EPILEPTIC INSANITY. 
—BY— 
JAMES H. McBRIDE, M. D. 
Superintendent of the Milwaukee Sanitarium 
for Nervous and Mental Disease, 
at Wauwatosa, Wis. 
A Lecture Delivered at the Chicago Poliolinic 
Medical College, May, 1893. 
KEPKINT FROM THE 
REVIEW OP INSANITY AND NERVOUS DISEASE. 
FOR SEPTEMBER, 1893. EPILEPTIC INSANITY. 
BY JAMES H, McBRIDE. M, D, 
[Supt. Milwaukee Sanitarium for Nervous and Mental Disease.] 
The clinical features of Epileptic Insanity entitle it to be 
considered separately, though its manifestations arc variable 
as regards the type of disorder. In some cases we observe 
the symptoms of acute mania, in others, occasional but pro- 
nounced depression, and in others dementia. The form of 
disorder doubtless depends upon the degree of dissolution of 
the psychical centers, melancholia being the milder degree, 
mania a greater degree of dissolution, and dementia a more 
serious dissolution still, showing as it does the wreckage that 
is left by repeated storms of convulsion. 
In speaking of Epileptic Insanity, it is necessary to treat 
with some fullness epilepsy itself, for they cannot well be 
separated, the insanity being the reverse side of the epileptic 
picture. 
At the outset we naturally ask, “What is the condition of 
the nerve centers that results in the epileptic fit ?” The view 
which is generally accepted is that the fit is due to a sudden 
and violent discharge of nerve force, which discharge results 
in unconsciousness or convulsions or both. The function of 
the nerve cell is to store up and expend nerve force. In 
Lecture delivered to the students of the Chicago Policlinic, May, ’93. 2 
EPILEPTIC INSANITY. 
health this discharge is only in response to stimulous, but in 
certain diseased states the cells become morbidly unstable and 
discharge, without a stimulus, violently and suddenly. 
Twenty years or more ago, it was the fashion to consider 
arterial cerebral spasm as the proximate cause of the epileptic 
fit, but this explained nothing, not even itself, and only 
exchanged one pathological puzzle for another. The theory, 
therefore, that epilepsy is primarily a discharge of unstable 
nerve cells is, for the present at least, the most reasonable 
explanation. 
It has been said that this is a theory only and cannot be 
demonstrated, but it accounts for the phenomena and should 
be valued accordingly. We should not despise theories, for 
they are the scaffolding by the aid of which all science has 
been built and are necessary to progress. We are indebted 
to theories for much of our scientific knowledge in medicine 
and out of it, and though the theories often bear little resem- 
blance to the facts to which they have led, they have at least 
held the lantern for man while he searched. 
What is the cause of the molecular instability of cells that is 
exhibited in the phenomena of epilepsy? One view commonly 
held is that this instability is due to some perversion of nutri- 
tion through which the structure of the cells becomes faulty 
and therefore excessively unstable. In this view there is not 
necessarily, a pathological condition demonstrable by the 
microscope, but some failure in the nutritive supply Whereby 
the inhibitory power of the higher cortical centers is lost, and 
a morbid instability with involuntary discharge results. 
Dr. Bevan Lewis claims to have found in epilepsy a certain 
pathological condition which, to his view, explains the phe- 
nomena of the disease. This consists in a degeneration of 
the nucleus of the cell which he claims is a constant factor in 
epilepsy. You know that the physiologists teach that the cell 
nucleus in some way presides over the nutrition of the cell 
and also acts as an inhibitory or controlling center of the cell. 
If the nucleus is diseased, the cell fails in the performance of BY JAMES H, MCBRIDE, M. D. 
its function and degenerates. Dr. Lewis finds in epilepsy 
degeneration of the nucleus of the cortical nerve-cells and 
this so constantly that he considers that it explains the disease. 
If the nucleus is the inhibitory or controlling center of the 
cell, presiding over its vital changes and its functions, then 
when it is degenerated it is to be expected we would find per- 
version of function, shown especially in irregular, sudden and 
wasteful explosions of energy. Dr. Lewis claims also to have 
found nuclear degeneration in alcoholic insanity, a form of 
disease having many features in common with epileptic insan- 
ity, especially in its explosive nature. 
With this exception there is nothing definitely known con- 
cerning the pathology of epilepsy. The pathological condi- 
tion of the cornu ammonis found in epileptics by Meynert 
and others, has probably no significance whatever. The 
claim by others that there is a morbid over-growth of con- 
nective tissue in chronic epilepsy does not explain the patho- 
logy of the disease as the over-growth of nuroglia is probably 
a result and not a cause of the epilepsy. 
