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openly antagonistic towards the mother and her authority. She could not bear to obey her, and yet in her fancy she day-dreamed and wrote of an ideal and harmonious relationship between mother and child. She says: "My mother is English; she is very set and stubborn and never acknowledges her mistakes even though the argument is against her." To meet this situation our patient often selects two or three points that are in her favour and thus 'saves her face' by such argumentative subterfuge, and she finally declares: "You see I am right after all." As regards her literary work, which began in her twelfth year and was discontinued when the epilepsy finally broke out, she says: "I wrote largely to relieve my feelings, bruised and harassed by an uncongenial and unsatisfying environment. Then when the 'stuff' worked itself up to a sufficient satisfaction, I got it on paper and felt relieved and satisfied." Then with a show of keen insight, she says: "You see I can't write any more now that I have attacks; the attacks let it all out of me so I have no themes or things worth while to say."

Just before the grand mal attacks came on she made an effort to sublimate the increasing demands for expression by physical activities, but she was naturally lazy and sluggish from childhood and this effort failed. She grew more morose and distrustful, and her shyness and unsociability became marked. She says: "I began to see that the close and intimate harmony with my mother which I desired and which I tried to sing of in my poems was all foolishness, and I went into open revolt against my mother's plans." Since this independent attitude asserted itself the mother, not knowing of the various internal struggles and incomplete satisfactions of a make-believe life which the daughter had led, insisted more fully that she should give her her confidence and respect. The daughter could not do this, and the fragment or wraith of a former poetic harmony disappeared. She then became definitely outspoken in her antagonism to the mother, had 'fits of temper,' sulked and hid herself from society. She became fond of argument and attached much importance to her position and views; she grew pedantic and set in her ways, and would not take on a college training as the rigid life of obedience and acquiescence fatigued and exhausted her. The irritation increased, she had fearful dreams, and headaches came on daily, except on Saturdays and Sundays, which days she spent as she pleased. She could not adapt herself to the college work and finally had a severe grand mal attack and then was quite all right again for a time; but slowly the old irritation came back. There were days of annoyance which were followed by 'blue' periods-a state in which she was not particularly depressed but in which she seemed to suspend consciousness of her environment. She did not talk, read, or do anything, yet could be easily aroused from the lethargy. Usually these 'blue' periods were followed by emotional storms of temper lasting two or three days, or she had attacks, after which the mental skies were cleared for a time. It may be said that just before the first grand mal attack at college she had been very homesick as well as unduly 'badgered' by the exacting college discipline, and that after the grand mal attack, while still in the automatic state, she fled from her room screaming for her mother.

In this case we see much of Clark's pathogenetic theory well justified. Early in life the patient showed evidence of an egocentric disposition and the unhealthy reaction of fleeing from reality into a dream world when her will was thwarted. Her mal-adaptation to her environmental conditions increased so that she became asocial, irritable, and openly antagonistic to authority.

Her attempt at sublimation of her increasing demands finally failed and after a period of increased irritability the first grand mal attack appeared.

It is true that the desire to negate reality, to become introverted and live much in phantasy, is by no means peculiar to the epileptic; for such tendencies are perhaps part of a fundamental trend which is common to many abnormal reactions. It is the whole clinical picture with a detailed life history that will demonstrate the epileptic temperament, which experience based on knowledge of these facts will confirm. Psycho-analytic findings have shown that it is in the instinctive life that we must search for the sources of abnormal adaptive behaviour, and Clark points out that in childhood the psychopathic disorders have their origin, not upon a full adult elaboration of a complicated psychic process, but upon the plane of inhibition and control of the impulsive, instinctive, reflex and ideational life of the child. Hence we should expect epilepsy to appear mostly at those periods when new adaptations are called for and special stress is apt to be felt. The great majority of epilepsies do commence in earliest life, and two-thirds occur before the twentieth year is reached, so that some error in the developmental life may be wisely suspected. Hitherto puberty has been the one stage recognised as requiring special adaptation, but our later knowledge of the developing psyche has taught us that mental struggles of various kinds take place normally in much earlier life. Clark would have it that the first stress period takes place in the first. two years of life when the impulsive and automatic processes of life have to be adapted to; and the second one when the child is beginning to walk and talk. The third, he thinks, occurs between the ages of five and eight years, when school is commenced and the social self is widening. The fourth is that of puberty, which is not only stressful physiologically but the time when parental and home ties undergo a transformation and the individual tends to lead a more independent existence. As one may well imagine, this is especially the period in which epileptic reactions may commence in those so predisposed. Clark lays especial emphasis on his observation that the actual or potential epileptic child shows abnormal adaptive tendencies even in the first adjustment called for, and draws attention to the fact that such children imperfectly perform such simple acts as those of sucking and chewing, that they tend to be incoordinate and slow in learning new movements, and show an instinctive life full of unrest. Very soon there are indications of a poor development in judgment and will, with a lability of mood. These defects, with a strong individualism and hypersensitiveness, form the nucleus of the afterdeveloping fully formed character of the idiopathic epileptic. The struggle continually goes on between the intense egocentric impulses and an unyielding environment, until pent up emotional energy finds an outlet in tantrums, rages, and lastly in definite epileptic attacks. Sudden intensive and stressful work or great adaptations to a new environment are especially apt to provoke grand mal attacks.

