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Read before the Ohio State Medical Society, April 6th, 1871. 64 1 \e-(\ Zan,\ The Relations of Epilepsy to Insanity and Jurisprudence. -/ BY ¥. J. CONKLIN, M. D„ Assistant Physician of Southern Ohio Lunatic Asylum, Dayton, O. Epilepsy and insanity may sustain various relations to each other. 1. The tAvo diseases may originate at the same time and be due to a common cause. The following cases are instances of this relation : L. L., set. sixteen, being alone one night during the absence of the family in Avhieh she served, Avas terribly frightened by two men endeavoring to enter her sleeping apartment. She Avas thrown into convulsions and became delirious, Avhen they ceased. Her mind rapidly failed. The fits recurred at short intervals, usually at night. She is now, ten years after the occurrence, a hopeless dement, and apparently from loss of muscular co-ordination is barely able to pronounce her own name. F. McK., set. 27 ; maternal cousin insane ; for three years he had given himself up to all manner of excesses and dis- sipations. He experienced a regular epileptic seizure, from Avhieh time his friends noticed symptoms of mental derange- ment. The convulsions returned at intervals of four weeks; after the third fit he became violently maniacal and was ad- mitted into the asylum. 2 Relations of Epilepsy to Insanity and Jurisprudence. 2. Epilepsy may be developed in the course of chronic insanity. Beyond question, the degenerated condition of the nervous system which the insanity itself indicates is a fertile soil for the springing up of nervous disorders of all kinds; but the frequency Avith which epilepsy occurs as a sequence among the chronic insane, by no means an inconsiderable per cent of our population, is not great. The tendency of many organic brain diseases is to epilep- tiform seizures. A large number of the cases of convul- sions occurring in the old residents of an asylum are due to the presence of a tumor, exostosis, softening or other cere- bral lesions, which Ave are, oftentimes, able to accurately diagnose during life. These cases should be excluded from epilepsy proper. From our limited experience, we are in- clined to consider true epilepsy as an infrequent result of insanity. Many so called cases of the relation under consid- eration are really examples of masked epilepsy: others may be cases of undiscovered epileptic vertigo, Avhieh have passed into the graver form of the disease. It may be considered a fact, that the appearance of con- vulsions in an attack of insanity is always of grave portent, and is usually the forerunner of death. Within the past two years, seven cases have occurred in this institution con- firmatory of this proposition. These include all cases in which the convulsions appeared primarily in the course of the mental disturbance, and they all died in from twenty- four hours to nine days after the supervention of the convul- sions. It may be well to remark, that none of them presen- ted the peculiar character of epileptic insanity. In two of the aboA7e cases the insanity had a duration of one year; in three cases it Avas of three years duration ; in one it dated back ten years, and in another tAventy years. Post mortem examinations of the brain were made in two cases. In one of them, in Avhoni the mental symptoms were of three years duration, the dura mater was found attached Ohio State Medical Society. 3 to the skull, and, in places, along the longitudinal fissure, Avas firmly united to the arachnoid. The vessels of the arachnoid and pia mater Avere enlarged and engorged with blood. About the middle of the right anterior lobe there Avas a loss of brain substance, measuring one half of an inch in length and one quarter of an inch in breadth. The puncta vasculosa of the white substance Avere quite numerous and distinct. The corpus striatum and optic thalamus of the right side Avere much less firm in texture than the corres- ponding parts of the opposite side. The autopsy of the second case in Avhieh the insanity Avas of twenty years standing, re\'ealed nothing abnormal, save an unusual adherence of the dura mater to the calvarium and considerable congestion of the left hemisphere. The brain substance Avas not microscopically examined in either case. 3. Another relation, important in a medico-legal as well as psychical point of A7iew, is that of transformation or re- placement, in Avhieh the mental manifestations take the place of the regular commlsion. The morbid action in the* sen- sory centres seems at one time to be transferred Avholly or in part to the motory centres, giving rise to muscular convul- sions ; and at another time to the mind centres, giving rise to conA7ulsive ideas. Epileptics often speak of the torture and anguish they feel, Avhen they have gone longer than usual without the fit, and the feeling of relief experienced after it is over. It is not unusual in the history of the insane to find some previous bodily lesion becoming latent or masked on the accession of the mental derangement, even though the latter may be the result of the former. This occurs frequently among the phthisical, Avhen on the supervention of insanity the tuberculization is for a time arrested. Dr. Buitoavs tells of an eloquent divine, who Avas always maniacal when free from pains in the region of the spine, and sane when 4 Relations of Epilepsy to Insanity and Jurisprudence. the pains returned to that spot. We knoAV that physical lesions will often for the time stop epileptic seizures. K. F., age 22, subject to epilepsy from her childhood, fell into the fireplace in a fit, and Avas terribly burned over the chest, abdomen and thighs. Her fits, Avhieh had been pre- viously severe, and rarely missing more than two days at a time, ceased, and did not return for twelve months, during Avhieh the Avounds Avere healing. As soon as the burn healed, the fits returned with their former frequency and seArerity. The arrest of the fits from any cause often produces an increase in the severity of the mental symptoms. This is seen in the effect of medical treatment. Often Avhen by the exhibition of some medicine the fits are lessened in frequency, the patient is rendered more irritable and peevish, it may be violent. In a discussion at the last meeting of Asylum Superintendents,* Dr. Gundry said, "One Doctor gave medicine, and six months aftenvards the cry Avas raised, ' You cured him of epilepsy, and the people Avish he had fits again, because he is so infernal cross.' I have found in many cases, I may say, when the fits were intercepted, the same nervous excitement takes their place." Dr. Walker, of the Boston Lunatic Asylum, said, " There are tAvo or three cases, as stated by Dr. Earle, Avhen the epileptic fits have been decreased, and they have been made irritable and are more violent. They Avere not subject to it when the fits came regularly, and it Avas thought proper to let them have a fit occasionally to sweeten them." Every asylum presents cases in Avhieh so long as the con- vulsions occur Avith their usual frequency, no unusual mental symptoms present themselves, but as soon as the seizures cease, the most marked mental disturbance ensues, often violent in nature, and attended with delusions and halluci- nations; Avith the reappearance of the convulsions the * American Journal of Insanity, October, 1870, Ohio State Medical Society. 5 patients resume their normal mental state. Still more fre- quently occur those cases, in which brief but violent out- bursts of fury—blind impulses to destroy, overpoAver the mind and impel to homicidal, suicidal or destructive acts— occasionally replace special convulsive seizures. The delu- sion or hallucination Avhieh often becomes apparent just before an outbreak may be justly compared to the aura; "the moral instability to the irregular involuntary character of the muscular action; the sudden impulse Avith the fit, and the temporary unconsciousness Avith the coma." Many instances of replacement will appear in the progress of this paper. In this connection we Avill relate but one case, taken from Dr. Schupman. An epileptic, during con- valescence from a severe attack of cholera, was free from his usual epileptic seizures. He became restless, agitated, con- ceived that he felt some liATing thing moving in his stomach, and finally declared that he was pregnant. The slightest contradiction led to such A7iolence that it become necessary to confine him to a chair. Many expedients Avere adopted to remove his delusion, among them an accouchment Avas imitated. He retained his delusion in spite of treatment, until the attacks of epilepsy returned, AA7hen it immediately disappeared. 4. Epilepsy may stand as the cause of insanity. This relation has a tAvo-fold nature: It may be a predispos- ing cause, or it may be an exciting cause. Epilepsy is noAV generally recognized as a strongly marked hereditary disease. Statistics show that epileptic children are more likely to be born from an insane than from an epileptic parentage. It may be stated as a general laAV, that the same neurosis from Avhieh the parent suffers is not neces- sarily transmitted to the offspring, but sa\'e in suicidal insanity alone, the type or character of the disease is more liable than otherAvise to be transformed. Families of epi- leptic parents sometimes exhibit insanity in one of its mem- 18 6 Relations of Epilepsy to Insanity and Jurisprudence. bers, epilepsy in a second, peculiarities of character in a third, and chorea or some other neurosis in another member. Rarely do Ave find individuals tainted with epilepsy to be entirely healthy. They nearly all possess some vice of con- stitution Avhieh renders them incompetent to meet success- fully the ordinary trials and troubles of life; often they exhibit the insane or epileptic neurosis, Avhieh are very similar to each other, and render the individual more sus- ceptible to the ordinary exciting causes of insanity. Dr. A. FoA7ille* gives an interesting account of seven observations upon epileptic families. He traced two families for three generations, and four families through four generations. I append his table, which comprises 129 persons, either ancestors or descendents of the special epileptic patient, Avho is designated by the initial of his name. * Annales Medico-Psych., Vol. 11., p. 229. SYNOPSIS OF SEVEN OBSERVATIONS OF THE FAMILIES OF EPILEPTICS. OBSER- VATION. I. II. III. IV. VI. VII. Total FIRST GENERATION. SECOND GENERATION. THIRD GENERATION. 