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ticularly dislike having them, unless there are special symptoms which entail mental suffering, some will actually desire attacks because of the release thereby of extra nervous tension, and a few have stated that they actually take pleasure in having seizures. A young adolescent who to all appearances seemed perfectly callous and unconcerned as to the outcome of his disorder, in a burst of annoyance made the frank statement: “I want these turns to come back after they are over. They give me a sense that there is still something missing, something that is not yet finished, something that I have not yet obtained. I always did enjoy them. They are a relief to me as well as being peaceful. I would like the severe one (grand mal) too, if it were not for the headache that I have afterwards.” Such conscious expressions of pleasure at having attacks, though drawn from a large material, are rather unique in clinical experience, so that the analysis of the unconscious content which may be spontaneously produced or forced during slight seizures becomes the more important. Even the minor epileptic episodes of irritation which so often herald an approaching attack are capable of analysis.
Clark states that in epileptics one has to analyse conflicts more crass than those found in most neurotics. The epileptic has a simpler emotional pattern and his resistances are less, and more superficial, than the neurotic's. On the other hand, the roots of his conflicts are deeper and constitute such a defect as is not to be strictly psycho-analysed, so that only an intensive exploration of the conscious and foreconscious life is undertaken by him.
It must be explained what content Clark mainly refers to, and how he has been accustomed to deal with such material. The interest lies in the more or less completely disorientated state at the cessation of a convulsion when the patient assumes a vacuous pleased appearance as if he heard or remembered something. While in this state, if he does not voluntarily speak he should be gently encouraged to do so about his automatic acts.
'What are you doing?” “What are you thinking about?” “What has happened?” and similar queries may be put to him, with perhaps some slight stimulation if he is too lethargic; but anything suggestive should be avoided. Usually some disjointed answer will be obtained and often in the optative mood, as “I am trying to,” “I'd like too,” or “I thought” so and so. If only a single word is received, the observer may repeat it and by tactful coaxing some amount of psychic content may be brought out. Even a few words may be of great value for subsequent free association, but often a series of cryptic phrases may be elicited. Practice is very helpful, as this stage before automatic repression sets in may only last a few seconds. In petit mal attacks any experienced person can get a mental content, but forcing one too much may unduly excite and fatigue. Whenever the same thing is said or the same action carried out in every post-epileptic automatic state, one may be certain that the patient's engrossment with such thoughts and acts has an intimate connection with his unconscious strivings. In petit mal there are modifications of the severity and different levels of unconscious impulses are tapped, but in the mildest the content is most compatible with conscious everyday desires. It is said that though with patience some material may be gained by breaking in upon the sleep of a grand mal case at the right time, the content is so archaic and crude that it is difficult to analyse and of little value. Once the patient shows annoyance at being questioned and shows resistance, one may be sure that conscious repression is again at work and nothing further is to be gained by enquiry.
Supposing we bave already considered the remote and immediate stresses that aggravate and lead up to the individual epileptic reactions and also the special psychic make-up, it now remains to analyse by free association the words or ideas found in the content spoken of above. Clark's experience is that in the analysis of the epileptic little affective reaction is shown in contradistinction to the reaction of an hysteric, and that the attitude towards the conflict and resultant disease is probably closely related. In extreme cases this makes for a poor prognosis.
In his writings this observer presents the details of many cases showing various contents and their analyses. From such clinical material he comes to the conclusion that the mental content in epilepsy proves that the epileptic regresses from the unpleasant difficulties of life, and in the first stages of the fit the stress alone may be uncovered; whenever the patient reaches a deeper unconscious state, he gains the level of an easily recognisable sexual striving. A study of the mental content, both conscious and unconscious, demonstrates (1) the depth of the unconscious regression, (2) the special types of conflict which the epileptic bas and the way he tries to solve them, (3) the specific type of primary defect in his endowment. In addition it has a therapeutic value in (4) furnishing a special point of analytic attack by simple explanatory talks, and (5) in showing more definitely the type of special education which should be adopted for each individual patient.
