(i) On right or left sided spasm at the onset of epileptic paroxysms, and on crude sensation warnings, and elaborate mental states. By J. Hughlings Jackson, M.D., LL.D., F.R.S. Physician to the London Hospital, and to the National Hospital for the Epileptic and Paralysed. Brain 1880: 2; 192–206. With (ii) On a particular variety of epilepsy (‘intellectual aura’), one case with symptoms of organic brain disease. By J. Hughlings Jackson, M.D., LL.D., F.R.S. Brain 1888: 11; 179–207. With (iii) Case of epilepsy with tasting movements and ‘dreamy state’—very small patch of softening in the left uncinate gyrus. By J. Hughlings Jackson, M.D., F.R.C.P., LL.D., F.R.S. and Walter S. Colman, MD, F.R.C.P. Brain 1898: 21; 580–590. With (iv) Epileptic attacks with a warning of a crude sensation of smell and with the intellectual aura (dreamy state) in a patient who had symptoms pointing to gross organic disease of the right temporo-sphenoidal lobe. By J. Hughlings Jackson M.D., F.R.C.P., F.R.S. Physician to the National Hospital for the Epileptic and Paralysed and Purves Stewart, M.A., M.D., M.R.C.P Assistant-Physician to the Westminster Hospital. Brain 1899: 22; 535–549.
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Writing in 1898, Dr Hughlings Jackson brings up-to-date the case of a medical practitioner, patient Z, whose ‘dreamy state’ or intellectual aura associated with tasting movements, being the indirect ‘reflex’ results of an epileptic discharge in the gustatory region of (Sir David) Ferrier, he had first described in 1888. Patient Z having died from an overdose of chloral in January 1894, Dr Walter Colman now supplements the updated clinical description with neuropathological examination. At first, Z had episodes so slight that he ‘regarded the matter playfully’ but within a few years ‘he had a[n] haut mal and ... knew the evil meaning of the slight seizures he had disregarded’. Referring to notes scribbled in his case-book in 1877, Dr Jackson reminds himself that the dreamy state included a sense ‘as if it were familiar, but yet he could not remember it’ ... requiring Dr Z to ‘attend to what was going on in [my] mind because [it was] interesting and dim to what [was] going on outside’. Writing of Dr Z in 1888 (Case V), Jackson prefers his own description of the dreamy state as a ‘reminiscence’ to Dr Z's designation of a ‘recollection’. He does, however, accept Dr Z's use of the term ‘aura’, ‘although I do not use it myself for any form of the "dreamy state"’. In Dr Z's words: ‘I first noticed symptoms which I subsequently learnt to describe as petit mal when living at one of our Universities, 1871 ... waiting at the foot of a College staircase ... my attention was suddenly absorbed in my own mental state ... a vivid and unexpected ‘recollection’ ... in a minute or two I felt quite normal again and was as much amused as my friend at finding that I could give no distinct account of what I had ‘recollected’ ... during (subsequent) years (on) a few occasions, I woke with an impression that I had succeeded in recollecting something that I wanted to recollect ... these feelings were uncomfortable and accompanied by a slight involuntary escape of saliva ... and by a soreness of the edge of the tongue, due ... to its having been slightly bitten’. By 1888, Dr Z has grown accustomed to these attacks and considers the key features of the ‘recollections’ to be: instantaneous, absorbing and vivid experiences that are satisfactory in filling up a void but followed, nevertheless, by an awareness that the recollection is fictitious and the state abnormal; reluctance to analyse or go over the abnormal state in retrospect; some episodes triggered by someone's voice, a thought, something read, or the remembered circumstance of a previous dreamy state and others provoked by physical activities such as playing tennis, travelling on the Metropolitan Railway line, or negotiating small crevasses on a Swiss glacier; the ability to act during the episode including correctly diagnosing and advising professionally on a case of left lower lobar pneumonia; writing in a reasonable script and with appropriate content and grammar, although some word choices later seeming ‘grotesquely mal à propos’; most attacks accompanied by vocalization and smacking of the tongue like a tasting movement but ‘the petits maux not associated with hallucinatory sensations of sight, sound, taste, smell or feeling’; and recovery more gradual than onset, episodes usually being followed by temporary loss of memory for habitually familiar names or facts.
