck and erythema. In CASE P.M. there was a
tumor similarly placed in the vicinity of one
foramen of Monro. At operation under local
anesthesia, the maneuver of scraping out the
tumor produced an attack of marked urticaria and
itching.
A complicated case of autonomic seizures has
been reported by Engel and Aring (1945). The
patient had a discrete cyst in the region of the
right dorsomedial nucleus of the thalamus, the
hypothalamus being intact. The "hypothalamic
attacks" were characterized by choryza, chills,
fever, nausea, vomiting, abdominal cramps, and
ohguria and associated with fluctuating
hypertension and tachycardia. The authors were
under the impression that this complicated train
of events could be precipitated by anxiety, and
the patient died during such a seizure which was
precipitated thus.
In many cases of infiltrating tumors mixed
seizures occur (autonomic and somatic) or two
distinct types may appear, as in the following
example:
CASE M.PN. Tumor of temporal lobe and
basal ganglia, autonomic seizures.
This woman of 29 years had minor attacks for
6 years, and major attacks for 5 years, with
uncinate symptoms present for 2 years. On
admission to the hospital, she had a right
homonymous hemianopsia, right lower facial
weakness, and a positive sign of Babinski on the
right.
While in hospital she had attacks of several
distinct types, which were carefully observed
and analyzed as follows: (1) Frank adversive
seizures, which began with turning of head and
eyes to the right and which were followed by
aphasia. (2) Autonomic seizures with headache.
The head began to ache rather suddenly in the
occipital region and back of neck. This was
usually associated with yawning and often
with hiccups. She nearly always wanted to void
during such attacks or afterward. Associated
with this there was numbness of the left arm and
left mouth, and once there was cyanosis of the
left hand. During these attacks she was
hypersensitive to being touched as though there
were a generalized hyperesthesia. Occasionally
aphasia and increase in the right facial
weakness followed such attacks.
(3) Autonomic seizures. The most dramatic of
these occurred at 2:15 A.M. on the day of her
death. It was recorded completely by Nurse M.
Hall: "The patient opened her eyes, looked at
the nurse and smiled with the left side of her
face. She was placed on bed pan. During the
process, both arms suddenly straightened out in
a rigid posture (this seems to suggest a tonic
postural seizure. It is not clear whether the
attitude resembled decerebrate rigidity or not);
eyes turned to the right and then back; right
pupil contracted and left dilated. Pulse became
rapid and weak. Respirations became slowed to 4
per minute. There was drooling from the mouth;
tears in both eyes.
"Then a deep flush was noticed on both arms
and also appeared on chest and face. It was
observed that in contrast with the flushing of
the rest of the face there was pallor on either
side of the nose and upper lip. On the
epigastrium in the midline a blotchy red
erythema appeared. Rash and flush disappeared
slowly, 12 to 15 minutes. About the time the
flush had gone the pupils were observed to be
equal. They remained so for less than a minute,
after which they were reversed and the left
pupil became small and the right one large for a
time and then they became approximately equal
again."
During this autonomic seizure the blood
pressure was taken once and found to he 200
systolic and 100 diastolic, although her
pressure ordinarily was 120 over 80. Miss Hall
noted irregularities in the pulse during periods
of recurring slowing of the respiration. The
pulse might then be full, and suddenly miss one
or two beats, and then perhaps be weak and
rapid. The pulse rate however rose to 150 and
continued to rise to 180 during the remaining 8
hours of her life.
There was one more seizure, a slight one at
6:30 A.M. In this attack there was a tremor of
the right side of the face, followed by flushing
and "goose flesh" over thorax and legs. There
was marked puckering of the nipple and a rash
appeared, though fainter than in the first
attack. The attack lasted about one minute.
The rapid rate of the heart continued. The
diastolic pressure remained elevated to 110, the
systolic fell to 124, the pulse pressure
becoming smaller, and circulation failed
gradually in spite of stimulation.
Autopsy was carried out at once and the
heart removed one hour and 40 minutes after
death. Immediate examination showed the glycogen
to be 0.348 gm. per cent (as glucose) and the
lactic acid 0.624 gm. per cent. This low figure
would indicate that death was probably due to
heart failure from the high rate at which it had
been driven by the autonomic centers. We have
been forced to a similar conclusion in regard to
death following neurogenic hyperthermia in
certain cases. Examination of the brain showed a
large astrocytoma occupying the whole left
temporal lobe and lower portion of corpus
striatum, while a cyst extended to the midline
and wall of the third ventricle.