The ruinous effects of the epileptic seizures upon the finer 
structure of the brain is apparent when we consider the deli- 
cacy and fineness of the ultimate anatomical elements, and 
that beside these there are myriads of undeveloped elements, 
waiting in there embryonic state, for the call of function to 
organize their relations, and discipline their powers to deli- 
cate and complex capacity. The violent and brutal discharge 
of the epileptic convulsion not only fills up the well worn 
channels of function, but spreads out as a devastating flood of 
energy over those yet unorganized and delicate nerve tracts 
f 
destroying one by one their fine relations and thus by exhaus- 
tion and repeated disruption of structure checks further 
development of the brain. 
The arrest of growth and the degeneracy thus initiated are, 
if the fits continue, progressive and general. The disappear- 
ance of the nerve tissue proper involves, however, a patho- 
logical necessity, that of the production of some form of tissue 
3 4 
EPILEPTIC INSANITY. 
to take the place of that destroyed, antf this is the origin 
of the sclerosis in this and other chronic cerebral diseases. 
Connective tissue, of which neuroglia is a special form, is a 
lowly organized tissue having simply the passive function to 
perform of holding together the higher structures. In lower 
animal forms we find relatively more neuroglia in the central 
nervous organs; and as we ascend in the animal series it 
diminishes in proportion as the nerve elements proper 
increase; that is nature gradually learns to dispense with this 
inferior tissue and replaces it with that of higher order. It is 
thus that she is able to pack in the small box of our skulls, 
the fifty precious ounces of structure with the wonderful 
results exhibited in cerebral function. When, however, the 
highly organized tissues, like nerve cells and fibers, dis- 
appear through disease, their complex structure renders their 
reproduction impossible; and so neuroglia having simple 
structure and low organization is produced to fill the place. 
Therefore, we find in the brain of the senile, in those of the 
chronic insane, and in epilepsy there is an overgrowth of 
neuroglia because in the absence of the higher tissues it is 
supplied at a low cost of vitality. The meaning, then, of the 
morbid growth of cerebral neuroglia in epilepsy is that it is 
secondary to cell degeneracy, nature uses it to fill up the 
vacant spaces that decay has made. 
It will be interesting to consider a moment the mechanism 
of the cerebral discharge which is exhibited in epilepsy. If I 
pile a number of bricks on top of each other on this table, 
each brick will, when put in place, represent just the energy 
that I expended in lifting it, and when it falls it will give out 
just that amount of energy in the form of heat, molecular 
motion, atmospheric vibration. In lifting them I stored up 
energy, in their fall this energy was expended. Nerve cells 
are composed of molecules and atoms, the former being 
aggregations of the latter. The molecules are associated in 
twos and sixes, etc., according to the complexity of the func- 
tioning cell and their relations are subject to incessant change BY JAMES H. MCBRIDE, M. D. 
5 
to correspond with the processes of function. The invisible 
servants of vitality are ever at work within the nerve cells 
placing these tiny nerve molecules and atoms in complex 
relations and in unstable positions from the fall of which 
nerve energy is set free. That is, the vital processes, when 
they lift them into unstable positions, store up in them the 
energy expended in lifting them, and when upon an appro- 
priate stimulus they fall back as my bricks did into simpler 
compounds, they give out that stored up energy. 
This briefly and imperfectly is the mechanism of normal 
cell action and morbid action conforms to the same law. In 
epilepsy there is this same molecular disruption, a disinte- 
gration of cell structure with the result not as in health of 
orderly and purposeful discharge but of violent and disorderly 
discharge. The path of the discharge varies so that the 
phenomena of epilepsy may be either motor, sensory or 
psychical. Epilepsy then, is a morbid discharge from cells 
which, owing to some abnormal condition, are pathologically 
unstable. 
The different forms of epilepsy may be named as follows: 
Grand Mai, or the ordinary epileptic seizure. 
Petite Mai, or cerebral or ?nental epilepsy. 
Nocturnal epilepsy. 
Jacksonian epilepsy. 
Epilepsy occurs in connection with other diseases, as 
hemiplegia, syphilis or alcohol, but there is no special form 
of epileptic insanity resulting from these conditions. 
Before proceeding to describe the various epilepsies and 
their resulting mental affections I wish to speak briefly of an 
important accompaniant of epilepsy, the so-called aura epilep- 
tica. This phenomenon is not present in every case of epi- 
lepsy, though it often is. Th$ aura, as you know, is some 
sensation, or motion, or mental impression immediately pre- 
ceeding a fit and announcing its coming. In some cases, there 
is a vague or strange sensory impression, as of some one’s 
breath being blown in the face or a sudden sensation of some- 6 
EPILEPTIC INSANITY. 
thing passing up the spine or leg to the brain, or it may be a 
twitching or cramping of a muscle or a trembling of some part. 
