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CLINICAL STUDIES 
 IN EPILEPSY 
 
 BY 
 
 L. PIERCE CLARK, M. D., 
 
 Consulting Physician, New York City Children's Hospitals 
 
 and Schools, Randall's Island ; Letchworth 
 
 Village for Mental Defectives, and 
 
 Craig Colony for Epileptics 
 
 NEW YORK 
 
 1917 
 
 G. E. STECHERT & CO. 
 
 LEIPZIG LONDON PARIS 
 

 SUPL. SOLD, 
 
 librarian 
 
 MED. LIB. 
 
Section I. 
 
 Page 
 The Nature and Pathogenesis of Essential Epilepsy, . 2 
 
 Section II. 
 A Study of the Epileptic Makeup, the Mechanism of 
 the First Attack, and Some of the More Notable 
 Life Reactions of an Epileptic, 45 
 
 Section III. 
 A Study Upon Two Septs of Familial Epilepsy, with 
 Detailed Report Upon the Mechanism in one Epi- 
 leptic Individual of the Series, 67 
 
 Section IV. 
 Method of Graphically Recording- the Mental Factors 
 
 Precipitating Epileptic Reactions, 101 
 
 Section V. 
 Experimental Study of the Mental Restoration of a 
 
 Deteriorated Epileptic, Ill 
 
 Section VI. 
 A Study of the Mental Mechanism by which Arrests 
 Have Been Brought About in Several Cases of 
 Epilepsy, 120 
 
 Section VII. 
 Some Therapeutic Suggestions on the Mental Therapy 
 of Essential Epilepsy Deduced from Analysis of the 
 Material of this Clinical Study, 137 
 
] cfifi ical stu dies in epilepsy. 
 
 By L. Pierce Clark, m. D., 
 
 New York. 
 
 Introdiiction. The study of essential epilepsy by the case- 
 method is here undertaken to show that this disorder is a 
 logical sequence of a certain type of individual make-up in 
 the process of its natural development, and that the varied 
 epileptic reactions occurring in such individuals have more 
 or less of a definite relationship to the existent defect of in- 
 stincts, plus the precipitating causes which act as psychic 
 irritants. 
 
 The first section re-states the hypothesis of the nature and 
 pathogenesis of essential epilepsy with a review of the litera- 
 ture bearing upon this particular hypothesis; then follows 
 some case notes in abstract to illustrate the make-up and 
 the genesis of the first epileptic reaction. 
 
 The second section is based upon a study of a single case 
 to show the ordinary pathogenesis of essential epilepsy. 
 The third section is another study of the make-up, the en- 
 vironmental stresses, and the sequential epileptic reactions 
 that occur in a classic, mildly deteriorated individual. The 
 fourth section is a study of two septs of familial epilepsy 
 with detailed notes of the pathogenesis of fits in one 
 member. The fifth section embraces some therapeutic 
 suggestions derived from the newer psychologic views of 
 essential epilepsy. The sixth and last section is devoted to 
 an analysis of several arrested cases of epilepsy, and the 
 probable mechanism by which the discontinuance of the 
 disease was brought about. 
 
THE NATURE AND PATHOGENESIS OE ESSENTIAL EP-JXEESY. 
 
 Two fundamental principles were'brbught forward in my 
 first thesis* on the nature and pathogenesis of epilepsy: 
 First, that there is invariably present an epileptic constitu- 
 tion or make-up in those individuals who later develop 
 essential epilepsy. The nucleus of this personality defect 
 is a temperament of extreme hypersensitiveness and egotism 
 and all that these two main characteristics entail. This 
 defect in character is not to be taken in any narrow or 
 moralistic sense, but is to be considered as a temperamental 
 defect in a broad, biologic view, a personality-defect which 
 makes its possessor incapable of social adaptation in its best 
 setting and which, if it remain uncorrected, renders the in- 
 dividual entirely inadequate to make a normal adult life. 
 Secondly, that the seizure phenomenon in essential epilepsy 
 is a direct outcome of the inability of such persons to sub- 
 ordinate their individualistic tendencies to those of the 
 so-called social demands and constitute a reaction away 
 from the difficulties in a loss of consciousness. In the most 
 badly adapted individuals, in which the temperamental de- 
 fect is also coincident with intellectual and somatic defects 
 of a pronounced type, one may note that even the minimum 
 of environmental stress may seemingly be lacking, and yet 
 a steadily progressive epileptic state persists. In such the 
 epilepsy attains its maximum frequency and severity. In 
 other individuals less afflicted with an adaptational handi- 
 cap, the disease of epilepsy does not appear until adolescence, 
 or even later when a full adaptive demand of an independent 
 career is required. 
 
 Perhaps it is unnecessary to say that the nature of the fit 
 reaction is essentially a psychobiological one, and is doubly 
 motivated. First: it is to make away with an intolerable 
 adjustment demand. Second: it is to retreat, to regress, to 
 a state where harmony and peace were wont to prevail. 
 The most primitive pleasurable state is that which is sup- 
 posed to have existed before consciousness developed, as 
 
 *N. Y. Medical Jour., Feb. 27 to Mar. 27, 1915. 
 
has been so correctly outlined to be the infantile and foetal 
 life — a state of metroerotism. 
 
 Inasmuch as the whole hypothesis of the pathogenesis of 
 the disease rests upon the recognition of the particular type 
 of constitutional make-up of the epileptic, I shall again 
 undertake to fully illustrate the psychobiological features of 
 this particular constitution as shown in a consecutive series 
 of actual case histories, which will show the innate defect 
 and how it reacts from a demanding environment in the 
 seizure phenomena of epilepsy. Obviously this thesis will 
 concern itself with the essential mechanism of classic idio- 
 pathic epilepsy only. The wide variation in the individual 
 pattern, the possible reactions to different types of environ- 
 mental stress, etc., will have to be considered at another 
 time in handling borderland cases. This study hopes only 
 to establish the main principle of the essential epileptic 
 temperament and its seizure reactions. 
 
 A review of the literature at this point, tedious as it may 
 be, I should have considered unnecessary if in many dis- 
 cussions it had not been specifically denied that there is a 
 constant make-up, or a so-called epileptic constitution in the 
 frankly pronounced epileptic. One also finds this view 
 actively held in neurologic writings, and I therefore feel 
 obliged to re-state the connoted opinion of some of the more 
 important writers upon this subject. It may be added that 
 epilepsy, like many another nervous disorder which lies in 
 the adjacent fields of neurologic and psychiatric study, has 
 suffered in its complete delineation by the workers in both 
 fields, in that each group has ofttimes misstated the different 
 symptomatology not rightly belonging to the province of 
 each other. For instance, if one follows the psychiatric 
 literature proper, the neurologic charge against it is that the 
 disease when thus observed has had a psychiatric setting 
 added which was not present in the essential disorder when 
 it was observed neurologically, and therefore such data 
 should not rightly be interpreted as a necessary part of 
 the epilepsy itself, but attributed to certain psychic elements 
 that apparently have arisen de novo. 
 
 However, since sane interned epileptics have been har- 
 
4 
 
 bored in institutions that care for all types and grades of 
 severity of the disease, one finds that these institutional re- 
 ports adhere closely to the views of the older psychiatric 
 writers upon the constancy and degree of mental make-up 
 of the epileptic constitution and that the latter is invariably 
 present, though varying in degree, as might be expected. 
 
 We may now cite briefly the views of a few authors taken 
 at random relative to the epileptic make-up: 
 
 Vogt* in his work on the psychology of epilepsy, first 
 quotes Sommer on the epileptic psyche as a total picture. 
 Essentially he defines it as shown in a poverty of ideas, pro- 
 longed reaction time, egocentricity, many religious reactions 
 and acts of servility. All these views were confirmed by 
 the studies of Fuhrmann, Bonhbffer, Krczpelin and Isserlin 
 as well as the findings of others. Jung and Ritterhaus 
 took up the subject on a wider and more precise basis of 
 psychologic study; the former investigator found a series of 
 peculiarities in the epileptic which also occur in some degree 
 in normal subjects, especially the uneducated class. There 
 was present superficial associations, which were in part 
 influenced by the ideas of the patient. From another view- 
 point the phenomena resembled those seen in the imbecile. 
 In many cases the stimulus word called forth those 
 which were nothing but explanations; these involved the 
 egocentricity, religiosity, and the like. 
 
 Roemer having tested a patient when he was "out of 
 sorts, " found a disturbance of "secondary identification" 
 involving memory pictures, etc., while primary (special 
 sense recognition) remained normal. Einti?iger found a 
 fewness in all associations or oligophasia, with persevera- 
 tion and reiteration; all of these pointed to an essential 
 poverty in the affectivity. Wiersma found periodical vari- 
 ations in attentiveness. Finally, Ritterhaus sums up the 
 epileptic psyche as follows: There is a narrowing of the 
 circle of ideas; there is prolongation of reaction time, ego- 
 centricity, emotional reactions and circumstantiality. The 
 preceding results lose somewhat in value as but relatively 
 few epileptics were tested. 
 
 Vogt states that while we are justified in isolating major 
 
 *Vogt, " Psychology of Epilepsy" in Ascliaffenburg's Handb. d. Psychiatrie. 
 
interval phenomena, the mildest forms simply represent an 
 alteration of the total personality. When this is carried to 
 a higher degree we speak of the epileptic character ( de- 
 veloped from the alteration) ; beyond this "character" we 
 find the epileptic psychosis. Vogt declares that the " epilep- 
 tic character " is a peculiar mixture of psychic components 
 which are mutually antagonistic. Obstinacy and contrari- 
 ness may exist with a high degree of docility, apparently 
 based on change of moods. Mendacity and ethical perver- 
 sions may be seen with piety and pleasing speech; openness 
 contrasts with distrust; misanthropy with a childlike cheer- 
 fulness. Through all this variegated expression, however, 
 one notes a general tendency to a severeethical degeneration. 
 The subject becomes unsocial, quarrelsome, is inclined to 
 lie and employ violence. Hence the great forensic importance 
 of the "character." 
 
 The intellectual faculties strictly as such may remain in- 
 tact during the development of the character; until the epi- 
 leptic psychosis develops with its well known intellectual 
 failure. This is naturally accompanied by persistence of 
 the character changes — the piety, the narrowing of the 
 horizon to self and family, the emphasis of trifles, and 
 the lack of judgment. The patient undervalues his disease 
 and his mental state as he magnifies his own importance 
 and becomes arrogant, etc. Vogt finally adds that in de- 
 pressed moods the affects are one-sided, monotonous and 
 superficial; or they are irritable and manifold. They are 
 sensitive, feel uncomfortable, are whimsical and ' know it 
 all; ' they show great obstinacy, distrust, and are inclined 
 to outbreaks of rage. Their intense irritability, their utter 
 disregard and tendency to violence, make them the most 
 difficult and least welcome in institutions. The instan- 
 taneous change of mood is largely responsible in this 
 respect. 
 
 Again, under "epileptic insanity," Krcepelhi* described 
 in full a case which seems to be only an exaggerated in- 
 stance of epileptic alteration with twilight states. No true 
 psychosis was mentioned. The first case, an epileptic alco- 
 holic, exhibited much of the "character; " but the peevish- 
 
 ♦Kraepelin, ''Lectures on Clinical Psychiatry," Am. ed., 1913. 
 
ness, irritability, etc., might be attributable to the alcohoL 
 The patient seemed driven to rage and violence by severe 
 pains and other physical symptoms. These phenomena 
 seemed to appear in spells, the patient showing great de- 
 pression which in turn led him to drink. He had attacks 
 of ill- humor every week or two. The patient was normally 
 egotistic and pietistic, and boasted much of his military 
 achievements (an old soldier). He looked down on all 
 other men, could do every man's work better than the man 
 himself; he was ceremoniously polite, saluted the doctor on 
 every occasion — but also expected a salute in return. He 
 took great pleasure in saying: "The good God never for- 
 sakes a German." This patient improved when alcohol 
 was withdrawn. Another patient was most of the time 
 friendly, easy to manage, and quiet, but had frequent spells 
 of depression and ill-humor, with great irritability. He 
 stated: "I have times when I am not at all irritable, and 
 then again times when I get wild at every trifle." This 
 second case, according to Kraepelin, had not yet developed 
 the character; when he did, the author believed the patient's 
 horizon would narrow, he would become egotistical with an 
 exaggerated self-esteem, and have a tendency to phrases 
 and pious saws. Another patient gave a " connected but 
 long-winded" account of his past and present status. He 
 spoke of joyous moods. He had had states of great ex- 
 citement and had committed crimes against property and 
 person. This patient was an alcoholic. He had about 
 everything sooner or later, including a "visit to Heaven " 
 which Kraepelin ascribed to the influence of alcohol. 
 
 In summarizing the epileptic character, Arndt* states, 
 that he is possessed with an inward fervor manifested as 
 love or religion. The latter was throughout egotistic, which 
 explained in part the epileptic moment which was a mix- 
 ture of cold calculation, regardless hardness (callousness), 
 cruelty, malice, piety, etc. Nevertheless, side by side with 
 a diabolical irritability and irascibility, with uneasiness, dis- 
 trust, 'know-it-all-ness,' obstinacy, stupidity and desire for 
 mastery, he shows docility, obsequious and flattering be- 
 havior, and self-depreciation. The fire of epilepsy is like 
 
 ♦Arndt, "Lehrbuchd. Psychiatrie," 1883. 
 
enthusiasm, in the interest of revenge and bloody atone- 
 ment. In the epileptic character there is something violent 
 and titanic. Very characteristic of epilepsy is attachment 
 to the family (as a whole, not perhaps to individual 
 members); they sing the family's praises, not forgetting 
 themselves; and Morel stated that self-praise was a sign of 
 the epileptic character. Arndt believes that the alcoholic 
 character, especially the dipsomanic type, strongly re- 
 sembles the epileptic. There is the same blunt egotism, in- 
 difference to wife and children; the same reaction to 
 irritation, etc. 
 
 While BianchVs view* of the epileptic character is neces- 
 sarily drawn from the statistics of a people highly unstable 
 emotionally, it is nevertheless quite in accord with those 
 given before; thus, speaking of the psychic disturbance in 
 epileptics he rightly holds that it is always present in essen- 
 tial epilepsy, and that the latter properly begins with the 
 epileptic character. This is inherited or acquired, more 
 frequently the former, and manifests itself at an early age, 
 or as soon as the infant realizes its relationship to the family. 
 The child is less bright, i.e., more dull, than normal. It 
 weeps much and without cause, and over long periods, even 
 until cyanosed. It persists in all exaggerated and ca- 
 pricious desires, despite attempts to reason with it. It 
 reacts by scratching its face, breaks objects, raises its voice, 
 stamps its feet, threatens, etc. When to these are added 
 sleep disorders — nightmares, terrifying dreams, somnam- 
 bulism — the character is perhaps developing into epileptic 
 seizures. 
 
 In favorable cases these symptoms are outgrown; in un- 
 favorable cases the subjects are beyond treatment. The 
 morbid character undergoes a hypertrophy of the ego. In 
 childhood and adolescence the epileptic character in one of 
 its groups closely resembles the moral character of the 
 antisocial instincts of the criminal. There is the same 
 inadaptability to environment, the preponderance of in- 
 dividualistic instinct, the cruelty, laziness, vagabondage, 
 evil life, precocious and excessive character of the sexual 
 instinct, irascibility and impulsiveness in both. If at ado- 
 
 •L. Bianchi, "Textbook on Psychiatry," 1906. 
 
8 
 
 lescence there are no convulsions, the subject must be 
 regarded as a criminal (save, perhaps, when there is a 
 history of infantile convulsions). In another group the 
 personality is less profoundly disturbed. These seem nor- 
 mal, well-behaved children in the home; when they leave 
 for boarding schools, etc., an anomalous character devel- 
 ops, due largely to the teasing, chaffing, etc., of which 
 they are victims. They now show excessive irritability, 
 suspicion, impulsiveness, irascibility — in other words, they 
 act excessively to their environment. The more they change 
 the greater objects they become for provocation. The sub- 
 jects now begin to threaten, and have to be sent home, even 
 if no convulsion appear. 
 
 As maturity is approached, further changes of character 
 appear. The epileptic isolates himself, avoids company 
 and conversation and at the same time turns to religion, or 
 rather the outward forms of it. He goes to church daily 
 and at home says prayers and chants. He becomes ex- 
 cessively humble — meek and submissive to those whom he 
 meets. He assumes an attitude of in feriority and an humble, 
 reverent pose. Beneath all this, however, he is irascible, 
 captious, violent, impulsive and cruel. A slight cause 
 given, and the mask is at once thrown off. 
 
 Irascibility and impulsiveness are then, in Bianchi's 
 opinion, the chief features of the epileptic personality ; 
 epileptics lose self control completely at the least opposition. 
 Their violent, obstinate desires are too overpowering to be 
 resisted, hence the egotism. But there must be defect in 
 the associative work of the brain. Malice is based on two 
 fundamental sentiments, — consciousness of inferiority to 
 others causes hatred and suspicion ; and contrariness, from 
 permanent irritability of the ego. The whole life of the 
 epileptic shows hatred, usually concealed and veneered, 
 perhaps, with good behavior. On the slightest provocation 
 the hatred bursts forth in all its brutality — all that is evil, 
 deadly, destructive is revealed to the mind of the subject, 
 although it may not be betrayed in actual display. The 
 religious sentiments are highly primitive, mystical and 
 ceremonial. Prejudiced against so many things as they 
 
are, these subjects easily abandon themselves to onanism, 
 sexual excesses and perversions, alcoholism, etc. 
 
 The father of the epileptic Misdea is cited by Bianchi as 
 one who was not himself an epileptic but showed the most 
 profound features of the epileptic character. He used to 
 curse his brother priests because they did not walk properly 
 to chapel or carry out his orders to the letter. 
 
 They like wine (Bianchi is describing Italians), and a 
 little of it awakens their brutality. Then they become ex- 
 acting, egotistic, captious, obscene, cynical, impulsive and 
 cruel. The remarkable mobility and contrasts suggest 
 double personality ( Lombroso) . Some epileptics, exclud- 
 ing the imbecilic, are not so nearly normal as they appear. 
 Many learn trades and professions, but are weak on the 
 affect side. Keenness of attention to every day realities is 
 subnormal, and this is responsible for minor automatisms, 
 such as day dreaming, absent-mindedness and various atti- 
 tudes of preoccupation. 
 
 One must remember that Bianchi is not writing of epi- 
 leptic imbeciles or dements, but of quasi normal subjects — 
 their perceptions are weak and the memory is not trust- 
 worthy. Ideation is variable. They are indifferent to all 
 that does not concern them. Grandiose ideas are common 
 with mystic ones, and ideas of persecution are ill defined 
 and fleeting (paranoidism). 
 
 In regard to the better class of epileptics Bianchi has 
 never seen a superior intellect and character in hundreds of 
 cases treated. 
 
 It would appear that a full recognition of an epileptic 
 constitution as such, independent of the deteriorating influ- 
 ence of excessive attacks which only brings it more mark- 
 edly in view, was not much recognized before 1860 or 1870; 
 thus Fafret the elder, an observer of about that time, and 
 Billod (1882)*, a pupil of Falret, as well as Kirchhoff^ 
 who wrote as late as 1890, believed that the peculiar mental 
 make-up of so-called sane epileptics did not possess mental 
 characteristics distinguishable from others in their particu- 
 lar station in life. 
 
 * E. Billod, " Des Maladies Mentales et Nerveuses," 1882. 
 + Kirchhoff, "Handbook of Insanity," Am. ed., 1893. 
 
10 
 
 It is interesting to note the view which a practical neu- 
 rologist would have upon the presence of a particular and 
 distinctive constitutional make-up. Oppenheim* \ a neu- 
 rologist of this type, states that the intellect of an epileptic 
 may be "absolutely intact." He cites the examples of 
 Caesar and Napoleon, but quickly adds that we see no such 
 cases to-day. In another division of his work he states 
 that sane epileptics are "often excitable, suspicious and 
 irascible" but hastens to offer an apology based upon the 
 nature of the disorder from which they suffer. He finally 
 adds, however, that a normal intellect becomes impaired 
 by the fits. 
 
 As soon as the defects in the affect were recognized in 
 psychiatry independent of purely intellectual ones, a nota- 
 tion of the former began to appear in the literature of the 
 psychology of epilepsy. Thus Hoche^ noted that epilep- 
 tics undergo disturbances of the affects as well as in their 
 intellectual life. When the former are of a certain inten- 
 sity they are known as the psychic epileptic degeneration. 
 In the foreground, occurring mostly in exacerbations, we 
 find excessive excitability, oversensitiveness, whimsicality 
 and attacks of rage from trifling causes. Such states are 
 really persistent, but have, as stated, a certain periodicity. 
 The psychic interests become narrowed, especially in the 
 ethical aspects. There now develops the peculiar behav- 
 ior — absence of affection, egotism, entire preoccupation 
 in self, regardless of the rights of others, obstinacy, false 
 imaginations of being snubbed, and accusations based 
 thereon. With self satisfaction may be associated family 
 pride, bigotry, piety, etc. 
 
 "Epileptic degeneration" is a term restricted to the 
 worst of these cases ; in mild cases we see in most cases 
 only the "epileptic character." 
 
 Occasionally as early as 1887 the dissociation between 
 the epileptic constitution and the mental changes brought 
 about as the result of the attacks is to be noted in studies 
 on epileptics. Thus SeeligmiillerX quotes Nothnagel to the 
 
 •Oppenheim (translated by Bruce), "Textbook on Nervous Diseases," 1911. 
 tHoche, "Handb. d. gerichtlichen Psychiatrie," 1901. 
 
 $Seeligmuller, " Lehrbuch d. Krankheiten d. Ruckenmarks und Gehirns," 
 etc., 1887. 
 
11 
 
 effect that two widely different conditions are to be consid- 
 ered here, viz.: the central epileptic alteration, and the 
 attacks. The former is inherited, and due to descent from 
 those with neuropathic and other taints, etc. With this 
 author "alteration" appears synonymous with "predispo- 
 sition "; it does not mean dementia or secondary changes. 
 Under " iuterparoxysmal pause" we find here as with 
 other authors phenomena described which represent second- 
 ary alteration. The epileptic is a misanthrope, to a 
 greater or less extent; he is habitually out of sorts, is irri- 
 table, distrustful, obstinate, irascible, etc. At times, and 
 often near attacks he is unnaturally cheerful. This the 
 author regards as wholly due to the unfortunate social 
 status of the epileptic, his dependence on others, his loneli- 
 ness. Even the wild outbreaks of rage and destructiveness 
 may be due to the hate of all people who are normal. 
 
 In recognizing the preconvulsive make-up of the epileptic 
 constitution and citing first the egocentricity and hyper- 
 sensitiveness as the essential mental features of the picture, 
 and later the occurrence of obsequiousness, effusiveness 
 and sweetness, Regis* notes that the latter were but the 
 natural outward adjustments to compensate for the inner 
 repressed feelings. 
 
 Now and then one finds in the neurological literature as 
 in contradiction to the psychiatric or psychologic view, an 
 attempt to find an organic basis for the epileptic make- 
 up just as we have seen some authors strive to see many of 
 the mental characters produced by the social restrictions 
 which the interned epileptic endures as a result of his 
 malady. Thus Cramer^, while firm in the belief that epi- 
 lepsy proceeds from cortical alterations, becomes confounded 
 and unable to explain the constitutional make-up by such 
 changes. However, in an attempt to rationalize the latter 
 he finds certain evidence of a particular form of abnormal 
 excitability of the nerve centers of the cerebrum as a 
 result of which discharges result from the summation of a 
 "subminimum irritation", there being inconsequence an 
 
 t Regis, " Precis de Psychiatrie," 1909. 
 
 X Cramer, "Die Epilepsie," Handb. d. Nervenkrank. im Kindesalter (Bruns r 
 Cramer & Ziehen), iyi2. 
 
12 
 
 inclination to react by convulsions in such individuals. 
 Again, such a "character" is subject to disorders of 
 metabolism. He adds that many persons with the consti- 
 tution never really become epileptic as the precipitating 
 causes are not applied to such. This author lays down the 
 character make-up as shown by the same behavior and con- 
 duct as outlined by Vogt and others. While he is willing 
 to admit the foregoing is the invariable rule for the psyche 
 of adult epileptics, he takes marked exception that it exists 
 in childhood. He claims to have seen well developed cases 
 of epilepsy in the young withoiit a trace of psychopathic 
 make-up. He states, without definite analysis of any case 
 material, that he has an entire series of cases, chiefly 
 drawn from the upper classes of society, in which epilepsy 
 occurred in "model children." In school they were 
 among the first in their classes. We may interpolate here 
 to say that one knows only too well how clever and devoted 
 parents carefully shield such children from a too precise 
 character analysis. Our author seems willing, however, to 
 admit that such children begin to show the epileptic con- 
 stitution toward the end of puberty — an analogously easy 
 place for many observers to note the beginnings of many 
 another neurosis and psychosis. A double substratum 
 of degeneracy and epilepsy is postulated by our author for 
 a "very large group " of children who have the character 
 and later develop epilepsy, and then follows the general 
 description of the well outlined constitution of our conten- 
 tion. Our author's degeneracy picture is held out of the 
 epileptic entity, — he says it "can not be regarded as any 
 part of the early stage of the after-coming malady." 
 
 Nearly all authors agree that the drug habitues and dip- 
 somaniacs have an identical constitution and often more 
 marked than that seen in the epileptic. 
 
 Under the heading of "epileptic temperament," Turner* 
 notes it is rare to find epileptics without some mental ob- 
 liquity, and even when slight and unobtrusive is a feature 
 of their hereditary degeneration. On the whole they are 
 self-opinionated and egotistical, have a high degree of con- 
 ceit and assurance. Their talk is usually prolix and 
 
 *A. Turner, " Epilepsy," 1907. 
 
13 
 
 pretentious. The character is mobile and unstable, and 
 they are now elated, now despondent. This affects their 
 mental processes. Other epileptics are tenacious and obsti- 
 nate and have strong likes and dislikes. Some "great" 
 epileptics seem to have owed their greatness to grand ideas 
 and tenacity. The majority of epileptics are religious in 
 strong contrast with their practical ethical standards. 
 
 Among the phenomena of latent epilepsy Harlmann and 
 di Gaspero* believe that long before the epileptic symptom 
 complex with its first undoubted paroxysmal phenomena 
 becomes manifest, an individual may show prodromes, the 
 relationship of which, however, to epilepsy can not be main- 
 tained with certainty. They cite many variations in affect 
 life in getting family histories of epileptics, and find such 
 are hardly ever missing from such histories. Here belong 
 the tendencies to abnormal, endogenous changes of temper, 
 excitations of irascible nature, anxious fears and sudden 
 depressions. Aside from the sequalae and prodromes of an 
 attack, the authors mention marked exhaustibility, rest- 
 lessness, anomalies of disposition, increased irritability, 
 distrust, depression, anxious fears, tendency to violent im- 
 pulses. In addition to the usual slight mental defects, the 
 authors note a tendency to unreal ideas. There are also 
 memory falsifications. The affect life as a rule shows great 
 departures. There are transitory phobias, ecstasies, and, 
 most common of all, irritable and depressive states. As 
 high as 78 per cent are said to suffer from these endogeneous 
 anomalies of disposition. As a rule consciousness is clear. 
 
 Under the progressive deterioration seen in advanced cases 
 of epilepsy, the authors refer to the deterioration. As a rule 
 the subjects react abnormally to external impressions. The 
 affective changes constitute that ethical depravity of the en- 
 tire personality known as the epileptic character. We see 
 here a morbidly augmented irritability of the temper, with 
 a special tendency to affect outbreaks of anger. The pa- 
 tients are regardless, often aggressive. An egocentric 
 contraction of the entire emotional life, pathological lying, 
 etc., may develop. The patients are hard to manage, irre- 
 sponsible, unsteady, and without definite aim. They are 
 
 ♦Hartmann and di Gaspero, •• Epilepsie," Lewandowsky's Handbuch, 1914. 
 
14 
 
 obstinate but may show a heightened sensibility. These 
 states gradually pass on to dementia. 
 
 Gelineaift and Griesi?iger\ both dilate at length upon the 
 essential continuity of the primary epileptic constitution, its 
 egocentric and hypersensitive characteristics and its ulti- 
 mate degeneration into the classic mental make-up noted in 
 previous authors. The latter mentions the labile affecta- 
 bility to be inherent and to exist for years before the malady 
 as such develops; further, that the slightest demands of an 
 exacting environment cause all the mental characteristics 
 to show themselves on the surface. The former author 
 (Gelineau) cites numerous cases in which he believes over- 
 work to have caused the disease. But his views are quite 
 understandable on psychologic grounds where we find that 
 the stress of disagreeable work, beyond the desire or ca- 
 pacity of the individual, produces "moral perturbations, 
 disequilibrations, and finally convulsions." His comment 
 on the instances are that the overwork seems to be the result 
 rather by reason of the fact that the individual does his 
 work with certain " overscrupulosity " and feels an inability 
 to reach desired results. One patient in particular who was 
 a writer had his overwork induced by writing and re- writing 
 a sentence "over and over, seeking for a more euphonious 
 expression." 
 
 Voisin has stated that every epileptic is original, fantas- 
 tic and difficult to live with, and that in a careful analysis 
 of the character make-up of one hundred and forty-eight 
 cases of so-called mentally sound epileptics less than 10 per 
 cent showed a perfect balance in the emotional make-up. 
 The intellectuality in all these cases was normal or even 
 above the average. Continuing their own investigations 
 Grasset and RauziesX came to the conclusions that no epi- 
 leptic was of sound mind. It is false to declare, however, 
 that they are ' ' alienated in the ordinary sense. ' ' Their defect 
 is in the emotional realm, they are essentially egocentric and 
 hypersensitive individuals and are so in some measure from 
 birth. In describing the ordinary mental state and charac- 
 
 * T. B. Gelineau, "Traite des Epilepsies," 1901. 
 tGriesinger, " Psychische Krankheiten," 5th ed.. 1892. 
 
 Grassetif and Rauzies, "Traite pratique d. mal. d. systeme nerveux." Vol. ii, 
 1894. 
 
15 
 
 ter of epileptics in a large number, Fere* believed that 
 the character and manner of epileptics can easily cause 
 suspicion of the disease long before the convulsions appear. 
 The emotional make-up is mobile and explosive, the former 
 rests upon a foundation of "impotence and sadness." 
 They may change in mood so suddenly as to resemble a dra- 
 matic coup. Long periods of calm are interrupted by brief 
 periods of mobility. In others the latter is constant. 
 Paroxysms are separated only by intervals of repair. Sub- 
 jects pass from an attitude of enthusiasm and benevolence 
 into one of implacable hate. They may be tender and 
 generous, and then show sordid rapacity and violence. 
 They may now be polite and obsequious, then all at once 
 insolent, or may be gay and expansive, then taciturn. Some- 
 times the change is in the mental processes. A submissive 
 subject suddenly becomes an obstinate adherent to a cer- 
 tain idea. The matter may be ever so petty but he can not 
 be reasoned out of it. The epileptic is not always change- 
 able. He may become permanently attached to certain 
 people or he may cherish certain ideas and purposes with 
 most extraordinary tenacity — such as is seen in "great" 
 men. (In point of fact, this is the rule.) Violence and 
 explosiveness may be contrasted with the following periods 
 of depression and amnesia. This depression is the real 
 cause of moral malaise, religiosity, pessimism, and jealousy 
 (very common). Insolence and cruelty often pass into ob- 
 sequiosity and panphobia and are thought by Fere to be 
 due to jealousy, for the epileptic realizes his helplessness 
 and defects in a vague manner. 
 
 Matter equally pertinent is that mentioned by Ardin- 
 Delteil\ in his study of the epileptic psyche, that the men- 
 tal affectivity is a basis of defect in epileptics. The epilep- 
 tic is in a state of mental hyperesthesia which exaggerates 
 sensations and the ideas derived from them and which cause 
 irresistible acts (Echeverria) . It seems that in these brains 
 there is always a certain virtuality of explosion, ' ' a deep 
 and deaf irritation of which the convulsion is the maximum 
 term." The epileptic finds himself in a constant state of 
 
 ♦Fere, " Les Epilepsies et les Epileptiques," 1890. 
 tArdin-Delteil, " L'Epilepsie Psychique," 1898. 
 
16 
 
 nervous tension, revealed by instability, petulence, perver- 
 sion of sentiments, hyperesthesia, promptness to motion. 
 Like a drop which causes a full vase to run over, any slight 
 cause, material or mental, leads up to the explosion. The 
 "potential" accumulates until a discharge results, and a 
 multiplicity of insults may hasten it. This increase of po- 
 tential gives rise to a certain irritability which always lies 
 at the foundation of every epileptic character. Another 
 constant is instability. While the extreme irritability 
 (Hack Tuke, Bucknill) is rapidly transformed into impuls- 
 ive acts, against others or one's self, the instability makes 
 of the epileptic a being who is capricious — in the morning 
 perhaps, lively, gracious, enthusiastic, satisfied; and later 
 in the day, sad, despairing, disgusted with life, depressed, 
 religious (Clouston, Schiile, Falret) . There is therefore a 
 veritable specific epileptic character defined by the vari- 
 ability and intermittence of mental dispositions. Whence 
 proceed these tendencies toward rupture of the mental and 
 moral equilibrium? Having discussed heredity as the 
 source of this character, the author asks how may the latter 
 be recognized ? It is betrayed by intense affectivity, by a 
 real failure of the moral sense. Candidates of epilepsy as 
 well as actual epileptics are egotists, distrustful, irascible, 
 violent, impetuous, malicious, knavish, with exaggerated 
 or simulated religion and piety, and prone to excesses. 
 Their moods are bizarre, contradictory, subject to frequent 
 and rapid changes. These unbalanced persons whose 
 dominant note is irascibility and irritability appear as the 
 incarnation of vice and cruelty. In all cases, the moral 
 sense is almost constantly attacked as shown by egoism, in- 
 difference to the rights of others and absence of remorse. 
 The homicide has not a word of compassion for his victim. 
 Crimes are done with the greatest cynicism and cold blood. 
 The murderer remains near his victim or goes about his 
 occupation as if nothing had happened. The child who is 
 to be an epileptic is vicious, already irritable and impulsive. 
 His motives are futile, he isolates himself or runs away, and 
 has sombre ideas. At the slightest reprimand he speaks of 
 suicide, or absents himself for days after a chiding. 
 
17 
 
 He is sexually precocious, an onanist, has night terrors, 
 somnambulism, etc. 
 
 In his work on mental affections, Macphersori* , states in 
 regard to the make-up of the epileptic, that the general 
 mental state is distinctive, although many during the inter- 
 paroxysmal period seem quite normal and attend to their 
 business affairs. Even in the "so-called" insane and de- 
 generate epileptics the intervals may show but these same 
 oddities and eccentricities of conduct, want of self-control 
 and instability of emotions. Most of these cases are hypo- 
 chondriacs taken up entirely with themselves, their bodies, 
 etc., and also their passions, feelings and sentiments. 
 They exaggerate mild ailments, constantly demanding 
 attention. They are usually vain, self-laudatory and nar- 
 row-minded, although at the same time usually obsequious 
 and agreeable. While kind and sympathetic with one 
 another, especially when their fellow patients have fits, 
 they also quarrel fiercely among themselves. They mostly 
 profess religion and observe its forms ostentatiously, and 
 many are really sincere. Their characteristic is also seen 
 in degeneracy as is also egotism, etc. Nearly all are pas- 
 sionate, and when angered are furious. They have no 
 self-control and hence indulge in alcohol, sexual excesses, 
 indecent behavior, etc. 
 
 Anyone acquainted with the well-formed peculiar mental 
 characteristics of the frank epileptic in institutional life will 
 easily recognize the classic description of the epileptic 
 make-up as given by Pilcz* when he states the following: 
 
 In relating anything the epileptic is never diverted and 
 always arrives at a conclusion. He repeats the same story 
 in the same language, and makes free use of commonplaces, 
 proverbs, and biblical texts. As a rule they are pietists,, 
 observe religious duties scrupulously. Their devotion is at 
 times exaggeratedly sweet. They flatter by frequently pre- 
 fixing "good" and "kind" in addressing others. In 
 striking and characteristic contrast to the foregoing is the 
 unusually marked irritability, sensitiveness and egotism. 
 The patient who assures ' ' his dear doctor ' ' that he will 
 
 ♦Macpberson, "Mental Affections," 1899. 
 fPilcz, "Lebrb. d. spez. Psychiatrie," 1904. 
 
