Wood-Martin: Pagan Ireland.
THE PSYCHOANALYTIC TREATMENT Of HYSTERO-EPILEPSY
BY L. E. EMERSON, PH. D.
Psychologist, Massachusetts General Hospital; Examiner in Psychotherapy, Psychopathic Hospital, Boston, Massachusetts; Assistant in Neurology, Graduate School of Medicine, Harvard University.
WHEN a new method of working in any field of endeavor is devised, or a new point of view is discovered, it is natural to turn to other similar fields to see if the method will work there. This is what is done when one approaches the study of Epilepsy from the point of view of psychoanalysis.
It is not my purpose to undertake an exhaustive psychoanalytic study of Epilepsy. Neither is it my purpose to enter into a discussion of the problems of differential diagnosis. It has already been shown, in borderland cases, that one cannot tell the difference between epilepsy and hysteria, without a prolonged psychoanalysis, and even then one cannot be certain. This suggests that the whole thing is more or less a matter of definition. Into such questions I cannot enter. My aim is much more modest. The immediate purpose of my paper is to study some of the problems of therapy, from the psychoanalytic point of view, of that small class of patients on the borderline between hysteria and epilepsy, or patients with epileptiform attacks.
The first publication of studies of this general nature was made by Dr. James J. Putnam and Dr. George A. Waterman in the Boston Medical and Surgical Journal for May, 1905, under the title "Certain Aspects of the differential Diagnosis between Epilepsy and Hysteria." In this paper the authors say, "No one, so far as we are aware, has as yet studied with sufficient thoroughness the subconscious memories of epileptics, and for all we now can say, closer resemblances may be found between these and the subconscious states of the hysterics than we now imagine." p. 513.
In this paper, however, therapy is only hinted at.
A contribution to our insight as to the epileptic state of mind is made by Jung, under the title, "Analyse der Assoziationen eines Epileptikers," in his, "Diagnostische Assoziationsstudien. Beitrage zur experimentellen Psychopathologie." p. 175 (1906).
He found an extraordinary number of emotionally toned, egocentric relations. There were some signs to suggest that the emotional tone in the epileptic was unusually lasting.
The first thing published on epilepsy avowedly from the psychoanalytic view-point was by Maeder: "Sexualitat und Epilepsy." Jahrbuch BI HI, 1909.
Maeder goes into the subject rather exhaustively, after characteristic German fashion, but his conclusions are comparatively simple. He says, "The sexuality of the epileptic is characterized by the prominence of auto- and allo-erotism. It retains much of the infantile form, but has undergone, nevertheless, a certain development, which I designate as 'sexual polyvalence.' For some unknown reason the libido seems to have an abnormal intensity." p. 154.
This is an important contribution to our knowledge of the psychic state of epileptics but it is notable that not a word is said as to therapy.
Sadger published the same year, "Ein Fall von Pseudoepilepsia hysterica psychoanalytisch erklart." (Wiener klein. Rundschau, p. 212, 1909.) But neither does he have anything to say about therapy.
Dr. Wilhelm Stekel, however, treats the problem from the therapeutic point of view in, "Die psychische Behandlung der Epilepsie." (Zentralblatt fur psychoanalyse p. 220 No. 5-6, Vol. 1).
The essential kernel of Stekel's view is that the epileptic is a repressed criminal. The convulsion is a substitute for the criminal act. He announces categorically that pseudoepilepsy is curable by psychoanalytic procedures. Of three cases which he completely analysed, two were cured. His final conclusion is fourfold: (1) Epilepsy, more often than we have hitherto thought, is of psychogenic origin. (2) In all cases there is a strong tendency to criminality which is unbearable to consciousness. (3) The attack is a substitute for an offense, hence, eventually a sexual offense. (4) Pseudo-epilepsy is curable by psychoanalysis.
