Part 39

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.

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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.

It might be very easy to think, under such circumstances, that this was all pretence. A number of these cases of ambulatory epilepsy have been under the observation of distinguished neurologists, however, and there seems no good reason to doubt that some of them, at least, were entirely without any fictitious element. In any given case the {263} possibility of the occurrence of an attack of what is really the assumption of a secondary personality must be judged from the circumstances, from the previous history of the individual, from the family traits, and from certain stigmata as narrowing of the field of vision and the like, which go to show the existence of a highly neurotic constitution. In this case the family history showed marked neurotic tendencies on both sides, and a brother had displayed a tendency to regularly spaced attacks of alcoholism about every six weeks, and finally became absolutely uncontrollable. There seemed good reason to think that the case was a real example of ambulatory epilepsy, and that the lapse of memory claimed by the patient really existed.