"THE OTHER SIDE OF A FIT"

by Glenn Doman, ScD, Edward B. LeWinn, MD, FACP, and Roselise Wilkinson, MD

Presented at the 1977 Annual Meeting of the World Organization for Human Potential, held in Rio de Janerio, Brazil, on May 24, 1977.

In the welter of technology which today is increasingly the basis for the study of human behavior and human ills, the process of simple observation has been all but lost. And yet, until recent decades the growth of our knowledge of ourselves and of the world around us has been almost entirely by means of what the late Odell Shephard, Professor of English at Trinity College in Hartford, called "the harvest of a quiet eye". Simple observation has been the basis for precepts and conclusions made by philosophers, mathematicians, astronomers, physicists and physicians who have profoundly influenced our lives.

This morning we shall present to you a superb example of the product of a keen eye, an attentive ear and a sensitive hand that led a remarkably receptive mind to exercise its curiosity, imagination and understanding and to express the meaning of such simple observation. We shall present, with comments, one of Temple Fay's classic papers, The Other Side of a Fit. We are certain that in the 35 years since it was first published this will be the first time any group of people will have given this example of Dr. Fay's perception and wisdom the attention it deserves.

Temple Fay published "The Other Side of a Fit" in the American Journal of Psychiatry, volume 99, number 2, September 1942, pages 196 through 200. Reprints of this remarkable article will be available on request to us. Dr. Fay, then Professor and Head of the Department of Neurology and Neurosurgery at Temple University School of Medicine, wrote as follows:

Since the earliest medical records, (2) "fits" have been considered manifestations of "evil spirits", or an affliction associated with the most dreadful concepts of disaster.

In the New Testament, Matthew, Luke and Mark (3) testify to the concept of those "possessed with Devils" and those which were "lunatic." Woolsey (4) points out that the Hebrew word "Nichpea" is defined by the Jastrow dictionary "to be inverted, upset; to be overtaken by a Demon, especially due to epilepsy." I need not mention that even to this present hour there are many who can see no good in convulsive seizures and view the entire episode as an unnecessary and horrible phenomenon.

If one were to view a major convulsive seizure with the same dispassionate tolerance as one might a severe sneezing attack or period of vomiting, the ordeal, unpleasant as it might appear, would hardly be ascribed to "evil spirits.". These reactions of defense are recognized as normal mechanisms of protection against irritants to the nose or to the stomach. The "mechanism of labor" in the primipara is usually a prolonged and unpleasant episode to view, but only primitive races still retain the idea that this portion of the phenomena of childbirth is the manifestation of evil spirits or a "demon."

Let us note parenthetically at this point that, even as we approach the twenty-first century, the connotation of "evil spirits" is still with us, implicit, for example, in the commonly persistent custom of saying, almost reflexly, "God bless you", or "Gesundheit" or Saude, or some similar incantation to the person who sneezes.

With regard to sneezing and vomiting (and he could have appropriately included coughing) Fay points out that they are reactions of defense, recognized as normal mechanisms for protection against irritants to the nose or to the stomach. Proposing that reason, tolerance and understanding be similarly exercised in the matter of seizures, Fay said:

If we are to look upon the other side of a fit to seek its possible benefits, we must pose two fundamental questions: (1) Why has it been necessary for "nature" to evolve such a violent mechanism and (2) What useful purpose could it have served?

In discussing the answers to these crucial questions, Dr. Fay approaches the usual clinical and emotional biases of the professional observer of seizures from a totally unaccustomed viewpoint. For Fay the behavior of people in seizures has quite a different meaning from that derived by his colleagues. This is because he saw the field of medicine with all of its subdisciplines, for what it really is. Medicine is, in fact, one of the special, most complex areas of contemporary anthropology. Fay appreciated the fact that the understanding of human behavior and human ills can be better accomplished by taking into account man's phylogenetic and developmental history.

Listen carefully as we read further.

The pattern of a major seizure is so consistent from the standpoint of certain muscle groups involved and the movements strikingly simple as compared with the complicated skilled rotary types possible in a well trained human adult that we must seek its counterpart far back in the evolutionary scale if we are to glimpse its origin and its purpose.

