[Reprinted from The Medical News, February 21, 1891.] A CASE OF EPILEPSY WITH DOUBLE CONSCIO USNESS. BY G. R. TROWBRIDGE, M.D., ASSISTANT PHYSICIAN TO THE STATE HOSPITAL FOR THE INSANE, DANVILLE, PA. " Double consciousness " being regarded by most writers as a strange phenomenon, especially when associated with epilepsy, the following case is de- serving of a short report. I regret that the history of the case is somewhat meagre, but I will give the data as completely as possible. The patient is a German, male, aged fifty-two years, admitted February 3,1888-his second admis- sion to the hospital. He is about 5 feet 8 inches in height, weighs about 150 pounds, and is thick-set, and very muscular. All of his toes have been lost, and his fingers more or less disabled by frost-bite. He has been subject to epileptic convulsions since 1862, and was first attacked while working on a transatlantic steamer, where he was a stoker. He thinks that the disease was caused by the intense heat to which he was exposed. There is no family history of epilepsy or of any other nervous affection, and no record of insanity. The epileptic attacks are of a most violent nature {grand mal), and occur about once every month or six weeks. He then has from three to six convulsions, and never during the time he has been in my charge has he had single con- vulsions in the intervals. For several days preced- 2 TROWBRI DGE. ing the convulsions he complains of pain in the left inguinal region, and says that it is " due to a fall he had when on board ship." There is no evidence of anything abnormal in this region, and I re- gard the pain as an aura, as he never complains of it except just before the attack. Shortly after this aura (from twenty-four to thirty-six hours) he has a convulsion, and on recovering from this becomes somewhat irritable and sullen. Other con- vulsions follow until he has had from three to six. His irritability and sullenness increase in propor- tion to the number of convulsions, and he finally lapses into a perfect condition of double identity, the original ego being completely destroyed, and during this period of second self it is necessary to place him in seclusion. The time occupied during the transition from the first condition to the second is from two to four days, varying according to the interval between the epileptic attacks. During this period of "second self" he becomes very violent and abusive, and can be approached only after being physically overpowered. When he passes into this condition he at first refuses nour- ishment, but toward the latter part of the period he will swallow if a cup is held to his mouth, though it is necessary to restrain his hands and feet. If left to himself he is, as a rule, comparatively quiet, and, as far as I can ascertain, his sleep is not disturbed. This condition lasts from five to ten days, and his return to a normal condition rarely occupies more than twenty-four hours, though on one or two occasions it has taken somewhat longer. For some time after the return to his normal condition he speaks in a husky voice, and complains that his throat is sore, and for some days he is abstracted and listless. DOUBLE CONSCIOUSNESS. 3 When in his normal condition, the man is of a pleasant disposition, and does a great deal of work about the ward. When questioned in regard to his sensations during the periods of " second self," he says he can tell nothing except that everybody and everything is strange to him, and that he knows nothing of what he says or does. But he can de- scribe circumstances and occurrences which took place before the development of his "second con- dition "-i. e., during a previous normal period. The expression of his face during the period of "second self" is altered, changing from a rather pleasant expression to one of intense anger and hatred. In short, I do not think that Stevenson's "Dr. Jekyll and Mr. Hyde " could be worse than this man, were he given his liberty. On one occasion, before his admission to this hos- pital, while in his second state, he was disturbed by his wife, who endeavored to make.him eat, and in the paroxysm of rage caused by this he tried to kill her with a hatchet, but was prevented by the timely interference of the neighbors. He afterward said that he had no recollection at all of the matter. It is difficult to understand the changes in the mind of an individual which produce such a phe- nomenon as double consciousness, and it is hard to explain how the absolute ego can be so completely destroyed for the time being. Undoubtedly the epilepsy is the cause of the transition in this partic- ular case, but how it so overwhelms a man's being as to render his own identity nil, is to me unex- plainable. Epileptic convulsions occurring in rapid succes- sion will, for a time, destroy the action of the in- tellectual centres, and for a short time after such 4 TROWBRI DGE. an attack it is common for the person to be either violently excited or correspondingly depressed, but never before have I seen a case in which there was complete loss of identity. Spitzka1 regards this condition as one of extreme rarity, and says, 11 it appears to be limited to the mental disturbances of menstruation and to periodical insanity." He also intimates that such a condition may occur in con- nection with primary confusional insanity, in regard to which he says : " It is noteworthy that a large number of the patients are aware that a change has taken place, that they are no longer their former selves, and they may be able to give-by snatches, it is true-a tolerably fair account of the circumstances preceding the outbreak of the disease. But as the latter develops, the patients cease to recog- nize their position, or to complain of the ' head trouble,' whose existence they previously admitted, and, at most, they speak of their former selves in the third person, or manifest a confused variety of double consciousness." In defining double consciousness the same author says: " This condition is characterized by the alternation of periods, in which the subject enjoys his memory and retains his sense of identity, with others, in which he fails to recollect the impressions of his healthy period, but possesses the faculty of learning new ones. In the next healthy period he recollects what occurred before the abnormal period, but does not reproduce every fact acquired in the other. In fact, the mental life of two distinct individuals seems to alternate in one person." Savage, in his work on insanity, maintains that double consciousness may be present with epilepsy, 1 Manual of Insanity. DOUBLE CONSCIOUSNESS. 5 and also claims that the condition is closely allied to somnambulism. A large number of cases of double consciousness presenting interesting facts have, from time to time, been reported, and in all the reports that I have seen the period of the second identity was longer than in my case. The interesting facts in this case are: First. The association of epilepsy and double consciousness; and Second. The almost unvarying periodicity and uniformity of the convulsions and sequelae. I may say, in conclusion, that various forms of treatment have been tried to prevent these epileptic seizures, but without success.