Throughout the 19th century, it was still unclear whether “epilepsy” fell into a neurological, psychiatric, or psychosomatic category, so that it became freely interpreted in the various medical disciplines. In the 20th century, building on the notion of “neuronal degeneracy,” racial anthropologists and eugenicists on both sides of the Atlantic interpreted epilepsy as a genetically inherited condition together with “feeble-mindedness” and decreased “intelligence.” Quite early on, epilepsy had been included in major eugenics-oriented publications, such as British neurologist John Hughlings Jackson’s (1825-1911) Neurological Fragments (1925, published posthumously) or German anthropologist Alfred Ploetz’s (1860-1940) Foundations of a Eugenics (1895). Likewise, the founders of the Eugenics Record Office in Cold Spring Harbour conceived their sterilization model law in 1914, so as to include “socially inadequate” persons and “epileptics” among the “feebleminded, insane, and dependent” people, who should be forcibly sterilized. Eventually, 12 US states adapted these suggestions in regional sterilization regulations. Some of the developments, which will be described here, led to the degenerative, somatic interpretation of epilepsy and gave rise to continued social and psychological stigmatization of people with epileptic conditions.
Eugenics, Degenerative Diseases, and Epilepsy
Although the term “eugenics” was not adopted into German until the 20th century, familiarity with the writings of the British polymath Francis Galton (1822-1911) gave rise on the Continent to considerations to prohibit the procreation of persons deemed as “unfit.” This included interest in Galton’s (1883) mentioning of conditions of “epilepsy” as an inherited disease in his Inquiries into Human Faculty and its Development, in which he called for a program of empirical research that would focus on the inheritance of mental traits such as “intelligence,” “addiction,” or “criminal behaviour.” German-speaking proponents of racial hygiene likewise analyzed the genetic preconditions of alcoholism, poverty, criminality, and “epilepsy” to develop new treatments for such individuals or otherwise plan for marriage laws and the social segregation of people with epilepsy. Upon a closer look at this complex of research into “degenerated bodies” in psychiatry and the brain sciences, it becomes evident that broad “sociocultural concepts” (such as eugenics) infiltrated basic research programs and clinical practice by the turn of the century.
One influential aspect of the conceptual transfer from society to the laboratory and clinic can be seen in the interpretation of neuropathy put forward by Berlin psychiatrist and neurologist Wilhelm Griesinger (1817-1868). His concept of neuropathy subsumed a variety of disorders that displayed transient signs of mental and physical agitation. It is instructive to note that Griesinger interpreted such phenomena as an interlacing of hereditary and environmental causes (see Griesinger, 1882). The interplay between hereditary factors and environmental ones among the “neuroses” is further explained by an 1877 handbook contribution of one of his followers, Munich internist Hugo Wilhelm von Ziemssen (1829–1902), where epilepsy became presented as a constitutional and thus inherited “neuropathy.” Ziemssen’s definition intriguingly shows how interchangeably psychological and neurological interpretations of epilepsy were used in the 19th century to explain “seizures.”
With his notion of “irritable weakness” seen as congenital nervous diseases, Griesinger alluded to Benedict A. Morel’s (1809–1873) concepts of “degeneracy,” which the latter had published in his “Treatise on Physical, Intellectual and Moral Degeneration of the Human Race” (1857/58). Griesinger, however, used the concept of nervous degeneration in a narrower sense, relating it only to a hereditary aetiology of individual diseases of the mind and brain. For many of his followers—such as eminent Munich psychiatrist Emil Kraepelin (1856-1926) in his 1908 lecture “On Degeneration”—degenerative pathologies were associated with correlates in the body. Also in his influential “Textbook of Psychiatry,” Kraepelin relates the conditions of the war-traumatized—among them many with post-traumatic epilepsy—not to external conditions of industrialized warfare, but to the degenerate dispositions which these individuals had since birth that now led them to “severe neurasthenic states,” “fright psychoses,” or “epilepsy.”
