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and discipline in my experience has almost always led to a relapse, and the second condition is worse than the first. As the predisposing element of causation consists in a neurosis which has been inherited, and as this has been developed in the large majority of cases during the sensitive periods of puberty and adolescence by the practice of the habit, the effects upon the brain become very profound and difficult of removal. In this respect the supersensitive and unstable condition resembles that which obtains in epilepsy.

Cases which have arisen in persons of a vigorous habit and stable condition of brain, by learning the practice from others, rarely become insane, and the vice is generally overcome by education and the progress of physical development.

Treatment.—The bromides serve largely to lessen the sexual excitement, and if used in connection with vesication of the prepuce or the camisole, or both these agencies, will control the morbid tendency in some degree, while the system has an opportunity to recuperate; but these measures cannot be followed up indefinitely, and whenever they are abandoned the old habit of excitement only too surely resumes its sway. The use of pins in confining the prepuce or other surgical treatment of the penis proves to be of no better service. Moreover, there always exists in these cases a demoralization of the moral element which does not pass away with the physical improvement, and no amount of instruction as to the absolute necessity of reform ever avails

very much.

The individual may, under the power of returning reason, as in one of the cases detailed, be willing to suffer mutilation as a remedy, and yet not have the courage and grip of resolution to stand up against a resumption of the wretched

practice, and again returns, as the hog, to his wallowing in the mire.

One of the most efficient means of fortifying the will in its effort at reform, if there exists any, is physical labor and life in the open air. These conditions will tend to equalize the circulation and eliminate the nervous energy, or turn it into other channels. There exists no doubt that in the large majority of cases the long-continued practice has led to a super-sensitive or hyperæmic condition of the nerve cells or sexual centres of the brain, which may be akin to the condition of certain areas of the cortex in some cases of epilepsy or of chronic alcoholism. A condition of good feeling and self-importance exists at times in both these disorders, which is like that which is present in many cases of general paresis, though it is much less persistent, and is not so extreme. The long-continued and oftenrepeated excitement attending the practice finally so far weakens the brain that the condition of hyperæmia becomes chronic; it ultimately gives way to a failure of nervous energy, and the mind passes into a consequent dementia, toward which the large majority of such cases tend.

Some of the more favorable cases which occasionally come to asylums may be benefited by such measures as have already been alluded to, supplemented by the use of nux vomica, the hypophosphites, and iron. Any course of treatment, however, must be followed up for a long period, and then, if successful, the person may be advised to contract marriage.

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LECTURE XXI.

EPILEPTIC INSANITY. Epilepsy and Insanity-Characteristics of Epileptics— Tendencies to Mental

Derangement-Responsibility of Epileptics—Epileptic Neurosis-Characteristics of --Symptoms of Epilepsy— The Aura Epileptica-Phenomena Attending 11—Hallucination of Any of the Special Organs of Sense-A Case-Swedenborg–The Aura May Affect both Sight and Hearing A Case—“ Petit Mal"-Symptoms of--Age-"Grand Mal”-Symptoms of-Derangement of Mind—“Epileptic Fury.”

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Among the several neuroses one of the most, if not the most, influential in causing mental derangement is that of epilepsy. In fact, the epileptic and insane neuroses are so closely allied in character that they are interchangeable in their hereditary tendencies, and the offspring of parents possessing either of them may have the other. The leading characteristic of both is instability of nerve tissue. The one manifests itself in morbid sensibility and motility, and the other in morbid mentality, and the first not unfrequently passes over into the second. This passage is more commonly a slow one, and may cover a period of years, though in cases in which the convulsions are of a very pronounced character they may develop insanity early.

Esquirol found that two-thirds of the epileptics in la Salpêtrière were insane. Doubtless the larger part of these had been epileptic for a long period; certainly no such proportion of epileptics in this country would be found to be technically insane, especially in the early stage of the disorder. Indeed, epileptics are not usually thought of as insane, and much less certified as such to asylums, until they present the most unequivocal evidence, which generally consists in marked mental deterioration, excitement, dementia, or the commission of some form of crime. The attention is almost exclusively drawn toward the physical phenomena which are immediately connected with the convulsive stage. These are so sudden, often so startling in character, and so overwhelming in their immediate effects, that they are observed by the general practitioner rather than the preceding or subsequent effects upon the mind. These latter, however, have been carefully observed by specialists, and epileptic insanity was one of the first of the etiological forms to be differentiated and described.

Epileptics tend to become changeable and uncertain in their mental states; very impressionable and impulsive; at times are irascible, morose, and untruthful; at other times, silly and good natured, or depressed and hypochondriacal. These various mental conditions may vary in all degrees of intensity. In many cases the subjects become merely harmless dements, while in others they become homicidal or suicidal maniacs of the most pronounced character. Probably there exists no form of mental disorder which is the immediate cause of more criminal acts, and many of them are of the most atrocious nature. A statement recently appeared according to which an epileptic, while in hospital, attempted to cut the throats of twenty-four patients who were in the ward with him with a razor which he had by some means secured. This form of insanity therefore becomes especially important from a medico-legal point of view. While, doubtless, no epileptic could rightly be regarded as responsible for acts in any degree connected with a convulsion, yet in the early stages there may exist long periods during which the subject is quite capable of regulating his conduct according to the standard of right and wrong, the intelligence and will-power are not affected, and some may pass through life without giving indications of any marked derangement or dementia.* Nevertheless, the large majority do sooner or later experience serious lesions of the mind, and many of them find their way to hospitals, where they are found to be among the most troublesome class of patients. And even that class who do not reach asylums generally give indications of mental impairment, which consists in a dulling of the normal keenness of mental action, a warping of the judgment, a clouding of the memory, and a destruction of the higher and the finer sensibilities.

It was formerly customary to refer to the epileptic neurosis as something akin to genius. In evidence of this the names of epileptics who have given indications of great

* The mere fact, therefore, that a person has experienced at some former period of life occasional epileptic attacks does not of itself furnish sufficient evidence of irresponsibility. A man was recently tried in one of the courts of Connecticut for the murder of a woman to whom he had formerly been engaged to be married. It appeared in evidence ibat he had experienced one or two fits when a boy and before coming to this country. It also appeared that on two occasions after he was confined in prison he lost consciousness for one or iwo minutes. In his consession, however, he was able to state just when he formed the resolution to kill her, and gave as his reason that if he could not have her himself he was determined no one else should. As he described what he did after taking his resolution, to accomplish it, his going to the house in the night, climbing on some lattice-work upon the roof of an ell of the house, his creeping carefully to the window and removing a screen which was in it (the weather being warm), how he entered the room and, finding her asleep, struck her with a sharp knise which he had for the purpose, and the course which he took to escape, the court held that as his act was deliberate and in no way connected with or dependent upon impairment of mind, he must be regarded as responsible.

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