18 
 
 remember him in his prayers, will insult him by word or 
 deed if he thinks he is being slighted in any way. They 
 are almost pedantically methodical in institutions, to which 
 they bring all their knick-knacks and presents, which are 
 carefully and neatly packed. These they carry with them 
 and keep, moreover, a sort of inventory. Handwriting is 
 painfully correct, ornamental, old-fashioned, etc. 
 
 Finally, we may cite the views af H'ubner who, in a care- 
 ful analysis of the mood or disposition of the epileptic, 
 states that as a rule these set in with no disturbance of 
 consciousness. The patients seem out of sorts, taciturn and 
 isolate themselves. If one makes up to them they are gruff, 
 and refuse to respond. At the very first opportunity they 
 pick a quarrel with someone. In institutions they complain 
 of the food, demand their discharge, behave disagreeably 
 to other inmates and keepers whom they regard as preju- 
 dicial to them. The facial expression is gloomy and 
 repellant, and they are restless and on the go. This spell 
 may be a matter of hours or days. After it has passed the 
 patient gives a good account of himself, says he has been 
 ill, how everything trifling was able to irritate him. There- 
 fore it was only natural that he should behave as he did. In 
 milder cases the subject is merely sad and depressed. His 
 capacity for work is diminished but he does not react to his 
 environment. Doubtless suicide is determined by these 
 moods. During these periods of moodiness and depression 
 some epileptics seek to benumb their feelings with alcohol, 
 but bear indulgence in it very poorly. Much more rarely 
 we see cheerful moods and a diagnosis from mania is then 
 not easy, as the patients laugh, sing, joke, talk incessantly. 
 One patient also exhibited himself. These moods may 
 stand in some relationship with a seizure but are also in- 
 dependent phenomena, and separately described. The 
 author, by the way, claims that true dipsomania occurs 
 chiefly in epileptics. Aside from moods, fuges, twilight 
 states, etc., there is the slowly developing alteration of char- 
 acter. In the author's experience this is encountered in 
 from 90 to 95 per cent of all epileptics. The epileptic as a 
 rule does not lose his power of orientation of time, place 
 
 -*A. H. Hubner, " Lehrbuch. d. Forensischen Psychiatrie," 1914. 
 
19 
 
 and person. There is a slowing of thought, which seems 
 to give rise to the very careful circumstantial accounts which 
 are held by the author as evidence of general (?) defect. 
 Despite this carefulness the epileptic does not express him- 
 self clearly. The judgment is always defective in advanced 
 cases. Memory fails both as to the long known and the 
 new. In the character of the epileptic two qualities domi- 
 nate. One is the strongly marked egotism which permits 
 the patient to think only of himself and never of the rights 
 of others. The other is the inclination to piety, which plays 
 a great role in the thoughts of the epileptic. The patient 
 prays much, occupies himself with religious problems 
 (which he does not in the least understand) and tries to 
 convert those in the neighborhood. They have God much 
 in the mouth, not often in the heart. Love of neighbors 
 vanishes as soon as egotism comes to the fore. The epi- 
 leptic is a liar, consciously or unconsciously, and is very 
 distrustful. He is rarely cheerful, quiet and approachable. 
 In the main he is easily irritated, gloomy and distrustful. 
 
 In accord with the main tenets of the views given in the 
 foregoing transcripts one might cite a number of writers 
 such as Esquirol, Bischoff, Clouston, Ball, Rtissell Reynolds, 
 Magnan, Howden, Romberg, Rosenthal and de Fleury. 
 However, I think it may be considered proven as far as 
 opinions and observations of the chief investigators of our 
 subject are concerned: ( 1 ) There is a more or less constant 
 affective defect in all epileptics, sane as well as insane; that 
 such defect is due to an inherent make-up of the psyche in 
 which mainly an egoceutricity and a highly sensitized feel- 
 ing are given to the individual; and that from this 
 constitutional make-up or alteration the ultimate deterior- 
 ation of the psyche, intellectually as well as emotionally, 
 is gradually developed, step by step, and if the state is not 
 corrected that this finally and logically ends in so-called 
 epileptic dementia. (2) The epileptic alteration is seen to 
 proceed from the mental make-up or constitution of the in- 
 dividual epileptic long before his malady reaches the 
 convulsive stage and that the one is but a further and 
 final unfoldment of the former. 
 
20 
 
 Lest it may be considered unfair to present only the pre- 
 dominant and salient psychic fault as shown in the epileptic 
 constitution, I may mention also that the so-called physical 
 stigmata of the epileptic make-up may be found in these in- 
 dividuals who have epilepsy in later life. One must bear 
 in mind, however, that clinical and pathologic studies show 
 such somatic defects to be most frequently absent in any 
 large series of cases and that the physical defects therefore 
 lose their etiologic significance in the after coming epileptic 
 reactions which are shown in seizures. Again, it has been 
 urged that even though there be no gross organic defect in 
 the epileptic make-up the general functional incompetency 
 of the epileptic economy may be demonstrated. Even 
 though this view be enlarged to include the finest methods 
 of clinico-pathologic research we find no adequate etio- 
 logic ground for the seizure phenomena in a majority 
 of all cases of essential epilepsy. We are therefore thrown 
 back again upon our original contention that the fault 
 in the constitutional make-up of the epileptic is psychical 
 and can be demonstrated in every case and that somatic 
 defects, when present, are but contributory to the pro- 
 duction of the fit phenomena in later life. That is, the 
 main fault in the psycho-biologic defect is in the psychical 
 sphere. 
 
 I shall now undertake by brief citation of case histories 
 to show that the rudiment of the epileptic constitution exists 
 not from puberty, but from the earliest childhood. I shall 
 then show how the possessor of such an inheritance finally 
 evolves into the frankly established epileptic and that the fit 
 mechanism becomes a necessary corollary or sequence of 
 such an individual inheritance. I shall present as briefly as 
 possible the mechanism of attacks in the paroxysmal or peri- 
 odic cycle of the disease in a few classic cases. In 
 subsequent papers I hope to indicate the immediate and re- 
 mote therapeutic principles that may be employed against 
 attacks in particular cases, and finally give a general plan 
 for a more exact study of therapeusis for the disease in 
 futurd 
 
21 
 
 CASE I . The notes of the first case are those of a young 
 girl of 22 years of age who has had grand mal attacks since 
 her 18th year. Petit mal have occurred at varying intervals 
 of weeks and months since she was 16, and occur with undue 
 excitement, annoyance or any excessive stress. She feels 
 irritated, then sullen and depressed, and 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 fetal position, drawing the bed 
 quilts tightly around her and over her head. Tongue-biting 
 and passing urine often occurs and the usual symptoms of a 
 grand mal attack are present. She suffers no apparent in- 
 tellectual 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 inherent instincts underwent 
 development and what part they play in the attacks above 
 outlined. 
 
 As a child she was self-centered 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 fear- 
 some all the time; in a few years she moved to a small town 
 where her family were the principal society folk of the com- 
 munity. She lost much of her outward irritability and 
 became more sociable, dreamed less and seemed more will- 
 ing 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 repressed; she soon 
 began to transfer the useless wonder- world of fairy tales to 
 
22 
 
 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 openly antago- 
 nistic toward 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 mis- 
 takes even though the argument is against her." To meet 
 this situation our patient often selects two or three points 
 that are in her favor and thus ' ' saves her face ' ' by such 
 argumentative subterfuge and she finally declares: "You 
 see 1 am right after all." As regards her literary work, 
 which began in her 12th year and was discontinued when 
 the epilepsy finally broke out, she says: " I wrote largely 
 to relieve my feelings, bruised and harassed by an uncon- 
 genial and unsatisfying environment. Then when the 
 ' stuff ' worked itself up to a sufficient satisfaction, 1 got it 
 on paper and felt relieved and satisfied." Then, with a 
 show of keen insight, she says: "You see T 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 mo- 
 rose 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 frag- 
 ment 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 
 
23 
 
 from society. She became fond of argument and attached 
 much importance to her position and views; she grew pedan- 
 tic and set in her ways and wouldn't 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 
 a 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 later broken 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. 
 
 So often one hears, on the one hand, that epilepsy is a 
 specie of feeblemindedness, and on the other, that many 
 epileptics of great ability lack nothing in the make up of 
 the normal individual. The following brief history is given 
 of a man of 36 years of age who is one of the notable 
 inventive genuises of our time: 
 
 Case 2. Our patient was born a delicate child, the 
 youngest in a family of six. He was a "crying, difficult 
 child." He had teething convulsions during the first year 
 of life. He was always keyed up, slept poorly, talked and 
 walked in his sleep. At school he paid no attention to the 
 studies he didn't like. In his own description he says: 
 "Literature and the sciences simply didn't exist forme." 
 Everything in regard to mathematics and the mechanical 
 world were attained without effort. At 11 or 12 our patient, 
 
24 
 
 sensing that the father intended to have him study his pro- 
 fession of law, flew into a sullen temper and left home. 
 He lived a nomadic life for three years, during which 
 time he wandered away into other countries and elaborated 
 his various inventive ideas in the mechanical field.* A 
 clever capitalist found him in dire poverty in a foreign city 
 and from that time on our patient came into his own. He 
 grew up to be a resourceful but "peculiar" young man. 
 For instance, he has never read the daily papers, has never 
 voted, nor taken any social interest in the world. He is 
 naive and childlike in all his enjoyments. Long before his 
 epilepsy developed he had gradually lost all contact with 
 the world of reality aside from his particular inventive 
 sphere, and had he kept to this field exclusively he prob- 
 ably would not have developed an epilepsy. But four years 
 ago business conditions required him to take an active part 
 in the practical introduction of one of his greatest inven- 
 tions in a distant city. There he was on call day and night. 
 The whole scheme was on the point of falling through, and 
 he became irritated and harassed. Then, too, he had to 
 handle business conferences and social associations for 
 which he had no training or aptitude. In one of his in- 
 tensive efforts to manage a business conference and while 
 under the greatest tension in explaining his mechanical 
 apparatus to the group, the "fatigue state and irritation 
 came over him like a nausea" and he had a momentary 
 lapse of consciousness in which he says: " the little wave 
 was but a few seconds in duration, but it was very blissful 
 whilefit lasted and had I not soon learned the nature of the 
 difficulty, I should have considered it as satisfying to me as 
 a short nap." From this time on it was only a question of 
 fatigue and stress, particular business reverses, or other 
 various occasions of irritation, to bring on frequent petit 
 mal or absences which finally broke out as grand mal 
 attacks two years ago. Our patient has had peculiar attacks 
 of absences one of which I personally witnessed. He was 
 in the midst of a several hours' intricate exposition of one of 
 
 *It may be said that at present he has some fifty-six patents, all practical, 
 some thirty of which are in actual use and of great economic importance and 
 value 
 
25 
 
 his inventions, when, without other appearance than that of 
 fatigue, he had three or four absences or petit mal which in no 
 wise interrupted his explanation and following which he con- 
 tinued his discourse with even greater lucidity. I was looking 
 directly at him at the time and I knew of the "sensations " 
 only when he told me about them afterward. He said: 
 " It was as though there were an instant of eternal calm in 
 my mind. I had a sense, however, that I was automati- 
 cally continuing the long sentence I had just launched and 
 that it moved on by itself; before it was finished I was back 
 on the line of thought in time to keep the full trend of that 
 which was already started in the argument going without a 
 break. " Occasionally when our patient works continually 
 in his private laboratory for four or five days, making per- 
 fect or "fool proof " some of his most intricate mechanical 
 appliances, a sudden irritation and anger at the stupidity of 
 his assistants comes on with a hurricane fury and he brushes 
 them all aside or drives them outside and then makes an 
 attempt to do all the work himself. At once he has eight 
 or ten sensations, and immediately he feels calmed and 
 quieted. He then becomes patient, kind and considerate, 
 and again permits his workers to co-operate with him. As 
 is not uncommon in the genius or creative world, our 
 patient dreams a great deal and gets many of his inspira- 
 tions for new patents from dreams or the twilight state just 
 after waking. "Awake or asleep, I am but in the different 
 working levels of my inventive mind " he is fond of saying. 
 Again, he says: "in the 'dizzy' turns people seem to 
 move with accelerated speed (sic), and the people seem a 
 bit unreal in such activity. Of late the 'turns' are a little 
 disagreeable inasmuch as they lower the mental tension 
 although they calm my thoughts. Several times I have 
 looked at myself in the mirror when I am having an attack. 
 I appeared perfectly normal to myself, with the exception of 
 once, when my face was very red. I feel a sense of elation 
 and exhilaration when they come on and can feel it all grad- 
 ually subsiding in my mind. I frequently work two days 
 without sleep." With an intensely illumined room and 
 plenty of water to drink he works on uninterruptedly. When 
 
26 
 
 intensely absorbed in his work he is fully oblivious of time 
 or surroundings. One may summarize his character in that 
 he is egotistical and supersensitive, though simple and 
 naive. With the inrush of disturbing reality he has an epi- 
 leptic reaction. Kept free from the latter, under moderate 
 adjustments of work he is free from attacks of any sort for 
 months. It is unnecessary to say that our patient is extra- 
 ordinarily difficult of control; he simply "forgets" rules 
 and regulations of every sort, and says " I must be allowed 
 to go to the devil in my own way." 
 
 Many epileptics appear for analysis and diagnosis wherein 
 it is not possible for one to get a good detailed history in its 
 finer setting. Again, many facts are often lost in a precise 
 understanding of the make-up and the causes leading up to 
 the epileptic reaction. One must often, then, be content 
 with the feeling that the situation might be made to yield 
 much more than the surface examination shows had one the 
 whole set of facts. Not being solely intent at this time in 
 making a special thesis in this paper I have selected the cases 
 here reported somewhat at random to show that when all the 
 data are not at hand one may suspect that the full set of facts 
 would make the analysis very clear. The following case 
 was sent me in the belief that it had none of the make-up of 
 the individual epileptic, nor did the family history show any 
 of the psychic taint or predisposition which would throw 
 light on the occurrence of epilepsy in the individual patient. 
 All the data I am to report were taken in a single interview 
 and given without leading the patient or mother to the set 
 of facts that they gave. 
 
 Case 3. The case is that of a boy of 18, who has had 
 grand mal attacks monthly since the first grand attack at 14. 
 The paternal grandfather had a lively, ill-repressed temper 
 and often drank to excess; the father was nervous and irri- 
 table, and " didn't agree with anybody very often or long." 
 He was called a " dissatisfied man " and had a roving 
 disposition in search of the perfect job. He drank to ex- 
 cess, and was very "difficult " in the family. Our patient 
 and the father resembled each other strongly in physical and 
 temperamencal make up. The boy showed marked prefer- 
 
27 
 
 ence to the mother; he and the father were always at 
 " sword's points." Our patient is the second in a family of 
 three, the oldest brother having died in convulsions at 6 
 weeks. The infantile and childhood development of our 
 patient was quite normal except it was noticed that he was 
 stubborn, took correction badly, could not be driven, and 
 was very sensitive. He was the only child until 6 years of 
 age and "made the most of it." At school it was found he 
 was not tactful or diplomatic. While not quarrelsome he 
 just walked away, " threw up the game if it didn't go right." 
 He played in few games in which he was not the leader. 
 He was of a naturally cold disposition. All his innate traits 
 of temperament are quite the contrary to those of his 
 younger brother. He became a day- dreamer early and grew 
 up "hypersensitive and gloomy like his father." From 
 what may be imagined, it is easy to understand that he took 
 his father's death " bravely." The father had many con- 
 vulsions at his death from tuberculosis, some two years ago. 
 Our patient got rid of a good deal of irritation after the 
 father's death and the attacks were better than for some time 
 before. He went several months without a symptom. At 
 14 he tried to do work in a store and also keep on with his 
 school; he got behind in his studies, lost a year and this got 
 him very much irritated with the store work. He hated it, 
 but stuck to it until the nervousness and insomnia caused 
 him to walk and talk in his sleep. Then he had a grand 
 mal attack at the end of a sleep-walking period. He says: 
 "the stress of the work was too much for me; yet I am con- 
 tinually irritated because I can not go on and realize my 
 ambition in life, and this seems to make for more attacks." 
 The plan of treatment in such a case is obvious. 
 
 Case 4 is that of a man of 45, who has had grand mal 
 attacks five or six times a year since he was 14. They be- 
 gan with petit mal attacks which are now of weekly occur- 
 rence and consist of "flashes of light and a feeling as 
 though wind were blowing ever the entire body." Then 
 there occurs a vague sense of past scenes and reminiscences 
 of childhood, and he becomes unconscious. Still more 
 recently under difficult circumstances and harassing diffi- 
 
28 
 
 culties, as an attack came on in his sleep, he was heard to 
 sigh deeply and say: "The day is o'er at last." 
 
 The boyhood setting was peculiar; everything was done 
 for him; even cake was placed in a dish beside his bed so 
 that he might eat during the night if he should awaken 
 hungry. Finally, the mother passed her "spoiled" boy 
 over to the care of his wife, who has apparently been spoil- 
 ing him ever since. As a youth he learned easily and 
 graduated well in his college class at 21 years. He had few 
 playmates as a boy, was self-contained and preferred to stay 
 at home, where he had his own way. There were no par- 
 ticular conflicts called up until later life. When irritated 
 and annoyed he took himself to his music room, where he 
 "played it off on his violin." He was an egotistical and 
 supersensitive boy and was handled "with kid gloves" by 
 his parents. When things went wrong his recourse was to 
 his violin and sombre music. He was very stubborn when 
 crossed and it is said that he underwent quite a conflict just 
 before his first attack, when he was finally given a piece of 
 cocoanut pie to quiet him. He was stubborn and resentful 
 and never got square with a boy friend if he once quarreled 
 with him. He was always over-precise and wanted things 
 in their place and "placed in a box." He was rather 
 cowardly and given to self-pity as a child. He day-dreamed 
 the most of his childhood. It was said by admiring relatives 
 that such states showed that he ' ' thought deeply, ' ' little 
 knowing how deep. When he had to stop the rather idle, 
 easy life at 14 and get ready for college he could not take 
 up his violin there and he found "no other way to get 
 square." He was never cheerful, always quiet and often 
 taciturn. He craves sympathy and has never really gotten 
 over longing for his mother, now dead a score of years. At 
 14. when irritated, he would flare up and then become sullen 
 and frequently would not speak for days, staying by himself 
 in his own room. Hypersensitiveness is a marked trait in 
 the family ; an older sister is so to a marked degree, and is 
 also occasionally epileptic after fits of extreme anger. The 
 supersensitive members of the family are all absent-minded. 
 One cousin used to go away to the city forgetting his wife 
 
29 
 
 was to go with him (they are now separated from each other). 
 In early life our patient was abnormally ill at ease with the 
 opposite sex. He had but one love affair, at 26, and it was 
 reported that on being jilted it " nearly killed him." He 
 used to cry all night. He was over-anxious and irritated 
 during the whole engagement. Attacks were frequent be- 
 fore the break but none followed it. It should be stated that 
 the patient had great difficulty in repressing masturbatic 
 habits at 14 and this increased the inner tension, irritability, 
 headaches, etc., until the attacks seemed to "enable him to 
 get square with the insistent longing of his sexual desires. 1 ' 
 As might be expected, the possession of an epileptic con- 
 stitution must be found to vary in degrees in different in- 
 dividual epileptics. In the worst adapted individuals the 
 epilepsy develops pari passu with the first impingements of 
 the child upon his environment; in such one may find no 
 trace of conflict or struggle, as we know it in an adult sense, 
 the conflict may even be below the threshold of conscious 
 life as shown in a nameless dread or a general irritation 
 against the simplest demands of instinctive life. In such, 
 one often sees the simplest accidents of fright, or even a 
 startle from quiet sleep or the induction of a cold bath, may 
 cause a loss of consciousness and a convulsion. The in- 
 ternists often designate such children as spasmophilics; 
 either congenital, or acquired soon afterbirth. If one bears 
 in mind Preyer's elaboration of the psychobiologic conflicts 
 the healthy infant may pass through, how immeasurably 
 greater must be the difficulty of those children handicapped 
 by poor adaptions to the stressful life of the nursling period 
 before a subordination of the impulsive life of the child is 
 attained. The obverse of this is also true. There are many 
 individuals who successfully survive the perils and pitfalls 
 of overwhelming conflicts during the infantile and adoles- 
 cent periods only to succumb to conflicts in full adult life or 
 even later. In such one needs to research the early life 
 carefully to determine whether the epilepsy of later life is 
 really an instance of essential epilepsy or one of sympto- 
 matic and organic origin. It may be interesting to show the 
 make-up and development of such a case in which consid- 
 
30 
 
 erable doubt was entertained as to the essential character of 
 the disease until the case was thoroughly researched.* 
 
 Case 5. A man of 67 years of age, who was referred to 
 me, had had infrequent attacks of epilepsy since his 43d year. 
 A cursory examination revealed no epileptic make-up. The 
 physical examination showed our patient to be a slenderly 
 built man, so well preserved that he appeared to be about 
 twelve years younger than he really was. There was no 
 arterial degeneration and no physical or functional defects 
 other than a mild degree of constipation, which followed 
 some years after his epilepsy developed, and at a time when 
 his occupation became most sedentary in character. He 
 has had an obsessive neurosis of a classic sort — a fear of 
 riding on railroads — which does not immediately concern us 
 at this time. To research the make-up more carefully we 
 placed the patient under trained observation and the follow- 
 ing facts in development were then revealed: 
 
 Mis earliest childhood is unknown. It was, however, 
 learned that at school he found it moderately difficult to 
 learn. He had to study hard, and fretted much over his 
 studies. His standing in school was up to the average but 
 he kept up to it only with great effort. He was especially 
 good in mathematics. His reports were signed by his 
 mother with the statement that she thought the standing 
 "was good for such a nervous boy." Although he was 
 quick and impulsive as a boy, very energetic and under a 
 tension most of the time, he was obedient and never had 
 tempers or rages. He was very sensitive and paid great 
 attention to aches and pains. He was inclined to criticize 
 others, and took advice and reprimands poorly. He liked 
 to form his own judgments. He was stubborn and very set 
 in his opinions. He always had a tendency to brood, to 
 look on the dark side of things. In adolescence, he had 
 but one love affair, which was broken off by the death of his 
 fiancee. It took a long time for him to recover from it and 
 even now he thinks much of it. He has never married. 
 The sexual life was active and not unusual in its history. 
 
 *In another paper I shall undertake to show how a patient who apparently 
 possessed no epileptic make-up, yet had two epileptic children, was finally found 
 fully to accord with our theory of the disease. 
 
31 
 
 In middle life, several years before his epilepsy began and 
 after he had been in the government employ, he showed 
 poor concentration, became unambitious and lost confidence 
 in himself. Never having made a wide acquaintance in his 
 boyhood, in middle life the anti-social tendency grew upon 
 him until he was almost friendless at 45 years of age. He 
 preferred to be alone at all times. He then became some- 
 what quarrelsome and dictatorial and a great stickler for 
 having his own way. Me also began to grow suspicious, 
 resentful, easily offended, and held grudges for along time. 
 He soon became rather jealous and thought the world treated 
 him badly. Dissatisfaction with his occupation and 
 environment came on as he saw no evidence of release from 
 the governmental position he occupied, in which the work 
 was exacting and painstaking and the salary moderate with 
 no chance of advancement. His deeper interests in political 
 and civic affairs began to dwindle and became perfunctory. 
 Gradually he became less frank and open in his confidences 
 with his business associates. He kept everything to him- 
 self, as that was the easiest way. If confidence was 
 inspired from without he could still talk freely. He began 
 to doubt the sincerity of all people and contracted his own 
 "never too strong charitableness and sincerity." Finally 
 he began to get the usual attitude of old government 
 employees, that his work was not appreciated, that the 
 government was indifferent and unfriendly to long suffering 
 servants, and he talked of little else than these injustices. 
 ( Fie has now been thirty years in the government's employ. ) 
 He became definitely committed to a routine and was exact- 
 ing about the way he did everything, doing his work in a 
 methodical way. His finicky ways about personal belong- 
 ings now spread to the minutest details of his work at the 
 office. He was strong in his demands for precision and 
 order in everything and felt relieved and free only when this 
 feeling was gratified. He began to worry and fret when 
 this feeling was not met. An exaggerated demand for 
 truthfulness and justice, especially the latter, began to grow 
 upon him. Gradually he lost the little iniative he had pos- 
 sessed and submitted, but with growing intolerance, to the 
 
32 
 
 "domination" of his superiors. He then began to day- 
 dream and plan how it could all be changed for the better 
 if his superiors would but accept his advice, which they 
 seemed to seek less and less. He lost courage and hope. 
 He became moody all the time as a sort of protection in 
 some way — probably to gain comfort or respite from the 
 growing irritation of his work and his associations. He 
 then began to grow despondent without apparent reason and 
 to worry about his health, which had always been perfect 
 since a young bo}^. He finally failed to make any effort to 
 overcome his despondency and the fixed mood of dejection 
 became more or less permanent. Soon he found irritability 
 and outbursts of temper were growing upon him, especially 
 under the slightest criticism. He finally lost interest in his 
 work completely, and at last lost all satisfaction in life; he 
 was ' ' never known to smile from one year's end to another. ' ' 
 He went automatically to work following a set routine, a 
 "government hack." He then became a " cog " in an in- 
 tolerable government system which he detested but which 
 he continued to be a part of from necessity. The re- 
 pression and depression deepened until it was thoroughly 
 intolerable, although he did not openly rebel. He kept the 
 year-long grudges to himself until a few days before his first 
 grand mal attack, when he was suddenly called upon to take 
 up two men's work in mid-summer. He felt he should die 
 from the indignity and humiliation to which he could not 
 object, and he had his first grand mal attack. In other 
 words, he "blew off the accumulation of years." Since 
 then a periodic discharge slowly accumulates every month 
 and he has repeated grand mal seizures. In his prolonged 
 vacations he "feels like a new man " and has no attacks. 
 
 I submit that the inherent traits shown in this man passed 
 to their logical conclusion in an early psychic deterioration 
 which occurred long before his epilepsy broke out, and 
 when the sudden and insistent demand of irritation stress 
 was placed upon such a deteriorated make-up, an epileptic 
 reaction was the logical consequence. 
 
 Before leaving this case I may say that our patient was 
 born in this city, of normal healthy parents, was college- 
 
33 
 
 trained in this country and abroad; in business life at 23, 
 he went from one unsuccessful occupation to another until 
 the sixth one finally located him in the government employ 
 at about 37 years of age, some six years before his first 
 grand mal attack. He had, however, begun to show the 
 psychic deterioration sketched several years before he 
 entered the government service. 
 
 Case 6. A further and more intensive analysis of the 
 make-up and the precipitating psychologic setting in Case 
 VII published in my former report is interesting and worthy 
 of note here. It may be remembered that this middle-aged 
 man had the classic make-up of the epileptic constitution 
 and showed the epileptic reaction only when he was 33 years 
 old, and that he has had but four classic grand mal attacks 
 in all. He has now been for nearly two years free from any 
 major attacks of epilepsy. 
 
 In researching the dreams after the last report, he had 
 one as follows: He was talking to his sister at home about 
 business and the old controversy. She and he were very 
 aggressive but the patient himself was the aggressor. He 
 was insisting upon his position and explaining it in detail. 
 She appeared non-committal, nevertheless not apparently 
 believing or agreeing with him. A further analysis showed 
 that the patient has a tendency to "carry things on" long 
 after they have been settled. He can not rid himself of 
 business affairs after leaving the office. Invariably he goes 
 back to his own personal feelings in reference to his brother 
 and sister, whose attitudes, either in the dreams or in the 
 waking state always make him feel supersensitive. 
 
 In a further inquiry about the gastric neurosis, it seems 
 that the first belching of food took place when the patient 
 was 15 or 16. At that time his father had died and the 
 patient was ready to enter on his work of going into the firm. 
 The sister insisted upon the patient taking an apprentice- 
 ship in another business much against his inclination. He 
 disliked the work intensely, and, in his words "the appren- 
 tice business didn't do him any good and it didn't have 
 anythiug to do with the after-work he should take up as a 
 member of the family firm." The sister said, " The busi- 
 
34 
 
 ness doesn't warrant our having to pay you a salary when 
 you are doing no service to us," a statement which the 
 patient has never been able to forget. 
 
 A few weeks after this apprenticeship work was under- 
 taken he began to belch food after the evening meal. At 
 such times he felt rather depressed, annoyed, irritated, and 
 the accumulated " cussedness of the day's occupation " was 
 very nauseating to him. He could not express his views to 
 the sister and this intensified the heaviness of his stomach 
 and the feeling as though he wanted to retire within 
 himself. 
 
 At times he thought he really should submit and be sym- 
 pathetic to the family views, but he " could not really feel 
 it." There was a great deal of conscious repression with- 
 holding his very definite views that he should be allowed 
 to be independent, but nevertheless as it had been decided 
 upon that he should stay at his work he kept at it, day by 
 day, always with the feeling that he was doing so because 
 he didn't want to hurt the feelings of the family, the older 
 sister in particular. At the same time he had an idea that 
 he might be oversensitive about the matter and that it would 
 work out satisfactorily in the end, but during his entire 
 apprenticeship he was never able to get his mind reconciled 
 to the enforced occupation in the firm where he had been 
 apprenticed. 
 
 The patient admits that he always resented correction as 
 a boy, especially about any personal behavior. The whole 
 family is inclined to be critical and rather severe upon the 
 conduct of the other members of the family. When he was 
 corrected as a child he usually refused to comply. Although 
 he thinks that the criticism was unmerited in boyhood, he 
 felt the same whether it was or was not. The patient and 
 younger sister were frequently held up to personal criticism 
 and to behavior and conduct to which the other members 
 of the family didn't comply. Even though he thought the 
 demands were just, he always felt as though he didn't get 
 things "out of his system." He felt a resentment, was 
 sullen and irritable. He thinks the intensity of his objec- 
 tion to criticism steadily increased by his apparently not 
 
35 
 
 resenting it openly. A part of the more coercive aspects of 
 the criticism disappeared at the death of the father. There 
 was a sense as though his personal rights had been trans- 
 gressed and a part of it was also his natural dislike toward 
 being coerced in any way. He would carry this sense of 
 being wounded and disliked for several days. There always 
 remained a "nexus of hurtness and dislike." He usually 
 made no particular effort to get square with these unpleas- 
 ant affects but went away by himself, then resorted to 
 reading poetry and engaging in some music. After such a 
 direction of interest he felt physically much quieter and let 
 down. By not meeting things openly he thinks he produced 
 a sort of "subconscious sensitiveness," but in time he re- 
 acted openly and felt relieved by it, though he has often 
 still felt that the discharge was not up to what the affect 
 should be. 
 
 It seemed to matter little to the patient what the sister's 
 attitude might be at the time of explaining why she de- 
 manded a certain type of conduct. Her unchanged 
 attitude of superiority made him much more indifferent to 
 any pleasurable situation she might initiate in any social 
 way. 
 
 A free criticism monologue, of the doctor, runs as follows: 
 "Possibly you think I am supersensitive and that there is 
 an undue desire for harmony and sympathy, which is prob- 
 ably something at the bottom of my lack of real active 
 social intercourse and this in turn has made me extra sensi- 
 tive. I do believe that 1 lack the make-up to see things as 
 they really are and you may think that I lack something of 
 maturity sufficient to my age — that there is a lack of grown- 
 upness in my make-up — that you think I am not flexible 
 and am inexperienced; but I am not really lacking in 
 experience, as experience would not necessarily change my 
 personal attitude; so long as my personality is as it is, my 
 view on life will not be essentially changed. Further, I 
 look at things more sensibly and evenly than I did, 
 especially eight or ten years ago." 
 
 " I haven't been essentially changed as regards my char- 
 acter by the doctor's impressions, although there has been 
 
36 
 
 a decided relief in the talks. There is just as strong a feel- 
 ing of lack of sympathy in the family, and dislike toward 
 the sister, as before; but my mental emotions are less buried 
 now and find easier expression and are more easily freed. 
 My general adaptability and mental agility have improved; 
 in other words, I find it easier to relieve my mind. This is 
 greatly helped by my talking things over with my wife. 
 When I am free from the self-consciousness, I am quite a 
 different person; I am not so detached from society." 
 
 " I really think that the doctor is not quite frank and still 
 looks on me as something of a child. The doctor has not 
 told me what he thinks, but has a mental reservation as to 
 whether my years are sufficiently full of experience and I 
 think his attitude is a slightly derogatory one. I feel this 
 at times, but not so much as the doctor seems to imply. 
 There is a something neglected in his expression of what he 
 thinks which is constantly persistent. Sometimes it is more 
 and sometimes less. I think that this is largely born of an 
 idea of self-superiority and possibly born of insight and 
 knowledge. It may not be so, but it seems evident in his 
 manner. I also think that the doctor believes I am un- 
 usually susceptible to flattery. His belief is somewhat 
 analogous to that which my sister has. Occasional^, I talk 
 all these matters over with my wife and she blocks me in 
 expressing them and says it is too deep and not to be 
 talked of." 
 
 For man}'' months before the epilepsy began the patient 
 had an unpleasant sleepy feeling about 8 p. m. after dinner. 
 If the social situation is rather interesting the sleepy feeling 
 is much curtailed and is often absent. Oftentimes, while 
 reading the paper he feels a sudden general fatigue, a sort 
 of brain fag. His head feels heavy at such times, and there 
 is a burning sensation in the e}^elids. He feels this sensa- 
 tion much more when he is mentally relaxed and it often 
 lasts until he goes to sleep. When no one is at home dining 
 with him he often sleeps from 8.30 until 7 next morning. 
 If he is allowed to sleep for two or three hours at the time when 
 this lethargy is on he becomes quite all right. Ordinarily, 
 the dullness at this time contains a feeling that the state is 
 
37 
 
 dreamless. When this lethargy is on he makes little effort 
 toward keeping np bis part of the conversation, and he gets 
 only snatches of it as he arouses himself at different times. 
 
 At such times he is rather irritable and sullen. Some- 
 times he is rather ashamed of this disinclination but he 
 finally loses any sense of shame and lets himself "drift off" 
 in this semi-conscious reverie. He feels then as if he goes 
 off into space, as if he were still conscious of something 
 about him and knows where he is and what he is doing. 
 The whole sensation, however, is entirely different from 
 ordinary sleep, "something like taking ether or narcotics." 
 
 Further inquiry shows that this detacheduess from reality 
 and the states of lethargy are but heightened states of sub- 
 jectivity in which the inner life dramatizes itself, somewhat 
 like day dreams and the states of mental abstractions which 
 are common enough in those not epileptic; but that which 
 gives them a distinct pathologic import is their unmanage- 
 ableness — the slipping away at times from conscious control 
 at the behest of something in him ' ' that demands ' ' appease- 
 ment, in other words an unconscious demand makes itself 
 felt and he has an epileptic reactive setting of an otherwise 
 common enough everyday abstraction (minor automatism). 
 
 A dream in which the family conference was on again took 
 place on another night. It all concerned the friendly atti- 
 tude regarding the former disagreement; previously the 
 patient had rather sensed in the dream that something of 
 an unfriendly situation was to be brought up. It had come 
 to a climax at last where the sister's husband was actually 
 coming into the business. Our patient was outlining con- 
 ditions under which the new partner would enter. Another 
 "trivial and not fully remembered dream" was something 
 in the manner of an explanation being in progress after a 
 sleep which was begun at midnight and the patient awak- 
 ened at 5.30 and could not go to sleep again. Something 
 of the old fright of an attack seemed to be present in the 
 sleeplessness that followed, but there was something in the 
 dream state not decipherable — that was not dissimilar to 
 the old controversy. Later, analysis brought out that the 
 situation was that of the old controversy situation with the 
 sister, and her husband was present also. 
 
