epilepsy, and yet, because the ailment involves so intimately the
relations of the nervous system and the bodily function, there are few
diseases of which less definite opinions can be given. This is
especially true as regards prognosis and the question of mental
deterioration in any given case. As a matter of fact the extension of
our knowledge of epilepsy, far from making the question of the
responsibility of the {252} epileptic under trying circumstances more
easy of solution, has rather served to show how difficult this problem
must ever remain.
There are many forms of the disease,--the frank epileptic convulsion
in which patients fall down, are seized with certain convulsive
movements, become pale and lose consciousness for a time and then come
to with an intense feeling of weariness which usually prompts them to
sleep for some hours--too familiar to need further description. There
are forms of epilepsy, however, quite different from these. In some
cases, the attacks occur only at night, and unless the patient happens
to be watched for some reason, there may be no trace of their
occurrence, except perhaps a sore tongue where it has been bitten, or
an intense feeling of weariness and depression in the morning. In
still other cases, the physical signs are lacking almost entirely.
There may be only a momentary loss of consciousness. A distinguished
professor of medicine in this country used to have a momentary attack
of confusion, during which he lost the thread of his discourse, and
always within a minute, with a somewhat flushed face, he was able to
go on, though he had to begin with another idea. The so-called psychic
epilepsy, in which the symptoms are entirely mental and consist of
some marked change of disposition for a time, are now universally
conceded as constituting well-marked phases of the disease. Curiously
enough it is with regard to these obscure cases, uncomplicated by
serious physical manifestations, that there is most mystery; and they
seem to affect the mentality and to disturb volition and
responsibility more than the supposedly severer forms which cause
convulsive attacks and are so easy of recognition.
Certain forms of masked or psychic epilepsy constitute the most
puzzling problem that the expert in nervous and mental disease has to
deal with where criminal acts are performed, apparently without
sufficient motive, and yet where the limits of responsibility must if
possible be determined. It is easy to dismiss these cases and to
consider that because a certain amount of intelligence has been
displayed in the performance of the act, and because the patient
ordinarily understands perfectly the distinction between good and
evil. {253} that therefore the will must have been entirely free in
the accomplishment of the criminal action and the intellect must have
understood what it was doing. As yet the general public refuses to
take the standpoint of the expert in mental diseases in many of these
cases; and only when clergymen also shall come to a realisation of the
pathological elements undermining free will in these cases, that
justice will be properly tempered, not by unworthy or misplaced
charity, but by the mercy which, knowing all, has learned duly to
appreciate what is and what is not criminal.
Epilepsy, in certain of its obscurer forms, is responsible for many
conditions in which there is a sudden access of insane excitement of a
violent, often very impulsive, character, though sometimes of very
short duration. During this state the patient is practically
irresponsible, and yet he may have sufficient control over his actions
to enable him to work serious harm. Such a stage of excitement may
last not more than an hour or two; usually all trace of it passes off
in a day or two; before and after it the patient may be in perfectly
sound sense and in apparently good health. One of our best authorities
here in America, Berkley, in his treatise on _Mental Diseases_, gives
the following striking opinion on this subject.
"The subject of masked epilepsy and the consequent mania is replete
with interest to the physician and the jurist, since such patients are
prone to impulsive acts of violence and automatic states in which the
most complicated, but entirely unconscious, actions and crimes may be
carried out without premeditation on the part of the sufferer, being
also out of all accord with his character during his intervals of
mental health. Besides the irritability, impulsiveness is an equally
characteristic feature. No form of insanity more frequently gives rise
to assaults and murder than epilepsy, and in no form of alienation is
the physician so frequently called to the witness stand to determine
the responsibility of the criminal."
One of the most prominent features of all epilepsy is the well known
tendency to irritability that characterises sufferers from the
disease. This of itself is an index of the fact that {254} their
responsibility is somewhat lessened, since they are unable to
withstand even the petty annoyances of life without exaggerated
reaction. Friends of epileptics know very well that it is a
preliminary symptom of the coming on of an attack of epilepsy for the
patients to become even more irritable than usual. Just after the
comatose condition which follows an attack of epilepsy patients are
also prone to be very irritable. An attack of epilepsy is really an
explosion of nerve force, for no rational purpose, along motor nerves.
This same tendency to an unwarranted explosion of energy is liable to
occur along other nerve tracts that rule the patient's disposition.
