Part 23

[Footnote 5: Nervous and Mental Diseases. Church and Peterson, 4th edition. Saunders, Phila., Pa., 1903.]

"From the beginning, and often for a long period antecedent to the appearance of cardiac symptoms, the subjects of Graves' disease present a considerable mental erethism. There is an indefinable and tormenting agitation, marked by mental and motor restlessness and an imperative and impulsive tendency to be doing. Their emotions are too readily excited, and they are unusually impressionable and irritable, reacting in an exaggerated manner to all the incidents of daily life. In more pronounced cases they become voluble and manifest the greatest mobility of ideas, but have no persistent concentration of logical order. Their affections are likely to undergo modifications, and they become irascible, fault-finding, inconsiderate, ungrateful, and hard to live with. In some instances this disturbance of mentation carries them over the border into active mania, marked, perchance, by delusions of fear, due to the cardiac symptoms of sensations of heat. Insomnia is often added and the fitful sleep is disturbed by horrifying dreams that are likely to be projected into the waking moments and woven into delusions which are usually unsystematised, and constantly changing, furnishing the analogue of the motor restlessness. Hallucinations of sight and hearing are not uncommon.

"The mental perturbance only rarely reaches the degree of actual mania, and then is, perhaps, equally dependent upon numerous other causes acting in a neurotic individual. But {248} a condition of abnormal mental stimulation is characteristic of the malady, and is as important an index as any of the cardinal triad." [Footnote 6]

[Footnote 6: Of physical symptoms, namely, the rapid heart, the prominent eyes, and the enlargement of the thyroid gland in the neck.]

Dr. Church considers, then, that the mental symptoms of the disease are as important a concomitant, and as little likely to be absent in any given case, as are any of the three or four well-known physical symptoms characteristic of the disease. Under these circumstances the necessity for the exercise of care in permitting such a patient to continue in the office of Superior must be manifest. It is a question not for religious authorities to decide but for physicians, and they are to be experts in mental diseases. There are many physicians who have had experience with cases in which Graves' disease has been a source of unfortunate conditions in religious life, owing to the failure to understand the relations of the physical affection to mental disturbances. At times unfortunate consequences follow that are irretrievable in the destruction of vocations and the impairment of the religious spirit in communities.

As a rule it may be said that the development of serious disease is almost sure to incapacitate a Superior from fulfilling the functions of office. This is true, however, not only for physical disease but for the so-called neuroses. These are maladies which have their basis in some disturbance of the physical constitution, though this is not always easy to find. We prefer to speak of them as neuroses rather than neurasthenia, because this latter name has somehow come to have an unwelcome sound and to carry with it the idea of imaginary rather than real ailments. A true neurasthenic, however, is supremely to be pitied.

It has often been noticed that such individuals, while perfectly capable of judging properly for others, are not able to form right judgments with regard to their own conditions. This principle, however, should not be taken as a rule, and it must not be forgotten that neurasthenics are often the subjects of compulsory ideas--so-called obsessions, in which they are not entirely responsible for actions performed. At such {249} times they are prone to be irritated by very trivial faults, and what is worse, to exaggerate slight defects into serious infractions of rule or of obedience. With regard to such persons, therefore, constant care has to be exercised to control their statements by those of others and not to take them at their full value without due substantiation. In this matter the subject is quite as likely to suffer as the Superior, and information obtained from them should not be acted upon without consultation with others who know the details of the case.

As a rule neurasthenic individuals become, as is well known, worse as far as the mental condition is concerned when they are asked to assume new responsibilities. This physical side of the choice of Superiors, and of those to be elected by members of the community, should always receive due attention, though sometimes it is entirely lost sight of. Not a few communities, however, have suffered in their usefulness and in the fulfilment of the design of their institute by the selection of Superiors whose neurotic conditions sometimes seemed to proclaim a high degree of piety, which was, however, rather emotional than practical. The physician's view of some of these cases would add materially to the knowledge of the character of such individuals.

It should in general be very clear that the development of any serious nervous disease, which is not likely to be cured by ordinary remedies or which requires freedom from responsibility as the first requisite for improvement, should be the signal for consideration as to a change of Superiors. Physicians see much more of the evil that may be worked in this way, and realise the true significance of what is often a sad state of affairs, much better than those who have not the secret of the cause of the unfortunate condition. It is almost needless to say that the question of obedience to some one whose responsibility is not complete, but is influenced by neurotic disturbance, becomes an extremely difficult problem for the subject, and one in which there is apt to be the feeling that it was not the original intention of his obligation of obedience to bind him under such circumstances.