1 Father, epileptic........ 1 Grandfather, insane, epileptic................ 1 Grandfather, insane.. 1 Father, epileptic...... 1 Grandmother, insane. 1 Father, epileptic. [l Uncle, imbecile .. 1 Grandfather, epileptic 8 Sons, epileptic........ 1 Father, insane, epileptic 3 Grandsons, epileptic.......... 1 (1. Male, epileptic............... 2 Sisters, insane.................. 1 Brother, intelligent but odd. f 1 Father, insane, married,! f 1 Sister, presumed sane. [l Mother, epileptic........ j (1 M. Female, epileptic. 1 Maz. Female, epileptic, married .......... ..... 1 Mother, presumed sane, f 1 Sister, died young. ! 1 X. insane, epileptic...... ! 1 Brother, epileptic..... I 1 Brother, insane....... [4 Others presumed sane f 1 Cousin, insane............ ( 2 Cousins, presumed sane f 1 Father, epileptic. \ [ 2 Aunts, sane........ I! 9 Children died early,... Son, presumed sane... (2 Sisters, died early. j 4 Brothers, died early. j 1 Bac. epileptic........... (_ 1 Sister, scrofulous. 1 Daughter, epileptic........--- 1 Daughter, presumed sane..... 3 Nephews, epileptic. 27 Nephews and Neices, sane. |'1 Ji. epileptic...................... ! 5 Brotliers and Sisters, died early j 1 Daughter, scrofulous......... [2 Daughters, presumed sane.. 4 Cousins, sane ................... 27 72 FOURTH GENERATION. 1 Great-Grandson, epileptic. ? 3 Children, died in infancy. 3 Presumed sarie. 1 Daughter, hysteric. 1 Daughter, epileptic. 4 Children, died early. 2 Little Children,so far sane. 2 Little Children,so far sane. Married, but no children. Not married. 5 Nephews and Neices, sane. No children. 22 8 Relations of Epilepsy to Insanity and Jurisprudence. Casting this table in a different form Ave find: Generation. Epileptics. Insane. Presumed Children Total. Sane. Died early. 15 3 8 2 14 3 10 27 3 11 2 39 20 72 4 2 1 12 7 22 Total, . . 32 9 61 27 129 It is but fair to presume that some of the sixty-one pre- sumed sane at the time the observations were made, Avould, if their subsequent history Avere traced, increase the number of the epileptic and insane. M. Herpin, in 380 relatives of 68 epileptics, found ten epileptic, twenty-four insane, and forty-four others laboring under some nervous disorder. He calculates that the rela- tives of epileptics exhibit epilepsy about five times more frequently, and insanity about tAventy four times more fre- quently than does the French population generally. The forty-two cases of insanity due to epilepsy, admitted into this institution, in which the parties Avere only interro- gated in regard to the prevalence of mental disorder in the ancestry, Ave find : M. E. T. No Hereditary Predisposition.......................13, 8, 21 Hereditary Predisposition....................... 8, 6, 14 TJnknoAvn............................................... 4, 3, 7 Total.....................................................25,17,42 The frequency Avith Avhieh epilepsy occurs as an exciting cause of insanity can not be exactly determined. The testi- mony of nearly all observers agree as to the ultimate result upon the intellectual faculties. Esquirol* found among 339 epileptic females in the Saltpetre, 269 in a state of mental alienation, and this proportion, though large, would doubt- less be increased if the final history of the remaining ones * Maladies Mentales, t. 1., p. 142. Ohio State Medical Society. 9 were traced. Trousseau* writes: as the fits recur, increase in frequency, in proportion as the disease progresses, the faculties fail, are impaired, become gradually extinct, and insanity follows. Dr. Echeverriaf holds the folloAving language : "Epilepsy contrasts singularly Avith the other diseases in the deep marks it impresses on the organic and moral constitution of the individual. Scarcely do we find confirmed epileptics, Avho, on careful examination, would not afford evidence of this statement. The intellectual impairment originates by de- grees, or. by imperceptible stages—nay, it may be tardy in its display, though it affects the instincts and emotions from the beginning." Dr. Sievekingt remarks: "A single fit may occur never to return, and Avithout leaving any trace of disease. More commonly, however, unless the disease be arrested and the habit broken, the fits recur with gradually increasing frequency, and it is then that Ave soon discover the intel- lectual faculties begin to fail." Dr. Blandford§ Avrites: "This is a condition quite distinct from the loss of memory and general dementia, which, if the fits are at all frequent, gradually encroaches upon the mind, and almost without exception terminates the career of every epileptic, even Avhen there has been no insanity so called throughout the entire illness." Dr. Reynolds,|| however, analyzed sixty-two cases in reference to their mental condition, and arrived at conclusions differing from the authorities above cited. He concludes: 1. That epilepsy does not necessarily involve any mental change. 2. That considerable intellectual impairment exists m some cases, but that it is the exception and not the rule. * Clinical Lectures, p. 67. t Echeverria on Epilepsy, p. 362. I On Epilepsy, p. 59. $ Insanity and its Treatment, p. 76, || Epilepsy, p. 46. 10 Relations of Epilepsy to Insanity and Jurisprudence. 3. That Avomeii suffer more severely and more frequently than men. 4. That the commonest failures is loss of memory, and this if regarded in all degrees is more frequent than integrity of that faculty. 5. That apprehension is more often found preserved than injured. 6. That ulterior mental changes are rare. 7. That depression of spirits and timidity are common in the male sex, but not in the female. That excitability of temper is found in both. He found the class in Avhieh there Avas no discoverable departure from normal mental action to be thirty-eight per cent, of the Avhole number. This result, so different from that reached by most observers, should receive a special in- Arestigation. Dr. Reynolds remarks, a page or two in advance, " From the following analysis I have excluded all cases of positive insanity, of general organic disease, of distinct cerebral disease, where, although there may have been convulsions, there Avas not prominently a case of epilepsy, and all instances of simple eccentric convulsions." That all in the above enumeration, save positive insanity, should be excluded, is right and proper; but it hardly seems fair to throAV out insanity resulting from epilepsy, in an in- quiry Avhieh has for its object the ascertaining of the effects of epilepsy upon the mental powers. It must certainly lead to erroneous conclusions, when in analyzing a certain number of cases to ascertain the frequency of a lesion all those cases in Avhieh the lesion is best marked are excluded. Epilepsy is a chronic and progressive disease, and the only Avay of accurately determining its effects upon the organism is by ascertaining the mental and physical condition in the later years of life. Because no mental or emotional irregularity Avas discoverable at the time his observations Avere made, Ohio State Medical Society. 11 does not prove that such irregularity did not manifest itself in the subsequent history of the case. Dr. Reynolds also selects loss of memory and apprehen- sion as points of departure in estimating the mental health of the individual. These, however, are certainly qualities of mind in which slight deviations are scarcely discernable, and the failure of Avhieh in any notable degree marks advan- ced disease. The departure from health would probably manifest itself primarily in the affective faculties, irrregu- larities of Avhieh nearly always precede derangement of the intellectual faculties. Unfortunately, on account of limited hospital capacity, nearly all of our asylums exclude insanity complicated Avith epilepsy because of its incurability, and hence the data for computing what per cent, of the insane is due to epilepsy, are very imperfect. Dr. Dunglison's statistics of 11,269 cases, compiled from the reports of American asylums, the large majority of which exclude epileptic cases, gives epilepsy as the. eleventh cause in frequency. Taking the annual reports for 1870 of Long- vieAV Asylum, State Lunatic Asylum, Pa.; Western Pennsyl- A'ania Hospital, and Missouri State Lunatic Asylum, in which institutions the chronic insane are not, so so speak, legislated against, I compile the folloAving table. It must, hoAvever, be remembered that the chronic insane are practi- cally excluded, owing to insufficient hospital accommodation and to the greater pressure rightfully made in favor of a recent and probably a curable case. o~ 3 a> w ,2-=! • 2 ^a %'*% ^>^ 3 3 3,3 f'*3 3 S 3 S.-S8 2 s a ASYLUMS. § C 3 - ° a 5.2 '% o 3 -1,801 1,500 ^5« .if g +; > 3 6th 4th 3 c a 2 §.s tM <° 2 OS 3 > a.ce Ph o 3d 3d O Q> ** 5 a1* 2 c.^ P. 3 a> o ^ 939 799 862 761 10th 6th Western Pennsylvania Hospital.... 1,602 6th 923 5th 674 6th 1,120 2d 640 2d 480 5th 6,083 3,306 2,777 12 Relations of Epilepsy to Insanity and Jurisprudence. Putting this result in a different shape, Ave find that in 6,083 admissions attributable to known causes, epilepsy is responsible for 6.39. Of 3,306 males, 8.62. Of 2,777 females, 3.74 are caused by epilepsy. Dr. Nichols, Superintendent of the Government Hospital for Insane, Washington, D. C, in a priA'ate letter, after remarking that it is impossible to state Avith accuracy the per cent, of admissions caused by epilepsy, says, "Nine per cent, of the admissions to this hospital are epileptic." Dr. Kellogg, Assistant Physician New York City Lunatic Asylum, Avrites me that of 436 males in the asylum, 7 per cent, are epileptic; of 864 females, 4.50 per cent, are epilep- tic. A census of the Aveak minded in Scotland, taken several years ago, showed nearly eleven per cent of the whole number to be epileptic. The conclusions warranted by the above data are only approximatively correct. The error is, how- ever, not in favor of epilepsy. All statistics as to the causation of insanity are to be received Avith allowance; the above with more than the usual allowance, since they only concern the few insane epi- leptics Avho have received admission into an asylum. The proportion which they bear to the Avhole number, may be judged Avhen we consider the crowded condition of our 'county and city infirmaries. From the foregoing we may consider: 1. That epilepsy is a potent cause of insanity. 