38 
 
 Thus one sees here the impossible reconciliation is not 
 allowed to lie dormant and unsolved. There can be no com- 
 mon truce such as one usually makes with the necessity of 
 life problem. Undoubtedly the motive that drives our 
 patient ever to seek for final peace and harmony is his ex- 
 traordinary sensitiveness and the nuclear egoistic desires 
 that no appeasement will be accepted short of full accord 
 and harmony; for it would appear that he has an irreconcil- 
 able attitude toward making life adjust precisely to his views 
 and that while he may suppress his inclination to make his 
 views known, yet he is not able to forgive, there is an 
 inability to transmute the hate and dislike into that of for- 
 giveness and love. He says "this can not be done " — that 
 the Old Testament concept "rules the world" and that he 
 probably "will have to continue with his disease if this is 
 required before he can recover." Yet he admits that he is 
 more flexible, adjustable and is taking more satisfaction in 
 life, getting a larger scope for his output of energies, espe- 
 cially his emotional feelings — the real basis of treatment in 
 such individuals. 
 
 In the reversed order of their genesis, we have attacks, 
 a gastric neurosis, supersensitiveness, day dreams, abstrac- 
 tions, and essential self-sufficiency and egotism. While the 
 patient feels supersensitive to the adaptation which he re- 
 quires of other people, he doesn't permit the same latitude 
 of feeling to others as regards his own conduct. He thinks 
 it would not be possible for him to take the initiative in 
 friendly intercourse with those of his own equal standing. 
 He is quite en rapport with his wife, whom he recognizes to 
 have a diametrically opposite personality as regards sen- 
 sitiveness. Toward no one else in the family or distant 
 relatives does he feel the same, his grandmother excluded; 
 he believes she is absolutely unselfish, but then she is the 
 counterpart of the ideal mother (the mother imago). 
 
 On going to sleep the patient frequently "starts all over," 
 and occasionally makes irrational statements such as: 
 '" What are you doing?" " No you won't." Butthe latter 
 are frequently made independent of the jumps or starts. 
 There is a sensation when the jumps are made as though it 
 
39 
 
 immediately sprang from the epigastric region and on fully 
 waking there is momentarily a sense of nausea and disturb- 
 ance of the proper feeling, which latter is not dissimilar to 
 that which exists a great deal of the time by day. The last 
 six months there has been no " disturbance of the surround- 
 ings " or other peculiar feelings after dinner. 
 
 At the time the evening sensations or lethargies were at 
 their classic stage, some three years ago, there frequently 
 was present before the eyes a bluish tinge in the air, of a 
 Japanese blue tint. This would last for two or three seconds 
 only, and often recurred two or three times in a five- 
 minute period; a possible explanation of a dimming of 
 consciousness of psychoanalytic importance. 
 
 The phenomena often occurred every two or three months 
 in rather set periods. Often at these periods there was a 
 desire to have people about, not because they gave sociable 
 intercourse — it was rather quite to the contrary — but their 
 continued presence would give the desired resistance 
 necessary for him to exert his will to keep a perfect state 
 of consciousness, and he wished to have them present 
 so that it would keep away the fear of a real lapse in con- 
 sciousness. Obviously, there were two kinds of motives 
 acting, one perfectly conscious, to retain consciousness 
 and ordinary mental activity, and the other, an unconscious 
 one, to draw the patient into a state of unreality, away from 
 his surroundings, into a different scene. 
 
 Previous to the sensation the patient often had a sort of 
 nightmare attacks in which he thought he was in different 
 surroundings, "like a dream," out of which by an intense 
 effort he was able to force himself to full consciousness; as 
 though he were "unreal and dead," and that there was a 
 struggle to get back to reality. After this there was a very 
 terrible feeling, and blueness came with it. 
 
 All the phenomena are really connected at bottom and 
 have a constant point of departure from the epigastric 
 region. The sleep sensations were as if one were fighting 
 one's way out of something, almost indescribable. This 
 goes with the blueness. 
 
 Sometimes in the past the ' ' mere thought of it " brought 
 
 J 
 
40 
 
 it on and most frequently an effort of the will was able to 
 drive it away. There was always a sense of annoyance 
 and fear. 
 
 These "different surroundings " are almost invariably the 
 same in character, not to be described, but as though the 
 patient had been there before, that he had experienced it all 
 in a sort of dream in which he was the center of the scene, 
 as if it were something that once transpired but was not 
 consciously remembered. It was like a dream-state, yet sub- 
 ject wholly to conscious review. The agreeable scenes and 
 happenings in these unusual surroundings were connected 
 with something that had taken place, or " might take place." 
 There was often a sense as though people were about as in 
 a dream. The scene and visualized sensations were of the 
 character ' ' as though he were in the center of it all, and all 
 things centered about him." The general physical sensa- 
 tion was always unpleasant and distressing when translated 
 into conscious terms or when he was fully free from them. 
 Yet while there they were all pleasant and harmonious. 
 
 It is perfectly obvious that the motive of the whole 
 foregoing type of reaction exquisitely demonstrates the 
 unconscious motivation of the whole mechanism of the epi- 
 leptic reaction, namely, the desire to abolish contact with 
 harassing and fatiguing reality and a desire to regress to 
 the infantile or fetal life of personal pleasure and freedom. 
 
 In the examination of our patient's musical and literary 
 faculties, we find that he is very fond of music, dislikes the 
 modern dancing because he finds he is a bit awkward and 
 ungraceful. Now that his violin work is progressing fairly 
 satisfactorily he finds keeping his place on the score and 
 understanding the phrasing melody are rather difficult. He 
 is a little rigid in his bowing, and does not develop the full 
 melody in the harmonies of music. In tests of reading 
 verse, poetry, etc., we find a fair attempt toward giving the 
 full meaning and expression, but there is rigidity in the 
 voice and a certain degree of improper phrasing; the rhythm 
 is a bit jerky and over-emphasized. The poetry in which 
 he is most concerned deals with the philosophy of life, its 
 meaning, tragedy, etc. 
 
41 
 
 As regards the innate feeling of being irreconcilable with 
 people who are radically and fundamentally different from 
 him, or where there is a feeling of insincerity in the attitude a 
 friend takes, are all portrayed in the dreams of the sister and 
 brother. His whole phase of reasoning and feelings, either 
 in the dreams or in the conscious state is quite the same 
 now as when a child and has not undergone any essential 
 change. The patient says: "My brother handles things 
 probably better than I do, but still I believe if he were 
 pushed to the extremity that his position and understanding 
 of things would be quite like mine; he has a way of just 
 letting it rest without settling it or coming to any final de- 
 cision or conclusion about it, while I seem destined to be 
 forever seeking for a solution and getting the matter satisfac- 
 torily ended, and to gam a harmony a?id understanding of it. 
 It may be, as you say, that my brother's way of handling 
 things is adult, while mine is still childlike; yet I believe 
 mine to be much more sincere, and to be much the better 
 way in the world." 
 
 It is common enough to get dreams, ecstatic states and 
 delirious episodes in the epileptic of all sorts of settings of 
 reconciliation or flights from reality, but the following rather 
 beautiful one is worth giving, in view of the previously de- 
 tailed history of our patient's firm attachment to the mother 
 imago and the age-long difficulties with the sister. The 
 general setting in the main is so clear that it is not neces- 
 sary at this time to point out its detailed interpretation. 
 The dream is given in the patient's words: 
 
 ' Last night I had a peculiar dream, a dream in which a 
 male cousin of mine was sitting at a table in a little way- 
 side inn, in a room next to the cafe, drinking. Very soon 
 there appeared a beautiful woman who danced about the 
 table and sang. No, she recited blank verse. She carried 
 with her some flowers which seemed to be a wreath, and when 
 she had walked about the table of my cousin, who had him- 
 self joined in the recitation, she sat down and drank with him. 
 Then she crowned him and also put some flowers in her hair. 
 Soon it was evident, in this dramatization that they were going 
 through, that she was intent upon making him drunk, and as 
 
42 
 
 the boisterousness increased with more intoxication she led 
 him to propose to her, which he did. Then suddenly it seems 
 as though the wedding- festivities had taken place and they 
 started hand in hand down the road, still reciting the blank 
 verse in dialogue. The roadway was decorated with trees, 
 shrubbery and blossoms, the sky was blue, and the whole 
 setting was that of a beautiful spring day. Suddenly across 
 the roadway a fence was interposed, which barred their way. 
 Into this fence a square hole was cut, about the size of a 
 big window. While still reciting the blank verse and act- 
 ing (although it seemed like real life), they leaned through 
 this window and seemed on the point of falling through. 
 Suddenly the fence disappeared, and in the next setting of 
 the dream the woman seemed to have fallen in the roadway 
 and received a mortal wound. My cousin stooped and held 
 the woman's head and wiped away the dirt and blood stains 
 from her face. She was still reciting to him, but the theme 
 was now changed to a long, full rhythmic metre and it 
 seemed as though she were about to die, and was asking his 
 forgiveness for all the wrongs she had inflicted upon him 
 and the things she had induced him to undertake for her 
 sake. Then she sang, or rather spoke, of Burgnovia; it 
 seemed to be a sort of Altruia, where eyerything was 
 peaceful and serene, heavenlike; a place of perfect peace, 
 contentment and satisfaction. 
 
 "To all this the man replied, in blank verse without 
 rhythm, of forgiveness; and while she was reciting this 
 ecstatic poem I felt thrilled, and as though it were some- 
 thing which I had once known myself but had forgotten, 
 and I began to recite with her the exalted words in the poem 
 dialogue. Just then, at the height of the ecstasy of the 
 words which thrilled me intensely, she arose from the road- 
 way, and the play dramatization was at an end. I 
 awakened with a start; I felt thrilled and ecstatic and abso- 
 lutely sleepless the remainder of the night. It was 3 A. M. 
 when I awoke and I remained wide awake; I was blissfully 
 happy and contented all the day and could still repeat the 
 theme in the dream, which was still ringing in my ears. 
 Otherwise, during the day everything was the same as usual, 
 and I felt quite well." 
 
43 
 
 Thus we have a reconciliation with the sister and some- 
 thing deeper, plus the "heavenly flight" from all the 
 "earthly sorrows." 
 
 Relative to the first grand mal attack that the patient had 
 six months after marriage, there were many situations of 
 adjustment at the time of getting married which disturbed 
 him considerably. After about two months of marriage a 
 trip to Europe was proposed, largely at the instigation of 
 his wife, in which plans our patient acquiesced and he pre- 
 pared to arrange for the trip, although at the time he was 
 still somewhat perturbed over the older conflicts with the 
 brother and sister, particularly the sister. 
 
 As the time drew nearer for the sailing, the patient felt an 
 increasing feeling of tension and a sort of nameless dread 
 and fear took possession of his mind most of the waking 
 period. This fear was not in reference to crossing the ocean, 
 but the possibility of illness of his wife or himself while 
 abroad. He had ' ' inwardly a very strong desire not to go, ' ' 
 but the preparations went on from day to day and he began 
 to feel under greater tension and inward disapproval of the 
 whole project. While he had made his adjustment to his 
 wife's manner of living and thought and feelings, he thought 
 that she had not quite adjusted to him. 
 
 He remembers no similar fears except when he was a 
 child, and this brings up the old associations as a child; the 
 sister had a tendency to make light of such latent fear rather 
 than treating the matter by a simple process of talking it 
 out. The ' ' mother- attitude ' ' was lacking in this as in other 
 situations previously outlined bv the patient. 
 
 The night before he was ready to sail he felt restless and 
 ill at ease, depressed, with a certain aspect of forebodings 
 and also of annoyance that his wife failed to comprehend 
 the real reasons why he didn't look with more favor on the 
 trip. The suggestion had been hers and it seemed as though 
 she had not quite caught his views, about what might be 
 worrying him. Had he taken the time, as he says, to ex- 
 plain to her, undoubtedly she would have appreciated his 
 position and probably modified plans to suit him. In the 
 patient's words, "the anticipation was as great as actual 
 
44 
 
 realization, and with this idea in mind I went to sleep. I 
 felt rather ashamed that I was so hypersensitive about it 
 and so little able to get the mastery of myself." During 
 this night he had his first grand mal attack. 
 
 When the patient was asked in what relationship he saw 
 the foregoing in relation to the attack, he said: "The 
 attack was an evasion of my mind from going on the trip." 
 
 To any one who has followed the inherent epileptic types 
 of defects of instincts and their gradual unfoldment into 
 the adult character, the gradual formation of day-dreaming, 
 mental abstractions, lethargies and dream episodes, the 
 "starts" and partial dimmings of consciousness, all of 
 which are motivated by the same unconscious forces, one 
 may wonder where the epilepsy really began. If one de- 
 sires to mark its advent by the occurrence of definite seizure 
 phenomena, then it is clear when our patient contracted his 
 disorder. But if one takes the view of the newer clinical re- 
 searches, one finds that such an epileptic as outlined here 
 has always had epileptic reactions and will probably always 
 continue to have them in some form. Obviously, the defi- 
 nite episodes of petit mal and grand mal can be fully 
 eliminated if the psychobiologic habits of life are properly 
 adjusted and the environmental stress does not suddenly be- 
 come too severe and demanding. The mystery of frequent 
 relapses in the epilepsies becomes no mystery if one views 
 such cases in their broader aspects. 
 
45 
 
 Section II. 
 
 A STUDY OF THE EPILEPTIC MAKE-UP, THE MECHANISM OF 
 
 THE FIRST ATTACK, AND SOME OF THE MORE NOTABLE 
 
 LIFE REACTIONS OF AN EPILEPTIC. 
 
 One is apt to forget that the psyche is undergoing de- 
 velopment pari passu with the physique as a whole, and 
 can therefore see no general application of the adult formu- 
 lation that the epileptic reaction is a more or less direct 
 outcome of the epileptic's inability to stand the stress and 
 harassments of life from which he seeks automatic or un- 
 conscious withdrawal. In a former essay* I undertook to 
 explain how the two principles were to be reconciled. One 
 should not think of the childish conflicts on the same level 
 as the adult ones, but no one may doubt that at their par- 
 ticular level they are as keen and painful as any adult 
 experiences. Common experience proves this to be true. 
 Not infrequently a denial of this truth has led one to think 
 that the child and primitive peoples are entirely free from 
 the ordinary trials of existence, hence the assumption that 
 nervous disorders in children occur on some exogenous or 
 physical basis rather than on a psychogenic one. The more 
 recent studies of the psychopathies of children prove that 
 the numerous disorders of childhood have their origin, not 
 upon a full adult elaboration of a complicated psychic pro- 
 cess, but upon the plane of inhibition and control of the 
 impulsive, instinctive, reflex and ideational life of the child 
 or infant. Therefore we might expect that the epochs of 
 new adaptations entailing new and more elaborated forms 
 of stress would be the periods of life in which we would 
 find the most frequent epilepsies to occur. We find that 
 
 *" Study of Certain Aspects of Epilepsy Compared with the Emotional Life 
 and Impulsive Movements of the Infant," Interstate Medical Journal, Vol. 22, 
 No. 10, October, 1915. 
 
46 
 
 two-thirds of all the epilepsies begin under twenty years of 
 age. Indeed, it has often been stated that epileptic attacks 
 occurring after twenty-five years of age are to be looked 
 upon askance, as not being of idiopathic origin. While of 
 course one knows this is not literally true, yet the fact that 
 the great majority begin in earliest life makes one hesitate 
 to ascribe the essential disorder to any other cause than an 
 error in the developmental life. This being granted, one 
 may note that the period from birth to two years is the 
 great one to which the infant finds the impulsive and auto- 
 matic processes of life must be adapted. The second stress- 
 period of marked objectivation of the individual child 
 takes place at beginning to talk and to walk. The third is 
 that of the school or community adaptations at five to eight 
 years. The fourth comes at puberty, which is the stressful 
 period of physiologic and psychologic separating of the 
 individual from the home ties. This period is the one par 
 excellence for the beginning of epileptic reactions in psy- 
 chopathically endowed children. The enormous demand 
 of social adaptations in work and the marriage relations 
 from puberty to adulthood makes us understand why so 
 large a number of epilepsies develop at this time. 
 
 Perhaps the issue is most difficult of acceptance in the 
 infantile period, hence a few remarks regarding this period 
 will not be out of place. In the development of mind, in 
 its simplest beginnings, we note that the actual or potential 
 epileptic child shows bad adaptive tendencies even in the 
 first adjustment called for. For instance, sucking, biting 
 and chewing are often imperfectly performed. Such in- 
 fants nurse at irregular intervals, they bite and chew their 
 food with gormandizing habits, they slobber and drool, 
 and bolt their food in immoderate boluses. There is often 
 a lack of rhythm and smoothness in movements of the 
 tongue and hands. Such children are often incoordinate 
 and slow in learning to sit, creep, stand and walk. The 
 jumping and climbing movements are awkward and lacking 
 in elasticity. The reflex movements are over excitable, 
 especially in regard to light, sound and contact. They are 
 easily startled. The instinctive life shown in disposition 
 
47 
 
 is without quietude and is filled with unrest in tone or 
 feeling. The extra lability of mood is shown in the mean- 
 ingless fits of crying and laughing. Finally the delibera- 
 tive life is motivated by reasons whimsical and lambent, 
 which disturbs the proper development of judgment and 
 will. Similar defects may be seen in simple psychopathies of 
 childhood, but the peculiar grouping of them around the 
 strong individualism and supersensitiveness of the epileptic 
 make-up give them, when thus constellated, the peculiar dis- 
 tinctions of the nucleus of the after-developing full-fledged 
 character of the classic epileptic. So soon as this stubborn 
 and intensive individualism comes in contact with an un- 
 yielding environment, like spun glass without elasticity, it 
 breaks into tantrums and rages, crying spells of impotence, 
 and finally into epileptic attacks of a definite character. 
 The breadth of contact with the environment is narrowed, 
 the child soon loses the advantages of physical development, 
 and emotional and intellectual retardation begins. The 
 speech and emotional expression become stiff and woodenish, 
 even though more intense defects may or may not appear. 
 If such defects of the instincts are not molded to normal 
 principles of development the individual child, not being 
 able or willing to adapt, steadily makes larger and larger 
 demands on its environment, and when this adjustment 
 is not forthcoming, the break occurs. Not infrequently 
 a sense of heightened subjective feeling comes with 
 an extraordinary supersensitiveness of the senses; thus one 
 of my little patients has learned to care only for people 
 whose touch she likes, and although but nine years of age, 
 for several years past she has unconsciously classified her 
 acquaintances by the kind and quality of handshake or 
 kiss. Another designates his friends by their individual 
 odors (like a dog). It is easy to comprehend how a dull 
 and inelastic world must disturb such barometric sensitive- 
 ness. How prosaic and stupid the ordinary sensate world 
 appear to the supersensitive epileptic, and with what 
 satisfaction he must dream of another world, where all was 
 supplied without even a wish or command. There is little 
 wonder that the epileptic imaginings and day-dreams are 
 
48 
 
 so vivid and real that reality is easily cast off in frequent 
 lapses of consciousness. It is also easy to understand that 
 with such a casual desire to maintain the proper mental 
 tension of interest such an individual may quickly deteri- 
 orate in mind and body, and that he carries in his innate 
 personality the forces for frequent severance of contact with 
 reality until the relationship, as MacCurdy has excellently 
 shown, may be more or less allowed to lapse into what 
 seems to the casual observer to be an inconsequential neg- 
 lect. A complete life study of a youthful epileptic, with 
 the, foregoing in mind, is instructive. When one under- 
 stands such a case in its extreme bearings upon origin, 
 prognosis and treatment of the disorder, the latter holds less 
 of strangeness and mystery and, above all, it clearly points 
 the way for further study of such families en bloc to estimate 
 correctly the importance and magnitude of the modern 
 problem of eugenics. 
 
 In order to estimate properly the innate defects of in- 
 stincts which our patient possesses and which will be de- 
 tailed later, it is desirable that we briefly review the make- 
 up of the family stock. The father was an extremely re- 
 sourceful business man. His early life was spent in a home 
 where extreme strictness of discipline was maintained. 
 His brothers and sisters left home early and avoided much of 
 the early exactions of the parents, but the father of our 
 patient early learned to repress his own views at home 
 and elsewhere, and grew up largely a stranger to his friends 
 and business associates. He never belonged to a firm, but 
 always carried out his business operations alone and un- 
 aided. Outwardly he gave little evidence of egotism or 
 conceit, but "deep down inside" (a favorite expression of 
 relatives in giving the real character make-up) he had such 
 definite and positive views that he was never known to be 
 persuaded to accept any others. His charities and benevo- 
 lences were of a perfunctory sort, but he saw to it that his 
 contributions were larger and more apparent than those of 
 anyone else. He had the implacable hate of an "Indian," 
 and was never known to forgive an injury. . He was extra- 
 ordinarily supersensitive, yet covered it up by retracting 
 
49 
 
 into himself or by a studied aloofness. He adapted illy to 
 new environments. Wherever he went he must have the 
 same rooms, food and service year after year. This rigid and 
 definite attitude was marked even in early manhood. His 
 wife became easily disciplined to his manner of living, and 
 seemed to have personally contributed to his rigid attitude 
 toward life until he had the home and environmental set- 
 tings of an " Oriental potentate." At the time of his mar- 
 riage at 48, his first and only love attachment, he had built 
 such a wall of reserve about him that "hardly anyone 
 penetrated it." His attitude toward the realities of life was 
 practical and matter-of-fact. He took all things seriously 
 and quietly. Never by word or sign did he show that re- 
 verses affected him. He never showed that he cared for 
 sympathy or affection. In a large business panic — eleven 
 out of thirteen banks in his native city failed at one time, — 
 he underwent a stressful financial period for three or four 
 years, but he never mentioned his difficulties to anyone 
 except in " a laconic sentence or two" to his wife. Later 
 in life (62 to 65) he displayed some tempers from which he 
 recovered slowly. He never used tobacco or alcohol, never 
 went to public amusements of any sort, and considered time 
 thus spent as a sheer waste. All his life habits were equally 
 set and formed, everything even to the exact folding of a 
 newspaper was according to a system. It was a crime for 
 him or his family to be a second late, and he insisted that 
 the whole household live on the same schedule as he had 
 planned for himself. His religious views were those of an 
 "extremely conservative Catholic," and he despised all 
 modernisms. For years he had sick headaches and " dizzy 
 turns," but they gradually ceased before his death at 68 
 from arteriosclerosis. 
 
 One may ask, why did not a man with such an extra- 
 ordinarily rigid character have "genuine" attacks of 
 epilepsy? The answer may be made that while he had a 
 narrow contact with reality, it was intense, self-generated, 
 and had continued variations of appeal such as a varied 
 business career ordinarily affords. 
 
 Inquiry into the make-up of the mother's family shows that 
 
50 
 
 there, too, is somewhat the same type of inheritance. The 
 grandfather (84 years of age) is a strong, austere man, un- 
 yielding and domineering, and "rules everything in sight." 
 The whole family — the mother of our patient included — 
 have great conceit and pride. All the women of the family 
 rule their husbands and have to be at the head of any club, 
 organization, or social affair in which they^enter. They are 
 rigid, precise and definite in all their views and purposes. 
 Added to this egotistical make-up they all have violent tem- 
 pers and "never forgive or forget." The mother says of 
 herself, " I used to have a violent temper myself, with tan- 
 trums and rages, but at my marriage at 27 years of age I 
 learned to get square with it by the training my husband gave 
 me, which, I suppose, I would not have taken or heeded 
 from anyone else. After marriage I never flew into a rage 
 as before. Under my husband's supervision I improved all 
 the time. I suppose I didn't have epileptic attacks as a 
 consequence of the suppression of incipient rages because 
 I didn't have time for them, and besides, the rapid appear- 
 ance of a large family of children made life varied and 
 interesting. Yet I did get headaches and exhausted feel- 
 ings when the rages were imminent. But after a time they 
 all disappeared, and I became a healthy, happy mother to 
 my six children. Even now though, I find the old rages 
 are deep down; they are rarely provoked sufficiently to rise 
 to the surface — and besides, I haven't got time to work 
 them up." From this statement one may infer the mother 
 has practically corrected in her make-up the potentiality for 
 epileptic reactions by a varied, earnest and continuous out- 
 flow of spontaneous interest. She has thus objectivated her 
 intense individualistic desires — a consummation devoutly to 
 be wished for in all epileptics, but which is so infrequently 
 fully attained. 
 
 The eldest son of the foregoing union is our patient, a 
 young man of 22 years of age who has had typical grand 
 mal attacks from his 17th year. The epileptic disorder began 
 with sensations, and myoclonoid ' ' jerks ' ' or spasmodic 
 twitchings accompanying such "sensations." The latter 
 symptoms still persist in the mornings before rising and 
 
51 
 
 occasionally recur during the day. It may be stated at the 
 outset that our patient suffers from no physical disability 
 whatever. He has been repeatedly examined by experi- 
 enced internists and specialists and no physical disorder has 
 ever been found that could in anyway be even remotely con- 
 nected with the causation or continuance of his epilepsy. 
 His birth was a rather difficult first pregnancy (five un- 
 eventful ones have occurred since) . The father was 50 and 
 the mother 28 years old at our patient's birth. He was a 
 bottle-fed baby and cried all the time for the first three 
 months. Teething was difficult and began only after he 
 was a year old. He was a fat baby and much constipated. 
 Although he did not cry ' ' very much ' ' after the first six 
 months, he was still restless in conduct and behavior, and 
 very stubborn and demanding. He began to talk at 18 
 months and made progress slowly and with difficulty; later, 
 at 7 to 9 years, he began to stammer, and had "speech 
 cramps " when excited, irritated or thwarted in his plans or 
 desires. He was not a physically strong child, and 
 appears to have had "latent" rickets and wore ankle 
 braces for the first few months of learning to walk. He 
 was a ' ' dainty ' ' eater, finicky and precise in little 
 ways and made adjustments slowly to the ordinary- 
 nursery ethics of the home. He was slow and " difficult " 
 in the kindergarten. Partly on account of the foregoing 
 and partly on account of his stammering, which steadily in- 
 creased in spite of special training to remove it, he failed to 
 get the regular school training. His power of concentra- 
 tion was but fair, and he was slow in "getting down to his 
 work." He had an aversion to most studies; they did not 
 really interest him and he quickly learned to day-dream a 
 good deal, which habit in its elaborated form will be dealt 
 with again in a more adult setting. He observed well in 
 some things but he often took notice of things in an odd 
 way, e. g., he often noted the stripes and colors of paint on 
 road and field carts, but could not remember who was in 
 them or how many there were. Having little interest in 
 things of an abstract nature, he turned his interest to the 
 concrete and mechanical. About this time (8 or 10 years) 
 
52 
 
 it was noticed he did not make a good friendly contact with 
 his playmates. He became exacting- and insistent that his 
 standards alone should be followed. He was quick and im- 
 pulsive, yet planned well and had a definite purpose, and 
 used tools well as everything mechanical pleased him. He 
 was active and lively as a child and always wanted to build 
 things, but in doing so they must be "just so." He was 
 egotistical yet very sensitive "deep down inside." These 
 two faculties made him rather shy and reserved with stran- 
 gers. It was said of him: " If he had an opinion and you 
 another, his must prevail. He never forgave or forgot a 
 a real injury. He was never tactful, but on the other hand 
 he did not go out of his way to quarrel. If he thought you 
 were doing wrong he would let you know about it in no un- 
 certain terms." While he was obedient as a small boy it 
 was always evident that he wanted his own way, and would 
 try to get it sooner or later. Though critical in natural tem- 
 perament, he would take advice well, or "at least listen 
 respectfully." He was easily offended and had many jeal- 
 ous moments in adjusting himself to the new situations of an 
 after-coming family of brothers and sisters. He was not es- 
 pecially frank, and never demonstrative. His reactions to 
 daily affairs were for the most part on the surface and gave 
 one no clue that there were deep currents of unrest and dis- 
 satisfaction. He has always been committed to a routine. 
 His belongings must always be just so in his room; this insist- 
 ence upon preciseness was innate and had much to do with 
 his slowness and indecision. While not inclined to take the 
 lead he did not care to be led. He was always fantastic, and 
 his air-castle building of what he wanted to do in life was 
 much beyond his innate capacity of realization, and did not 
 show a very keen insight. His mood was always one of 
 underlying seriousness. He was not enthusiastic but rather 
 pessimistic and very conservative in his innate tendencies. 
 His great ambition at the present time is to run his mother's 
 extensive farm before the superintendents in charge break 
 it down. He is quite perfunctory in his religious ideas; he 
 does not see that his attitude of not forgiving an injury is 
 essentially unchristian, and easily assumes a stern literal 
 
53 
 
 moralistic attitude toward the shortcomings of the workmen 
 on the farm. 
 
 One may picture the actual facts of his youthful career 
 by saying that when he stopped at home he did somewhat 
 as he pleased and got on fairly well; when he went to pri- 
 vate schools, usually secular, he had his main difficulties. 
 His difficulties at one of these schools are shown in the 
 following statement of the patient: 
 
 "While in this school my speech got worse; the professor 
 and another who had charge of us in the yard and during 
 the time we were not in classes threatened to mop the floor 
 with me. I was about 15 years old. There were a couple 
 of other boys as old as 17 and they were afraid of them and 
 would give in to these two men. They used to beat the 
 kids, and me too. They would use a stick or a strap and 
 were always threatening us. All the teachers did it more or 
 less, but these two in particular had the devil in them. I 
 used to get the worst of it. If we didn't stand in line just 
 right they would get cranky. They would hit us on the 
 hand and probably at night when we were in bed the} r would 
 come after us then." 
 
 It is comparatively easy, then, to understand that with 
 the demanding exactions of this school life the patient re- 
 acted with extreme nervousness, did poorly in his class work 
 and lost ground physically. In the interim between the 
 school periods, he spent his summer vacations in the free 
 open life at the seashore, horsebacking, swimming, etc., and 
 in the evenings attended dances and little social affairs and 
 theatre entertainments. In his words: "I liked this life 
 very much." In short, without stress and necessary 
 demands our patient got on quite all right. 
 
 We find that he was subject to masturbation, as early as 
 10 years of age and he remembers having discussed such 
 acts with the boys at 8 to 9 years of age. At 11 it was tem- 
 porarily stopped and he apparently got square with the 
 physical restlessness induced thereby by physical gymnas- 
 tics, coasting, and Nature study. But at 16 the habit 
 returned and he was involved in it for six months. He 
 kept it up until January or February in the year preceding 
 his first grand mal attack. 
 
54 
 
 We may now take a view of the mechanism of the onset 
 of the attack: First we have the instinctive defect as 
 already outlined; this entailed an inadequate development, 
 retarded his intellectual processes and rendered him inade- 
 quate to meet the school training (probably not of the best) 
 but which many another boy stood and "got away" with. 
 His precocious sexuality at puberty ran an irregular and 
 prolonged course and he failed to make the next adaptation 
 in adolescence required of the normal boy. He could not 
 sublimate the defective puberty habits into an objective life 
 of work and play and sympathetic outside interests. Re- 
 garding his school life he says: "You see I am naturally 
 slow and deliberate and I think I was sort of paced off my 
 feet. Of course, I didn't study or work harder than any 
 number of other boys, but I just simply could not do as they 
 did and get away with it." 
 
 When asked what happens at the slight sensations he 
 says: ' ' The loss of consciousness is much like taking ether 
 or chloroform. I seem detached and slowly sinking out of 
 life. Things seem far off and I am removed from life; not 
 dead, but just suspended, away from things." Thus one 
 sees he is involuntarily withdrawn from reality, which 
 happens to coincide with the motive of his conscious desire. 
 
 Thus the motivation of the first series of ' ' sensations ' ' 
 and attacks would seem to have. been brought about, in part 
 at least, by certain types of pleasurable acts that are com- 
 monly employed for " outraged nerves " as seen in many 
 another neurotic. Further, the patient says: "After the 
 severe attack if they put something cold on my head it 
 seemed to soothe me, and in point of fact when I was a 
 child stroking my head by someone whose hands were cold 
 often put me to sleep and lessened my headache, and has 
 apparently often prevented my attacks." 
 
 Regarding his attacks of anger and general irritability, 
 he says: "When I get angry to a moderate degree I walk 
 away from the difficulty, but if it grows serious I burst out 
 in a torrent of words; I see red, I fight and I never am really 
 able to forget or forgive an injury." 
 
 Regarding his habit of day-dreaming and its use, vicari- 
 
55 
 
 ous or otherwise, as a help to ward off attacks or to get 
 square with a too demanding environment, our patient says: 
 " I think from the period beginning with the stress in school, 
 and more frequently thereafter, I day-dreamed a great deal. 
 When things went badly I used to day-dream more. Just 
 preceding the day-dreams and castle-building I would be a 
 little depressed and the day-dreams seemed to help me out 
 of it." 
 
 Again, in further elaboration of the cause of the disorder 
 of flights away from reality (loss of consciousness) and the 
 desire for acts of pleasurable liberation of a crude sort our 
 patient states: " You see, my physical coordination is slow; 
 I never drew well nor did any mechanical thing easily, and 
 when I am hurried up or the work is more exacting it often 
 drives me into a sort of muscular cramp, particularly in 
 my speech. I felt in school as if I were over- pushed and 
 when I came home I wanted some fun, some other kind of 
 energy in me needed to be released. You see I had an hour's 
 lesson of speech work and then I went bicycling, but I had 
 to bicycle very fast to cover the distance to get -to the gym- 
 nasium and back; neither the gymnasium work nor the 
 cycling was real fun; they were too forced and it was too 
 much in the nature of a drilling for me to take it leisurely 
 or get as much fun out of it as I would have had had I 
 played handball and free sports." 
 
 Many patients have a vague sense of the direction in 
 which they must proceed in order to get well, as shown in 
 our patient's remarks, "I can get well by doing the op- 
 posite 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." 
 
 To show that the stammering is a part of the same mech- 
 anism as the epilepsy, we note the patient's statement, "My 
 stammering and inability to speak gradually came on at 
 six or seven years and was worse every time I put prohi- 
 bitions against free pleasures, play, and finally self-abuse, 
 and whenever difficult tasks were to be met, like reciting, 
 
56 
 
 talking over the telephone or meeting people (defense 
 mechanism and prohibition). When I am not tired and not 
 obliged to hurry and can take my own leisure I have little 
 or no stammering." 
 
 For a short period before the disease developed and ever 
 since that time there has been a sudden wave-like fluctua- 
 tion of three to four weeks of feeling quite all right and 
 three to four weeks in which the patient is nervous, a little 
 irritable, slightly depressed, and the stammering is much 
 more intense. These depressions in general feelings and 
 general fitness succeed a number of different causative fac- 
 tors, such as lack of sleep, too much excitement, over in- 
 dulgence in food, and depressing emotions and exhilarations 
 due to too much social activity. 
 
 Very frequently during the depressed periods there occur 
 slight mental abstractions during which the patient persists 
 in the activities previously indulged in and during which 
 he is unable to undertake any new alteration of the same 
 (slightest grade of diminished activity of consciousness 
 short of an attack). During the nervous and depressed 
 periods our patient conserves his energies by sleeping longer 
 in the morning, engages in such mild occupations as going 
 to the post office, doing simple errands, seeing a few family 
 friends or lying about reading light literature that requires 
 no special effort. If sudden intensive and stressful work is 
 called for, or great adaptations to a new environment is re- 
 quired, he is apt to have a severe grand mal attack. He 
 has always disliked the city and liked the freer life of the 
 country where he can take things easy and do things that 
 he has an inclination to do. He would now enjoy going to 
 the city for a day or two and ' ' speeding it up, ' ' and then 
 would like to return for a comfortable rest in the country, — 
 the basic principle in many a "periodic' ' 
 
 Another attempt at elucidating the motive producing the 
 epileptic disorder shows that the mildest sensations began in 
 August or September of 1910. It seemed they were brought 
 about by an inability to get rid of the "energy" and, on mak- 
 ing an attempt, to force sleep; when this state of mental ex- 
 hilaration was on, thoughts of a rather exciting character, 
 
57 
 
 which had formerly been of a sexual nature, were now di- 
 rected toward driving' automobiles, sailing ships, riding the 
 bicycle, etc. Such thoughts were not satisfying and in- 
 creased the tension, and when these thoughts were turned 
 away from and sleep did not supervene the feelings of a 
 "sensation" occurred. In a still more frankly autobio- 
 graphical statement he said, " If I had had someone to do 
 things with me I would have been able to liberate thL energy. 
 When I knew that I had to go to sleep the concentration of 
 my mind on the necessity for sleep would bring on the sen- 
 sations. These sensations were, and still are, the fore- 
 runners of the same kind of things that lie at the bottom of 
 my severe attacks. There was a sensation in the head as 
 though it was shaking inside, a vibration; it was slightly 
 unpleasant as it interrupted the ordinary train of thought 
 and yet it gave relief and I could then go to sleep." 
 
