Sigmund Freud (18561939). Selected Papers on Hysteria and Other Psychoneuroses. 1912.
Chapter III. The Case of Miss Elisabeth v. R.
IN the fall of 1892 I was requested by a friendly colleague to examine a young lady who had suffered from pains in her legs for over two years and who walked badly. He also added that he diagnosed the case as hysteria, though none of the usual symptoms of the neurosis could be found. He stated that he knew something of the family and that the last few years had brought them much misfortune and little pleasure. At first the father of the patient died, then the mother underwent a serious operation for the eyes, and soon thereafter a married sister succumbed to a chronic cardiac affection after childbirth. Our patient had taken an active part in all the afflictions and in all the nursings of the sick. I made no further progress into the case after I had seen the twenty-four-year-old patient for the first time. She seemed intelligent and psychically normal and her affliction, which interfered with her social relations and pleasure, she bore with a happy mien, thus vividly recalling the belle indifference of hysterics. She walked with the upper part of her body bent forward, but without any support; her gait did not correspond to any known pathological gait and it was in no way strikingly bad. She complained of severe pains on walking, of early fatigue in walking as well as standing, and after a brief period she would seek rest in which the pains became diminished but they by no means disappeared. The pain was of an indefinite natureone could assume it to be a painful fatigue. The seat of the pain was given as a quite extensive but indefinitely circumscribed location on the superficial surface of the right thigh. It was from this area that the pains radiated and where they were of the greatest intensity. Here, too, the skin and muscles were especially sensitive to pressure and pinching, while needle pricks were rather indifferently perceived. The same hyperalgesia of the skin and muscles was demonstrable, not only in this area, but over almost the entire surface of both legs. The muscles were perhaps more painful than the skin, but both kinds of pains were unmistakably most pronounced over the thighs. The motor power of the legs was not diminished, the reflexes were of average intensity and all other symptoms were lacking, so that there was no basis for the assumption of a serious organic affection. The disease developed gradually during two years and changed considerably in its intensity.
I did not find it easy to determine the diagnosis, but for two reasons I concluded to agree with my colleague. First, because it was rather peculiar that such a highly intelligent patient should not be able to give anything definite about the character of her pains. A patient suffering from an organic pain, if it is not accompanied by any nervousness, will be able to describe it definitely and calmly; it may perhaps be lancinating, appearing at certain intervals, extending from this to that location, and in his opinion it may be evoked by this or that influence. The neurasthenic describing his pain gives the impression of being occupied with some difficult mental problem reaching far beyond his powers. His features are tense and distorted as though under the domination of a painful affect, his voice becomes shriller, he struggles for expression, he rejects all designations that the physician makes for his pains, even though they are undoubtedly afterwards found as appropriate. He is ostensibly of the opinion that language is too poor to give expression to his feelings. His sensations are something unique, they never existed before so that they can not be exhaustively described. He never tires of constantly adding new details and when he has to stop he is surely controlled by the impression that he was unsuccessful in making himself understood to the physician. All this is due to the fact that his pains absorb his whole attention. In the case of Miss v. R. we had just the opposite behavior and we had to conclude from this that she attributed sufficient significance to the pain, but that her attention was concentrated on something else of which the pains were the accompanying phenomena, perhaps on thoughts and sensations which were connected with the pain.
A still greater determination for the conception of the pain must, however, be found in a second moment. If we irritate a painful area in a patient suffering from an organic disease or neurasthenia his physiognomy will show a definite expression of discomfort or of physical pain. Furthermore, the patient winces, refuses to be examined and assumes a defensive attitude. With Miss v. R. when the hyperalgesia skin or muscles of her legs were pinched or pressed her face assumed a peculiar expression approaching nearer pleasure than pain, she cried out andI had to think of a pleasurable ticklingher face reddened, she threw her head backward, closed her eyes, and her body bent backward; all this was not very distinct but sufficiently marked so that it could only agree with the conception that her affliction was a hysteria and that the irritation touched a hysterogenic zone.
Her mien was not in accord with the pain which the pinching of the muscles and skin were supposed to excite. It probably harmonized better with the content of the thoughts which were behind the pain and which were evoked in the patient by irritating that part of the body associated with them. I have repeatedly observed similar significant expressions on irritating hyperalgesia zones in unmistakable cases of hysteria. The other gestures evidently corresponded to the slightest indications of a hysterical attack.
We could not at that time find any explanation for the unusual localization of the hysterogenic zone. That the hyperalgesia chiefly concerned the muscles gave material for reflection. The most frequent affliction causing the diffuse and local pressure sensitiveness of the muscles is the rheumatic infiltration of the same, the common chronic muscular rheumatism about which aptitude to mask nervous affections I have already spoken. The consistency of the painful muscles in Miss v. R. did not contradict this assumption, as there were many hard cords in the muscle masses which seemed to be especially sensitive. There was probably also an organic change in the muscles, in the assumed sense, upon which the neurosis rested and which significance was markedly exaggerated by the neurosis.