The aura may start from any part of the body, from the skin, 
organs of sense, or from the internal organs, especially those 
supplied by the vagus nerve. It may involve the special 
sense organs or it may be purely psychical. One patient 
always saw a cat before a fit, others see balls of fire, flashes 
or various colored specks; others hear bells ring, hear roaring 
or voices; others have hallucinations of senses of smell or taste, 
the latter, however, being very rare. In some cases there 
may be a habitual combination of aura affecting two or more 
senses. One patient said to Dr. Reynolds that just before a 
fit he always had a horrible smell of green thunder, a rather 
picturesque description of the involvement of three senses. 
In some patients there is the recurrence of some emotion or 
idea at the oncoming of a fit. In one the same idea always 
occurs, in another a feeling of fright or terror. Pelops, the 
master of Galen, was the first to use the term “Aura;” his 
attention being called to it by patients who referred to a sen- 
sation of vapour passing from some part to the head. Believ- 
ing the arteries to contain air, he suggested that their sensa- 
tion was correct, the vapour passing up the vessels, and he 
called it “spirituous vapor.” Statistics show that a little 
more than fifty per cent, of epileptics have an aura. 
Of the two kinds of epilepsy most commonly met with the 
Grand Mai and the cerebral or mental epilepsy are not always 
well demarkated, there being intermediate forms between the 
two extremes; in some cases the fits partake of the character 
of both; some cases begin as one form and pass into the other 
or exhibit both. I had one case under observation in which 
the first attacks were a temporary aphasia only lasting a few 
seconds; later, there was temporary aphasia with mental con- 
fusion but no unconsciousness. A year later there was devel- 
opment of Grand Mai with disappearance of the milder 
attacks. 
It is unnecessary for me to mention the features of the BY JAMES H. MCBRIDE, M. D. 
7 
ordinary epileptic seizure as you are all familiar with it. The 
insanity that results from any of the varieties of epilepsy may 
be, as stated, of different form in different cases. The epi- 
leptic insane may be depressed and morose, subject to delu- 
sions, usually those of persecution and suspicion. Others 
are violently maniacal; others, without showing any of these 
types of disorder, become progressively weak-minded, victims 
of the hopeless epileptic dementia. 
Epileptic dementia is that condition of mental weakness 
which results from epileptic seizures and especially when the 
disease is of long standing. It is not necessarily associated 
with any more active mental derangement, but may and often 
does begin soon after the epilepsy develops and progresses 
to mild or serious loss of mental power. This form of 
dementia while being in the main much like the terminal 
dementia of other insanities, presents in the appearance of 
the patient some distinguishing characteristics, though these, 
I confess, are not easy to convey in words. The bloated 
face and dull, sodden expression, associated with some hesi- 
tancy of speech and mild mental confusion usually suggests 
to the expert an epileptic origin. 
In a very large proportion of chronic epileptics dementia 
in some degree is a concomitant. At first there is the 
slightest dulling of the mental faculties, such as faulty judg- 
ment, a difficulty in grasping what was formerly easy to 
understand, slight failure of memory for recent occurrences, 
some difficulty in fixing the attention. All these indicate a 
slight failure of the mental vigor and are the first steps in the 
long descent of mental deterioration that ends in hopeless 
obliteration of the mental faculties. 
In the extreme degree of mental degradation that results 
from epilepsy there is but the slightest trace of mind left, the 
patients take on flesh, grow dull and listless and are sluggish 
in movement; they only comprehend the simplest ideas and 
even such with apparent effort.' The destruction of the mind 
is as thorough as if the cortex had been cut away. There is 8 
EPILEPTIC INSANITY. 
in some of these cases a tragic exhibition of the mild and 
timid manners of a child in their helplessness, with occasional 
explosions of furious and destructive violence. There are 
many cases of epilepsy in which these attacks of violence 
never occur, however. They are timid and hesitating in 
manner, slow of movement, speech and comprehension, good 
natured, easily pleased and childlike. It is one of the most 
forcible as it is one of the saddest exhibitions of the dissolu- 
tion of the brain by disease. 
The mania of epilepsy, from whatever form of fit, is of the 
most furious and violent kind. There is nothing in the round 
of mental disorders that equals in brutal and destructive fury 
the mania of epileptics. They are utterly abandoned to 
raving violence that nothing can check or turn aside for a 
moment. I had a man under my care some years ago whose 
father was an epileptic, whose sister had been insane, and 
who had himself been an epileptic from his fourteenth year. 
