7 Some
Aspects of
the
Epileptic
Problem.
^
By J. Tylor Fox, M.A., M.D., D.P.M. Medical
Superintendent, Lingfield Epileptic Colony.
the idiot. He is found a mental range of the epileptic is from the genius to discover normal person among his fellows in the workaday world: we may easily detains which the and insanity him among the neurotics and psycho-neurotics, the take our in country may form 01 about 6,000 epileptics in mental hospitals classification almost any of the recognised psychoses. Whether we are essaying a we from the point of view of social fitness, of emotional defect, or of mte lgence, from deviation This widespread shall find epileptics in every class or grade. we are to avoid be too clearly recognised if cannot a mental like anything type witn mistaken generalizations about epileptics. The connection of epilepsy erime and delinquency has become so widely known, that almost every eir in 1 may read in our papers of criminals who claim epileptic irresponii lty ot great hold positions defence: less recognised is the fact that many epileptics world, and are honoured and and business the in professional responsibility e a o more t an respected in their day and generation. We are told that mus a. so we ut lowest grade of primary aments are liable to fits (Tredgol ), on epilepsy, of the remember the formidable list, to be found in every text book been World's great men who are believed to have epileptic. a he
ay^we
2
STUDIES IN MENTAL INEFFICIENCY.
By reason of these facts it is clear that the epileptic problem is not likely to be very simple one. Partly perhaps for the same reasons, the disease is one that up to the present has not yielded any rich and easily garnered harvests to the investigator. The neurologists, stimulated by Hughlings Jackson's work on convulsions of organic origin, have endeavoured in vain to discover a corresponding anatomical basis for the idiopathic disease, or to claim much success for any new form of its medical or surgical treatment. Psycho-analysts have found epileptics as a whole, not readity accessible, and even in cases favourable in this respect the results of analysis have been generally disappointing. Recent work on epilepsy has, however,served to define more clearly what is usually referred to as the epileptic temperament. Pierce Clark and others have not only described the chief features of this temperament, but have laid down for a
view of the relation between it and the convulsive attacks. The epileptic egocentric, and an egocentric whose difficulties are made the greater by hypersensitiveness. The social handicaps of such a temperament are obvious: as the individual grows out of his mother's arms and his nursery into an ever-widening circle of people and things, his inability to adapt himself becomes more and more obvious, and he becomes a social misfit. His mental life is fraught with constantly increasing stress, and the periodic losses of consciousness characteristic of the disease are supposed to be in the nature of protective reactions away from an environment that has become intolerable. The stress is avoided by the temof obliteration to this view, then, the fits are secondary porary reality. According to the mental make-up of the patient. This is usually referred to as a psychogenic theory of the origin of epilepsy, but it must be remembered that while social maladaptation and mental causes fill a large place in the picture, the bottom of the trouble is an abnormal make-up which is inherited, and therefore, presumably? physical: and to that extent the disease is in reality more physiogenic than psychogenic in origin. Of the great importance of environmental stress in the determination of fits in one already liable to them, no-one who has lived much among epileptics can have any doubt. While the sun shines, while there are new interests about and pleasureable occupations, attacks are few: but when the patient is tired of his work (and he readily becomes so), when there is some worry or anxiety in his mind, when he is out of harmony with his environment, attacks are frequent. But must not confound the determining causes of fits in a declared epileptic with the and the cause of the disease. The claim that the inherited us a
new
is born
an
temperament
prime
the fits may contain truth, but I venture to think that it can be claimed with equal fairness that the fits themselves accentuate, if they do not in some cases actually cause, the egocentricity and hypersensitiveness that are the two basic features of the temperament, and that underlie the abnormal outlook and unsocial conduct of the epileptic. Take the case of an epileptic boy in a poorer class family in one of our large Let us suppose that he starts with a normal outlook, and let us see ho^r towns. his outlook on life, and in consequence his conduct, is likely to become modfiied by the periodic convulsive attacks to which he is liable. From his earliest years he will realize that he is in some way different from his brothers and sisters; he
consequent social mal-adaptation
cause
STUDIES IN MENTAL INEFFICIENCY.
