Reprint from Cincinnati Lancet and Clinic, Feb. 9, 1884. Epileptic Insanity, A Paper read before the Academy of Medicine, February 4th, 1884, BY Philip Zenner, A.M., M.D., CINCINNATI, O. THE CINCINNATI LANCET PRESS PRINT. Reprint from Cincinnati Lancet and Clinic, Feb. 9, 18S4. Epileptic Insanity. A Paper read before the Academy of Medicine, February 4th, 1884, BY Philip Zenner, A.M., M.D., CINCINNATI, O. THE CINCINNATI LANCET I'KESS PKINT. EPILEPTIC INSANITY. Philip Zenner, A.M., M.D., Cincinnati. The epileptic is doubly afflicted. In addition to his deplorable bodily malady he is usually doomed to an early mental decay. True, history furnishes some noted names, as Caesar, Mahomet, Napoleon, who are said to have been subjects of this disease; and, probably, epileptics are known to many of you who, apparently, re- tain their intellectual powers. But, never- theless, in the majority of cases epilepsy causes a gradual but sure downfall of mind. The character also changes under the influence of this disease. Both the char- acter and the mental impairment are often so characteristic as to be immediately rec- ognized by the experienced physician. The patient assumes a constant religious tone and air which are exceedingly superficial. He is, at the same time, very irritable and suspicious. 'The slowness of apprehension and forgetfulness, the first symptoms of mental impairment, are at first only present during a shorter or longer time following an epileptic paroxysm. We have then ! the singular anomaly that, with a fair mem- ory for passing events, there are inter- | current periods of whose occurrences the j patient has almost no recollection. The j failure of intellect is often directly due to i the paroxyms, shown by the fact that when the latter cease to appear, or become less frequent, as the result of treatment, the intellectual powers again become more vigorous. The condition which we have just por- trayed might very well be termed epileptic | dementia. We will not speak further of it here. It has been mentioned in order that it may not be confounded with quite another psychic disorder, which it is the special object of this paper to discuss, true epileptic insanity. Epileptic insanity, just as the epileptic convulsive seizures, comes on in paroxvsms. It is of special importance and interest to the general practitioner, because it usually comes directly under his observation rather than in the charge of the alienist, and because of the seriousness and danger of the paroxysm itself. For the attack, sudden in Its onset, and usually short in its duration, is often the explosion of the most violent fury, threatening the life of its sub- ject or of those about him. The epileptic is the most dangerous of maniacs. These outbreaks of insanity are, as just mentioned, usually periodical, and they are generally in immediate connection with a convulsive seizure. 'They most frequently occur after a convulsion, but they may occur before, and, not infrequently, they appear to take the place of an ordinary epileptic paroxysm. Epileptic insanity presents a great variety of clinical pictures. Of these we will attempt to portray a few of the most striking ones, and then point out some general features | most characteristic of such attacks. The simplest form of psychic disturbance j is the fit of momentary absence of con- | sfiousness. The patient is aware that j there was a momentary blank in his mind, i though he may have continued automati- cally the action with which he had been occupied. Thus Trousseau (') mentions a musician who was often thus attacked in the act of playing, yet the latter was con- tinued even during the interval of uncon- sciousness. Hughlings Jackson reported j the case of a woman thus seized while in the act of cutting bread; the cutting was continued, and she inflicted a deep wound in the hand. One of the companions of my youth was subject to these momentary absences. He was often attacked while climbing trees or in other dangerous atti- tudes, without sustaining injury. He was always aware afterward that there had been 4 EPILEPTIC INSANITY. a blank in his consciousness. He, at a later period, became subject to severe con- vulsive seizures, became partly demented, and died of an intercurrent disease. A common trait of the more prolonged psychic disturbances is a tendency to wander aimlessly about. A patient in my charge, some years ago, was frequently found many miles from home, and when returning to full consciousness was always surprised to find herself in a strange local- ity, being entirely unable to account for her presence there. But a more common and most dangerous form of these epilectic mental disturbances is now to be described. The patient’s mind is entirely clouded, he is filled with an indescribable and intense sense of anx- iety and terror, his actions are impulsive, apparently motiveless, most violent, and rife with danger to himself or others. It is usually epileptics in this condition who cause the most appalling disasters, suicide, homicide, or other dire calamities. We will now mention other forms of these paroxysms which are far more puz- zling. The consciousness is not so much clouded. The conduct of the patient may appear so intelligent and reasonable, that it may not be detected that his mental con- dition is different from the normal. Never- theless such periods have the stamp of the epileptic seizure, in as much as the most