2. That a larger percentage of male than of female admissions are due to epilepsy. A question naturally arises in this connection, possessing much interest in a medico-legal sense, as to what is the true mental condition of epileptics. There is no denying the fact that persons subject to periodical attacks of epilepsy are of unsound nervous constitution. The fact that there is an utter unconsciousness at the time of, and for a variable period succeeding the fit, during which coma may ensue, or Ohio State Medical Society. 13 automatic acts, from the mildest to the most destructive, may be performed; during which the person is, so to speak, morally dead, shows a vast difference between the class of people under discussion and perfectly healthy ones. True, Ave are all periodically unconscious during sleep, and may perform acts of Avhieh there is afterAvards no remembrance, but there is this prominent difference : the latter is a physio- logical phenomenon, and to a slight extent is under the control of the will; the former is a pathological pheno- menon Avholly removed from the control of the will, and de- pendent upon a disease, the tendency of which is to a gradual extinction of the mental faculties. Esquirol says, "They (epileptics) have exalted ideas, they are very susceptible, irascible, obstinate, difficult to please, odd—they all possess some peculiarity of character." M. Cahneil Avrites: "That all epileptics not yet insane are irascible, very impassionable, and disposed to false interpre- tations." Baillarger* says: "All authors are agreed in admitting the fact that epilepsy, before leading to complete insanity, produces very important modifications in the intellectual and moral condition of certain patients." Dr. Burgessf Avrites: "Epilepsy and chorea are so closely associated with madness as to obtain a special and family character with it." Dr. Blandford| Avhile holding that epilepsy is not the equivalent of insanity, admits that there is good grounds for considering the mental condition of epileptics unsound. Dr. BroAvne,§ Ex-Commissioner of Lunacy for Scot- land, says: " However much the minds of epileptics may in some respects resemble those of healthy indiATiduals, they differ from all those and differ in the same respect." * Medical Critic and Psych. Journal, A"ol. 1. f Relations of Madness, p. 45. j Op. cit., p. 172. $ Journal of Mental Science, Oct., 18C5. 14 Relations of Epilepsy to Insanity and Jurisprudence. That persons prominent in the world's history, and others aa71io haA'e achieved eminence in particular callings, have suffered from epileptic seizures does not negative the propo- sition. Let us, however, briefly glance at the roll. Napo- leon is usually quoted as an example of this class. His character certainly has many points in common Avith the epileptic character, and presents numerous evidences of a diseased nervous system, but I am unable to find authority for the assertion that he Avas an epileptic. The translator of Trousseau refers to Sir Thomas Watson,* but he distinctly says: " Napoleon is said, I knoAV not upon Avhat authority, however, to have suffered something like epilepsy during sexual intercourse." Mahomet is also included among the number. The re- searches of Dr. Weil and Washington Irving confirm the suspicion that he was subject to epilepsy; although his biography is so enshrouded by Arabian fables and traditions, Avhat is known certainly presents evidence strong enough to convince the most sceptical that he was the possessor of an unhealthy nervous organization. Ayesha, one of his wives, and Zeid a disciple, bear witness that he was at one time siezed Avith violent convulsions, after Avhieh he Avould lie with his eyes closed, foaming at the mouth, and bellowing like a young camel. Cadijah, his first Avife, also noticed similar spells while in Mecca, before the pretended revela- tion of the Koran. Irvingf finds the explanation of his conduct in his " enthusiastic and visionary spirit gradually wrought up by solitude, fasting, prayer and meditation, and irritated by bodily disease (epilepsy) into a state of tempo- rary delirium, in which he fancies he receives a revelation from heaven, and is declared a prophet of the most high." As to Csesar, Ave are told that at one time Avhen the Sen- ate was offering him special honor, he acted discourteously * Principles and Practiec of Physic, p. 414. f Life of Mahomet, pp. 61, 335 : Arol. 1. Ohio State Medical Society. to the Senators, and observing their displeasure, bared his throat for the knife to the A7ery men assembled to show him respect. He then excused his conduct on account of the malady from which he suffered, saying: That those attainted are unable to speak when standing in public, that they ex- perience shocks throughout their frame, that they suffer from vertigo, and finally lose consciousness altogether.* Peter the Great, Avho Avas subject to some nervous dis- order, considered by many to have been epilepsy, has also been included in the list. At the death of his son by Catherine, he Avas seized with convulsions; he threAV himself prostrate upon the ground and remained there unattended for three days and nights. Charity Avould certainly try to shield his many shortcom- ings under the garb of disease. The civilization of the period in Avhieh he lived can hardly be responsible for the neglect of all the civilities and politenesses due to equals, especially Avhen he is their guest, any more than his, at times, almost barbarous treatment of the Czarina. It is related, that when stopping at Magdeburg, on his road to Berlin, he gave an audience to the select Magdeburg public. Dur- ing the audience, the Duke of Mecklenburg with his duch- ess, who Avas a niece of the Czar, arri\Ted. At the sight of the latter " Peter started up, satyr-like, clasping her in his arms and snatching her into an inner room, with the door left ajar, and there — it is too Samoedic for human speech, and would excel belief wrere the testimony not so strong." f Shortly after, dining with Friedrich Wilhelm and the Queen, at Berlin, the Czar placed himself by the side of the Queen. During the meal he experienced a seizure, became convulsed, gesticulated Avildly, danced around the Queen with a knife in hand, and finally grasped her hand with such violence as to cause her to shriek out. *Psychologie Morbide; Moreau. P. 551. t Frederick the Great; Carlisle. Vol. 1., pp. 348—350. 16 Relations of Epilepsy to Insanity and Jurisprudence. Petrarch, Italy's greatest lyric poet, Avas an epileptic; and see him, all his life long a victim to his passion for Laura, of whose virtues and memory he so delighted to sing, and from whom neither fame nor friends nor time could wean him. He fell in love Avith her on seeing her in church, and even went so far as to declare his love, though she Avas al- ready the wife of another. For ten years he was constantly agitated between his love and his reason. Depressed in spirits, he left Avignon and travelled, to rid himself of his passion, but in vain. His love for her Avas not exclusive, for we learn that the mortification of being the father of an illegitimate son, though he afterward' had an illegitimate daughter by the same woman, he retired to Vancluse, Avhere " his ears Avere disturbed only by the sounds of nature, and only one female came, a swarthy old Avoman, dry and parched as the Libyan desert." From Dr. BroAvne* I quote the following: " Conceive the golden-mouthed apostle Bossuet, a victim to the petit mal, terrified by the prospect of lythotomy, losing language, shorn of the glorious gifts which even now give him a prominent place among the orators and defenders of the Christian faith, and think of him as haunted, persecuted, tyrannized over by an ever-recurring ode of Horace, Avhieh excluded every other thought and feeling. " Moliere has been added to this group. Suffice it to say, that he was incapacitated for thought or Avork, for that was his work, for fifteen days after every fit, that he lived on milk ; drew his oavu portrait in writing " Le Malade Imag- inaire;" had a fit Avhile acting the part, Avhieh, Avith con- summate skill, he concealed under a laugh; that he was es- tranged from his wife; chose an old Avoman critic of his plays; and was denied Christian burial, as much on the ground of his eccentricities as his infidelity. " NeAvton's glimpses of ' cycle in epicycle rolled/ ended in *Jour. Ment. Science. October, 1865. Ohio State Medical Society. 17 epilepsy and dementia. The tic nerveu and perhaps the opiomania of Madame De Stael ended in delirium. The delicately strung system of Pascal is a sort of lay figure upon Avhieh to study the most rare and mysterious neuroses. He lived under incessant attacks of petit mal, and died con- vulsed. He Avrote the bitterest satire and the most generous and genial dissertation on ethics. He Avas a mathematician, moralist, philosopher, but he believed in charms and amu- lets, and at all times, however occupied, there was an ever- yawning gulf beside him — a gulf into Avhieh he could not divest himself of the apprehension that he might be precip- itated." Hence, we see that these men, great as they were and who are usually considered as examples of epileptics suffering no departure from mental health, when closely scrutinized give unmistakable evidence of a diseased mental organization. These cases, hoAve\7er, constitute the exception; all that could be proven by them Avould be that such men had intel- lectual stamina enough to withstand to any degree the injur- ious effects of the disease. Had their mental power been no greater than the large majority of epileptics, they would have exhibited the failure of the class. Just hoAv far the disease may have affected their private and social relations it is impossible to judge; doubtless much of the irritability which is excused on account of their peculiar surroundings is in reality the outcropping of the disease. Again, great as these men were, the characters of most of them present some grave moral obliquities, and Avho will say that some blots which now blacken their fame would haA'e occurred had their nervous systems been healthy. The mental condition of epileptics may manifest itself prominently in three directions : 1st. In temporary outbursts of delirium or uncontrollable fury. 2d. In a perversion of the moral qualities. 19 Is Relations of Epilepsy to Insanity and Jiirisjirudence. 