will find that special
care is being taken of him, that in his bath, by the fire, and the staircase he is being watched in a way that the others are not. As he grows a little older, and begins to run about out-of-doors, his troubles increase. If his parents are careful he will find that his freedom out-of-doors is very much curtailed : perhaps he may only go for walks, holding his mother s or his big sister s hand, and neither his mother nor sister have the same idea of the scope and duration of outdoor activity as he has. If his parents are by temperament or by necessity, not so careful, he will have fits in the street, perhaps come to some serious physical damage, and be brought home by the police. In the end, in either case, it will mean a good deal more confinement indoors than any boy should have. His interests now begin to widen. He saves up his half-pennies for the cinema theatre at the end of the road, he puts in an appearance at Sunday School. All goes well until he adds his quota to what is going on by having a noisy fit; there is a commotion, and he is removed unconscious after having successfully disturbed the order of events. He does it again, and it is suggested kindly but firmly that his company is unwelcome. The same fate dogs him at school. Too often, both teacher and fellow-scholars alike, come to regard him with apprehension, with fear or with an active dislike: and the end is exclusion from school. At home, meanwhile, parental love tries to make up for the handicaps and the limitations which life is so obviously bringing to him. The bonds of parental discipline are loosened a little. If he gets into a temper, and invades the property rights of his brothers and sisters, he must not be judged just as they are. By violence or lamentations, he finds that he can get his own way writh comparative ease. His desire for unsuitable articles of diet is humoured: worse still he is allowed to eat a great deal more than he should, with consequent increase of fits. Such a boy's outlook on the world must differ much from that of the other members ?f his family and of other boys of his class. He sees himself regarded askance as someone to be afraid of, or disliked, he sees himself cut right out of much of the Play and work of his fellows, he sees himself as someone who needs special protection and special sympathy, he sees himself as immune from many of the ordinary rules of life, and from many of its penalites, he sees that obstinacy, bad-temper, or crying are, for him, and for him alone, comparatively easy roads to the attainment of desire. And there, without any need to predicate much in the way ?f a special temperamental inheritance, is, I suggest, the basis of a character, self-centred and hypersensitive, that must inevitably lead to abnormal conduct, violent tempers, hysterical outbursts are part and parcel of the
on
bloodiness,
picture, delinquency
and crime almost its natural outcome. present time attending our School at Lingfield an active intelligent boy of 14, who was born and brought up in a part of a tenement house in Jsiorth London. This boy was excluded from school, no doubt quite rightly, because of his frequent fits, and was left to roam about the streets. The house in ^hich he lived had no garden, front or back, there wras no park within a mile. Under such conditions the natural outlets for a boy's energies were, to say the least, limited: and who can wonder if he came up against the forces of law and order? We might be willing to sit on the magistrates' bench and allot punishments to fit his crimes: but blame, if blame there must be, could not, with any
There is
at the
4
STUDIES IN MENTAL INEFFICIENCY.
