AS registrar in a hospital for incurables, the Budapest Salpêtrière, I had in my time to observe hundreds of epileptic fits. This turned out to have been a useful experience during the war years, when I became medical superintendent of a department of a military hospital, where one of my duties was the ‘verification’ of such fits. I do not propose here to go into the difficult and sometimes insoluble problems presented by individual cases in which we were called on to decide whether we were confronted with malingering, hysteria, or true, ‘genuine’ epilepsy, but shall confine myself to a few observations and reflections on those cases in which the typical picture of true epilepsy was presented without any doubt—that is to say, dilated, reactionless pupils, tonic-clonic spasms, complete extinction of sensibility, including corneal sensibility, biting of the tongue, noisy, laborious breathing, foaming at the mouth, ejection of the contents of the bowels, and post-epileptic coma.
The impression made on the psycho-analyst by these fits is of a regression to an extremely primitive level of organization in which all inner excitations are discharged by the shortest motor path and all susceptibility to external stimuli is lost. In observing such cases I was continually reminded of the first attempt2 made by me long ago to classify epilepsy among the psycho-neuroses. I then suggested that an epileptic fit signified a regression to an extremely primitive level of infantile ego-organization in which wishes were still expressed by uncoordinated movements. It will be remembered that this suggestion was subsequently taken up by the American psychoanalyst McCurdy, who modified it by showing that the epileptic’s regression went back even further, to the intra-uterine situation, that of the unborn child in the womb. A similar opinion was expressed by my colleague Hollós, who in a paper read to the Hungarian branch of the International Psycho-Analytical Association compared the mental state of an epileptic during a fit to the unconsciousness of an unborn child.
Observation of innumerable epileptic fits during the war years caused me to move nearer to the views of these two authors. One of the chief symptoms of such a fit is obviously the breaking off of all contact with the outer world, of the vie de relation, as the great Liébcault would put it. This, however, is something which an epileptic fit has in common with the ordinary state of sleep, which psycho-analysis regards as a regression to the antenatal state.1 In sleep all interest is withdrawn from the outside world and sensibility to external stimuli is noticeably diminished. Epilepsy, however, must be regarded as a state of exceptionally deep sleep, from which the sleeper is not to be awakened even by the strongest external stimulus.
The conflict between my original view (‘epileptic fit=regression to infantile omnipotence by means of uncoordinated movements’) and its modification (‘epileptic fit=regression to intra-uterine situation’) was resolved, however, when I took the whole course of the fit into consideration. The seizure generally begins with the patient’s collapse (with or without a loud scream or cry), and this is followed by general tonic contractions and clonic spasms. The duration of the period of tonic-clonic convulsions varies, but is interrupted by shorter or longer periods of rest, during which, however, unconsciousness, dilation of the pupils, stertorous breathing accompanied by signs of threatening oedema of the lungs (foaming at the mouth), and strong palpitations persist. During these pauses the epileptic’s attitude certainly resembles that of the foetus in the womb, which we must think of as completely motionless and unconscious (as well as apnoeic, of course). The first period of collapse and convulsions is, however, in my opinion much more reminiscent of the uncoordinated expressions of unpleasure of a newly-born child that is dissatisfied or has been irritated in some way. It is thus possible that both the original and the modified view of the level of regression involved may be correct, in the sense that during the seizure the epileptic goes through a whole gamut of regression, from the infantile to the intra-uterine-omnipotent situation. In cases in which periods of rest and convulsions alternate, we must think of the excitation as going up and down through the whole gamut. The ‘post-epileptic’ stage, and the transition stage which normally intervenes before the patient comes round, is much more like ordinary sleep. The patient makes defence movements, his pupils react again, and only an inclination to ‘ambulatory automatism’, a kind of sleep-walking, provides evidence of a remaining pathological, generally violent, hypermotility.