3d. In an attack of regular maniacal excitement, lasting from a few hours to several weeks. These divisions are to a certain extent arbitrary, it is rare to find them distinct for any length of time; they usually blend together, or occur at different times in the same indi- vidual. Still for description it serves our purpose, inasmuch as the first or second condition may for quite a while be the only psychical manifestations of the disease. We may state in the outset, that epileptic insanity in any of its manifestations is paroxysmal, like the seizures to Avhieh it always bears some relation. As the convulsion is the grand de appui, the mental symptoms naturally arrange themselves into, 1st, Those immediately preceding or suc- ceeding the fit; 2d, Those occurring between the fits. Our first division, characterized by paroxysms of blind fury, and Avhieh not infrequently constitute the only depar- ture from normal mental action, possesses great legal inter- est. In the intervals, Avhieh may continue for months or even years, the person manages his business affairs and per- forms the ordinary duties of life, seemingly Avith as much tact and judgment as ever; still, close scrutiny reveals a certain mental condition peculiar to the class, prominent in Avhieh may be mentioned a changeableness of thought, ac- tion, and feeling. He becomes irritable, is greatly annoyed by trivial matters, groAvs suspicious of those around him, at times is despondent and given to gloomy thoughts, or again he is over-exhilarated and abounds in magnificent projects for the future. As the disease progresses, he becomes at one time quarrelsome, and again, is imbued with religious sentir- ments. He becomes forgetful, suffers from confusion of thought and loss of apprehension. He leaves off his indus- trious habits, becomes niggardly, or, it may be, prodigal of his worldly goods, until finally his insanity becomes unques- tionable. This storm of passion — this furor epilepticus — at times Ohio State Medical Society. 19 sweeps like a Avhirlwind over the mind and impels to the most Avanton acts. The Avill of the sufferer seems over- whelmed by the disease, and he is transformed into a perfect automaton, dealing injury and destruction to persons and things around him. The paroxysm may expend its force in harmless action, but usually culminates in some act of vio- lence. The painful nature of the delusions and hallucina- tions of epileptics may afford a partial explanation of the violence of their actions. Hallucinations of sight, and espec- ially of blood and red colors, occur most frequently. Often just preceding and during the explosion they see armed men,. ghosts, assassins, who rush upon them to kill them. These paroxysms may precede, folloAV or replace the regu- lar epileptic convulsion. In the majority of cases the men- tal excitement precedes the convulsion. It is not unusual to hear an attendant say, " Doctor, I don't believe she Avould1 have her fits if she did not get so angry. She gets so mad at some one that she throws herself into a fit." In point of fact, the anger is as much beyond the patient's control as is the convulsion Avhieh it foreshadows. The fact that the psychical phenomena do replace the seizure is admitted by all; and in some cases, constituting the epilepsia larA7alis of Morel, these mental symptoms may be the only manifesta- tions of disease. The explanation may be that the morbid activity which in uncomplicated epilepsy is restricted to the medulla oblon- gata, is by some means extended to the cerebrum, causing an epilepsy or convulsion of the brain; for it must be admitted, that the delirium in the suddenness of onset, the violence of its course, the shortness of its duration, and h\ the resem- blance of successive attacks, presents strong analogies to the physical phenomena. However, Avith our present imperfect knowledge of the pathology of epilepsy, we are unable to Avholly explain the above phenomena, or to understand why an attack of furor or mania should occur in connection with 20 Relations of Epilepsy to Insanity and Jurisprudence. the convulsion in one person and not in another, or in the same person at different times. Dr. Blandford* says that " we must suppose that the disturbance in the brain circula- tion implied by the epileptic seizures does not at once sub- side, as it does in a patient Avho in an hour appears to be in all respects sane and unchanged. The reaction, if Ave may so term it, after the fit or fits brings about a great disturb- ance of the circulation, and, according to the degree thereof, symptoms of insanity may appear, varying from a moderate mania to Avild and unconscious delirium." The second manifestation of epileptic disease is in the perversion of the moral faculties. "Epilepsy leads to de- pravity," says a recent author, and its truthfulness is at- tested by all having experience Avith this form of disease. When little or no intellectual aberration is apparent, the moral qualities seem to be blunted. This moral blindness, which contrasts strongly Avith the individual's previous char- acter, may continue as the constant state, or, which is the more common, may be of variable duration, and of period- ical recurrence. It occurs occasionally as the first manifes- tation of epileptic disease, and may occur at regular intervals for a long period before convulsions make their appearance. The subsequent appearance of the convulsive seizures offers a«L explanation, if not justification of their conduct. In this class, lying, thieving, and the whole category of minor crimes is indulged in, seemingly out of pure love of crime; little regard is paid to law, either human or divine, and they figure constantly on the police dockets. Maudsly associates moral insanity more frequently Avith epilepsy than Avith any other disease. Epileptic criminals prove Avholly incorrigible and nothing is more significant than the fact that in spite of all punishment they persevere in their criminal ways. This state of affairs, hoAvever, soon changes, the intellect becomes involved and undoubted insanity results. *Op. Cit.; p. 76. Ohio State Medical Society. 21 We iioav proceed to examine that form in Avhieh the ex- citement extends over a longer period, rarely, however, per- sisting longer than two or three Aveeks at a time. In- sanity into Avhieh epilepsy enters, either as a cause or com- plication, has, so to speak, a physiognomy of its own. It may manifest itself in any one of the three grand divisions of mental disease, mania, melancholia, and dementia, but it so impresses its peculiar type upon the symptoms, that the epileptic element can be readily diagnosed. Of the mental condition of the asylum epileptic in the interval between his paroxysms of excitement, it is unnecessary to add to Avhat has already been said, except to state that the peculiarities then spoken of are all increased. He is forgetful, irritable, suspicious, fault-finding, liable to outbursts of anger and impulsive actions of all kinds. The peculiarities of epileptic insanity are, first, the ab- ruptness of the invasion. Often the attack can only be fore- told a few minutes previous to its occurrence; the more common prodromes are changes in his disposition or feelings, or pain in his head. The onset may be violent, or the pa- tient may leave off his occupation abruptly and Avander here. and there Avithout any definite idea—a vague feeling of rest- lessness comes over him, a desire to go, whither or why he knows not. "This impulsi\*e want to Avander about," says Jules Falret, "is nearly constant in this mental state, and deserves to be carefully pointed out." In this state, he is subject to gloomy fears and forebodings, and often, a word spoken, the presence of certain persons, or it may be a mere subjective sensation, is sufficient to call forth the most mur- derous attacks. These explosions of violence, during Avhicli homicide or the most atrocious crimes may be committed, of which Ave have already spoken as constituting in some cases the only tangible departure from mental health, are equally characteristic of this form of the disease. They also occur- in the demented. E. M., perfectly demented, whose insanityr 22 Relations of Epilepsy to Insanity and Jurisprudence. dates back a quarter of a century, has convulsions only at long intervals, but is subject every few days to terrible par- oxysms of fury. With a scream she Avill throw herself on the floor, strike her head, kick and bite, and talk incohe- rently about graveyards. In a feAv minutes the paroxysm ends as quickly as it began, and she returns to her nor- mal condition. The attack, though violent, is brief, and generally ends suddenly, though not Avith the abruptness that marks the onset. The culmination is sometimes reached in an explosive act, after Avhieh the patient wakes up as from a dream. In one case, where the excite- ment had extended over seA7eral Aveeks and avIio was espec- ially dangerous to his companions, the patient struck a per- son in no Avay interfering Avith him, a violent blow over the eye, and almost immediately the attack ended. Other cases run a different course, and present merely the volubility of words and restlessness of action of ordinary mania, and still rarer cases present the depression of melancholia. Hoav- ever, these cases usually present greater perversion of the moral qualities, are very suspicious, often manifest erotic tendencies, and are more irritable and impulsive in their doings, than similar cases not having the epileptic element. There are two other peculiarities of these attacks of mania which deserve especial mention from their judicial impor- tance. I refer to the coherency of thought manifested dur- ing the period of excitement, and the imperfect recollection afterwards of things said and acts done. The observations of Jules Falret are so pertinent that I quote the following: *" In spite of the disorder and violence of their acts, their language is in general considerably less incoherent than that of many insane individuals. It is surprising how easdy, in spite of their state of agitation, one can follow the train of ideas expressed by epileptics. Their delirium is more con- nected and comprehensible than is usual in mania. They * Quoted by Trosseau. Clinical.Lectures ; p. 76. Ohio State Medical Society. 