The enigmatic figure of Leon Pierce Clark and his contribution to epilepsy

Abstract

Leon Pierce Clark (1870-1933) was a prominent American neurologist and psychiatrist and an enigmatic figure. He made enduring contributions to status epilepticus and to epilepsy. In the 1910s and 1920s, his chief focus was on the psychological mechanisms of epilepsy and on the personality of those with idiopathic epilepsy which he interpreted from a psychoanalytical perspective. He also described the epileptic voice sign, wrote psychobiographies of among others Abraham Lincoln and Napoleon Bonaparte, and published a book of poetry. He held many important positions in American professional societies and yet was embroiled in controversy.

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Key Points

• A study of the work of a prominent early 20th century neurologist providing an insight into the ideas of the time.

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INTRODUCTION

In the symposium celebrating the achievements of Claude Wasterlain, it seemed appropriate to recall the contributions of one of his interesting American predecessors, also a polymath, and also someone whose work, like that of Claude Wasterlain, created a paradigm shift in the field of status epilepticus. That person is Leon Dennis Pierce Clark (1870-1933). In my view rather overlooked by the passage of history but certainly an unusual and enigmatic figure.

Early life and career

His earlier life is described in the fulsome obituary by a leading American neurologist of his time, Smith Ely Jelliffe,¹ and from which many biographical details below are taken. Pierce Clark was born in the small hamlet of Ingleside, New York State, where today there are only a few houses remaining (along with a letting agency called Shangri-La (sic), a church and a dog grooming service). He was educated at the Naples Academy (now the Naples Junior/Senior High School) and then studied medicine in New York. Graduating at the age of 22 years, he served first in the city hospital on Blackwell's island and then became assistant director and neuropathologist at the Connecticut state hospital in Middletown, an asylum for the insane. There he began to publish papers, including, in 1894, observations on Bevan Lewis’ method of preparing brain tissue² for pathological examination. This demonstrated his careful and detailed neuropathological approach which was to pay dividends in his later papers on status epilepticus. His interest in epilepsy was probably kindled in both institutions, for it was while working in the asylum on Blackwell Island that Manuel González Echeverria had written the first American monograph on epilepsy³ and at Middletown Clark had begun to study Flechsig's method of treating psychotic epileptic patients. Bevan Lewis was pathologist in the British West Riding Lunatic Asylum which, a few years earlier, James Crichton-Browne had transformed into a research Institute, where David Ferrier and John Hughlings Jackson developed their interests in epilepsy. In that period, it was in such mental asylums that much pathological and clinical research into mental disease was carried out, and appointments to the institutions were desirable stepping in the careers of ambitious doctors. So perhaps it was not surprising that Clark then accepted the position, in 1896, of First Assistant Physician at the Craig Colony for Epileptics in Sonyea. In 1901, he and Thomas Prout spent a year in Europe, including a period at the National Hospital Queen Square with Hughlings Jackson and in Vienna with Marburg and no doubt this also deepened his knowledge of epilepsy. In October 1902, he was sufficiently established to open a private office in New York and to become elected as a member of the American Neurological Association in 1906.

The Craig Colony had been established in 1894 through the efforts of the remarkable Oscar Craig and William Prior Letchworth, whose combined efforts for epilepsy changed the context of epilepsy in the USA and who stimulated much of the epilepsy research of the time. William Spratling was appointed superintendent and was Clark's immediate superior, and Craig Colony soon became a center for the academic study of epilepsy. From there, in 1904, Spratling published Epilepsy and its treatment,⁴ which became a standard work on the subject and was the first comprehensive American textbook on epilepsy. It was there too that Clark began his studies of epilepsy in earnest. It was from there that the most enduring of all his work was carried out and published, with Thomas Prout, in the celebrated trio of papers, Status epilepticus: a clinical and pathological study in epilepsy, in 1903.⁵

Status epilepticus

Status epilepticus: a clinical and pathological study in epilepsy⁵ is a brilliant analysis of the historical development, clinical features, pathology, treatment, and prognosis of status epilepticus. These papers are a landmark in the history of status epilepticus and were fully appreciated at the time, winning the prestigious 1903 Stevens Triennial Prize for Original Research awarded by Columbia University.