his shoulders. Ten months ago the boy came to us: school was open to him, there was football and cricket, and green fields to play in. Theft and other unsocial acts were no more necessary to him now than to any other of his fellows, and they have completely disappeared. What I have sought to suggest so far is that in many cases of epilepsy, a great deal of the mental instability and of the social mal-adaptation may be diieetly due to the occurrence of the fits, and not to any inevitable and primary inheritance. The picture I have endeavoured to paint is not a complete one. Congenital mental defect, in varying degrees, enters in in a great many cases; and, if congenital mental defect in the narrower sense of the term, no doubt other forms of congenital mental abnormality as well, and the mind of the epileptic as has already been said, is not readily represented as a type. But if the picture is not complete, it is at all events not hypothetical. It is a composite picture whose clear outlines are derived from a pretty close acquaintance with a large number of epileptic school children. Can a better environment be found for these children ? I believe that it can, and that if only the patient is placed in the right surroundings early enough in the course of his disease, much of his mal-adaptation and unhappiness may often be avoided, and incidentally the fits themselves much diminished. It is a serious thing to take a child out of his home altogether: and if it is only to treat some disease or defect directly due to bad physical conditions in the home, obviously the better course is to concentrate our efforts on the removal of those conditions. But there is no evidence of this in the care of the epileptic. There is, indeed, 6omething to be said for the removal of the epileptic child from the point of view of his brothers and sisters. Frequent and violent fits are a very disturbing element in a school, or a home: and their occurrence may well do considerable mental damage to any specially sensitive child who has to live in a daily apprehension of seeing them. I think the point will appeal to any of us who have children of our own. There is moreover, in the case of epilpetics, often an additional factor in the home environment which militates against their happiness. Epilepsy, it is now recognised, is but one manifestation of a neuropathic inheritance. The direct transmission of the disease itself from father to son is a comparatively rare event; the rule is to find in the direct ancestry of an epileptic, or among his collaterals, cases of insanity in one of its many forms, epilepsy, mental deficiency, alcoholism or suicide, or of such lesser manifestations of the neuropathic inheritance as bad tempers, hysteria, migraine, etc. If a parent or an older brother, then, is hysterical, bad-tempered or alcoholic, the atmosphere of the home is all the more difficult for the epileptic child: a state of affairs which unfortunately is all too frequently within the experience of those who work among
justice,
sit
on
once more
epileptics.
The alternative to home life must be an institution; and it will already be clear that in my opinion the institution should be for epileptics only. Certain advantages of institutional life will be at once obvious. The more serious risks of physical damage during fits can be reduced to a minimum, a suitable diet can be ensured and over-feeding avoided, fresh air, regulated hours of sleep and other elementary matters of ordinary hygiene are easily attained. The Insti-
STUDIES IN MENTAL INEFFICIENCY.
tution should be in the country. For over 350 patients at our Colony at Lingfield, we have eight playing fields, besides four pieces of asphalted playground. Our
experience goes
to show that a warm, rather relaxing climate is likely to suit best. But the effects of the new environment on the child will not be limited to these matters of hygiene, important as they are. In a Colony he goes to school again: he has concerts and the pictures once more to look forward to. there is football, cricket and hockey. lie sees himself as a normal member of the society in which he moves. To have occasional fits is no't the exception, but the rule: and therein I believe lies the commonest reason why the majority of epileptics are much on a than at or a general institution. in In home, happier Colony a smaller number of cases, the removal of an alcoholic or neuropathic relative from the child's immediate surroundings is of greater importance. Can these claims be substantiated ? I think they can. The degree of social adaptation cannot be expressed numerically, but if anyone were to take the trouble to read the histories of our cases before admission, and to compare them with their records in our Homes or school, they would be convinced of a general improvement. That is not to say that dishonesty, untruthfulness, violent tempers, and the like are unknown among our children, but they are certainly far less widespread than their former histories would indicate. The incidence of fits is & much more measurable quantity than the degree of social adaptation; and here the improvement is very marked. It is rare indeed for a child to have as many fits during the first year at Lingfield as he is supposed to have had the year before he came in: and in a good many cases, the fits cease altogether. At the present time out of 149 children in our school who have been with us for more than six months, 21 have had no attack of any kind since the day of admission. It is worth while considering what the cause of this cessation of fits is likely to be. In every case the child was sent to Lingfield certified by a medical officer specially approved by the Board of Education, as suffering from epileptic attacks, so severe, or so frequent, as to unfit him for attendance at an ordinary public elementary school. It is unlikely that many of them were not cases of idiopathic epilepsy, and all the more so when we note that in ten out of the twenty-one cases there is a record ?f either epilepsy or insanity in near relatives. This proportion is a little higher than the average figure we obtain in a large series of cases, but no doubt the true proportion is higher still as complete histories are difficult to get, especially where Cental trouble is concerned. Mai-diagnosis, then, is not likely to account for the stoppage of fits in more than two or three of the twenty-one cases under consideration. Drug treatment, again, can be entirely ruled out. It is our practice not to give bromides or other sedative drugs to any child for the first three months after admission, unless there is some special reason for it, and, as a of fact, none of these cases have had a single dose of bromide or similar ug while they have been at Fresh air, simple food, daily baths, and Lingfield. the like may have been important factors, but I believe that in the type of case sudden cessation of fits, the change is due to the removal of some undesirable actor in the child's environment. Such a factor is likely to be an unpleasant emotional stress in the home, associated with, say, violent tempers or alcoholism some members of the family. The actual incidence of fits has become associated
epileptics
fatter
^ith
6
STUDIES IN MENTAL INEFFICIENCY.
