« 上一頁繼續 »
appear, or whether these are not psychically determined. To begin with numbers: A case is quoted of a man who said he had lived 3 million 699 years and at one time had 3 million 695 radishes in him. He said he was 39 years in his mother, on another occasion 3990 years in his mother, and that 3 years after he fell out of her his reason returned to him. The authors note the special preference for the number 3 and its multiples, and compare the paretic's use of numbers with the neurotic's preferences for 'sacred' numbers.
The delusions are frequently found to be related to actual experiences: in the patient's case quoted he said that he wanted to cure lung diseases (his father and sister had died of tuberculosis, so the poverty in his home was associated with this disease); early on in the disease he phantasied playing on an electric flute and earning 4000 kr. daily, with which sum he bought sacks of food, chocolate, sardines, cheese and butter (before admission he had been a beggar and was in abject poverty); he wished to cure infective diseases [lues] (he was infected with chancre in his 33rd year); he even heals psychic disorders (on admission he recognized that he was in an asylum and was diagnosed insane); he will found a Socialist state (he was persecuted by the White faction for being in the Hungarian Bolshevist Government). Thus on the superficial layers we find frank wish-fulfilment phantasies built on the infantile pattern, poverty is turned to riches, persecution to honours, and above all there is gratification in much eating and drinking (Griesinger and Freud).
The state of sleep with relaxation of the censorship and the closure of the sensory end of the psychical apparatus favours dream formation. The same factors are not found in paresis. The patient generally perceives the outer world quite well, there is nothing corresponding to the closing of the sensory end of the psychical apparatus. The explanation of the fact that the delusions are adhered to in spite of contradictory impressions from without is found in an infantile regression of the critical faculty. The patient quoted constantly repeats that he is 33 years old although he claims to have lived for ever. Why always repeat that he is 33? The suspension in the passage of time may be attributed to a fixation at an important date-a misfortune, namely, his lues; it is significant that he contracted this in his 33rd year. Other cases are given supporting this. A further explanation may be found in the "shattering of the ego-sense" produced by an ulcer or a disease of the genital, a complaint in this part being apt "to draw the entire ego into sympathetic suffering," and with this is coupled the idea of a threatened impotence. In the case quoted a remarkable phenomenon was noticed: soon after admission he freely recounted when he had been infected, i.e. sixteen years before, in his 33rd year; later when grandiose ideas developed he denied lues altogether but began to speak of his 'immortality,' and his age as the unchanging 33. He said that not he but his son had lues, who then crept into him and thus was cured. The equation son = penis is here manifest. Once he said that not he but his companion Michael Tohn had syphilis "who crept into me-the scoundrel— who played a part inside of me" (Michael Tohn is the patient's name!). Similar cases are given, The "lues complex is repressed and the fixed age takes over the rôle of a memory cloak, where there is a return of the repressed it takes the form of a change to the opposite, the idea of a fatal disease becomes the beginning of a new life."
This act of repression is only a special case of repression of consciousness of sickness in general, and as we should expect the repressed will betray itself
at times; the patient asked his physician for a match to light a cigarette "to cure my sickness" instead of "to light my cigarette," although at the time he was denying that he had any sickness to cure.