The main symptom of importance in the case, and the one on which
depends the recognition of the existence of the epileptic condition,
is the actual occurrence of typical epileptic seizures. These do not
always occur. Sometimes the periodic attacks take the form of what are
called epileptic equivalents, that is, certain anomalous states of
consciousness or disposition, which can be accounted for only on the
supposition that there is some more or less latent explosion of nerve
force in progress. At times even so simple a condition as migraine so
nearly simulates epilepsy of the psychical type, because of its
complications and sequelae and the regularity with which it occurs,
that it has been spoken of as an epileptic equivalent. There is no
doubt that, in successive generations, epilepsy and migraine may have
a relation to one another that is something more than merely a
coincidence.
A very interesting feature of epilepsy for confessors and spiritual
directors is the tendency to religious emotionalism which so often
accompanies what is called idiopathic epilepsy. This means epilepsy
that develops without a direct cause, and which is evidently dependent
on some essential defect of the nervous system of the individual. In
asylums epileptics that have become irrational are known for their
religious manifestations, and very often for perversion of their
religious tendencies. As has been well said, an epileptic may carry
his Bible under his arm, read passage after passage from the
Scriptures, sing psalms continuously, and yet be so {255} ungovernable
as to be a nuisance, and so irritable towards his fellow patients and
attendants as to be a constant source of worriment. He may read just
those passages which have reference to love and charity for one's
neighbour and dwell on them until they become a bore by repetition,
and yet in a moment of irritation implore to be allowed to get hold of
some deadly weapon in order to kill the usually inoffensive person who
has done him some imaginary injury.
This last is a marked feature of the disease, for epileptics are prone
to foster fancied grudges, and to consider without due reason that
they have been ill treated. This is especially true with regard to
their relatives or to those in attendance on them, and must be always
borne in mind when the subjects of epilepsy bring tales of woe and
persecution, which they pour out to anyone who will listen to them,
and especially to anyone whom they think will set them right. These
fancied wrongs are as real to the patients themselves as if they had
suffered from actual maltreatment. The idea of revenge may easily
obtrude itself. It can be kept under control, as a rule, during
ordinary health, between attacks, but just preceding or after an
attack it may very well become of the imperative character that sets
an uncontrollable impulse at work.
On the other hand, no class of patients is apt to exhibit the low
cunning of the insane in so marked a degree as the epileptic. Not only
this, but even during ordinary health between attacks they may, owing
to their disposition, plan cunningly to simulate some of the symptoms
of an attack and then accomplish a really malicious purpose with
deliberation. In a word, these patients present to the alienist the
most serious problem in the calculation of responsibility that can
possibly be imagined. As an expert has declared, "It is ofttimes
impossible to decide whether an assault has been committed with full
consciousness, or in a transient but blind epileptic fury."
There are a series of attacks that occur in which there are some
almost typical convulsive movements followed by loss of consciousness
that simulate epilepsy very closely, yet are not true epilepsy. These
attacks are usually due to some {256} cerebral affection or perhaps to
some injury of the brain. Chronic intoxications, that is, the long
continued presence in the body in noxious quantities of some poisonous
substance, are especially liable to cause these attacks, which are
called from their character epileptiform. Characteristic epileptiform
convulsions occur as the result of lead poisoning or from alcohol or
syphilis. Lead poisoning, for instance, may very well occur in others
than those engaged directly in the manufacture or handling of lead.
Certain persons are extremely susceptible to the influence of lead. In
them such small amounts as are contained in a hair-dye, or even in
water that is being used by others without any bad effect, may cause
particularly the nervous symptoms of lead poisoning.
Chronic alcoholism is also a relative term in this regard. Some
persons are able to stand very large amounts of alcohol without
serious consequences, even though it is taken for long periods. Others
succumb to its influence very rapidly; some especially susceptible
people are liable to suffer from epileptiform convulsions almost
whenever they take alcohol to excess. This masked epilepsy may take on
an anomalous form. The story is told of a student of a Catholic
college in the eastern part of this country, who, during one vacation,
was given as a joke by some friends a rather strong dose of liquor in
a glass of ginger ale. He was very thirsty at the time and did not
notice the presence of the alcohol until he had swallowed the whole
glass. As he was well aware himself he was extremely susceptible to
the influence of alcohol. During the course of half an hour he became
almost wildly drunk, and going down the street with an open
pocket-knife he murdered the first person whom he met, who happened to
be an entire stranger to him. The occurrence took place in New Jersey,
and, in spite of every influence that could be brought to bear--the
incident took place some thirty years ago--Jersey justice would have
its way and the young fellow of less than twenty was hanged.
The epileptiform attacks that occur in the midst of these
intoxications are quite as likely to be accompanied by various forms
of mental disturbance as are attacks of true {257} epilepsy. Only one
feature with regard to them is more favourable, and that is that the
ultimate prognosis is not bad. The neutralisation of existing poison
in the system, and the prevention of further ingestion of the toxic
material, puts an end to the tendency to epileptiform convulsions, as
a rule, and also to the mental symptoms associated with them.
