cholic heaps upon himself really represents complaints directed against a person he formerly loved, and this is the reason why he is not ashamed. of his supposed deficiencies and does not behave as though they were true, conducting himself rather as someone who has been unjustly wounded. What has happened is that after some disappointment or injury connected with the loved person he has withdrawn his love from this object, but instead of transferring it to a new one, as the normal person would, or introverting it on to unconscious phantasies, as the neurotic does, or, again, applying it to the ego, as the paraphrenic does, he replaces it by a narcissistic identification of the self with the former object, there being in this process doubtless a regression to the original narcissistic way in which he fell in love. Analysis seems to show that three conditions are necessary for this outcome: first an actual loss, as in grief, though the loss is more often due to disappointment than to death; secondly the combination of a strong narcissistic fixation on the loved object with a lack of resistance in its investment; and thirdly a marked ambivalency, as in the obsessional neurosis. The ego thus becomes split; one part, to which the conscience belongs, can criticise, abuse, and hate the other part formed by fusion with the idea of the object. It is this ability to treat the self as an object which makes suicide. possible, and there is an interesting discussion of this matter. Freud incidentally contrasts the narcissistic identification present here with the common hysterical identification, in which, on the contrary, some connexion with the idea of the real object is retained. The fixation-point characteristic of melancholia, which is intermediate between the fixation-points of paraphrenia and the obsessional neurosis, he places in the first pregenital stage known as the oral phase of the libido; doubtless to be correlated with this is the fact that also the psychology of melancholia is intermediate between that of these two affections. He does not maintain that his conclusions are valid for all forms of melancholia, and thinks it possible that certain forms might be produced by a toxic impoverishment of the ego-libido. In conclusion he discusses the more obscure problem of mania as representing the triumph of the opposite side of the ego in the intrapsychical conflict.

At the end of this review I am even more conscious of its deficiencies than I expected at the beginning to be, and can only hope from it that it will serve to stimulate some of you to study at first hand the works with which I have dealt so inadequately. It is only fitting that I should conclude by expressing one's gratulation and indebtedness to Professor Freud that he has been able to accomplish so much in the most trying and difficult circumstances.

BIBLIOGRAPHY.

(1) CLARK, PIERCE. "A Personality Study of the Epileptic Constitution,” Amer. J. of the Med. Sciences, 1914; "The Nature and Pathogenesis of Epilepsy," New York Med. J., 1915; “A Study of certain aspects of Epilepsy compared with the emotional life and impulsive movement of the infant," Interstate Med. J., 1915; "Clinical Studies in Epilepsy," Psychiatric Bull., 1916 and 1917; "Some therapeutic suggestions derived from the newer psychological studies upon the nature of essential epilepsy," Med. Record, 1916; "The psychological and therapeutic value of studying mental content during and following epileptic attacks," New York Med. J. 1917; "The True Epileptic," New York Med. 1918.

J.,

(2) READ, STANFORD. "A Review of the Recent American and English Literature on Psycho-Analysis," Int. J. of Psycho-Analysis, 1920. For reviews of the foreign literature on the subject see the Int. Zeitschr. f. Psychoanalyse, 1920. (3) FERENCZI. "Technische Schwierigkeiten einer Hysterieanalyse," Int. Zeitschr. f. Psychoanalyse, 1919, Jahrg. v, Heft 1.

(4) FREUD. "Wege der psychoanalytischen Therapie," Int. Zeitschr. f. Psychoanalyse, 1919, Jahrg. v, Heft 2.

(5) FREUD. Six articles entitled "Zur Technik der Psychoanalyse," reprinted in his Sammlung kleiner Schriften zur Neurosenlehre, Vierte Folge, 1918.

(6) FERENCZI. "Zur psychoanalytischen Technik," Int. Zeitschr. f. Psychoanalyse, 1919, Jahrg. v, Heft 3.

(7) FREUD. Aus der Geschichte einer infantilen Neurose," Sammlung, etc., Vierte Folge, 1918, cap. XXXII.

