CHAPTER XIV. EPILEPSIES AND THEIR LEGAL RELATIONS. 307. Are Epileptics of Unsound Mind?-[218] Lawyers and medical men have not, so far as we know, paid any attention to the legal relations of this disease. The attention which has been paid to this subject has generally consisted in denying that it has any legal relations at all, except in so far as toothache or phthisis may be said to have legal relations. Lawyers at the present time are, it seems to us, prepared to deny that any bodily disease, or any disease simply affecting bodily functions, should in any way alter the relation which an individual bears to the community of which he is a member. Although each disease may have its psychical aspect-although it may be true that panic is invariably associated with cancer, and that hope is associated with phthisis, yet it would be inexpedient to admit that any such modification of mental health should be considered by law as any disqualification where the exercise of rights is involved, or as any way taking away from the responsibility which a man has where the commission of criminal acts is in question. It would be as reasonable to graduate a man's responsibility with regard to any act in relation to its commission before or after dinner. The question as to whether the existence of epilepsy should be regarded as in any way modifying a man's relations to his fellow-men depends upon another question, and that is, Are all epileptics persons of unsound mind? To decide this is, in the first instance, of importance. To answer it, it is necessary to understand what epilepsy really is. 308. The real Nature of Epilepsies.-Much light has been thrown upon this important subject by some of the most recent physiological and pathological researches. Thus Pro fessor Ferrier's most important experiments in continuation of the work so well begun by Fritsch and Hitzig, which were first published in the West Riding Asylum Medical Reports,' and have been continued by means of the assistance of the Royal Society, confirm an opinion which had been previously held that "chorea is of the same nature as epilepsy, dependent upon momentary and discharging lesions of the individual's cerebral centres." The similarity of choraic, epileptic, and tetanic seizures is by no means an unimportant recognition, and has led to what seems to us a true definition of epilepsy as an "occasional, sudden, excessive, rapid, and local discharge of gray matter." When the brain discharges its accumulated force like a Leyden jar instead of like an ordinary battery by continuous flow, the brain produces an epilepsy instead of producing healthy mental or muscular action. But these local discharges may take place in various organic directions. Free energy, as has been shown by Mr. Herbert Spencer in his admirable essay on "Laughter," will always run in accustomed channels, and, as we might have expected, these explosions take place in the direction of least resistance, and that is the direction in which habit has directed voluntary energy. We find as a fact that epileptic fits usually begin in those parts of the body which have most voluntary uses. "The order of frequency," says Dr. Hughlings Jackson, "in which parts suffer, illustrates the same law. I mean that fits beginning in the hand are commonest; next in frequency are those which begin in the face or tongue, and rarest are those which begin in the foot. The law is seen in details. When the fit begins in the hand, the index finger and thumb are usually the digits first seized; when in the face, the side of the cheek is first in spasm; when in the foot, almost invariably in the great toe." But not only may the direction vary under the influence of past voluntary use or habit, but it may vary infinitely in degree. There may almost be healthy epilepsy. "The longer repair goes on unopposed by appreciable waste," says Spencer, "the greater must become the instability of the nerve centres, and the Vol. iii. p. 30. Cerebral Physiology and Pathology, p. 95. On the Anatomical, Physiological, and Pathological Investigation of Epilepsies, by Dr. Hughlings Jackson, West Riding Reports, vol. iii., p. 331. Lancet, February 1, 1873. greater their readiness to act; so that there must at length come a time when the slightest impressions will produce motions. On awakening from refreshing sleep, there commonly occurs an involuntary stretching of the muscles of the whole body, showing an immense undirected motor discharge." "A sneeze," says Dr. Hughlings Jackson in the essay already referred to,2 “is a sort of healthy epilepsy." But from this trivial discharge there are varying degrees of epilepsy, which are ascribed by some physicians to nutrition defective in quality although not in quantity, and which Dr. Hughlings Jackson has classed as follows: (1) A sudden and temporary stench in the nose, with transient unconsciousness; (2) a sudden and temporary development of blue vision; (3) spasm of the right side of the face, and stoppage of speech; (4) tingling of the index finger and thumb, followed by spasm of the hand and forearm; (5) a convulsion almost instantly universal, with immediate loss of consciousness; (6) certain vertiginous attacks. These have been spoken of as partial seizures, but they are really to be regarded as the varying results of stronger or weaker discharges. One of Schroder Vander Kolk's conclusions as to epilepsy is apposite in this place, and when taken in connection with Mr. Spencer's description of the dischargeability