With regard to women especially, it must be remembered that there is for them a period between the ages of forty {250} and fifty, during which for several years they are extremely unsuited for the responsibilities and exacting duties of a Superior. These years prove even to mothers of families, surrounded only by their own children and the ordinary circumstances of home life, a time of worry and irritation that plays sad havoc even with the best of dispositions. Mothers constantly complain to their physicians of an irritability of temper which they can scarcely account for, and which makes them do and say things which they are extremely sorry for afterwards. It is easy to understand, then, that a Superior with still more insistent duties when brought in contact with a number of persons, some of whom are almost sure not to be entirely sympathetic, is likely to suffer from irritation that is not a sign of absence of a fitting religious disposition, but only a physical manifestation of the physical strain through which she has to pass at this time of life. The years of the menopause, to be very plain, should not be allowed to make a Superior's life miserable and to add to the difficulties that a religious community always has to face in its relations to its Superior and to one another. Charcot, the distinguished French neurologist, used to say that women should never be asked to assume special responsibilities during the days of their monthly period, for their judgments are often warped by their physical condition. It is doubtful whether, in the majority of normal women, this is quite true, though the expression deserves to be remembered. There is no doubt, however, that the years of the change of life do bring on very serious modifications of the character of the individual, and occasionally these changes are lasting.

JAMES J. WALSH.

{251}

XXII

EPILEPSY AND RESPONSIBILITY

From the very earliest times epilepsy has been looked upon as a mysterious and in many ways an inexplicable disease. The Romans spoke of it as the _malum comitiale_, the comitial disease, because if an attack of it occurred during the meeting of the Roman people known as the _comitia_, in which municipal officers were elected and other city business transacted, an adjournment was at once moved, and no further proceedings were considered valid. During more modern times, especially during the middle ages, and almost down to our own time, those affected by the disease frequently came to be looked upon as the subjects of possession by the devil. Hysterical manifestations were even more frequently considered signs of possession (diabolical manifestations) but even in our time it is not always easy to make the distinction between certain forms of hysteria and epilepsy. Many of these sufferers were considered as not responsible for their actions. In this respect, at least, the advance of modern medical science has only served to confirm the popular impression of less sophisticated times, and it has come to be recognised that quite a large number of the sufferers from epilepsy must be deemed lacking in responsibility.

There are few nervous diseases that have been more studied than epilepsy, and yet, because the ailment involves so intimately the relations of the nervous system and the bodily function, there are few diseases of which less definite opinions can be given. This is especially true as regards prognosis and the question of mental deterioration in any given case. As a matter of fact the extension of our knowledge of epilepsy, far from making the question of the responsibility of the {252} epileptic under trying circumstances more easy of solution, has rather served to show how difficult this problem must ever remain.

There are many forms of the disease,--the frank epileptic convulsion in which patients fall down, are seized with certain convulsive movements, become pale and lose consciousness for a time and then come to with an intense feeling of weariness which usually prompts them to sleep for some hours--too familiar to need further description. There are forms of epilepsy, however, quite different from these. In some cases, the attacks occur only at night, and unless the patient happens to be watched for some reason, there may be no trace of their occurrence, except perhaps a sore tongue where it has been bitten, or an intense feeling of weariness and depression in the morning. In still other cases, the physical signs are lacking almost entirely. There may be only a momentary loss of consciousness. A distinguished professor of medicine in this country used to have a momentary attack of confusion, during which he lost the thread of his discourse, and always within a minute, with a somewhat flushed face, he was able to go on, though he had to begin with another idea. The so-called psychic epilepsy, in which the symptoms are entirely mental and consist of some marked change of disposition for a time, are now universally conceded as constituting well-marked phases of the disease. Curiously enough it is with regard to these obscure cases, uncomplicated by serious physical manifestations, that there is most mystery; and they seem to affect the mentality and to disturb volition and responsibility more than the supposedly severer forms which cause convulsive attacks and are so easy of recognition.