The therapy followed out was based on a supposition of a mixed affection. We recommended the continuation of a systematic massage and faradization of the sensitive muscles without regard to the pain produced, and in order to remain in communication with the patient I undertook the treatment of her legs by means of strong Franklins sparks. To her question whether she should force herself to walk we answered decidedly in the affirmative.
We thus attained a slight improvement. She particularly liked the painful shocks of the influence machine and the stronger they were the more they seemed to suppress her pains. My colleague meanwhile prepared the soil for the psychic treatment, and when after four weeks of sham treatment I proposed the same and gave the patient some explanations concerning the procedures and its effects I found a ready understanding and only slight resistances.
The work which then began became eventually the most arduous that ever befell my lot, and the difficulty of giving an account of this work ranks well with the obstacles that had to be overcome. For a long time, too, I did not understand the connection between the history of the disease and the affliction, a thing which should really have been caused and determined by this row of events.
When one undertakes a cathartic treatment he at first asks himself whether the patient understands the origin and cause of her suffering. If that is so one does not need any special technique to cause her to reproduce the history of her ailment. The interest shown in her, the understanding which we foreshadow, the hope of recovery extended to her, all these will induce the patient to give up her secrets. With Miss Elisabeth it seemed probable to me right from the very beginning that she was conscious of the reasons for her suffering, that she had only a secret but no foreign body in consciousness. On looking at her one had to think of the poets words,
At first I could thus forego hypnosis, reserving it, however, for future use if in the course of the confession conditions should arise for which explanation the memory would not perhaps suffice. Thus in this first complete analysis of a hysteria which I had undertaken, I reached a process of treatment which later I raised into a method and employed it consciously in the process of removing by strata the pathogenic psychic material which we used to compare with the technique of excavating a buried city. I at first allowed the patient to relate to me what was known to her, paying careful attention wherever a connection remained enigmatical or where a link in the chain of causation seemed to be lacking. Later I penetrated into the deeper strata of memory by using for those locations hypnotic investigation or a similar technique. The presupposition of the whole work was naturally the expectation that a perfect and sufficient determination could be demonstrated. The means of the deeper investigation will soon be discussed.
The history which Miss Elisabeth gave was very dull and was woven of manifold painful experiences. During this recital she was not in a hypnotic state; I merely asked her to lie down and keep her eyes closed. I however made no objection if she from time to time opened her eyes, changed her position or sat up. Whenever she entered more deeply into a part of her history she seemed to merge spontaneously into a condition resembling a hypnotic state. She then remained motionless and kept her eyes firmly closed.
I shall now reproduce the results of the superficial strata of her memory. As the youngest of three daughters she spent her youth with her parents, to whom she was devotedly attached, on their estate in Hungary. Her mothers health was frequently disturbed by an affliction of her eyes and also by nervous conditions. It thus happened that she became especially and devotedly attached to her jovial and broadminded father who was wont to say that this daughter took the place of both a son and friend with whom he could exchange his thoughts. As much as the girl gained in mental stimulation in consequence of this intercourse it did not escape the father that her psychic constitution deviated from that ideal which one so much desires to see in a girl. Jocosely he called her pert and disputatious. He warned her against being too confident in her judgments, against her tendencies to tell the truth regardlessly to everybody and expressed his opinion that she would find it difficult to get a husband. As a matter of fact she was very discontented with her girlhood; she was filled with ambitious plans, wishing to study or obtain a musical education, and revolted at the thought of being forced to give up her inclination to sacrifice her freedom of judgment on account of marriage. Meanwhile she was proud of her father, of the regard and social position of her family, and jealously guarded everything connected with these matters. The indifference with which she treated her mother and older sisters, as will be shown, was considered by her parents to be due to the blunter side of her character.
The age of the girls impelled the family to move into the metropolis, where for a time Elisabeth enjoyed the richer and gayer life. But then came the calamity which destroyed the happiness of the home. The father either concealed or overlooked a chronic cardiac affection, and one day he was brought home in an unconscious state after the first attack of edema of the lungs. This was followed by an illness of one and a half years, during which Elisabeth took the most prominent part in nursing him. She slept in her fathers room, awoke at night at his call, watched over him faithfully during the day, and forced herself to appear cheerful while he went through a hopeless condition with amiable resignation. The beginning of her affliction must have been connected with this time of her nursing, for she could recall that during the last half year of this care she had to remain in bed on one occasion for a day and a half on account of severe pain in the leg. She maintained, however, that these pains soon passed away and excited neither worry nor attention. As a matter of fact it was two years after the death of her father that she began to feel sick and became unable to walk on account of pain.