Since the "convulsive mechanism" may now be demonstrated to be present in man and throughout the animal world by means of electric shock and metrazol, it can no longer be considered as pathological. As a latent and retained "reaction of defense", it may be potentially present throughout life without need for expression.

What Fay says here is of the utmost importance. He points out that the neurological mechanism for convulsion as a potential reaction of defense exists in all of us. All human beings, on observing another person in a convulsion, may well say, "There, but for the grace of God, go I." The seizure mechanism is not unique to the person with seizures. Anyone may have a seizure if he is subjected to the conditions which set the stage for activation of our innate, defensive, convulsive mechanisms.

It is the commonly accepted procedure in medicine to carefully obtain a history of the patient's background and onset of symptoms before attempting to diagnose or treat organic disease. This is true in the psychiatric field as well where complex emotional and ideational manifestations in a patient, in order to be properly judged, must include a careful review of early childhood experiences.

It is possible to apply the same procedure to the analysis of a "symptom-complex" such as a convulsive seizure. The seizure, per se, if a defense reflex, should be reviewed in the light of the early neurological history of the vertebrates.

This is exactly what Fay proceeds to do: to examine seizures "in the light of the earlier neurological history of the vertebrates".

Among the countless experimental structural and neurological patterns of life, neurological mechanisms which have survived the evolutionary process are those which were able to adjust themselves to the physical and predatory influences of their environment.

The simple pattern of a convulsive seizure includes the turning of the head and eyes; the twisting of the trunk or extension of the back and the repetitive flexor-extensor movements of the prime muscles of the extremities. These are all characteristic of the amphibian level of motor development.

Attention is now drawn to the dramatic effects of the organism's evolutionary shift from the watery environment of the sea to that of land and air, a shift through which, in effect, every human being must go.

Perhaps the greatest event in the history of evolution was the emergence of the land forms from the saline surroundings of the oceans. The transition phase between water and land forms of life evolved simple motor patterns concerned with swimming, paddling and crawling about on the belly, aided by crude legs responding to flexor-extensor impulses. With the advent of appendages, a new motor mechanism developed, superimposed upon the older pattern (Coghill), and it is strikingly significant that a convulsive seizure does not include these later rotatory coordinating movements.

Where tissues had freely obtained water, O2, salts and electrolytes from the surrounding ocean, they were now required to seek O2 from the air, salts from deposits on the land, and water from distant pools. From these widely separated necessities of life, a constant and proper saline mixture and O2 balance had to be maintained in the nerve centers, as well as other vital areas (by circulation). When dangerous deficiencies arose on the land, protection and replenishment were assured by the prompt return to the ocean. Those forms of life that learned to emerge and "flip" back again evidently survived to try another time.

Fay now shows the connection between these events and human convulsive patterns, a connection which continues to be insufficiently recognized and understood.

To have established and retained a constant reflex motor pattern so persistently in the neurological mechanism, even to the present day, would seem to indicate that the convulsive pattern was required to cope with some threatened danger, sufficiently serious to demand a total "all out" response. This threatened danger might be a physiochemical one of undesirable proportions, recognized by the sensitive nervous tissues as needing immediate correction to save the organism.

"The other side of a fit," therefore, may find some reasonable explanation in the circumstances which surround its typical amphibian motor pattern.

The forms of life abounding in the oceans had at their disposal water in unlimited quantity; oxygen in solution (obtained through the gills and other permeable membranes for the purpose of respiration and metabolism); salts, in all varieties to select from and apply to their chosen needs. Motility and migratory possibilities gave rise to access to the zones of favorable temperature, so that a veritable paradise for cellular life existed, where the only concern was the seeking of food and reproduction of the species (still a dominant factor).

On the other hand, the vertebrates that attempted survival on the land required storage of water in the tissues and replenishment from "water hole to water hole." Oxygen, freely available in the air, necessitated a greater surface of exposure in order that it might be obtained, captured and retained for metabolic purposes. The lungs were developed to meet this need. Salts were obtained through food, or at "salt licks" or by revisits to the saline surroundings of their evolutionary ancestors. Increasingly infrequent visits, however, required more highly developed storage and replacement by other tissues. The process of evolution has been the eternal struggle to meet and solve the external problems presented by the environment of first the waters of the oceans, and subsequently the solid surfaces surrounded by gaseous mixtures called air.