An experiment that I undertook, needless to say with the greatest precautions, enabled me in numerous cases to disturb the stage of ‘epileptic rest’ as described above and to provoke a repetition of the convulsions, or even the sudden awakening of the patient. During the stage of rest the patient’s teeth are firmly clenched and his tongue and palate are sunk backwards, as is shown by his loud snoring; respiratory movements of the thorax take place, but no breathing is possible through the mouth, and the encumbered respiration leads to a congestion of the pulmonary circulatory system and the expectoration of large quantities of serous sputum. If the patient were unable to breathe through the nose, persistence of the seizure would cause him to suffocate (as does happen in certain cases). If during the stage of rest I held the patient’s nostrils, so that he could not breathe at all, tonic-clonic spasms (i.e. a less deep state of non-reaction) generally set in again immediately, and if I went on holding his nostrils he generally awoke and his pupillary reaction and his sensibility returned. This experiment is, of course, not without its dangers; if the patient’s breathing were stopped too long, he might really suffocate. There were instances in which the patient’s condition did not alter after 20–30 seconds; of course, in such cases I did not force the experiment. During it I always carefully observed the patient’s pulse.
I learned from it, however, that an epileptic in a fit is far more sensitive to interference with his remaining breathing capacity than he is to other external stimuli, however painful these may be (application of heat or cold, blows, touching the cornea, etc.). If we regard the rest stage of the seizure as a regression to the intra-uterine, this is intelligible. In an epileptic seizure, as in ordinary sleep, the illusion of the womb can be maintained only if a minimum supply of oxygen is steadily maintained from outside. If the patient’s restricted breathing is stopped by holding his nostrils, he is compelled to wake up and breathe through his mouth, just as a new-born child is compelled to breathe and to awaken from its intra-uterine unconsciousness by the cutting off of the blood-supply through the umbilical cord.
In the paper mentioned above I indicated that the epileptic should be regarded as a special human type, characterized by the piling up of unpleasure and by the infantile manner of its periodic motor discharge. To this it should be added that these people are able to interrupt their consciousness, their contact with the outer world, and 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.
Individual differences in the various forms of attack may originate from the fact that in some cases it is the motor discharge which is emphasized, while in others it is the apnoeic regression. Even in the same patient, one fit may show the former and the next the latter characteristic of the epileptic process.
The fact that there are traumatic, toxic, and also ‘reflex’ epilepsies apart from constitutional ones need not, since the acceptance of the Freudian complemental series in the aetiology of the neuroses, cause us any difficulty. Obviously no one is completely immune to epileptic regression, but in one case a severe head injury, or chronic alcoholic poisoning, or a very painful irritation of the peripheral nerves is required to cause an epileptic fit, while in another, where there is a disposition to it, it may take place without such contributory factors.1
In the absence of a methodical psycho-analytic investigation, nothing definite can be said about the nature of the affects discharged in epileptic fits. It is, however, to be expected that sado-masochistic instinctual components will turn out to play at any rate a large part in them.
I also suspect that epilepsy—like tic in my opinion2—will turn out to occupy a border-line position between the transference and narcissistic neuroses.
When the fit is at its height we may assume a state of narcissistic regression far exceeding that of ordinary sleep and resembling cataleptic rigidity and the wax-like flexibility of catatonia. On the other hand, in the motor discharge and in post-epileptic delirium the patient rages at the outer world or turns his aggression inwards against himself; he thus clings fast to his ‘object-relationship’.
The regression theory of epilepsy throws some light both on the close connexion between epileptic fits and the state of sleep (that is to say, a milder state of the same regression) and on the combination of epileptic dispositions with other disturbances of organic development and atavisms.
Let me return for a moment to those cases in which the epileptic really suffocates instead of being awakened by having his breathing stopped. Cases have, of course, been described in medical literature in which the patient has collapsed head forwards into a shallow pool and drowned in a situation in which the slightest movement would have saved his life; I have been told about a patient, whose seizures always occurred at night in bed, but who invariably lay on his stomach as if he were deliberately seeking out the position in which he would be most likely to suffocate because of the pillow. (He subsequently died during one of his seizures, but no one was present, so that the exact circumstances of his death could not be established.) It could be said that the name of epileptic is truly deserved only in those cases in which the unconsciousness is so complete that there is no reaction to an interruption, or attempted interruption, of the breathing. Another view which deserves attention is that there are various degrees of epileptic unconsciousness, and that the extreme case is when the patient really suffocates, for then he has regressed through the pre-natal and the intrauterine stages to the stage of not living at all.1
Instances are known in nature in which animals save themselves from intolerable pain by self-dismemberment or mutilation (autotomy). That might well be the phylogenetic pattern of the ‘turning against oneself’ to be observed in many neuroses (hysteria, melancholia, epilepsy). The metapsychological assumption behind this would be the withdrawal of libidinal cathexis from one’s own organism, which is then treated as something alien, i.e. hostile, to the self. Great suffering or great physical pain can so accentuate the longing for absolute rest, i.e. the rest of death, that anything that stands in its way provokes defensive hostility. I was able to observe this not long ago in the sad case of a woman dying in unspeakable agony who reacted to all attempts of the physician to awaken her from her increasing lethargy with angry and often desperate defensive movements. From this point of view epileptic fits can be regarded as more or less serious attempts at suicide by suffocation; in mild cases the suicide is indicated only symbolically, but in extreme cases it is carried out in reality.
