Part 24

Of course, even in severer forms of epilepsy, mental disturbances do not appear at once. It sometimes takes many years for the constantly recurring manifestation of explosive nerve force to produce the deterioration that gives rise to lowered rationality. Distinct mental deterioration is eventually inevitable, though modern experience with epileptic colonies, in which patients are enabled to live a quiet life, most of it in the open air and under conditions of nutrition and restfulness especially favourable for their physical well-being, shows that the development of insanity may be put off almost indefinitely.

There are many advertised cures for epilepsy. None of them is successful, and all of them may do harm. The bromides have a distinct effect in lessening the number and frequency of seizures, but if taken to excess they have a serious depressing effect upon the patient. There have been more cases of mental disturbance among epileptics, and intellectual degeneration sets in earlier, since the introduction of the bromides, than before. It is the abuse of the drug, however, not its use, that does harm. More important than any drug is the care of the patient's general health. The digestion must be kept without derangement; the bowels made regular; all sources of worry and emotional strain must be removed. Patients should as far as possible live in the country, and farm life has been found especially suitable. Relatives are often a source of irritation rather than consolation to these patients, and the life in epileptic colonies has been found eminently helpful.

JAMES J. WALSH.

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XXIII

PSYCHIC EPILEPSY AND SECONDARY PERSONALITY

One of the most interesting phases of epilepsy is the type of the disease in which, without any significant motor symptoms, psychical manifestations prevail very markedly. A special manifestation in this affection is the occurrence of a more or less complete assertion of what is called a secondary personality. Apparently the individual becomes so divided in the use of the mental faculties that there are two states of consciousness. In one of these the patient knows and remembers all the ordinary acts of life, the other carries the record of only such actions as are done in a peculiarly morbid psychic or epileptic condition. It is rather easy to understand that this strange state of affairs may readily give rise to even serious complications as regards the individual's relations to others, and may make the problem of responsibility for apparently criminal acts that have been performed very difficult of solution. Undoubtedly, however, this set of phenomena constitutes a form of mental alienation that must be reckoned with in many more cases than might be thought possible. The difficulties that may have to be encountered in the proper appreciation of the actions of such individuals is best illustrated by some cases.

At a recent meeting of the New York State Medical Association a case was reported that shows how extremely difficult it may be to judge of responsibility under these pathological circumstances. The patient, a young man of about twenty-two, was the son of parents themselves of marked nervous heredity, signs of which appeared in other members of his generation. While in attendance at a public academy he had been quite severely maltreated during the {260} course of an initiation into a secret society of the students--the more or less familiar processes known as hazing being employed. As a result of this he had suffered from an attack of unconsciousness that lasted for several hours. No other symptoms, however, or sequelae, appeared for nearly a year. Then, while boarding with his sister, he became morose and difficult to get along with. He quarrelled with his sister several times and generally their relations were rather strained. He came home one evening very late to supper, and because things were not to suit him on the table, he grew violently angry. He went upstairs to his room in this morose state and, procuring a revolver, after a short time came down and shot at his sister.

Fortunately he missed her. He at once left the house but was followed by his brother-in-law, and, after he began to run away, by others whose attention had been attracted by the shot. He left the country road and ran across the fields. He was found at the foot of a rather high stone wall in a state of unconsciousness. From this unconsciousness he did not recover until the next morning. In the meantime he had been brought home and put to bed. The next morning he claimed that he had absolutely no remembrance of anything that happened after he became angry at the table because of his supper. The family made no further difficulty about the matter, and, as nothing serious had resulted, the boy went home to live with his father on a farm and seemed to grow much more equable in temper.

One day, when very tired and out of sorts because things had not been going as he wanted them to, he was asked to clear a potato patch of potato bugs by spreading Paris green over it. Some hours later he was found in the field suffering from severe pains in the stomach and with evident signs of having swallowed some of the poison. A doctor was called, an emetic was given and he purged, and after a time he recovered from the symptoms of poisoning. He claimed that he had no recollection of what he had done, nor did he know how he came to take the poison. After this he begged the family to watch over him carefully and not to let him be alone at times when they recognised that he was somewhat {261} morose in temper. He was not melancholic in the sense that he wanted to commit suicide, but something seemed to come over him in spells, and while in a state of mind of which he had no recollection afterwards, he performed actions that seemed voluntary and yet were not.