The countless experiments over millions of years, as well as myriads of forms which failed to adjust themselves are unknown to us today. Gradually, however, there seems to have evolved a "defense" pattern in the nervous system which could be called into action when the vertebrate encountered improper tissue concentrations of water or oxygen, or alterations from the established physiochemistry of relationships of the oceans. This "reflex of defense" was concerned with such movements of the extremities as tail-twisting, flapping, jerking and slapping responses that were best calculated to return it to the water again. The fortunate species possessing this phenomena, although it may have wandered beyond the margin of safety, regained the electrolytes so necessary for survival; readjusted its needs and then returned to explore again its new and solid environment. (5)

We believe that looking even lower in the evolutionary scale emphasizes Fay's view of the phylogeny of seizures. The mobility patterns of fishes are even more primitive and limited in their scope than those of amphibia. How many of us who have caught fish have observed their movements when newly pulled from the water, the "reflex of defense" the "tailtwisting, flapping, jerking and slapping" actions made in an effort to return to the water?

Dr. Fay continues:

The convulsive pattern of movements in man may signify an attempt at readjustment and "defense" along the old and established rules when the organism is faced with profound physiological changes in electrolytes and oxygen at the brain level.

Adding emphasis to all that he has said earlier in the article, the author then states:

It is not surprising, therefore, to find in a man a primitive basic reflex, as protective in its way as the vomiting reflex, which admittedly has its purpose. If its purpose be the re-establishment of normal physiology, in terms of oxygen, salts, electrolytes and metabolism,

then it is obvious that the search for specific pathology will be fruitless and the concept of a "disease" untenable. That there are many types of pathological threats to the brain capable of producing and calling forth this primitive response, merely indicates a basic response to a serious need, no matter what the cause.

To refer to the condition as a "disease," or to speak in terms of a "cure" would be as foolish as to consider an exaggerated patellar tendon reflex as something to treat and cure, rather than the cause. The same may be said for vomiting-one does not "cure" vomiting; one controls it (usually by treating the cause). The periodically recurring act of vomiting does not constitute a disease, it is only a defense reflex against some unfavorable state.

"The other side of a fit," in my opinion, is that the convulsive seizure represents a normal "defense reflex" of simple pattern, evolved for the purpose of protecting the economy against alterations in the basic formula of water, oxygen and certain salts. That the human being responds to these abnormal alterations, with the basic purpose of regaining again, by convulsive efforts, the favorable formula which once was standardized and easily obtained in the primitive environment of the ocean, sees more reasonable to me than the idea of "demons", disease, or the spread of some mysterious "alpha substance" throughout the brain surface.

Fay applies these views to the observation of a major seizure when he points out:

Perhaps the strongest argument in favor of this concept is the failure of the skilled rotatory and prehensile movements to appear in a true major seizure. One never sees the coordinating movements of chorea and athetosis in a typical major convulsion. In spite of years of skill and training, the seizure in the adult is similar to that in the child. Skilled, motor acts belong to the motor cortex and the theory of irritation and direct involvement by pathology thus has little support, either on the basis of Hughlings Jackson's law of motor function (a diseased or injured motor cell cannot hyperfunction) or, upon the idea that local pathology of fixed type (scars, meningiomas and pressure) is responsible for generalized seizures. Such fixed irritants would be expected to produce either epilepsia partialis continua or status epilepticus. Both of these conditions are comparatively rare.

In the intervals between seizures, intervals which may last from seconds to a lifetime, a matter of seventy or more years, why are there no overt convulsions? If pathology causes convulsions, does that pathology come and go? If not pathology but demons or that "mysterious alpha substance", where do they hide in the intervals between seizures? Fay touches on this point.

There still must be added the reason for the attack free interval, with or without focal pathology, and the reason for the particular moment of precipitation of the seizure, although the pathology was present, one hour before, or even days and years.