Certain forms of masked or psychic epilepsy constitute the most puzzling problem that the expert in nervous and mental disease has to deal with where criminal acts are performed, apparently without sufficient motive, and yet where the limits of responsibility must if possible be determined. It is easy to dismiss these cases and to consider that because a certain amount of intelligence has been displayed in the performance of the act, and because the patient ordinarily understands perfectly the distinction between good and evil. {253} that therefore the will must have been entirely free in the accomplishment of the criminal action and the intellect must have understood what it was doing. As yet the general public refuses to take the standpoint of the expert in mental diseases in many of these cases; and only when clergymen also shall come to a realisation of the pathological elements undermining free will in these cases, that justice will be properly tempered, not by unworthy or misplaced charity, but by the mercy which, knowing all, has learned duly to appreciate what is and what is not criminal.

Epilepsy, in certain of its obscurer forms, is responsible for many conditions in which there is a sudden access of insane excitement of a violent, often very impulsive, character, though sometimes of very short duration. During this state the patient is practically irresponsible, and yet he may have sufficient control over his actions to enable him to work serious harm. Such a stage of excitement may last not more than an hour or two; usually all trace of it passes off in a day or two; before and after it the patient may be in perfectly sound sense and in apparently good health. One of our best authorities here in America, Berkley, in his treatise on _Mental Diseases_, gives the following striking opinion on this subject.

"The subject of masked epilepsy and the consequent mania is replete with interest to the physician and the jurist, since such patients are prone to impulsive acts of violence and automatic states in which the most complicated, but entirely unconscious, actions and crimes may be carried out without premeditation on the part of the sufferer, being also out of all accord with his character during his intervals of mental health. Besides the irritability, impulsiveness is an equally characteristic feature. No form of insanity more frequently gives rise to assaults and murder than epilepsy, and in no form of alienation is the physician so frequently called to the witness stand to determine the responsibility of the criminal."

One of the most prominent features of all epilepsy is the well known tendency to irritability that characterises sufferers from the disease. This of itself is an index of the fact that {254} their responsibility is somewhat lessened, since they are unable to withstand even the petty annoyances of life without exaggerated reaction. Friends of epileptics know very well that it is a preliminary symptom of the coming on of an attack of epilepsy for the patients to become even more irritable than usual. Just after the comatose condition which follows an attack of epilepsy patients are also prone to be very irritable. An attack of epilepsy is really an explosion of nerve force, for no rational purpose, along motor nerves. This same tendency to an unwarranted explosion of energy is liable to occur along other nerve tracts that rule the patient's disposition.

The main symptom of importance in the case, and the one on which depends the recognition of the existence of the epileptic condition, is the actual occurrence of typical epileptic seizures. These do not always occur. Sometimes the periodic attacks take the form of what are called epileptic equivalents, that is, certain anomalous states of consciousness or disposition, which can be accounted for only on the supposition that there is some more or less latent explosion of nerve force in progress. At times even so simple a condition as migraine so nearly simulates epilepsy of the psychical type, because of its complications and sequelae and the regularity with which it occurs, that it has been spoken of as an epileptic equivalent. There is no doubt that, in successive generations, epilepsy and migraine may have a relation to one another that is something more than merely a coincidence.

A very interesting feature of epilepsy for confessors and spiritual directors is the tendency to religious emotionalism which so often accompanies what is called idiopathic epilepsy. This means epilepsy that develops without a direct cause, and which is evidently dependent on some essential defect of the nervous system of the individual. In asylums epileptics that have become irrational are known for their religious manifestations, and very often for perversion of their religious tendencies. As has been well said, an epileptic may carry his Bible under his arm, read passage after passage from the Scriptures, sing psalms continuously, and yet be so {255} ungovernable as to be a nuisance, and so irritable towards his fellow patients and attendants as to be a constant source of worriment. He may read just those passages which have reference to love and charity for one's neighbour and dwell on them until they become a bore by repetition, and yet in a moment of irritation implore to be allowed to get hold of some deadly weapon in order to kill the usually inoffensive person who has done him some imaginary injury.

This last is a marked feature of the disease, for epileptics are prone to foster fancied grudges, and to consider without due reason that they have been ill treated. This is especially true with regard to their relatives or to those in attendance on them, and must be always borne in mind when the subjects of epilepsy bring tales of woe and persecution, which they pour out to anyone who will listen to them, and especially to anyone whom they think will set them right. These fancied wrongs are as real to the patients themselves as if they had suffered from actual maltreatment. The idea of revenge may easily obtrude itself. It can be kept under control, as a rule, during ordinary health, between attacks, but just preceding or after an attack it may very well become of the imperative character that sets an uncontrollable impulse at work.