He did not have very good health on the farm, and so he was advised to try the effect of life at sea. A position as assistant steward was obtained for him on a coastwise vessel. In this position he gained rapidly in weight and seemed to have excellent health. All tendencies to moroseness of disposition disappeared. After a time he was promoted to a stewardship and later became the purser of a rather important vessel. He has given excellent satisfaction and feels in every way that he is in a much more balanced condition than ever before.

He still insists that he remembers nothing of how the two almost fatal incidents in his life came about. All his family are convinced that it was not a responsible state of mind that led him to attempt either of the crimes. It seems not improbable that this is one of those fortunately rare cases in which an attack of psychic epilepsy sometimes obliterates for a moment the individuality of a patient. At times these attacks last much longer, and the change to a secondary personality may represent a rather long interval. A number of cases of what are called ambulatory epilepsy have been brought to the attention of the general public of late years because of certain interesting features of the cases that have been exploited in the daily press.

Patients suffering from this form of nervous disease may wander from their homes, and while performing automatically a number of actions, such as buying tickets, travelling on cars and railroad trains, or even arranging the details of their journey for a long distance, may yet be in a state of mind that is not their ordinary consciousness. Men may leave home under the circumstances and find themselves after months in a strange town where they have established themselves in some quite different occupation from that to which they were formerly accustomed, or for which their early training fitted them. There seems to be an absolute division between the {262} states of consciousness that rule the individual during the intervals of ordinary and extraordinary personality. There are, of course, many reasons for thinking that at times such a change of personality might be feigned; but many of the cases have been followed with too much care to allow this thought to serve as an explanation for all of them.

A case which serves to bring home very clearly the possibility of such a state of mind giving rise to serious complications is the following: The patient was a young man in attendance at the medical school of a university in a foreign city. He had been very careless in money matters, and had aroused family suspicion that even the money sent him for tuition was being used extravagantly. A friend of the family came to see him unexpectedly in order to assure himself how the boy was actually getting along. The boy's accounts were in a very disordered condition; he had not bought the books for which he pretended to want money; he had not paid his tuition. He realised that all this would come out as soon as the university authorities were consulted. Very naturally he was in an extremely perturbed state of mind.

While on the way to the university with this friend they passed a corner pharmacy, and the young man asked to be allowed to step in for a moment for a remedy for headache. The friend waited on the sidewalk for him, and when, after some minutes, the young man did not come out he went in to inquire for him, and found that after purchasing a headache powder the young man had gone out by a side door. For three days nothing was heard from him. Then a telegram announced that he was in a hospital in a distant city and that he had been picked up on the street unconscious. When he came to in the hospital he had no idea where he was, and, according to his own story, no recollection of how he got to the distant city.

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

In these cases it is usual for the so-called secondary personality to assert itself at moments of intense excitement, especially if they have been preceded by days of worry and fatigue and nights of disturbed rest. The secondary personality is not a complete personality, but is a manifestation of the original ego with the memory for past events as a _tabula rasa_. It is well known that the memory is one of the intellectual faculties most dependent on physical conditions. It is the lowest in the scale of mental qualities and is shared to a very large degree by the animals. Injuries to the head not infrequently produce lacunae in the memory. These lacunae often have very striking limitations. It is not an unusual thing to find that old people remember events of their very early childhood better than things that have happened within a few years. Still more interesting is the fact that languages learned in youth may continue to be easily used, when those that were learned later in life, though perhaps known better than the previously studied languages, are forgotten.

It has often been noted that people who suffer from apoplexy may have peculiar affections of their memory. This may include such striking peculiarities as the forgetting of the uses of things, though their names are retained, or more commonly, the forgetting of names while the knowledge of uses remains. The one form of memory disturbance is called "Word Amnesia;" the other is called "Apraxia." It is on {264} record that a person suffering from a hemorrhage in the brain has lost completely the use of a language acquired later in life, though the memory of the native language, long since fallen into disuse, was perfectly retained. One apoplectic woman patient who had left Germany before she was ten years of age, and who had lived in America until she was fifty, forgot absolutely the English she knew so well and had to set herself to work to learn it over again, though her German came back to her very naturally. These are wonderful peculiarities of memory-pathology that show how much this faculty is dependent on the physical basis of mind and upon the cellular constituents of the brain.