The electroencephalographer often demonstrates the presence of what is termed electrical seizure activity, even though there are no clinical manifestations, no overt convulsions. It is sad that many clinicians see fit to treat these paper seizures with anticonvulsants instead of seeking to understand and correct the reasons for a purely technological manifestation.

Fay now goes on to examine the other side of a fit from still another related viewpoint, that of the integrated functional levels of the anatomical and neurological hierarchy of the brain. In keeping with the events in human phylogeny and ontogeny, he begins with the lower levels.

From an evolutionary standpoint, we must abandon the irritative theory, for one of release of higher levels. We must view the convulsive seizure as we do the patellar reflex. The response becomes exaggerated and more violent as the higher motor levels of the brain are removed, simple reflex arcs under proper sensory stimulation may then act independently and "convulsively" (so called "spinal epilepsy" seen in chronic cervical transverse myelitis) and the spread of the motor responses from the level of a patellar tendon reflex may involve all four extremities, where inhibitory influences of the brain have been completely withdrawn.

The simple convulsive pattern is but an integration of the spinal segment-arc response, coordinated with certain primitive head-eye-trunk movements. Although slightly more complex than the tendon reflex response, it nevertheless follows the same release phenomena and therefore might be expected to be precipitated by normal sensory impulses during a period of loss of cerebral control.

There is ample evidence of the loss of cerebral control in the act of "falling", "unconsciousness", "tonic phase" (decerebrate rigidity). Intelligent, skilled and coordinated movements that represent higher motor patterns as well as the antigravity reflex group, evolved after the amphibian stage, are all absent during a major seizure, indicating that their controlling influence has also been temporarily removed.

With obliteration of the higher motor levels (more recent evolutionary integrations), a simple primitive motor pattern, free to respond without restraint, takes charge of the unconscious victim in an heroic attempt to save the day. The degree, extent and duration of an attack must obviously vary in proportion to the extent of removal of the higher controlling mechanisms.

Once again, but this time from the clinical aspect, Fay examines a fit in relation to the amphibian stage of phylogeny.

That the "convulsive spasms" do not succeed in "returning the human being to the water" is, of course, fortunate, in view of our present dependence upon air for our oxygen. If, however, we place the human being on the abdomen and view the attack with the extremities in the water, the simple head-neck-body, paddle and swimming movements suggest the evolutionary level of the motor pattern, as well as its probable purpose.

A convulsion may appear to be a horrible and purposeless series of movements when the individual is lying on the back, but when suspended in a fluid medium, face down, the convulsive movements do credit to the amphibian level, where they probably arose.

Although the prone position of the person having a seizure may present disadvantages for the observer, for the patient himself the advantages over the supine position in which he is usually placed can be considerable. (1) In keeping with Fay's concept that during a seizure the individual is reduced to the functional neurological level of the amphibia, the horizontal, face-down position of the body is closer to what seems to be the intent of the defensive convulsive mechanism. (2) Gravitational effects on cerebral circulation are reduced by the horizontal position of the body. (3) Should vomiting occur, aspiration is less likely. (4) In supine position, gravity causes the tongue to fall back into the pharynx, thus obstructing the airway, while in prone the opposite is true.

Once more Fay proposes a clearer understanding of the present through the knowledge of man's past:

Those who do not choose to associate our superior human state of today with the evolutionary past, the most significant period of which was concerned with getting out of the water and solving the problems of the air and the land, should glance a moment at the present. The most significant event in the human experience is when he emerges from the saline, watery protection of the amniotic sac at birth, into the world of air and solid surfaces. This moment of transition is a critical one-condensed into a few minutes, it represents the supreme achievement of Nature, requiring untold millions of years in the evolutionary struggle, to bring a forth a land surviving type.

In view of the hypothesis presented above, that the convulsion may have as its purpose restoration of fundamental physiological relationships, whether disturbed by deficient environment, inadequate circulation or local pathology, and thus be considered as a "defense reflex" it may not be out of place to ask the questions: (1) What is the relative frequency of convulsive seizures in aquatic vertebrates, as compared with the air-breathing land types? (2) What is the relative frequency of convulsive seizures in the embryo in utero, during the last six months of its free-swimming state, as compared with the infant's first six months, as an air-breathing land type after birth?