Spratling calls attention "to the value of an occasional convulsion in certain cases. In some patients the fit acts as a safety valve that unquestionably permits escape from insanity... In many cases the convulsion seems t o come as the termination of an obscure (auto-toxic) cycle which varies in duration in different individuals and bears some relationship to the ascending period of the folie circulaire of the French. It seems that the specific cause of the fit in these cases is something that permeates the entire organism; something that comes and goes; that grows rapidly in intensity, exerting a pernicious influence on the patient by making him act out of harmony with his normal state, until the limit is reached and the mind loses its direction and control. The power of inhibition being finally destroyed, the nervous storm breaks with great force and violence." p. 361.
Although Spratling had in mind a toxic agent, one cannot but be struck with how completely his terms describe an emotional outburst.
In a paper read in Boston last winter, Dr. L. Pierce Clark advanced the view that the epilpetic seizure was the symbolical expression of the desire of the patient to return to the mutterleib. The convulsive moments were such reflect and random acts as one sees in infants or infers in the embryo. Regard for social sanctions is lost. This, of course, suggests the first step in criminality. Clark found that favorable cases were amenable to psychic treatment and said that some cases had been very much helped by psychoanalysis. I am not certain whether he claims to have cured any particular case of pseudo-epilepsy or epileptiform attacks, by psychoanalysis. In presenting some of my own cases let me begin with one that certainly was not a complete success, but nevertheless was much helped by psychoanalysis.
This case is that of a young girl, aged 14, without known inherited tendency. Her first attacks had occurred about a year previous in the form of fainting spells. These were afterwards followed by convulsions. In convulsions the patient thrashed about, kicking her legs and clawing at her chest. These convulsive movements stopped after a while and were followed by a deep sleep, after which the patient awoke without any memory of what had happened.
It was found that during the convulsion the patient imagined she was being pursued by a black-faced figure with claw-like hands, of a peculiar shape like her father's.
Further investigation showed that her father got drunk and did chase her, sometimes kicking her out of the house. She would undress her father sometimes and put him to bed. Once when taking off his shoes he kicked her, as she was bending over him, in the lower part of the abdomen. This was just before the convulsions developed. The fainting spells occurred soon after she had first seen her father naked. The image of his nakedness so distressed her by continually coming before her mind that she made the most desperate efforts to repress it, finally partially succeeding. Speaking of her father she said, "Every time I think of him I feel like taking a fit. Oh! It makes me feel terrible."
Her father had kicked her in the chest, too, which perhaps partially accounts for the clawing.
In the light of this knowledge the convulsive movements become a little more comprehensible. They are futile attempts to run away. They are the partial movements of flight.
The cries that sometimes initiated and accompanied the convulsions at first, afterwards became sufficiently articulate to be understood as calls "Mama, Mama, Mama."
It was found that when her father would chase her about the house, in drunken fury, she would call for her mother in frantic fear. Here, apparently, is a meaning of the call preceding the convulsions.
Under a very short psychoanalytic treatment the patient showed marked improvement. Her attacks became much less violent and much farther apart. She became able to control them to a great extent. Finally she became so well that one might say she had practically recovered.
Apparently there is no hint here of a repressed criminal complex. But a little deeper analysis suggests it, however. The first attack, which was in the form of a faint, occurred under the following circumstances. The patient was at the funeral of the father of her best girl friend. As she looked at the dead body of her friend's father the thought flashed through her mind, "He was so good, and now he is dead, while my father who is so bad, still lives. I wish he were dead." Shortly after she fainted.
There were a number of reasons, seemingly adequate, for incomplete success in this case. In the first place, the patient had been in this country only a few years and spoke very broken English. She is a Russian Jew. Obviously this was a very great barrier to understanding. In the next place it was almost impossible to change conditions of home, although Social Service worked wonders in this case. The father continued to get drunk, and one of the last of her now infrequent attacks occurred on his return from jail. The patient was dreadfully afraid lest her father find out that the knowledge of his delinquency had been discovered through her.