23 understand better the questions put to them, they answer them more directly, more exactly, and notice what goes on around them more frequently than most insane persons suf- fering from general delirium Avith excitement. The less marked incoherence of the delirium and the greater distinct- ness of ideas during the attacks, are all the more remarkable that they singularly contrast Avith the nearly total oblitera- tion of all recollection of the fit after it is over, a defect of memory Avhieh is also an almost constant symptom of the attacks of epileptic mania." The following cases illustrate the above: M. S. has been subject to fits for the last eight years, rarely escaping longer than a Aveek at a time. She had several seizures during the day; suddenly she sprang up from the bed, upset everything in her room, and ran up and down the Avard, praying in a loud voice for deliverance from the e\Til-doers around her. It became necessary to remove her to another Avard, at Avhieh she became A7ery indignant, refused to go, declaring that she Avas remoA7ed because her clothes were not as "costly as some fine ladies," that Ave had long tried to cheat her out of her rights. She put a false interpretation upon every explana- tion that we offered, charged the nurses Avith every kind of misdeed, and became very obscene in her talk. Yet her statements Avere so coherent and her accusations so plausibly supported, that it seemed like nothing but an exhibition of bad temper. In a few days the excitement passed off; she was surprised to find herself in another Avard, and had no remembrance of her removal, or of her sayings at the time, and felt grieved Avhen told of them. A. B., set. 26, has been subject to epileptic vertigo and night attacks of epilepsy since her twentieth year. Several times her shoulder has been dislocated during the fit by the violence of the muscular contractions. She had shown .no symptoms of mental derangement, aside from a failure of memory and occasional despondency, which was the more 24 Relations of Epilepsy to Insanity and Jurisprudence. noticeable from her naturally cheerful disposition. One Sunday morning, a few months'ago, she went to the barn, seized an axe that stood near, and placing her head against a wagon wheel, struck several bloAVS on her forehead and head, making some ugly Avounds. She fell senseless, Avaa soon discovered by her friends and carried into the house. She remained in this condition until her Avounds were dressed by the surgeon, Avhen she aAvoke and became so violently manircal that it Avas necessary to confine her hands to pre- vent her from tearing off the dressings and injuring others. The excitement passed off in a few hours, and she had no recollection of her suicidal attempt or her after acts, and seemed much astonished Avhen told of them. She Avas ad- mitted into the asylum before her Avounds Avere healed, and has since shoAvn no evidences of insanity farther than the failure in memory and the irritability peculiar to the class. There are three points of special interest in the case: 1st, She had no fit for several days either preceding or succeed- ing the suicidal attempt, Avhieh in all probability took the place of the regular convulsion. 2d, The interest Avhieh at- taches to it in a medico-legal view. Had the impulse been homicidal instead of suicidal, how difficult it Avould have been to convince the court Avith the present ruling that she Avas an irresponsible agent. 3d, The fact that she has never experienced but the one paroxysm. Morel first described a form of epileptic insanity to \vhich he gave the name of epilepsie larvee. We have already al- luded to it incidentally, but its importance in a legal point of view entitles it to a more careful consideration. In this form, the common convulsive phenomena are absent, but the mental phenomena are so characteristic that tire class to Avhieh the disease belongs cannot remain in doubt. Morel * gives as the peculiar symptoms: "Periodical excitement fol- lowed by prostration and stupor; excessive irascibility Avith- * Jour. Ment. Science. January, 1863. Ohio State Medical Society. 25 out cause; the manifestation of aggressive violence, marked by instantaneity and irresistible impulse; exaltation of the sensibility; homicidal and suicidal tendencies; intercurrent insane ideas connected Avith the state of cerebral excitement; exaggerated notions of physical poAver, of Avealth, of beauty, or of intelligence; erotic tendencies coupled Avith exalted religious feeling; hallucinations of terror; sensation of lu- minous atmosphere; horrible dreams or nightmare; gradual progressive debility of the poAvers of understanding, espec- ially of the memory; loss of recollection of events transpir- ing during the paroxysms, the insane symptoms of each per- iodic attack having, both Avith reference to the ideas which occupy the mind and to the actions committed, the same iden- tical character; and lastly the violence and duration of the delirious excitement determined by the duration of the re- mission." Some observers, among whom is Dr. Sankey, re- fuse to recognize the disease under consideration as a distinct species of epileptic insanity, but rather consider the cases adduced in its support, as examples of periodic or recurrent mania. The natural history of the two forms, however, presents many points of contrast. The epileptic form is marked especially by the abruptness of its invasion, the un- controllable impulses to violence, oftentimes homicide and suicide, the brevity of the attacks, the absolute resemblance in deed and act of successive attacks, and the suddenness of the intermission. In ordinary recurrent mania there is a better marked period of incubation, during which the mani- acal symptoms gradually appear, the attack gradually in- creases in seArerity, rarely stopping short of Aveeks, it may continue for months Avithout abatement. Its force expended the patient is left for a variable period afterward in a de- pressed condition, from Avhieh he gradually passes into his normal condition. Though recurrent disease is not infre- quently associated Avith acts of violence, they do not possess the furious and vicious nature of epileptic impulses. Very 26 Relations of Epilepsy to Insanity and Jurisprudence. often the diagnosis is confirmed if the earlier history of the patient can be traced and Ave find him to have formerly suf- fered from epileptic seizures, or again, if conAmlsions should appear in the subsequent course of the disease. I present the following cases: H. K., set. 18, Avas admitted in an attack of mania. The accompanying medical certificate said he was not sub- ject to epilepsy. For several months he had at times shown symptoms of mental derangement; he had been inclined to Avander about, quarreled Avith persons around him, became irritable and easily excited. For ten days previous to his admission he had been very violent. Ordinarily he pre- sented the restlessness of action and thought peculiar to mania, but at times he Avas seized Avith a perfect fury, Avould destroy his clothing, break up the furniture of the Avard, and spring furiously upon any one avIio chanced to be near him, using any Aveapon at hand. He gave no premonitions of his attacks. He Avas very revengeful, and after the beginning of the attacks Avould seek out those Avhom he disliked and attempt to injure them. On removing him to his room, which Avas not often done without difficulty, the excitement soon passed off. He remained in this condititon about six Aveeks, when, after severely cutting the face of an unoffend- ing patient, he seemed to Avake up and speedily recovered. He had a very imperfect recollection of coming to the Asy- lum, or of his doings Avhile here. In two Aveeks afterward, he had a AA7ell defined epileptic convulsion, and Avas subject to them at irregular intervals during the remainder of his stay in the Asylum. In tracing back his history it Avas ascertained that he had at least two epileptic seizures about a year before. During the eight months in Avhieh he exhib- ited irregularities of conduct and had an attack of mania, the seizures did not recur, but made their appearance imme- diately after the mental improvement. M. G., set. 23, when admitted had never experienced a Ohio State Medical Society. 27 regular convulsion, but had for some time past been subject to occasional attacks of " dizziness or blindness." Her dis- ease is paroxysmal; during the intermissions she is usually pleasant and assists in the Avork of the Avard. At times she will jump up, run down the ward, break a window, and then quietly resume her seat. Again she will suddenly leave off whatever she may be doing, become abusive to the attend- ants Avhom she has just been assisting, strike persons, saying they are making faces at her, declares she is going off, and makes every attempt to get out. Several times she has suc- ceeded, in spite of efforts to prevent her, and on one occasion she ran quite a distance over the fields Avith barely enough clothing to cover her nakedness. She kicks, bites and fights terrifically Avhen returned. Usually she becomes stupid and droAvsy, and rapidly comes out of her paroxysms Avith a very indistinct recollection of her doings. In her better periods she says she does not know what makes her act so, that she cannot help it, and does not want to go home until she is well. Her paroxysms recur frequently, and all bear a re- markable resemblance to each other. During the first re- mission she attended a dance in the chapel. She seemed to be highly pleased, when Avithout a single premonition she gave a scream, and struck the patient sitting next to her. On being removed from the chapel, she escaped from the nurses, and getting into a dining-room where the table Avas set, assaulted them with dishes, and was soon master of the situation. The last two paroxysms passed off with tolerably well marked convulsions, and the drowsiness of previous attacks. Dr. Thorne Thorne, in St. Bartholomew Hospital Report, 1870,* relates the folioAving case, Avhieh I abbreviate : " H. S., set. 36., was admitted for an attack of bronchitis. He seemed to be strange in manner shortly after admission, and on several occasions said his wife was looking in at the ward * Quoted in Jour. Ment. Science; January, 1871. 