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. J., 1918.

(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.

in bed entirely covered up by the bedclothes which when removed reveal him lying in the same attitude as the foetus assumes in utero. He thus shuts out the external world and to the best of his ability reconstructs his primitive environment.

Whether many would go SO far as to accept such an hypothesis, Clark thinks it may be considered as proven that (1) there is a more or less constant affective defect in all epileptics, sane as well as insane, which is due to an inherent make-up of the psyche, and that from this an intellectual and emotional deterioration is gradually developed which, if not corrected, will end in socalled epileptic dementia; (2) the epileptic change proceeds from the mental make-up of the individual long before his malady reaches the convulsive stage which is but a further step of the former. Somatic defects may be present, but when found are only regarded as contributory to the production of the fit phenomena in later life, and the main fault in the psychobiologic defect is insisted on as being in the psychical sphere. Clark's writings abound in excellent case-histories to illustrate his thesis and his early ones show that the roots of the epileptic constitution exist in earliest childhood, how the epileptic picture gradually evolves therefrom, and how the fit becomes a natural sequence. Notwithstanding its length, it seems essential to quote one of his cases in order to grasp his meaning more adequately.

A young girl of 22 years of age has had grand mal attacks since her eighteenth year. Petit mal attacks have occurred at varying intervals of weeks and months since she was 16, and are brought about by undue excitement, annoyance or any excessive stress. She feels irritated, then sullen and depressed, then 'something bursts through,' and an attack occurs. The grand mal attacks are but a further and more intense elaboration of the petit mal. While still unconscious or confused after an attack she talks baby-talk and acts like an infant, cooing and petting her mother's face or arm, and often says, "Mumsey, I wants dinky." She then snuggles down in bed, often assumes the foetal position, drawing the bed quilts tightly around her and over her head. Tongue-biting and passing urine often occur, and the usual symptoms of a grand mal attack are present. She suffers no apparent intellectual impairment, and has produced artistic works of considerable promise and worth. Ordinarily she would pass current in society as a refined and cultured young lady. We shall now note how the instincts underwent development and what part they play in the attacks above outlined.

As a child she was self-centred and early had definite set views on just how things should be done. When she could not get her way she got square with the states of irritation by day dreams and fairy tales. She never got interested in things and kept at them. She had a very lively temper and was not sociable, preferring to be by herself in her dream world. Life in a large city oppressed her and she felt fearful all the time; in a few years she moved to a small town where her family were the principal society folk of the community. She lost much of her outward irritability and became more sociable, dreamed less and seemed more willing to direct her interest and energies into better efforts to 'grow up' and get an education. She began to have better health, there were less headaches, and she slept better. However, the dream world of greatest satisfaction was ever her refuge when she became irritated or depressed; she soon began to transfer the useless wonder-world of fairy tales to that of poetic composition and story writing. The central themes of these stories were mother, childhood, the sea, and the dream fancies of infancy. Soon she grew