Not the least of the reasons militating against complete success was the short time possible for psychoanalytic treatment. The patient was seen only three weeks. As the time needed for a psychoanalysis is variable depending on the particular patient, it is clear that this would be too short a time to enable a young girl, only recently here from Russia, to understand, or to overcome resistances. That the treatment was as nearly successful as it was is perhaps encouraging to the hope that suitable cases under favorable conditions might be cured.
The next case is one where the diagnosis lay between hysteria and epilepsy. The symptoms were as follows: The patient had attacks in which she became unconscious, gasped, and spittle ran from her mouth. She also bit her tongue. She becomes stiff, eyes stark, and is left tired and weak. These attacks were first noticed about five years ago. Since then she has had about five similar attacks, the last three coming within five months. The last two were within a day of each other and frightened her so she came to the hospital. At the age of eight or nine she said that she had flashes of speechlessness, and a thought which she cannot define, as of a horse or a man. She never became unconscious or bit her tongue. After her first catamenial these flashes of speechlessness and thought came only at this time. At the age of two the patient said that she had fallen down stairs and hit her head. She said she was unconscious twenty-four hours.
As a result of a psychoanalysis the following facts were learned. The patient was a very sensitive child, exceedingly responsive to her environment. She was also stubborn and self-willed, at times. She was reserved and capable of great repression. When she was about three or four she remembers seeing in the Bible a picture of the Devil on a white horse. This used to make her shudder, but it also had a sort of irresistible fascination. Later, when she was seven or eight, it would come into her mind in school even and make her feel so badly she would lay her head on her arms. But she never told anybody what it was that troubled her and she would put it out of her mind. She thoroughly believed her mother when she told her that the Devil would come and get her if she did wrong.
At about the age of ten or eleven she began going with a girl much older than herself. She used to visit this girl and spend the night with her, and in turn have her at her own home. In this way they spent the night together quite frequently. Soon the girl wanted to masturbate her and although she repelled her advances at first she finally allowed it because she was told she would be regarded as queer if she didn't as other girls did it and liked it. She, however, never did get any pleasure out of the practice, and remained perfectly passive. She thought if her friend enjoyed it and it didn't hurt her she should let her have her pleasure. She never told of this.
The patient now began having what she called staring spells. These never lasted more than a second or so and they were never observed. She carefully concealed them. Just before the patient began to menstruate which was when she was about fourteen, she noticed that the day after she had been with the girl who masturbated her she had a terrific headache. Then she remembered that for a long time it had been so though she had never connected the headaches before with the masturbation. She stopped the practice immediately and never allowed it to be resumed.
After menstruation began the staring spells became grouped and came only during her periods. But they were more numerous. She would have a number in one day. They were not yet sufficiently observable to be noticed. At about this time she had a terrible fright. She was kneeling at her mother's side listening to a story when she thought she saw a woman's face looking at her over her mother's shoulder. She was speechless with terror. This was not noticed and she did not tell. Around this time too she had another fright. She was studying one evening at the dining-room table when she saw a face looking in at the window. She screamed, and kept on screaming, but finally was able to tell that she had seen someone looking in at the window. Her father took her out and showed that it couldn't be so because there were no tracks in the snow which was on the ground. She wouldn't or couldn't stop crying, however, and kept it up all night, she said. Just before menstruation she did some sleep-walking. She got up one night and went to her mother and said she had something to tell her. Her mother tried to get her to say what it was but could not, and saw that her daughter was asleep. She kept saying, "you know what it is." The mother did not dare to waken her and finally got her quietly back into bed. The next morning she remembered nothing of what had happened.
When the patient was about sixteen she married. Her husband did not want any children and practiced coitus interruptus, but she became pregnant nevertheless and had an abortion performed. Although c.i. continued to be practiced she became pregnant again and this time she had a daughter. Four more years of c. i. followed. During all this time the patient had the staring spells, but they were never noticed and she never told, not even her mother. Then, like a thunder bolt out of a clear sky, came a tragedy.