Thus far Hollós. Ferenczi now takes up the argument. Bodily invalidism leads to a peculiar distribution of the libido, the patient withdrawing interest and love from outside objects and concentrating it more or less on the self or the diseased organ; his 'narcissism' is a repetition of the infantile state before object relations had developed. Ferenczi has already elaborated this theory in Ueber Pathoneurosen (1917) (translation in preparation by the Institute of Psycho-Analysis) to the effect that quantities of energy can be stored up not only in the Ego but in sick organs (or their psychical representations) and that these stores of energy may play a part in organic regeneration and healing. A shock accompanied by a severe wound leaves less trace of psychical disturbance than one without such wound. If the narcissistic libido mobilized by the trauma is used in an organ for purposes of healing it cannot fluctuate freely and cause neurosis. From war shock cases is but a step to making some reflections on illness in general; (1) a wound to or injury of an erogenous zone may produce a severe psychical illness (puerperal psychoses, for example); (2) severe narcissistic psychoses of a psychogenic nature may be cured by intercurrent organic disease, at least for a time (melancholia, for instance). The surplus libido is imprisoned in the diseased tissues. Ferenczi now makes a jump: some of the mental symptoms of paresis may be regarded as a Cerebral Pathoneurosis. Only students of the recent psycho-analytical publications will be able to follow the next intricate steps taken. Is the brain, then, an erogenous zone! In a sense any organ may become such; there is no organ whose stimulation or disorder does not influence sexuality and there are reasons for thinking that the brain has an unusually large share in this narcissistic libido, for just as the peripheral organs give up the greatest share of self-gratification to the most favourable of the leading (genital) zones, so that this last (the genital itself) takes priority over the others, so the brain takes over the Ego functions. It is the most significant advance in development, that the sexual stimuli should be centred in one group of cells (making the genital the central erotic organ); the apparatus for subduing stimuli, on the other hand, comes into closer and closer association with the organ of the Ego impulse; but while the genital maintains its rôle of executive organ of erotism unchanged, the narcissistic undertone of accompanying higher psychic acts can only be explained by certain assumptions taken from psycho-pathology. In the case of G. P. I. the metaluetic brain infection by disturbing the organ of the Ego function provokes not only symptoms of defect but also acts as a trauma, upsetting the narcissistic libidinal balance, and so produces a paretic mental disorder. He is careful to add that this notion commands only personal credence. How does it apply to Bayle's classification of paretic symptoms into stages of (1) initial depression, (2) manical excitement, (3) paranoid delusions, and (4) terminal dementia? Ferenczi thinks only the very early 'neurasthenic' symptoms are attributable to defect, the patient is usually first seen in the stages of compensation. One of the symptoms of the 'neurasthenic' phase is diminution of potency which may be taken as a sign of withdrawal of libidinal interest from the sexual object and prepares us to expect that the libido so withdrawn will be put to some other use; that it is not due to degenerative processes is shown by the frequent return of potency at a later stage of the disorder. The curious hypochondriacal symptoms so
frequently complained of probably accounts for some of the libido withdrawn from the sexual object. These sensations are those of a 'narcissistic actual neurosis,' of a painful storing up of libido in bodily organs. These hypochondriacal states are found not only in patients with anatomically intact organs but also organs which are diseased or injured. If the store of libido mobilized as 'counter-cathexis' exceeds the amount required for healing it must be mastered [bound] in the psychical sphere. This is specially the case with pathoneuroses and may go a long way to explain the flaring up of hypochondriacal symptoms in paresis. Then how explain the euphoria and enhanced interest in objects (sexual and non-sexual)? It may be regarded as an overcompensation for the narcissistic-hypochondriacal lack of pleasure a convulsive object cathexis. But the undertone of hypochondria persists all the same, it is only masked by euphoria, it is "hypochondria with a positive sign." Then there are two stages of 'actual psychosis' [by which term he draws a parallel with the 'actual neuroses' that are of somatic origin and result from disorders of amount or distribution of sexual excitation], and these have to be distinguished from the superstructure which is mainly psychic. Put into a formula: the paretic actual psychosis' is built up of symptoms which can be traced in part to libido discharge and convulsive object-cathexis and in part to a pathoneurotic, narcissistic intensification of the libido provoked by organic lesions.