It is possible that the respiratory crotogenous zone which D. Forsyth (London) found to be the chief factor in certain respiratory disturbances in children may be the dominant zone in epileptics.
For those who are aware of the immense real importance of symbolism in life, and of the regularity with which the symbolism of death and that of the maternal body are associated with each other in dreams and neuroses,2 it will be no surprise if epileptic fits turn out to have that double meaning.
According to this interpretation, the epileptic would appear to be a person of strong instincts and violent affects who succeeds for long periods in protecting himself from outbursts of his passions by extremely powerful repression of his urges, or sometimes by exaggerated humility and religiosity; but at appropriate intervals his instinctual drives break loose and rage, sometimes with bestial ruthlessness, not only against his whole environment, but against his own person, which has become alien and hostile to him. This discharge of affect then brings about, often only for a few very brief moments, a sleep-like state of rest, the pattern of which is that of the unborn child in the womb, or alternatively death.
In certain cases, particularly in the aura, the state of epileptic fugues and ‘equivalents’, aggression against the environment predominates, and may express itself in impulses to mass murder and a blind, destructive fury. In other cases the violence is chiefly turned inwards and does not rest until the unconscious aim of suicide has been achieved. In so-called petit mal—attacks of temporary unconsciousness unaccompanied by convulsions, the temporary happiness of the same embryonic state of rest is achieved without the dramatic discharge of affect, simply by withdrawal of libido and interest from the outer world, the apparatus of perception merely ceasing to function.
The importance of the place occupied by sexuality among the instincts to which an epileptic fit gives rein is shown by the exceptional frequency of so-called sex criminals among epileptics, and the numerous sexual perversions, often in quite remarkable combinations, to be found among them, as described, for instance, by Maeder.1 In a number of cases the fit appears to be actually a ‘coitus equivalent’, as in the case of a patient observed by me who was able to avoid fits only by having coitus daily, and sometimes several times daily. That epileptic fits (and, according to Freud, hysterical fits also) recall the sex act in many respects (convulsions, alterations in breathing, disturbance of consciousness) was correctly recognized by the older doctors. I hope to be able to give a theoretical clue to the explanation of the numerous analogies between sleep, fits, and orgasm on another occasion, when I shall have something to say about the meaning of that remarkable combination of aggressive actions and alterations in the psycho-physical state which we call the sex act and which recurs in such a remarkably similar manner in so many different kinds of animals.1
For the time being I shall confine myself to remarking that in the state of orgasm the whole personality (the ego) identifies itself, in my opinion, with the genitals, and (as in sleep and in certain stages of epileptic fits) demands a hallucinatory return to the mother’s body; and that the male organ advancing towards the womb attains this aim partially, or more correctly ‘symbolically’, and that only the genital secretion, the semen, attains this destiny in reality.
1 Posthumous paper. First published in German: Bausteine III (1939). First English translation.
2 In ‘Stages in the Development of the Sense of Reality’. First published in 1913. Reprinted in First Contributions to Psycho-Analysis, Hogarth Press, London, 1952.
1 Cf. my paper quoted above, ‘Stages in the Development of the Sense of Reality’, on the first sleep of the newly born.
1 Jacksonian epilepsy, which arises from a purely mechanical irritation of the motor centres of the brain, is not to be included with the psychogenic epilepsies dealt with above.
2 See ‘Psycho-Analytical Observation on Tic’. Further Contributions, p. 172.
1 See Freud’s remarks on the death instinct in Beyond the Pleasure Principle.
2 See my recent papers on symbolism: ‘The Symbolism of the Bridge’ (1921) and ‘Bridge Symbolism and the Don Juan Legend’ (1921), both reprinted in Further Contributions, Hogarth Press, 1926.
1 In Sexualität und Epilepsie: Jahrbuch für psychoanalytische und psychopathologische Forschungen (1909), 1, 19.