Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

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.