with such periods of stress, so that the latter have come to act as "conditioned" stimuli. In the absence of the stress the fits have ceased. In some cases the connection seems fairly clearly established: in others one can make a pretty shrewd guess. We must not, however, make the mistake of idealizing our institutions. The best of them are inherently bad things, because in time their populations tend to become "institutionalised." Their outlook on life is limited by the borders of the Colony; they are citizens of a Colony, not of a state. And this, especially in the case of epileptics, where a progressive narrowing of the mental horizon is one of the most characteristic features of the complaint. Moreover, whenever patients remain for a long period in an institution where life is ordered and inevitable, and where there is no struggle for the necessities, there is a tendency towards a certain loss of individuality. John Jones becomes less and less John Jones, and more and more No. 31 in Block E. Further, institutions for epileptics have to deal with a very wide variety of mental grades, a much wider variety than, for instance, institutions for mental defectives. Grading is imperative. It is not fair to put children of normal, or even super-normal intelligence, to live with the lower grades of mental defectives just because they are liable to epilcptic attacks. The recent circular of the Board of Education assigning more children to each teacher among epileptics than among mental defectives, is, I believe, unfair. There is a far wider range of intelligence in the schools for epileptics, and unless the school is very large indeed, satisfactory grading is impossible, and there must be an enormous amount of individual teaching. Moreover, the mental instability of the epileptic is an additional handicap; and there are the fits to cope with. The question of grading, and the considerations I have brought forward with regard to institutionalization are both vital factors in the problem of how we should deal with our epileptics. In this article I have dealt mainly with the epileptic child. Epilepsy is essentially a disease that begins in early life, and if treatment away from home is best, obviously the earlier it is started the better. But most of what has been said applies equally to the adult, with the proviso that the outlook with regard to fit incidence as well as social adaptation is not so good. The difficulty of grading, both for children and adults calls for large colonies: or better still, for some degree of centralisation of effort with regard to epileptics, with a view to grading by institutions. Sooner or later centralisation is bound to come, very probably under a department of the Ministry of Health, and under such centralisation it may well be anticipated that the intelligent, the markedly delinquent, and the mentally defective epileptic may find themselves in different institutions. If the Colonies themselves should be large, the units within the Colonies should be small and well separated. The ideal children's home would contain only 10 or 12, that for adults perhaps a larger number up to 25. In this way the patient would retain his individuality, and a family rather than in institutional atmosphere would be encouraged. But there is no use pretending that these small homes would be as economically run as larger ones. The "institutionalisation" tendency must be fought in every possible way. All the syllabuses for schools and Continuation classes want careful modification with this
STUDIES IN MENTAL INEFFICIENCY.
7
point
in mind. We have a new and powerful weapon in the cinema, rightly chosen films have an enormous education value. With a very little money, a good deal of planning, and some courage, one can arrange to take patients right away from the Colony once a year. This year almost all our patients at Lingfield, little and big, will have a day at the seaside, and in most cases they will pay
for their excursion by their own hardly-saved pence. For this reason it will be all the more enjoyed, and the effect on the mental horizon is difficult to overestimate. In a word, the aim must be to increase, in every way we can, the contacts between our Colony patients and the world outside. To sum up, the mental development and outlook of epileptics presents such enormous variations that it is difficult to speak of an epileptic type. There seems, however, to be a distinctive epileptic temperament, which is no doubt largely inherited. It is claimed, however, that many features of this temperament and much of the social maladaptnticn resulting from it, are directly due to the social consequences of having periodic epileptic fits, and it is further suggested that if the patients are resident in special colonies rather than in their own homes, many ?f these untoward results Under these circumstances the may be avoided. patient's fits will be less, his physical and mental health will improve, and he will be happier.