At the age of twenty-eight he had one of his usual fits and 
immediately became violent and was under my care during 
its continuance which was about three months. For six 
weeks he was continuously maniacal with the most terrifying 
hallucinations, screaming, crying for help, begging for mercy> 
attacking every one that came into his room, and could only 
be calmed by drugs for a short interval. This maniacal con- 
dition passed away rather suddenly and he afterwards recov- 
ered and returned home to his occupation. This particular 
attack seemed to produce no lasting bad effect upon his men- 
tal faculties and with the assistance of his wife he continued 
in the management of a business that brought him a fortune. 
The epileptic fits had, however, perceptibly weakened his 
mind previously. It is now thirteen years since the attack of 
mania and he has had no return of it though the fits continue. 
This illustrates the fact that is observed in many epileptics 
that there may be an out-break of maniacal violence but 
once in a life time and which may last from a few hours to 
several weeks and the patient may go on having the fits and BY JAMES H. MCBRIDE, M. D. 
9 
there not again in years or a long life be a recurrence of 
the insanity. 
Epileptic insanity may precede a fit, take the place of a fit, 
or it may immediately follow it, and there are other cases in 
which the insanity occurs in the intervals of fits neither imme- 
diately following nor preceding one. The one most important 
feature of epileptic insanity is the tendency to violent and 
homicidal acts. The epileptic is specially liable to vicious 
and criminal conduct, being irritable, suspicious and impul- 
sive, and hence of all lunatics he is the most dangerous. 
Among the mental perversions preceding a fit may be 
irritability, moroseness and a desire to wander about alone 
refusing usual companionship or occupation. Those who 
are associated with an epileptic are often able to predict a 
fit from this condition. The epileptic will fly into a passion 
about some trivial matter, perhaps become furious and strike 
or violently attack some member of the family. Other cases 
are despondent and some times suicidal for a short time 
before the attack. Others have head-ache, are dull and list- 
less. There are others who for a short time before a fit are 
elated and exalted, loquacious and egotistic and coarse in 
manner and conversation. After the recurrence of the con- 
vulsion there is a return to the usual mental state. The fit, 
therefore, is in some cases the end of a condition of mind 
that is actual insanity or on the border of it, the explosion of 
the convulsion seeming to clear the mind and restore it to its 
normal condition. In some cases a violent attack of tran- 
sient mania seems to take the place of a fit or it may be said 
to be the fit expended in the psychical sphere. The charac- 
ter of the insanity is not modified by its time relation to the 
fit, that is by the fact that it occurs before or after a fit or in 
the interval. 
Miudsley, in his work on “Responsibility in Mental 
Disease,” mentions an epileptic who seeing a companion 
asleep in a field seized a stone and crushed his head killing 
him instantly. He then fell down in a stupor in which he 10 
EPILEPTIC INSANITY. 
was found by persons passing. Being found an epileptic he 
was sent to an asylum and while there almost succeeded in 
killing an attendant. Echeverria mentions a patient of a 
particularly gentle and affectionate disposition who arose in 
the morning after having a fit in the night, walked into his 
brother’s room and after pacing the floor excitedly, seized a 
razor and cut his own throat quite seriously. On another 
occasion while at breakfast with his sister, upon her asking 
him if he would have some coffee, he rushed upon her and 
attempted to injure her. His brother, coming to the sister’s 
assistance, found the patient leaning on the back of a chair 
with a knife in his hand unconscious in an attack of petite mat. 
Such illustrations might be multiplied indefinitely. 
There is a condition called epileptic automatism which is not 
infrequently associated with the disorder and which is of 
great interest. Some observers hold that this automatism is 
only observed as a sequel to a fit, others that it may replace 
a fit. Further observation is necessary to settle this point. 
In cases where epileptic automatism is shown it certainly 
most usually develops after a fit. In some cases there is a 
manifestation of it after a fit in the way of doing simple but 
incongruous or silly things. For instance one patient always 
attempted to undress, and if allowed to do so would attempt 
to put his clothing on again, but was apt to mistake his coat 
for his pants or his shirt for his coat. Other patients run 
about kissing those they meet even strangers or even articles 
of furniture. Others steal and hide things or pick pockets 
with great cunning. There is no subsequent recollection of 
any of these acts. Echeverria mentions a boy who took a horse 
and buggy he found in the street, and after driving for some 
time left it at a stable saying it was his. There was no sub- 
sequent recollection of his having done this. He mentions 
another epileptic who enlisted as a sailor in New York, and 
suddenly recovered consciousness in mid ocean while the 
vessel was sailing for London. There are many instances 
where epileptics in this state have stolen and concealed 
articles, have committed homicide, arson, etc. BY JAMES H. MCBRIDE, M. D. 