It is not surprising, then, to find that lapses of memory may occur and that, as a consequence, so many of the facts that ordinarily enable us to identify ourselves as particular persons may be in abeyance. That apparently a secondary personality asserts itself,--though not in the sense that there is ever another ego present, another mind or another will,--practically all experts in psychology and nervous diseases are now ready to concede. There are, however, involved in this question a number of important problems of responsibility that have not as yet been entirely worked out, and with regard to which prudent persons are withholding their judgment. Each case must be studied entirely on its own merits, with a leaning in favour of the criminal or patient, in case there are evidences in past life of serious disturbances of mentality, though only of very temporary nature, or if there is a strong nervous or mental heredity.

The notion of the possibility of a secondary personality asserting itself is a much older idea than it is usually thought to be. When Stevenson wrote _Dr. Jekyll and Mr. Hyde_, the immediate widespread popularity of the book was not due to recent psychological studies on dual personality and popular interest in a rare but striking mental phenomenon, but rather to the traditional feeling, long existent, of the possibility of two personalities in almost any individual. The other law in his members, of which St. Paul speaks, is an expression of this feeling, and its recognition was not original with him since it is after all a phenomenon at least as old {265} as the existence of conscience. It is one of the basic ideas in religious feeling. Nearly everyone has something of the consciousness that there is in him possibilities for evil that somehow he escapes, and yet the escape is not entirely due to his own will power. There is here the mystery of temptation, of free will and of grace as the drama of conscience works itself out in every human being. At times the evil inclination seems to get beyond the power of the will and a period of irresponsibility sets in. Needless to say, the adjudication of how much may be due to the habitual neglect of repression of lower instincts is extremely difficult, and this constitutes the problem which the alienist must try to solve. In the meantime there is need in many mysterious cases where secondary personality may play a rôle, of the exercise of a larger Christian charity than that hitherto practised. Pretenders may succeed in deceiving only too often, but in the past not a few innocent individuals have been held to a responsibility for actions for which they were not quite accountable.

JAMES J. WALSH.

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XXIV

IMPULSE AND RESPONSIBILITY

Not unlike that condition which develops as the result of so-called psychic epilepsy, in which patients perform apparently voluntary acts, while the mind is really clouded by an epileptic attack, are those states in which, as the result of a more or less blind impulse, acts are performed for which the responsibility of the individual is at least dubious. Modern experts in nervous and mental diseases have sometimes spoken of these states as obsessions. This term is adopted from the older writers on mysticism who used it to designate states of mind in which an individual was under the influence of some spirit, though his intellectual and volitional state was not as completely under the subjection of this spirit as in the condition of possession.

It seems clear to the modern student of these obscure conditions that the old mystics and the modern alienists practically talk about the same state of affairs when using this term. As the result of obsession, mystical writers would have conceded that responsibility is not quite complete, though it is not entirely done away with. The modern alienist is just as sure of the diminution of responsibility, though he considers it due to the fact that for some physical reason the will is not able to act or prevent action as it is under normal conditions. The will is sometimes spoken of by certain of these modern psychologists as mainly an inhibitory faculty, that is, a faculty which prevents certain reflex acts from taking place, though permitting one set of reflexes to have its way. Under the influence of an obsession or, as the French call it, _une idée obsédante_, this inhibition is not {267} exercised and as a result an action is accomplished which the agent may very shortly afterwards regret exceedingly.