Aspects of
the
Epileptic
Problem.
^
By J. Tylor Fox, M.A., M.D., D.P.M. Medical
Superintendent, Lingfield Epileptic Colony.
the idiot. He is found a mental range of the epileptic is from the genius to discover normal person among his fellows in the workaday world: we may easily detains which the and insanity him among the neurotics and psycho-neurotics, the take our in country may form 01 about 6,000 epileptics in mental hospitals classification almost any of the recognised psychoses. Whether we are essaying a we from the point of view of social fitness, of emotional defect, or of mte lgence, from deviation This widespread shall find epileptics in every class or grade. we are to avoid be too clearly recognised if cannot a mental like anything type witn mistaken generalizations about epileptics. The connection of epilepsy erime and delinquency has become so widely known, that almost every eir in 1 may read in our papers of criminals who claim epileptic irresponii lty ot great hold positions defence: less recognised is the fact that many epileptics world, and are honoured and and business the in professional responsibility e a o more t an respected in their day and generation. We are told that mus a. so we ut lowest grade of primary aments are liable to fits (Tredgol ), on epilepsy, of the remember the formidable list, to be found in every text book been World's great men who are believed to have epileptic. a he
ay^we
2
STUDIES IN MENTAL INEFFICIENCY.
By reason of these facts it is clear that the epileptic problem is not likely to be very simple one. Partly perhaps for the same reasons, the disease is one that up to the present has not yielded any rich and easily garnered harvests to the investigator. The neurologists, stimulated by Hughlings Jackson's work on convulsions of organic origin, have endeavoured in vain to discover a corresponding anatomical basis for the idiopathic disease, or to claim much success for any new form of its medical or surgical treatment. Psycho-analysts have found epileptics as a whole, not readity accessible, and even in cases favourable in this respect the results of analysis have been generally disappointing. Recent work on epilepsy has, however,served to define more clearly what is usually referred to as the epileptic temperament. Pierce Clark and others have not only described the chief features of this temperament, but have laid down for a
view of the relation between it and the convulsive attacks. The epileptic egocentric, and an egocentric whose difficulties are made the greater by hypersensitiveness. The social handicaps of such a temperament are obvious: as the individual grows out of his mother's arms and his nursery into an ever-widening circle of people and things, his inability to adapt himself becomes more and more obvious, and he becomes a social misfit. His mental life is fraught with constantly increasing stress, and the periodic losses of consciousness characteristic of the disease are supposed to be in the nature of protective reactions away from an environment that has become intolerable. The stress is avoided by the temof obliteration to this view, then, the fits are secondary porary reality. According to the mental make-up of the patient. This is usually referred to as a psychogenic theory of the origin of epilepsy, but it must be remembered that while social maladaptation and mental causes fill a large place in the picture, the bottom of the trouble is an abnormal make-up which is inherited, and therefore, presumably? physical: and to that extent the disease is in reality more physiogenic than psychogenic in origin. Of the great importance of environmental stress in the determination of fits in one already liable to them, no-one who has lived much among epileptics can have any doubt. While the sun shines, while there are new interests about and pleasureable occupations, attacks are few: but when the patient is tired of his work (and he readily becomes so), when there is some worry or anxiety in his mind, when he is out of harmony with his environment, attacks are frequent. But must not confound the determining causes of fits in a declared epileptic with the and the cause of the disease. The claim that the inherited us a
new
is born
an
temperament
prime
the fits may contain truth, but I venture to think that it can be claimed with equal fairness that the fits themselves accentuate, if they do not in some cases actually cause, the egocentricity and hypersensitiveness that are the two basic features of the temperament, and that underlie the abnormal outlook and unsocial conduct of the epileptic. Take the case of an epileptic boy in a poorer class family in one of our large Let us suppose that he starts with a normal outlook, and let us see ho^r towns. his outlook on life, and in consequence his conduct, is likely to become modfiied by the periodic convulsive attacks to which he is liable. From his earliest years he will realize that he is in some way different from his brothers and sisters; he
consequent social mal-adaptation
cause
STUDIES IN MENTAL INEFFICIENCY.