Kraepelin’s views––like those of 21 prominent psychiatrists, 31 physicians, and 12 biologists at the German Society for Racial Hygiene in 1916–– shifted the emphasis from the social origins of mental disease towards a purely biological perspective that envisaged modern “collective culture” or the “folk body” as directly altered through the population’s genetic makeup. Kraepelin’s psychiatric colleagues Ernst Ruedin (1874-1952) and Alfred Hoche (1865-1943) later even interpreted the devastating effects of the “Great War” in terms of a negative selection from the germ line.
In the US, similar conceptions of biological degeneracy and inherited mental illness were inscribed into eugenics pamphlets and the “Eugenics Model Law,” which the Eugenics Record Office published in 1914. The Eugenics Model Law tried to segregate the “orphans, ne’er-do-wells...and paupers” as much as the “alcoholics and epileptics” from society. This suggestion became readily taken up in the sterilization laws of 12 US states as a cost-saving way to reform their welfare budgets, which were already under strain from “feeble-minded” persons and the “insane.” While until 1924, nearly 3,000 persons had been forcibly sterilized in the state of California alone, the state of Virginia saw likely the first case of a 17-year-old girl from the Virginia Colony for the Epileptic and the Feebleminded to become sterilized as an epileptic person with the view to diminish the role that “heredity plays … in the transmission of insanity, idiocy, imbecility [and] epilepsy.”
Somatic and Neurosurgical Treatment Forms of Epilepsy
The history of treatments for epilepsy is related to the early phase of brain stimulatory approaches, which reach back to the 1920s and the interwar period. The influential Canadian neurosurgeon, Wilder Penfield (1891-1976), learned his operative neurostimulation technique principally during two research periods with Otfrid Foerster (1873-1941) in the years 1928 and 1931 in Breslau, Lower Silesia (now Wrocław, Poland), which he later summarized in a research report to McGill (1932).
After returning from his European tour, Penfield began to develop a modern neuroscience center, later called the Montreal Neurological Institute modeled on Foerster’s clinic. At the MNI, Penfield and his associates developed a vast and detailed research program on the cortical localization of brain functions, which they investigated by electrically stimulating patients in neurosurgical intraoperative settings. Penfield closely monitored and mapped the movement effects, sensory perceptions, and psychological results in his epileptic patients. This differed from Foerster, since his German mentor had initially used the method of brain stimulation as a treatment option for his patients with post-traumatic epileptic disorders. Epileptic conditions following brain injuries were very common after the First World War, which had brought tens of thousands of patients with head wounds into neurological departments all over Europe and North America. Foerster’s initial therapeutic approach would later be inverted in Penfield’s program, which increasingly emphasized research into the cellular and physiological arrangement of the human cerebral cortex. During this time, Penfield’s patients (similar to those of Manfred Sakel (1900-1957), Bruno Cerletti (1877-1963), or Lucio Bini (1908-1964), who pioneered other somatic treatments in neurology and psychiatry) were not told about the research intentions of the physician before agreeing to receive “surgical treatment.” This internalistic combination of research investigations and ethical considerations did not find its introduction into the doctor-patient-relationship before the 1960s. Instead, ethical deliberations continued to be restricted to the decision-making of the operating surgeon and some preliminary discussion with expert colleagues or hospital staff. Few sources reveal Penfield’s personal ethical views on medicine; in this sense he appears to be no exception to most of the clinical neuroscientists of the first half of the 20th century. Penfield’s approach, nevertheless, focused on the surgical treatment of areas of the brain that were seen as causally relevant to the aetiology of epilepsies and tumours.