It remains now to see what therapeutic suggestions Clark has to bring forward as naturally deduced from his pathogenic views. In making his plea for a rational psychologic therapy he does not lose sight of the fact that sedatives and physical therapy are not without value when used in their proper sphere, and endocrine research must not be underrated.
The diagnosis, treatment and prognosis of idiopathic epilepsy should be properly made by taking into strict account the degree and kind of primary character endowment of the epileptic and its modifiability under a system of training, together with an analysis of the seizure phenomena. It follows from what has been said that the child who in its make-up shows itself to be a potential epileptic should have a special training from the start and by someone specially fitted for such a task. Tantrum episodes must be tactfully handled, and in sizing them up it must be judged when interest should be side-tracked into another channel and when they should be ignored, and there should always be a friendly review of all the circumstances that led up to them. Repressive measures must not be undertaken too early, and an alternate path must be at hand before the main issue is repressed at all, and instead the child should be taught to inhibit his own bad conduct if possible, and his attention should be directed elsewhere without coercion. The poverty of altruistic instincts renders any appeal to personal motives of little use until a much later period. Fatigue from simple mal-adaptations often soon appears and the bored or tired egoistic child has a tantrum not far distant, so that the problem of rest is not infrequently important. Less insistent demands must be made and for shorter periods of time than in normal children even in minor matters. The method by which the child secures its first adaptations to hunger and fatigue, and to social adjustments of work and play with its fellows, should be a guide for the proper after-training of the potentially epileptic child. A complete change of the make-up is not possible, but it can be modified, and a self-directive government should be the aim of a good system
a of nursery ethics. Journ. of Psych. (Med. Sect.)I
Later the school training should be intensely individualistic and constantly elastic, for the epileptic requires novelty and a wide range of educational appeal. Though he may appear intellectually retarded, this is often due to a weakened attachment to reality. The maximum of school training should be concrete rather than abstract, and along the lines in which the patient exhibits the keenest interest and most distinct capabilities. The training should slowly accustom him to types of stress which he must get used to if he is later to make a proper adaptation to life. In future the epileptic must be helped to objectivate his interest in work, study and play.
In the frankly developed epileptic, by analysis of the mental content we may determine the defective make-up and its specific conflicts, bring to the patient's mind a better insight into his malady and thus cause him to see the sequence and consequence of his crude handling of life. Simple analytic talks are supplemental guides to more definite methods of training out the personality defect. It has been found that coincidental with a gradual disappearance of epileptic reactions as shown in the fits per se, there must be a corresponding increased capacity for work and other spontaneous living interests. It is to be noted that though many epileptics may be quite deteriorated, it is often possible to train back their once discarded mental interest and thus restore much of their emotional and mental dilapidation. In the more favourable cases great improvement in the convulsive symptoms occurs in many such individuals, and more or less permanent arrest of the disorder in not a few cases.
In the foregoing I have abstracted the essence of Clark's studies in idiopathic epilepsy which, however one may regard them otherwise, cannot but be looked upon as highly interesting, stimulating and suggestive. The great majority of our neurologists have been so trained to look upon the diseases which fall within their purview in the light only of neuronic mal-functioning, that they look askance at hypotheses which have a more or less purely psychological basis. Nevertheless Clark's work is materially confirmed by much that has been discovered by research into other nervous and mental reactions of an abnormal type. Few, therefore, who are not blinded by tradition and unconscious bias, will refuse to recognise the great value of these pathological ideas and the therapeutic possibilities they open up before us. When we reflect upon the enormous percentage of epileptics in the community and how unproductive and costly they are to society, any new light thrown on the problem should be highly welcome. There is no doubt but that we are greatly indebted to the prolonged and painstaking study by Pierce Clark of this abstruse and misunderstood disease.
REFERENCES TO THE LITERARY CONTRIBUTIONS ON
EPILEPSY BY PIERCE CLARK.