The only comparable earlier work on status epilepticus was that of Bourneville fifty years earlier and of Lorenz in 1890. Clark and Prout broke new ground. Status epilepticus was a feared condition, and as Clark and Prout put it: “The appalling sight of the brutal expenditure of muscular energy in the status is not more vivid than the physician's feelings of helplessness in attempting medical aid” which in “superstitious times… was regarded as a climax of hurricane fury of demoniacal possession.” It was Clark, one suspects, who provided much of the clinical and historical data in these papers, as well as the alliterative and lively style of writing. They attributed the expression “état de mal” to Bouchet and Cazauvieilh in 1825 (although in fact Calmeil had used the term in his doctoral thesis of 1824).⁶ Clark and Prout considered that by the time of their own studies, about 300 cases of status epilepticus had been described in the medical literature, and the condition was considered “a rarity.” They cite Gowers’ view that the condition was only seen in asylums, although this is not exactly what Gowers wrote (which was that severe status was very rare, at any rate out of asylums for the insane),⁷ and who in his second edition published in 1901 considered that the condition was often brought on by the sudden withdrawal of bromides.⁸ They defined status epilepticus, much as Gowers and Bourneville had done as “the maximum development of epilepsy, in which one paroxysm follows another so closely that the coma and exhaustion are continuous between seizures” and this definition remained essentially unchanged for the rest of the century. Bourneville had already noted that an episode of convulsive status epilepticus was often a staged phenomenon (another concept still held), with a convulsive stage evolving into a nonconvulsive form which he called the meningitic state.^9,10 Bourneville had also recognized a prodromal state (calling this état de mal de passage) in which serial seizures of increasing frequency preceded the status—as “stepping stones.” Clark and Prout confirmed these findings and also emphasized the staged nature of convulsive status epilepticus, and also described in detail the neurological and autonomic effects, focusing, as Bourneville did, on the temperature (the fever curve) respiration and pulse rates. Claude Wasterlain, over a century later, acknowledged and confirmed Clark's concept, beginning their influential review with the words “As in Clark and Prout's classic work, we identify three phases of generalized convulsive status epilepticus”.¹¹ Clark and Prout also broke new ground with the recognition that “as with epilepsy proper, there are many varieties and equivalents,” describing various nonconvulsive forms of status taking the form of delirium, stupor or coma, or a variety of psychic states and that, in contrast to convulsive status, the temperature might not be elevated. They described a personal case who had 769 psychic or absence seizures in 12 h and then over a few days 500 psychic seizures, with a subnormal temperature—it was “a most unexplainable and interesting freak in the psychic phenomena of epilepsy.” Their papers go on to provide detailed descriptions of status epilepticus in its various forms, emphasizing that one might merge into another. As for its frequency, they stated that status epilepticus was a common cause of death among epileptics in the asylum, and in dramatic fin-de-siècle mood was the “true climax of the disease and less a chance termination which by proper treatment could be avoided; certainly, chance plays no part as agent in the production of the status.” Of interest and originality also is their detailed discussion of prognosis. “An epileptic is foredoomed to die of the status as the maximum development of the disease.” In idiopathic epilepsy, “each seizure increases and accentuates the abnormality, setting in train a series of degenerative changes whose logical termination is the last episode of fatal status epilepticus”—the reiteration of Gowers’ aphorism, repeated by Turner in 1907, that “s eizures beget seizures”¹² and again emphasized a century later by Wasterlain.