She was pregnant again, and visiting her mother, expecting her husband for over Sunday, when she received a letter saying he had left her and had gone off with another woman. When she read the letter she lost consciousness.
Then followed a terrible time. In hate of her husband and on account of fear lest she be unable to care for her baby she had another abortion performed. This time she nearly died through not having proper medical attendance afterwards, but she finally recovered and lived a life of feverish activity and hate.
During her marriage she had been entirely frigid with respect to the sexual act. A friend told her she had been missing an essential experience of marriage. About a year after her husband left her she met a man who thrilled her through and through, and thought, "this is what my friend meant." This man showed her some attention and she set out consciously to seduce him. She soon succeeded and though he was wildly in love with her and wanted to marry her, she steadfastly refused on the score of not loving him, but was his mistress for two or three years. During this time her staring spells seem to have been at a minimum, but I cannot assert that they disappeared.
Then she met the man who became her second husband. She had refused to marry her lover because she did not "love" him. She now dropped him completely, and getting a divorce from her husband on the ground of desertion, married.
She was happy about a year and a half when her husband moved to a country cross-road near a "hotel" (bar-room). Here he began drinking badly, and consorting with prostitutes. For three years she fought her husband off, in fear of infection. During this time she had no intercourse. At this time began the attacks of unconsciousness. She was alone one night, while her husband was off carousing, when she had a terrible fright on seeing a man trying to get in at the window. This was probably hallucinatory as nothing came of it. But from this time forth she was subject to attacks, in which she lost consciousness, had convulsions, frothed at the mouth, and bit her tongue badly.
At the end of about three years, however, her patience broke, and she told her husband that if he did not stop she should leave him. This threat brought him to his senses apparently, and he completely reformed. But her love for him was dead. And though she now permitted marital relations to be resumed, she remained from this time on absolutely frigid. Her husband too, now suffered from premature ejaculation. Thus from the point of view both of "passion" and of "love" the patient was not satisfied. Her attacks increased in number and violence, coming now at any time, not being confined to the menstrual period as at first, and coming days as well as nights.
In this patient we have represented the points of view both of Stekel and of Clark. The patient showed conclusively her capacity for criminal action. She also illustrates the craving for a return to the mother. The morning of the day on which she had the first attack in which she bit her tongue, she passed through the town where her mother was living and thought, "Oh, if I could only go to my mother." But remembering she had promised her lawyer to live a year with her husband, she went on. Of the sexual character of her conflicts no further comment is necessary.
Here then we have the natural history of what? Hysteria? or Epilepsy? This question I shall not attempt to answer. But what has been the therapeutic result of psychoanalysis? This question I can answer.
In the six months during which the analysis has been in progress the patient has had no attacks in which she has had convulsions, frothed at the mouth, or bitten her tongue. She has had only three spells in which consciousness was lost and these were mild. The last one was described by the daughter. She said it was like a faint; that her mother was in it only a short time; that she had none of the symptoms she used to have; and was all right soon afterwards with no bad after-effects. She added that since her mother had been coming to the hospital she had improved so much they never thought of her now as being sick. The bad feelings have diminished so much in number and intensity as to be almost negligible. Family relations have so improved husband and wife are practically at one in their purposes. Social relations have also improved to such an extent that the patient has been able to prevent the wreck of the home of a friend, and in her church is an active worker on a number of committees. She is now doing her best to get her daughter started right in life. The patient regards herself as having practically recovered.
The next case I wish to present for your consideration is that of a young man twenty-six years old. He was brought into the accident-room of the hospital one night last Summer suffering from convulsions. He continued to have convulsions throughout the night, and as many as five interns were required to hold him quiet. These convulsions seemed to have enough purpose in them to warrant the diagnosis of hysteria, so the next morning he was referred to me.