11 
A satisfactory explanation of this condition is perhaps not 
possible. It has been said that in this state the patients are 
unconscious, and in a sense this is probably true. It is con- 
sciousness perverted and acting on a lower plane, a plane too, 
on which normal consciousness cannot act. Consciousness is 
a variable quantity, there being many degrees of it in the 
normal state, from those processes that lie upon the border- 
land of sleep to those that play clear and vigorous in our most 
active mental operations. Morbid conditions degrade the 
order of normal mental processes and they do this by involv- 
ing first the higher processes, that is those that are more 
complex, more delicate, more unstable, more easily disinte- 
grated by disease. The result of this degradation of the 
highest structures is that the lower orders of association 
become active and the mental processes that are shown, are 
the exhibition of the brain working upon an inferior level, 
producing a consciousness of an inferior order. The lower 
levels or orders of mental action are those of instinctive acts, 
in which self control is weakened or destroyed. These acts 
may be purposeless or silly or they may be in the line of 
animal gratification, or criminal, as pilfering or homicide. 
These instinctive tendencies exist potentially in every mind 
and when disease weakens the higher faculties that hold these 
tendencies in check then they act without restraint. 
Concerning epileptic automatism it is important to remem- 
ber that during its continuance there may be apparently sane 
and conscious acts of an intelligent and complex nature per- 
formed; there may be apparently intelligent conduct extend- 
ing over several hours or days involving conversation, busi- 
ness transactions, traveling long distances, crimes committed, 
etc., and all this done when the patient is in an abnormal 
mental condition and of which he will on recovery have no 
recollection whatever. 
The mental condition of epileptics during the intervals of 
the fits is by no means constant. Some are normal or nearly 
so between the fits, others showing various degrees of 12 
EPILEPTIC INSANITY. 
derangement. Some authors hold that it is in only a minority 
of cases that there is any mental failure in chronic epilepsy. 
This is not in harmony with my own experience, and the best 
recent authorities deny its correctness. My personal obser 
vation is that epilepsy almost always produces some mental 
impairment and in the majority of epileptics the impairment 
is decided. It is surprising how quickly the mind suffers 
from epilepsy in some cases. One young man who developed 
epilepsy from long overwork came to me within three months 
after having had his first fit, and yet he could see himself that 
his mental vigor was distinctly impaired. There are some 
chronic epileptics who attend to business sucessfully, and who 
to an untechnical observer would appear perfectly well and 
yet who have suffered considerable mental impairment. It is 
probable that you are all acquainted with such cases. The 
members of one’s family are not always competent judges of 
the mental condition of an epileptic, as the mental deteriora- 
tion is often so slow that their associates fail to note it. 
There are other epileptics, who, while not showing actual 
insanity, show some departure from the normal state; they 
are iiritable and morose in the intervals of the fits, showing 
lack of normal sympathy and affection for relatives, lack of 
interest and ambition in occupation. Others, in whom the 
disease has made more progress, are subject to fits of passion 
or attacks of violence, or of delusions of suspicion and per 
secution. 
Some epileptics may be quite orderly in their conduct and 
yet entertain delusions of persecution, making them dangerous 
to others; they may, however, and often do conceal their 
delusions, because they are suspicious and fear to confide in 
any one. 
Epileptics are not infrequently morbidly self-conscious, 
having exaggerated ideas of their own importance and feeling 
themselves unappreciated and neglected. The epileptic, in 
this condition, is usually selfish and self-centered in all his 
plans ; his interest is wholly in himself and his imaginary JAMES H. MCBRIDE, M. D. 
13 
troubles. Being irritable and suspicious, he is on the look- 
out for slights and neglects; he misinterprets remarks and 
acts of others into intentional insults and builds extravagant 
delusions of personal wrong and insult upon the most inno- 
cent and trivial acts of others. They will lie in regard to 
their treatment by others, make false accusations of ill treat- 
ment and exhibit self-inflicted bruises as evidence of the 
truth of their statements. Women will accuse husbands of 
immoral conduct and tell the most circumstantial and plausi- 
ble stories of outrages attempted upon them. The lower 
grade of epileptics will show these characteristics with less 
artifice and less success at deceiving. The moral perversion 
of some of them is extreme, especially in regard to the sexual 
propensities, soliciting improper attention from men or other 
women in the most open and shameless manner. 