The euphoric mood gives place as a rule to melancholia when the Ego cannot help recognizing its injury. In this mood we find the frequent symptoms of melancholia, insomnia, sphinctor paresis, suicidal tendencies, emaciation, and distinguished from psychogenic melancholia by the physical symptoms. He applies the Freudian theories of the latter disease to explain this stage of paresis; it is a narcissistic psychosis, its symptoms are those of any great injury and libido impoverishment brought about through damage to or devaluation of an ideal with which the Ego had deeply identified itself. The sadness is a mourning, the self-accusations are sadistic impulses directed against the earlier love object that is now incorporated in the Ego-system; there is also regression to oral sadism. There may be 'identification melancholias' and those following direct damage to the Ego itself. Ferenczi regards this paretic stage to be of the second sort. The patient, owing to loss of Ego feeling, mourns for the loss of a once fulfilled Ego-ideal. So long as the defect symptoms involved only separate peripheral organs, the paretic could withdraw from the situation with only a pathoneurotic hypochondria; when the disease invades the highly-estimated Ego itself (intellect, morality, aesthetic sense), self-observation compels a feeling of impoverishment. So long as the libido itself can be satisfied by various psychical activities, any amount of bodily destruction can be tolerated, but driven first from bodily gratification and then from self-esteem the path would seem to lead to melancholia.
And where does it lead? These patients get rid of their distress by mania or hallucinatory wish fulfilments by delusions of grandeur. The mania here as in the psychogenic disorder is a triumph over melancholia by dissolving the Ego-ideal into the narcissistic Ego, or, put in other terms, the patient gives up the identification with an external object and releases the energy of the cathexis which had been spent in mourning. The author attempts to answer the questions: How can these processes occur in an Ego attacked by disease? Does not the disintegration of disease nullify the integrating forces within the personal Ego? The answer involves a detour into Ego-analysis. Catatonics, in a state of waxy flexibility, permit anything to be done to them
because their bodies have become indifferent to them; there is a 'sequestration' of the psychical representation of the body from the Ego, the whole of the patient's narcissism has retreated into a 'spiritual Ego.' In paresis the psychical Ego may get 'sequestrated' and there is a concomitant regression to earlier levels of Ego development.
A brief review of Ego development is here given and must be abstracted in the hope that some clarity may be given to these hypotheses. A person passes through the stages of unconditioned and later hallucinatory omnipotence, through the stages of magic gesture, to the realm of the 'reality principle,' when he begins to separate his personal wishes from reality. Adaptation to society makes continual demand on the narcissistic self, compelling recognition of reality. How does a person become attentive, clever, prudent, wise, moral and at the same time elastic; how is the change brought about from complete self-centredness to that degree of self-sacrifice demanded by society which may at times be even heroic? It occurs gradually by a continual progression of identifications with educators taken for the Ideal-by a development of the Ego-ideal. This becomes an 'Ego-nucleus' (Freud) which behaves as subject to the rest of the Ego, it founds the institutions of censorship, conscience, reality testing [Freud has withdrawn this last from the Egoideal, now called by him Super-Ego, and given it back to the Ego; Ferenczi's and Hollós' paper was written before Das Ich und das Es appeared], and self-criticism. Every new capacity means the attainment of an ideal and is a narcissistic gratification as well, an enhancement of self-feeling and the reattainment of Ego stature which has been diminished by unfulfilled ideal standards. Object libido passes through a certain education too, but less severe; one has at least to avoid incest and certain perversions, so even object love must become Ego-syntonic.
In paresis, self-observation supplies information to the Ego-nucleus that not only bodily but also psychic functions are being ruined, and the Egonucleus replies to this with depression. [Freud's revised Ego hierarchy places reality-testing in the Ego, Ferenczi in this sentence seems to confirm this topography by saying "self-observation sends the report to the Ego-nucleus..." (my italics). He goes on to assume that the Ego-nucleus gets depressed. Freud's assumption is that depression belongs to the Ego (as contrasted with Super-Ego, or Ego-Ideal), the depression being caused by the disparagement of the Super-Ego. Confusion may arise unless Ferenczi's speculations are kept distinct at junctures such as this from those set out by Freud in Das Ich und das Es.] If the psychical pain becomes intolerable there is narcissistic compensation in regression to earlier stages in development, i.e. the patient surrenders the ideals imposed by education, and narcissism regresses to the infantile past when the patient was complacent and all powerful. The manic-delusional stage is the one in which narcissistic libido has regressed to a point in Ego development which has been mastered: from the psychoanalytical view-point General Paresis is Regressive Paresis.