of nerve force in motion during health, shows the true nature of epilepsy as well as the fact which we have repeatedly insisted upon, viz., that we always find the type of disease in health, or, to put it in other words, "symptoms of instability in disease are an exaggeration with caricature of the effects of healthy discharges." The special seat and starting point," he says, "of these convulsive movements is situated in the ganglionic cells of the medulla oblongata, which, as reflex ganglia, possess the peculiar property that when once brought into an excited condition, they may more or less suddenly discharge themselves and communicate their influence to different nervous filaments. After their discharge, a certain time is again Spencer's Psychology, vol. i., p. 90. Dr. Hughlings Jackson, op. cit., p. 325. * Op. cit., p. 326. Since this was written, Dr. Hughlings Jackson has contributed some most valnable papers to the Medical Press and Circular upon this most important subject. These are worthy of most careful study. required to bring them to their former degree of excitability and to render them capable of fresh discharges, just as we see to be the case with electric batteries or in the phenomena of electrical fish.” 309. Common Manifestations of Epilepsy.-It is obvious from what has been said above that there are innumerable degrees of epilepsy, and that the term "epileptiform," which has been applied to such seizures as are unaccompanied by loss of consciousness, is an unnecessary and confusing distinction. But in a medico-legal aspect, only certain wellmarked kinds of epilepsy are of real importance, and in relation to these the definition an "excessive discharge of unstable gray mattter" is not sufficient, and a more detailed description is necessary for the purposes of easy and safe recognition. The epilepsy with which the medical jurist has to do consists of, or is manifested by, obscured consciousness which follows a premonitary sensation or aura which is an abnormal condition of the coenoesthesis. This sensation is accompanied by pallor of the face; there is a cry, and then an entire loss of consciousness. The muscles are contracted; the thumb is frequently found pressed into the palm of the hand by the fingers which are folded firmly over it. The muscles of the face are twisted generally to one side, the sterno-cleido mastoid being convulsed. The eyes and lips are distorted, and the aspect is hideous. Respiration is suspended, the pulse is quick. The pallor of the face is succeeded by flushing, and subsequently the color deepens to a red purple. The veins of the forehead are swollen, and there is frequently an involuntary discharge of urine, spermatic fluid, and fæces. The mouth generally remains open, the tongue is protruded, the lips are covered with froth and blood, which flows from some wound made by the teeth upon the tongue. On some occasions, however, the teeth are firmly pressed together. This spasm may last from ten to sixty seconds. It is followed by an alternate contraction and relaxation of the muscles, which may continue for one or two minutes. This condition is followed by complete relaxation. BR. INS.-29 Syd. Soc Trans., p. 283. There is a deep sigh, stertorous breathing, coma, and a partial or entire unconsciousness even after the coma has passed away. Subsequent to these phenomena a state of mania or of stupidity comes on, and during this stage of the disease the epileptic may be, and often is, dangerous to himself and others. The progress of an attack of epilepsy may be described thus: At first there is a premonitary susceptibility to external impressions; (2) an aura, affecting some of the external senses; (3) coma; (4) excitement; (5) dementia. During each one of these stages of the epileptic seizure there is more or less abnegation of consciousness, the amount of which may be ascertained subsequently by questions which refer to the acts of the individual, or to the events which occurred at the time. For just in proportion to the defect in memory will be want of power to concentrate consciousness. Where there is no attention the person is unconscious; and some people have gone so far in their admiration of attention as to assert that it alone distinguishes the genius from the booby. Besides this enfeebled power of concentration, other mental powers are partially enfeebled, it may be, owing to the mental defect just alluded to, and there is a considerable change in the disposition of the individual. 310. The Varieties of Epilepsy.-All these circumstances are observable in connection with this disease, but it, like other diseases, is capable of infinite diversity in its manifestations; and all or almost none of the symptoms above alluded to may in any individual case be discoverable. It may exist (220)simply as the mental aura, which has been called petit mal. It may be masked, and "there are,” says Falret, "certain incomplete attacks of epilepsy which hold a middle place between simple vertigo and the complete attack during which, in the intervals between the convulsions, the patients appear to be conscious of what is passing around. They speak and act in such a manner as to inspire doubt as to the real nature of these attacks, and to attach to what is said and done in this peculiar state of the nervous system a character of moral liberty to which they possess no title. This singular mental condition resembles in many respects somnambulism, and other extraordinary nervous states. It |