extravagant acts may be performed, and the occurrences are afterwards entirely or almost entirely forgotten. In the lighter forms there is only a slight cloudiness of the consciousness, perhaps a confusion of ideas from a too rapid flow of thoughts, or a feeling of despondency with anxious fore- bodings, or the patient feels an impulse to perform some strange or wild act while h£ is fully conscious that his condition is ab- normal, and tries to check his impulsive action. At the same time he answers prop- erly any question put to him. In severer forms the mind is more cloud- ed. The actions of the patient are unlike those of his ordinary life, and in contradic- tion to his character. He acts like a som- nambulist. After the attack he has lost all memory for its occurrences. Trousseau mentions a lady of very re- fined habits, who, during such a seizure, is unusually witty, makes obscene remarks, etc., of all which she is much surprised to hear afterwards. Samt (*) mentions a man, who, during ! such a paroxysm, acts the circus clown ad- i mirably. Echeverria (3) gives an interesting ac- | count of a young man subject to such at- tacks: “One evening he went into the street, took a horse and buggy which he found in front of a house, rode over a mile and a half to his father’s grave, pulled the flowers from the bushes planted over it, and brought them home to his mother, whom he invited to take a ride. Being i asked where he procured the horse and 1 buggy, he replied that he found them lost | on the street. His mother directed that he ; leave them forthwith in a livery stable, that I they might be returned to their owner. He started to do so, but left them at the stable as his own. When discovered by the owner, the transaction was looked upon as larceny, thereby causing great mortification and annoyance to his family. The boy, however, could never account for his con- duct, and forgot completely every circum- stance connected with it.” At another time the same patient, while in such a fit, was engaged by a shipping agent to go as a sailor on an English ves- sel. A few days after the vessel departed, on coming out from the state of epileptic insanity, he was surprised to find himself on a vessel for London, being completely ignorant how he came there. Lasegne (4) reported the case of a man of high social standing, who, while in a perfumery shop, pocketed various small trinkets lying on the counter, and went away without paying for them. He was afterward arrested, but knew nothing of the transaction. I will mention but one instance more in illustration of these varying forms, a pa- tient seen by myself, some years ago, in Professor Meynert’s wards, in Vienna. The patient had religious visions, gave utter- ance to what might have been deemed to be prophecies. The case was of interest because it was doubtless like some others which have at different times misled super- stitious people. It is not difficult to under- stand how such an epileptic, with his fer- vid utterances, his whole being elated, might be looked upon as possesing true prophetic gifts by the ignorant and super- stitious. We will now mention some of the char- acteristic features of these seizures, fea- tures common to many or to all of them. These are chiefly, the acute onset, the EPILEPTIC INSANITY. 5 either partial or complete obliteration of consciousness, the sense of anxiety often extreme, the impulsive blind actions, and the almost complete forgetfulness of what has occurred during the paroxysm. Of importance, and almost characteris- tic in many instances, is the nature of the delirium. There is often something mystic in the delusions, the utterance of some re- ligious word; God, etc., even when the consciousness is so completely clouded that no other words are pronounced; or there is great difference between uttered words and actions, as words denoting anxi- ety, while the patient smiles. In some in- stances, when the thoughts appear to be lucid, there is an absence of knowledge of very simple things, as of the day of the week, very recent occurrences, etc. Thus a careful study of the condition during a paroxysm, will often enable the experi- enced physician to form a correct diagnosis, even when there is no knowledge of the pre- vious history. Let us briefly analyze the mental condi- tion and more closely scrutinize some of its elementary parts. The first and most important element is the affection of consciousness. The latter is always affected—a fact which gives us a key to otherwise incomprehensible con- ditions. In some instances there is com- plete unconsciousness, and any act then performed might be termed purely auto- matic. In others the consciousness is only partly obtunded. The anxiety and terror often felt, and the impulsive actions are worth more care- ful study. Hallucinations and delusions are often present in a paroxysm. These are of the most diverse kinds, sometimes giving origin to the most absurd acts, not infrequently they are like those of the de- lirium of grandeur. But generally they are of a frightful kind and, in so far, pro- duce or foster the anxiety and terror or the impulsive actions. Yet the latter are not to be altogether thus explained. It may be impossible to detect such delusions. The epileptics often have in their parox- ysms a feeling of intense discomfort and distress from the condition of the generally sensibility. This is perhaps the chief cause of both