Looking back on his earlier description, by 1898 Dr Jackson wants to emphasize the smacking movements of Dr Z's lips and jaw but without a sense of taste. Since these had not been noticeable to another highly accomplished medical man, Jackson presses Dr Z on the point. In a letter dated May 1890, Dr Z replies: ‘I have asked observers to describe such a sound as I have made, and which in former notes I described as a smacking of the tongue like a tasting movement, I have not found it so described, but rather as some indistinct attempt to speak’. Jackson notes the slight feeling of dread: ‘it was not a fear of the fit; the dread came first and then the fit, or rather the rest of the fit’. And in describing some of Dr Z's post-ictal automatisms, Dr Jackson discretely mentions that, on one occasion, ‘there were post-epileptic actions of a kind which in a man fully himself would be criminal, and must have led to very serious consequences had not, fortunately, his condition been known. What he did was overlooked by those concerned’. Thus, a precedent is set for acts of display and exhibition that periodically require medical intervention in adjudicating on the law. But in the case of lobar pneumonia and other medical consultations performed by Dr Z during dreamy states, all is not quite as he would wish. His notes read: ‘for the last few days his beginning (starting to walk? [inserted by Dr Z at a later date]) is more difficult for his tenderness of speechlessness and quick power of talk light swolleness of feet last three days’. If the patient noticed these lapses, no comment was made such was the deferential doctor-patient relationship enjoyed by the Victorian physician. Never one to allow casual ambiguities in assigning credit, Jackson turns for localization of the lesion underlying these dreamy states to (Sir David) Ferrier (Functions of the Brain, 1876, p. 189): ‘I say this not only because credit should be given to the right man, but also because, having said what I have said, I can without immodesty put some facts more strongly than I otherwise should like to do ... I suppose that ... the onset of the seizure [is] "reflex" ... epileptic discharges ... in the gustatory cortical region ... for taste’. Uncertain on which side a lesion might be found, Jackson acknowledges his earlier erroneous guess that it would prove to be right sided. For Dr Colman finds a focus of softening—a small cavity, collapsed and almost empty—not of recent origin but likely resulting from thrombosis or embolism in the uncinate gyrus on the left (see Figs 1 and 2).
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The paper from 1888 that first describes Dr Z, also summarizes Jackson's clinical experience of around 50 cases with the dreamy state, a term he prefers to ‘intellectual aura’ since the latter implies, wrongly in Jackson's opinion, that these experiences are part of the epileptic attack: epigastric and other systemic sensations and movements; defects of consciousness—‘bemazement’, ‘transplantation to another world, lasting a second or so’ or ‘imagining that I was in exactly the same position years ago’; a general tone of unpleasantness; and features that are uncommon as part of these attacks—vertigo, hallucination of colours, and migrainous paroxysms with visual and auditory projections. There are exceptions to these generalizations, and several are described. Another medical man (to be known as ‘Quaerens’) who consulted Jackson in February 1880 likened his own symptoms to the state of reminiscence ‘on which Coleridge, Tennyson, Dickens and many others have written ... ‘we have all some experience of a feeling which comes over us occasionally, of what we are saying and doing having been said or done before, in a remote time – of our having been surrounded, dim ages ago, by the same faces, objects and circumstances – of our knowing perfectly what will be said next, as if we suddenly remembered it (David Copperfield)’. But for Quaerens, ‘whatever pretty suggestions Coleridge and Tennyson may make ... and however universal its occurrence may be regarded by Dickens, it ... ought to be regarded as showing disturbance of brain function’. Despite this opinion of the physician-patient, Jackson doubts that he would ever diagnose a dreamy state as epilepsy without more tell-tale accompanying symptoms; and he has never been consulted with the symptom of ‘reminiscence’ in isolation. That said, mea-culpa, he refers to a report from 1875 in which he ignored the dreamy state and so, for a while, failed to diagnose epilepsy; and another in which Mr Wholey, his house physician, spotted papilloedema (‘double optic neuritis’), Jackson having forgotten to examine the fundi!