The pathological changes in status were the topic of their third paper. This is a most detailed description. They came to the conclusion that epilepsy was primarily a sensory reflex phenomenon at the level of the cerebral cortex. They dismissed hippocampal sclerosis as the essential lesion or epilepsy or cerebral anemia as the cause of convulsions and provide a critical account of the various pathological changes found in epilepsy, including vacuolation, minor anomalies of the cortex, and gliosis and “neuroglial hyperplasia.” They found striking changes in the nucleus and nucleoli of the cortical cells, gross chromatolysis, vacuolation, destruction of pyramidal cells particularly in the third cortical layer, infiltration of the cortex by leucocytes, and proliferation of the neuroglia. Most of these changes are now fully accepted. They reviewed microscopic changes, including Ammon's horn sclerosis, and attributed the damage largely to diseased sensory cells (as suggested by Bevan Lewis, whose work they did not cite).

In his description of the celebrated case of Marie Lamb in 1874, Bourneville had described his recommended treatments—the use of poultices, purgative enema, and quinine sulfate to no effect.¹⁰ Amyl nitrate was introduced into usage in 1876, and Gowers in 1881 recommended bromides and morphia. Clark and Prout adopted what seems a most sensible and effective approach to treatment based on the stages of status, a regime with echoes of that used today: a rapid increase in the dose of bromide in the premonitory stage, with opium and chloral supplementation and then inhalation of chloroform in the convulsive phase, and then switching to complete anesthesia in severe cases.

Chloral and the intrathecal administration of bromide could also be tried at this stage along with numerous other remedies including cold baths and venesection. In the stuporous stage, their approach shifted and stimulants were needed, including treatment with strychnine, digitalis, and whiskey. Abundance of nutritious food and very careful nursing were considered essential.

Clark wrote the chapter on status epilepticus in Spratling's 1904 book¹³ (and he and Prout, the chapter on the pathology of epilepsy), and it was clear that by then he was considered an authority on status epilepticus, but perhaps surprisingly after this seemed to have paid little attention to the condition.

Psychoanalysis

Clark’s next intellectual adventure was into psychoanalysis. He was not alone, and several of the most influential American neurologists and psychiatrists of the period were also strongly attracted to psychoanalytical theories of brain function including Ely Jelliffe who was greatly influenced by Clark and whose Disease of the Nervous System: a textbook of neurology and psychiatry¹⁴ was the standard textbook of neurology of the period, and in which he categorized epilepsy as a disorder of “psychic or symbolic systems.” In Clark's early writings, there is little evidence of an interest in psychoanalysis, but in the 1910s and 1920s he wrote extensively on this topic (see for instance refs^15-27). His book Clinical Studies of Epilepsy²² demonstrates how his thought had evolved over the decade since his work on status epilepticus. The book was, as he wrote: “a study of essential epilepsy by the case-method… to show that this disorder is a logical sequence of a certain type of individual makeup 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 instincts, plus the precipitating causes which act as psychic irritants.” To Clark there were two fundamental principles about the nature and pathogenesis of idiopathic (“essential”) epilepsy.

“First, that there is invariably present an epileptic constitution or makeup in those individuals who later developed essential epilepsy.” At its core, was extreme hypersensitiveness and egotism, personality defects which render the individual incapable of social adaptation and “entirely inadequate to make a normal adult life.” In addition and related to hypersensitivity and egotism, Clark found those with essential epilepsy to demonstrate lability of mood, lethargy, maladjustment, be prone to rage and lack of good-fellowship, were aloof, and emotionally and sexually under-developed. In his view, the epilepsy could be considered “in the nature of a life-reaction, comparable to a state of rage or anger seen in bad-tempered individuals or excessive emotionalism in the supersensitive.” To Clark, the clinical phenomena of essential epilepsy were “a direct outcome of the inability of such persons to subordinate their individualistic tendencies to those of the so-called social demands and constituted a reaction away from the difficulties in a loss of consciousness.”