The want of understanding and sympathy that such reactions receive only tends to cause a greater and greater self-centredness, the outlook on life is narrowed and emotional and intellectual retardation begins. The emotional deterioration is detected in the speech, which fact has enabled Scripture through his experimental work to make recorded speech waves of special diagnostic significance. Strictly speaking, the epileptic does not lack emotional feeling, but it is wrongly directed. As he grows up his enlarged emotional power is turned back upon himself, often increasing his innate sensitiveness

and other egocentric habits of feeling and conduct. Later in the life of such epileptics the periodic attacks may be courted as a partial release of the extra tension of emotional feeling not otherwise normally directed. We find then that as greater and greater demands are made by the environment, the ability to adjust normally becomes increasingly difficult until the break occurs. If we realise the essential personal traits of the epileptic, it is not then difficult to understand with what satisfaction he retreats into a phantasyworld of his own, and how when the stress is great and potential high, reality must give way to lapses into unconsciousness. That this is the essential psychological interpretation of petit mal will be more clearly seen later when studies of the mental content are spoken of.

There comes a time when the struggle of adaptation is given up and all interest in the external world gradually ebbs. This, according to MacCurdy, is the explanation of the demential state which he thinks has no relation to the frequency or severity of the fits and which he says he can abort or often even cure by re-establishing interest in the environment and encouraging fresh adaptations. Clark says that many patients have a vague sense of the direction in which they must proceed in order to get well, and quotes a patient's remarks to this effect: "I can get well by doing the opposite of what I did in getting sick, and I want sleep and lots of it, and then I seem to want a sober, nice lot of fun, and I think in that way I will be able to release this deep down energy which doesn't find a proper outlet in any of the things that I have been accustomed to doing." It is certainly more than probable that there are many individuals in the community who from their defective psychic constitution are potentially epileptic and who abort such reactions by a continuous outflow of spontaneous interest. This point will be dealt with later when therapeutic suggestions are discussed.

Clark feels that it may be thought that too much stress is laid on the psychological settings in the causation and continuation of epilepsy and states that he recognises there are also physical counterparts to the mal-development which, if not portrayed in actual physical anomalies, show themselves in functional incompetence. This was touched upon when speaking of early defects in childhood. He therefore would also employ hydrotherapy for vasomotor disorders, adjust diets, take special measures to combat constipation and other bowel trouble, endeavour to overcome any muscular incoordination by graduated exercise, as well as train the intellectual and emotional spheres.

It is an interesting problem as to what constitutes the precipitating factor in a seizure, and though a trained observer may be able fairly definitely to predict the advent of one, the relation between cause and effect is by no means always patent. Even though an external and conscious cause of irritation is present, the real motivation is often unconscious, and a small upsetting episode may produce an attack while a more definite trauma may not be followed by one. The epileptic varies much daily in his capacity to face difficulties with equanimity. When he is spontaneously following out his own interests, he is contented and least likely to manifest any abnormal reactions; when he has to be stimulated at his work and routine he is more likely to do so; if neither condition exists he often leaves reality for the dream world, any arousal from which provokes irritability and renders him liable to attacks. Those who are in daily contact with epileptics and have care of them are fully cognizant of these facts on reflection; but how many study the problem

intelligently with a view to prophylaxis? If there be a dynamic element in the modification of the daily routine of the epileptic that tends to produce or inhibit seizures, the subject may be of prime therapeutic importance. It is, however, insisted on that the ordinary immediate stimulus to the fit in epileptics is not the irritation per se, but the repressive effort not to respond to the irritative stress which the epileptic feels; for such response, if fully allowed expression, would probably be of such violence that it would be too painful or humiliating. In time many epileptics acquire so supersensitive a mental state that even the most trivial accessions of repressions may precipitate an attack.