 Again, "I tried to make the exhilarating thoughts of 
 ordinary physical activity succeed the sexual thoughts 
 completely about in May. I had succeeded in getting 
 square with the former in greater part during the winter and 
 they dissappeared entirely in May or June." Then in July 
 and August all sexual ideas were completely changed into 
 strivings for physical activity, dancing, swimming, etc. 
 But these did not give full freedom to the pent-up energy, 
 and additional efforts towards forcing the mind to change 
 from these to that of a mental concentration on going to 
 sleep was sufficient to break the mental states into attacks. 
 He says, " It was as though I had a certain kind of a job 
 to do in order to go to sleep. After a time the sensations 
 seemed to be caused from a loss of sleep and then concen- 
 tration of the will made them more frequent and severe — 
 the sensation and the loss of sleep made the necessity for 
 sleep all the more important, but the sensations seemed to 
 make sleep a little more easy to attain; they let off the extra 
 tension." Similar reasoning is given in the not infrequent 
 use of alcohol when one is extra fatigued and can not get to 
 sleep. The same principle is shown in the whining cry of 
 infants who are too excited or fatigued to go to sleep until 
 they have had their crying spell. 
 
58 
 
 He continues, ' ' I am persuaded that the sensations and 
 the disease really all began in my mind and the difficulty 
 of controlling the same, and making it become satisfied 
 with things as they really were, especially in the ability to 
 change my train of thought from the unsatisfying physical 
 activities to that of going to sleep. In September the sen- 
 sations came fast and severe when I was really starting in 
 at very hard school work and when there was no pleasure 
 to keep my mind in an active state, or even half way satis- 
 fied, such as had been the case during the summer. I felt 
 all in. If there was an accumulated fatigue the sensations 
 would come up on trying to go to sleep." 
 
 Since coming under trained observation and treatment 
 (a period of ten months) our patient has had but two grand 
 mal attacks, although his daily average dose of 45 grains 
 of bromides has been entirely removed. The patient seems 
 to have been able to drive all conscious thoughts of sexual- 
 ity as such out of his mind, but as usually happens in such 
 direct repressions when the former are not digested or sub- 
 limated, the dreams are filled with sexual matters, most 
 frequently of the simplest and crudest sort, and occasion- 
 ally with those of a thinly disguised symbolical character. 
 Such dreams occurred almost nightly for the first month. 
 As time progressed, however, they became less frequent 
 and insistent until now (end of ten months) they are from 
 a week to two weeks apart. He says, "A nocturnal emis- 
 sion makes me feel the next morning as bad as though I 
 had had an actual attack, yet the dreams (nocturnal emis- 
 sions) seem to provoke an attack; they seem to stir some- 
 thing in my mind, deep down that must come out or up." 
 We know the nocturnal emissions or even masturbation 
 often serves as an inciter to normal desire for coitus. Prob- 
 ably the lack of a conscious psychic discharge in such 
 dreams or masturbatic acts creates a real need for the latter. 
 Still more likely, the dream was but the organic demand 
 not gotten square with in the daily sublimations. In some 
 measure the sensations and attacks in this case are defin- 
 itely related to this unrequited psychic discharge teased up 
 by nocturnal emissions. However, most frequently the 
 
59 
 
 causes for individual attacks, now seen in our patient, are 
 endogenous. For instance, abreacting from a painful sit- 
 uation, that of a fellow patient's death, our patient had 
 been much concerned to find that his companion could not 
 be recovered from his fatal pneumonia; he became some- 
 what depressed, day-dreamed, was listless in his usual 
 sports and duties and finally had a grand attack, and while 
 confused in the state subsequent to the convulsion (auto- 
 matic state) he went to his own bed and lifting the cover- 
 let he corkscrewed his way under the bedclothes until he 
 reached the foot; after getting a little breathing space he 
 drew all the clothes snugly over his head and body and 
 with a rhythmic petting and rocking of the body he then 
 went to sleep. But just before he fell asleep he was heard 
 to mutter, "Everybody is all right now; Mr. A. is well, 
 isn't he?" 
 
 I would consider the above to be an abreaction from a 
 too painful situation and an infantile flight to the protection 
 and comfort of a state of metroerotism. Although he went 
 about much relieved after this attack, on learning his friend 
 was not better but considerably worse he was again de- 
 pressed; as he said, "it is still in my system and not out 
 yet." 
 
 In order that he might receive the benefits of vocal cul- 
 ture for stammering he was given lessons for two or three 
 months. We find singing defects in our patient analogous to 
 those noted previously in other epileptics (Clark sign), a gross 
 defect in the general emotional life. His teacher reports 
 that he had a very defective faculty of appreciation of notes 
 by the ear, and was not able to sing the scale when he be- 
 gan his work, but after some practice he is now able to strike 
 octaves on the key with few exceptions. The melody and 
 harmony qualities of the voice are bad. The tones are not 
 well sustained and the phrasing is still very incoordinate. 
 
 To show how slight and trivial the external cause may be 
 in inducing attacks in such an individual, it was noticed 
 at first that whenever attention was forced, especially to 
 giving attention to conversation or explanations where the 
 subject was a difficult one to follow, the patient often felt a 
 
6o 
 
 sort of aching pain that arose from the back of his head 
 and came to the front, and this endured for a period of eight 
 or ten seconds. During this time patient said he was 
 half conscious, felt rather absent-minded but was able to 
 repeat what was actually going on; he was unable to hold 
 his mind on the subject, and would not be able at such 
 times to reply in an intelligent manner. This was particu- 
 larly so when he started on a subject which someone was 
 reading to him, or when he was greatly fatigued. The sen- 
 sation came from the back of the head and projected for- 
 ward to the right eye and sometimes to the left. As the 
 sensations gradually disappeared these states of mind, 
 which were a sort of warning of lighter phases of what 
 would have been sensations, seemed to take their place. 
 
 After three months of special treatment it was noted that 
 our patient fussed less about his room, his habits were more 
 orderly, direct and definite, he did better work, was more 
 persevering, less irritable and made excellent progress in 
 his reading and discussion of ordinary events of everyday 
 life. The sensations were much less frequent, many times 
 only to be recognized by the patient himself. The myo- 
 clonic jerks were seen only at times, as noted in the notes 
 that follow. There was a steady decrease in childish traits 
 and manner of conduct; coordination was better; the speech, 
 except on occasions when he was under considerable ex- 
 citement, was very nearly normal. In the dreams his gen- 
 eral attitude was much less openly sexual in character, the 
 nervous periods were less intense and less resistant. As 
 regards the day-dreaming, on the tennis court it was fre- 
 quently noticed that he would be fairly talkative, would 
 stop his work, and stammer badly. Very frequently his 
 ideas became so vivid to him that he stopped working and 
 stared in front of him or looked listlessly in the opposite 
 direction and it seemed as though he was having a petit 
 mal attack. Careful analysis showed that this was but a 
 form of day-dreaming in which he was carrying out some 
 elaborate fancy about what he intended to do when he got 
 home. 
 
 The simple use the patient makes of dreams of attacks is 
 
61 
 
 given in the following instance: In the night he had 
 dreamed that he had had an attack and that when he awak- 
 ened next morning he wanted to go down to his breakfast 
 but the nurse would not let him, saying that he would bring 
 his breakfast up to him. The patient thought this dream 
 was real, as his nurse was dressed and out of the room when 
 patient awakened in the morning. 
 
 Under precise daily analysis and observation we find that 
 our patient begins the day by dressing according to a defi- 
 nite routine which is invariably followed. When this 
 routine is interfered with he becomes sullen and uncom- 
 municative and finally if not released from it, he flies into 
 abusive rages. His greatest wish, which lies at the bottom of 
 his day-dreams, is to return home and assume his position 
 as head of the family; to enlarge the ranch, and to make suf- 
 ficient money so that he would not have to borrow from 
 anyone; he wants motor cars, a launch and a private fishing 
 and hunting preserve. He never expresses a wish that does 
 not center about himself. While to ordinary observation he 
 appears to be gentlemanly, kindly and courteous, he can 
 easily be aroused at the fancied aggressive qualities which 
 he believes his companions entertain towards himself and 
 others. In all his daily activities he continually strives 
 to reach a state of perfection for purely personal sat- 
 isfaction and pleasure. No subject is too monotonous for 
 him to argue about. His set, rigid views frequently throw 
 him into violent conflict with everyone about him, and not 
 being able to shift or modify his opinions the consciousness 
 of getting the worst of the argument causes him extreme 
 annoyance. Avoiding all discussion is the one way to 
 obviate disappointments. 
 
 An episode in the life of our patient is worth citation for 
 several reasons: First, because one may see the manner in 
 which a sentimental attachment may harmfully excite 
 deeper sexual desires, and inflate other unconscious de- 
 sires, withdrawing the libido from safer and more stable 
 sublimation, and provoking epileptic symptoms in conse- 
 quence. Secondly, the situation gets beyond all the ordinary 
 character controls, and at the height of the condition char- 
 
62 
 
 acteristic sexual dreams appear; these being unsatisfying, 
 the tension is relieved by desultory employment and sport. 
 Then there follows a renunciatory dream of more intensity, 
 after which the unconscious demands begin to collapse, and 
 the patient is finally saved from an attack. 
 
 Our patient had been introduced to a young lady for 
 whom he gradually formed ideas of an attachment of a more 
 or less sensuous character. He talked and walked with her 
 and engaged in some athletic sports. So soon as the attach- 
 ment, more or less clandestinely planned for, had advanced, 
 he dropped off his study and work in shop and garden. He 
 became restless, snappy in his conversations and disinclined 
 to follow any routine. He spent long times in his room 
 alone, could not concentrate his attention, and everything 
 went wrong. He felt "tired all over." Long talks with a 
 fellow patient followed on sexual matters and marriage. 
 He then began to have frightening dreams of robbers, fire, 
 etc., and others of a frankly sexual character. He had 
 rather persistent headache, did no work and could not sit 
 or lie still. His sensations (petit mal) then began to appear. 
 He could not converse with anyone, and stammered greatly. 
 Going about doing as he wished seemed the only way he 
 could "avoid having a grand mal attack." He finally be- 
 gan to complain of various aches and pains, fussed with his 
 clothes and bureau drawers. He moved about slowly, rub- 
 bing his head and face and grunting to himself. The 
 sensations then increased to mild "myoclonoid" jerks but 
 they were not sufficient to throw him down. He now took 
 nearly two hours to dress in the mornings, was dull, grouchy, 
 and answered briefly or not at all at the table. He could 
 not decide in anything and was reduced to complete phys- 
 ical and mental impotence. He still carried on a lively 
 imaginative fancy in regard to the girl, although he no 
 longer saw her or wrote to her. He said afterwards that he 
 was "in a fog or a mist," had felt nervous all over, and 
 wanted no one to speak in his presence. He no longer had 
 any particular aversion to anyone about him or to any phase 
 of his environment; he simply wanted peace and quiet — to lie 
 abed and neither sleep nor dream (extreme shrinking from 
 
63 
 
 reality). He then had a dream of conquest and triumph, 
 which ended in a magnificent renunciation. Following 
 the ' great " dream he felt less shut out of reality and in a 
 couple of days gradually came back to his study, work and 
 play. During the greater part of this episode, as he was 
 not able to ascertain the real nature of his conflict our pa- 
 tient was allowed to do just as he pleased; he was "let 
 alone" by the others and gradually succeeded in "righting 
 ship" without having a grand mal attack. 
 
 As an illustration of the difficulties the patient has ex- 
 perienced in adapting to a new environment, the following 
 gives us an understanding of many of his personal char- 
 acteristics not yet fully adjusted or subdued: 
 
 He displayed no particular interest in the departure from 
 the country at the end of the summer season, other than the 
 usual preparations of packing, etc., in which he showed the 
 childish attitude of being unable to decide what should be 
 done first, becoming depressed, annoyed and upset when he 
 was not allowed his way. He was quite satisfied to return 
 to the suburbs and pleased with the arrangements that were 
 being made about his accommodations, for this had all been 
 explained to him and he knew what to expect. 
 
 On arriving at the new quarters he looked over both 
 houses and at once decided to live in the house Miss X. 
 occupied. This house appealed to him, and by being lo- 
 cated there he saw an opportunity of being relieved of the 
 necessity of associating with a Mr. A. for whom he enter- 
 tained a great dislike. It may be said that this dislike 
 started quite naturally; when he first joined the club some 
 ten months ago he became very fond of the companionship 
 of a certain girl patient and her nurse, but on the arrival of 
 Mr. A., who was more developed, quick and naturally clever, 
 he was gradually crowded out of this girl and nurse asso- 
 ciation. Jealousy and envy of Mr. A. then grew apace. 
 Now, when he was informed that it was not feasible to take 
 accommodations in this house, he sulked, became grouchy, 
 and went about the house frowning and mumbling to him- 
 self and otherwise showing his displeasure. He answered 
 only when absolutely necessary, and then only in monosyl- 
 
64 
 
 lables. Explanations by the nurse and physician relieved 
 the tension somewhat, at least to the extent of making it 
 more bearable, but it was evident that it still held a promi- 
 nent place in his mind. When he was told that he must not 
 hold grudges, and that he only made himself unhappy by 
 assuming this antagonistic attitude, he said: " If I give in 
 now it will only be worse next time." 
 
 Finding he could not gain his point in regard to having 
 his room changed, he turned his attention to getting permis- 
 sion to spend a whole day in the city. He was informed by 
 his physician that half a day would suffice to attend to his 
 business there. This produced the grouchy condition again, 
 and he went about with sullen expression, mumbling to him- 
 self and otherwise appearing displeased at not being able to 
 have his own way. He said he was being treated like a 
 boy. The grouch, however, gradually passed off, and he 
 became cheerful with everyone and at once turned his 
 attention to golf, wood carving and his correspondence 
 course. 
 
 However, such a prolonged degree of stress and irritation 
 had at last to be repressed, and two or three days after he 
 began to develop a period of extra frequent and severe my- 
 oclonoid jerks for several mornings. In the language of his 
 nurse: "He came within an ace of having a grand mal 
 attack." 
 
 As is well known, each frankly established epileptic has 
 a more or less definite cycle of recurrence of attacks. In 
 this case the distance between the crest of the wave of one 
 incipient storm to the other has gradually widened from a 
 few days to several weeks. The intensity of each rising 
 storm period steadily lessens. For instance, we have a day 
 or two of irritability when things go altogether badly, inter- 
 est in all work and play falls away, and there succeed 
 several days of dilapidation finally ending in a period of 
 rest and extra sleep; then once more our patient begins to 
 mend his desultory interest and start in again on his corre- 
 spondence course, handicrafts and outdoor sports. He is 
 then contented, free from "sensations" and any stress. 
 He soon desires from pride or ambition to hurry the previ- 
 
65 
 
 ously neglected duties faster than he is able rightfully to 
 manage; then there soon succeeds a feeling of increased 
 nervous tension, some defect in concentration and attention 
 and a failing grasp and retention of the subject matter. 
 This irritates and disheartens the patient. He then lays the 
 discouragement upon some trivial misunderstanding with 
 his associates, which finally ends in arguments and dis- 
 agreements. Stammering, slowness and awkwardness in 
 all duties again come to the fore, and our patient is again 
 at the crest of another break. Even though the bad hand- 
 ling of his activities is so obvious, to gain his confidence 
 and acquiescence to guidance is no easy matter. That he 
 has had no grand mal attacks in a year, however, speaks 
 well for the routine handling of such a case. 
 
 Finally I may say that the myoclonoid jerks have largely 
 disappeared, under ordinary circumstances. For the most 
 part they have been concentrated into morning ' ' sensations ' ' 
 and are appreciable only to the patient. He has become in 
 a large measure well adapted to his particular environment, 
 attends to his gardens, engages in wood carving, and stud- 
 ies well with little prompting. He is much less restless, 
 irritable and self- assertive, and is thoroughly interested in 
 the whole system of physical and mental upbuilding. 
 
 We may briefly summarize this case by saying our young 
 man had certain inherent traits and instincts from birth, 
 and as his general development advanced, these defects be- 
 came more telling factors in hindering the development of 
 proper intellectual and moral habits. These in turn re- 
 tarded and weakened the whole capacity of the young man 
 to adjust himself to adolescent life; the friction of the en- 
 vironment became too great, and he could not make the 
 sublimation of the masturbatic period into sports, play, and 
 finally work of adult life. It would seem when the mastur- 
 batic habits had to be repressed the lack of an adult 
 adaptation or outlet increased the tension to the point that 
 the unconscious demands chose nothing less than a com- 
 plete epileptic reaction by withdrawing the individual 
 entirely from a too demanding environment (in loss of con- 
 sciousness); later, when this failed to be sufficient, the 
 
66 
 
 degree and amount of release demanded superadded con- 
 vulsive phenomena, as indicated in my former studies. 
 Undoubtedly the neurotic symptoms of stammering in this 
 case were a partial and earlier break into a neurosis at a 
 higher level; this mechanism of defense, on the part of the 
 organism unfortunately, and yet like most other neurotic 
 symptoms, entailed further and severer handicaps on our 
 patient and made the wreckage of a final epilepsy more com- 
 plete. The crying demand for an early and wise therapeusis 
 in such cases is only too obvious. 
 
 Lest one may think that too much stress is laid upon the 
 definite psychologic settings in the causation and continu- 
 ance of the epilepsy here, it may be said that there are 
 also physical counterparts to the maldevelopment. If not 
 shown in actual physical anomalies they can still be shown 
 in functional incompetence. To meet these, such as the 
 defect in vasomotor tone, hydrotherapy is fully employed in 
 packs and friction rubs, spray, douches, etc.; the enor- 
 mously ravenous appetite has been controlled and adjusted 
 to a lower proteid diet, the constipation and mucocolitis has 
 been met by proper laxatives and colonic flushes, and ordi- 
 nary laboratory tests are frequently requisitioned. The lack 
 of muscular endurance and incoordination is met by setting 
 up exercises, wood chopping and tending garden, wood- 
 carving, and suitable games such as tennis, golf, medicine 
 ball, and pool. As for proper guidance in intellectual devel- 
 opment a course of study in agriculture and the fundamentals 
 of a business education have been outlined and used. 
 Above all and through all runs the moral training of proper 
 habits and obedience to the physical and mental hygiene 
 such as might be expected of a normal boy of his age. The 
 proper adjustment to a normal diversified life is aimed at 
 under the wise guidance and supervision of the nurse and 
 physician, who strive to enter fully the patient's life from 
 all aspects and help him in best ways to help himself. 
 
67 
 
 Section III. 
 
 A STUDY UPON TWO SEPTS OF FAMILIAL EPILEPSY, WITH 
 
 DETAILED REPORT UPON THE MECHANISM IN ONE 
 
 EPILEPTIC INDIVIDUAL OF THE SERIES. 
 
 Occasionally opportunity is given to study an entire 
 sept through several generations of epilepsy. This is a 
 matter of considerable importance in our present day 
 understanding of the nature and pathogenesis of epilepsy. 
 During the past few years I have had two such families 
 under study. The first family is comprised of the grand- 
 father, who has had but one or two grand mal attacks in 
 his life and who possesses the epileptic make-up; and of the 
 grandmother, a confirmed epileptic since her 43rd year, 
 who has not the epileptic make-up. From this union there 
 were four children: The eldest, a daughter, appears to be 
 perfectly normal with none of the epileptic character or 
 temperament; the next, a sou, is also a healthy, normal indi- 
 vidual; the third, a son, is an occasional epileptic with little 
 of the make-up; the youngest, a daughter, is a confirmed 
 epileptic of long standing and possesses the classic make-up. 
 In the case of the latter, who married while epileptic, there 
 are two children, one of which seems to have the mother's 
 make-up and disposition. Thus we have eight cases for 
 personality study. 
 
 The grandfather (No. 1) was a poor boy, very energetic 
 and resourceful mentally, but he possessed very little capac- 
 ity to do any practical work . Although people as a rule liked 
 him, he was never fond of them. He was rather conceited 
 and inclined to be a leader. He was impatient and could 
 brook no interference with any of his plans. He had vio- 
 lent tempers as a boy, and when provoked at a great dis- 
 appointment at the age of twelve he had a classic grand 
 mal attack. He rapidly learned to control his tempers after 
 this incident. He threw himself into his school work and 
 finally entered on a successful business career at 21 years 
 of age, where he found full scope for his extraordinary en- 
 ergies. His tempers of early life entirely disappeared, and 
 
68 
 
 (Epileptic) -j_ 
 Possesses 
 epileptic 
 make-up 
 
 (Epileptic; 
 
 Possesses 
 epileptic make-up 
 
 Chart I. Showing three generations, of which two of the four epileptic 
 members, and one non-epileptic, possess the classic "epileptic make-up." 
 
69 
 
 he had no more epileptic attacks. His epileptic daughter 
 resembles him very markedly, both physically and men- 
 tally; they never could agree, and were always at odds. It 
 is said of the father that he has never accepted a physician's 
 statement that his wife or children are epileptic, and when- 
 ever it is so affirmed he says, " Oh, yes, the doctors think 
 they are epileptic, but they don't know." He has never 
 interviewed a physician regarding them and ignores the 
 whole subject entirely. 
 
 To summarize, the grandfather is a bright, energetic 
 "driving" type of personality, rigid and firm in his disci- 
 pline, who sees only the "things he wants to see." He 
 had the temperament and character make-up of the epileptic 
 constitution but obtained the proper trend of interest and 
 outlet in adolescent and adult life, and has, so far as known, 
 never had another attack. 
 
 The grandmother (No. 2) is now 69 years of age and is in 
 fairly good health aside from her epilepsy. She had her first 
 epileptic attack at 43 at the birth of her last child (No. 6), 
 when she suffered a severe general infection with ' ' men- 
 ingitic symptoms." Soon after, she came under my care 
 for classic grand mal attacks, which under the most inten- 
 sive principles of treatment were never greatty benefited. 
 The attacks occur weekly. There has been very little de- 
 terioration in memor}^ or character, and she lacks the epi- 
 leptic character in any of its settings, either in youth or adult 
 life. 
 
 The epileptic daughter (No. 6) was a stubborn, difficult 
 child from birth. She was rather lazy and sluggish and 
 had no power or inclination to get square with tempers by 
 physical exercise or sport. She had many tantrums. 
 Girls whom she did not like "didn't exist" for her, and 
 
 she never seemed to notice their presence." When com- 
 plimented about her good looks she would reply with acerb- 
 ity, " You needn't tell me that; I have my mirror." She 
 had few friends and seemed to care little for them. It was 
 easy for her to take on new acquaintances if she cared for 
 them, and quite as easy to part, and she never mentioned 
 their names after they had once moved away. She never 
 
70 
 
 forgot or forgave an injury. She was egotistical and super- 
 sensitive, and never affectionate or demonstrative toward 
 any one. She was indifferent to social life during her stu- 
 dent days, but stood well in college classes. She made few 
 friends while at school but seemed little annoyed about it. 
 She had her first grand mal attack at 14 after a prolonged 
 irritation in not being allowed by her father to have her 
 own way. She was first repressed, sullen, and then the 
 attack came on. For years after the attacks were in evi- 
 dence, the relatives believe she delayed or put off many of 
 them through an escape b}^ her music. Her speaking voice 
 is monotonous; her singing is clear and distinct, but not 
 especially melodious or musical, and "something in the 
 quality of expression is left out." "She has none of the 
 qualities of the mother in feeling or understanding ' ' is the 
 statement of the brothers. She has always lacked in verac- 
 ity, but unlike the telling of exaggerated stories by the father, 
 'she doesn't seem to know what the exact truth is." At 
 the age of 24 she married socially beneath her, much against 
 the advice and wishes of the whole family. The husband 
 knew she was an epileptic, and also knew she would receive 
 no funds or other considerations from the family. There are 
 two children by this marriage: the elder is very animated and 
 normal and resembles her father (husband of No. 6); the 
 younger daughter, now 2>% years old, has the identical make- 
 up of the mother, and has already shown the same epileptic 
 character. In comparing mother and daughter our inform- 
 ant states that this child " is little M. all over again." As 
 might be expected, the marriage has been a failure after 
 seven years' trial. This is apparently due to the fault of 
 the wife; and she abruptly left her husband and children, 
 went back to her own father's home, and expresses no con- 
 cern whatever for them. Her leaving her husband and his 
 home was apparently motiveless; she says, " I just got tired 
 and left; maybe I will go back again sometime." Her sis- 
 ter says ' ' she shows no evidence of mental deterioration as 
 ordinarily understood, but there is a profound ethical and 
 moral degradation in the short years of her married life, 
 and yet they are only her old faults writ larger and more 
 
71 
 
 indelibly, and her attacks seem to be but an expression of 
 the whole lack of proper development." Since returning 
 to the father's home she does little but go about and enjoy 
 herself, and the attacks are much less frequent and severe. 
 We will now consider briefly the make-up of the brother 
 (No. 5) 28 years of age, who has had infrequent epileptic 
 attacks since his eighteenth year. He is of a perfect robust 
 physique and probably has had but six or seven attacks in 
 all, and but three grand mal in type. Almost from birth 
 he was considered a difficult, stubborn child. When rep- 
 rimanded he resented it and had tantrums. If punished he 
 "smouldered with hate." At the times of his tantrums his 
 mother, not being strong enough to cope with the difficulty 
 of managing him, would pour cold water on him, which 
 had the desired effect. His physical development was not 
 retarded or imperfect, but it was noticed that he was slow, 
 but not stupid or lazy. He had little interest in many of 
 his studies and did not seem to care. He was always tu- 
 tored, and his education is not up to his opportunities. He 
 went only one year to college because he simply did not 
 want to go. He has since been admitted to the bar and 
 does corporation practice faithfully and well. Since leav- 
 ing college he has mapped out his own course and has 
 gotten on much better. Compared with his father it is 
 stated that he is not so energetic as the former, although as 
 he grows older and shapes his own activities he is growing 
 in this respect. In late adolescence he was able to make a 
 better social adaptation, and now is universally liked; he 
 never loses his temper. As a child he played freely 
 with other children, although he had to be handled 
 with a certain amount of tact. He was affectionate 
 and demonstrative and was never suspicious or mistrust- 
 ful, although easily offended. He was always frank and 
 open but has never cared to unburden himself and wants 
 to do things in his own way. Although cheerful and light- 
 hearted in temperament, he becomes easily depressed. His 
 emotional reactions to daily life are shown in his ' ' being 
 way up or way down." Since being in business he has 
 grown a little more irritable, and he often comes home and 
 
72 
 
 says, " I have just smiled all day long, and I can not smile 
 any more." His irritation lasts but a short time now, and 
 can be gotten square with by music and social intercourse 
 with his friends. 
 
 The sister says, in regard to the temperamental make-up 
 of this brother, that he has some of the characteristics of 
 both parents. Like his father he is supersensitive and ego- 
 istic, wants good food and clothes and likes to spend freely; 
 but he gets the refinements of his nature from his mother. 
 His appreciation of beauty, music, flowers, architecture, 
 etc., is from her, and undoubtedly helps him out in '"tight 
 places." His present position is thought to be quite a 
 strain, with the hurry and bustle of business requirements. 
 Since he became epileptic he was jilted by the girl to whom 
 he was engaged, and took the situation very hard; he cried 
 and trembled violently; a convulsion seemed threatened but 
 none occurred. He then went away for several days to 
 visit friends, enjoyed himself, and very soon was apparently 
 all over it. About three years ago a grand mal at- 
 tack occurred, at a time when he was much worried, had 
 slept little, and was obliged to go without his breakfast on 
 a particularly cold day. It is said of him that he goes on 
 the theory, ' ' I will go ahead anyway, no matte?' what hap- 
 pens.'" He keeps to no physical or hygienic regulations 
 and is probably on the way to a later epileptic career, al- 
 though his resources of adjustment by way of music and the 
 arts have enabled him to get square with the irritation and 
 annoyances of daily life fairly well. Having started in life 
 with the epileptic character, he found vicarious outlets and 
 trends of interest sufficient to relieve the irritable tension; 
 finally, since he has gone his own way, he has had in- 
 frequent attacks and those mostly of the petit mal type. In 
 just such cases the most hopeful prognosis may be enter- 
 tained if the patient can be influenced to lead the proper 
 life, satisfying and non-irritating, with plenty of emotional 
 outlets of interest to balance the sensitiveness of the indi- 
 vidual make-up. Of course ordinary physical and mental 
 hygiene should also be maintained. 
 
 A minute detailed examination of the remaining two in 
 
73 
 
 the family, sister and brother (No. 3 and No. 4), reveals 
 none of the character of the epileptic make-up and is not 
 sufficiently interesting from a pathologic standpoint to 
 warrant detailing here. 
 
 To summarize this family as a group, one sees that the 
 grandfather had but one or possibly two grand mal attacks, 
 but nevertheless possessed the classic epileptic make-up. He 
 had, however, the innate capacity of life adjustment to save 
 him from further manifestations of outspoken epilepsy. The 
 grandmother probably contracted a meningitic lesion which 
 took on an epileptic reaction of the symptomatic or organic 
 type in the apparent absence of the epileptic make-up. Of 
 the children from this union, two are epileptic, the one girl 
 with the classic make-up and classic attacks; the brother, 
 with about the same initial defect in instincts as the sister, 
 began early to make better adaptations and has succeeded 
 in overcoming the character in greater part, but not quite, 
 and therefore he still pays for the defect by occasional epi- 
 leptic reactions. The other sister and brother in the family 
 possess none of the epileptic character and are quite im- 
 mune from any epileptic manifestations. The married 
 epileptic daughter has one child with classic make-up akin 
 to her own, and everything will be done to conserve this 
 child from epileptic reactions in later life. The unmarried 
 sister has a true insight into the nature of the situation and 
 is able and willing to devote her life to bringing up the epi- 
 leptic sister's children in a healthy manner. I may say that 
 I have had opportunity to examine carefully all the 
 members of this family-group, with the exception of the 
 grandfather. 
 
 The second family group consists of but two cases of pro- 
 nounced epilepsy in two of the three generations under 
 observation. The grandmother (No. 2 on chart), one of my 
 patients, is now 50 years old, and contracted her epilepsy at 
 33 years of age. The attacks have occurred three or four 
 times a year in a series of three to four grand mal at each 
 period. She was born of a neurotic family stock. Her 
 mother was a resourceful, masterful woman, and the neu- 
 
74 
 
 Possesses partial 
 epileptic make-up 
 
 Possesses 
 
 epileptic 
 
 make-up 
 
 (Epileptic) 
 
 Possesses 
 epileptic 
 make-up 
 
 (Epileptic) 
 
 Possesses 
 epileptic 
 make-up 
 
 Chart II. Showing three generations, of which the two epileptic members, and 
 two non-epileptics, possess the "epileptic make-up." 
 
75 
 
 rotic element seemed most dominant in the mother's brothers, 
 all of whom had violent tempers — one in particular is 
 said to have gotten into uncontrollable rages in which he 
 hurled abusive language, and afterwards would attempt to 
 mollify the recipient of his abuse by handing him a ten dol- 
 lar bill. The patient herself had several brothers who are 
 said to have inherited their temperament from the maternal 
 side. She was a petted, spoiled child from birth, being the 
 only girl in a family of several boys, and the latter together 
 with the parents supplied all her needs and gratified her 
 merest whims. She had a proud, imperious disposition, but 
 as it was never thwarted there was no evidence of what 
 might have happened if it had been. She was not atten- 
 tive in school and never applied herself seriously. Her 
 school standing was very indifferent, and her general edu- 
 cation was not up to her opportunities. She had a final 
 fashionable boarding-school education. She was slow in 
 making up her mind, was impractical, and was slavishly 
 fond of her mother, now dead a score of years but whose 
 previously expressed thoughts and principles she follows out 
 as carefully as though she still lived. Her point was ever 
 to be dignified and not show emotions. She was never de- 
 monstrative toward anyone, her mother, her husband or her 
 own children. She always chose her own gifts, was always 
 critical, and often "pouted" at fancied slights. All her 
 life she has had no conception of punctuality, can not man- 
 age little things or situations, and seems rather surprised 
 when others are able to accomplish these things. If she 
 is hurried she becomes flustered, and it is said that "she 
 just goes her own sweet way and lets the other fellow wait." 
 Everyone about her bows to the inevitable, and thus every- 
 thing moves smoothly. When flustered she seems lost for a 
 time, says nothing and does nothing, and "there is just an 
 extreme, placid calm on her face." When others who have 
 been delayed and annoyed, storm and protest, she herself 
 remains serene and sweet through it all, and never loses her 
 temper. Nothing seems to be known of her inner life as a 
 child or in girlhood, and she herself says there was nothing 
 especially thought or felt during that period. In later ado- 
 
76 
 
 lescence she was very morbid and liked funerals, and she 
 would never miss a funeral if she could manage to get to it. 
 Once she had charge of the funeral of a man whose wife 
 was her dearest friend. The remains were three or four 
 days in coming home, but she insisted on having the casket 
 opened to satisfy her curiosity when it arrived. She likes 
 to be around people who are ill, and exhibits a sort of mor- 
 bid curiosity. In caring for the sick she experiences a keen 
 sense of fulfilling her duty. When her mother died she in- 
 sisted on helping to dress her, although there was no 
 necessity of her assistance. When anything happens she 
 keeps her dignity very well; she very rarely cries, and never 
 gets excited. At one time her daughter was seriously ill, 
 and through it all she remained very quiet, dignified and 
 
 brave. ' ' She is inclined to take life over-seriously . When 
 anything unusual is going on, she hates to be cheated out 
 of it; for instance, she was furious because she was not in- 
 formed in time to be with the daughter when her child was 
 born, and stated emphatically that she " did not want to be 
 saved from the ordeal." She has no sense of humor, and 
 is not optimistic. She feels neglected if the daughter fails 
 to telephone each morning to ask how she is, although her 
 answer is invariably, "Oh, so-so," and she never says she 
 feels fine. She takes pleasure and good news very quietly, and 
 has never been known to be jovial or enthusiastic. She took 
 up a little settlement work, and rather enjoyed hearing hard 
 luck stories but never really entered into the spirit of the 
 work. She is fond of the theatre, but always likes to be 
 coaxed, even to do the things she enjoys doing. 
 
 When her daughter married she did not quite know how 
 to meet the situation. She had previously disapproved of 
 the match, and did not want to greet the son-in-law as a 
 friend, nor yet to recognize him as a son-in-law. She seemed 
 to be waiting to know her husband's viewpoint and depend- 
 ing on his attitude, and in the meantime she was simply 
 lost. She is now devoted to this son-in-law, and the latter 
 brings a great deal of enjoyment into her life. 
 