will find that special
care is being taken of him, that in his bath, by the fire, and the staircase he is being watched in a way that the others are not. As he grows a little older, and begins to run about out-of-doors, his troubles increase. If his parents are careful he will find that his freedom out-of-doors is very much curtailed : perhaps he may only go for walks, holding his mother s or his big sister s hand, and neither his mother nor sister have the same idea of the scope and duration of outdoor activity as he has. If his parents are by temperament or by necessity, not so careful, he will have fits in the street, perhaps come to some serious physical damage, and be brought home by the police. In the end, in either case, it will mean a good deal more confinement indoors than any boy should have. His interests now begin to widen. He saves up his half-pennies for the cinema theatre at the end of the road, he puts in an appearance at Sunday School. All goes well until he adds his quota to what is going on by having a noisy fit; there is a commotion, and he is removed unconscious after having successfully disturbed the order of events. He does it again, and it is suggested kindly but firmly that his company is unwelcome. The same fate dogs him at school. Too often, both teacher and fellow-scholars alike, come to regard him with apprehension, with fear or with an active dislike: and the end is exclusion from school. At home, meanwhile, parental love tries to make up for the handicaps and the limitations which life is so obviously bringing to him. The bonds of parental discipline are loosened a little. If he gets into a temper, and invades the property rights of his brothers and sisters, he must not be judged just as they are. By violence or lamentations, he finds that he can get his own way writh comparative ease. His desire for unsuitable articles of diet is humoured: worse still he is allowed to eat a great deal more than he should, with consequent increase of fits. Such a boy's outlook on the world must differ much from that of the other members ?f his family and of other boys of his class. He sees himself regarded askance as someone to be afraid of, or disliked, he sees himself cut right out of much of the Play and work of his fellows, he sees himself as someone who needs special protection and special sympathy, he sees himself as immune from many of the ordinary rules of life, and from many of its penalites, he sees that obstinacy, bad-temper, or crying are, for him, and for him alone, comparatively easy roads to the attainment of desire. And there, without any need to predicate much in the way ?f a special temperamental inheritance, is, I suggest, the basis of a character, self-centred and hypersensitive, that must inevitably lead to abnormal conduct, violent tempers, hysterical outbursts are part and parcel of the
on
bloodiness,
picture, delinquency
and crime almost its natural outcome. present time attending our School at Lingfield an active intelligent boy of 14, who was born and brought up in a part of a tenement house in Jsiorth London. This boy was excluded from school, no doubt quite rightly, because of his frequent fits, and was left to roam about the streets. The house in ^hich he lived had no garden, front or back, there wras no park within a mile. Under such conditions the natural outlets for a boy's energies were, to say the least, limited: and who can wonder if he came up against the forces of law and order? We might be willing to sit on the magistrates' bench and allot punishments to fit his crimes: but blame, if blame there must be, could not, with any
There is
at the
4
STUDIES IN MENTAL INEFFICIENCY.