Freud conjectures that analysis of the psychoses will show similar conflicts and mechanisms of repression even in the sphere of Ego psychology just as they are revealed in the transference-neuroses in conflicts between Ego and Object. [Freud (again revising) regards neurosis as a conflict between Ego and 'Id' whereas psychosis is an analogous outcome of a similar disturbance in relation of the Ego and its environment.] In paresis the manic phase renders the injury to the Ego ineffective by 'sequestration,' which is analogous
to neurotic repression, the patient withdraws libido from the body and recompensates' by luxuriating in phantasies of power. The patient described above found it sufficient to rub his nipples in order to create boundless quantities of daily requirements, i.e. he had regressed to the stage of hallucinatory gesture, though impotent he can recreate the human race by extragenital infantile sexual activities. If hallucinatory magic fails to obscure his observation of his deterioration he projects this on to someone else (his companion Michael Tohn had syphilis-but this was his own name!) or he will rise in rank as his deterioration increases. Or again he keeps a certain Ego complacency by retaining the age before his injury. Coincident with this is a tendency to every sort of sexual activity that was once abandoned; it is as if the polarity of Ego centre (brain) and genital, which was so laboriously achieved, disappears and the Ego becomes again flooded with erotism. The two kinds of melancholia can be contrasted in a phrase: while in psychogenic melancholia the grief is over the loss of an ideal, in paresis the disease successively destroys one grade of identification after another, one ideal after another, the sum of which constituted the Ego-ideal. These Ideals and Identifications may, like hallucinatory images, have a kind of independent existence within the Ego, and normally cohere, but they may appear in independence in dream or psychosis. This is the 'sequestration process' above referred to, and has an analogy in projection-the opposite process is the partial 'ideal-introjections' which constitute the pabulum of Ego development.
A psycho-analytical theory must offer some explanation of why one type is manic, another melancholic, another passes quickly to simple dementia. As in other diseases, psycho-analysis supposes an admixture of constitutional and traumatic factors, and on these is the 'choice of neurosis' dependent. Psychiatry has followed up the endogenous factors, psycho-analysis deals with way the Psyche reacts to cerebral noxae, with the Ego and libido constitutions, with the weak points, the fixation points in development-these last are important in all pathological processes. We can assume that a man who is strongly narcissistic from an early age will present a different type of paresis from one of a 'transference type. The readiness to regress to oral or sadistic-anal erotic fixations will give rise to different symptoms from those with fully developed genital primacy; also the stage reached by Ego development, the cultural level of the patient will influence the psychotic reaction.
Unexpected death evokes more intense grief, sudden disappointment in a narcissistically loved object brings deeper depression, and so a stormy pathological process may evoke a more vigorous patho-neurotic reaction than a slowly developing brain disease. In slow disease traumatic effect is lacking, and therefore, there being less narcissistic libido mobilized, there will be less likelihood of paretic melancholia or mania. In addition to this time element we have to consider topographical factors in Freud's sense, namely, the influence of the disease on the relations between the Ego nucleus and narcissistic Ego. If the Ego nucleus remains immune the decline in physical and psychical capacity will bring on strong psychotic reactions, but if this is involved too, if Ego criticism fails, the clinical picture will be one of simple deterioration. If this be so, the excited paretic is not so 'completely uncritical' as current literature would lead one to believe. That can only be said of the paretic with simple deterioration; it is the 'sensory self-criticism' which calls forth the striking symptoms of the manic and melancholic types.
A part of the patient can (in the case of the last two named types) recover