 She takes real troubles very hard and can not get over 
 them. She is very conventional in her grief. She insisted 
 
77 
 
 upon wearing mourning for a year when her mother died, 
 even though her brother, a physician, requested her not to 
 do so. After three or four months had elapsed she con- 
 sented to go to the theatre after a good deal of urging. She 
 argued that if the mother were alive and could be consulted 
 she would expect her to wear mourning. It seemed 
 absolutely to be a matter of going against convention rather 
 than any depth of feeling. She was pedantic, phlegmatic 
 and rigid, and could not be moved. Her husband almost 
 went down on his knees begging her to resume her life, to 
 go about and follow her usual activities, but it took months 
 before he succeeded in having her do it; she still continued 
 to wear mourning, however, after she finally consented to 
 go about socially as the others did. She always felt sorry for 
 herself, yet would not have had things otherwise for the 
 world; she just luxuriated in her woe. She now procrasti- 
 nates in moving from her present home, and sighs deeply at 
 the thought of making a change. She is not religious and 
 derives no comfort from religion, but goes to church once in 
 a great while as she wishes to be "represented." At the 
 grave of her mother (who had been an invalid for years) 
 she was very calm. The daughter once roused her to great 
 anger by saying she hoped she would never live to be old 
 and decrepit. Our patient said it was a terrible thing to 
 say and reflected on the grandmother. She said: "if 
 you feel that way, I hope I never will." She clings 
 tenaciously to tradition and is very reactionary in civic, re- 
 ligious and social views. She often remarks: "I do not 
 think anyone could have improved on the way my mother 
 brought up her family. " She does not like the idea of go- 
 ing away from home, yet becomes a different woman when 
 she can be urged to do so. The husband came home one 
 afternoon after she had been preparing for two weeks to go 
 to a distant city to consult a physician, and said he 
 thought it best to start that night. She replied: "No, I 
 can't go to-night; the laundry isn't put away yet." 
 
 At present she has no intimate friends excepting those 
 who have taken a strong liking to her and with whom she 
 plays bridge. She is very kind and thoughtful of them; 
 
the others are mostly family ties. She has a stupendous 
 family pride and is ' ' forever talking about her ancestors 
 and their ancient achievements." 
 
 Now, upon this extraordinarily supersensitive and child- 
 like make-up were thrown three great emotional crises, and 
 we shall see their results. The first was a romatic fancy 
 for an elderly friend of her brothers. When this friend be- 
 came engaged she became depressed, was sleepless, lost her 
 appetite, and had "faints" (probably petit mal in char- 
 acter from the description). She stayed at home and 
 remained in bed for two or three months. Under special 
 mental treatment and distractions, which finally ended in a 
 change of scene, the episode was passed. The second trial 
 occurred some three or four years before her first grand mal 
 attack. She married at 24, some six years after the 
 "first love affair." Sexual intercourse was painful and 
 always unpleasant. Her first child, a girl, at 7 years of 
 age contracted spinal curvature, and the mother then came 
 out of her "eternal calm" and worried about it continually, 
 night and day. She slept poorly, lost in weight, was fear- 
 ful, depressed, and had anxious dreams. She has always 
 admired erect persons, and possesses a beautiful physique 
 herself. She has always admonished her son to stand 
 erect, sit straight, etc. Four of her brothers had good 
 physiques, and two had not; one brother had scarlet 
 fever, and this affection left him with a weak back 
 but he finally overcame it and carried himself well; 
 the youngest brother has one shoulder higher than the 
 other. Her own mother, who was a little round-shouldered 
 in later years, had been considered a very handsome woman 
 and was married at 16. Our patient says: "I could not 
 bear the thought that a daughter of mine should have other 
 than a perfect physique; this has been our family pride, and 
 it seemed as though my only daughter should not break the 
 traditions in this respect; the idea was unbearable." She 
 then began to take the daughter to many physicians. Even 
 though the daughter pleaded that she was satisfied with the 
 treatment she was getting, the mother would turn to her 
 sharply and say: ' ' I don't want you to grow up and accuse 
 
79 
 
 me of not doing all I could for you." To the mother the 
 whole affair was unendurable, and though the curvature was 
 finally controlled she continued to worry, and this ended in 
 an attack of grand mal. She has gradually become recon- 
 ciled to the daughter's defect, but with a continued epilep- 
 tic reaction whenever stressful periods supervene. The third 
 period of mental stress was when her only son was pro- 
 nounced epileptic, at which time a series of attacks occurred. 
 For the past nine months, since the son has shown a marked 
 improvement, she has had but one attack, whereas half a 
 dozen might have been expected. 
 
 To summarize, we have here the history of a rigid and 
 supersensitive woman, who was given no adaptive or ad- 
 justment training or education; who was self- centered, re- 
 pressed, and so slavishly attached to her mother that she has 
 continued emotionally infantile throughout life ; one who 
 has never accustomed herself to handling any strong emo- 
 tional episode without epileptic reactions. Her husband 
 says, "She is too sensitive to the rude winds of life, and 
 must be protected from them as much as I can make 
 possible for her." We may say in passing, that we have 
 followed his lead, and she has been advised to give up 
 housekeeping and to take up an active outdoor life, which 
 she has always liked and wanted to do. In addition she is 
 living under a regime of as good physical and mental 
 hygiene as possible. 
 
 We shall now pass on to the son's case (No. 4). He is 
 now 24 years old and began his epileptic career at 15, with 
 minor attacks or absences which finally terminated in grand 
 mal attacks at 18. In the petit mal attacks he first experi- 
 ences a feeling of tightness in the stomach, and a sense of 
 uneasiness as though gas were present there; then he won- 
 ders whether he is going to have a sensation and becomes 
 interested to see how it will end and whether a sensation 
 will develop or not. After this there is a feeling of dryness 
 of the mouth and tongue — a condition similar to that which 
 he has experienced when keyed up for examinations, at a 
 school recitation, or when something hard has to be accom- 
 plished, especially if it has to be done in a hurry. Then 
 
80 
 
 there is a heightened sense of subjectivity, and homesick- 
 ness and lonesomeness succeed. The above takes place in 
 an incredibly short time, and then a "wave ' ' occurs. 
 
 Just before the sensations are to occur the patient often feels 
 a lack of rapport with those whom he may be with and a 
 sense of indifference or boredness follows in which he feels 
 a heightened sense of his own body and mind, and a ' ' de- 
 tachment from others about him" (increased subjectivity). 
 There often follows a sensation of ' ' disgust ' ' in the pit of 
 his stomach, which is always directed toward, or felt for, 
 his surroundings and the people about him. The indiffer- 
 ence exists long before there are "waves" or other actual 
 epileptic symptoms: they occurred especially in the absent- 
 minded states of which his mother complained when he was 
 a small boy and which were often spoken of as states of 
 absentmindedness. These states are now attended by con- 
 fusion or loss of consciousness; otherwise they are identical 
 with the earliest habits described. First there is a feeling 
 of apprehension, then staring, and disgust; secondly, a feel- 
 ing of pleasurable amiableness and contentment. As the 
 petit mal departs there is an irritable depression in which 
 the patient seems to want to be undisturbed, and as though 
 he were "trying to remember or wishes to finish something" 
 before coming back to the everyday conscious state. 
 
 From earliest infancy he was a stubborn, difficult child 
 and had frequent tantrums all through his childhood. In 
 his best periods, however, he was generous, kind-hearted, 
 thoughtful, and affectionate. As a child he was fond of 
 romancing and if anyone interrupted him he would start all 
 over again at the beginning. He was inclined to wander 
 from the point, and simply could not speed up his mental 
 action. It was noticed early in life that he had what is 
 known as the epileptic voice sign. His speech was scan- 
 ning, with an irregular phrasing of his sentences. 
 While he was lively as a child he never coordinated 
 fast or well. He was a fat boy, constipated and had poor 
 physical endurance. His mind was never rich in ideas but 
 he could accumulate facts. While he learned easily he 
 never did things that were especially original or clever. He 
 
81 
 
 never weiit into anything deeply. If he had an idea and 
 was balked in carrying it out he never argued or teased 
 about it; he at once threw himself on the floor and went 
 into a tantrum. He was supersensitive and never could 
 bear disappointment of any kind, and this has always been 
 his peculiar temperament. He was alwaj^s afraid of getting 
 sick, or being poisoned, and he could not bear the sight of 
 blood. Aches and pains bothered him a good deal, and in 
 any illness he always felt very sorry for himself. After the 
 tantrums there was always a sense of relief, never any 
 moroseness or sulking. However, if he really wanted a 
 thing he made up his mind to get it, and was never known 
 to be sidetracked or to give up the idea of getting the de- 
 sired object. Even when he had reached the age where he 
 could be reasoned with, he would still " fly off the handle." 
 When the sister was asked what caused his epilepsy she 
 said, " I suppose the minor attacks are but the forerunners 
 of the severe ones, and that the former came on as a part 
 expression of his lack of proper mental development. His 
 mind did not grow with his body. First, the tantrum epi- 
 sodes were an expression of his inability to get square with 
 things; later, the attacks of anger replaced the earlier child- 
 tantrums. When the anger episodes were not sufficient to 
 express his mental attitude, the abstractions came up and 
 then the attacks followed." 
 
 While the sister (who has a somewhat similar make-up) 
 went to the father to straighten things out, our patient went 
 to the mother to get his desires satisfied. The mother never 
 reasoned with him or explained the difficulty away and 
 rarely yielded to his desires, and yet he never went to the 
 father who handled such situations quite differently. Our 
 patient's difficulties were largely on ethical grounds; he 
 could or would not make a compromise with necessity, and 
 consequently he was a "much disappointed boy." His 
 conflicts largely came about because he always had a latent 
 desire to do things only in a certain way — any other way 
 would not do, and to be opposed or directed generated heat. 
 When he was allowed to do as he pleased he was smiling and 
 happy and went about whistling. Even when any contro- 
 
82 
 
 versies came up with the neighborhood boys he went ' ' all 
 to pieces, ' ' threw up the game, and would not play. 
 
 A sample of the day-dreaming of earliest childhood is 
 shown in the patient's statement that when he was very 
 young he found great pleasure in being near his mother, 
 and at such times he would seem to forget everything and 
 apparently wander off in thoughts of his own; he was con- 
 scious of all that went on and could hear any conversation 
 that was being held, but would not join in it and did not 
 have the desire to do so. His mother on these occasions 
 would scold him and tell him he looked foolish staring into 
 space. As he recalls these flights, he says that they were 
 pleasant and satisfying. 
 
 Something of the nature of our patient's social reactions 
 in his ' ' deep down ' ' dislike of his associates who do not 
 fully meet his nice conception of society, and the beginning 
 mental settings leading up to a series of attacks, may be 
 gained from the following and other notes. They are taken 
 from the close study of our patient after he had joined the 
 club for detailed observation and a training treatment. 
 
 While under observation the patient went through a 
 period in which he became rather quiet and made no effort to 
 join the general conversation unless directly addressed. He 
 remarked that he was ' ' not at all homesick, ' ' but frequently 
 referred to home and said he wished he were going home 
 instead of with the rest of the group to the country. On 
 being asked his views relative to the different members of 
 the group, with whom he was thrown in contact, he said 
 that Mr. A. possessed a childish personality he could 
 not like, and that he had no patience with him and 
 found it annoying to be in his company. He then said 
 there" were very few in the group he cared to associate 
 with as he considered them not up to the mental standard 
 their age would demand. He liked Miss X., whom he con- 
 sidered far superior to the other patients, and also derived 
 enjovment from the society of two male nurses. On the 
 whole^he found the other guests rather boresome, and did 
 not care to associate with them for that reason. Although 
 it was apparent that he was homesick, the patient himself 
 
83 
 
 attributed his disagreeable feelings to his associates. He 
 said he knew it was wrong to let this feeling get the better 
 of him and he would try to forget it, but "it was hard to 
 do so when such conditions were present." 
 
 To show that such superficial rationalizations and a de- 
 sire to overcome his attitude only stirred the surface of 
 things, we note that although our patient became cheerful 
 and happy and talked freely, nevertheless he repeatedly ex- 
 pressed his desire to be going home instead of preparing 
 for a summer in the country, and within twenty-four hours 
 he had a series of petit mal and grand mal attacks. Fol- 
 lowing these attacks the patient was decidedly more cheer- 
 ful, and the marked depression so apparent in the early 
 hours seemed to pass slowly away. 
 
 When asked to describe the feeling that gave him the 
 warning of approaching trouble the patient at once began 
 to hesitate and replied, "Why — it's like a — a feeling of 
 (frowning and making motion with index finger and an 
 expression of annoyance) — like gas passing or trying to get 
 out." Although able to talk freely after the attacks, pro- 
 vided the conversation does not apply to the cause of the 
 disturbance, if this subject is brought up he at once frowns 
 and has great difficulty to describe what he feels at such a 
 time. In point of fact, it is indescribable, and hence prob- 
 ably quite unconscious. 
 
 The patient's infantile attitude toward the mother- father 
 complex is shown in many ways. For instance, while vis- 
 iting with relatives he preferred to spend his time with the 
 women, and sat near the aunt and held her hand. Fre- 
 quently on going out for a short while he kissed each one, 
 and again on his return. When talking to the male relatives 
 he assumed an attitude of submission, he allowed them to 
 do all the talking, and agreed with them in all things; he 
 was timid, blushed easily, and made no effort to speak with 
 authority while conversing with them. 
 
 As a young boy the patient's greatest friends were a 
 family of six boy cousins, who were allowed many privi- 
 leges which appealed to the patient but of which his 
 parents did not approve, such as playing cards, staying 
 
84 
 
 out late, etc. When the patient did these things, he 
 was reprimanded; while he considered that he had done 
 no wrong, he knew he would be brought to task and 
 brooded over the situation from day to day. When in 
 company with his cousins he was told that he inter- 
 fered with their pleasure because he wanted to go home 
 too early, and rather than offend them he would remain, 
 saying, "Well, I'm in for it again." When he reached 
 home, no matter what the time was, his father or mother 
 would always call to him and ask where he had been. 
 If he happened to slip in without being heard he knew he 
 was sure to be catechized in the morning. This state of 
 affairs began when he was twelve years old, and became 
 more unbearable as he grew older. Previous to the age of 
 twelve the patient recalls that when he fought with his 
 sister he was usually blamed for causing the trouble, the 
 parents as a rule taking the sister's part. 
 
 For many years the patient was conscious of "being held 
 within bounds ' ' and resisted being in this position and pre- 
 ferred the freer life his cousins lived. His parents were 
 very nervous and nagging, and he now states that they 
 were wrong to be so strict, and that it was their own con- 
 dition that brought about his attacks. A member of the 
 family states that the patient was chastized many times for 
 remaining out late, because the parents were afraid some- 
 thing might happen to him; he exhibited a violent temper 
 and they found it very difficult to control him. In a free 
 monologue our patient gives the following family setting as 
 being responsible for bringing on many attacks. 
 
 "When I had my first attack, my parents consulted a 
 physician, who, after giving me a careful examination, 
 began to talk to me, and during the conversation he said I 
 ought not to go with my boy cousins. How could he have 
 known about them if my parents had not told him? Later 
 my cousins told me I should not go with them because I 
 was sick and should live more in the open, and that I could 
 not do this and continue to associate with them. I knew 
 that my father had told them to talk to me in this way; I 
 felt as if my parents nagged me, and wrongly, because I 
 
8.5 
 
 would have been so much better off had they allowed ine to 
 go my own way." The continued interference with the 
 manner in which he wished to lead his life caused another 
 outburst of attacks immediately after he was placed under 
 medical attention. 
 
 To return to more recent settings: After a period of clear 
 mental skies, the irreconcilable attitude toward the social 
 setting of the club was again in evidence, but after he had 
 talked over the various situations and become more con- 
 sciously adjusted, the attacks became less in evidence. 
 One evening after supper the patient said he would like to 
 talk with the nurse about something which he had men- 
 tioned several times before. He started by saying, "Now, 
 B., don't you think that A. is awfully tiresome?" When 
 the nurse admitted that A. and all the rest of the group 
 were tiresome but all in a different degree, the patient 
 smiled and said, "Yes, I know that; and I am trying to 
 get so I will not talk sharply or crossly to A. when I 
 have to talk to him. " He added that he was getting to see 
 many good points in Z. that he had never seen before, to 
 which the nurse replied that he would soon begin to see 
 some good in everyone, that it was onty a matter of prop- 
 erly adjusting himself to his surroundings and getting to 
 understand the different dispositions. The patient said he 
 was trying hard to do this, but that there were some things that 
 kept popping up every now and then that were disagreeable 
 and did not appeal to him, but that after a talk with the 
 nurse or physician he was able to minimize their import- 
 ance. After such conversations the patient is generally 
 more cheerful, appears to have gotten some mental relief, 
 and makes a conscious effort to follow out the advice given. 
 
 Next day, on reading over his mail, the patient went 
 around pouting like a child, and talking only when ad- 
 dressed. Later he said he had received several letters, all 
 telling him of the good times going on at home and what he 
 was missing. At dinner he seemed unable to hold in any 
 longer, and told the nurse that he could not help it if he 
 was grouchy when he got letters and invitations from the 
 West telling him of all the good times going on there. 
 
86 
 
 When told he should not allow this to depress him, but 
 work all the harder to get better so that he could return and 
 join in the good times, and in the meantime to rejoice that 
 his friends were having such an enjoyable time, he said, 
 "Well, what about me? That doesn't do me any good; I 
 don't care about them as long as / have a good time." 
 After a while he smiled and said, "Well, I suppose I am 
 acting like a kid, but it makes me sore to be missing every- 
 thing. " A few hours later he had a mild attack. He was 
 cheerful the following day, but it was evident that the 
 slightest indisposition caused him to become moody, grouchy 
 and uncommunicative. The next day he had a very mild 
 attack in the early morning, and on recovering and being 
 questioned by the nurse, he smiled in an offhand manner 
 and said, "Oh, I had just a little attack." He at once be- 
 came moody, and when spoken to by A. he made no an- 
 swer at all. He went about showing his displeasure at 
 everything but made no comments. The patient becomes 
 very much depressed over the attacks, and blames himself for 
 his weakness in not being able to ward them off. At the same 
 time he admits that he encourages them to come on for the 
 reason that it is a disagreeable feeling and better out of his 
 system. " It is just like a sneeze, not at all pleasant coming 
 on, but when over gives a sense of relief." 
 
 There is an excellent exposition of the wish motive in 
 the minor attacks and the sympathetic pitying appearance 
 of the person hallucinated, who is always his "good 
 friend." When the attack goes deeper, however, the whole 
 situation becomes unmanageable and he seems to retreat 
 into a "goneness " that is often described as something that 
 "draws him down or in." Often now during the minor 
 attacks he suddenly thinks of someone — his mother, father, 
 nurse, or some of the guests. He seems to be suddenly 
 transferred to the presence of this person, who appears to 
 be looking at him with a look of infinite sadness, which 
 greatly distresses him. He does not know why he feels so 
 distressed at the manner in which they confront him, but 
 the persons that are hallucinated always seem to need his 
 sympathy. 
 
87 
 
 Three characteristic episodes that are quite instructive 
 will now be incorporated in this patient's report. The first 
 followed a rather prolonged effort of voluntary repression 
 of his displeasure-affects toward the social group at the 
 club: Symptoms of marked mental depression were pres- 
 ent; the patient felt great resentment toward his fellow- 
 guests, and the atmosphere of his surroundings became un- 
 bearable. He felt that he could no longer associate with 
 his present companions, and desired most of all to be at 
 home with his family, to return to work, and to live the life 
 he was accustomed to living before he came under the pres- 
 ent treatment. This feeling had been entirely absent for 
 some time, but on this date it became so pronounced that he 
 felt as if he could not stand it for a moment longer. He 
 thought that being free from attacks for a longer period 
 than ever before had brought about so much improvement 
 that he could just as well spend his time at home rather 
 than in the company of people he was not interested in and 
 in an environment of depression and lonesomeness. 
 
 This feeling took the form of resentment against every- 
 thing that caused him to be kept at the club. Some days 
 previous to this acute condition the patient had a dream in 
 which the doctor w T as keeping him in bed against his wishes; 
 he rebelled against this, but was told by the doctor that al- 
 though he might feel well it was better for him to remain in 
 bed. (Thus he put the doctor in the wrong.) 
 
 The patient knew he was wrong in thinking that the ex- 
 isting conditions were not the best for him, but he had no 
 power to stop the antagonistic feeling that seemed to be over- 
 powering him. He felt as if he were being pressed from all 
 sides, and everything seemed to tighten around him. To 
 use the patient's own words: "Even the skin on my face, 
 and in fact upon my whole body, felt tight; my mouth was 
 dry, and my tongue felt rough and coated, and I frequently 
 found myself clutching my face with my hands in a nerv- 
 ous manner. I lost interest in my surroundings and carried 
 on my work in an automatic way, having only the one de- 
 sire, to be home with my family. I found the greatest relief 
 and comfort in being alone and enjoying my own company. ' ' 
 
88 
 
 After a visit to the physician he felt better and this feeling 
 of freedom lasted all the afternoon. The patient joined in 
 work with the others, was cheerful, and talked pleasantly 
 on all subjects that came up, and never once referred to the 
 depressed feeling so marked before his visit to the physician. 
 He was interested in his various duties and anxious to ac- 
 complish more than usual. However, in the evening while 
 playing bridge the depression and annoyance seemed to re- 
 turn, and he showed keen displeasure at the plays of his 
 companions and told them what cards they should have 
 played. 
 
 The following day he was again depressed; this feeling 
 appeared slowly at first while he was dressing, but as he 
 came in contact with the different tasks of the day and was 
 thrown with individuals that were annoying and distasteful 
 to him, it increased until it had all the characteristics which 
 were so marked the day before. He became moody and 
 silent, went about with an air of indifference, and answered 
 in monosyllables, showing no desire to be pleased with any- 
 thing. When in the company of those whom he liked he 
 seemed more contented and talked less about himself; but 
 manifested his displeasure to the others by answering quickly 
 and sharply, and plainly showing that he did not desire 
 their company. These symptoms continued throughout the 
 day, the routine was carried out indifferently and the patient 
 showed no real interest in anything but a strong desire to be 
 left alone. 
 
 On the third day of the depression a trip to W was 
 
 planned, to which the patient looked forward with great 
 pleasure as a sort of deliverance from the people and sur- 
 roundings that were so distasteful to him, and also to have 
 the society of the guests who were most pleasing to him. 
 The depression was therefore less marked, but nevertheless 
 present, as noted by the sullen expression and manner in 
 which he went about the morning's tasks. In the afternoon 
 the trip to W was made, and this he thoroughly en- 
 joyed. He shopped and went about the town with all his 
 old-time happy mood, never referring to the depression so 
 noticeable the earlier part of the day. He returned home 
 
89 
 
 in time for supper and was agreeably surprised to receive a 
 card from a favorite cousin telling him that he would receive 
 a visit from him the following Sunday. He at once tele- 
 phoned to the city to ascertain the time the cousin would 
 arrive, and made arrangements for his reception at the club. 
 This was done in an excitable manner and it was apparent 
 he was in a state of suppressed elation, but when all was 
 completed he was more at ease and felt that at last he was 
 to have some "real companionship." He retired at the 
 usual hour and slept soundly all night. 
 
 The next day, Saturday, the patient seemed to live in 
 anticipation of his cousin's visit, and showed less the 
 symptoms of depression that were hanging over him. He 
 attended a lecture but was greatly annoyed at the actions 
 of some of the guests, and remarked that it was a shame 
 people of intelligence didn't have better manners. He made 
 no reference to the depression, but was keyed up and under 
 tension. In the evening he had two very mild psychic at- 
 tacks. On going to bed he said that he felt better and knew 
 he was foolish to be so depressed over conditions that were 
 in reality not at all as he saw them. It was very apparent 
 that the petit mal had lessened the tension to a marked 
 degree. 
 
 Sunday was spent visiting with his cousin, and the patient 
 appeared cheerful and spent the morning talking about 
 home, former companions and all that had occurred since 
 he had left home. He was greatly pleased that nothing un- 
 usual had happened during his absence, and that after all 
 he had not missed so much. During the day the patient 
 had three psychic attacks while with the cousin, which were 
 so slight in character that no one but himself had observed 
 them. In the afternoon a visit to a fresh air home proved 
 a great success. He began to take a real interest in every- 
 thing and to appear bright and cheerful when he saw all the 
 children together and heard them sing. He was greatly 
 taken with the parental attitude of the superintendent and 
 his wife and the manner in which they looked after the chil- 
 dren. His heart went out to them, and when they cordially 
 invited all to return again, the patient was more than en- 
 
90 
 
 thusiastic in accepting. He returned to the club for supper 
 and showed no signs of the depression that had been pres- 
 ent for the past five days. He was cheerful and happy, and 
 talked pleasantly with everyone without any apparent effort. 
 He states that he feels sure the slight psychic attacks allowed 
 him to give in more and to realize that he was wrong; be- 
 fore the attacks occurred he knew that he was wrong, but 
 could not give in. The attacks, therefore, played an im- 
 portant part in relieving the tension. He remarked that he 
 would rather have the attacks and get relief from the de- 
 pression, because they were over within a short time, while 
 the depressed feeling would have to last for a long time if 
 it had to be handled naturally. 
 
 Interest in things that were pleasing relieved this de- 
 pressed state. Companionship of those who were of a 
 pleasing type helped a good deal, while to be thrown in the 
 company of those who were distasteful to him produced 
 marked annoyance and depression. 
 
 The foregoing outline of a mental conflict and its favor- 
 able outcome would seem to be something as follows: On 
 
 going to W the patient was able in part to get away 
 
 from the disagreeable situation which had not permitted of 
 solution; going to town and shopping, etc., improved the 
 condition of his mental outlook. On his return to the club 
 and getting the message from his cousin from home that he 
 would make the patient a visit, he felt more of the displeas- 
 ure modified. Two mornings after, the actual visit with his 
 cousin in which he was told that he had not missed much 
 at home, that many of the things he was interested in had 
 not been much changed since the patient left, and a detailed 
 account of how his father and mother were and how they 
 had spent their time during the summer, was of great satis- 
 faction to him. In addition to that, the occurrence of three 
 or four slight attacks (which were conscious to the patient 
 only and could not be observed by the others) helped to dis- 
 charge still more the unconscious demand for relief from 
 displeasure. Then the afternoon visit to the fresh air 
 home was the final means of more or less complete release 
 of the inner tension. There he saw children con vales- 
 
91 
 
 cing from various diseases, who were living under a regime 
 somewhat comparable to his own; above all he was delighted 
 with the superintendent and his wife who were in charge of 
 the place. They were kindly disposed, rather elderly peo- 
 ple, comparable to his parents. They talked with him in a 
 very friendly and intimate manner, and this served the same 
 purpose of the deepest release as making a visit home and 
 seeing his own parents. Immediately after this visit the 
 patient returned to his normal condition, without having a 
 grand mal attack. 
 
 Change of environment is often a disturbing factor. In 
 the next setting we shall see what influence the transfer of 
 the club back to its winter quarters in the suburbs had on 
 our patient. 
 
 With the departure of his favorite companions he at once 
 turned his attention to clearing his room of all decorations, 
 packing his trunks, and making all preparations to leave at 
 once. As the date he was to leave was very uncertain, he 
 became restless and faultfinding with the guests still in the 
 house. Everything went wrong, his companions were irri- 
 tating to him, and they had nothing in common. He kept 
 to his room and talked continually about the unpleasant- 
 ness of everything, and how he wished he could leave. It 
 was then tactfully suggested by his nurse that it might be a 
 good plan to visit his aunts in the city for a few days until 
 his new quarters were ready. This at once met with his 
 hearty approval; his countenance lit up and he became 
 cheerful and happy. He could not get away quickly enough, 
 and even hired an auto to take him and his nurse to a nearby 
 town so that an earlier train could be taken to New York. 
 On the train he was cheerful and talkative about everyday 
 events but made no reference to the place he had just left or 
 his companions that had been his favorite topic of conver- 
 sation all summer. On the other hand, he frequently spoke 
 of how glad he was going to be to see his aunts. Arriving 
 in the city he rushed about to get the quickest conveyance 
 to take him to the house, and on reaching there he kissed 
 both aunts effusively and at once entered into a long account 
 of the terrible conditions that had existed all summer. The 
 
92 
 
 aunts listened attentively, but showed no assent to his views, 
 and he gradually became less demonstrative toward them. 
 In the morning he announced to his nurse that he was go- 
 ing to have things pleasant and comfortable at the club 
 during the winter, that he was "not going to stand for any 
 foolishness," and if things were not just right he would go 
 to some other place; if the doctor did not approve he would 
 go home. A casual visit to his new quarters aggravated 
 his irritation; he found the house still upset, the room not 
 furnished, and everything looked gloomy, the day being wet 
 and foggy. He became depressed and said he knew every- 
 thing was going to be unpleasant. He spoke of all this in 
 an excited manner to his aunts on his return to the city; he 
 even became demanding in his desire to be heard and to ex- 
 press fully his views. He again took up the subject with 
 the nurse next morning, and the following plan was adopted: 
 The patient was asked to describe all that was pleasant and 
 all that was unpleasant about the new environment and sur- 
 roundings at the club, and to give his candid opinion of 
 everything as he saw it. The nurse explained that this was 
 to be a trial balance of the whole difficulty, to find out just 
 where the mistakes were and to devise some method from 
 the result so that everything could be adjusted properly. 
 The nurse made a debit and credit side on a piece of paper. 
 On finishing the interview it was shown to the patient that 
 he had a complete debit. He was asked if he thought this to 
 be a truthful statement, if it could be possible for every- 
 thing to be as wrong as he had pictured it. He thought for 
 awhile without speaking; then tried to reply, stammered and 
 blushed, and finally got up from his chair and paced the 
 floor. At last he said: "Well, I suppose — Oh, I know I 
 am wrong, but I can't help it, because it's my infernal dis- 
 position I suppose; that's all there is about it." The nurse 
 then asked if the patient did not think there was a little good 
 in everything, that some redeeming feature might be found in 
 everything if one only took the trouble to look for it; further, 
 that if the patient would only assume this attitude he would 
 get more real pleasure out of life, as it was only by looking at 
 the bright side that life was made easier, and by being cheerful 
 
93 
 
 and making- the best of things one gradually got a balance 
 to his credit, and the more credit one obtained of this sort 
 the better one would be guarded against the little trials that 
 came up in daily life. During this explanation the patient 
 lost his forceful, determined manner, became silent and sub- 
 missive, and agreed with the nurse in everything. He said, 
 however, that he thought normal people would view the sit- 
 uation in the same light as he did. While he was assured 
 that this might be so, it was pointed out that his attitude to- 
 ward the facts and his reactions toward them were unnatural 
 and harmful, and that normal individuals did not allow such 
 trivial matters to annoy them but found means to adjust to 
 all conditions. The patient then became more cheerful and 
 promised to make an effort to do his part in being agreeable. 
 He did not again refer to the conversation but on returning 
 to the new quarters he showed his willingness to cooperate 
 with the nurse and physician. He was pleasant and cheer- 
 ful with his companions and became occupied in arranging 
 his room and putting everything in order. He became en- 
 thusiastic over golf and tennis, his wood carving, and his 
 music and took up his daily routine in a manly fashion. 
 
 A rather unusual outcome of such a conversation is shown 
 in the patient's insight by his remark that he "feels such 
 talks with the physician and nurse are just what he needs 
 and that he derives great benefit from them. ' ' He says they 
 "straighten him out and put him on the right road again." 
 He shows an appreciation of how fundamental the defect in 
 his character is, in an after-statement that he feels as if he 
 would never get into such a fussed up state again when 
 anything appeared to be so depressing and disagreeable. 
 
 I may say, however, lest one may think such lines of 
 treatment are final and conclusive, within three or four days 
 our patient had typical resistive dreams, which in turn ex- 
 pressed themselves or inflated the deeper unconscious to 
 bring about a discharge in a series of psychic attacks and 
 one grand mal attack a week after the close of the above 
 incident. But the whole epileptic reaction was much less 
 severe and disabling than any other for several months past. 
 
 It is important to note the disastrous effects in the reverse 
 
94 
 
 of gentle wise training-treatment in such individuals as our 
 patient. Through a peculiar misunderstanding the nurse 
 drove ' ' our patient for two days at rather top speed in 
 every way, almost duplicating the type of bad care and in- 
 attention such supersensitive individuals receive before their 
 first attack of epilepsy. The enforced plan of daily routine 
 chanced upon a Sunday, on which day it had been custom- 
 ary for the patient to rest and take it easy. As usual on 
 this morning, he made preparations to remain in his room, 
 to read the papers and write letters. At this juncture he 
 was called upon to take a long walk with other guests at the 
 club, and he hurried to finish the letter he was writing. 
 The pace on the walk was extra severe, and he was rushed 
 along mile after mile. He managed to keep up pretty well 
 after the first mile, and although he tried to appear cheerful 
 he began to grow rather silent in conversation and worried 
 lest they might be late for dinner. They covered about 
 seven miles, and, as the patient predicted, they were late for 
 dinner. He had a ravenous appetite after the walk, but 
 was not allowed to satisfy it by extra helpings as usual. 
 He looked disappointed, but submitted in silence, and went 
 to his room to write his belated correspondence and read the 
 morning papers. He spent but an hour or so in this easy 
 atmosphere, when he was asked to go for another little walk. 
 He now began to complain, saying he felt tired and had 
 other things to do. He finally submitted with apparent re- 
 luctance and walked four miles more. Although he was 
 neither sullen nor displeased, it was seen that his good feel- 
 ings were "wearing thin." He now remained quiet and 
 started no new subjects of conversation and evinced no in- 
 terest in the topics brought up by the nurse. Nothing 
 unusual happened during the evening, as he was allowed to 
 do just as he pleased. His various remarks and comments 
 were disputed but he showed little annoyance at such criti- 
 cism. He went to bed and slept well. The next morning 
 he was inclined to be uncommunicative, his replies were 
 brief and it was quite evident that he did not wish to talk. 
 His face was a trifle pale and drawn, and he appeared pre- 
 occupied. He soon showed that he wanted to be left alone, 
 
95 
 
 and that he wished to initiate the usual routine of daily 
 duties himself. He began to question the nurse's sugges- 
 tions and wanted various plans of work modified. He said: 
 I feel as though I want things to go along smoothly to- 
 day, and I'd rather this scheme be followed rather than what 
 you (the nurse) have planned." When asked if he was 
 not feeling well, he appeared annoyed and offended, and 
 answered quickly: "Why, yes; I'm all right," which 
 statement, however, was belied by his manner and facial 
 expression. He then went about his duties silently and with 
 downcast appearance. He sat at his desk until breakfast, 
 which was unusual as he most frequently dresses quickly 
 after his morning plunge and goes about singing and whist- 
 ling, and joshing the other guests who are behind in getting 
 up. He usually hurries downstairs, gets the morning paper 
 and seeks the society of his favorite guest or takes a walk 
 outside to see what the weather promises for engaging in 
 sports. After breakfast he was not allowed the usual little 
 rest but was rushed out on a mission several miles away. 
 He was required to carry bundles and a series of ques- 
 tions were fired rapidly at him, put to him in such a 
 manner that he was required to answer. His opinion was 
 asked, and then disputed. He felt as though " he was be- 
 ing kept on edge " all the time, and felt pushed at a physical 
 and mental pace to which he was unaccustomed. However, 
 he stood all this fairly well, although he showed more desire 
 to be let alone but without being moody or depressed. When 
 allowed to stop for some music records and do as he liked 
 for an hour he brightened up and seemed momentarily happy, 
 but so soon as the lesson questioning was begun again on 
 the way home and the pace grew quicker he fell altogether 
 silent and sullen, and spoke only when absolutely necessary. 
 Arriving home he at once lay on his bed and busied himself 
 with his home paper. While he had not openly revolted at 
 the treatment, he indicated by his attitude that the whole 
 plan was not to his liking. Physically he showed his ability 
 to stand even more forced exercising, but he began to show 
 that it all interfered with his peace of mind. Now he be- 
 gan to be more listless, pale, and lapsed into a sullen and 
 
96 
 
 morose state in which he seemed "to withdraw from his en- 
 vironment " and lapsed into long periods of deep thought. 
 After his dinner he was sent with some of the guests he did 
 not particularly like to a vaudeville performance. On his 
 return he expressed his displeasure at being ' ' forced to go 
 to such a show in such company." It was apparent sev- 
 eral times that he had other deeper objections to offer but 
 which he fairly repressed. He spent the remainder of the 
 afternoon by himself reading and writing letters. After 
 supper he was a little more cheerful but was not his usual 
 self. He was most at ease in his room alone. The next 
 morning, the third day of enforced routine, he was plainly 
 in his old mood of dissatisfaction and moroseness; in his 
 words: he "felt sore and didn't have a 'good morning' for 
 anyone." He showed great inclination to omit the morn- 
 ing exercises. He went about his daily task slowly and in 
 a negligent, disinterested manner, speaking only when di- 
 rectly addressed. He had a sullen expression and answered 
 sharply and in monosyllables. It was plainly apparent that 
 he was on the verge of a "wave series," and a halt in the 
 enforced draught ' ' treatment was made. He was allowed 
 his own time to do his different duties. Still he showed that 
 he thought everything was wrong. He was annoyed be- 
 cause "certain letters" didn't come; then, too, he would 
 not join the golf club if he didn't hear that very day of his 
 election. His expression was dull, eyes starey, and face 
 pale. Tennis, his favorite sport, was suggested, but there 
 was something wrong there; then a final straw was a sug- 
 gestion to saw and chop wood. He at once asked in a 
 pleading tone if he might wood-carve. Everything was 
 made ready for the carving. The nurse helped him with 
 the more difficult part of the work, the carving was has- 
 tened along and finished, and the tray which they perfected 
 was sent as a present to one of the patient's friends. At 
 first the work was begun in silence, but as it advanced he 
 began to regain his spirits. He volunteered the informa- 
 tion that somehow he felt better, a load was taken off, 
 etc. But the latent feeling of irritation had been stirred 
 too deeply to be gotten rid of at once. At the dinner 
 
97 
 
 table he made a few cutting remarks, but seemed to 
 gain added spirits as he did so, especially when he 
 received no "scratch" in the fray. He then became a 
 bit elated, jocose and boyish in spirits. He attended a 
 football game in the afternoon and remarked that he was 
 getting his balance again and that he had felt a growing dis- 
 like toward everyone and everything, a sort of disgust in 
 his stomach, but it was now passing away. However, the 
 great depth to which the irritation had penetrated still pre- 
 saged itself in the night dreams. He dreamed he was 
 wood-carving (favorite craft) and that he was conscious he 
 was going to have an attack. The nurse was out of the 
 room (a personal objection to the latter 's attitude of the past 
 two days) and when another (unfriendly) guest sought to 
 call the nurse our patient showed anger and said: "You 
 fool, I'm all right; I've gotten rid of it." The attacks are 
 always used in the dream in their proper psychologic sense 
 (to get rid of unpleasant things). 
 