In mental or cerebral epilepsy there is as the only outward 
indication of the fit, often a sense of vertigo and faintness 
with facial pallor; in others there is no vertigo, but pallor and 
twitching of facial muscles; in others temporary confusion 
and a momentary pause in work or conversation. • The men- 
tal processes are temporarily arrested, the patient, if busy, 
stops for a moment and then takes up the conversation or 
work. In some cases .there is a vacant stare for a moment 
with a lapse of consciousness. 
A French jurist was subject to these attacks and would 
leave his seat in court, walk out of the court room, wander 
about for a few moments and return and continue his duties. 
Following these attacks there may be and often are periods 
of confusion or insanity lasting from a few minutes to days 
and during their continuance patients may wander away from 
home, steal and hide various articles, or under the influence 
of hallucinations commit homicide or arson. Some epileptics 
during this stage desire to kill some one or set fire to build- 
ings. A patient of mine said one of his first morbid fancies 
was that he must burn the church building in which he 
officiated as pastor and he actuallv tried to do it twice but 14 
EPILEPTIC INSANITY. 
failed. In the only attack I saw him have he became violent 
and remained so for half an hour. Naturally he was a gentle 
and mild mannered man. 
Following these attacks there may be perfect lucidity and 
continuance of usual occupation or there may be confusion or 
mental derangement. The patient may wander away from 
home, commit thefts or other crimes such as I have already 
detailed. A man was under my care some time ago who had 
been from boyhood subject to cerebral epilepsy. He was 
considered harmless and lived at home. One day he sud- 
denly became furious and killed both his parents with an ax. 
He refused to give any explanation of the crime, but there is 
no doubt that he did the act in an attack of epileptic fury. 
These seizures that last only a moment and may pass 
unnoticed for a long time may be followed by attacks of the 
most furious violence. Lewis mentions a man who, during 
the night, thought he saw two burglars attacking his wife 
and he ran for a hatchet. He remembered nothing after that 
but was subsequently found wandering in the street with a 
bloody hatohef in his hands with which he had killed his 
wife. It was believed he had a hallucination during an 
epileptic seizure and had killed his wife thinking he was 
attacking a burglar. These attacks are sometimes associated 
with unpleasant or even terrifying hallucinations that drive 
the victim to fury and violence. The patient sees some one 
striking at him with a knife, he hears some horrible accusa- 
tion from an enemy and becoming desperate he rushes upon 
and attacks the first person he meets. In this state a man 
ran through the streets in New York some years ago stabbing 
every one he met, seriously injuring several persons. This 
form of epilepsy may precede the usual Grand Mai form or it 
may replace it or occur in the intervals of other fits. Some 
have Grand Mai at rare intervals and cerebral epilepsy more 
frequently. This latter form of epilepsy causes more rapid 
failure of the mental powers than any other kind of fit. Fit- 
ful brilliancy of mental powers has been associated with this BY JAMES H. MCBRIDE, M. D. 
15 
form of epilepsy. Swedenborg and Mahomet who were both 
subject to this and the usual form of the attack are instances. 
The extravagance and visionary character of their belief is in 
harmony with the self-centered consciousness of the epileptic 
whereby he magnifies his personality and exaggerates all 
impressions, being especially subject to hallucinations of the 
senses. 
Nocturnal Epilepsy may be either the grand mal or mental 
epilepsy. It is thus named, of course, from its occuring at 
night and it may exist for a long time unsuspected by patient 
or friends. Some years ago I was called to see a little boy 
of nine years who had for some time and on many occasions 
attacked his younger brother while they lay in bed at night. 
Repeated punishing having done no good and the boy showing 
some mental peculiarities, they requested me to examine him. 
I learned he sometimes complained of headache on the day 
following the scenes with his brother and was dull and indis- 
posed to play and also alleged he had no recollection of hitting 
his brother. His mother stated that he passed his urine in 
bed quite frequently. Suspecting epilepsy, I had him watched 
and my suspicions were confirmed. Some months later he 
had attacks during the day of cerebral epilepsy and was 
invariably violent afterwards. He became an epileptic imbe- 
cile, his mental development being arrested by the fits, and is 
now, at nineteen years of age, in an asylum. His younger 
brother afterwards had epilepsy, though I do not know the 
form of the disease in his case. 
The Nocturnal Epileptic fit may occur without waking the 
patient from sleep. Sometimes there is the initial cry and 
convulsions, at other times these are not observed and in some 
cases they are never observed. The patient, however, is 
almost certain to have morning headache, feeling dull and 
probably irritable. The face will be flushed or bloated with 
minute petechiae on face and neck, and sometimes with sore 
tongue, the result of its having been bitten during the fit. 
