Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

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.