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-157 JAN 1 2 1924
Entered as second-class matter March 28, 1918, at the Post Office at Concord, N. H.,
under the Act of March 3, 1879
THE TREATMENT OF CASES OF PSYCHOLEPSY, OF EMOTIONAL ORIGIN, IN WHICH PSYCHOANALYSIS PROVED OF SERVICE *
JAMES J. PUTNAM, M.D. It is important that all persons who are interested in the subject of epilepsy and its treatment should make themselves familiar with all the conditions which simulate epilepsy yet which are really of a different sort. This is especially important in view of the fact that these conditions are usually more amenable than epilepsy, to treatment. Indeed, the pathogenesis of epilepsy itself is by no means so clear but the study of these symptomatically similar conditions may throw light upon it, different in essential nature though they are.
The first case is that of a lady, fifty-two years old, who consulted me eight years ago for the following symptoms, which had been present for three years,—that is to say, since she was forty-one years old: Her main trouble was that she was liable, under certain circumstances, to a sudden loss of automatic and voluntary control over her muscles, so that her head would fall upon her chest, her eyes close, her lower jaw drop, and frequently her whole body collapse in a heap upon the floor. The duration of these attacks varied from one to three or five minutes, but they would be shortened if some one took hold of her by the hand, thus giving her a sense of protection and support. Sometimes, instead of falling to the ground she could guide herself to a chair, but even then there was almost complete relaxation of the muscles of the trunk and limbs. Indeed, further investigations, which were made repeatedly and carefully by myself and verified by a colleague, showed that both the knee-jerk and the pupillary light-reflex would instantly disappear when this relaxation came on, both phenomena returning gradually as the attack passed off. At the time I saw the patient she was liable to have several such attacks as these a day, but the number varied greatly according to the conditions of her environment. Thus,
* A large number of conditions have been brought together under the heading of psycholepsy, amongst which these cases can properly be classed. Janet has described a number of these in his book, "Les Obsessions et la Psychasthénie." Others were recorded by Dr. George A. Waterman and myself in the Boston Med. & Surg. Jr., 1905, Vol. clii, p. 509, and still others by Dr. Wm. G. Spiller in the Jr. Nerv. & Ment. Disease, 1907, Vol. 34, p. 411. It seems unnecessary to bring the bibliography up to date.
anybody who could induce in her a fit of laughing-to which she was easily moved—could throw her into an attack at once. This happened often, and it was noteworthy that a jocose remark by her brother (with whom she lived alone, and whose sense of humor was acute) was especially apt to have this effect upon her. One is reminded of the very severe results induced by tickling-especially with certain persons, at the hands of special tormentors -and also of the extreme muscular relaxation that sometimes attends prolonged fits of laughing (“die of laughing”). The analogy of these phenomena with those here recorded is indeed closer than one might think (see below) because in both cases there is probably a personal “abandonment," of hysterical character, which has a deep emotional and even sensuous root. A tendency is also occasionally noticed, especially among children, as a true epileptic symptom, to “catch the breath” and even to lose consciousness altogether under conditions of excitement.
My patient's attacks generally occurred indoors, but sometimes, also, in the street, though never unless she was startled, as happened once when she was accosted by a friend coming up unexpectedly from behind. The result, under these conditions, was strangely disproportionate to the manifest or apparent cause.
As time went on these seizures tended to occur somewhat independently of the special causations that had appeared necessary at first, though scarcely ever except on the basis of an emotion which might be of a trivial sort but which always, or nearly always, was induced suddenly, and ostensibly through some other person. Occasionally they would come on when she was alone, but then apparently in consequence of a thought which would connect her with a person. The further study of the history showed, indeed, that from the psychological standpoint, these attacks implied a peculiar longing for a personal relationship, the type of which was illustrated by a special series of experiences spread over a considerable number of years. In other words, the case seemed to be one of hysteria.
I did not, however, allow myself, at first, to accept this diagnosis, especially in view of the loss of knee-jerk and pupillary-reflex* and of the fact that the patient was usually unable to speak during the attacks, so that it was difficult to be convinced that consciousness was not lost, or at least modified, for a brief space, in spite of her opinion to the contrary.
Another symptom from which the patient suffered at about the same period with these psycholeptic seizures was an extreme tendency to drowsiness, which might cause her to fall asleep at any hour of the day, provided she sat quietly in a chair, either with or without a book, and almost invariably made her drop off when riding in a train. Sometimes, indeed, she would fall asleep at table. This tendency also has been observed a number of times in what is called true epilepsy. The same symptom is met with to some extent in myxoedema; but a careful examination failed to show other signs of this disorder in the case of my patient, nor did the thyroid treatment, which I instituted, have any effect in checking any of her symptoms.
* The observations of late years have shown that these reflexes may fail in hysteria, as is, indeed, well known.
A good many of her seizures occurred in my office, and I learned to detect their approach by a peculiar drawling which came in her speech, and by the dropping of the corners of the mouth and half closure of the eyelids. When these symptoms appeared I could sometimes help her to cut short the approaching attack.
One more symptom should be noticed, which I found later to be of considerable significance--namely, a distressing set of feelings in the legs, not localized and not necessarily associated with the attacks or with the loss of strength. These feelings she determined to be of sensuous origin, and this conclusion helped to bring the true nature of her whole illness clearly before her mind.
As regards her personal history, I found, on careful inquiry, that this lady, although ostensibly gay, really had a streak of profound sadness (not melancholy) in her disposition, and that she looked back upon her childhood, which in all outward respects had been a very happy one, as a period of great inward unhappiness. The environmental conditions had been favorable, her parents were judicious and affectionate, and she cherished a great affection for them-which, perhaps, in the case of her father, was too strong for her own good. The essential point was that she was overcome by passionate longings which she repressed without understanding their meaning; and it may perhaps be reckoned as an indirect sign of this that the mysteries of nature, especially strong winds, had a remarkable influence in bringing on a strong sense of fear and sadness.
I must abbreviate the history leading up to the psycholeptic seizures (which was gradually brought out through many interviews), and say, in the first place, that these repressed longings found a temporary expression in a prolonged homosexual friendship with a young girl of her own age, when both were in their adolescence, and later in a long, absorbing, and, in its results, a tragic relationship with a much older and married man, an old family friend, who took advantage of his position to induce in her, through constant and, one might justly say, villainous and heartless repetitions of a sort of personal attention which he understood well how to use for his own pleasure, an almost complete subordination to his selfish will. These attentions—which, so far as her state of mind was concerned, had all the evil effect of a seduction-went on through many years,-for a period, indeed, which began in her childhood and continued until circumstances broke them off not long before the attacks above recorded first appeared.
I have recently studied at considerable length the case of another patient, who, in a series of recurrent dreams which began in childhood, imagined herself pursued and finally falling in a species of abandonment at the feet of her pursuer. The study of the case now under consideration made it clear that the attacks of muscular collapse were virtually of the same nature, and that their continuance served to keep alive a sort of organic memory of a series of events by which her emotions were overpowered, and her chances for happiness through the establishment of a new home were swept away.