 The next day our patient said, "I can't understand why 
 that old feeling came up in my stomach for the past two 
 or three days; I think it must have been on account of the 
 weather, or something not going right outside my recollec- 
 tion now " — a bit of false rationalization common enough 
 in the study of causes in normal individuals, to say noth- 
 ing of a similar reasoning in the pathogenesis of epilepsy 
 itself. It may be added that no attacks were incipient at 
 this time and no attacks occurred for over 10 days after the 
 above notes, nor has our patient been depressed or sad. 
 
 Even though for all ordinary routine affairs he has learned 
 to adapt himself fairly well, the old irreconcilable attitude 
 to uncongenial changes has not been fully met. While he 
 may be rescued from ordinary epileptic reactions, such as 
 epileptic attacks, long after these he will have minor con- 
 tests that may be below the level of the demand for a fit re- 
 action of the grand neurosis. 
 
 From the sketched outline of the foregoing case it is ob- 
 vious that our patient has relatively the same inherent epi- 
 leptic make-up as the mother — the inability to develop out 
 of the infantile emotional life of the narcissistic period, ego- 
 
98 
 
 tistic and supersensitive as it is shown to be. Further in- 
 fringements of outside demands make such an individual 
 break into tantrums, employ day dreams, later violent 
 tempers and mental abstractions, and finally as the puberty 
 and adult demands appear, one sees the epileptic reaction 
 supervene with its well-known setting and peculiar mech- 
 anism. 
 
 It is interesting to note what the sister's reactions are, 
 endowed as she is with a somewhat similar make-up to that 
 of the brother. (See No. 3 on chart.) She also has the 
 same kind of temperament and "can not bear disappoint- 
 ment." She is rather quick tempered, but has it more 
 under control ; as the disappointments or anger situations 
 occur she feels keyed up inside and her knees begin to 
 shake, and then she " undergoes a state of agony that other 
 people can't realize." She gets square with things by 
 letting the conflicts wear off, but there is always a feeling 
 of resentment. She is very sensitive to her surroundings, 
 and states that she can tell immediately when a person is 
 not in good humor without looking at him. As a young girl 
 music helped a good deal, especially when lonely or miser- 
 able. She now has a sympathetic husband who carries 
 her over many difficulties; she has two children, the older 
 one very much resembling herself. She says, " My mother 
 is a dear, sweet woman, but it never occurred to her to try 
 to understand her children, but to make them what she 
 thought they ought to be. My father is different, and 
 reason is one of his uppermost ideas; when he said 'No' 
 he meant it. But with my mother there wasn't any sym- 
 pathy or understanding; I miss it very much and have 
 always regretted this lack of sympathy very keenly." 
 
 The sister met similar situations at home that the brother 
 did; she frequently had a sense of being balked, but never 
 went into a rage of the tantrum type. She argued a great 
 deal more; and though she bore a great deal of resentment 
 at times, she would argue and generally end the conflict in 
 weeping if she could not get her way. She would fight it 
 down or go to her room and cry it off. Once she wept a 
 whole day, but when the parents would not give in and she 
 
99 
 
 found she was the only one suffering and no one bothered 
 about her, that she was simply working herself up for noth- 
 ing, she gave in. She realized that in opposing her mother 
 it was like "ramming against a stone wall." A great 
 advantage in her handling these episodes was that she 
 went forward to find some way out, to seek some solution 
 that was endurable, as it were. She felt that she could not 
 reason with her mother, and if she wanted anything granted 
 she always went to the father and found it a great satisfac- 
 tion to talk it out with him, even though she could not get 
 her way. He would present the facts, and would then give 
 her the privilege to decide; this, of course, was not the 
 mother's method at all. The brother's conflicts were never 
 adjusted this way, because he never went to the father. 
 
 While the spinal curvature might have been bad for her 
 physical welfare, it certainly won for her some distinct res- 
 pite from the mother's rigid moral discipline and she was 
 soon sent away to a congenial environment in a sisters' 
 school in a distant city. In regard to the slight permanent 
 curvature not noticeable at present, she says, ' ' Perhaps I 
 am keenly sensitive because the curvature has been the 
 greatest burden I could ever imagine — to be what I should 
 not have been. For years I could not bear to go without a 
 coat. I wanted to be a nun, and thought their lives ran so 
 smoothly. Then I realized that the perfection they had 
 reached was not 'real' life." 
 
 Regarding her little son (No. 6), three years old, who re- 
 sembles her in physical and mental make-up, but who 
 possesses characteristics identical to those of her brother 
 (No. 4), she says: "Occasionally my little boy sits and 
 dreams; whether he does it consciously I don't know; when 
 we try to get him back to reality he refuses to be aroused for a 
 while. He isn't restless, but sometimes, such as waiting 
 for lunch, he just sits and dreams. I have been very care- 
 ful with him; I don't want to stir him up to any great men- 
 tal force and don't like to clash wills at all. I have never 
 tried to break his will and have never spanked him. I had 
 a nurse last year of whom he was very fond; one time she 
 tapped his fingers for doing some little thing, and it nearly 
 
100 
 
 broke his heart. If I speak at all firmly to him he will 
 look up and say, 'You love me, mother, don't you?' and 
 if not assured that I do, he will be all cut up over it and 
 cry. He loves to play with his dolls and is happy for hours 
 with them. Both of my children talk to their dolls and 
 pet them, and never spank them." The boy often gets 
 into a mental attitude which indicates he is about ready 
 for a tantrum and says "I won't," then stiffens up, and 
 "one word more" would drive him into a "physical as 
 well as a moral cramp." Then he is taken by himself and 
 a kindly talking to smoothes out the whole situation. The 
 mother wisely says, "it is simply a matter of getting him 
 to unfold his rigid will, and meeting the situation with 
 gentleness is the only way to get around these episodes." 
 
 To summarize, we have here the grandmother with the 
 epileptic character and reaction ; the son with the same, the 
 daughter with the make-up in greater part but with enough 
 of the paternal characteristics and proper training under 
 the father's guidance, together with a prolonged training 
 away from home, to enable her to adjust herself to the var- 
 ious vicissitudes of "irritating reality" without epileptic 
 reactions. A grandson with the apparently identical make- 
 up his uncle possesses, is being trained wisely and sanely 
 by his mother, and it would seem as though he stands a 
 fair chance to avoid an epileptic reaction in later life. 
 
101 
 
 Section IV. 
 
 METHOD OF GRAPHICALLY RECORDING THE MENTAL 
 FACTORS PRECIPITATING EPILEPTIC REACTIONS. 
 
 In the psychological study of the frank idiopathic epilep- 
 sies the question often arises, why may not one more or less 
 definitely predict the occurrence of seizures in the individual 
 case, especially when definite upsetting- mental factors are 
 in evidence? 
 
 Even if one were able to exclude the many inciters to 
 attacks arising on a physical basis, such as are notably seen 
 in constipated epileptics, the problem would still be far from 
 a satisfactory solution. First, because the real motivation 
 of the fit is frequently unconscious, even though an obvious, 
 external and conscious cause of stress and irritation be at 
 hand. Often a more or less definite upsetting episode, 
 seemingly harmless in itself, produces or is followed by an 
 attack, and frequently a trying situation is not followed by 
 an attack. However true this may be, the fact still 
 remains that a trained observer can tell rather definitely 
 when an epileptic is about to have some sort of seizure 
 reaction. These observations have not been handled with 
 the degree of careful study the subject would seem to 
 warrant. If there is a dynamic element in the modification 
 of the daily routine of the epileptic that tends to produce 
 or inhibit seizures, our subject may be of prime therapeutic 
 importance. The attacks would then be viewed as a result 
 of the degree and amount of mental perturbation which 
 the individual epileptic can not ordinarily handle in a 
 healthy manner. Obviously there are so many physical as 
 well as psychical factors to be reckoned with in the indi- 
 vidual epileptic's life that we can outline only in most 
 general terms the relationship between upsetting types of 
 stress and their sequential epileptic reactions. To compli- 
 
102 
 
 cate further the task, the epileptic himself varies consider- 
 ably from day to day in his ability to handle his difficulties. 
 However, for some time in the past not a few observers 
 have striven to record a parallelism between certain toxic 
 states and epileptic fits. 
 
 I have thought it not unprofitable to chart some of the 
 mental states in their relationship to the epileptic reactions. 
 The charts are self-explanatory. It has been observed, when 
 the patient is living in a mental state in which he manu- 
 factures his own interests, he is happy and contented and 
 least likely to show epileptic reactions. When he is acting 
 under the direction of a trainer and must be encouraged 
 daily at his work and ordinary routine, he is more likely to 
 have attacks. So soon as neither condition exists, he often 
 falls into states of lethargy or day-dreaming, and when 
 aroused may be irritable and angry, or sullen and illy dis- 
 posed, and then attacks are not far distant. States of 
 elation also have a significance in relation to attacks. 
 
 The charts are taken from actual daily observation; all 
 these cases are under my personal supervision, and so far 
 as possible the existence of physical factors has been ruled 
 out. 
 
 Chart No. I. 
 
 
 
 CHARTo 
 
 fEI 
 
 >ll 
 
 EP 
 
 TIC REACTSOh 
 
 "S 
 
 for Month of 
 
 Har, 
 
 916. 
 
 
 
 I 
 
 2 
 
 3 
 
 4 
 
 5 € 
 
 > 7 
 
 3 
 
 9 ! 
 
 II 
 
 \2 
 
 S3 
 
 [4 
 
 15 
 
 16 
 
 17 
 
 18, 
 
 19 
 
 20 
 
 21 2 
 
 2 23 24 
 
 25 26 
 
 27 
 
 28 
 
 29 
 
 30 
 
 31 
 
 6RANDMAL 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 $ ! 
 
 
 
 
 
 
 
 
 Petit Mal 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 *■ i 
 
 a 
 
 
 
 
 
 
 
 Phenomena 
 
 
 
 
 
 1 
 
 | 
 
 
 \\\ 
 
 [ 
 
 
 
 
 
 
 
 
 
 
 
 
 I 8 
 
 
 
 
 
 
 ElATION 
 
 
 
 
 
 
 
 
 '1 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 Anger 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Irritation 
 
 II 
 
 II 
 
 II 
 
 II 
 
 
 III 
 
 
 ll 
 
 
 
 
 
 
 1 
 
 1 
 
 I 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 IETHAR6Y 
 
 II 
 
 II 
 
 
 
 
 mi 
 
 
 III 
 
 : 
 
 
 
 
 
 1 
 
 1 
 
 f-j 
 
 I 
 
 i 
 
 
 i y 
 
 
 
 
 
 
 
 Interest 
 
 1 
 
 1! 
 
 
 
 
 
 II 
 
 
 
 
 
 
 ■1 II II II II II II II Ml II 
 
 
 
 
 
 
 spontaneous 
 Interest 
 
 4- 
 
 
 
 1 
 
 
 
 
 _i 
 
 1 
 
 U 
 
 1 
 
 ■1 M -1-U-l- 1 1 1 '[■ 
 
 1 
 
 1 
 
 1 
 
 1 
 
 i\ 
 
 Chart I. Beginning March 1st, the patient's interest in 
 the routine had to be directed; he preferred to sit in his 
 room and read, becoming irritable when certain orders were 
 insisted upon. This condition lasted up to the 4th. On 
 the evening of the 4th he received a message from a favorite 
 cousin telling him he would spend the following day with 
 him. The patient went to bed in a very happy frame of 
 
103 
 
 mind. On getting- up the next day he was cheerful and 
 remarked frequently that he was glad he was going to see 
 "someone from home." The cousin arrived, and the 
 patient at once took the initiative ; he showed the cousin 
 about the grounds, made arrangements for dinner, played 
 the piano for him, and spent a very pleasant day. The 
 next day, however, he was moody, and pouted when told 
 to hurry along with the morning work. During the day he 
 had two mild psychic waves. On the 7th it was necessary 
 to direct him to follow out his daily tasks. He showed a 
 desire to sit and dream, and became irritable when told he 
 had certain duties to perform. The 8th showed a condition 
 that still required direction, but no lethargy or irritation 
 resulted. On the 9th and 10th mild psychic waves were 
 noted, probably due to the suppression of the irritations 
 some days previous. From the 11th to the 15th there was 
 an entire change in the patient's disposition. He was 
 cheerful, happy and contented; his interest was spontane- 
 ous, and he produced good work. From the 16th to the 
 20th a condition of marked irritability was present. 
 Nothing seemed "just right." He did not want to follow 
 out even the simplest directions, preferring to be left alone 
 in his room where he spent his time trying to read although 
 he could not concentrate; he sat and stared as if dreaming 
 or in deep thought, and was irritated by being told it would 
 be best for him to try to follow out the regular order of 
 routine. On the 21st and 22nd complete attacks were 
 noted. On the 23rd he felt greatly relieved but could not 
 " get started, " as he put it. He was allowed to rest all 
 that day. On the 24th and 25th he had mild psychic attacks. 
 This apparently relieved the patient completely, for he at 
 once took hold of things of his own accord, as he had so 
 noticeably done on the 11th, and for more than a week his 
 interest was spontaneous and he showed a rapid improve- 
 ment in all his work. 
 
104 
 Chart No. II. 
 
 
 157 DAY 
 
 2*P DAY 
 
 35? DAY 
 
 
 A,n 
 
 II 
 
 A.M. 
 
 3 
 
 P.M 
 
 5 
 
 P.M. 
 
 9 
 
 P.M. 
 
 7 
 
 A.M. 
 
 b>30 
 AM 
 
 ii 
 
 AM. 
 
 ||30 
 
 AM. 
 
 5 
 
 P.M. 
 
 5 
 
 P.M. 
 
 IT 
 
 AM 
 
 9 IO 
 
 AM. AH 
 
 1130 
 
 AH 
 
 • 
 
 1230 
 
 P-M 
 
 RM 
 
 z 
 
 RM 
 
 GRAND PtAL 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 PETIT MAL 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 PSYCHIC 
 PHENOMENA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ELATION 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ANGER 
 
 
 
 
 
 
 
 
 
 
 
 
 l 
 
 
 
 
 
 
 
 
 IRRITATION 
 
 II 
 III 
 
 i \m 
 
 
 
 
 1 
 
 
 
 
 | 
 
 N 
 
 
 1 
 
 
 
 
 
 
 LETHARGY 
 
 llll 1 
 
 II 
 II 
 
 mill hi 
 
 II 
 II 
 
 
 
 
 
 
 DIRECTED 
 INTEREST 
 
 III II II III 
 
 1 HI II II II 1 
 
 III III 
 
 
 
 
 SPONTANEOUS 
 INTEREST 
 
 1 1 1 
 
 
 11 1 II 1 1 II II 
 
 ll 
 
 Chart II. It is important to note the disastrous effects 
 of the reverse of gentle and wise training treatment in pro- 
 ducing the type of emotional disturbances which are 
 frequently seen preceding attacks. 
 
 Through a peculiar misunderstanding, the nurse "drove " 
 this patient for two days at rather top speed. The enforced 
 routine chanced upon a Sunday, on which day it had been 
 customary for the patient to rest and take his ease. As 
 usual, on this morning, he made preparations to remain in 
 his room, to read the papers and write letters. At this junc- 
 ture he was called upon to take a long walk, and he hurried 
 to finish the letter he was writing. The pace on the walk 
 was unusually severe, he was rushed along mile after mile, 
 but managed to keep up pretty well. Although he tried to 
 appear cheerful, he began to grow rather silent, and worried 
 lest they might be late for dinner. They covered about seven 
 miles, and, as the patient had predicted, they were late for 
 dinner. He had a ravenous appetite but was not allowed to 
 satisfy it by the usual extra helpings. He looked disap- 
 pointed but submitted in silence, and went to his room to 
 attend to his belated correspondence and read the papers. 
 He spent but an hour in this easy atmosphere when he was 
 asked to go for another walk. He now began to complain, 
 saying he felt tired and had other things to do. He finally 
 submitted with obvious reluctance, and walked four miles 
 
105 
 
 more. Although he was neither sullen nor displeased, it was 
 seen that his good humor was " wearing thin." He now re- 
 mained quiet, started no new subjects of conversation, and 
 evinced no interest in the topics brought up by his compan- 
 ions. Nothing unusual occurred during the evening as he 
 was allowed to do just as he pleased. Although his various 
 comments and remarks were disputed, he showed little 
 annoyance at such criticism. He went to bed and slept 
 well. The next morning he was uncommunicative; his re- 
 plies were brief and it was quite evident that he did not wish 
 to talk. His face was pale and drawn, and he appeared 
 preoccupied. He soon showed that he wanted to be left 
 alone, and that he wished to initiate the usual daily duties 
 himself. He began to question the nurse's suggestions and 
 wanted various plans of work modified, saying: " I feel as 
 though I want things to go along smoothly to-day, and I'd 
 rather we should do this than what you have planned." 
 When asked if he were not feeling well, he appeared an- 
 noyed and offended, and answered quickly: "Why, yes; 
 I'm all right." His statement, however, was belied by his 
 manner and expression. He went about his duties silently 
 and with downcast appearance. He sat at his desk until 
 breakfast, which was unusual as he most frequently dresses 
 quickly after his morning plunge, goes about singing and 
 whistling, and "joshes" the other guests who are late in get- 
 ting up. After breakfast he was not allowed the usual little 
 rest but was rushed out on a mission several miles away. 
 He had to carry bundles, and questions were fired rapidly at 
 him, put in such a manner that he was required to answer. 
 His opinion was asked, and then disputed. He felt as if 
 he were being "kept on edge" all the time, and pushed at 
 a physical and mental pace to which he was unaccustomed. 
 However, he stood all this fairly well, showing more desire 
 to be let alone than moodiness or depression. Arriving 
 home, he at once lay down on his bed and busied himself 
 with his home paper. While he had not openly revolted at 
 the treatment, he indicated by his attitude that the whole 
 plan was not to his liking and interfered with his peace of 
 mind. He began to be more listless and pale, lapsing into 
 
106 
 
 a sullen, morose state in which he seemed to "withdraw 
 from his environment, " and indulging in long periods of deep 
 thought. After his dinner he was sent with some guests he 
 did not particularly like to a vaudeville performance and 
 expressed his displeasure at being ' ' forced to go in such com- 
 pany . ' ' After supper he was a little more cheerful although 
 not his usual self. Next morning, the third day of his 
 enforced routine, he was plainly in his old mood of dissatis- 
 faction and moroseness; in his words, he "felt sore and 
 didn 't have a ' good morning ' for anyone. " He went about 
 his daily tasks in a negligent, disinterested manner, speak- 
 ing only when directly addressed. He had a sullen 
 expression and answered sharply. It was plainly apparent 
 that he was on the verge of a "wave" series. A halt in 
 the enforced routine was made, and he was allowed his own 
 time to do his various duties. Still he showed that he 
 thought everything was wrong. His expression was dull, 
 his eyes starey, and face pale. Tennis, his favorite sport, 
 was suggested, but something was wrong there; then 
 the final straw was a suggestion to saw wood. He at once 
 asked in a pleading tone if he might wood-carve. Every- 
 thing was made ready for the carving, the nurse helped him 
 with the more difficult part of the work, and the carving of 
 a tray was hastened along and finished. This the patient 
 sent off immediately to one of his friends. He then showed 
 signs of regaining his spirits, and volunteered that somehow 
 he felt better, a load was taken off his mind, etc. The 
 latent feeling of irritation had been stirred too deeply, how- 
 ever, to be gotten rid of at once. At the dinner table he 
 made a few cutting remarks, but seemed to gain added 
 spirits when he received no ' ' scratch ' ' in the fray . However, 
 the great depth to which the irritation had penetrated still 
 showed itself in the night dreams. He dreamed he was 
 wood-carving and that he was conscious he was going to 
 have an attack. When the nurse was out of the room (a 
 representation of his objection to the latter's attitude of the 
 past two days) and another (unfriendly) guest sought to 
 call the nurse, our patient showed anger and said: "You 
 fool, I'm all right; I've gotten rid of it" (the attack). 
 
107 
 
 The next day our patient said: "I can't understand why 
 that old feeling (epigastric aura) came up in my stomach 
 for the past two or three days; it must have been on account 
 of the weather, or something not going right outside my 
 recollection now." 
 
 It may be added that no actual attacks appeared at this 
 time, and none occurred for over two weeks after the above 
 notes were made, during which period the patient felt neither 
 depressed nor sad. 
 
 Chart No. III. 
 
 
 1 2 
 
 . 3 * 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 li 
 
 12 
 
 13 
 
 14 
 
 IS 
 
 16 
 
 17 
 
 18 
 
 19 
 
 20 
 
 21 
 
 22 
 
 23 
 
 24 
 
 25 
 
 26 
 
 27 
 
 28 
 
 2930 31 
 
 6RAHDMAL 
 
 HI 
 
 1 1 
 
 | 
 
 
 M 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 PETIT MAL 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Patch ic 
 
 Phenomena 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Elation 
 
 i 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 AN6ER 
 
 H 
 
 IN 
 
 1 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Irritation 
 
 y 
 
 II 
 
 II 
 
 1 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 LETHAR6Y 
 
 i 
 
 
 
 !'! 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Directed 
 
 
 
 
 J 
 
 1 | 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 spontaneous 
 Interest 
 
 
 
 i 
 
 1 
 
 ;■:■ 
 
 ® 
 
 H 
 
 \l 
 
 
 1 
 
 H 
 
 1 
 
 1 
 
 1 
 
 M 
 
 9 
 
 1 
 
 Z 
 
 2 
 
 1 
 
 1 
 
 1 
 
 1 
 
 i 
 
 u 
 
 B 
 
 1 ll ■ 
 
 Chart III. On the initiation of the observation period 
 it was noted that the patient had been irritable and in an un- 
 stable 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 which began with irritation, anger, 
 and finally elation. Next day she was irritable and angry 
 and refused to cooperate. The following day, however, 
 there was an effort on her part to comply with the prescribed 
 routine but later in the day her interest lagged and she be- 
 came irritable, angry, then elated, and later had another 
 grand attack. 
 
 On the 5th she was irritated at everything and became 
 very angry when directed to certain duties. But on the 6th 
 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 soon followed by the old 
 irritable state. The following day another period of spon- 
 
108 
 
 taneous 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 con- 
 tented, going about her daily tasks without being irritated 
 or annoyed, but on the 11th she resented being told by her 
 nurse she must act in a certain way when in the company 
 of the other guests, that she must not be so 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 attacks 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 her- 
 self to her music and tennis and cooperated 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. 
 
 Chart No. IV. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 & i 
 
 > 10 
 
 II 1 
 
 2 13 
 
 14 
 
 15 
 
 IGI 
 
 7 18 
 
 19 
 
 20 
 
 21 
 
 22 
 
 23 
 
 24 
 
 252 
 
 627 2 
 
 829 
 
 3031 
 
 Grand mal 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 Petit Mai 
 
 
 
 
 
 
 
 
 1 
 
 
 1 11 
 
 II 
 
 
 
 1 
 
 | 
 
 
 
 
 
 
 
 
 
 
 | 
 
 PSYCHIC 
 PHENOMENA 
 
 
 
 
 
 
 
 
 u 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L 
 
 ELATION 
 
 
 
 
 
 
 1 
 
 1 
 
 u 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 1 
 
 . 
 
 
 
 ANGER 
 
 i ii ii ii ii minimi ii muni ■ 
 
 
 
 
 
 
 1 
 
 
 I.I 
 
 1.1 
 
 
 J 
 
 
 | 
 
 Irritation 
 
 n 
 
 i 
 
 1 
 
 1 
 
 1 
 
 
 I 
 
 a 1 
 
 1 I 
 
 i , : 
 
 
 
 
 \i 
 
 H 
 
 9 
 
 1 
 
 
 II 
 
 H 
 
 
 1 
 
 
 
 LETHARGY 
 
 H 
 
 1 
 
 1 
 
 $ 
 
 1 
 
 
 t 
 
 j i .; 
 
 1 '' ! 
 
 3 I 
 
 toi 
 
 1 
 
 I I 
 
 1 
 
 ■ 
 
 i 
 
 
 R 
 
 
 i 
 
 1 1 
 
 ■ 1 
 
 8 
 
 
 Directed 
 Interest 
 
 i ii ii ii ii minimi ii n ii ii ii ii ii ii ii ii ii ii ii ii ii ii mil 11 imni 
 
 SPOIITANEOUS I 
 
 i i \m 
 
 Chart IV. A fellow patient died at the Club, and this 
 seemed to increase the irritable state already present when 
 our patient arrived. She had dreams of fright. She be- 
 came depressed and moody, sat about in a listless fashion, 
 and became angry when told to follow out the simplest direc- 
 tions. This condition lasted from the 1st to the 5th. Then 
 
109 
 
 for three days she tried to do as the nurse suggested and on 
 each occasion became elated, laughed and talked with her 
 nurse, saying that she, the patient, was a good girl and 
 would do everything she was told; but the effort was too 
 great, and out of the elated state there developed first petit 
 mal and then grand attacks. She again became irritable, 
 depressed, and made no effort to adjust herself, and the 
 three days following she had attacks of a more or less severe 
 type. The slightest difficulties seemed mountains to her. 
 She complained constantly of everything and everybody. 
 She would put her hands over her eyes, jerk her shoulders, 
 clasp and unclasp her hands, and otherwise show the 
 nervous tension under which she was laboring. 
 
 Then followed three days in which she was obedient, 
 seemed anxious to please, and was solicitous of the nurse's 
 comfort; but she soon tired of this attitude and became irri- 
 table. The next day she went through the same phase of 
 trying to keep up with the routine, became irritable and then 
 elated, and said: " Oh, my Lord, will I ever be like other 
 people! " A slight attack followed, after which she became 
 excited and angry. She became angry over a bill she had 
 paid the newspaper man, and declared he was a cheat. She 
 kept talking about it during the day and carried it about in 
 her hand. Looking abstractedly into space she said to the 
 nurse: "That bill — I am going to have an attack." She 
 lost consciousness for a few seconds and then began to 
 undress, next she twisted her body, putting her hands under 
 her back and lifting her entire body, kicking her feet, and 
 laughing and trying to talk. She was induced to lie down, 
 when she assumed the fcetal position and went to sleep. 
 From then on until the end of the month she made efforts to 
 keep up with the daily routine, but found fault with every- 
 thing, becoming excited, irritated, depressed and elated by 
 turns, and had several attacks. 
 
110 
 Chart No. V. 
 
 
 m DAY 
 
 
 2*P DAY 
 
 
 
 
 
 
 
 
 
 s 
 
 7 
 
 7 
 
 8 
 
 fc» 
 
 (O II 
 
 
 
 
 
 
 
 GRAND MAL 
 
 
 
 
 
 
 II 
 
 
 
 
 
 
 
 Petit mal 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 PSYCHIC 
 PHENOMENA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Elation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Anger 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 Irritation 
 
 I II 1 
 nun 
 
 
 
 
 
 
 
 
 
 
 
 
 Lethargy 
 
 i ii ii ii ii m 
 
 
 
 
 
 
 
 DIRECTED 
 INTEREST {J 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 SPONTANEOUS §§ 
 INTEREST 11 
 
 
 
 , 
 
 , 
 
 — 
 
 , 
 
 
 ' 
 
 , 
 
 1 
 
 , 
 
 , 
 
 Chart V. The patient, aged 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 cen- 
 sured. He immediately ceased his spontaneous interests 
 and did poorly at directed ones. He was told he must apol- 
 ogize and restore the stolen fruit and that his comrades would 
 be told of his misconduct. He made no effort toward hand- 
 ling the situation, was greatly dejected and experienced a 
 keen mental anguish. He had an intense conflict with him- 
 self as to how he might get out of the situation rather than 
 take the simple course of acknowledging his fault and mak- 
 ing apologies, thus regaining the usual friendly relations of 
 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, refus- 
 ing to follow the ordinary routine. All the forenoon he 
 continued to be lethargic and indifferent, gaping and yawn- 
 ing, and at 11 o'clock had a grand mal attack. Immediately 
 after the attack, although he had made no effort at adjust- 
 ing the difficulties, he appeared greatly relieved and went 
 
Ill 
 
 about his routine duties as if the whole matter had been 
 quite removed. However, he was not amnesic for events 
 that had occurred. 
 
 The foregoing system of charting epileptic reactions shows 
 that it is not only feasible but desirable that each and every 
 case-history should have a similar graphic chart for easy 
 reference in the case summary. Inasmuch as the funda- 
 mentals of the tantrum reactions of the "difficult" child 
 are embraced in this scheme of chart recording, it is obvi- 
 ous that this method might be extended for use in other 
 types of reactions simpler than those leading up to epileptic 
 seizures. 
 
 Section V. 
 
 EXPERIMENTAL STUDY OF THE MENTAL RESTORATION OF 
 A DETERIORATED EPILEPTIC. 
 
 As has been suggested a number of times in this study, 
 the deterioration of the epileptic may, in some measure at 
 least, be dependent on mental factors — on the maintenance 
 of his interest and habit reactions. In so far as this is 
 true, the clinical picture of this deterioration ought to be 
 modifiable and the best material with which to demonstrate 
 this would be a case where the epilepsy comes on late in 
 life where a fair foundation of mental habit has once ex- 
 isted on which to build.* An excellent opportunity for 
 such a therapeutic attempt presented itself some three years 
 ago in the case of a man who had not developed his con- 
 vulsions until his 38th year but in three years had shown 
 
 * The plan of treatment was aided in no small part by the experience obtained 
 in the recovery of V. A. S., a chronic deteriorated epileptic, mentioned first as 
 Case II in my article "Curability of Idiopathic Epilepsy," published in the 
 Archives of Internal Medicine, January, 1912, Vol. 9, and detailed in " The Nature 
 and Pathogenesis of Epilepsy," N. Y. Medical Journal, February 27 to March 
 27, 1915. In this case of extreme memory and habit disorganization a simple 
 and sensible scheme of re-establishing a series of spontaneous interests was 
 successfully made use of. This case was also commented on by Dr. John T. 
 MacCurdy in his article "A Clinical Study of Epileptic Deterioration," Psychi- 
 atric Bulletin, Vol. I, April, 1916, p. 257. In this article MacCurdy. in 
 addition to giving an excellent descriptive study of epileptic dementia, also dis- 
 cusses the possibility of mental factors having a share in the development of 
 the deterioration of some epileptics, and for the first time, he formulates the 
 mechanisms by which these mental factors may be conceived to operate. A 
 study of MacCurdy's paper is therefore advisable in connection with this 
 account of more empiric treatment. 
 
112 
 
 grave dementing symptoms. In the absence at that time of 
 any work on this aspect of the disease the treatment adopted 
 was purely empiric but the results are no less instructive on 
 that account. Unfortunately he died of a grippe pneumonia 
 (March 5, 1914) after eighteen months of treatment, so that 
 we can not say what the ultimate results might have been. 
 The aim of this report is, therefore, not to claim a specific 
 therapy for this condition but merely to demonstrate how 
 accurately his improvement ran parallel to certain psycho- 
 therapeutic experimental measures. 
 
 His family history showed a definite heredity of feeble- 
 mindedness and insanity but no definite epilepsy. 
 
 The makeup was distinctly of the epileptic type. In 
 school he was slow in acquisition, particularly with those 
 subjects which required concentration. It is important to 
 note that his favorite study was drawing. He was abnor- 
 mally sensitive in the school period of life, " feeling hurt for 
 days" when criticized, and reconciling himself to discipline 
 only with great effort. Later in life, when confronted with 
 mistakes, he tried to make good his excuses and if this 
 failed would become abusive, excited and filially absent 
 himself for hours from the troublesome environment. He 
 had few friends because he was hypercritical of his acquaint- 
 ances and insincere in his protestations of affection. What 
 superficial intimacies he enjoyed never lasted long, as he 
 was too self-opinionated to maintain these friendships. In 
 his earlier years his chief interest seemed to lie in fussing 
 about his home, while later in life the interest centered 
 almost entirely on his father's business, which it was ex- 
 pected he would inherit. He never paid any attention to 
 games or sports of any kind. In general one might say 
 that he was preponderantly self-centred with little ability 
 to objectivate his interest or get in rapport with others. 
 
 It is hard to say when his epilepsy began, for, years before 
 convulsions occurred, there were mental changes highly 
 typical of that disease. This deterioration had a gradual 
 onset, the abnormalities of his character passing imper- 
 ceptibly over into definite symptoms. On leaving school 
 there became evident an increasing difficulty in cooperating 
 
113 
 
 with others and he grew steadily less able to adapt himself 
 to new situations. His sensitiveness increased to a morbid 
 degree, for on slight provocation he would turn irritable, 
 abusive and finally lapse into sullen silence, not speaking 
 to the offender for days. Naturally, with this, he became 
 less respectful of the rights of others and much less tactful. 
 Coincidently, his interest in matters not directly affecting 
 himself grew steadily narrower. His business — his whole 
 life — contracted into routine ; he was finicky in demanding 
 order and precision. Frequently he lapsed into day dreams 
 of living back at home with his mother, although he was 
 married and had children of his own. Interest withdrawn 
 from the world around him centered on his own body ; he 
 became hypochondriacal. Worry over his health often led 
 to restlessness and then long periods of sullen, moody 
 silence. 
 
 Life was becoming too great a strain on him and at 38 
 his first convulsion occurred. The circumstances are sig- 
 nificant. He spent a large part of one day at a business 
 conference where he had great difficulty in controlling his 
 annoyance at what he called the " pig-headedness " of 
 his associates. Before the meeting was over he became 
 pale, restless, trembled and had a headache. During the 
 day he had taken little food, went home successful, but still 
 worrying about the outcome of his schemes, ate a hearty 
 dinner and then had a grand mal attack. His subsequent 
 seizures usually showed similar prodromata. They repeated 
 themselves with ever increasing frequency, reaching a rate 
 of two a week. 
 
 The mental changes, which up to this time had been 
 slowly progressing, now advanced at greater speed. He 
 totally lost his ability to adapt himself to anything outside 
 his business; interest in general activities went with the 
 loss of adaptation and soon the business itself ceased to 
 attract him, although this was the last interest to disappear. 
 Intellectual degradation set in, for pari passu with loss of 
 interest his memory faded out. He was reduced to staying 
 at home, paying no attention to anything except to his appe- 
 tites, disregarding even his family. With this inactivity he 
 naturally began to suffer physically. 
 