The answer to those questions, revealing as they might be, obviously is that at the present, at least, no one actually knows.

There seems ample reason, however, to consider not only the "other side of a fit" but many sides of a normal and inherent mechanism in man, capable of being elicited by means of "electric shock," almost as easily now as obtaining a tendon reflex.

The article which we are discussing was first presented at the 1942 meeting of the American Psychiatric Association. Fay now refers to a prediction made by him at an earlier meeting of that body.

Four years ago I stated before this section, that the day would come when the profession would be referring to "normal" convulsive responses, as we do to normal reflexes. A glance at the program of The American Psychiatric Association on "electric shock" this week indicates this day has actually arrived.

As he approaches the close of his article on "The Other Side of a Fit", Dr. Fay condemns generally held beliefs and practices with regard to seizures which today, 35 years later remain distressingly unchanged.

So too, has the day arrived when we must throw out the concept of "demons," "disease," and "disgrace"; abandon the fruitless search for a specific "pathology" for a "normal reflex" mechanism, give up the fixed idea that the seizure is a "base," "horrible," "undesirable" manifestation, simply because we do not like to see it, do not understand it and often cannot control it. The observations and facts of the past 2000 years have never fitted into this prejudiced concept of a human affliction. On the "other side" there is an endless stream of evolutionary, symptomatic and physiological evidence to support the idea that a convulsive seizure is a primitive integrated "reaction of defense" for a purpose and as an emergency release mechanism, reverting back to a primitive motor pattern. To seek the reasons which require the playing of such an ace card, in the effort of defense of the brain would seem a more intelligent approach to therapy than the practice of medicinal "black-outs" to relieve our offended senses.

"To seek the reasons which require the playing of such an ace card in the effort of defense of the brain would seem a more intelligent approach to therapy than the practice of medicinal 'black-out' to relieve our offended senses". Here Dr. Fay anticipated by three decades the condemnation of the use of anticonvulsants by this body in 1971 referred to by Dr. LeWinn in his State of The World Organization for Human Potential address when this meeting opened two days ago. Unfortunately, in spite of the truth and clarity of these statements, Fay's words have otherwise been largely ignored.

Dr. Fay touches briefly on one familial factor as a possible cause of convulsions. In keeping with his entire view of the other side of a fit, it has to do with blood supply to the brain.

Instead of the family historical search extending back only to some convulsing ancestor, it should reach back to the evolutionary level when the pattern was developed, if it is necessary to create a satisfying alibi.

As pointed out in another presentation,(6) hereditary tendencies to reproduce small and inadequate cardiovascular systems offer a handicap and a threat to the brain from the circulatory standpoint. The basic physiological relationships may be altered by momentary stasis either from the insufficiency of a Stokes-Adams syndrome or in the direct presence of a brain tumor, scar or clot.

Dr. Fay refers here to another article entitled "Diagnosis in Convulsions", published in the American Journal of Surgery in April 1942. He sums up the present paper on The Other Side of A Fit as follows:

Finally, it seems more reasonable to accept the convulsive symptom complex as a "defense reflex," along with other similar integrated patterns like vomiting, laughing and the mechanism of labor than to view it as an affliction and a curse incited by some evil spirit or elusive pathology.

Whether or not this theory eventually finds support is of little consequence. What is needed today is a wider point of view and a substantial basis for removal of the disgrace and despair that in the past have surrounded recurrent convulsive seizures. It is high time that we took a look at "the other side of a fit."

It has been aptly said that every innovator begins as a minority of one. Innovation in ideas is often regarded as dissent, and by those who remain comfortable in what Lawrence Lessing has termed "the persistence of pernicious ideas", innovation is equated with heresy. Let it be noted that Temple Fay no longer stands as a minority of one, nor has he for nearly three decades. Although we are still a minority in this, as in other matters concerning human potential, we are a growing minority.

In the commencement address at Antioch College in 1859 Horace Mann, the great American educator said, "Be ashamed to die until you have won some victory for mankind." Temple Fay died in 1963 at the age of 68 years. Today we have celebrated one of his many victories for mankind through this rereading and review of his profound insight into The Other Side of a Fit.