28 Relations of Epilepsy to Insanity and Jurisprudence. window. One night he suddenly jumped out of bed, and rushed wildly to the door, which he had no sooner opened than he fell prostrate on his back. He seemed to retain consciousness, but offered no explanation of his conduct. Occasional attacks of mental excitement similar to the above, occurred during his stay in the hospital. It was as- certained that for several years he had complained of severe pain in the head, and of dimness of sight and trembling. Four or five years before admission, he had several Avell- marked epileptic seizures, which have constantly recurred, and now average about every three weeks in frequency. Prior to his entering the hospital he had never shown any morbid mental symptoms. Several times since leaving the hospital he has suffered from mental depression which passed into maniacal excitement. His countenance becomes wild, intellect confused, and he will snatch a knife and threaten to kill his children. He rushes after them as they in terror seek to hide themselves. Several times when his Avife had locked herself in the room Avith him, it has required all her strength and tact to prevent him from throAving himself out of the AvindoAV. This excitement may last from several hours to an entire night, Avhen he gradually becomes quiet, and usually sleeps. On aAvaking, he has but a dim recol- lection that he has been ailing, and none whatever as to what has been said or done. The patient often returned home Avithout being able to give an account of his doings, and in these states has been guilty of pett)' thefts. At one time, Avhile in this stupid state, parcels of scented powders Avere found on his person, Avhieh he could have had no ob- ject in purchasing, and of Avhieh he emphatically declared he kneAV nothing. Dr. Thorne very properly remarks, " it is impossible to overestimate the importance of such a case from a medico-legal point of vieAV, because, though persons suffering from masked epilepsy may be as this man was, and still is, able to folloAV their daily avocations, yet they must Ohio State Medical Society. 29 necessarily be considered as placed, at least during the con- tinuance of their attacks, beyond the category of healthy and responsible minds. Volition is hi abeyance, and hence responsibility must be also." The prognosis of epileptic insanity as to permanent recov- ery is exceedingly unfavorable. So far as recovery from the particular maniacal excitement is concerned, the prognosis is good, but with the presence of the same cause, and that cause a progressiva one, the liability to relapse is very great. Several cures are recorded by good observers, but these must be received Avith some degree of allowance, since the mental and physical phenomena of epilepsy may become la- tent for a considerable length of time, inducing false hopes in its.A7ictims, and then break out with accumulated severity. It is ATery doubtful Avhether the mind ever thoroughly re- gains its tone after it has once become affected through the seizures, yet the periods of remission from active symptoms do occasionally extend over months, and even, in some re- corded cases, for years. The prognosis as to life is unfavorable, the larger number dying before the middle period of life is reached. Last year I reported to this Society on " The Temperature of Certain Nervous Diseases," and gave a table of thermo- metrical observations on insane female epileptics. Further experience in the use of the thermometer has confirmed the general conclusions then arri\-ed at, and which may be briefly summed up: I. The temperature of epileptic insanity is high, the eve- ning altitude being in excess of that of the morning. II. The temperature of the same individual varies largely and bears a relation to her mental condition at the time the observation is made. The periods of excitement present an increase, often amounting to several degrees over the usual temperature. III. A depression of temperature occurs just before a 20 30 Relations of Epilepsy to Insanity and Jurisprudence. single fit, Avhieh is better marked in the sleep that follows the seizure; several hours usually elapse before the inter- paroxysmal range is reached. - IV. A succession of fits increases the temperature, and several days may elapse before the thermal equilibrium is restored. We do not propose a thorough discusskm of the jurispru- dence of insanity, even when complicated Avith epilepsy, this is already in the hands of a special committee; but merely propose to point out the medico-legal aspects of one factor, epilepsy. The courts have for a long time ruled the irresponsibility of acts committed in close connection with the convulsion, and tacit jurisprudence has limited the time to four days — tAVO days preceding, and two succeeding the fit. This rul- ing Ave hope to show is Avholly at variance Avith our present knoAvledge of the mental condition of epileptics, and Avith the ordinary psychical phenomena of the disease. We have already shown that the sanity of epileptics at any time after the development of the disease is an open question. Beyond doubt the character of the person so afflicted undergoes modification. This change can sometimes be noticed after the first seizure, becoming better marked as they recur, and is evidenced in both their mental and moral natures, the latter not infrequently betraying the greater alteration. Dr. Ray * Avrites, " the fact of its (epilepsy) existence be- ing established, is it going too far to say that legal responsi- bility is presumptively annulled, and that the burden of proof lies on the party that alleges the contrary? People are scarcely prepared for it yet, perhaps, but to that com- plexion they Avill come at last." All epilepsy, according to Marc, Avarrants upon the event of a criminal act the suspicion of mental disorder, which suspicion is increased in the absence of personal motive. * American Journal of Insanity. October, 1867. Ohio State Medical Society. 31 Dr. Bucknill, in the preface to his Prize Essay, * says: "The existence of habitual epilepsy might justify the deci- sion that a violent and unprovoked assault Avas not the re- sult of criminal passion, but of uncontrollable excitement of the brain. * * * The psychical phenomena of epilep- tics are of a kind to set the metaphysicians at defiance ; sim- ple, uncontrollable anger, with or Avithout some slight cause, and accompanied by the most reckless violence, or gloomy and cruel revenge for some supposed injury, or simple, mo- tiveless rage, all Avithout delusion or the presence of any of the metaphysical tests, and quickly passing into an ordinary and apparently a healthy state of the mental functions are the psychical characteristics of this fearful and obscure dis- ease." Dr. Burgessf holds that "a person may act and conduct himself rightly for a long period; in epilepsy he may do so for months, and even years, and although quick to evade his. particular hallucination, and point out and oppose the errors of others, he may be suddenly attacked Avith mania himself,. and neither the epileptic nor those afflicted Avith intermittent madness can at any time be held responsible." Baillarger concludes a lecture before the Academy of Medicine (Paris,) with the following propositions: % First,, That besides declared insanity, there exists with certain epi- leptics a special moral and intellectual condition. Second,, The medical jurist ought in many cases to apply himself to make apparent the principal traits Avhieh characterize this condition, to extenuate, at least as much as possible, the re- sponsibility of the sufferer." Wharton and Stille § hold, " Persons truly epileptic are easily excited to anger and revenge on the slightest provoca- tion, in the intervals between their attacks. Although their *0n Criminal Lunacy, p. 37. f Op. cit., p. 104. % Med. Critic and Psych. Journal. Vol. I, p. 512. $ Medical Jurisprudence. P. 117. 32 Relations of Epilepsy to Insanity and Jurisprudence. attacks do not always attain to such a degree as to deserve the name of mental derangement, yet it should never be for- gotten that there is ahvays a morbid predisposition to insane ebullitions, and in general a morbid irritability Avhieh must impair, if not destroy, the moral responsibility of actions growing out of them." In opposition to the aboA7e views, Ave have Caspar* ask- ing, "How completely objectionable to declare epilepsy to be a disease which renders those affected with it irrespon- sible agents, as is done by the earlier authors and their mod- ern compilers — the fact taught by experience that epilepsy occurs in nature in innumerable degrees of intensity, is op- posed to the general applicability of any such dogma." We do not believe that all the acts of epileptics should be excused because of the presence of epilepsy, as will appear further on. Dr. Caspar founds his belief upon the assertion that the mania of an epileptic patient does not differ psycho- logically from ordinary mania, Avhereas we have endeavored, successfully or not, to show that epileptic disease does mani- fest itself in peculiar psychological phenomena, and differs in this very respect from mental irregularity dependent upon ordinary causes. Dr. Echeverria f writes: "Believing that there is a mor- bid obliteration of moral feeling in epileptics and that they are mastered by uncontrollable impulses, I Avould hesitate to fix the limits of their responsibility. Chronicity, to my mind, is as essential as any of the other characteristics of epilepsy, wherefore I Avould be far from thinking a person epileptic because he or she Avere troubled at some previous time with epileptiform convulsions that have not reappeared. Consequently, I reject exculpating any overt act attributed to epilepsy unless committed in clear relation Avith the spasm or while the perpetrator exhibited plain signs of cerebral * Forensic Medicine. P. 188, vol. IV. t Op. cit., p. 362.' Ohio State Medical Society. 