It seems quite likely that the headache, of
which she sometimes complained, was the result
of the elevation of blood pressure that occurred
with her autonomie attacks.
The following case may be recorded here in
which yawning was the most striking
phenomenon, but which included other phenomena
exhibited by J.HL. above.
CASE L.J. Autonomic seizures.
This young man was referred to us by Dr.
Albert Brousseau of Quebec because of attacks of
yawning. There was a history of head
injury but no evidence of a cerebral lesion. His
attacks of yawning varied in duration
from a few minutes to 3 hours.
Each attack was ushered in by sweating of
hands and scalp, and a prickling sensation in
scalp and back as though all the hairs were
standing up. He felt his heart pounding at these
times, and a feeling that things were going away
from him, and, weakness, so he had to sit or lie
down. He would then yawn continuously and
tears would flow from his eyes.
Wilder Penfield and Herbert Jasper
1954
Dr.
Wilder Penfield révolutionna les
techniques de chirurgie du cerveau. Il est
l'auteur de découvertes importantes
portant sur la mémoire, la
sensibilité et la douleur, la
cognition.
Ces travaux commencèrent en
recherchant la cause et le traitement
d'épilepsies jusqu'alors incurables. Il
fonda l'Institut neurochirurgical de Montreal en
1935, original par l'association de chirurgiens,
physiologistes et chercheurs au sein de la
même structure vouée tant à
la recherche, qu'aux diagnostics et aux
traitements de la pathologie
cérébrale.
C'est à l'Institut que Penfield
perfectionna "la
procédure montréalaise".
Recourant à la seule anesthésie
locale, il enlevait le volet osseux, mettant
à nu le cerveau. Guidé par les
réponses du patient, il recherchait la
région génératrice des
crises. Cette technique lui permit aussi
d'apporter sa contribution à l'ère
des localisations cérébrales tant
pour la mémoire que pour les
émotions. Voir
la vidéo.
A woman of 29, with a tumour involving
the under surface of the left temporal lobe and
extending to the midbrain and thalamus. She had
had recurring slight attacks consisting of
sudden headache, followed by
yawning
and hiccuping and sometimes associated with
patchy erythema in different areas of the body.
There was one attack of greater severity,
characterized by a rise of blood pressure to 200
over 90, whereas the usual level approximated
100 over 70. With this there was a simultaneous
rise of the pulse rate to 120, flushing and
appearance of irregular erythema over the chest
and thighs, spontaneous appearance of "goose
flesh", slowing of the respirations to 4 per
minute, salivation, lacrimation, dilatation of
the left pupil, and contraction of the right.
"Diencephalic
autonomic Epilepsy"
This description tallies sufficiently with
the first to make it clear that we are not
dealing with a discharge of a parasympathetic
system alone, as Cushing concludes in reviewing
the first ease. It is an explosive,
undiscriminating, discharge which betrays the
spatial relationships both of parasympathetic
and sympathetic function. The dilatation of the
peripheral vessels and sweating might be
considered as parasympathetic in nature, but the
pilomotor response and increased pulse rate,
increased blood pressure, and protrusion of the
eyes obviously belong in the sphere of the
sympathetic. Another instance may be cited.
Dr.
Wilder Penfield revolutionized the
techniques of brain surgery and made major
discoveries about human cognition, memory and
sensation.
Penfield's medical exploration began with
the causes and treatment of epilepsy, which was
considered incurable. In 1935 he set up the
Montreal Neurological Institute, which brought
together surgeons and scientists for cooperative
projects in the research, diagnosis and surgical
treatment of brain disorders.
At the Institute, Penfield perfected his
"Montreal
Procedure." Applying only a local
anaesthetic, he would probe the exposed brain
tissue. Guided by the responses of the patient,
Penfield would search for the scarred tissue
that caused the epilepsy. This procedure also
revealed specific functions performed by various
unmapped regions of the brain. Penfield
discovered the source of memory, tapped the
reservoir of long forgotten sensations and
emotions, and located the storehouse of dreams.
See
the video