Second, “the inability to inhibit egotistical trends in the face of social demands results in an evasion of the difficulties by a loss of consciousness—the epileptic fit.” He conceived the seizure to be a mechanism which “dispels an intolerable demand” and is a “psychobiological” phenomenon which acts as a refuge from an intolerable adjustment demand and also constitutes a regression to a pleasurable primitive state, “a retreat into a state where harmony and peace were wont to prevail,” a state of fetal life in which there is perfect peace as existed in the mother's womb, a state of metroerotism, as he termed it. In his view, a seizure was essentially a pathological functioning of the unconscious… It is a state due to mental infantilism caused by or co-incident with a libidinous fixation on the earlier stages of “psychosexual development.” In the unconscious state, the patient gains the infantile “level of easily recognized sexual striving.”

A detailed supportive assessment of Clark's views on epilepsy was published by Stanford Read²⁸ who considered “The great majority of our neurologists have been so trained to look upon the diseases which fall within their purview in the light only of neuronic malfunctioning, that they look askance at hypotheses which have a more or less purely psychological basis. Nevertheless, Clark's work is materially confirmed by much that has been discovered by research into other nervous and mental reactions of an abnormal type. Few, therefore, who are not blinded by tradition and unconscious bias, will refuse to recognize the great value of these pathological ideas and the therapeutic possibilities they open up before us.”

Clark’s views were widely cited and highly regarded in both the neurological and psychiatric arenas. Many other psychoanalysts took a similar view to Clark about the personality structure of “epileptics” which is a necessary precondition for developing essential epilepsy. This included features of perverse sexuality—and as Ernest Jones wrote “There is no kind of perversion that may not commonly be met within epilepsy.” In this latter respect, the sexual activities resemble those of normal young children.²⁹ Freud's close associate, and a leading analyst of his day, Sandor Ferenczi too viewed the epileptic: “as a special human type, characterized by the piling up of unpleasure and by the infantile manner of its periodic motor discharge… They take refuge in a completely self-contained and self-sufficient way of life as it was lived in the womb, that is to say, before the painful cleavage between the self and the outer world took place.”³⁰

It is notable that Clark melded the organic and the psychological in a thoroughly modern way. He emphasized that epilepsy was a physiochemical phenomenon at one level, but that the physical changes were linked to, and dependent on, the abnormal psychological development: “chemical, physiologic, and pathologic defects are only a small part of the whole organism… and are secondary in point of importance to the fundamental defect of the epileptic character and the model reaction of this makeup. From our viewpoint, it is as absurd to look for an exact anatomic seat for the causative cortical lesion or lesions in essential epilepsy as it is for that of consciousness, or mind itself…. The epileptic makeup is a defect in the integrative activity of the organism.”²¹

The epileptic voice sign

Another strange contribution by Clark to the field of epilepsy was his work on the “epileptic voice sign” (he called this the “Clark Sign” in one of his case histories in Studies in Epilepsy). This was an entity which first saw the light of day in a paper presented, and an abstract published, in 1908.³¹ He had rigged up an apparatus connecting a mouthpiece and recorder to a rapidly revolving smoked drum and recorded visual traces of the voice of patients. He claimed that those with essential epilepsy spoke with a characteristic pattern of sound, in a voice which proceeds by even steps of “plateau speech” and with a tendency to monotony. The more severe the epilepsy, and the longer the duration, the more abnormal was the voice. He considered these abnormalities were a sign of the brain degeneration which was then universally thought to accompany idiopathic epilepsy. He considered that abnormalities of voice occurred in all idiopathic cases and could be detected by the ear once attuned, and thus was of diagnostic and prognostic value. He also thought there were abnormalities in singing, with melody and harmony affected, tone not well sustained and phrasing incoordinate.

Other professional contributions and honorary work

Whatever one might think today of his psychoanalytical theories and his voice sign, it does seem likely that Clark was highly regarded by his peers in both the psychiatric and neurological establishments of East Coast America. He was elected to the presidencies of the New York Neurological Society (1911-1912), the New York Psychiatric Society (1916), the National Association for the Study of Epilepsy (1919), and American Psychopathological Association (1923). He also served as a trustee of the Letchworth Village and was a founding editor of the quarterly Archives of Psychoanalysis. How his enthusiasm for psychoanalysis went down with the more straight-laced in the neurological fraternity is not recorded, but there is no doubt that he irritated and gained enemies among some. He lived through the eugenic era of neurology and psychiatry, at a time when many of his peers were enthusiastic eugenicists engaged in the involuntary sterilization and segregation of their unfortunate patients; but Clark seems not to have been taken much interest in this and for that he must be congratulated. At the time of his premature death from myocardial infarction, it is said that he was planning a textbook on epilepsy.