33 epilepsy; and whichever be the medico-legal faith given to this last form of the disease, it is nevertheless positive that epileptics undergo a moral degeneracy through their malady and that we are neA7er safe with them, as has recently been asserted with great truth by Delasiavue." He gives further on in the chapter two cases. I abbreviate the folknving: "One morning an epileptic made an assault on one of his companions with a knife, for Avhieh no proA7ocation had been offered. He was subject to nocturnal attacks, but no men- tion is made of a fit having occurred the previous night. The mental trouble in this instance is not apparent to any person Avho would not inquire closely into the patient's symptoms." Our courts have occasionally recognized the sufficiency of epilepsy as a defence in capital crimes. In the trial of Fyler for the murder of his wife, in Onondaga county, New York, 1855, the defense of epilepsy was entered for the first time in this country. Fyler had for several years been subject to epileptic convulsions, but Avithout producing any obvious mental impairment beyond the immediate effect of the fit. No evidence Avas offered to show that a fit had occurred about the time of the homicide, or that he exhibited any of the ordinary signs of a fit. The trial, after various delays, came on a year after the commission of the crime. He was found guilty, but a committee appointed by the court to in- vestigate his mental condition, adjudged him then insane, and he Avras remanded to an asylum. Dr. Gray, Superintendent of the NeAv York State Asy- lum, relates the folloAving case: * An epileptic Avas on trial for the murder of his Avife. The plea of insanity Avas en- tered, but the counsel having giA7en their entire attention to the fact of insanity and little or none to the question of epi- lepsy, the evidence did not warrant the experts in consider- ing the case one of insanity or irresponsibility. The pris- * Amer. Jour. Insanity. October, 1870. 31 Relations of Epilepsy to Insanity and Jurisprudence. oner had a well-marked epileptic seizure in court. Dr. Gray, who sat beside him, Avrote a note to the judge, stating that the prisoner was in an epileptic state, and unconscious of Avhat Avas going on. The jury returned a verdict of guilty, but the court did not pronounce sentence. Under a subse- quent investigation, the prisoner Avas committed to an asy- lum, on the ground that he had been an epileptic, was still an epileptic, and Avas, therefore, possibly a person of doubt- ful responsibility. Again, the convulsions may occur at night, and the pris- oner or his friends be unaAvare of the fact that he is an epi- leptic. Baillarger gives the case of Councillor Lemke as an instance of epileptic furor. It Avas this case that gaAre rise to the division of mental disease known as Mania Tran- sitoria. The Councillor Avas seized Avith a sudden fury to kill in the middle of the night. He attempted to throw his Avife out of the window, when assistance coming, she was released. His stertorous breathing a few moments before had awakened his wife, and her efforts to relieve him called forth the furious attack. Trousseau was consulted by a ncAvly-married couple under the following circumstances : The wife, soon after their mar- riage, Avas aAvakened by the strange movements of her hus- band. Suddenly she Avas attacked, and had her screams not brought help, she would have been severely injured. On a subsequent occasion, she was awakened in time to strike a light, witness the convulsion, and escape from the fury which immediately followed. Epileptic attacks were, up to this time, unsuspected. Dr. Delasiavue * relates the case of a man who was'once a patient in the Bicetre, and Avas subsequently returned after killing his wife. A His occasional aberration of mind was plead in his defense and prevailed. It was only in the asy- lum on his second admission, where, save a few transient * Noted in Amer. Jour. Ins. October, 1855. Ohio State Medical Society. 35 agitations, he exhibited perfect lucidity, even to his death, occurring a long time afterwards, that his momentary wan- derings, and, in part, his criminal acts, were traced to night attacks of epilepsy. Irresponsibility should not be made dependent upon the convulsion, since vertigo or petit mal may be folloAved by as impulsive actions and as disastrous results as the general con- vulsion. Marc, with many other authors, places prominently among the conditions of immunity, the intensity of the par- oxysm. Cases, hoAvever, are not infrequent in which there is no convulsion, and even the loss of consciousness is un- known to the person himself, and only observable by others in the sudden stoppage in the midst of a sentence or an act. Yet in this unconscious interval lewd words may be spoken, laughter indulged in, incongruous or criminal deeds per- formed, and no recollection of them remain. Certainly the unconscious criminal should not be held responsible, though he seems sane a moment before and after. As examples, I mention an epileptic architect"who does not hesitate to ascend the loftiest scaffolding. When he has a fit, he runs rapidly over the scaffolding, shrieks out his OAvn name in a loud AToice; in a quarter of a minute he re- sumes his occupation and gives his orders to the workmen. Unless he is told, he does not recall his singular act. The President of a provincial tribunal, while holding court, abruptly left his seat, muttering a feAv unintelligible word-*, and shortly returned. He had no recollection of having left his seat. Going out in a similar way on another occasion, the usher folloAved him. He went to the council room, made water in the corner, and returned, perfectly ig- norant of his incongruous act.* An out patient of the London Hospital has in connection with his epilepsy subjective sensations of smell. He has had convulsions in wi.ich he has bitten his tongue, but re- * Trousseau. Op. cit. 36 Relations of Epilepsy to Insanity and Jurisprudence. cently there have been losses of consciousness Avithout moA7e- ment of the limbs. In these, he is unconscious, becomes pale, and usually remains still. In one attack, he went from Poplar to Deptford — eight miles. The facts are, he lost himself at Poplar, and found himself again at Deptford where, fourteen years ago, he used to live. Sometime since he walked into a canal during a seizure.* I Avas recently consulted in the case of a lady, Mrs. B., set. 50, who for a year past has been subject to Avhat her friends call "fits of absence." She often stops in the middle of a sentence or an act, stares fixedly, and not infrequently makes remarks having no connection to the previous conversation, or hides aAvay articles near at hand ; in a few seconds she is able to finish the sentence or proceed Avith her work wholly unconscious of the interruption. These seizures occur at irregular intervals, but are gradually becoming more fre- quent, and have lately been attended with more or less twitching of the facial muscles. To give an instance: At the close of services on the previous Sunday, she experienced a seizure just as the parson's Avife, Mrs. A., spoke to her. Mrs. B. shook hands, and remarked, "By high heaven, it shall not be done, I Avarn you." She passed half the length of the church aisle before she recovered. Then, after salut- ing some friends, she turned again to Mrs. A., shook hands cordially, expressed pleasure at meeting her, and engaged in conversation, Avithout knowledge of her actions but a few minutes before. Aside from a greater irritability and sus- piciousness, her friends, as yet, can detect no mental irregu- larity, except such as is connected Avith her seizures. I could adduce several cases confirmatory of the above propo- sition, coming under my notice in the Asylum, but prefer to offer the above examples, because the sanity of the parties was not questioned. Dr. Pritchard and others hold that freedom from epileptic * London Lancet, March 18, 1871. Ohio State Medical Society. 37 symptoms for a considerable period renders the individual amenable to the law. We have endeavored to show that one of the chief characteristics of epileptic disease is its periodical and sudden recurrence; the remissions may be well marked and may continue for a long period, and yet all of the phenomena may reappear with accumulated sever- ity on the slightest cause. Dr. Burgess* says upon this point: " Insanity being in the system, as in epilepsy, either fully developed or in a state of incubation, the paroxysmal madness is liable to commence or to return at any moment, and it is difficult to say when a lucid interA7al exists, when it is gone, and Avhen it will return." Dr. Burrows f relates the case of a quiet, sober and indus- trious tradesman, subject to fits of epilepsy. He was sitting calmly reading his Bible, when a female neighbor came for some milk. He looked Avildly at her, seized a knife, and at- tacked her, and then his Avife and daughter. Their cries brought assistance, and he Avas secured before he had inflicted any fatal wound. After the paroxysm ended he had no re- collection of his acts. A year before, he had experienced a slight attack; nine years haA^e since elapsed, without a re- currence of epilepsy, or disturbance of his mental faculties. The strongest reason for the non-association of the crime and fit in casting up the prisoner's responsibility, is the fre- quency with which the furor or madness replaces the fit, constituting the different grades of masked epilepsy. We have already referred to this in different connections, and it is unnecessary to multiply examples; suffice it to say, that no fact in psychological medicine is better established than that the mental phenomena do, at times, replace the convul- sions. The attack is characterized in most cases by uncon- sciousness, in others, by an entire forgetfulness of the act afterwards, yet these are not essential, as in the case of the * Op. cit., p. 105. f On Insanity, p. 156. 3S Relations of Epilepsy to Insanity and Jurisprudence. epileptic avIio in one paroxysm murdered several persons suc- cessively as he met them on the road, and had afterwards a perfect remembrance of each murder. Noav since the existence of these cases is undoubted, Avhy should the laAV not recognize them? Because they seem sane just before and after the commission of the act, and are then abundantly able to judge between right and Avrong, proves absolutely nothing. The ungovernable impulses are the outgrowth of a morbid condition of the nerve element very like the fit, and the convulsive impulses of the brain are as much removed from the control of the individual as are the convulsive movements of the limbs. It would certainly be as reasonable to hang a man for not keeping his limbs quiet, as to hang him for not keeping his brain quiet. The epi- leptic furor is not reasoning, it does not, as a rule, recognize right or wrong during the paroxysm: there is little room for doubt but that the criterion of responsibility set up by the courts is founded in error and results in great injustice to this unfortunate class. Dr. H. Tukc, at a meeting of English lawyers in 1865, called to consider the justice of capital punishment, said that fifty-four asylum physicians had combined to combat the doctrine that the legal responsibility of the insane de- pends upon their knowledge of right and wrong. They agreed that " the belief in the responsibility of the insane based on their appreciation of the right and Avrong, is irre- concilable with facts known to all alienists, because it is clear that this appreciation often exists in individuals AA7hose in- sanity is undoubted, and it is even observed together with insane ideas and those of a dangerous and impulsive char- acter." The German and French Alienists have almost universally expressed a similar opinion. It is not alone the ability to decide ;between the right and wrong, but the poAver to do the right and abjure the wrong, that should determine one's responsibility. Inasmuch as the Ohio State 3Iedical Society. 