On the other hand, no class of patients is apt to exhibit the low cunning of the insane in so marked a degree as the epileptic. Not only this, but even during ordinary health between attacks they may, owing to their disposition, plan cunningly to simulate some of the symptoms of an attack and then accomplish a really malicious purpose with deliberation. In a word, these patients present to the alienist the most serious problem in the calculation of responsibility that can possibly be imagined. As an expert has declared, "It is ofttimes impossible to decide whether an assault has been committed with full consciousness, or in a transient but blind epileptic fury."

There are a series of attacks that occur in which there are some almost typical convulsive movements followed by loss of consciousness that simulate epilepsy very closely, yet are not true epilepsy. These attacks are usually due to some {256} cerebral affection or perhaps to some injury of the brain. Chronic intoxications, that is, the long continued presence in the body in noxious quantities of some poisonous substance, are especially liable to cause these attacks, which are called from their character epileptiform. Characteristic epileptiform convulsions occur as the result of lead poisoning or from alcohol or syphilis. Lead poisoning, for instance, may very well occur in others than those engaged directly in the manufacture or handling of lead. Certain persons are extremely susceptible to the influence of lead. In them such small amounts as are contained in a hair-dye, or even in water that is being used by others without any bad effect, may cause particularly the nervous symptoms of lead poisoning.

Chronic alcoholism is also a relative term in this regard. Some persons are able to stand very large amounts of alcohol without serious consequences, even though it is taken for long periods. Others succumb to its influence very rapidly; some especially susceptible people are liable to suffer from epileptiform convulsions almost whenever they take alcohol to excess. This masked epilepsy may take on an anomalous form. The story is told of a student of a Catholic college in the eastern part of this country, who, during one vacation, was given as a joke by some friends a rather strong dose of liquor in a glass of ginger ale. He was very thirsty at the time and did not notice the presence of the alcohol until he had swallowed the whole glass. As he was well aware himself he was extremely susceptible to the influence of alcohol. During the course of half an hour he became almost wildly drunk, and going down the street with an open pocket-knife he murdered the first person whom he met, who happened to be an entire stranger to him. The occurrence took place in New Jersey, and, in spite of every influence that could be brought to bear--the incident took place some thirty years ago--Jersey justice would have its way and the young fellow of less than twenty was hanged.

The epileptiform attacks that occur in the midst of these intoxications are quite as likely to be accompanied by various forms of mental disturbance as are attacks of true {257} epilepsy. Only one feature with regard to them is more favourable, and that is that the ultimate prognosis is not bad. The neutralisation of existing poison in the system, and the prevention of further ingestion of the toxic material, puts an end to the tendency to epileptiform convulsions, as a rule, and also to the mental symptoms associated with them.

Epilepsy remains, notwithstanding all the advance in modern nervous pathology, quite as mysterious a disease as it has ever been. It matters not what its cause, or how slight it may be, sooner or later it is almost sure to be followed by mental disturbance and deterioration of intellectual and will power. At times there are periodic attacks of mental perturbation that may become true insanity. Even the mild form of epilepsy known as Jacksonian epilepsy, and consisting not of general convulsive movements, but of convulsive movements in only one member or one side of the body, are, if allowed to continue, followed by some mental disturbance. It would seem as if the explosion of nerve force in the brain centres,--which, physiologically speaking, an attack of epilepsy evidently is,--causes eventual deterioration of the physical basis of mind and will, so that mental operations can no longer be performed with their wonted expertness or accuracy, nor decisions made as rationally as before.

In general, it is well understood that the more serious the epilepsy the more liability there is of the development of permanent mental disturbance. The earlier in life the epilepsy declares itself, too, the more unfavourable is the prognosis as to the enduring retention of complete mental sanity. In people in whom the epilepsy commences late in life, the process of mental deterioration does not begin to be noticeable so soon as when it occurs in younger years, and besides, it practically never runs a rapid course. Epilepsy, however, developing late in life, unless for some special cause, as injury or the development of syphilitic tumours in the brain, is an extremely rare affection. Idiopathic epilepsy, that is, epilepsy for which no definite cause can be discovered, is usually dependent on hereditary instability of the nervous system and is typically a disease of early years, of childhood {258} and adolescence. According to the best authorities, about one-fourth of the cases of epilepsy make their appearance before the age of 7 years. Over 50 per centum of all cases develop before puberty. About one-third of all the cases develop between 14 and 20. And even of the remaining, less than 20 per centum, over 12 per centum develop between 20 and 25, leaving scarcely more than 5 per centum for all the remaining years of life.