114 
 
 He came to me for treatment after the convulsions had 
 been present for three years. It was found that he had a 
 poor circulation, flabby musculature, enterocolitis and 
 serious constipation. Mentally he lacked any spontaneity, 
 was dull in appearance and had such a memory defect that 
 he could retain a simple fact no longer than a minute or so. 
 
 The treatment, as has been said, was purely experimental. 
 The first efforts were naturally directed towards improving 
 his physical condition. This period lasted for six months 
 and, during' this time, although he became bodily well, 
 there was no result, so far as either his convulsive or deteri- 
 oration symptoms were concerned. 
 
 In the next period of eighteen months (terminated by his 
 death) the treatment was focussed on the mental aspects of 
 his condition This, for some time, seemed a hopeless 
 task. The usual routine occupations failed to awaken a 
 spark of enthusiasm in him. He was put at cutting wood, 
 wood-carving, shop work and handicrafts of various kinds 
 but all to no avail. He neither showed any interest in them 
 nor did his convulsions diminish in frequency. A whole 
 series of occupational studies were tried — travel and nature 
 studies, horticulture; these, too, failed of result. It now 
 became evident that nothing could be grafted on him, so 
 the more rational scheme was attempted of reawakening 
 his strongest interests, of appealing to what had previously 
 meant most to him — his feeling of self-importance and his 
 business. This was successful and, as his intellectual pro- 
 cesses began to accelerate, the simpler stimuli were made 
 more complex. 
 
 Inasmuch as he had shown considerable capacity for 
 drawing, it was thought this would be the best method of 
 inducing a mental reintegration. He was asked to make 
 maps of his own town from memory (he was now living in 
 another part of the country under treatment). Day by day 
 he was led to make them more and more detailed, drawing 
 in houses, roads, etc. The first map he drew showed only 
 crude outlines with practically no details. After he had 
 made a map of his home town, he outlined similar detailed 
 drawings for two other places. It was customary for him 
 
115 
 
 to move back and forth every six months from the country 
 to the city. His capacity to remember the city, which he 
 enjoyed much more than the country, was shown in the 
 ability with which he mapped the former. In the city he 
 had more social life, and it was more like the type of his 
 home town. 
 
 So soon as his interest became thoroughly aroused in map 
 drawing, he became sociable with the other guests, and 
 explained the community life that went on in the various 
 places detailed on his maps. Whereas before he had always 
 been very retiring, he now began to engage in conversations 
 with others in the group. His main topic was his maps 
 and the things they suggested relative to business and 
 society. This created his first spontaneous topic of con- 
 versation. 
 
 As a young man he had shown a great interest in atmos- 
 pheric conditions, the tides, etc.; he was now induced to 
 get a barometer, whose readings he took great pains to 
 record morning and evening. The significance of the 
 barometric changes had been one of the chief topics of con- 
 versation at home as they had a direct bearing on the family 
 business. All these little attentions revived his interest in 
 his home surroundings and his earlier contacts with life 
 which he had so negligently allowed to fall away. At this 
 point he began to show some insight as to the manner in 
 which his mental disintegration had come about, and spon- 
 taneously began to undertake more self-direction in carry- 
 ing out this training treatment. He turned his attention to 
 reviving his memory and took more heed of the latter than 
 of the occurrence of attacks which had before filled his 
 whole horizon. 
 
 His interest still ran in rather slender channels, for wood- 
 carving easily fatigued him because his interest in it was 
 not keen except in so far as he saw a possibility of utilizing 
 it in his business. While carving, he day-dreamed and 
 watched the clock, waiting for the end of the lessons; and 
 had more frequent attacks at this occupation than at any 
 other. However, when he carved a chest for his family, 
 placing their coat-of-arms on it, 'he worked very hard. 
 
116 
 
 Carving then had an attraction for him, which it never 
 exerted before. All handicrafts still remained quite second- 
 ary to his interest in map-drawing, especially in what con- 
 cerned the exact location of his manufacturing plant and 
 all the details of the family home and those of the employees 
 in the village. Continuing the map work, he drew it to 
 scale and outlined all the ground plans of the manufactur- 
 ing plant. The latter was very difficult and had to be 
 undertaken for very short periods of time. It seemed to 
 fatigue him greatly to recollect the exact proportional rela- 
 tionships of the various machines in the shops. He liked 
 the work nevertheless, and so soon as he began to do it 
 fairly well, he became much elated over the accomplish- 
 ment. 
 
 The improved mental attitude and interest in regaining 
 his memory were soon reflected in the lessened severity of 
 attacks and their much less disturbing influence upon his 
 daily activities and interests. After several months of this 
 educational training his sociability was noted towards others 
 outside the immediate household where he lived. Although 
 he was still unable to talk on varied subjects, he showed a 
 willingness to take an interest in topics that were related to 
 those he had talked about at home. An ambition for a 
 friendly contact with a larger group developed him, and to 
 re-establish the social ties previously allowed to lapse, 
 became a sort of mania with him. The desire, however, 
 entailed new work; in order to do this well he had to remem- 
 ber many things that were not even remotely related to the 
 subjects which had been discussed in his home. In other 
 words, he had to remember incidents about which he had 
 no particular personal concern. He had to cultivate a 
 liking for subjects because the new acquaintances liked 
 them. This task was very difficult, but still he persisted as 
 it was essential to the fulfilment of his aim. In order to 
 encourage this tendency of rebuilding his social contacts, 
 he was given a little book in which to jot down the names, 
 characters, and subjects of interest which his companions 
 possessed. He spent much time in going over them, and 
 sought continued tutoring in recalling these data. Even 
 
117 
 
 after several months of this training he had to be prompted, 
 like a reciting schoolboy, with a name or a sentence from 
 the book before he could undertake these new conversations. 
 The amount of memory defect to be overcome may be justly 
 estimated when it is stated that at the beginning he could 
 not remember a single name of his household associates 
 with the exception of his own nurse. 
 
 In the last six months of the training, he began to take 
 more interest in plays and various forms of entertainment. 
 At first he paid attention only to the personnel in the play 
 productions. So soon as he was able to recall the substance 
 and thread of the plot, he showed a genuine enthusiasm in 
 the performance itself. He never cared for moving pictures 
 as the rapidity of action was too fatiguing; the sense of the 
 play was received only through the one avenue of sight 
 and he could not grasp the meaning. To increase his fund 
 of ideas his companions often asked him to give them a 
 resume of the different acts he had seen and what he con- 
 sidered most interesting about them. This scheme enabled 
 him to have something definite to contribute to his friends, 
 and it increased his own confidence and self-importance. 
 Of course the things he remembered at first always had a 
 more or less personal interest. It was interesting to note 
 what a lopsided view of plays he took. His description 
 often tallied poorly with that of other individuals who had 
 witnessed the same productions. 
 
 Not the least interesting aspect of his methods, in reawak- 
 ing his long disused memory, was the cleverness with which 
 he would either find out the main facts which he had lost, 
 or avoid those issues in conversation. If he lacked the 
 connecting link of a particular name, or the time a certain 
 thing occurred, he would adroitly get these facts from his 
 companions and then launch the entire conversation to suit 
 himself. The requisitioned data were always furthest 
 away from the concrete and usually quite removed from 
 his personal interest. 
 
 His daily reading gradually extended from an almost 
 complete engrossment in his little home paper to world-wide 
 affairs gleaned from the city dailies, and his interest in the 
 
118 
 
 activities of the people employed in his manufacturing 
 plant gradually widened. 
 
 The influence which this improved mental state had upon 
 his everyday life was interesting. For instance, the habit 
 of gorging himself with food gradually lessened — not that 
 he cared less for it, but because he noticed others did not 
 do so. He desired to conform to the regulations which 
 others adopted. He did very well on a lighter diet; he was 
 able to eliminate many of the heavy meats, and lost entirely 
 his former habit of over-indulging in sweets. His habits 
 of dress also changed. So soon as he became more observ- 
 ant of people about him, he gave up wearing clothes cut 
 only in certain styles. His manner of dress was less rigid 
 and more easily adapted to season, time, and place like that 
 of others about him. 
 
 As his memory continued to improve and the scope of his 
 interest increased, he realized the necessity of getting rid of 
 his disorder so that he might again resume his position in 
 the firm. As he gained a better insight into his innate 
 defects of memory, he saw how necessary it would be to rid 
 himself of them as well as of the attacks. Formerly he had 
 thought that all he had to do was to return home and take 
 entire charge, when he would be able to handle everything 
 without counsel or advice. Latterly he remarked, ' ' 1 see 
 now that I can't keep up with the business, but I feel I 
 could be of help to my brothers. Of course I would not 
 attempt to carry on a third partnership. I would do the 
 things laid out for me, that I could do and yet keep my 
 health." 
 
 One of the character alterations, last and least changed 
 by the treatment, was the feeling of sympathy with and 
 confidence in those concerned with improving his physical 
 and mental welfare, a characteristic so constantly absent in 
 epileptics. It always seemed difficult for him to desire a 
 completely sincere and sympathetic relationship. The 
 central core of his egoistic attitude seemed to preclude the 
 possibility of attaining this high attribute; in consequence 
 his social rapport, even when the treatment had been long 
 maintained, was often not very strong. It could be easily 
 
119 
 
 broken by the slightest feelings of suspicion or distrust. A 
 seeming carelessness or indifference on the part of the 
 individuals concerned in helping him with his problems 
 was almost immediately widened into a chasm, and if allowed 
 to endure for long seemed to constitute an impassable 
 barrier to further progress. It showed that the fundamental 
 fault in his instinctive makeup had been by no means slight. 
 
 How far his progress might have gone had he not died one 
 can not say. It must be admitted that here, as in similar 
 cases, the defects in the primary instincts retarded prog- 
 ress. One often fails in restoring memory and reforming 
 habits, or at least in bringing them up to the standard of 
 normal reactions. The very nature of the character defect 
 from which the epileptic suffers precludes this consumma- 
 tion. Undoubtedly the retention of mental stability in the 
 epileptic individual (as in ourselves) must ever be condi- 
 tioned upon a willingness and desire to lose nothing of 
 original endowment and its after-development in adoles- 
 cence. 
 
 To summarize the case: We have here a man whose 
 primary endowment of the epileptic character precluded a 
 normal and stable adolescence. In adult life when the 
 stress of social and business adaptations became too great, 
 his imperfect character development began to deteriorate. 
 This deterioration went on for years. For a time it was 
 definitely noticeable only to those most immediately associ- 
 ated with him. First he had mental reactions of the epilep- 
 tic type in various social and business settings. As he 
 grew older and the stress of work and home affairs increased, 
 his defects expressed themselves in grand mal attacks of a 
 classic type. Coincident with this mishap the physical 
 habits on which the maintenance of good health depends, 
 also underwent dilapidation. A severe form of chronic 
 epilepsy soon followed and the patient presented evidences 
 of a progressive mental deterioration. Under a hygienic 
 living he slowly mended his physical health. His epilepsy 
 and mental deterioration, however, remained unchanged 
 until the mental training treatment above outlined was put 
 in operation. In a period of eighteen months he regained 
 
120 
 
 much of his memory and initiative. His mental horizon 
 was broadened and his social interests were in process of 
 restoration. His epileptic attacks were diminished to one- 
 half of their former frequency and severity. The improve- 
 ment, which was slow in the beginning, gradually extended 
 from a pure memory rehabilitation to that of a comprehen- 
 sive character restoration, and gave promise of even greater 
 results had the experiment not been interrupted by death. 
 The case has been detailed at some length to illustrate what 
 may possibly be done for similar epileptic individuals even 
 when deterioration is far advanced. Although many 
 chronic epileptics may not entirely recover, one should not 
 despair of improving their lives to the advantage of all 
 concerned. 
 
 The objection might be made that the improvement in 
 this case was not the result of the mental treatment but 
 rather of a betterment in some obscure physical condition, 
 the relative recovery with the treatment being a mere 
 coincidence. No final denial of this claim can be made, 
 nor is this case cited as an argument in faver of the exclu- 
 sively psychic origin of epileptic deterioration. The object 
 of the publication is to give an example of symptomatic 
 improvement proceeding hand in hand with reawakened 
 interest. If deductions may be drawn from this case they 
 would be that no superficial nor perfunctory stimulation 
 will benefit an epileptic. An inherent fundamental interest 
 must be touched. Results obtained from this first effort 
 may slowly be added to, by the cautious increase of demands 
 on the patient's energy. Progressive improvement, how- 
 ever, comes only when patient himself begins to realize 
 and conquer his difficulties. 
 
 Section VI. 
 
 A STUDY OF THE MENTAL MECHANISM BY WHICH 
 
 ARRESTS HAVE BEEN BROUGHT ABOUT IN 
 
 SEVERAL CASES OP EPILEPSY. 
 
 Before an intensive study of the epileptic makeup was 
 made, the character and temperament of such individuals 
 were thought to be caused by the after-developing disease, 
 
121 
 
 but, as has been shown by many careful studies, the in- 
 stincts and trends of such an epileptic constitution antedate 
 for years the onset of the epileptic reactions, and, indeed, 
 are a part of the original endowment. It has also been held 
 that the mental deterioration is a direct result of the seiz- 
 ures in spite of the fact that many cases do not deteriorate 
 in a life-long epileptic career, while many other epileptics 
 having few seizures deteriorate quickly. We seem to have 
 laid too much stress upon the seizure phenomena in epilepsy 
 as causal factors to the mental states attending the disease. 
 
 When it is shown that a particular epileptic has begun to 
 readjust his bad adaptation to life, one is apt to believe the 
 cessation of the attacks has accounted for the improved men- 
 tal condition, but such a direct causal relationship can not 
 be maintained, as the mental state often enough shows signs 
 of mending before the frequency of attacks is diminished. 
 
 The apparent truth of the matter would seem to be that a 
 better mental and physical adjustment enables the patient 
 to meet the fundamental biologic demands of his existence 
 more capably. The mind, therefore, improves, and the 
 attacks decrease also. 
 
 In giving the following case notes, one should not infer 
 that the ordinary regulations of diet and general physical 
 health rules were not also used in treating and caring for 
 these cases. But the outstanding fact is, that with the in- 
 stitution of the latter alone, the symptoms did not especially 
 improve until the mental treatment had been given. The 
 importance of the latter is the point I wish to make in this 
 section, a study of the end results in some arrested cases. 
 
 The first case is that of a man now 33 years old, whose 
 epilepsy first became pronounced at 17 years, although he 
 had petit mal at 7 or 8 years. With the exception of one 
 attack three years ago, details for the recurrence of which 
 will be given, this man has had an arrest of his epilepsy for 
 the past ten years. He is the oldest of four brothers. There 
 is no neuropathic heredity. The patient was a highly 
 sensitive, crying baby; under a rather rigid parental disci- 
 pline, he grew to repress his violent tempers and became 
 quite " rigid " in his daily deportment. At 7 to 8 he got on 
 
122 
 
 poorly at school. While he learned easily he had an intense 
 dislike for his teacher. He grew pale and listless and soon 
 began to have headaches, becoming very irritable. His 
 sensitiveness grew apace; when punished he sullenly smoth- 
 ered his resentment, and "set his teeth." He steadily 
 became more rigid in his cooperation with other children 
 and soon had to be taken out of school at intervals. About 
 this time it was noted that he day-dreamed. Finally, these 
 periods of abstraction were seemingly replaced by petit mal 
 attacks. The introduction of an entirely care-free life soon 
 brought these absences under control. He then got along 
 quite all right until he reached his 17th year, at which time 
 he was ready to graduate from high school. Close applica- 
 tion and the stress of keeping up with his class at this time 
 engendered pallor, increased irritability and sensitiveness, 
 and he finally had his first grand mal attack with tongue- 
 biting and passing of urine. Thereafter in the next four 
 years he had about a dozen grand mal attacks. He did poorly 
 under any form of sedative treatment, especially at home. 
 He had a restless, roving type of disposition, and he was 
 permitted latitude in self-direction. He had vagabonded 
 through different parts of the country on several occasions 
 and was finally allowed to go into the Northwest, where he 
 took up railroad engineering and became a sort of prospect- 
 ing free lance in hydraulic work (developing water power 
 for railroad companies) . His memory, which before he took 
 up this life had steadily grown poorer, improved; his dilap- 
 idated habits of life began to mend; and his attacks became 
 less frequent, and finally ended. However, with the extra 
 stress of forced work in surveying under a captious and 
 critical "boss" he had one grand mal attack some three 
 years ago. The steady increase of mental stress and har- 
 assment leading up to this recurrence was quite classic of its 
 kind. Since this time he has kept himself well within the 
 limitations of his capacity of endurance and has been quite 
 well. In a recent communication he states that he now 
 knows what he must do to remain well and he intends to 
 keep well by leading the ' ' right kind of life. ' ' From being 
 a rather morose, solitary individual, sensitive and irritable 
 
123 
 
 and egoistic, he has steadily widened his fields of interest 
 and vital contact with his fellows and is a fairly good 
 "mixer," as well as an expert autochrome photographer 
 in what he terms " God's country." 
 
 We may summarize this case by saying we have here a 
 boy with a not very intense epileptic makeup, who under 
 the stress of a too rigid and demanding school and home 
 life developed epileptic reactions of a mild type. Under a 
 freer life of spontaneous interests he quickly recovered from 
 his seizure reactions, but when the stress again became too 
 severe at 17 years of age, a definite grand mal epilepsy en- 
 sued and continued till a broad hygienic life was instituted 
 in a new environment. Even under this life regime a re- 
 lapse occurred when too much stress was again superimposed. 
 I may say that although at present this young man shows a 
 full arrest of his disorder, the latter might be reinvoked 
 should he become indifferent toward objectivating fully his 
 keen egoistic personality into a healthful life about him and 
 also should he permit too great a mental stress to develop. 
 
 Case II is a boy of 14 years, an only child, whose epi- 
 lepsy developed at 8. After a definite course of treatment 
 and a cessation of attacks for nearly two years, he relapsed, 
 but has been placed once more on the road to permanent 
 arrest. The father's makeup was of the classic epileptic 
 type yet he never had convulsive seizures; when a young 
 child he had a tantrum which did not cease until his mother 
 had given him her Easter bonnet, whereupon he tore it to 
 bits with the greatest satisfaction. All the father's family 
 were stubborn, egotistical and had bad tempers; they showed 
 much psychic dilapidation and deterioration before middle 
 age. Their mother had never believed in discipline, and all 
 her children followed their free bent in behavior and conduct. 
 
 The mother of our patient is a keen, quick, resourceful 
 woman; she has found it almost impossible to understand 
 the physical and mental incapacity for quick and easy adap- 
 tation which her son has shown in the home and school life. 
 
 Our patient walked at 18 months and began talking rather 
 late, at 2 years. He was a crying, difficult baby. He en- 
 tered public school at 7 but did poorly there, being inordi- 
 
124 
 
 nately slow and inattentive, and at the end of two years he 
 was removed on account of ' ' anemia and nervousness. ' ' At 
 10 he attended private school, but nervousness and attacks 
 caused his removal. 
 
 The first epileptic attack came on after a period of pro- 
 longed mental stress in keeping up with his English classes. 
 One morning while hurrying to get off to catch a train, he 
 complained of dizziness and immediately fell into a severe 
 grand mal attack. Attacks followed this first one at fairly 
 regular intervals of every two or three months until 
 January, 1914, after which time he had no attacks for two 
 years. 
 
 In his early boyhood he was stubborn and quietly egotis- 
 tical, and set out rather determinedly to win his own way. 
 When reprimanded he was apt to sulk. Not having an 
 agile mind or body it was difficult for him to get into good 
 social contact with the school life. He would sit inactive, 
 day-dream, and engage in vague childish speculations which, 
 as he said, fairly compensated him " for the things he did 
 not get out of school." Just before the first attack not only 
 had school grown distasteful, but he thoroughly disliked 
 the badgering, nagging teacher, who insistently urged him to 
 conform to the routine of the class. He became listless, 
 easily irritated, and " withdrew into himself " He then be- 
 gan to play less freely and spontaneously with other children. 
 While the first attack slackened the pace at school, he still 
 easily grew listless, tired, and dawdled on all occasions, tak- 
 ing hours to dress. He was quite rigid and nonadaptive 
 even in simple things; the slightest misplacement of his be- 
 longings bothered him greatly. At the time he came under 
 my care, some three months before the arrest of attacks, it 
 was easily seen that his interest in life had flagged, and his 
 school and home adaptations were steadily growing poorer. 
 
 First, he was taken from school and given a free restful 
 life of open-air activities. As the tension gradually lessened 
 he began to pick up games and sports that appealed to him, 
 and finally to read books of adventure. He was encour- 
 aged to take up music and to practice what he liked. As 
 his interest quickened, his application grew apace, and he 
 
125 
 
 coordinated better. Finally he was able to ride a wheel 
 and to ice-skate. He became more tactful and obedient 
 without seeming- to smother an inward resentment as for- 
 merly, and instead of withdrawing when reprimanded he 
 now was fairly agile in finding substitutive reactions to 
 get square with situations. He soon began to generate a 
 spontaneous interest in mechanics; this showed him the 
 necessity of gaining a better general education, and helped 
 him to take up the latter with more zest than ever before. 
 
 After eighteen months of training treatment and in the 
 absence of any seizure phenomena it was decided to allow 
 him to return to public school, which was done for a full- 
 time attendance without the physician's knowledge. He 
 went back at the full-time work with the old dislike, although 
 he was only six months behind the grade of his age. Things 
 would have gone fairly well, perhaps, if he had had some 
 special tutoring or a little more consideration from the teach- 
 ers, who, it must be said, are often prone to be rather 
 merciless upon a backward pupil. He was still poor in Eng- 
 lish and mathematics, and although he would have liked to 
 engage in sports after school, the extra time required for his 
 studies gave him little opportunity. The lack of a full 
 amount of time to play, once not cared for, now became 
 very annoying, and it was often difficult to get him to his 
 meals when out playing with the boys. The school work 
 gradually grew more severe; in addition to English and 
 mathematics, in which he stood poorly, he strove to gain a 
 standing in geography which would enable him to enter the 
 final examinations. An attack finally occurred on Decem- 
 ber 26 (1915). Since this time the school life has again 
 been readjusted, and there have been no attacks up to the 
 present time. 
 
 First of all we have in this boy the makeup in which seiz- 
 ure reactions were induced by a too stressful demand at 
 school. When he was withdrawn from this difficulty and 
 placed in an ideal environment with a chance to develop 
 spontaneous interests, he became responsive and began fully 
 to adapt himself to a proper physical and mental adoles- 
 cence. But when he was again thrown into the same 
 
126 
 
 difficulties he broke as he did at first. He is now once more 
 quite well adjusted in an environment comparable to that 
 which brought about the first arrest two years ago. 
 
 It is interesting to note that while his many paternal rela- 
 tives had the epileptic character in a great measure, they 
 probably did not become frankly epileptic because, either 
 by chance or design, the grandmother permitted them to es- 
 cape many of the stubborn difficulties in behavior and 
 conduct which no doubt, unpleasantly antisocial as they ap- 
 peared, really seem to have allowed her children to escape a 
 worse consequence had they been held rigidly to an exact 
 discipline, as in the grandchild, the boy under report. 
 
 Case III is that of a boy 11 years of age whose grand 
 mal epilepsy has been in arrest for five years. He had 
 attacks usually in a series of two to eight or ten, and had 
 at least three or four status periods, in one of which he had 
 150 grand mal attacks in a single day, attended by delirium 
 and high fever (103°). There was no distinct nervous 
 disorder in the family, but all the father's relatives had the 
 epileptic character in various degrees of severity. They 
 were stubborn, wilful, had tantrums and rages, and com- 
 mitted acts of impulsive violence. They were fisher folk 
 and at times had passed through a definite lawless career. 
 Our patient was an only child. He had one convulsion at 
 dentition. He was a crying, stubborn, difficult child. He 
 attended school for three months, his first trial, at five years 
 of age. It was not only difficult for him to apply himself 
 while there but he was absolutely incorrigible and could 
 not sit still in the classroom. Even now when taught pri- 
 vately he is able to study but an hour, and thereafter must 
 be allowed to play and do as he likes. He was always 
 quick and impulsive and extraordinarily overactive. For 
 instance, in one of the half-hour private consultations with 
 the mother he was allowed the freedom of a private estate; 
 during this time he picked nearly all of the flowers from 
 the private flower beds, stoned all the pigeons from the 
 dovecote, killed a cat, broke a barn door, broke a whip, 
 and smashed a child's cart. Additional minor destructions 
 gradually came to light. The mother thought these defects 
 
127 
 
 in behavior were not particularly unusual; she still believed 
 her boy to be only a little less tractable than others of his 
 age. Coupled with his unbounded egotism he was very 
 sensitive and when reprimanded often cried himself to 
 sleep even after the mildest chastisement. He always had 
 to be the centre of any group in the family or neighborhood 
 circle. He never played any game in which he could not 
 be the leader. All during his early life he had violent 
 tantrums and was so irritable that his parents could not 
 talk aloud when he wished to go to sleep. 
 
 On close investigation of this crass egoistic and super- 
 sensitive boy, one finds he was treated with absolutely none 
 of the ordinary child discipline. While it was possible for 
 him to endure the demands of home life with rages and 
 tantrums, when these later had to be repressed at school 
 he could not subordinate these crude individualistic ten- 
 dencies; first he grew listless, then more irritable and finally 
 broke out into an uncontrollable temper, was punished and 
 sent home. As his mother said, "I don't know what 
 seemed to fret and irritate him so; while he was home a?iy- 
 thing he wanted to play with we tried to get him. Of course 
 going to school those three months must have started his 
 trouble.'" His first grand mal attack came on one night 
 after a particularly exasperating day at school, but he had 
 been steadily growing more irritable and run down for 
 a month before. After the first attack he still continued at 
 school with all its steadily accumulating annoyances until 
 a month later when he had five grand mal attacks in one 
 night; since that time he has not gone to school. After the 
 series of attacks, which frequently began on one side of the 
 body or the other, he had exhaustion palsy for several days 
 in parts most convulsed. After the status of 150 attacks 
 the palsy did not disappear for a week. Before all the 
 series of attacks he was unusually irritable, as if he 
 
 could not stand things. ' ' He would be harder to manage, 
 was very fretful, and "nothing seemed to go right." But 
 after an attack he would be quite cheerful and agreeable, 
 and he acted as if he "had gotten rid of things." 
 After a score or more of attacks had occurred following the 
 
128 
 
 second occurrence of his disorder he was entirely removed 
 from study at school as well as at home; his adenoids were 
 removed and a course of active sedation with bromides 
 followed without cessation of attacks. He then came under 
 a still freer removal from irritative surroundings and all 
 medication for the disease as such was discontinued. He 
 was allowed to do just as he pleased, to go and come with 
 his father in the fishing- boats as he liked. In a few weeks 
 the attacks began to subside but he still was very irritable; 
 little or nothing still seemed to precipitate tantrums and 
 rages, but the latter were not so severe or prolonged. As 
 his mother said, "He no longer threw things or assaulted 
 others with his fists and teeth." 
 
 His first spontaneous interest in his environment was in 
 the management of a boat at 6 years of age. Then the 
 attacks began to subside. He worked furiously at learning 
 to row and to handle the sails on a boat until he was abso- 
 lutely exhausted, whereupon he would lie quietly on the 
 beach or fall asleep in the "net bin " in the fishery. Often 
 he was so ' ' dead with sleep ' ' that he would be carried 
 home and put to bed without waking and without supper. 
 Gradually the tantrums and rages were brought under the 
 control of the will and he could then be reasoned with; he 
 began to ask to be taught simple reading, writing and 
 arithmetic; but he wanted only so much of these studies 
 as he found immediately necessary for him to know in order 
 to carry on his practical understanding of the fishing 
 industry, and any knowledge which he considered super- 
 fluous to meet this requirement made him restless, irritable 
 and impatient. Soon after he began to read fairly well, he 
 contracted the "catalogue habit. " He also developed an 
 interest in almanacs as they gave him knowledge by which 
 he could make out the time of the tides and weather indi- 
 cations for the fishermen. At 8 years he had gotten so 
 he could play in a fairly friendly manner with neighboring 
 children without "scraps," and during the past year he 
 has actually become popular with some of the boys, although 
 he is still not a little feared for his former reputation of 
 being a "bruiser." In a recent interview he says, "Yes, 
 
129 
 
 I like to go to school (one hour of private instruction); I 
 like the teacher; but I am down around the river most of 
 the time. I go fishing with the men and boys and can do 
 all the things most of them can." "No, I don't play 
 baseball as there are too many kids around (meaning the 
 game is too complicated in teamwork for him to submit 
 readily to the rules and to take his turn at batting). There 
 is more fun up the street, anyway. I like to be with the 
 men better" (in that sort of group greater freedom is allowed 
 him than there would be in a crowd of boys). "Can I 
 scrap? Golly, yes! Sure, I can lick any boy of my own 
 age; yesterday I licked one 13 years old. No, the boys 
 don't pick on me; they leave me alone." From this 
 one may infer that there are still important principles of 
 social adjustments for him to make in the future. From 
 precise tests one finds this boy is about three years behind 
 in school study, but this is not necessarily a defect as ordi- 
 narily considered as he probably possesses that type of 
 native shrewdness and common information equal to boys 
 of his age if not in advance of them. Finally, his mother 
 writes, "He is now more easily handled, easier to direct, 
 less demanding and insistent, and he daily gains in docility. 
 He shows improvement in conduct all the time." 
 
 Resembling his father and grandfather in disposition and 
 temperament, he is naturally ambitious to be in the fishing 
 business with them, although of late he has spontaneously 
 become very much interested in electricity, and the workings 
 of the wireless in particular. He has shown a very keen 
 appreciation in reading electrical magazines on the subject. 
 However, he- never wants to read or be told any more of 
 the theoretical part of any subject than he can immediately 
 apply or use. In closing the history notes I may say that 
 dietary treatment was given in general terms only and aside 
 from an occasional laxative no medicines were given. 
 
 In a brief summary we may say that we have here a boy 
 of the extreme classic epileptic makeup, the main char- 
 acter and traits of which seem to have been inherited from 
 the paternal side, and that, when the subordination of the 
 egoistic tendencies were required of our little patient, he 
 
130 
 
 could do so only partly and with exhibitions of tantrums, 
 rages, and the like. Finally, when he had to make the 
 next social adaptations, away from home in the school 
 training where even more was required, he could not do so 
 without epileptic reactions of a violent sort, that of grand 
 mal seizures. When the extra social demands of school 
 and its intellectual requirements were removed he still con- 
 tinued epileptic both in character and behavior independent 
 of grand mal attacks. Not until he found spontaneous in- 
 terests in boats, fishing, and all the opportunities such 
 activities gave him to objectivate his individualism did he 
 begin to mend from his disorder. This boy will probably 
 remain well from the latter just in so far as he is able to 
 gain a good adaptive and adjustable outlet for his keen 
 egoistic desires, or is able to submit to their blocking and 
 accept other outlets or substitutes for them. 
 
 Case IV. The next case is that of a girl now 22 years 
 old who has been free from epileptic reactions for ten years. 
 She had the worst possible heredity, including alcoholism, 
 insanity, feeblemindedness and epilepsy in either one or 
 both parental families. She was born a rather weak, puny 
 child and continued so to her tenth year. Her epileptic 
 attacks, grand mal and petit mal in character, occurred at 
 10 years of age. They continued at irregular intervals for 
 two years, since which time she has had no evidence of her 
 disease as such. 
 
 The circumstances surrounding the first grand mal attack 
 at 10 were as follows: She had been in a girls' camp; the 
 food was rather badly cooked and served, and our patient 
 took great exception to this as well as the fact that she had 
 to work in a garden a mile from the camp. After this 
 "hurry up " work in the sun she was compelled to go to 
 the gymnasium for routine exercises which she disliked in- 
 tensely; then she had another long walk up a steep hill for 
 her dinner. She hated the teachers and was easily pro- 
 voked to stubborn resistances at "anything they said." 
 She felt they worked her too hard, the work was monoto- 
 nous and uninteresting, and she grew to hate the whole 
 scheme of life. However, she repressed her dislike all she 
 
131 
 
 could and said nothing in open revolt. She then began to 
 sleep poorly, looked pale and drawn, and day-dreamed a good 
 deal when she had the opportunity. Soon she began to 
 have attacks of indigestion, and finally refused food and 
 asked to be released from the camp environment. This 
 request was delayed in the hope that she might satisfactorily 
 adjust herself. Then the grand mal attack occurred and 
 she was taken home. The next two grand mal attacks 
 occurred while at home under less stressful circumstances, 
 but the inability to adapt herself even to the home life to 
 which she had returned from the camp was still in evidence. 
 
 It was noticed at this time that our patient had always had 
 a peculiarly difficult mental makeup. She had had tantrums 
 as a child and early thought that, being a member of a 
 prominent family, she didn't have to like people "if she 
 didn't want to." She was selfish but sympathetic, kind 
 hearted but not altruistic. She could not cooperate with 
 others and was very stubborn and demanding. As she now 
 says, "As a child I always had to have my own way." 
 She was affectionate toward few people. She was irritable 
 and very sensitive. Her general interests and activities 
 were perfunctory and childlike. She continued habits of 
 biting her finger nails, picking her face, and sucking her 
 finger on going to sleep until nearly 18 years of age. She 
 was little interested in athletic sports and did poorly in 
 them. Broadly speaking, one may say that her emotional 
 attitude and behavior were childish, and even now she has 
 many of these imperfections of development which have 
 not been eradicated. 
 
 Upon this epileptic endowment, which was making for a 
 poorer adaptation to the growing demands of puberty, was 
 suddenly thrown the summer camp life with its crude country 
 setting. The girl could not adjust herself to the new en- 
 vironment, and the extra stress entailed soon produced the 
 epileptic reactions as just set forth. 
 
 At first the treatment was by drug sedation and repressive 
 lines of discipline, but this sort of life and treatment seemed 
 to deteriorate the girl both physically and mentally. As 
 she now states, " During the period in which I was having 
 
132 
 
 attacks my memory was poor and my general interests were 
 few. During that summer I read one of Dickens' novels, 
 but can remember scarcely any of it now. I got so I didn't 
 care for anything or anybody." 
 
 After a year's treatment of the usual routine sort, our 
 patient was removed from her rather artificial and monoto- 
 nous city environment and placed in the country to do just 
 as she pleased. In a few weeks she generated a spontane- 
 ous and continued interest in birds and flowers and spent 
 all her time in the open. Then she underwent a self-educa- 
 tion which was good although desultory. It extended gradu- 
 ally from the central interest of bird life to flowers, trees, 
 and animal life in general. She then began to read and 
 study about these subjects. Finally she undertook work 
 embracing the care of flowers, animals and a vegetable 
 garden. The latter, which at one time had been so distaste- 
 ful to her, now became the main object of her interest, and 
 this was due in no small part to the fact that the garden 
 and animals were her very own. When this life began to 
 grow somewhat monotonous and she had outgrown it, she 
 was introduced to travel and history with the ultimate object 
 of visiting the countries studied. This was undertaken and 
 carried out with complete success. At the present time she 
 is a strong, robust, intelligent girl who has a variety of 
 home and neighborhood interests, duties and cares. She 
 is never tired, listless or indifferent, and many occupations 
 once done poorly are now completed with energy and dis- 
 patch. While the fundamental character makeup has not 
 materially changed (indeed, never greatly changes in so- 
 called cured cases; the voice sign is still present), our 
 former patient is now capable of generating any number of 
 spontaneous interests. Balked now and then by a too cen- 
 sorious relative, she is adroit in avoiding open conflicts and 
 assumes fairly well the control and management of all her 
 own business affairs. One can not help seeing in such a 
 girl the possibility of a reestablishment of the epileptic re- 
 actions should some unforseen circumstance block or shear 
 away the spontaneous interests plus a renewed imposition 
 of an intensive mental or emotional stress. However, at 
 
133 
 
 present the permanency of an arrest or cure in such an in- 
 dividual would seem fairly well assured. It is interesting 
 to note that the relatives in this instance as well as in the 
 case to follow are firmly of the belief that the "cure " was 
 brought about by simple physical hygiene and that the 
 gradually improved mental adaptations were of decidedly 
 less consequence than the selection of this or that particular 
 article of diet. This attitude is prejudicial to the patient's 
 ultimate welfare and relatives should be gradually educated 
 to the broader biologic view of the patient's treatment. 
 