(8) FREUD. "Ueber neurotische Erkrankungstypen," Sammlung, etc., Dritte Folge, 1913.

(9) FREUD. Vorlesungen zur Einführung in die Psychoanalyse, Dritter Teil, 1917. (10) JONES, ERNEST. 'Anal-Erotic Character Traits," ch. XL of Papers on PsychoAnalysis, 1918.

(11) JONES, ERNEST. "Hass und Analerotik in der Zwangsneurose,” Int. Zeitschr. f. Psychoanalyse, Jahrg. 1, Heft 5.

(12) FREUD. “Die Disposition zur Zwangsneurose," Int. Zeitschr. f. Psychoanalyse, Jahrg. 1, Heft. 6.

(13) ABRAHAM. "Untersuchungen über die früheste prägenitale Entwicklungsstufe der Libido," Int. Zeitschr. f. Psychoanalyse, Jahrg. IV, Heft 2.

(14) FREUD. "Einige Charaktertypen aus der psychoanalytischen Arbeit," Imago, Jahrg. IV.

(15) FREUD. "Beiträge zur Psychologie des Liebeslebens," reprinted in his Sammlung, etc., Vierte Folge.

(16) FREUD. “Zur Einführung des Narzissmus,” Jahrb. der Psychoanalyse, Bd. vi; also Dritter Teil of his Vorlesungen, cap. XXVI.

(17) FREUD. Totem und Tabu, 1913; also Ferenczi, Contributions to Psycho-Analysis, 1916, ch. VIII.

(18) ABRAHAM. "Die psychosexuellen Differenzen der Hysterie und der Dementia Praecox," Centralbl. f. Nervenheilk. u. Psychiat. 1908, Heft 2.

(19) FERENCZI. “Über Pathoneurosen," and "Die Psychoanalyse eines Falles von hysterischer Hypochondrie," chs. I and v of Hysterie und Pathoneurosen, 1919. (20) JONES, ERNEST. "War Shock and Freud's Theory of the Neuroses," Proceedings of the Royal Society of Medicine, Section of Psychiatry, April, 1918.

(21) ABRAHAM, FERENCZI, AND SIMMEL. Zur Psychoanalyse der Kriegsneurosen, 1919. (22) FREUD. "Triebe und Triebschicksale," "Die Verdrängung," "Das Unbewusste," "Metapsychologische Ergänzung zur Traumlehre," "Trauer und Melancholie," reprinted in Sammlung, etc., Vierte Folge.

THE PATHOGENESIS OF EPILEPSY

A SURVEY OF THE CLINICAL STUDIES OF PIERCE CLARK

By C. STANFORD READ

Very largely through the influence of Freudian teachings we have of late tended more and more to regard nervous and mental diseases from a psychobiological point of view, and in this respect non-symptomatic epilepsy has been studied with the result that its essential pathological basis may be found to be mainly a psychological one. The old idea of epilepsy as a disease entity is passing away in favour of its recognition as a syndrome in which the seizure is the most striking of many symptoms. Various theories of its aetiology have been put forward from time to time, many of them dogmatically, but none of them can be considered as satisfactory, whether they deal with chemical blood derangements, mal-functioning of endocrine organs, or an indefinable cortical irritation. It is certain that our advance in knowledge has been hampered by clinical interest having been centred on the fit itself, while the mental state of the individual in the inter-paroxysmal period has received but little attention until recently. Nevertheless neurologists and psychiatrists have long recognised the peculiar traits of the epileptic constitution. In the mildest forms we note an alteration of the total personality, in a higher degree we can speak of the epileptic 'character,' and beyond this we find the epileptic psychosis. Vogt declares that the epileptic character is a peculiar mixture of psychic components which are mutually antagonistic. Obstinacy and contrariness may exist with a high degree of docility, apparently based on change of moods. Mendacity and ethical perversions may be seen with piety and pleasing speech; openness contrasts with distrust, misanthropy with childlike cheerfulness. One notes a general tendency to ethical degeneration. The subject becomes quarrelsome, unsocial, is inclined to lie and employ violence. Irascibility, egocentricity, impulsiveness, and a shallow religiosity are all so marked in extreme cases that the epileptic patients in our mental hospitals are a constant source of trouble and require great tact in supervision. Notwithstanding this recognition of the epileptic's anomalous character, the deeper currents of his mentality and the maladapting factors which are so often seen prior to his attacks have until recently received but scant notice. Féré, however, believed that the character and manner of epileptics could easily cause suspicion of the disease long before the convulsions appeared, and other observers have noted that there is always a virtuality of explosion, a deep irritation of which the convulsion is the maximum term. The potential accumulates until a discharge results.