The urine is not infrequently passed in bed at the time of the 16 
EPILEPTIC INSANITY. 
fit. Stains of blood and saliva are also occasionally found 
and are important confirmatory evidence of a fit. Nocturnal 
Epilepsy is very injurious to the mental faculties, and especiallly 
in children it produces early arrest of mental development. 
All forms of epilepsy are much more injurious to children than 
adults. The delicate and imperfectly organized cerebral 
structure is rapidly impaired in function and arrested in growth 
by the violent and repeated shocks of the fit. Epileptic som- 
nambulism occasionally follows the nocturnal seizure and in 
fact all the phenomena observed to follow the diurnal fit may 
be observed in these. Patients attack others sleeping with 
them or in an adjoining room, or get up and walk some dis- 
tance performing apparently intelligent and conscious acts and 
return to bed without regaining normal consciousness. 
Trousseau suggested that all nocturnal accidents should sug- 
gest epilepsy. Morel, Echeverria and others have published 
many cases in which nocturnal epilepsy had led to crime. 
There are some characteristics of the epileptic insane that 
I have thought would be more easily remembered if considered 
separately from the general description. 
An important characteristic of the epileptic is his impulsive- 
ness. There is more danger from the impulsiveness of the 
epileptic than from his intellectual derangement. Of all 
classes of the insane, they are the most impulsive. The fits 
weakening their control and leaving their nerve centers hyper- 
sesthetic and irritable, they react quickly and without thought 
to all impressions. Their mental reflexes are exaggerated 
and their self-control weakened. They are then controlled by 
feeling and passion and their acts are sudden and instantan- 
eous. Combine with this their characteristic suspiciousness 
and you have about as dangerous a person as can be imagined. 
This mental irritability is especially marked at about the time 
of a fit and the utmost tact is necessary in their management. 
This characteristic of epilepsy was impressed upon me in my 
early experience in an insane hospital when one day I placed 
my hand on an epileptic’s shoulder, intending to speak to him; JAMES H. MCBRIDE, M. D. 
i7 
he turned and struck me, however, in the face before I could 
speak. Instantly he regretted his act, saying he struck with- 
out thinking or even knowing there was any one to strike. 
At such a time, an abrupt remark or a touch or some one 
entering the room suddenly will cause an attack of violence. 
A case has been reported in which an epileptic shoe-maker 
attacked with a shoe knife and seriously injured his little 
daughter who suddenly entered the room where he was. He 
had no recollection of the attack. Epileptics having ideas of 
suspicion in the intervals of the fits are apt to have them 
exaggerated at or about the time of seizures and this, together 
with their_ irritability and impulsiveness, render them dan- 
gerous at such times. 
The memory of epileptics is often impaired or confused. 
Very many have no recollection of a fit and though mental 
derangement may succeed a fit and last for hours and days 
during which the patient may do complex and apparently 
intelligent acts, yet there may be no subsequent recollection 
of it. This unconsciousness associated with epilepsy is 
important to have in mind because of its medico-legal rela- 
tions. Again the memory of an epileptic of a criminal or 
other act may vary. In some cases there is for a short time a 
partial or confused memory of the occurrences of the abnor- 
mal state and then in a few hours this may be replaced by 
complete oblivion of the occurrence. The statement, there- 
fore by an epileptic that he had no recollection of an occur- 
rence and at another time that he had a confused recollection 
may both be true. This of course rarely occurs but there are 
said to be undisputed instances of it. 
Much has been written in regard to the religious character 
of epilepsy and it is indeed a strange phenomenon. Many 
epileptics are obtrusively religious, saying their pra}'ers where 
they are observed, declaring their moral superiority to others, 
carrying their bible in their hands and reading it where the}' 
are noticed; and these patients are apt to be the most trying 
cases of epilepsy, egotistic in the extreme, wholly absorbed 18 
EPILEPTIC INSANITY. 
in self, deceitful, treacherous and quarrelsome, addicted to 
grossness in conduct and language. Dr. Gowers has pub- 
lished a case in which an epileptic girl had visions of being in 
heaven and seeing and talking with persons there. Such 
experiences remind us of those of Swedenborg and Mahom- 
met both of whom were epileptics. 
The medico-legal relations of epileptic insanity are impor- 
tant. How far should the existence of epilepsy render a 
person irresponsible? While some general principles may 
be laid down for the guidance of the physician, no rules 
applicable to all cases can be established. Each must be 
carefully studied and judged by its special indications. 
