CHAPTER XV
THE EPILEPTIC PSYCHOSES
Ancient history contains numerous references to epilepsy. The "Morbus sacer" of the Romans was apparently a subject of great interest to Hippocrates,[325] who wrote, over two thousand years ago, "The sacred disease appears to me to be no wise more divine nor more sacred than other diseases; but has a natural cause, from which it originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like other diseases." Presumably for a somewhat similar reason the disease was also referred to as the "Morbus Sideratus," it being thought that those affected were "star struck" or smitten in some mysterious and supernatural manner. By others it has been suggested that the theory regarding the divine origin of the disease was attributable to the seizures which always preceded the prophesies of the priests of Apollo. Herodotus is responsible for the statement that Cambyses, the king of the Persians, was subject to the "sacred disease" from birth. Such historians as Hippocrates and Euripides have definitely established the status of Hercules as a confirmed epileptic. "Morbus Herculeus" was one of the earliest designations of the disease. It was referred to by Plutarch in his writings. Suetonius describes the emperor Caligula as unquestionably afflicted with epilepsy. No less an authority than Lombroso speaks of Napoleon, Molière, Julius Caesar, Petrarch, Peter the Great, Mohammed, Händel, Swift, Richelieu, Charles V. Flaubert, Dostoieffsky and St. Paul as all being victims of the same affection. Truly this is a noble assemblage,—one which might readily make the disease fashionable!
Maudsley ("Body and Mind") was convinced that Swedenborg suffered from a form of epileptic insanity. The following quotation from his diary would lend some color to that theory:—"There happened to me something very curious. I came into violent shudderings, as when Christ showed me His Divine Mercy. The one fit followed the other ten or fifteen times." After his fifty-fifth year, according to Maudsley, Swedenborg was permanently insane. The historian Sloan in his "Life of Napoleon" accepts as an established fact the statement that this great military strategist was an epileptic. Appian's "Roman History" certainly justifies Lombroso's reference to Julius Caesar: "At length, whether he lost all hope, or else for the better preservation of his health, never more afflicted with the falling sickness and sudden convulsions than when he lay idle, he resolved upon a far distant expedition against the Gatae and the Parthians." Washington Irving in speaking of some of the peculiar experiences of Mohammed suggests that, "Some of his adversaries attributed them to epilepsy." Even a very brief review of the historical aspects of this disease should perhaps not omit the contribution made by Shakespeare: "My Lord is fallen into an Epilepsie. This is his second Fit." (Othello)
Epilepsy and the mental disturbances associated with it are so intimately related that they can hardly be considered separately. Notwithstanding that fact it must be admitted that there is no sharply circumscribed clinical entity properly definable as epilepsy. Nor is there anything distinctive about the psychotic manifestations occurring during the course of that disease, although Tuke's Dictionary mentions over thirty different varieties. In the most exhaustive study of epilepsy ever made in this country Spratling[326] reported that memory defects were noted in ninety per cent of the patients examined by him. It should be borne in mind that the group studied did not include any committed mental cases. He found from eight to ten per cent so slightly affected as to be legally "sane," "except at the brief moment of attack." Fifty per cent were mentally incompetent with rational intervals and forty per cent were "continually irresponsible." This latter class included from twenty to twenty-five per cent of imbeciles and idiots and from fifteen to twenty per cent recognizable as insane "by law and medicine alike." The prevalence of mental disease in a hospital population composed exclusively of epileptics is shown by his statement that of 801 patients examined at Craig Colony forty-one could not tell their own names; 166 did not know their age; 267 could not name the year, 263 the month, and 226 the day of the week; 238 did not know where they were; 378 were unable to state the year of their birth, 183 the last place of residence, 219 the name of the institution, and 248 the length of time there; in addition to this, 224 could not write well enough to sign their own names. It is interesting to note that the disease had its onset in 38.5 per cent of his cases before the age of ten years, in 43.5 per cent between the ages of ten and twenty, and in 9.5 per cent between the ages of nineteen and twenty-nine. Gowers found that seventy-six per cent developed symptoms before the age of twenty. Spratling classified the mental conditions found in epileptics as follows:—Psychic epilepsy, epileptic automatism, pre- and postparoxysmal mental disturbances, paroxysmal states (epileptic mania), and interparoxysmal conditions. The latter included transitory ill-humor, slight dulling or clouding of the intellect, feeblemindedness, imbecility, idiocy, epileptic dementia and acute confusional insanity which he says belongs to the manic-depressive group. He warns against the danger of classifying as dementia conditions due entirely to the use of bromides.