Epilepsy remains, notwithstanding all the advance in modern nervous
pathology, quite as mysterious a disease as it has ever been. It
matters not what its cause, or how slight it may be, sooner or later
it is almost sure to be followed by mental disturbance and
deterioration of intellectual and will power. At times there are
periodic attacks of mental perturbation that may become true insanity.
Even the mild form of epilepsy known as Jacksonian epilepsy, and
consisting not of general convulsive movements, but of convulsive
movements in only one member or one side of the body, are, if allowed
to continue, followed by some mental disturbance. It would seem as if
the explosion of nerve force in the brain centres,--which,
physiologically speaking, an attack of epilepsy evidently is,--causes
eventual deterioration of the physical basis of mind and will, so that
mental operations can no longer be performed with their wonted
expertness or accuracy, nor decisions made as rationally as before.
In general, it is well understood that the more serious the epilepsy
the more liability there is of the development of permanent mental
disturbance. The earlier in life the epilepsy declares itself, too,
the more unfavourable is the prognosis as to the enduring retention of
complete mental sanity. In people in whom the epilepsy commences late
in life, the process of mental deterioration does not begin to be
noticeable so soon as when it occurs in younger years, and besides, it
practically never runs a rapid course. Epilepsy, however, developing
late in life, unless for some special cause, as injury or the
development of syphilitic tumours in the brain, is an extremely rare
affection. Idiopathic epilepsy, that is, epilepsy for which no
definite cause can be discovered, is usually dependent on hereditary
instability of the nervous system and is typically a disease of early
years, of childhood {258} and adolescence. According to the best
authorities, about one-fourth of the cases of epilepsy make their
appearance before the age of 7 years. Over 50 per centum of all cases
develop before puberty. About one-third of all the cases develop
between 14 and 20. And even of the remaining, less than 20 per centum,
over 12 per centum develop between 20 and 25, leaving scarcely more
than 5 per centum for all the remaining years of life.
Of course, even in severer forms of epilepsy, mental disturbances do
not appear at once. It sometimes takes many years for the constantly
recurring manifestation of explosive nerve force to produce the
deterioration that gives rise to lowered rationality. Distinct mental
deterioration is eventually inevitable, though modern experience with
epileptic colonies, in which patients are enabled to live a quiet
life, most of it in the open air and under conditions of nutrition and
restfulness especially favourable for their physical well-being, shows
that the development of insanity may be put off almost indefinitely.
There are many advertised cures for epilepsy. None of them is
successful, and all of them may do harm. The bromides have a distinct
effect in lessening the number and frequency of seizures, but if taken
to excess they have a serious depressing effect upon the patient.
There have been more cases of mental disturbance among epileptics, and
intellectual degeneration sets in earlier, since the introduction of
the bromides, than before. It is the abuse of the drug, however, not
its use, that does harm. More important than any drug is the care of
the patient's general health. The digestion must be kept without
derangement; the bowels made regular; all sources of worry and
emotional strain must be removed. Patients should as far as possible
live in the country, and farm life has been found especially suitable.
Relatives are often a source of irritation rather than consolation to
these patients, and the life in epileptic colonies has been found
eminently helpful.
JAMES J. WALSH.
{259}
XXIII
PSYCHIC EPILEPSY AND SECONDARY PERSONALITY
One of the most interesting phases of epilepsy is the type of the
disease in which, without any significant motor symptoms, psychical
manifestations prevail very markedly. A special manifestation in this
affection is the occurrence of a more or less complete assertion of
what is called a secondary personality. Apparently the individual
becomes so divided in the use of the mental faculties that there are
two states of consciousness. In one of these the patient knows and
remembers all the ordinary acts of life, the other carries the record
of only such actions as are done in a peculiarly morbid psychic or
epileptic condition. It is rather easy to understand that this strange
state of affairs may readily give rise to even serious complications
as regards the individual's relations to others, and may make the
problem of responsibility for apparently criminal acts that have been
performed very difficult of solution. Undoubtedly, however, this set
of phenomena constitutes a form of mental alienation that must be
reckoned with in many more cases than might be thought possible. The
difficulties that may have to be encountered in the proper
appreciation of the actions of such individuals is best illustrated by
some cases.
