PSYCHO-ANALYTIC NOTES ON A CASE OF HYPOMANIA. BY ERNEST JONES, M. D., M. R. C. P. (Lond.), The psycho-analytic methods developed by Freud in the past fifteen years have been singularly neglected by workers outside of German-speaking countries, as is illustrated by the fact that no psycho-analysis carried out in any other country has up to the present been published. Yet these methods are unquestionably destined to have a far-reaching influence not only in the case of the psycho-neuroses but in much wider fields, and particularly in that of insanity. Already in dementia præcox Jung' has applied Freud's principles to the elucidation of the mental changes present in this obscure malady, and in spite of the great technical difficulties encountered has met with such brilliant success as greatly to encourage workers in this and allied spheres of investigation. Up to the present no psycho-analysis of a case of manic-depressive insanity has been recorded, for the only one published under that name, by Otto Gross,' was almost certainly, as Jung and others have pointed out, a case of dementia præcox. The same objection may be open as regards the case presently to be described, but in the writer's opinion the evidence seems here definitely to point against the diagnosis of dementia præcox. Before detailing some of the results of the study carried out by the Freudian methods, I will first give an account of the case as observed on ordinary lines. 'Jung: The Psychology of Dementia Præcox. Translated by Peterson and Brill. Journal of Nervous and Mental Disease, Monograph Series, 1909. See also two excellent analyses by Brill, Journ. of Abn. Psychol., Vol. III, p. 219, and Amer. Journ. of Insanity, Vol. LXVI, p. 53. 'Otto Gross: Das Freud'sche Ideogenitätsmoment und seine Bedeutung im manisch-depressiven Irresein (Kraepelin's). 1907. Previous History. The patient, S. T., is a woman aged 39. Her father died of pneumonia at the age of 55. Her mother, aged 78, is still alive; she is said to have suffered from "hysteria." One brother died of an aortic aneurism at the age of 35; two others are alive and well. There was no instance of insanity known in the family. The patient was brought up in the country, in a Northern American State, and was at home until she married. At school she was unusually quick in learning. She began to menstruate at the age of 14, and had no dysmenorrhoea. She married at the age of 19, and in the next year bore a son, who is still alive and well. A year or two later she had a miscarriage; this was followed by pelvic complications, evidently of a septic nature, which kept her in bed for five months. In 1892, when aged 23, she underwent double ovariotomy. This operation had no effect on her menstruation or on her sexual feeling. Ill health persisted, and she suffered much from painful sensations in the top of the head. Three years later her uterus was curetted for this. A period of depression followed and she was given electrical treatment for six months. In the succeeding years she was well for varying periods, and in the intervals suffered much from weakness, malaise and pelvic pain. In the summer of 1904 her health again badly broke down, and she was in hospital for three months of that year and for six months of the next. In June of the latter year (1905) she had a broad ligament cyst removed; it was at the time noted that the ovariotomy had been complete. Since this last operation she has rarely been free from sleeplessness, lack of appetite and other symptoms, though these greatly varied in intensity from one time to another. Two months before her admission to the asylum a marked exacerbation of them took place, as will presently be detailed. At different times during her married life she had entered into irregular relations with men, which lasted for varying periods. Her husband, who was a commercial traveller, was aware of this. He attributed it to irresponsible eccentricity caused by her markedly erotic temperament, and took the view that his duty was to forgive, and, wherever possible, to guide her. His attitude towards his wife was one of exceptional patience and fondness, and domestic scenes between them were rare and insignificant. It should be mentioned that the patient had always from a girl been religious, but only to a reasonable extent. Present Illness.-For two months before admission the patient had been restless, irritable, depressed and excited, varying greatly in mood from one day to the next. She had conceived an aversion towards her husband and son, and thought they were conspiring to harm or destroy her. She imagined that various clergymen were in love with her, that people were discussing her reputation, and conspiring to injure it. Her food was being poisoned, and she refused to eat it. Electricity was being pumped up through the floor to hurt her, and there were strange odors in the room. The house was full of men and spirits. The front of the house was transparent, so that everything could be seen from the street. She tried to throw herself out of the window, and to run out into the street undressed. She became violent, uttered loud screams, and had to be forcibly restrained. Throughout, however, she seemed to have considerable insight into her condition; she realized that her mind was sick and that she was going insane. First Admission.-She was admitted to the asylum on January 30, 1907. From the note taken during her stay the following points may be added to the account given above. Her attention was easily gained, and was well maintained. There was no clouding of consciousness. She was well oriented. She cried readily. She was fretful and, later on, depressed. She made a good recovery and was discharged on March 27, 1907. Second Admission.-The patient was readmitted on September 27, 1908, with the story of having suffered from a very similar attack to the previous one. The symptoms had developed only a week ago, and had ensued on another gynecological operation to which she had recently been submitted. They began with considerable depression, which was soon followed by excitement. The same erotic delusions were present as on the previous occasion. She was exceedingly restless and excited, gesticulated wildly, swore, sang, wandered from room to room, and threw things out of the window. She would toss herself about in bed until she reached an ecstasy of excitement, banging the walls with her fists, and so on. She would eat the most curious things, such as stove polish, etc. Her first act on being brought to the asylum was to smash a window pane with a chair. On examination the patient was seen to be still in this excited condition. She was in continual movement, made frequent attempts to climb out of the window, constantly flourished her arms and declaimed at a high voice. Her hands, when she was not gesticulating, were busy crumpling or tearing fragments of paper. At times exacerbations of great violence occurred in which she needed restraint. Her hair was dishevelled, and her personal appearance neglected. Her expression was distinctly lascivious, though her behavior was never indecent. On studying her logorrhoea one found that it consisted of a series of rapidly uttered words and short phrases, mostly related one to another by sound associations. The following are examples: "What a pretty tie. I wish I were tied to someone who was pure, and had pretty eyes. I'm fond of pretty eyes. Fond of lies. Not fond of the kind of lies I've been accused of. Oh yes, I was. There are different kinds of lies, lie up, lie down." The significance of the last words will be seen later. "I don't trust him. New York trusts. Roosevelt is all right. Except when he talks about race suicide. Bearing children is all very well when you have no bearing-down pains. There are too many panes in this window; I should like to open one." We see how prominent is the impulsive and rapid transition, along the most superficial associations, from idea to idea, so characteristic of the manic flight of ideas. The patient was perfectly oriented in time, place and personality. She retained insight into her condition, knew exactly why she had been confined, and that she would soon be better and about again. After the early stage no hallucinations occurred, except of smell. Her delusions have been mentioned above, and will be discussed in the course of the analysis. Her memory was unimpaired, as was so far as could be tested-her power of retention. There was no sense deficiency, no contraction of the visual fields or disturbance of sensibility, and no other stigmata of hysteria. Her judgment in everyday matters was sound, and there was no evidence of intellectual deterioration. No mannerisms, catalepsy or stereotypies were ever noted. |