L. Pierce Clark[327] looks upon epilepsy as the logical development of a well defined individual make-up described as the "epileptic constitution" and existing from the earliest childhood. In support of that theory he has reviewed the contributions of other writers on this subject. He found that Vogt called attention to the epileptic "poverty of ideas, prolonged reaction time, egocentricity, many religious reactions and acts of servility." Jung referred to a series of superficial associations, influencing the ideas of the patient, somewhat similar to those occurring in imbecility and sometimes observed in normal individuals of the uneducated class. Roemer speaks of a disturbance of "secondary identification" involving memory pictures with special sense recognition unimpaired. Eintinger described an essential poverty of affectivity and Wiersma, periodical variations in attentiveness. Ritterhaus defined the epileptic mental content as one of poverty of ideas, prolonged reaction time, egocentricity, emotional reactions and circumstantiality. Arndt included in the epileptic character peculiar inward fervor, characteristically egotistic in nature, and resembling the alcoholic temperament. Bianchi believed that the disease developed on a personality basis strongly suggesting the criminal type. He spoke of an inadaptability to the environment, the preponderance of individualistic instinct, cruelty, laziness, evil life, precocious and excessive development of the sexual instinct, irascibility and impulsiveness. Turner described an epileptic "temperament." He found these individuals to be egotistical, conceited, pretentious in conversation, emotionally unstable and sometimes obstinate or over-religious. Hartmann and di Gaspero noted as prodromal manifestations, abnormal changes of temper, excitability, anxious fears, sudden depressions, restlessness, irritability, distrust, memory falsifications, and violent impulses. Voisin found that less than ten per cent of epileptics showed a perfect balance in the emotional make-up. Hübner expressed the opinion that true dipsomania occurs chiefly in epileptics. He found alternations in the character of the individual in from ninety to ninety-five per cent of his cases.
Clark's[328] conclusions were summarized by him as follows:—"1. There is more or less constant affective defect in all epileptics, sane as well as insane; that such defect is due to an inherent make-up of the psyche in which mainly an egocentricity and a highly sensitized feeling are given to the individual; and that from this constitutional make-up or alteration the ultimate deterioration of the psyche, intellectually as well as emotionally, is gradually developed, step by step, and if the state is not corrected that this finally and logically ends in so-called epileptic dementia. 2. The epileptic alteration is seen to proceed from the mental make-up or constitution of the individual epileptic long before his malady reaches the convulsive stage and that the one is but a further and final unfoldment of the former." As Clark expresses it, "The nucleus of this personality defect is a temperament of extreme hypersensitiveness and egotism and all that these two main characteristics entail ... a personality defect which makes its possessor incapable of social adaptation in its best setting and which, if it remains uncorrected, renders the individual inadequate to make a normal adult life." He looks upon the epileptic reaction as a "more or less direct outcome of the epileptic's inability to stand the stress and harassments of life from which he seeks automatic or unconscious withdrawal." This exhibits itself as a loss of spontaneous interest, day-dreaming, lethargy, somnolence, etc., terminating finally in epileptiform attacks when the strain becomes too great. A rather complete description of the "epileptic character" appeared in Schüle's "Klinische Psychiatrie" in 1886.