"Last Wednesday night," he said, "I was having dinner with a customer at the Hotel Thorndike. I began to feel sick and went to the toilet and vomited. Then I went back and got my friend and started for a drug store in Park Square to get some quinine. But before I got very far I began to shiver and shake and I knew that it took quinine two or three hours to work so I started back to the hotel to get a room. No rooms were to be had, so I said 'get a taxi and take me to the hospital.' I lost the use of my legs on the steps and they had to carry me. In this attack I was more or less conscious all through it." What were you thinking of in the taxi, I asked. "I don't know. I felt as if I wanted to jump at something and grab something." Can you not remember what was in your mind, I continued. "Only what I've told you," he answered. Will you lie down and close your eyes and imagine yourself back in the taxi, I asked. Now tell me what you see. After a moment he said, "I see flames." What else do you see? "Nothing, only flames. I feel as if I wanted to jump into the fire." Did you see flames in the taxi, I asked. "Yes, that was what I wanted to jump at." At this moment the patient gave a start. What did you see then, I asked. "There is something in the flames, an object, I don't know what it is. It might be a thing or a person. I feel as if I wanted to grab the object." At this instant the patient gave a violent jump into the air and then sank back relaxed. What did you see, I asked. "This object. It seemed to be attracting me." Can't you tell what it is, I said. "No. But it seems almost like a person. It seems as if I could see an arm." What else do you see? "The arms seem beckoning me." It is a person then? Is it a man or a woman? "I don't know. I can't make out." Look. "It is a woman. I can see now." Is it anybody you know? "No, I can't see any face." What do you see? "Just a woman, standing in the flames, with outstretched arms, as if imploring me to come. I feel a yearning, as if I must jump and grab her." The patient stiffened slightly and gave a sort of spring up from the couch and then sank back, breathing a little heavier. What did you see, I asked. "I thought she beckoned me to come." Can you see who it is now? "No The face is blank." Look again and see if you can't tell who it is. What do you see? "I can't tell. I see several faces come and go." Do you recognize them? "Yes. The first is my little girl's; then I see a former sweetheart of mine; then I see my wife's face."
Gradually the following story was elicited from the patient. His mother died when he was seven and his father married again in less than a year. The former sweetheart was his step-mother's half-sister who came to live at their house because the schools were better. He became infatuated with this girl and his step-mother did everything she could to encourage his feeling as she thought it would be a good match. The vision of his sweetheart in the flames was based on an actual occurrence. She was sitting in front of a fireplace once when a log of burning wood fell out and he jumped to pull her away and held her close in his arms for a moment.
Finally, however, he broke off absolutely all relations with the girl. The reason seems quite adequate. Why didn't you marry, I asked. He answered, "we quarrelled and I left her. I didn't like her morals. She went with other men and had connection with them. I saw her go into the woods one night with another fellow, and once at Salisbury Beach I saw her go into a hotel with a man and register as his wife."
About a year after this the patient began going with another girl more in an attempt to crowd the image of his former first love out of his mind than because he had fallen in love again. A year later they married. From the first his married life was not entirely happy. More or less unconsciously he began to regret lost opportunities. He was a travelling man and soon after marriage his route was enlarged necessitating his being away from home a month at a time. On these trips he used to get exceedingly lonesome especially as he steadily refused going with other travelling men and making a night of it as they often did. One of his routes took him to Virginia and he said that he had returned from New York on the way there just for the sake of spending a night with his wife. Once, in New York, he was unfaithful to his wife and on that occasion contracted gonorrhea. This, however, was the only time he has ever had extra-marital sexual relations, he said.
Just before his attacks began, which was about four years ago, he was told by his wife's doctor that it would be impossible for her to have any more children as she was suffering from heart disease. To his mind this meant giving up coitus. Then, unconsciously, he began to dream of Anna, his first love. He regretted more than ever not taking advantage of his former opportunities, and unconsciously dallied with the thought of deserting his wife. Just at this time his attacks began.