Clinical experience during the late war has largely unified our conception of abnormal nervous and mental reactions, so that the dividing line between hysteria and epilepsy has been more and more difficult to establish, and authoritative observers have on analysis tended to find similar mental mechanisms producing the two conditions. It is quite certain that typical epileptic seizures frequently took place as frank reactions to particular en

vironments and specific situations. In some of my epileptic admissions at 'D' Block, Netley, during the war, I was struck with the prolonged unreasoning violence often shown in an unconscious state. Such observations have led to the belief that in some way the fit represented emotion of an aggressive type. Psycho-analysts have endeavoured to analyse the mental material that might lead to such an outburst. Jung of Zurich found signs suggesting that the emotional tone in the epileptic was unusually lasting, and in his association experiments found good evidence of egocentricity. Stekel regards the epileptic as a repressed criminal, and a convulsion as a substitute for the criminal act. He believes that epilepsy is, more often than we have hitherto thought, of psychogenic origin, and that there is a strong tendency to criminality which is unbearable to consciousness. Some cases that came under my care at Netley, the analyses of which I published1, bore this theory out.

It has nevertheless been left to Pierce Clark to make an intensive study of the epileptic mentality, and by his painstaking work he has been enabled to put forward a highly interesting hypothesis of the nature and pathogenesis of essential epilepsy from which therapeutic suggestions are naturally deduced. It is at once obvious to those who read his literary contributions that his theories are not the result of wild speculations, but the inevitable outcome of observation and psychological dissection of the case material he dealt with. From his study Clark brings forward two fundamental principles which he and others regard as largely established. First, that those individuals who later develop essential epilepsy invariably present a special make-up or epileptic constitution, the core of this anomaly in the personality consisting of an extremely hypersensitive and egotistical temperament with all that such characteristics entail. This biological defect renders the individual incapable of adequate social adaptation, so that adult reactions become necessarily abnormal. In the second place this inability to inhibit egotistical trends in the face of social demands results in an evasion of the difficulties by a loss of consciousness-the epileptic fit. Naturally one will see a definite relationship between the amount of environmental stress and the degree of temperamental and somatic defects. Where the latter are slight, the definite epileptic reaction may not appear until special adaptive demands are made, such as at puberty or later, but when the constitutional defect is extreme, the smallest amount of stress may be provocative of a severe and progressive epileptic state. In those who are least adaptable, the epileptic reactions may develop as soon as the child comes into contact with his environment. There may be no patent mental conflict, or what exists may be vague and below the threshold of consciousness, portraying itself in a nameless dread or a general irritation against the simplest demands of the instinctive life. In such cases the simplest accidents of fright, or startle from quiet sleep, or the induction of a cold bath, may cause loss of consciousness and a convulsion.

The fit is looked upon as a psychobiological reaction which acts as a refuge from an intolerable adjustment demand and also constitutes a regression to a pleasurable primitive state. In Clark's opinion this regression harks back to the mutter lieb, to the perfect peace which is supposed to have existed in the mother's womb, a state of metroerotism, as he terms it. As he points out, it is no uncommon sight in institutions to see the highly demented epileptic

1 "A study of epileptoid cases in soldiers." Journal of Abnormal Psychology, vol. xIII. No. 1, April, 1918.