There is no doubt that impulsions or impulsive ideas may push an individual into the performance of an action which his reason condemns. Uncontrollable anger is a well recognised example of this. Impulses of other kinds may exercise just as tyrannic a sway, though it is harder to recognise the elements that make up the mental condition in other cases. Of course it may well be said that man must control his impulses. It is, however, just such impulses as can not be controlled that lessen responsibility and sometimes seem entirely to destroy it. It would, without doubt, be very easy to advance the uncontrollable impulse as an excuse for many criminal actions. In fact, the discussion of responsibility and its limitation by impulse would seem to be open to so many abuses as to make it advisable, in the present indefinite state of our knowledge, to put the subject aside entirely. The argument, however, from the abuse of the thing, does not hold, and an effort must be made to get at the truth concerning certain mental conditions which modify responsibility.

It is generally conceded that no two men are free in quite the same way with regard to the actions which they may or may not perform. Allurements that are almost compelling for some individuals, for others have no influence at all. Some men are so under the influence of anger that irritation may easily lead them to the commission of acts for which they will be subsequently supremely sorry. This may even be the case to such an extent as to endanger their lives, yet they are not able to control themselves. Many men suffering from degeneration of the arteries of the heart have been warned, like John Hunter more than a century ago, of the extreme danger of a fit of anger, yet, like John Hunter, have succumbed to bursts of anger, notwithstanding the warning, because someone irritated them beyond their rather limited powers of endurance.

It is extremely difficult ever to come to any proper appreciation of the responsibility of a given individual from a {268} single act. Preceding acts, however, may very well give evidence of the state of mind and the tendencies to disequilibrium which may make an apparently normal individual irresponsible under trying circumstances. The only way to render this clear is to illustrate such conditions by a concrete case.

Not many years ago one of the large cities of this country was shocked, for one twenty-four hours at least, by the news that a business man had shot his partners and himself, while at a consultation in which the affairs of the partnership were being settled up, after legal dissolution had taken place. The man in question had paid some debts of the firm with his own personal checks, and without taking proper legal recognisance for the moneys paid. When the partnership had been dissolved his partners insisted that instead of obtaining credit for these payments he should, on the contrary, pay his share of these debts once more as a partner. The state of the evidence was such that his lawyers told him it would be useless to take the case before the court at all; there was nothing to do but pay the unjust demands. He went to the meeting of his partners with a certified check for the amount of their claims in his pocket. As he took out his pocket-book to pass it over to them he seems to have realised very poignantly the fact that he was paying money that he knew he did not owe, and that his partners knew he did not owe, and that they were evidently taking advantage of a legal quibble in order to cheat him. Evidently it was an extremely trying situation. It was too much for his mental balance and he took a revolver from his pocket, shot both his partners dead, and then shot himself.

Taken by itself it is extremely difficult to say anything about the responsibility of a man who commits an act like this. In ordinary life he was known as a clever business man; to his friends he was known to be rather irascible and impatient, but a fairly good fellow. He was known to have what is called an awful temper; he had, however, never committed any violent act before. It is possible, of course, that a man should give way to a fit of anger for the beginning of which he is responsible, and then do violence {269} much greater than he would justify himself for in calmer moments.

There was another occurrence in the man's life that seemed to throw informing light on his mental condition. When he first came to live in the large city in which he died he began paying attention to a young woman, and the young woman was informed by a friend that he probably had a wife living. The young woman investigated this by putting the question directly to him. He denied it at once, wanted to know the name of her informant, and finally laughed the whole matter out of her mind. Within a week after his marriage to her, while on their wedding tour, he was arrested, charged with bigamy at the instance of his first wife, and it became evident at once that the charge was well substantiated.

Here is a man, then, who twice at least in life, when put in the presence of trying conditions, goes on to do the irretrievable, though the act is eminently irrational.

With regard to the murder and suicide it is said that he had talked to friends of shooting the scoundrels who were cheating him, but had been persuaded of the utter foolishness of any such idea. He had apparently given it up entirely. Notwithstanding this, he went to the last conference with his former partners with a loaded revolver, as well as the certified check for the amount of their claim. In the case of his bigamous marriage, notwithstanding the warning that his second fiancee's questions must have been, he followed out his preconceived idea of marrying her, though he must have realised in saner moments that discovery of his double dealing was inevitable. In a word, he was a man who, becoming dominated by an idea, an obsession it may be called, to do something, could not get away from the sphere of its influence even though it might be made very clear to him it was eminently irrational to follow out the idea.