39 cases are few in which the courts have ruled the irresponsi- bility of epileptics in the absence of the fit, those cases, of which many are recorded, in which suicidal and homicidal impulses have been felt, but through physical restraint or by the exercise of great will poAver have been overcome, are deserving of careful study. They are entitled to greater credence, because the same urgency for deception does not exist as when the individual is arraigned as a criminal be- fore the judiciary. Esquirol quotes the following: A peasant, set. 27, had been subject to epilepsy since his eighth year. For tAvo years the disease changed, became masked, and instead of the convulsions from which he had previously suffered, he was periodically seized with an almost irresistible desire to mur- der. He could foretell a paroxysm for hours, and sometimes for days before its invasion. From the moment of this pre- sentment, he earnestly demanded to be tied or chained, in order to be prevented from the commission of crime, the moral nature of which he perfectly appreciated. He would suddenly shriek out, "Save yourself, mother, or I shall choke you." When bound, he made frightful grimaces, sang, &c. The paroxysm usually subsided in a clay or two, Avhen he would ask to be released and be thankful that he had in- jured no one. Dr. Echeverria* relates the folloAving case: A Avoman subject to grand and petit mal, has slight attacks of vertigo during the day, preceded by a vision of a sudden dash of fire. Her memory has failed, and she complains of feeling insane without a will. She has at times blind impulses to strike her child, and being unable to resist them, her mother has been obliged to take the child aAvay from her. That form of disease knoAvn as Mania Transitoria, and which has been the cause of so much bitter discussion among alienists and jurists, is probably in a large number of cases * Op. cit., p. 370. 40 Relations of Epilepsy to Insanity and Jurisprudence. a manifestation of epileptic disease. If the history of those cases usually quoted as examples of transitory mania, be traced, quite a number will be found to present evidence of epilepsy. The modern view that muscular contraction is not essential to epilepsy, but that a momentary loss of con- sciousness may be the only sign of an attack, enables us to better appreciate these cases. We have already shoAvn that the mental phenomena are not in proportion to the violence of the muscular seizures, but on the contrary may often bear the very opposite relation to each other. We do not affirm that all cases of transitory fury are epileptic. It must of course be borne in mind that all forms of nervous disease are more or less paroxysmal, and that hereditary insanity in particular is especially liable to explosiATe actions similar to those that characterize epileptic insanity. The increased susceptibility by which internal and exter- nal impressions become altered and transformed in the pas- sage to the sensorium deserves notice. In the peculiar tem- perament which epilepsy begets, an act, word, excess in liv- ing, or any irregularity which Avould scarcely disturb the equilibrium of a healthy organism, taken in connection with the terrible hallucinations and illusions which the epileptic experiences, and which the diseased sensory ganglia may connect with surrounding persons and things, are sufficient to instigate him to the most cruel and violent acts. If nothing more, the knowledge of this fact should extenuate the punishment meted out to his crimes. These facts almost lead us to adopt the sweeping conclu- sion of Trousseau: That when a man commits a murder on a sudden impulse and without motive, if that man has not previously shown symptoms of madness, and if he were not in a state of intoxication, his action should almost alvvTays be explained by the existence of epilepsy. Dr. Maudsley* says: "Whenever a murder has been * Body and Mind, p. 72. Ohio State Medical Society. 41 committed suddenly, Avithout premeditation, without malice, without motive, openly and in a way quite different from the way in which murders are commonly done, we ought to look carefully for evidence of previous epilepsy, and should there have been no epileptic fits, for evidence of an aura epileptica and other symptoms allied to epilepsy." Epileptics, in addition to their pathological infirmities, are subject to all the other infirmities of our common humanity, and hence may be guilty of misdemeanors and crimes inde- pendently of their disease. Whether any special misdeed or exhibition of anger is the result of criminal passion, or the outgrowth of disease, bearing constantly in mind the liability of these paroxysms to attend epilepsy, must be decided upon the data for deciding upon insane acts in general: i. e., the relation the parties sustained to each other; the character of the crime; the manner and place and time of its execution; the conduct just before and after its commission, &c. When we remember that epilepsy, if not leading to un- doubted insanity, brings about, in its very inception, a change in the social, moral and intellectual life of the in- dividual; that the Avill power is sapped and the individual is to a greater or less degree governed by morbid impulses : when wre recall the sudden and transient nature of the ma- niacal attacks, and the liability of homicidal acts to attend them; especially when we consider that the criminal act may replace the convulsion, and that apparent sanity may exist just before and after its commission, we are impressed .with the necessity of great care in passing upon the legal respon- sibilities of this class of society. Jurisprudence has, hoAveArer, a two-fold object: the protec- tion of society as well as the protection of the criminal. The existence of epilepsy established, it is probably going too far to excuse the party from all responsibility, but it cer- tainly should be held to have this effect until the contrary is proven, until it be shown that the criminal act was not the 42 Relations of Epilepsy to Insanity and Jurisprudence. offspring of the disease. Society rightfully asks that it be protected from a recurrence of the crime. Humanity, with an equal right, asks that if the crime is the result of disease the prisoner shall be spared the disgrace of punishment. An asylum is, beyond question, the proper place for the large majority of epileptic criminals. We would also recommend this disposition in those doubtful cases which so perplex ex- pert and judge, since in these cases, a careful Avatch, often- times for a considerable period, is the only Avay to mete out justice. If it should appear that the disease is not father of the crime, the ends of justice Avould not suffer by the delay. It is not the SAviftness of punishment, Avhieh often savors of revenge, but the certainty Avith which the offender receives his just rewards, that deters criminals and upholds the maj- esty of the law. In conclusion, permit me to urge upon this Society, so noted for its appreciation of all public charities, the claims which this unfortunate class have upon us, and to ask you to second the recommendation of the Board of State Chari- ties for the establishment of a special hospital for epileptics. The necessity of such an institution is seen in the present deplorable condition of the epileptics in the jails and infirm- aries of the several counties. The number of this class at present in asylums, jails and infirmaries is about five hun- dred. Of this number, three hundred and fifty are in the jails and infirmaries, of whom, according to the last annual report of the Board of State Charities, fourteen are in close confinement, tAvo are chained, and eight are quite filthy. I have no means of estimating the number of epileptics in their homes throughout the State, but from the frequent ap- plication made here for the admission of insane epileptics, I , infer the number is not inconsiderable. Another object gained by such an institution would be the relief afforded to our overcrowded insane hospitals. Even when the asylums now in process of enlargement and con- Ohio State Medical Society. 43 struction are ready for occupancy, they will be insufficient to accommodate the insane, exclusive of the epileptic insane. Every one will readily recognize the impropriety of re- ceiving epileptics into the insane asylums: First, Because the restlessness of thought and action in mania proves a con- tinual source of irritation to morose epileptics. Second, Be- cause of the deleterious effect upon an already disturbed mind, or one just struggling back to health of witnessing the frightful appearance and apparent suffering of one con- vulsed. In an institution designed expressly for this class, some modifications could be made in the present plan of hospital construction, so as to better meet their special Avants. The suddenness of an epileptic seizure and the fall which attends it, render some provision necessary against accidental injury to themselves. Still more, epileptics, except in very rare cases, should sleep alone. The associated dormitories so common and so commendable in our insane asylums, are un- fitted for epileptics. No fitter commentary can be made than to cite you to the sad case that occurred in the Lawrence County Infirmary.* Two epileptics, both subject to night attacks, Avere crowd- ed into the same room and bed. " One morning the young- er of the two Avas found strangled to death." The old man is now serving his life sentence in the penitentiary. * Rep. Board of Charities, 1869. V BRARV OF MEDICINE '■ £_ CC . > C CCct c cc : ^ £c ^c •«2«C C C C^ c « «C c c c .. v. C C f <*- «E^C C C C •. v. «r ct <"<- «.ff«r <: <~ c c < : cc