 Case V is that of a young man now 20 years old who 
 was epileptic for five years, and who has been free from any 
 epileptic reactions for six years. There is an epileptic and 
 neuropathic inheritance from the father's family. The 
 paternal grandfather was a sharp, aggressive antisocial in- 
 dividual. He had violent outbreaks of temper and seemed 
 never to be able to control them. The father had the same 
 mental makeup but under the grandfather's training learned 
 to handle and control it better. The mother comments that 
 our patient ' ' has much the same temperament as the father 
 but controls himself much better than either the grandfather 
 or father; although he has grown lately to express himself 
 more freely, it is not a purely destructive willfulness but he 
 goes ahead to show he is in the right." The mother adds 
 in reference to her own makeup, ' ' Once in a while I have 
 a temper; as a child I had a furious one, and would get 
 angry enough to knock a person down. I now have it 
 under control. I got the better of it by gradually making 
 up my mind; I used to be punished, and that made me very 
 much worse. If I were shut out of the kitchen, for in- 
 stance, I would go into a tantrum. If anyone questioned 
 whether I was telling the truth I would fly into a rage. 
 They used to tease me a good deal just to start my temper. 
 I would take a book and throw it. That lasted until I was 
 about 10 years old." 
 
 Our patient was born a rather weak child. He was a 
 "lively, active infant" and a restless, crying baby. He 
 required being ' ' taken up a lot, ' ' was rocked a great deal and 
 as soon as he was asleep and placed in his crib, would im- 
 
134 
 
 mediately awaken and cry to be taken up again. His first 
 attack of epilepsy came on at 10. He had already found 
 it hard to study, and to concentrate his mind. He then 
 began to "develop " a temper. He became very sensitive, 
 stubborn and set in ideas relative to dress and food. He 
 said little, but in getting him to adapt himself to the daily 
 demands of living the mother felt she was "up against a 
 brick wall." The repressed and inhibited attitude of the 
 epileptic period of the boy's career is well shown in that the 
 clash between the father and son used to be met by the son's 
 sulking and grumbling. His mother states, "He acted as 
 though he were crushed or had a sense of smothered resent- 
 ment, but since he has recovered from his attacks he holds 
 up his head and answers with spirit if he thinks his father's 
 remarks are unjust, and then the whole matter is disposed 
 of in short order. Formerly he felt hurt and angry when 
 criticized; now he takes all things in an amused manner 
 and often laughs at absurd demands." Just before his 
 first attack he often said he felt under a great deal of pres- 
 sure at school and was much hurt by the sharp criticism of 
 the father when he did poorly at school. He began to look 
 pale, lethargic and "day dreamy." He "braced" him- 
 self against the stress of home and school and finally broke 
 down completely in a series of attacks. 
 
 The grand mal attacks were often 12 or 14 daily; he once 
 had a status attack with temperature and several days of 
 mental and physical prostration following it. His natural 
 characteristics gradually increased upon him "whether he 
 had attacks or not " (he was free from attacks for a year) 
 until he became a morose, irritable, stubborn pedantic 
 invalid. A sedative treatment of a very intensive sort 
 seemed to increase the attacks and render him too stupid to 
 sit up. He was so drugged that he hallucinated and 
 suffered from extreme bromism. 
 
 First the sedatives were gradually withdrawn, the diet 
 made simple and he was given free eliminative treatments 
 of salines, colonic flushings, etc. Under a simple hygienic 
 physical regime the number and intensity of attacks were 
 reduced but were not removed altogether; not until he 
 
135 
 
 began to take a spontaneous interest in camp life, away 
 from a too solicitous parental care and discipline, did he 
 show an improved mental attitude and freedom from epilep- 
 tic reactions of the " absence " type. Although he kept up 
 some of the physical care routine, baths, naps, diet, etc., 
 he got entire satisfaction in the manual and industrial train- 
 ing school which he asked to attend. Gradually he became 
 more self-directive in his study and work and began to plan 
 his own education and activities. He soon began to ex- 
 pand his interest in his father's business, a part of which 
 he succeeded in getting under his own control and manage- 
 ment. Slowly he began to pick up better mental attitudes 
 toward sports and boy and girl associates. He can stand 
 joking and is as free and agile mentally as the average boy 
 of his age. The voice sign still persists. He says, "if 
 people oppose me, I hold to my own opinion pretty defi- 
 nitely. I think I could have even more liberties and still 
 keep my health. About five years ago mother had me pretty 
 well under her control, but I didn't notice it; I didn't know 
 what a good time was then. I got pretty well bored being 
 around with the chickens but didn't mind it so much. It was 
 more the gardening I disliked. I don't think I minded the 
 routine and mother's attention then, because I didn't seem 
 to have so much energy and I really didn't know what a 
 good time was. At present I don't want to modify my diet. 
 I really do pretty nearly everything I want now, and never 
 have much irritation within the past two or three years even 
 though I am not able to do things. I like camp pretty 
 well. I belonged to a military company there, and am now 
 considered a member of the First Regiment." 
 
 The mother was encouraged to allow her son to go to 
 camp and enlarge his personal freedom as he seemed a 
 little irritable and faultfinding; in camp he led a free life, 
 and mixed in with men and boys. He ate everything, in- 
 cluding mince pie and bacon, and gained in weight while 
 there. He took long jaunts after which he would return to 
 the camp quite fresh while the other men felt fatigued. 
 
 To summarize, we have here a young man who probably 
 had a double neuropathic inheritance of the epileptigenic 
 
136 
 
 constitution and who broke into severe and frequent epilep- 
 tic reactions of an intensive sort as soon as the school and 
 social demands became too onerous. When he was placed 
 upon a physically hygienic plan of treatment minus the 
 unusually large doses of bromides, he began to mend, but, 
 as shown, this plan was not sufficient — not until he was 
 given a proper outlet of his physical and mental activities 
 in healthy spontaneous interests did he cease having epilep- 
 tic reactions. It seems fairly conservative to say that he 
 will remain well so long as this mental and physical regime 
 endures. 
 
 It is interesting to note that at least four of these cases 
 under report had as bad a neuropathic heredity as it is pos- 
 sible to imagine. Indeed, I venture to state that the 
 majority of arrested cases are recruited from the ranks of 
 such epileptics. May it not possibly be due to the fact that 
 the epileptic reactions in such are but the more intensive 
 expressions of their natural inborn temperament and, as 
 other bad mental traits, such as tempers and tantrums, are 
 more easily socialized, and, indeed, are the only ones that 
 can be ? * 
 
 * In connection with the foregoing case-reports I may briefly cite a rather 
 novel case of arrested epilepsy in a dog. Several years ago a skye terrier, prob- 
 ably between six months and a year old. was rescued from bad surroundings 
 in the congested district of Suffolk Street in New York City where the puppy 
 was in abusive hands. He had been having many attacks of what seemed to 
 be grand mal epilepsy. He was taken to the country where for several months 
 occasional fits occurred, but under the influence ot better surroundings and 
 kindly care the dog grew strong and well and the fits ceased so that for years 
 the dog never had any more attacks. He was a great out-of-doors animal and 
 never could be held even in a wagon but loved to run with the horse ■whenever 
 the family who owned him went anywhere. On such trips he would race over 
 the fields, hunting woodchucks or rabbits, becoming nearly dead with heat. It 
 used to annoy his owner greatly to have him go on these driving trips because 
 whenever a watering trough was approached the dog would swim blissfully in 
 the trough and consequently the water would not be fit for the horse to drink 
 from the dust depo.Mted by the terrier. He showed, like all skye terriers, a 
 great fondness for the water and when warm often ran off to the river to swim 
 and cool off and drink. He has never had any more epileptic attacks. (Data 
 furnished me by Dr. Edward L. Hanes, Rochester, N. Y.) 
 
137 
 Section VII. 
 
 SOME THERAPEUTIC SUGGESTIONS ON THE MENTAL THER- 
 APY OF ESSENTIAL EPILEPSY DEDUCED FROM ANALYSIS 
 OF THE MATERIAL OF THIS CLINICAL STUDY. 
 
 It is interesting to note that the modern therapy of epi- 
 lepsy has many heritages from the past. Two rather recent 
 therapeutic experiments have contributed the greater part of 
 our present day attempts at the treatment of the disorder. 
 The first had its advent with Lay cock's introduction (1851) 
 of the bromides as the ideal sedative treatment for epilepsy. 
 I venture to say this therapy, while having important and 
 distinctive advantages, has done more to obscure the nature 
 and pathology of the disorder than any other factor of re- 
 cent appearance. For more than half a century at least, 
 the sedative treatment of epilepsy with bromides has pre- 
 vailed, and despite every encouragement to look upon 
 epileptic therapy in a more rational light, the bromides still 
 usurp first place in any general plan of treatment. 
 
 An historical resume of the evil effects of bromide seda- 
 tion would cast shame on medical thought and practice of 
 this period. During the past two decades, however, a more 
 rational therapeutic theory has been making slow progress 
 against the sedative conception of treatment. This phys- 
 ical therapy, of hydrotherapy, diet, cleansing enemas, and 
 a detailed plan of work and exercise, is the principle of the 
 latter advance. 
 
 Still more recently we see a generally recognized effort to 
 introduce a rational psychologic therapy for epilepsy. One 
 may say that this is really not new, and is in accord with 
 the modern conception of mental hygiene and the more pre- 
 cise interpretation of the nature and treatment of the 
 psychoneuroses and psychoses. It is simply a careful effort 
 to understand the makeup of the individual epileptic and 
 the mental mechanism of his disorder, and to apply broad 
 yet specific principles of treatment. In making a special 
 plea for this type of therapeutic approach, the fact is not 
 lost sight of that sedatives and physical therapy, partic- 
 ularly the latter, are not without value. We wish merely to 
 
133 
 
 insist on the limitations of this kind of therapeutic theory. 
 The enlarged view will be more rational and also more hu- 
 mane, yielding- not a little of value in the way of a broader 
 psychologic and sociologic conception of this disorder. It 
 must also contribute its share of enlightenment on many a 
 similar problem in adjacent fields of mental therapeutics. 
 
 Undoubtedly the treatment of the primary and fundamen- 
 tal makeup of the epileptic must be our main concern as it 
 is a defect which antedates the seizure phenomena for years. 
 Next in importance for treatment are the epileptic reactions 
 shown in behavior and conduct disorders, which when care- 
 fully looked for, can almost always be found in a case of 
 the essential disease. These latter symptoms are of daily 
 occurrence in the potential epileptic and often give the phy- 
 sician and relatives most concern even after a frankly 
 convulsive epilepsy has become firmly and enduringly estab- 
 lished. Finally, as has been shown in the preceding sections, 
 and elsewhere by other investigators, the seizures themselves 
 often follow episodes of stress and disappointment which 
 seem to precipitate the attacks. These need to be given 
 more attention in future comprehensive plans of treatment. 
 A certain degree of mental deterioration in the frank epi- 
 leptic is a natural corollary or sequence of the epileptic 
 character when care is not exercised to correct this tendency, 
 and my own case studies abundantly illustrate this point. 
 It would seem, indeed, that the diagnosis, treatment, and 
 prognosis of idiopathic epilepsy can be properly made in 
 future only 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. Though this statement 
 makes the seizure phenomena distinctly of secondary mo- 
 ment, a similar view has been more or less tacitly assumed by 
 good clinicians of the past as cited in the beginning of this 
 clinical study. To establish proper principles for the treat- 
 ment of epilepsy, epileptologists must cease to give their 
 attentions entirely to the occurrence of individual attacks 
 and their treatment as such. When this is done, and only 
 then, shall we be in a position to make a just estimate of the 
 
139 
 
 extent and character of the disease and formulate a com- 
 prehensive plan of treatment. As a pure drug therapy for 
 epilepsy already savors of quackery, so should a purely 
 physical therapy grow more and more to be regarded in the 
 same light. 
 
 Sufficient clinical experience is now at hand for us to out- 
 line more definitely the mental therapy of the essential 
 disorder.* It will be remembered that the usual makeup of 
 the potentially epileptic child is one of egocentricity, emo- 
 tional poverty, morbid sensitiveness, and an instinctive 
 inability to take on the adaptive social training as does the 
 normal child in the home and school. A morbid exhibition 
 of this latter defect is shown in the display of rages and tan- 
 trums. Such children should have special training from 
 earliest infancy, and particularly by someone specially gifted 
 for the task. Often this is best done by someone other than 
 the parents. So soon as the keen individualism of these 
 children comes into contact with an exacting or unyielding 
 environment, it is expressed in rages and tantrums. Great 
 tact is necessary to size up the factors of each tantrum epi- 
 sode and judge how they may be properly handled. At one 
 time the child may be sidetracked by directing his interest 
 into another channel; at another he may be completely ig- 
 nored throughout the entire tantrum, especially if the child 
 be too observant of the effect his conduct has on the family. 
 One should be sure not to offer bribes or rewards for a res- 
 toration of proper conduct. Often such concessions are the 
 first irreparable beginnings of a downfall of government and 
 discipline. If the child is to be diverted to some other in- 
 terest, this should always be supplied early and before any 
 severe repressive measure is brought to bear. In these ex- 
 hibitions of a balked desire, one should look upon the child's 
 psychic activity as a continuously outflowing stream of in- 
 terest unfortunately thwarted, which should not be dammed 
 
 *I do not mean to underrate the importance of chemotoxic and endocrinic re- 
 search in epilepsy. A rational therapy based upon reasonably demonstrated 
 results as such studies should be, will probably give us ultimate enlightenment 
 upon the "why" of the disorder. For the present, however, an interpretive 
 therapy can be provided upon the " how " of the genetic symptomatology of the 
 disease, along psychotherapeutic lines which can not help but be of immediate 
 practical value. 
 
140 
 
 or blocked any more than an active mountain stream. One 
 should always be sure of having the alternative at hand 
 before the main issue is repressed to the slightest degree. In 
 the most difficult children it is best to teach the child to 
 place his own inhibition on his bad conduct and direct his 
 attention to the new object without coercion or too much out- 
 side persuasion. No tantrum episode should be allowed to 
 pass without a friendly and sympathetic review of all the 
 circumstances which led up to the disorder. Tireless and 
 tactful restatement is necessary of the great personal loss the 
 child himself has suffered in consequence. To be fully effec- 
 tive, every opportunity for right conduct at the tantrum 
 periods must be fully coupled up with the actual personal 
 disadvantage the child suffers from his acts. The issues in 
 question must be plain and simple, comparable with the de- 
 gree of mental development to which the child has attained. 
 The explanatory period is often at hand long before one 
 ordinarily thinks it is possible. For instance, several 
 children whom I have known have been given these simple 
 talks in their third year, with much success. The plea of 
 personal motive to right conduct in such children may be 
 ultimately fortified by altruistic and social advantages, but 
 these should never form the central core or main issue of 
 training against tantrum episodes in their early manifesta- 
 tions. The absence of altruistic instincts, or their very 
 rudimentary character in these children, is quite character- 
 istic of the type. As regards the everyday or general 
 behavior of these children, a stiffening of the will or a 
 broadening of emotional inhibition should not be undertaken 
 too early or too intensively. Such children are usually in- 
 ordinately slow in adopting simple or mildly difficult 
 adaptations, and in consequence fatigue unbelievably soon. 
 I know a child who at 5 or 6 years of age can not bear even 
 the slightest coercive direction for more than an hour or two 
 without complete rest and frequent day naps. Children of 
 this type do not always show their exhaustion in simple 
 ways; they often look pale and haggard, pupils are dilated, 
 or they grow lethargic, sit and day dream or slowly mount 
 on a thin crest of hilarity easily broken by ' ' squalls ' ' of ap- 
 
141 
 
 parently meaningless crying; or they may show gross motor 
 incoordination and make unusually precise and rigid de- 
 mands of deportment on the part of their playmates. The 
 trained observer gets to know these varied signs of fatigue 
 and is often able to lower their nervous tension tactfully by 
 quieter play. Under one pretext or another these children 
 may be persuaded to seek rest of their own accord, after the 
 higher level of their activity has been gradually lowered. A 
 tantrum is not far distant in the bored or tired egoistic child, 
 and running counter to his playmates is one of the common- 
 est means which he takes to break the intolerable situation. 
 However, one usually feels that to give so much attention 
 to the crises of personal conflict which the epileptic child 
 manifests, is again to really miss the main point of the train- 
 ing treatment. The fault is quite comparable in a way with 
 the obsessive attention physicians, nurses and relatives com- 
 monly give to the epileptic fit in the frankly established 
 disorder itself. Long before the child displays tantrums, 
 one finds much slighter but equally obtrusive manifesta- 
 tions of mal-adaption to the simple processes of life. Often 
 these children must be slowly and carefully inured to the 
 unpleasant demands of hunger and fatigue, a failure of 
 which is frequently expressed in the restless crying baby. 
 One must more slowly accustom such children to the ham- 
 pering and unpleasant contact of the clothing, which often 
 forces them into stereotyped positions. The desire for rid- 
 dance of clothing is so much a part of the instinctive life of 
 the epileptic child that many seizures of the milder sort oc- 
 curring in the later life of such individuals are attended by 
 automatic movements of disrobing, which acts are often 
 performed in a childlike manner. The potentially epileptic 
 child should have less insistent demands placed upon him, 
 and for shorter periods of time than other children. His 
 preference for certain types of dress should also be taken 
 into account and yielded to so far as practicable. An equally 
 wise attitude may be assumed toward the bath and diet. If 
 left somewhat to self selection and direction in many of 
 these matters, such difficult children much more readily and 
 safely mend their ways. The same principle also applies to 
 
142 
 
 the type and character of play. The lesson derived from 
 other children doing the conventional thing, most tactfully 
 supplies a corrective influence which a parent or nurse may 
 not exert. Frequently an incentive to reasonable conduct 
 once planted by the right kind of associates bears more fruit- 
 ful results than many and oft-repeated injunctions from the 
 child's elders. A similar principle for handling the more 
 benign types of conduct disorders in the normal child has 
 long been recognized and practiced with advantage. 
 
 One may safely say that 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. Sufficient data are now at hand to indicate 
 that this primary endowment of makeup is probably always 
 hereditary in the potential epileptic, and it often rests with 
 us whether we shall allow it to develop to its logical con- 
 clusion in an outspoken epilepsy or by our attitude and 
 manner of handling it prevent such development. A com- 
 plete change of the makeup is probably beyond our power, 
 but the modification of it should be our main concern in the 
 future, if we wish to conserve such children from following 
 an epileptic career in later life. 
 
 One may think that the infantile and child life are 
 without stress and conflicts. However, one need but to 
 remember what Preyer has shown, that the unpleasant 
 feelings are greatly in the ascendency all during this child- 
 hood period. Even with the most careful nursing, diet, 
 ventilation, and regulation of temperature of the air and 
 bath, under the most favorable surroundings, it is not granted 
 the average child to pass many days without suffering. 
 How much more painful, then, must these discomforts be 
 to such a supersensitive child as we are considering. 
 Granting the above, what may one propose on the dynamic 
 or positive side in the proper adaptation of the epileptic 
 child? For this task one needs to study the child with 
 greatest care. If the parents are incapable of a sympathetic 
 understanding of what the child is striving for and his main 
 trends of interest, then the work must be entrusted to others 
 
143 
 
 possessing this gift. A system of ethics can easily be built 
 up around almost any line of activity the child may select. 
 One may note its presence in all races, even in those whose 
 life activities are most antipodal to our own. It is the atti- 
 tude of approach toward one's specific surroundings that 
 matters, — not necessarily the things themselves. If our 
 type of child chooses either a practical or an imaginative 
 approach, then he should be encouraged to find a proper 
 healthful adjustment to that kind of life. The incessant 
 clamoring of the child for variety and novelty of interests 
 is but the natural demand that is his birthright — to see as 
 many of the different facets of life as possible. Our concern 
 is not to limit these novelties, but to see that the child shall 
 have a thoroughness of experiencing them. The very 
 completeness with which the difficult child may be made to 
 do this is the safest protection against day dreams, lethargies 
 and like abreactions from his work and play leading to bore- 
 dom and irritability, — the forerunners of rages and tantrums. 
 To establish at the earliest possible moment a self- directive 
 government in the potential epileptic child should be our 
 aim. The end sought is really to have him learn to penalize 
 himself and adjust his own capabilities and desires to reality. 
 Frequent psychotherapeutic talks relative to his difficulties 
 are of greatest moment, and these can be undertaken only 
 by someone in full sympathy and confidence with such a 
 child, and for good results one must carefully chose the 
 correct time and place. An instance in point is the little 
 boy (No. 6) casually mentioned on page 185 of this clinical 
 study (Psychiatric Bulletin, April, 1916). 
 
 In brief, then, the foregoing embraces the main outlines 
 of some of the more important suggestions for the proper 
 mental therapy of the potentially epileptic child in the home 
 before the school age is reached. The proper inculcation 
 of a good system of nursery ethics is by far the most impor- 
 tant object in training such children. 
 
 While the scholastic training for all children must rest 
 somewhat upon the same common grounds, the goal to be 
 won for the education of the epileptic youth must be 
 arranged to suit his peculiar makeup. The methods of 
 
144 
 
 attaining it are quite distinct and special. For instance, 
 where there is an intellectual defect coincident with an 
 epileptic makeup the problem is to educate this type 
 of individual somewhat as if he were feebleminded. 
 Even if this is done, sooner or later there will be a 
 distinct outcropping of the peculiar epileptic instincts 
 that would demand a considerable modification of the 
 school system; but while this class forms a large part of 
 institutional charges, numerically it is not so important in 
 the general run of epileptic children. The former may show 
 further handicaps of mental arrest or even mental deterio- 
 ration, forcing one to modify the school training very con- 
 siderably. Often the purely intellectual training has to be 
 entirely omitted and the whole time given over to tutoring 
 the epileptic youth in social behavior. In other words, the 
 school training for epileptics should be intensively individ- 
 ualistic and constantly elastic. The very monotony which 
 the feebleminded enjoy in any scholastic training, is 
 poisonous to the soul of the epileptic. The latter requires 
 novelty and a wide range of educational appeal. More- 
 over, in a large number of epileptic youths the intellect, as 
 such, suffers but little or no impairment, and the educational 
 training which these individuals need is little different from 
 that which is ordinarily given to normals, except that it 
 includes adjustment to work and adaptations along ethical, 
 moral and social lines. 
 
 On the whole one may say it is a great mistake to 
 approach the problem of educational training for the 
 epileptic, in its broadest sense, on the old ground that he is 
 only a little less retarded than the feebleminded, because 
 in reality his primary fault is his egoistic trend and an 
 emotional poverty. These abnormalities affect his environ- 
 mental rapport and often he suffers from a lack of intellec- 
 tual stimulus because of a weakened attachment to reality. 
 Simply because he is mentally retarded is no reasom for his 
 education being placed on the plane of that for the feeble- 
 minded. The same might be said of the deteriorated 
 dementia praecox patients whose psychometric test brings 
 them within the middle range of the feebleminded. If the 
 
145 
 
 schooling is like that for the feebleminded it should be 
 possible to modify its routine so as to make it adjustable to 
 the demands of the epileptic character. The retarded 
 epileptic has such an irregular mental age level at best that 
 he is not often capable of doing well in any large class 
 teaching as does the feebleminded. 
 
 The differences between the feebleminded and the epileptic 
 are by no means essentially purely academic. They are 
 sufficiently common and far reaching to compel the atten- 
 tion of educators, and they should be particularly recognized 
 by those who plan to place the two classes together in one 
 institution. Should this plan be adopted to any large extent 
 in this country, the innate differences in makeup and men- 
 tality of the two classes should be recognized, and proper 
 classification made in the schools. The laisser faire attitude 
 of slightly modifying a feebleminded school to fit the epileptic 
 should not be allowed to prevail. 
 
 It is easy enough to see that epileptic youths who have 
 very frequent attacks can make little use of any system of 
 regular intellectual training because of the nature of their 
 attacks and the amount of acute mental disturbance 
 entailed. The attacks prevent a consecutive attendance at 
 school, hence much of the education is rendered useless on 
 account of the break in its continuity. 
 
 We find a system of educational training of most value 
 in epileptic youths who have infrequent attacks, and have 
 a fair intellectual endowment as well as ability to generate 
 directed, and finally spontaneous, interests. Primarily the 
 colonization of epileptics means most to these individuals. 
 It supplies a continually interesting and varied environ- 
 ment with all the possibilities of modification from season 
 to season, so that monotony and boredom can be avoided. 
 
 After the above rather negative views as to why the 
 epileptic should not be given the treatment of the feeble- 
 minded type, let us consider the positive, dynamic aspect 
 of the proper treatment. 
 
 The system of education in the schoolroom must be an 
 essential and integral part of the occupational life of the 
 epileptic, whether he recovers from his epilepsy or not. 
 
146 
 
 What he needs is to have his educational training coupled 
 up with the occupations in which he is engaged and which 
 he cares about. For instance, those who are interested in 
 agriculture should have a system of book instruction and 
 class work that will make for a further elaboration and 
 understanding of all the daily duties grouped around this 
 particular type of interest. It is obvious that the maximum 
 of school training shall be concrete rather than of an 
 abstract nature, and along the lines in which the patient 
 exhibits the keenest interest and most distinct capabilities. 
 Abundant illustrations are furnished in foregoing case 
 histories to show that the type and manner of school train- 
 ing should be properly adapted to the peculiar makeup of 
 the individual child. 
 
 The greater part of what has already been said applies 
 to the training of those children who may also show frank 
 epileptic seizures during early childhood. The actual pro- 
 tection of the mental and physical integrity of the frankly 
 epileptic child becomes doubly necessary when attacks 
 have once commenced. First of all the child usually needs 
 to be withdrawn from the average school which often fur- 
 nishes the stress that is too much for him. A period of 
 care-free existence should then be maintained sufficiently 
 long for the little patient to recover his mental balance and 
 the proper regulation of physical health. The pallor, 
 nervousness, disturbed sleep and like symptoms are usually 
 removed quickly under such a let-alone treatment. At this 
 stage the real trial begins, because from this point on we 
 must have two motives in operation in handling the patient: 
 first, to remove all the too stressful situations which the 
 patient has reacted away from in the attacks; and secondly, 
 to begin a careful system of training in slowly accustoming 
 the patient to types of stress which he must get used to if 
 he is to make a proper adaptation in life when he has 
 recovered from his more gross epileptic manifestations. 
 The reconciliation of these two motives in a training treat- 
 ment calls for the greatest discernment and tact. Often 
 this can be initiated only away from home — especially away 
 from either a too harsh and unsympathetic discipline, or a 
 
147 
 
 too inconstant and overindulgent one. I have succeeded 
 fairly well, however, in training the least neurotic of the 
 two parents in many instances to undertake the proper 
 training- treatment for their epileptic child. But the per- 
 sonal sacrifice entailed is very great, even though the 
 training treatment progresses satisfactorily. 
 
 There is a parallel in the training treatment of the frankly 
 established epileptic and that of the epileptic child before 
 the disease has become established. With the former, 
 however, efforts must be redoubled and placed on a more 
 adult plane. One should not rest content with the removal 
 of a stress from the life of the epileptic youth, for this is 
 only a preliminary treatment. If this let-alone principle 
 only is followed, the situation which will soon develop will 
 be but little less intolerable for all concerned than the 
 original condition. If left to himself, the frank epileptic 
 soon occupies himself with day-dreaming, lethargies, and 
 all sorts of idle dissipations, which in their turn often beget 
 more epileptic reactions. 
 
 One should study how best one may help the epileptic 
 individual to objectivate his interest in work, study and 
 play in accordance with his ability. To carry this into 
 effect, the closest scrutiny of his emotional and intellectual 
 interests is necessary. His environment, which in most 
 instances may have been reduced in social demands, ought 
 still to offer sufficiently varied outlets from which he must 
 choose a number of interests and amusements. Probably 
 no greater mistake is made than to tell epileptic individuals 
 to betake themselves to the country and then allow the 
 matter to end there. Many epileptics almost at once have 
 an increased number of attacks and, what is still worse, 
 begin to deteriorate mentally and emotionally through lack 
 of proper stimulus. There must be a certain novelty in the 
 occupations and amusements, and not a few to select from; 
 hence the importance of epileptics being in a country 
 environment not too dissimilar to that to which they have 
 been accustomed, — only the tempo, as it were, is to be 
 reduced. Some of the large public colonies for epileptics are 
 richly supplied with such potential advantages but unfortu- 
 
148 
 
 nately for economic reasons alone a number of highly trained 
 and gifted attendants and physicians are not at hand to assist 
 these more sluggish epileptics to get the proper start in con- 
 genial work. Lacking personal direction and attention, 
 many an epileptic manufactures his own interests only after 
 a long time, or not at all. 
 
 All frankly pronounced epileptics are doubly handicapped 
 by their natural antisocial tendencies as well as by the 
 epileptic seizures themselves. Such a temperament is a 
 direct hindrance to the epileptic taking up a healthy inter- 
 est in any life offered him. In the absence of a spontane- 
 ous interest, the remnants of former ones must be pieced 
 together or new ones induced. This can be effected only 
 by actually living in close contact with the daily lives of 
 the patients, assisting and encouraging them to start the 
 cold and uninviting task anew each day. Often before 
 work and study can actually be put in operation the epilep- 
 tic individual must be given many kindly explanatory talks 
 concerning the treatment, the common-sense view taken of 
 his disorder, and the method planned for its riddance. 
 These talks have to be endlessly varied, and simplified to 
 the individual's understanding. The friendly association 
 which many another neurotic or psychotic may have with 
 the nurse and physician plays but little part in dealing with 
 epileptics. The very nature of their makeup precludes this, 
 and the treatment is, therefore, at times most disheartening. 
 Of course the unlikability of such epileptic individuals, 
 and the physician's and nurse's failure to transfer their own 
 deep interest to them, are proverbial. Still the task must 
 be done in spite of the mutual unstable and weakened trend 
 of sympathetic interest. Until a satisfactory talk makes 
 the problem clear to the patient, little can be done. Even 
 when the new regime is fully inaugurated it may fail in a 
 single day and the whole process of confidence and assur- 
 ance must be reinvokedthe next. A few gifted individuals 
 may succeed in the role just detailed, but may fail in the 
 next step of putting the theory into practice. The 
 general dislike of the epileptic to perform sustained labor 
 day by day is well known, and the faithful attendant 
 
149 
 
 must himself participate in the activities outlined and in 
 most instances must take the lead until such time as it can 
 be borne without direction and guidance. Probably the 
 motive back of the advice given in foreign text-books 
 that the epileptic should live in a country clergyman's 
 family is to gain for such invalids the varied and sustained 
 cooperative interest of the family. Unfortunately in this 
 country either the clergy are not inclined to undertake such 
 work, or they are too illy equipped by nature to cope with 
 such a delicate humanitarian problem. What is even 
 more unfortunate, our country practitioners are often 
 but little better qualified to understand the far-reaching 
 importance of taking epileptic individuals under their 
 personal supervision. To be sure, it implies an intense 
 preoccupation in the minutiae of the lives of such persons, 
 but the issues can not otherwise be met if the profession is 
 to assume the obligations. Perhaps a broader understand- 
 ing of the purpose of modern mental hygiene will remedy 
 this lack in the future. If so it will be to the lasting 
 advantage of epileptics as well as many another mental 
 invalid. 
 
 Just as we made note of the inadequacy of considering 
 only the tantrum of the potentially epileptic child, neglect- 
 ing the whole issue of understanding and correcting the 
 lives of such children, so we may reiterate here the useless- 
 ness of exclusive concern in the epileptic's life at the time 
 of or shortly before his attacks. To do so is to fail in a 
 considerable number of instances, to lose a proper evalua- 
 tion of the mental precipitating factors of fits, as well as to 
 lose sight of the broader principles concerned in the proper 
 mental treatment of the individual case. The immediate 
 factors often found to make for attacks have already been 
 illustrated by charts in a preceding section; suffice it to say 
 here that such chartings are often of the utmost practical 
 moment in shaping a training treatment. By avoiding 
 these stressful factors and substituting other lines of activity 
 and interests, one may introduce an effective mental therapy 
 in many cases. There is rarely a case in which intelligent 
 care in this direction may not signally aid one in formula- 
 
150 
 
 ting a progressive treatment. Not a few therapeutic 
 generalizations have been laid down in an article already 
 published* 
 
 Conclusions : One may summarize the results of this 
 clinical study of essential epilepsy as follows : 
 
 (1) There exists a more or less definite type of consti- 
 tutional makeup in epileptics which has long been recog- 
 nized by many able neurologists and psychiatrists and this 
 defect accounts in no small part for the so-called "predis- 
 position " to the disease — a term in common use to-day. 
 The essential defects of instincts are egocentricity, super- 
 sensitiveness, an emotional poverty, and an inherent defect 
 of adaptability to normal social life in its broadest signifi- 
 cance. The main defect is an inheritable one. This 
 makeup is the primary or original mental endowment of 
 the potentially epileptic individual. It is accentuated and 
 made the more obvious by the further advance of the disease 
 only when seizures develop. It is then often spoken of 
 as the " mental stigma " of the disease. The attacks are 
 not solely responsible for epileptic deterioration, but the 
 seizures are themselves symptoms and exhibitions of the 
 deteriorating disorders. The seizures do not always indi- 
 cate the progress and degree of deterioration in any given 
 case ; i. e., the number and severity of fits in a given case 
 may not be an index to the amount of deterioration, nor 
 may one postulate the severity of seizure reaction in a par- 
 ticular case by the type of deterioration. 
 
 (2) The precipitating mental factors that often seem to 
 bring about epileptic reactions in a potential epileptic, 
 which range all the way from simple disorders of conduct 
 to definite seizures, are types of stress and annoyance, 
 causing a loss of spontaneous interest, and an intensive 
 regression to day-dreaming, lethargies and somnolence. 
 The attack occurs at the final break of a too severe tension, 
 and psychologically may be viewed as an intense reaction 
 away from the intolerable irritation, a regression to a primi- 
 tive mentality comparable to that of infancy or intra-uterine 
 life. 
 
 * Clark, " Some therapeutic suggestions derived from the newer psychology 
 cal studies upon the nature of essential epilepsy,'' Medical Record, March 4, 1916. 
 
151 
 
 (3) The therapeutic suggestions for a mental therapy 
 in essential epilepsy would be to overcome, by proper train- 
 ing and education, the earliest beginnings of epileptic 
 reactions in childhood. More particularly should the train- 
 ing concern itself with the eradication, as far as possible, of 
 the defective instincts shown in egocentricity, supersensi- 
 tiveness and rigidity of adaptation to the home and com- 
 munity. This is best brought about by (a) reducing and 
 limiting the undue stress of the environment; by (b) steadily 
 teaching the child adaptation to various types of stress so 
 that he may ultimately be able to live a fairly normal life 
 without exhibition of such grosser epileptic reactions as are 
 shown in the seizures of his disorder, (c) The epileptic 
 may be shown and taught to find a spontaneous outlet for 
 his keen individualistic desires and thus manufacture his 
 own interests in a heathful environment suitable to his needs 
 and capacity. 
 
 (4) Even though many epileptics may be quite deterio- 
 rated, it is still often possible to train back their once 
 discarded mental interest and thus restore much of their 
 emotional and mental dilapidation. In the more favorable 
 cases great improvement of the convulsive symptoms occurs 
 in many such individuals and with the more or less perma- 
 nent arrest of the disorder in not a few cases. A series of 
 arrested cases of frankly pronounced epilepsies are cited to 
 show the mental mechanism by which arrests have been 
 brought about through an application of the foregoing 
 therapy.* 
 
 * I wish to acknowledge my thanks to my nurse-trainers, and especially to 
 Mr. T. E. Uniker, for valuable assistance in the minute observation of many of 
 the cases incorporated in this study. 
 
DATE DUE 
 
COLUMBIA UNIVERSITY 
 
 0032093535