his shoulders. Ten months ago the boy came to us: school was open to him, there was football and cricket, and green fields to play in. Theft and other unsocial acts were no more necessary to him now than to any other of his fellows, and they have completely disappeared. What I have sought to suggest so far is that in many cases of epilepsy, a great deal of the mental instability and of the social mal-adaptation may be diieetly due to the occurrence of the fits, and not to any inevitable and primary inheritance. The picture I have endeavoured to paint is not a complete one. Congenital mental defect, in varying degrees, enters in in a great many cases; and, if congenital mental defect in the narrower sense of the term, no doubt other forms of congenital mental abnormality as well, and the mind of the epileptic as has already been said, is not readily represented as a type. But if the picture is not complete, it is at all events not hypothetical. It is a composite picture whose clear outlines are derived from a pretty close acquaintance with a large number of epileptic school children. Can a better environment be found for these children ? I believe that it can, and that if only the patient is placed in the right surroundings early enough in the course of his disease, much of his mal-adaptation and unhappiness may often be avoided, and incidentally the fits themselves much diminished. It is a serious thing to take a child out of his home altogether: and if it is only to treat some disease or defect directly due to bad physical conditions in the home, obviously the better course is to concentrate our efforts on the removal of those conditions. But there is no evidence of this in the care of the epileptic. There is, indeed, 6omething to be said for the removal of the epileptic child from the point of view of his brothers and sisters. Frequent and violent fits are a very disturbing element in a school, or a home: and their occurrence may well do considerable mental damage to any specially sensitive child who has to live in a daily apprehension of seeing them. I think the point will appeal to any of us who have children of our own. There is moreover, in the case of epilpetics, often an additional factor in the home environment which militates against their happiness. Epilepsy, it is now recognised, is but one manifestation of a neuropathic inheritance. The direct transmission of the disease itself from father to son is a comparatively rare event; the rule is to find in the direct ancestry of an epileptic, or among his collaterals, cases of insanity in one of its many forms, epilepsy, mental deficiency, alcoholism or suicide, or of such lesser manifestations of the neuropathic inheritance as bad tempers, hysteria, migraine, etc. If a parent or an older brother, then, is hysterical, bad-tempered or alcoholic, the atmosphere of the home is all the more difficult for the epileptic child: a state of affairs which unfortunately is all too frequently within the experience of those who work among
justice,
sit
on
once more
epileptics.
The alternative to home life must be an institution; and it will already be clear that in my opinion the institution should be for epileptics only. Certain advantages of institutional life will be at once obvious. The more serious risks of physical damage during fits can be reduced to a minimum, a suitable diet can be ensured and over-feeding avoided, fresh air, regulated hours of sleep and other elementary matters of ordinary hygiene are easily attained. The Insti-
STUDIES IN MENTAL INEFFICIENCY.
tution should be in the country. For over 350 patients at our Colony at Lingfield, we have eight playing fields, besides four pieces of asphalted playground. Our
experience goes
to show that a warm, rather relaxing climate is likely to suit best. But the effects of the new environment on the child will not be limited to these matters of hygiene, important as they are. In a Colony he goes to school again: he has concerts and the pictures once more to look forward to. there is football, cricket and hockey. lie sees himself as a normal member of the society in which he moves. To have occasional fits is no't the exception, but the rule: and therein I believe lies the commonest reason why the majority of epileptics are much on a than at or a general institution. in In home, happier Colony a smaller number of cases, the removal of an alcoholic or neuropathic relative from the child's immediate surroundings is of greater importance. Can these claims be substantiated ? I think they can. The degree of social adaptation cannot be expressed numerically, but if anyone were to take the trouble to read the histories of our cases before admission, and to compare them with their records in our Homes or school, they would be convinced of a general improvement. That is not to say that dishonesty, untruthfulness, violent tempers, and the like are unknown among our children, but they are certainly far less widespread than their former histories would indicate. The incidence of fits is & much more measurable quantity than the degree of social adaptation; and here the improvement is very marked. It is rare indeed for a child to have as many fits during the first year at Lingfield as he is supposed to have had the year before he came in: and in a good many cases, the fits cease altogether. At the present time out of 149 children in our school who have been with us for more than six months, 21 have had no attack of any kind since the day of admission. It is worth while considering what the cause of this cessation of fits is likely to be. In every case the child was sent to Lingfield certified by a medical officer specially approved by the Board of Education, as suffering from epileptic attacks, so severe, or so frequent, as to unfit him for attendance at an ordinary public elementary school. It is unlikely that many of them were not cases of idiopathic epilepsy, and all the more so when we note that in ten out of the twenty-one cases there is a record ?f either epilepsy or insanity in near relatives. This proportion is a little higher than the average figure we obtain in a large series of cases, but no doubt the true proportion is higher still as complete histories are difficult to get, especially where Cental trouble is concerned. Mai-diagnosis, then, is not likely to account for the stoppage of fits in more than two or three of the twenty-one cases under consideration. Drug treatment, again, can be entirely ruled out. It is our practice not to give bromides or other sedative drugs to any child for the first three months after admission, unless there is some special reason for it, and, as a of fact, none of these cases have had a single dose of bromide or similar ug while they have been at Fresh air, simple food, daily baths, and Lingfield. the like may have been important factors, but I believe that in the type of case sudden cessation of fits, the change is due to the removal of some undesirable actor in the child's environment. Such a factor is likely to be an unpleasant emotional stress in the home, associated with, say, violent tempers or alcoholism some members of the family. The actual incidence of fits has become associated
epileptics
fatter
^ith
6
STUDIES IN MENTAL INEFFICIENCY.