At a recent meeting of the New York State Medical Association a case
was reported that shows how extremely difficult it may be to judge of
responsibility under these pathological circumstances. The patient, a
young man of about twenty-two, was the son of parents themselves of
marked nervous heredity, signs of which appeared in other members of
his generation. While in attendance at a public academy he had been
quite severely maltreated during the {260} course of an initiation
into a secret society of the students--the more or less familiar
processes known as hazing being employed. As a result of this he had
suffered from an attack of unconsciousness that lasted for several
hours. No other symptoms, however, or sequelae, appeared for nearly a
year. Then, while boarding with his sister, he became morose and
difficult to get along with. He quarrelled with his sister several
times and generally their relations were rather strained. He came home
one evening very late to supper, and because things were not to suit
him on the table, he grew violently angry. He went upstairs to his
room in this morose state and, procuring a revolver, after a short
time came down and shot at his sister.
Fortunately he missed her. He at once left the house but was followed
by his brother-in-law, and, after he began to run away, by others
whose attention had been attracted by the shot. He left the country
road and ran across the fields. He was found at the foot of a rather
high stone wall in a state of unconsciousness. From this
unconsciousness he did not recover until the next morning. In the
meantime he had been brought home and put to bed. The next morning he
claimed that he had absolutely no remembrance of anything that
happened after he became angry at the table because of his supper. The
family made no further difficulty about the matter, and, as nothing
serious had resulted, the boy went home to live with his father on a
farm and seemed to grow much more equable in temper.
One day, when very tired and out of sorts because things had not been
going as he wanted them to, he was asked to clear a potato patch of
potato bugs by spreading Paris green over it. Some hours later he was
found in the field suffering from severe pains in the stomach and with
evident signs of having swallowed some of the poison. A doctor was
called, an emetic was given and he purged, and after a time he
recovered from the symptoms of poisoning. He claimed that he had no
recollection of what he had done, nor did he know how he came to take
the poison. After this he begged the family to watch over him
carefully and not to let him be alone at times when they recognised
that he was somewhat {261} morose in temper. He was not melancholic in
the sense that he wanted to commit suicide, but something seemed to
come over him in spells, and while in a state of mind of which he had
no recollection afterwards, he performed actions that seemed voluntary
and yet were not.
He did not have very good health on the farm, and so he was advised to
try the effect of life at sea. A position as assistant steward was
obtained for him on a coastwise vessel. In this position he gained
rapidly in weight and seemed to have excellent health. All tendencies
to moroseness of disposition disappeared. After a time he was promoted
to a stewardship and later became the purser of a rather important
vessel. He has given excellent satisfaction and feels in every way
that he is in a much more balanced condition than ever before.
He still insists that he remembers nothing of how the two almost fatal
incidents in his life came about. All his family are convinced that it
was not a responsible state of mind that led him to attempt either of
the crimes. It seems not improbable that this is one of those
fortunately rare cases in which an attack of psychic epilepsy
sometimes obliterates for a moment the individuality of a patient. At
times these attacks last much longer, and the change to a secondary
personality may represent a rather long interval. A number of cases of
what are called ambulatory epilepsy have been brought to the attention
of the general public of late years because of certain interesting
features of the cases that have been exploited in the daily press.
Patients suffering from this form of nervous disease may wander from
their homes, and while performing automatically a number of actions,
such as buying tickets, travelling on cars and railroad trains, or
even arranging the details of their journey for a long distance, may
yet be in a state of mind that is not their ordinary consciousness.
Men may leave home under the circumstances and find themselves after
months in a strange town where they have established themselves in
some quite different occupation from that to which they were formerly
accustomed, or for which their early training fitted them. There seems
to be an absolute division between the {262} states of consciousness
that rule the individual during the intervals of ordinary and
extraordinary personality. There are, of course, many reasons for
thinking that at times such a change of personality might be feigned;
but many of the cases have been followed with too much care to allow
this thought to serve as an explanation for all of them.
A case which serves to bring home very clearly the possibility of such
a state of mind giving rise to serious complications is the following:
The patient was a young man in attendance at the medical school of a
university in a foreign city. He had been very careless in money
matters, and had aroused family suspicion that even the money sent him
for tuition was being used extravagantly. A friend of the family came
to see him unexpectedly in order to assure himself how the boy was
actually getting along. The boy's accounts were in a very disordered
condition; he had not bought the books for which he pretended to want
money; he had not paid his tuition. He realised that all this would
come out as soon as the university authorities were consulted. Very
naturally he was in an extremely perturbed state of mind.
While on the way to the university with this friend they passed a
corner pharmacy, and the young man asked to be allowed to step in for
a moment for a remedy for headache. The friend waited on the sidewalk
for him, and when, after some minutes, the young man did not come out
he went in to inquire for him, and found that after purchasing a
headache powder the young man had gone out by a side door. For three
days nothing was heard from him. Then a telegram announced that he was
in a hospital in a distant city and that he had been picked up on the
street unconscious. When he came to in the hospital he had no idea
where he was, and, according to his own story, no recollection of how
he got to the distant city.