The Use of Epileptic Patients in Clinical Neurophysiology Research
What holds for the diagnostic and treatment approaches of epileptic and seizure patients in early neurostimulatory programs also holds for many developments in the neurochemical and public health responses to epilepsy. In many ways, the “modern era” of epilepsy treatment began at the Institute for Brain Research in Leipzig, where, for example, Mihály von Lenhossék (1863-1937) discovered the nerve “growth cone.” This discovery also offered a morphological explanation for the neurophysiological findings of exacerbated electrical activity in the cortex, by drawing attention to the additional axonal sprouting activities after brain injury. Nevertheless, one of the major breakthroughs in epilepsy treatment occurred here, when psychiatrist Siegfried Walter Loewe (1884-1963) tested the drug Luminal in 1916 on his hospital patients at the University of Leipzig. What was intended as a sleeping drug for the mentally ill became one of the first successful pharmacological treatments for epileptic neurological patients. This is especially noteworthy since the neurochemical advances happened at the same time as neurologists interpreted epilepsy as an inherited “neurodegeneration” that was hardly accessible to clinical treatment.” Heinrich Klien (1875-1941) and Carl Schneider (1891-1946) worked in Leipzig on the psychopathology of nervous disorders. With the Nazi Machtergreifung, however, Schneider assumed the directorship of the department of psychiatry at the University of Heidelberg and later became infamously known for his psychiatric expert role in the Nazi euthanasia program. The Nazi government’s T4 program eventually killed more than 70,000 psychiatric patients and asylum inmates in the German Reich, while the Nazi sterilization program forcefully sterilized more than 400,000 individuals––at least one tenth of them had been individuals with epilepsy and seizures. Loewe’s pharmacological breakthrough and the brain stimulation techniques––although spuriously used––where perceived as too costly and as treating the wrong sorts of people, namely people who had a “life not worth living.”
Progress in epilepsy treatment in North America came rather from the traditional neurosurgical direction, as Penfield has pointed out in his autobiography No Man Alone: A Neurosurgeon's Life (1977), since “the electrical stimulation that must be used to guide the neurosurgeon in his removal of the cause would perhaps tell the thoughtful surgeon many secrets about the living, functioning brain…This would help the neurosurgeon to understand the interrelationship of the mind to localized functional mechanism of the brain” (p. 168). In contrast to Penfield’s program, the public resonance to another major neurostimulatory working group around Robert G. Heath (1915-1999) at the Tulane School of Medicine in New Orleans was enormous. It gave rise to a wide public controversy in the United States. Heath began his investigations within a psychiatric context, in which informed consent from the patients was seldom sought; he applied electrical currents in a seventeen year old schizophrenic girl by means of deep brain electrodes to the septum region of the diencephalon as a treatment option for epilepsy. The Tulane researchers also moved their electrodes to other brain regions of interest, such as the thalamus, trying to find out what happened in their patients. In so doing, these clinical researchers sought to derive knowledge from the ad hoc intraoperative experiments, conceived when the skull of their patients lay open in front of them (see human experimentation). Major changes in clinical attitudes toward epilepsy came about mainly due to the new technological advances in medicine rather than the sporadic public media critique. Stimulation methods lost their appeal during the 1970s as neuropharmacological treatments for epilepsy (such as Luminal, Valproic Acid, and Diazepam) became more common. Conversely, the neuropharmacological treatment options also helped to de-stigmatize epileptic and seizure patients, transforming epilepsy into a “treatable” and thus “normal” disease, a process that could build on the anti-psychiatry movement of the 1960s as well as patient activism since the 1980s.
The individual developments presented in this concept entry point to the long and meandering history of “epilepsy” as both a psychological and neurological condition in psychiatry and mental health until the 20th century. The examples provided indicate the ambivalences in the relationship between the therapeutic intentions in the health care system, by psychiatrists and clinical neurologists, and the social and economic conditions to which medical research answered and which it followed since the end of the century before the last. From the days of hospitalizing the mentally ill (and this largely included “the epileptics”) and the creation of somatic therapies and electrostimulation programs between the 1900s and the 1930s, the gap between the physicians’ healing intentions and the harm produced in patients and their relatives was enormous. It is precisely this amalgamation which adds further questions to the problem of distinguishing between the epistemologies that psychiatrists and neurologists brought to their operation theatres, clinics, and test laboratories when pursuing research on patients with epilepsy.
-Frank W. Stahnisch
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