the anxiety and uncontrolable im- pulses. So the anxiety often appears to be a primary element, and the violent impul- sive acts instinctive, and quite independent of mental judgments. The most singular feature is the entire I forgetfulness. Acts, which to the lookers- ! on, seem to be the result of a fully con- i scious intelligence, are afterwards entirely unknown to the performer. But the ob- livion is not always so complete. It not j infrequently happens that a patient can re- j member all the occurrences of a paroxysm I immediately after it is over, while he has | completely forgotten them after a short in- terval of time. Still more singular are some cases of partial memory for such oc- currences. Samt reports two patients who recalled some of the events occurring dur- ing a paroxysm, while they had entirely forgotten others. In this entire forgetfulness, epileptic in- sanity distinguishes itself from most other mental diseases. Acts performed in delir- um from other diseases may be remem- bered afterwards. Magnau (s) mentions two interesting cases, in which epileptic paroxysms occurred during alcoholic deliri- um. One who had been previously delirious, when the epileptic paroxysm occurred tried to hang himself. When he recovered he remembered the alcoholic delirium, but would not believe the statement that he had attempted to hang himself. The second patient was taken from the street while in the epileptic attack. He believed he was Henry IV, that people prostrated themselves before him, etc. After being removed to the asylum, he saw cats, rats etc. When he recovered he remembered his alcoholic delirium, but knew nothing of his regal pre- tensions. Another strange feature not mentioned, but which often has much practical value, is the fact that the delirium in the different paroxysms of the same individual is often nearly the same. The very words and acts may recur in almost a stereotype form. It would be interesting to know to what ex- tent thoughts, which are uppermost during a paroxysm, form a part of the ordinary thinking in the intervals. Doubtless, in many instances, thoughts most familiar to the mind in the lucid intervals, recur in the paroxysms in a more violent form. But nevertheless the patient must not be held responsible for acts then committed, as he appears to have lost all controling power. Did time permit, it would be interesting to attempt an explanation of some of these strange phenomena, especially the forget- fulness and the great similarity of paroj- 6 .EPILEPTIC INSANITY. riod. Nevertheless the attack of insanity in some instances appears to be the first manifestation of epilepsy. Yet in such • cases a careful examination will often re- veal the former presence of the unrecog- nized disease. Thus Magnen reports a case where a man, who had been supposed by himself and others to be perfectly well, in an insane attack killed a comrade for whom he had previously manifested the greatest affection. A subsequent examina- tion revealed the indubitable evidence of previous epileptic seizures. The patient often had bruises that he could not ex- plain ; he had evidently had frequent at- tacks of unconsciousness, whose signifi- cance was entirely unknown to him. Such paroxysms recur with varying fre- quency. In some persons not more than one attack is observed. In others they occur frequently. They can often be made less frequent or to cease altogether by ap- propriate treatment. In many old cases, especially where there is complete de- mentia, they frequently cease to appear. We must now briefly consider the medi- co-legal aspects of our subject. When in- dividuals are known to be afflicted with this disease, and an entirely motiveless act of violence has been committed without effort at concealment, there can be no ques- tion of accountability or punishment. But the matter is by no means always so simple. We have seen that patients are sometimes in an apparently lucid condition; yet they should not be' held responsible for acts then committed, shown by the fact that they may be in complete variance with their usual conduct, and are entirely for- gotten afterwards. But acts committed at such time could very easily be misjudged. The case reported by Echeverrie, already mentioned, of a boy taking a horse and buggy from the street is a good instance of this. Magnen also reports an interesting case in point: A man being found wan- dering aimlessly about, was arrested. He at first spoke lucidly. But when brought before a magistrate he threatened and then attempted to injure him, for which he was condemned to two years’ imprisonment. The next day he knew nothing of the whole I occurrence. Thus it may happen, if it be the first known paroxysm, or the previous history is unknown, that it will be impossible to determine the true state of things. We have already mentioned that a paur- ysms in the same individual, or to consider what light, the study of these psychic phenomena might throw upon the general theories of epilepsy. But such considera- tions. which would be largely speculative, must be omitted in this brief sketch to make room for more practical matter. The duration of an attack of epileptic in- sanity varies greatly. It may be only mo- mentary, more frequently it is a few hours or days, rarely it continues several weeks. It closes usually as abruptedly as it began. But the beginning, though abrupt, is of- ten preceded by a change in