Psychobiography and poetry

Clark was not only a prolific medical author, but he also wrote for a more general audience, and was noted in particular for his “psychobiographies.” These were biographies of famous individuals viewed from a psychoanalytical perspective; and among his victims were Alexander the Great, Fyodor Dostoevsky, Napoleon Bonaparte, Abraham Lincoln, Michelangelo Buonarroti, and the Pharaoh Akhenaten. A common theme was how they suffered from such psychopathology as narcism (his own term for narcissism and defined as an uncontrolled love for one's idealized self; and possibly a word he invented for I have not been able to find an earlier usage), regression and the Oedipus complex. A similar concept was recently introduced by the doctor-politician David Owen with his idea of the “hubris syndrome.”^32,33

Clark’s biography of Lincoln,³⁴ for instance, revolved around the idea that Lincoln had an “infantile memory-image of his mother” which was “a slender thread [which] winds in and out of his whole existence… it shapes the ideals, the plan, the purpose, of Lincoln's life”… As a mirage in the desert, a phantom from the fields of Elysium, she will lead his footsteps onward’. He considered the tendency deeply repressed and yet dictated all his actions. The New York Times review of this book opened with the thought that “Admirers of Lincoln might have hoped to have been spared a Freudian biography” but then went on to praise Clark's work which the reviewer considered to be an original and apposite approach to Lincoln's life and work which moved “us to pity as well as to reverence… in singularly beautiful language.”³⁵

It was his biography of Napoleon³⁶ though which seems to have generated most contention. Clark suggested that Napoleon had a morbid excess of narcism, which was in Clark's view the reason for Napoleon's “overweening disease for omnipotence.” Clark saw Napoleon's life decisions as an effort to overcome the unpleasantness of reality in order to repossess his fetal state of perfection and omnipotence with his beloved mother. He postulates that Napoleon had epilepsy, a widely held view,³⁷ and although his grand mal seizures were infrequent that he was also prone to partial seizures which resulted in “lethargie—transitory befogged epileptic reactions so common in ordinary epilepsy.” It was these epileptic lethargies that caused the disasters in Egypt, various known events in his life, and his dithering and failures at the battles of Jena, Leipzig, Borodino, and Waterloo. Seeing epilepsy as a causal factor in many major events of the 20th century, Clark entitled his chapter on Austerlitz, the battle Napoleon liked to name the “Battle of three Emperors,” as “the battle of the three epileptics” noting that “not only did Napoleon suffer from epilepsy” but that the “Russian Emperor Paul was an epileptic dement…while the Archduke Charles was also known to suffer from epileptic fits”. Clark's entry on Wikipedia claims that his reputation suffered at the end of his life by accusations of plagiarism over this book on Napoleon. I cannot find any documentation of this except in a bizarre and excoriating anonymous review in the Journal of Mental and Nervous Disease.³⁸ The reviewer snidely noted that Clark's “historical scholarship” was quite inconsistent with his previous work and that there was no acknowledgment to the Napoleon scholars Professors James Harvey Robinson, nor Harry Elmer Barnes, nor Rudolf Riefstahl and Herbert R Cross, nor Century or Braun Companies publishers. In fact, in the edition of the book that I own (with no indication that this is not the first or a reprinting) there are fulsome acknowledgments to all these persons and the two publishers, and furthermore James Harvey Robinson contributed a foreword to the book. Nowhere can I find evidence of what work was said to have been plagiarized. The second, and contrasting, criticism of the book was that his psychoanalytical analysis was naïve and banal. To me, this criticism has more force, and Clark's psychoanalytical views do seem superficial. The reviewer wrote “Narcism… occurs and recurs and then like a Bach fugue of one refrain is reiterated an explanation of almost everything, but nowhere do we find any appreciation of what psychoanalysis means by narcism” and the reviewer sarcastically concluded that “Perhaps because of the historical heights, we failed to find the depths of psychoanalytic profundity” and that “‘Narcissists don't like to have their mistakes pointed out’ we suspect is as near to the ‘deep psychology’ as this book ever gets.”

