The epileptic state leads in a certain pro portion of cases, if it has begun in early life, to conditions of feeble-mindedness, imbecility and idiocy or it has originally been associated with these conditions. It produces in many cases a very profound general mental deteriora tion. The progress toward this condition as well as the ultimate clinical picture present an accentuated manifestation of the heightened infantile and egocentric character of the epileptic character and reaction. It is asso ciated in a close inter-relation with the super ficiality and ready loss of interest. As has been said: °This process . . . consists of a pro gressive loss of interest associated with a fail ure of mentation in respect to normal stimuli in which interest is lost. Both loss of interest and intellectual decay proceed from the barely perceptible early stages to total loss of speech and other acquired functions, when a condi tion is reached equivalent to the lowest grade of idiocy or the helplessness of a suckling in fant." The dementia does not manifest itself in a withdrawal into an hallucinatory world or in the further symbolic activities of other types of dementia. It consists rather in this gradual withdrawal from all contact with environment until a stage of complete infantilism is reached when the individual is merely a biological ego centric entity in the state of supreme infantile dependence and security which characterize the earliest post-embryonic, almost the fetal period. This is also the psychic goal attained tem porarily by the attacks which produce pro found unconsciousness. Such a conception of the meaning of the tendency and ultimate end of the psychic reaction has been made possible through the psychoanalytic understanding of controlling impulses belonging to the uncon scious and determining such reactions. The ap plication of psychoanalytic knowledge and methods to individual cases has led to and con firmed these conclusions and throws a light upon the obscure problems of epilepsy which have so far baffled the neuropathologist and the psychiatrist of older schools. This psycho logical approach to the problem does not ex clude further research along anatomical and pathological lines. On the contrary it awaits accurate and conclusive knowledge which can only come through such exact research and which must form the physiological basis for complete psychological understanding and en large the possibility of prophylactic and thera peutic control.
Meanwhile a psychic therapy is proving its efficacy in a more rational understanding of the epileptic constitution and its inadequacy before the demands of life. This brings an explana tion of its yielding at points of particular diffi culty and utilizing the characteristic modes of energy discharge. It thus affords a prophylactic basis for education and early training to coun teract the essential egocentricity and super ficiality of interest and in further treatment, whether able to effect a cure or merely to al leviate existing conditions and retard or pre vent the ultimate dementia, it stimulates to a sympathetic and watchful interest in the patient in order to meet him at the points of least resistance and rearouse a flagging interest and utilize his very tendencies for counteracting his self-centring. The epileptic colony pro
vides the ideal environment for this course of treatment. The patients are there under the con stant supervision of the trained psychotherapist who has this necessary understanding. The variety of occupations provided furnish means for the essential change of interest and the patients are not subjected to a competition which they are constitutionally unable to with stand.
The question of the use of drugs is an im portant one because of a widespread belief in their efficacy. Bromide is the only one, how ever, which deserves consideration, being in fact the basis of most of the other remedies offered for this condition. The larger concep tion of the clinical picture which recognizes the convulsion as not the disease, nor even the cause nor the first expression of it, but only one form of its outward manifestation, an outlet for the accumulated and unutilizable energy, seriously questions the rationality of bromide niedicatioh. Experience seems to show that the convulsion is only postponed, that sooner or later the energy discharge will take place and the drug may indeed in the end produce a summation of at tacks which will lead up to that final stage of which the epileptic stands in danger, the condi tion known as status epilepticus, a terminal stage which consists of repeated and continued convulsive attacks associated with high fever and usually ending in death. It cannot be denied that the bromides have a function in regulating the convulsions when such a danger is imminent but they must be employed with the utmost caution and consideration on the part of the physician. The general observance of hygienic measures is of course ofgreat im portance. An outdoor life with a mild, health ful occupation, plain, digestible food, the absence of tobacco, alcohol and other stimulants, a free intestinal canal and surroundings in consonance with the mental capacity of the patient are very desirable features. Treatment during a con vulsion is merely protection to prevent injury to the patient. Beyond these measures, how ever, lies the more comprehensive understand ing of the constitutional burden of the epileptic and the very practical aid which this must bring to him in directing and adapting his capacity to the demands of his environ ment. Consult Jelliffe and White, 'Diseases of the Nervous System> (2d ed., 1917).