the general condition of the patient. Frequently the patient is very irritable and despondent for several days preceding the mental explo- sion. This period, too, may be fraught with danger as we will see later. An aura often foretells the immediate outbreak. This aura, though constant for the same individual, varies as much as that with the usual convulsive seizure*. It sometimes seems to be the perception of the condition which [/receded the first par- oxysm. Sommer (6) mentions the case of a little girl who, from fright at seeing a dog spring towards her, was seized with a first convulsive seizure. Afterwards every par- oxysm was preceded by the vision of a large dog springing toward her. In another case, a man epileptic for many years, the patient saw one and the same landscape, otherwise unknown to him, just before each paroxysm. The frequency of epileptic insanity can not be stated with any degree of certainty. In the majority of epilepitics the mind be- comes impaired, but a far less number ever become epileptic maniacs. Reynold judg- ed from his observations that about one- tenth of those subject to epilepsy have attacks of epileptic insanity. But accord- ing to general experience probably a larger number are thus affected. It has long been believed that attacks of so- called petit mat or epileptic vertigo are more frequently followed by failure of the intellectual powers than attacks of graiui mal. It is not improbable that also attacks of insanity more frequently follow the slighter than the greater convulsive seizures. Insane attacks are generally found only after the patient has been subject to ordi- nary epilepsy for a long time. Falret states that such an attack is most likely to occur when a quick succession of convulsive seizures has followed a long quiescent pe- EPILEPTIC INSANITY. 7 oxysm is often preceded by a change of character and disposition of a few days’ duration. Crimes committed at this period are more difficult to properly estimate. A few years ago a case of this kind ap- peared before the Cincinnati Courts. A young man had been epileptic for several years. The disease had caused some en- feeblement of the mental powers. He had attacks of insanity, which usually followed a convulsive seizure. But the latter was always preceded by a very irritable and de- pressed mental condition. At one time, while in a trivial quarrel with a companion he shot the latter. A few days subsequent- ly he was found in a state of stupor. There was every evidence that this was a post epileptic stupor. The crime was commit- ted while the patient was in that morbid condition of mind, which preceded a par- oxysm. Patient remembered afterwards the quarreling and the shooting. He had, naturally, no knowledge of the convulsion and the subsequent stupor. So the crime was committed while he was in a mood where he was more easily provoked to pas- sionate acts than normally, but he was fully aware of what he was doing. To what ex- tent should he be held accountable for this act? Here we approach a question which can not yet be appropriately answered either by law or medicine. We can not place an exact limit where responsibility be- gins or where it ends. In this instance the judge wisely consigned the man to confine- ment for purposes of public safety, rather than for criminal punishment. What should be done with epileptic mani- acs is a perplexing and difficult question. It is unavoidable that many move unre- strainedly in our midst, who may at any time become dangerous to society. Even those who have had paroxysms of a dan- gerous character and in whom others of a like kind may be expected, can not, in many instances, be kept in perpetual con- finement. For, at least, with the present general arrangement and management of our asylums, individuals can not, usually, be indefinitely retained, who are ordinarly perfectly sound in mind, and only at long intervals have very short attacks of insanity. But, at least, it is well to remember what cases are most dangerous. We must re- member, a fact already mentioned, that paroxysms usually recur in the same form, and when a dangerous one has preceded, future ones of the same kind must be awaited. Fortunately, in some instances, one can foretell the explosion a sufficient time to guard against its dangers. But if this does not occur, those, who are subject to paroxysms of a dangerous nature, should, if possible, be under constant surveillance. .As to the treatment, I need add but ltttle, The therapy of epileptic insanity is exactly the same as for ordinary epilepsy, and that, you know, is the bromides per excellence. Though the extensive experience with this drug has failed to realize the bright hopes once entertained for it, it has nevertheless proven by far the most valuable means in treatment. Meynert, whose experience in this dis- ease, has scarcely been surpassed, recom- mends only the Bromide of Potash. He begins by giving one gram (15 grains) three times a day, and increases the daily quan- tity by one gram every time there is a re- currence of a paroxysm. He says the medicine appears sometimes to have no affect until a certain dose is reached, when it apparently entirely controls the disease. He has never found it necessary to exceed sixteen grams a day. It may not be neces- sary to continue the large doses, but the medicine must be given for years. The difficulties from its administration are the disturbance of