How much controversy there was, and who else weighed in is not clear. Certainly, the world of academic neurology was then (as now) notoriously venomous, a snake pit in which the advice not to “turn your back on an academic neurologist” should be heeded well. In Jellife's laudatory obituary, there is no mention of any such controversy and he concluded, perhaps with some exaggeration, that “Nowhere in medical literature is there to be found more intense application to the study of the epilepsies than can be found in Dr Clark's work”.

Much less contentious, but arguably more banal, were Clark's attempts at poetry. He published a book of 154 poems entitled “Warp and Woof” in 1915.³⁹ Several feature epilepsy, and one is entitled “The Status” which perhaps well captures his poetic style:“I know not why God burdens so! Convulsed with painAnd bathed in stup'rous death Contending hells possess my prostate formMy muscles knot The blood stands still The breath not less than spiritFilled with woe I live, I dieAnd nights enslave my soul Ah, God, why burden so!Yet slay entire And rend the body quite,But let my spirit go! The awful pain, the black night-tide,Unconsciousness – I hope not gift from heaven nor hell, I only ask for rest, but some great boulder rock,Unmoved, Forgotten if thou wilt!”

CONCLUSION

So what can we make of Dr Clark? He is, to me, an enigma, mixing sense and nonsense in equal proportions. The only photograph I can find of him is in his aforementioned obituary and reveals a rather chubby person, with the air of a respectable bank manager rather than a renegade psycho-neurologist. Balding and serious looking, he seems the epitome of the middle-class establishment. Yet, he was in the thick of the battles between neurologists and psychiatrists, which raged not least over psychoanalysis, and despite this he seems to have been respected in both communities. He had a thriving practice and died prematurely of a heart attack in the midst of his consultations. His contribution to status epilepticus was very much in the mainstream of academic and scientific neurology and has stood the test of time. Yet, much of his subsequent work seems to us now peculiar or even to be arrant nonsense. Of course, the context of our times is different, and as many highly intelligent people were convinced by his psychoanalytical views, we must be careful before rejecting these. Clark was a prodigious author, as well as a busy clinician, and yet intriguingly details of his life are scant. Most of what is included here has been based on secondary sources. If his personal papers still exist, they might fill in the gaps. Certainly, more deserves to be discovered. Jelliffe concluded his obituary with the words: “Ideas flowed from his ready mind in rich profusion. He was a loyal friend, worked unremittingly in spite of the many severe blows dealt him by life's changes, but he never swerved from his interest in humanity in his medical work.” What were these “severe blows”? The death of his wife and premature death of his son may be what was being referred to, or was it the contention over his psychoanalytical theories or battles over plagiarism. Clark remains an enigmatic figure whose contending hells, as time has passed, may never be fully known.

ACKNOWLEDGMENTS

The ideas and some text of this paper are partly taken from the Idea of Epilepsy,⁴⁰ Psychoanalytical concepts of epilepsy,⁴¹ and Status Epilepticus⁶ by the same author. This is an expanded version of a paper given at the Festschrift for Claude Wasterlain on July 31, 2021, and I extend my grateful thanks to the organizers of this occasion for the opportunity to present this paper. I also would like to thank Claude Wasterlain for his outstanding work on status epilepticus which has so advanced the field—and without recourse to doggerel or psycho-babble.

CONFLICT OF INTEREST

I have no conflicts of interest to disclose.

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