In order to demonstrate the frequent emotional fluctuations and how prodromal abnormal variations occur prior to a definite outbreak, Clark has devised a daily chart of epileptic reactions which in any individual case will illustrate what has been said above. Each day can be graphically recorded thereon, from below upwards, the factors of spontaneous interest, directed interest, lethargy, irritation, anger, elation, psychic phenomena, leading on to attacks of petit mal and finally of grand mal. A glance at such a chart completed for a month or two, when combined with a knowledge of the various adaptations required of the epileptic, gives one an interesting insight into the relations of cause and effect. It seems certain that any investigator sufficiently interested in the problem, would, by using such a method of analysing the patient's psychic life, find much confirmation of Clark's views. The many factors, which to the uninitiated physician may seem trivial but which to the hypersensitive and egocentric epileptic have a great significance, are thus seen in their right perspective. The inherent interest taken in some task, the amount of stimulation required to direct interest, the attitude of those who supervise, the receipt of letters, the visits of friends, the drudgery of long continued routine, are all thus seen to be modifying influences on the mental state and lead either away from or towards attacks, as the case may be. One can well understand the disastrous effects of harsh and unwise training treatment in producing the type of emotional disturbances which are frequently seen preceding attacks. In our mental hospitals how much time or trouble is taken to investigate into the origin of any recalcitrant behaviour of an epileptic? And yet so often even a superficial enquiry made by a sympathetic and understanding medical officer would reveal the source of irritation which in future might be obviated. One can so well see the disastrous effects of harsh and unwise training treatment in producing the type of emotional disturbances which are frequently seen preceding attacks. To quote two of Clark's cases in illustration.

(1) On the initiation of the observation period it was noted that the patient had been irritable and in an unstable mood. She laughed at little or nothing, became exhilarated and talked loudly when in the company of others. She found fault with trivial things. On going to bed she had a grand mal attack. She passed the following day without attacks, but in the evening had another major seizure following a period of irritation, anger, and finally elation. Next day she was irritable and angry, and refused to co-operate. The following day, however, there was an effort on her part to comply with the prescribed routines, but later in the day her interest lagged and she became irritable, angry, then elated, and later had another grand mal attack.

On the fifth she was irritated at everything and became very angry when directed to certain duties. But on the sixth she again made an effort at

readjustment and her interest for a time was spontaneous, but she soon tired and lapsed into a state of lethargy which was followed by the old irritable state. The following day another period of spontaneous interest was noted for a time, but the irritability soon reappeared and she had a grand mal attack.

The next three days the patient appeared happy and contented, going about her daily tasks without being irritated or annoyed, but on the eleventh she resented being told by her nurse that she must act in a certain way when in the company of the other guests, that she must not be talkative, etc. She became angry and irritable and remained in this mood for the rest of the day.

Following the reactions noted, there ensued a period of freedom from attack for over eighteen days. During this time the patient was active and cheerful, going about the daily routine in a happy state of mind. She devoted herself to her music and tennis and co-operated with her nurse in every way. About this time her mother took exception to certain articles of jewelry and finery that the patient wished to wear. Her mother took her to task rather severely and the patient retired to her room and cried for over an hour. She finally went to her mother and said she thought she saw the matter in the right light and would comply with her request. This episode with the mother took place at 10 in the morning and at 12.30 she had a typical grand mal attack.

(2) The patient, aet. 12, had been free from grand mal attacks for several weeks when the following incident occurred.

Boy-like, he had helped himself to some fruit which he was not permitted to indulge in. He was detected and censured. He immediately ceased his spontaneous interests and did poorly at directed ones. He was told he must apologise and restore the stolen fruit and that his comrades would be told of his misconduct. He made no effort toward handling the situation, was greatly dejected and experienced a keen mental anguish. He had an intense mental conflict with himself as to how he might get out of the situation rather than take the simple course of acknowledging his fault and making apologies, thus regaining the usual friendly relations with the people about him. He wished especially not to be shamed in the eyes of his boy companions. In this state of mind he went to bed. He moaned and tossed in his sleep, and on waking next morning he was listless and indifferent, refusing to follow the ordinary routine. All the forenoon he continued to be lethargic and indifferent, gaping and yawning, and at 11 o'clock had a grand mal attack. Immediately after the attack, although he made no effort at adjusting the difficulties, he appeared greatly relieved and went about his routine duties as if the whole matter had been quite removed. However, he was not amnesic for events that had occurred.

In these case-histories it is seen that the fit is largely a protective phenomenon, a reaction away from painful reality. It is, of course, too, a primitive method of reaction, a regression, and Clark believes that in the deepest regression the state sought or obtained in the unconscious is comparable to the extremes of infantile life. In confirmation of such ideas he has studied fragments of the mental content obtained during the milder types of seizures which show the depth of the regression which the epileptic takes. From this may perhaps be determined what bearing this content has upon the epileptic's former life and its defects. Attention is drawn to the fact that these sufferers make a poor emotional adjustment to their illness and attacks and many assume strange attitudes towards them. Not a few do not par

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