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One frequently observes in the feeble-minded acute or subacute mental outbreaks which appear in various clinical forms: maniacal excitement, depression, sometimes delusions more or less imperfectly systematized. Often the mental disorders appear as exaggerations of a constitutional anomaly, essentially a function of the subject's make-up. An individual habitually touchy and suspicious develops persecutory delusions, another habitually psychasthenic suffers an attack of depression, etc. Such episodes in imbecility are incontestable clinical realities, and nothing is more justifiable than, for instance, a diagnosis of maniacal excitement in an imbecile. Unfortunately it is very difficult to assign for such episodes a place in psychiatric nosography. Do they constitute mental disorders peculiar to imbecility? Are they not, on the contrary, periodic psychoses to which the imbecility merely imparts special features: mobility of the symptoms, childish character of the delusional conceptions? For my part, I am rather inclined toward the second hypothesis. In fact a full series of transition cases leads from classical manic depressive insanity to the more typical attacks of imbeciles. Moreover, such attacks in imbeciles present the same tendencies toward recovery and toward recurrency. It must be noted, however, that the influence of external causes, psychic as well as physical, in bringing about recurrencies, appears to be more marked in imbeciles than in manic depressive persons who are not defective. It is also to be noted that the effect of suggestion upon the
mental symptoms is surely more pronounced in the psychoses of imbeciles than in ordinary types of intermittent psychoses, so that psychic treatment is here found to be more efficacious.
Prognosis, diagnosis, treatment. - Arrests of development are not diseases, but infirmities; their prognosis is, therefore, grave. Education may, however, exercise a favorable influence upon some subjects.
The elements of diagnosis are to be found in the history of the subject; the absence of any vestige of more complete intellectual development previous to the time of examination must be established.
FROM a psychiatric standpoint epilepsy manifests itself by permanent disorders and by paroxysmal accidents.
Permanent intellectual disorders. These impart to the epileptic personality a peculiar stamp and often lead one to surmise the existence of the neurosis independently of any medical examination. We shall consider separately anomalies of disposition and intellectual disorders.
(A) Anomalies of disposition. These are always very marked. The following are the principal ones: (1) Irritability and variability of moods, egoism, duplicity.
(2) Habitual apathy, sudden impulsive reactions, violent and at times terrible fits of anger.
(3) Lack of consistency between the patient's conduct and his ideas, more rarely abnormal stubbornness and tenacity: "Some celebrated men who are supposed to have been epileptics are more noted for their pertinacity than for the greatness of their conceptions." 1 (4) Morbid religious fanaticism, not constant, but frequent, usually merely ostentatious, with more regard
1 Féré. Les épilepsies et les épileptiques, p. 423.
for the rites, ceremonies, and customs, and without any influence upon the morality of the patient.
(B) Intellectual disorders. - Epileptics are sometimes, but not often, as claimed by some authors, men of great intelligence. Some hold prominent places in history, in literature, and in the arts: such were Cæsar, Napoleon, Flaubert, and others. Others, though in a more modest sphere, are honorable occupants of offices requiring a lucid intelligence and a sane judgment. These cases are, however, exceptional. Intellectual inferiority almost always forms a part of the clinical picture of epilepsy. Often it is congenital, for most epileptics are originally feeble-minded; in other cases it is acquired; the manifestations of epilepsy-crises, vertigo, delirium exercise a harmful and lasting influence upon the intelligence. When sufficiently marked, the intellectual enfeeblement becomes epileptic dementia.
The degree of dementia depends in a measure upon the number and severity of the seizures. "It cannot be doubted that the stupor produced by major attacks is more marked than that resulting from minor ones; and it is certain, as is admitted by Legrand du Saulle, Voisin, Sommer, etc., that major seizures occurring at frequent intervals much more rapidly lead to dementia than do incomplete seizures." 1
The two essential features of epileptic dementia are: (1) its irregularly progressive development, with aggravations following the seizures; (2) its being to a certain extent remittent, the intellectual enfeeblement
1 Féré. Loc. cit., p. 227.
becoming less marked as the intervals between attacks become longer.
Paroxysmal mental disorders. These are either associated with, or replace, the epileptic seizures. We shall review briefly their principal forms.
(A) Sensory and psychic auras. The first consist in hallucinations or illusions; the second "usually consist in a recollection of either a pleasant or an unpleasant character; perhaps a recollection of some person or of some important event in the patient's life."1
(B) Unconsciousness accompanying the convulsive phenomena: though most frequently complete, it is sometimes but partial, so that there may be:
(a) Vertigo, which is a dazzling sensation rather than true vertigo,2 and which is sometimes, but not always, accompanied by falling and slight convulsive movements. Together with pallor of the face and subsequent anæmia, these phenomena constitute a rudimentary epileptic seizure.
(b) Absence, essentially characterized by a momentary suspension of all psychic operations. The patient suddenly becomes immobile, his gaze fixed, his expression vacant; the attack having passed, he resumes his work or conversation at the point where he left off. In some cases the patient continues automatically through the attack the work or the movement in which he happens to be engaged. A barber mentioned by Besson thus continued during his absences to shave his clients, performing his work just as skillfully as in the normal state.
1 Magnan. Loc. cit., p. 6.