Hughlings Jackson had previously listed the variety of experiences that may accompany an epileptic fit. The paper from 1880 focuses much on epileptic vertigo, and a "warning of smell ... a sensation referred to ... the epigastrium ... movements of mastication ... like those of tasting ... indicat(ing) discharges of centres for taste (but) it is very rare to find any sensation of taste as a warning of any kind of seizure’. And the distinction is made between this reproduction of normal actions and the ‘clotted mass of [epileptic] movements we call spasm’. In passing, Jackson is irritated by inexact usage of the terms ‘objective’ and ‘subjective’: thus, a ‘patient, who can smell nothing, and yet has stenches in his nose (at the onset of epileptic seizures ...) is said to have no objective sense of smell, but to have subjective smell’. Illustrated by reference to cases of epileptic vertigo, tinnitus, red vision and epigastric awareness, Jackson has it that objective sensations are those relating to things in the environment whereas the subjective are referred to the body. Turning to the intellectual aura, Jackson muses on how best to describe these states: ‘dreamy feelings ... dreams mixing up with present thoughts ... double consciousness ... silly thoughts ... feelings of being somewhere else ... as if I went back to all that occurred in my childhood’. Although occurring in association with subjective sensations, often spitting, the dreamy state is too complex to be the result of a focal epileptic discharge. Rather, these arise from raised activity of healthy nervous arrangements consequent on loss of ‘control’. And it is his impression that they are much more likely to accompany some subjective sensations, especially those felt in the thoracic and epigastric region and associated with fear (sometimes amounting to terror and rarely, by contrast, ever with a sense of pleasure) and chewing movements, than others. Having subsequently ‘understood’ Dr Z's epileptic onanism, Jackson takes another hostage to medico-legal fortune by acknowledging that the dreamy state may be accompanied by an uncontrolled urge to injure and cause damage to others. In 1880, Jackson's main preoccupation is with localization and lateralization: for him, the dreamy state is likely to be left-sided. ‘Some of the statements I put forward ... are made with great diffidence as to their exactness. He who undertakes a task of this kind is sure to make mistakes ... this short paper, I may say, represents great labour ... I am far from asserting that I have done anything of value ... and I trust that I have fairly acknowledged the difficulties and uncertainties necessary to investigations in which we have to trust so much to our patients’.
Even in 1899, Hughlings Jackson has more to say on the dreamy state. A.B., another member of the medical profession, had septic infections of the chest wall and hand, at an interval of 3 years, after which periodically he acted strangely and with apparent lapses of memory before experiencing episodes associated with a sensation of smell and the dreamy state, in which he seemed to himself to be ‘saying, doing and looking at things which he had experienced before’: people had strange expressions and were physically distant. Later, the attacks were characterized by vertigo with nausea, and a sense of fear and impending death. Their frequency increased and headache ensued. On initial examination, there was a partial left hemiparesis but AB's condition rapidly deteriorated and 2 days later he is dead. No autopsy was performed. The case had been discussed by Hughlings Jackson with (Sir William) Gowers, (Sir Charles) Ballance, (Sir Victor) Horsley and (Dr, later Sir James) Purves-Stewart. Right-sided tumour of the temporo-sphenoidal lobe was suspected but operation not advised. Jackson now refers to the dreamy state, occurring with or without subjective sensations, as ‘uncinate seizures’ arising not from that gyrus itself but from the more distributed system of which it forms part. The dreamy state is a form of ‘mental diplopia’. It combines a (negative) defect with a quasi-parasitical (positive) dreamy-state of consciousness, and remnants of normality. Thus, there is double consciousness; and with fear, ‘one facing an expected horror’, an impending sense of death and, rarely, anything at all pleasurable in the emotional content. ‘I advise the younger medical neurologists to study [Théodore Herpin's (1799–1865)] writings on Epilepsy. I have long known his valuable work, Du Pronostic et du Traitement Curatif de l’Épilepsie, 1852, but I have only recently heard of his still more valuable work, Des Accès Incomplets d’Épilepsie, 1867 ... [in one of 300 cases] ... Herpin's "third smell case" is what I take to be a "dreamy state" ("tristes souvenirs" – "un trouble intellectuel") ...’. Jackson quotes 62 lines from Herpin's original French text to emphasize ‘statements essentially the same as those I make were made by a great authority long ago’. Then, he restates text from his 1888 paper warning practitioners that dismissing the dreamy state as merely curious is to consign patients with a serious disorder, epilepsy, to a diagnostic waste-land. Written in the golden age of descriptive neurology by a practitioner who considered that ‘no better neurological work can be done than the precise investigation of epileptic paroxysms’, these case studies anticipate the further consideration of the temporal lobe epilepsies described in the present issue by Carmen Barba and colleagues (page 1957).
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