There are some epileptics in whom the mind is unimpaired 
and these of course could not be considered irresponsible 
except during a fit. There are others in whom there is a 
slight shade of mental failure, some blunting of the normal 
acuteness but with no delusions. Others again are, at or 
about the time of a fit, irritable, suspicious, and perhaps des- 
pondent and morose, showing noticable mental weakening 
yet in the intervals of the fits pass for normal persons. 
Others again have delusions and yet others have paroxysms 
of violence. Epileptics who commit crimes are usually 
chronic cases. While there are exceptions to this rule they 
are rare. We would expect this to be so, for the longer 
the epilepsy has existed, the greater the mental degen- 
eration. Crimes are some times committed at the time 
of a fit but more often in the intervals of fits. The Roman 
law exempted all epileptics from responsibility for three days 
before and three days after a fit. All criminal acts committed 
by epileptics should lead to a careful investigation of their 
mental condition at the time of the act. Some people have 
fits infrequently and are apparently normal in the intervals. 
A crime committed during such interval would not neces- 
sarily be due to the epileptic condition. The nearer, there- 
fore, the act is to an epileptic fit, the greater the chances that 
it was the result of the fit. The nature and manner of the BY JAMES H. MCBRIDE, M. D. 
19 
crime may help to determine the condition. *A crime, if 
apparently motiveless, reckless and furious, is probably due 
to epileptic insanity if committed by an epileptic. 
As we have seen in the case of the man who killed his wife, 
a crime may be committed under the influence of a hallucina- 
tion. Some years ago, in New York city, a man by the 
name of McDonald choked to death his brother with whom 
he was sleeping. He would give no explanation of the 
crime. Some weeks afterwards while in prison he attempted 
to choke another person who slept in the same cell. The 
superintendent of the City Insane Asylum being asked to 
examine him recognized in him an old epileptic patient whom 
he had discharged from the asylum some months before. 
Epilepsy is relatively common among criminal classes and 
also among those who drink. Crimes, when committed by 
them not otherwise explainable should be examined for 
evidences of epilepsy. 
The important features of epileptic insanity may be sum- 
marised as follows: 
1. The forms or varieties of epilepsy liable to lead to 
insanity are the ordinary, Grand Mai, Mental Epilepsy, Noc- 
turnal Epilepsy. 
2. Nocturnal epilepsy and mental or cerebral epilepsy 
produce more rapid mental deterioration than other varieties. 
3. Epileptic insanity may precede, take the place of, or 
follow a fit. 
4. It may be a quiet type of insanity or the most violent 
mania. 
5. The mania may occur only once in the course of the life 
of an epileptic who has the disease from childhood. 
6. Epileptic insanity is a most dangerous form of mental 
disorder as the subject of it is suspicious, irritable, and 
impulsive being conspicuously weakened in self-control. 
7. There is usually loss of memory of events of the insane 
period though occasionally there may be a confused recol- 
lection. 20 
EPILEPTIC INSANITY. 
8. That a condition of mental automatism may follow an 
epileptic fit which may last for days during which a person 
may transact business, buy a ticket and travel distances, con- 
verse intelligently, and yet afterwards have absolutely no 
recollection of anything that occurred during the period. 
9. The epileptic attacks may occur during sleep and not 
during the waking state, and that this nocturnal epilepsy is 
apt to be associated with violence and ultimate mental 
weakness. 
10. That insanity is more apt to be associated with the 
mild fits called cerebral or mental epilepsy than those in 
which the convulsions are violent. It must not, therefore, be 
thought that the condition is a trifling one and the danger of 
mental disorder slight because the fits are apparently mild 
and of short duration. MILWAUKEE SANITARIUM 
KOK 
/Nervous and Mental Disease. 
(£)T he Sanitarium is beautifully located in the country, three miles from 
*_L the City of Milwaukee. It is within a few minutes’ walk of the Chi- 
cago, Milwaukee & St. Paul Depot, but is in a quiet and retired spot, 
where patients have the freedom of a large park without observation or 
intrusion. 
The institution is designed for the treatment of nervous disorders, 
including mild cases of insanity 
The buildings are new and were constructed for the special purpose of 
a Sanitarium. They are heated by steam and lighted by electricity, and the 
entire sanitary arrangements of the institution are the best. 
Each patient is provided with a separate room, and skilled nurses are 
always in attendance. 
The Sanitarium is organized on the home plan The officers live with 
the patients, sharing their meals and their social life In this way it is 
divested of the characteristics of an institution and assimilates to that of. 
the home 
For information, address the Medical Superintendent, 
J. H. McBRIDE, M. D., 
WAUWATOSA, Milwaukee Co., Vf\i. (