with such periods of stress, so that the latter have come to act as "conditioned" stimuli. In the absence of the stress the fits have ceased. In some cases the connection seems fairly clearly established: in others one can make a pretty shrewd guess. We must not, however, make the mistake of idealizing our institutions. The best of them are inherently bad things, because in time their populations tend to become "institutionalised." Their outlook on life is limited by the borders of the Colony; they are citizens of a Colony, not of a state. And this, especially in the case of epileptics, where a progressive narrowing of the mental horizon is one of the most characteristic features of the complaint. Moreover, whenever patients remain for a long period in an institution where life is ordered and inevitable, and where there is no struggle for the necessities, there is a tendency towards a certain loss of individuality. John Jones becomes less and less John Jones, and more and more No. 31 in Block E. Further, institutions for epileptics have to deal with a very wide variety of mental grades, a much wider variety than, for instance, institutions for mental defectives. Grading is imperative. It is not fair to put children of normal, or even super-normal intelligence, to live with the lower grades of mental defectives just because they are liable to epilcptic attacks. The recent circular of the Board of Education assigning more children to each teacher among epileptics than among mental defectives, is, I believe, unfair. There is a far wider range of intelligence in the schools for epileptics, and unless the school is very large indeed, satisfactory grading is impossible, and there must be an enormous amount of individual teaching. Moreover, the mental instability of the epileptic is an additional handicap; and there are the fits to cope with. The question of grading, and the considerations I have brought forward with regard to institutionalization are both vital factors in the problem of how we should deal with our epileptics. In this article I have dealt mainly with the epileptic child. Epilepsy is essentially a disease that begins in early life, and if treatment away from home is best, obviously the earlier it is started the better. But most of what has been said applies equally to the adult, with the proviso that the outlook with regard to fit incidence as well as social adaptation is not so good. The difficulty of grading, both for children and adults calls for large colonies: or better still, for some degree of centralisation of effort with regard to epileptics, with a view to grading by institutions. Sooner or later centralisation is bound to come, very probably under a department of the Ministry of Health, and under such centralisation it may well be anticipated that the intelligent, the markedly delinquent, and the mentally defective epileptic may find themselves in different institutions. If the Colonies themselves should be large, the units within the Colonies should be small and well separated. The ideal children's home would contain only 10 or 12, that for adults perhaps a larger number up to 25. In this way the patient would retain his individuality, and a family rather than in institutional atmosphere would be encouraged. But there is no use pretending that these small homes would be as economically run as larger ones. The "institutionalisation" tendency must be fought in every possible way. All the syllabuses for schools and Continuation classes want careful modification with this
STUDIES IN MENTAL INEFFICIENCY.
7
point
in mind. We have a new and powerful weapon in the cinema, rightly chosen films have an enormous education value. With a very little money, a good deal of planning, and some courage, one can arrange to take patients right away from the Colony once a year. This year almost all our patients at Lingfield, little and big, will have a day at the seaside, and in most cases they will pay
for their excursion by their own hardly-saved pence. For this reason it will be all the more enjoyed, and the effect on the mental horizon is difficult to overestimate. In a word, the aim must be to increase, in every way we can, the contacts between our Colony patients and the world outside. To sum up, the mental development and outlook of epileptics presents such enormous variations that it is difficult to speak of an epileptic type. There seems, however, to be a distinctive epileptic temperament, which is no doubt largely inherited. It is claimed, however, that many features of this temperament and much of the social maladaptnticn resulting from it, are directly due to the social consequences of having periodic epileptic fits, and it is further suggested that if the patients are resident in special colonies rather than in their own homes, many ?f these untoward results Under these circumstances the may be avoided. patient's fits will be less, his physical and mental health will improve, and he will be happier.