(1) “The epileptic voice sign,” Med. Record, Oct. 31, 1908. (2) “Curability of idiopathic epilepsy,” Arch. of Internal Medicine, Jan. 1912, ix. (3) “A personality study of the epileptic constitution,” Amer. J. of Med. Sci. 1914,
CXLVIII. 729. (4) “The nature and pathogenesis of epilepsy," New York Med. J. Feb. 27 to
March 27, 1915. (5) "Study of certain aspects of epilepsy compared with the emotional life and
impulsive movements of the infant,” Interstate Med. J. Oct. 1915, XXII. X.
(6) “Some therapeutic suggestions derived from the newer psychological studies
upon the nature of essential epilepsy," Med. Record, March 4, 1916. (7) “Clinical studies in epilepsy," Psychiatric Bull. Jan. 1916 to Jan. 1917. Also
published in Utica State Hosp. Press, Cases I to VI, pp. 21-44. (8) “The psychological and therapeutic value of studying mental content during
and following epileptic attacks," New York Med. J. Oct. 13, 1917. (9) A further study of mental content in epilepsy,” Psychiatric Bull. Oct. 1917. (10) "Some therapeutic suggestions on the mental therapy of essential epilepsy,”
Utica State Hosp. Press, 1917. (11) “Care, treatment and management of epileptics,” Interstate Med. J. Feb. 1918. (12) "The true epileptic," New York Med. J. May 4, 1918. (13) “Notes on the prognostic value of psychometric tests as compared with clinical REVIEWS.
signs in epilepsy,” Amer. J. of Med. Sci. May, 1918.
Treatment of the Neuroses. By ERNEST JONES, M.D. (Lond.), M.R.C.P. (Lond.).
London: Baillière, Tindall and Cox, 1920. pp. viii + 233.
In this book Dr Ernest Jones has undertaken to give a review of the principal methods of treatment of the neuroses, together with the minimum of psychopathology and symptomatology necessary to make this account intelligible. For the sake of convenience, he has devoted most of his space to a consideration of hysteria, discussing the pathology and treatment of this disease in great detail, and using it to illustrate the relative merits of different schools of thought. In this way he has avoided unnecessary repetitions, and has also conformed to the historical situation, for hysteria has been more intensely studied and more extensively written about during the last half century than all the other neuroses and psychoneuroses put together. But as a leading exponent of the Freudian school, he might perhaps have been expected to devote a larger amount of space to the consideration of what he calls obsessional neurosis,' since the superiority of psychoanalysis over other forms of psychotherapy is so very apparent in this disease. Indeed, no other method is of any permanent value here, and practitioners are therefore in special need of instruction as regards the ultimate psychoanalytic solution of such cases (which are very numerous) and the main features of the technique required.
Dr Jones follows Freud in his classification of the neuroses and psychoneuroses, and has set them out in a concise but masterly way. He dismisses the Janet concept of 'psychasthenia,' since it covers a group of diseases really heterogeneous, and he treats the neuroses under the headings: ConversionHysteria, Anxiety-Hysteria, Anxiety-Neurosis, Neurasthenia, Obsessional Neurosis, Hypochondria and Fixation-Hysteria, and finally the Traumatic Neuroses. He leaves a very clear view in the reader's mind of the nature of these diseases and their inter-relations. He draws balanced and instructive contrasts, such as e.g. that between neurasthenia and anxiety neurosis. “In the former the apparent [sexual] excitations are deficient, and the efferent discharge excessive; in the latter the afferent excitations are excessive, and the efferent discharge deficient” (p. 187). Again, comparing conversion- and anxiety-hysteria, he reminds us of important contrasts: “It is true that in both there may be physical symptoms, paralysis being an instance in the one case and palpitation in the other, but these are quite dissimilar in kind. In conversion-hysteria the physical symptom is the external symbol of a group of ideas, whereas in anxiety-hysteria it is merely the expression, the necessary physiological accompaniment, of a given emotion; in the former case the symptom has a precise mental meaning, in the latter it has none” (p. 177).
There is an instructive chapter on the Prophylaxis of the Neuroses, of special significance for educationists.
The methods of suggestion and re-education are discussed in some detail, and on the whole quite fairly, although it is plain throughout that the discussion is meant to lead up to a superseding of them by the psychoanalytic method of Freud.