An analysis of these mental mechanisms leads naturally to certain therapeutic indications. In view of the history of the bromide therapy, since the time of its introduction by Laycock as the ideal form of treatment in 1851, such suggestions should be given serious consideration. Clark advocates the early use of educational methods in correcting the defects of the epileptic constitution. Thus he would obtain control of the egocentricity and hypersensitiveness by reducing environmental stresses, teaching adjustment to the surroundings, and finding suitable and normal outlets for the spontaneous desires of the individual. He is of the opinion that in the apparently deteriorated cases mental interests can be restored and emotional and mental dilapidation greatly improved. He has reported a series of cases showing that the frequency and severity of seizure can be greatly influenced "with the more or less permanent arrest of the disorder in not a few cases."[329] A subsequent study of the mental mechanisms involved was summarized by Clark[330] in these words: "It is fairly obvious that the mental content in epilepsy proves that the epileptic regresses from the displeasurable difficulties of life, and in the first states of the fit the stress alone may be uncovered; whenever the patient reaches a deeper unconscious state, he gains the level of an easily recognized sexual striving."
Kraepelin[331] would differentiate between "symptomatic" forms of epilepsy due to organic diseases, injuries or growths; and the "genuine" variety not associated with any coarse brain lesion. He describes as indications of impending attacks, occurring several hours or even days before, headache, irritable ill-tempered moods, general discomfort, weakness, palpitations, oppression, anxiety, vertigo, nausea, hot and cold sensations, sense deceptions of various kinds, muscular twitching, sexual excitement, disturbed sleep, unpleasant dreams, etc. Binswanger found these symptoms present usually in the severer forms of the disease. Finkh found them in twenty-five per cent of his cases. Psychic, sensory, motor and vasomotor aura are described. Kraepelin after discussing first the paroxysmal attacks occurring in the disease speaks of the various forms of psychic epilepsy as constituting the second important group of clinical manifestations to be considered. These conditions may be looked upon as pre- or post-epileptic insanity, depending on their relation to convulsions, or may be entirely independent of them or considered as equivalents.
The most common form of psychic epilepsy he describes as periodical ill-humor. It begins sometimes with sexual excitement (Ducosté). The patient becomes moody, surly, irritable, quarrelsome, gives up his work, refuses to eat and complains of everything around him. In some cases uneasiness, gloom or depression are manifested and suicidal tendencies may develop. Consciousness is clear although the patients complain that they cannot think or are confused and forgetful. Some have headache, perspire, show dilated pupils, vasomotor disturbances, nausea, etc. The picture is often complicated by alcoholic indulgence with attacks resembling dipsomania. This sometimes results in an epileptic clouded or dream state in which the patients become blustering, abusive, and violent or make senseless journeys. They may manifest a sudden impulse to wander from place to place without any apparent reason. Sexual excitement frequently occurs, with masturbation and exhibitionism, attacks on children or homosexual tendencies. Usually there is no recollection of these episodes. Occasionally expansive or ecstatic moods appear and rarely a flight of ideas is noted. These attacks of ill-humor usually last from a few hours to several days, often disappearing suddenly. Alcoholism always lengthens the duration. In some cases active hallucinations and clouding of consciousness occur. Dreams are common. Others show anxious states with hallucinations and sometimes well marked delusions. An actual delirium may appear, although usually only for a very short time. The hallucinations and delusions may persist for months, suggesting dementia praecox.
A second large group shows a more marked clouding of consciousness. These are the characteristic twilight or dream states of epilepsy. Thought is confused, desultory, retarded or incoherent. Sometimes there is a tendency to rhyme and repeat questions, or even a genuine flight of ideas. The mood may be depressed, anxious or irritable, although ecstatic states occur. The patient may become quiet, inaccessible, stuporous or cataleptic. Some, however, become excited. Later, defects of memory occur and amnesic periods may extend over a considerable length of time. The patellar reflexes may be increased and the pupils dilated and sluggish. There may be a contraction of the field of vision or disturbance of color sense, tactile sensation, smell and taste, with muscular weakness, Babinski reflexes, speech defects, dizziness, uncertain gait, nystagmus, etc. Somnambulism is sometimes encountered in epilepsy, although it is strongly suggestive of hysteria. The great majority of cases present the picture of a simple dreamy stuporous condition. Apprehension is clouded, the patients become confused, cannot control their thoughts, mistake the persons around them, lose themselves on the street, and wander away. They destroy their clothes, undress in the street, etc. Sexual excitement, exhibitionism and masturbation are common. Characteristic dream states may appear as equivalents.