The gap which the father left in the life of this family consisting of four women, the social solitude, the cessation of so many relations which promised stimulation and pleasure, the increased infirmity of the mother, all these clouded the mood of our patient, but simultaneously stimulated a warm desire that the family might soon find a substitute for the lost happiness and urged her to concentrate her entire devotion and care on the surviving mother. At the end of the mourning year the eldest sister married a talented and ambitious man of notable position, who by his mental capacity seemed to be destined for a great future, but who, however, very soon developed a morbid sensitiveness and egotistic perseveration of moods, and dared to show his disregard for the old lady in the family circle. That was more than Elisabeth could endure. She felt herself called upon to take up the fight against her brother-in-law whenever he gave occasion for it, while the other women took lightly the outburst of his excited temperament. To her it was a painful disillusionment to find that the reconstruction of the old family happiness experienced such a disturbance. She could not forgive her married sister because with feminine docility she strove to avoid espousing her cause. Thus a whole series of scenes remained in Elisabeths memory to which were attached a number of partially uttered grievances against her first brother-in-law. But what she reproached him most for was the fact that for the sake of a promotion in view he moved with his small family to a distant city in Austria and thus increased the lonesomeness of her mother. On this occasion Elisabeth distinctly felt her inability and helplessness to afford her mother a substitute for the lost happiness, and the impossibility of following out the resolution made at the death of her father.
The marriage of the second sister seemed to promise more for the future of the family. The second brother-in-law, although not of the same mental calibre as the first, was a man after the heart of delicate ladies, and his behavior reconciled Elisabeth to the matrimonial institution and to the thought of the sacrifice connected with it. What is more the second couple remained near her mother, and the child of this brother-in-law and the second sister became Elisabeths pet. Unfortunately the year during which the child was born was clouded by another event. The visual affliction of the mother demanded many weeks treatment in a dark room, in which Elisabeth participated. Following this an operation proved necessary and the excitement connected with this occurred at the same time that the first brother-in-law made preparations to move. Finally the operation, skilfully performed, proved successful, and the three families met at a summer resort. There Elisabeth, exhausted by the worries of the past months, had the first opportunity to recuperate from the effects of the suffering and anxiety that the family had undergone since the death of her father.
But during the time spent at this resort Elisabeth was attacked by the pain and weakness. Afterwards, the pains, which had become noticeable for a short while some time previously, manifested themselves severely for the first time after taking a warm bath at a small watering place. In connection with this it was thought that a long walk, really a walk of half a day, a few days previously, had some connection with the onset of the pains. This readily produced the impression that Elisabeth at first became fatigued and then caught cold.
From this time on Elisabeth became the patient in the family. Following the advice of the physician she spent the rest of the summer in the watering place at Gastein, whither she went with her mother, but not without having a new worriment to think about. The second sister was again pregnant and information as to her condition was quite unfavorable, so that Elisabeth could hardly decide to take the journey to Gastein. After barely two weeks at Gastein both mother and sister were recalled as the patient at home did not feel well.
An agonizing journey, which for Elisabeth was a mixture of pain and anxious expectations, was followed by certain signs at the home railroad station which forebode the worst, and then on entering the chamber of the patient they were confronted with the realitythat they arrived too late to take leave of the dying one.
Elisabeth not only suffered from the loss of this sister whom she dearly loved but was also grieved by the thoughts caused by her death and the changes which it caused. The sister had succumbed to heart trouble which was aggravated by the pregnancy.
She then conceived the thought that the heart trouble was the paternal inheritance. It was then recalled that in her early childhood the deceased went through an attack of chorea with a slight heart affection. The family then blamed themselves and the physicians for permitting the marriage. They could not spare reproaches to the unfortunate widower for impairing the health of his wife by two successive pregnancies without any pause. The sad thought that this happiness should terminate thus after the rare conditions for a happy marriage had been found, thereafter constantly occupied Elisabeths mind. Moreover, she again saw everything fail that she had planned for her mother. The widowed brother-in-law was inconsolable and withdrew from his wifes family. It seemed that his own family from whom he was estranged during his short and happy married life took advantage of the opportunity to again draw him into their own circle. There was no way of maintaining the former union; to live together with the mother-in-law was improper out of regard for the unmarried sister-in-law, and inasmuch as he refused to relinquish the child, the only legacy of the deceased, to the two ladies, he for the first time gave them the opportunity of accusing him of heartlessness. Finally, and that was not the least painful thing, Elisabeth received some indefinite information concerning a disagreement between the two brothers-in-law, the occasion for which she could only surmise. It seemed as if the widower made some requests concerning financial matters which the other brother-in-law considered unjustifiable, and thought, that in view of the recent sorrow of his mother, it was nothing but an evil extortion. This then was the history of the young woman of ambitious and loving disposition. Resentful of her fate, embittered over the failures of her little plans to restore the lustre of the home; of her beloved ones, some being dead, some away, and some estrangedwithout any inclination to seek refuge in the love of a strange man, she lived thus for a year and a half nursing her mother and her pains, separated from almost all social intercourse.
If we forget the greater sufferings and place ourselves in this girls position, we can but extend to Miss Elisabeth our hearty sympathy. But what is the physicians interest in this sorrowful tale; what is its relation to her painful and her weak gait; what outlook is there for explaining and curing this case by the knowledge which we perhaps obtained from these psychic traumas?
For the physician this confession of the patient signified at first a great disappointment, for to be sure it was a history composed of banal mental shocks from which we could neither explain why the patient became afflicted with hysteria nor how the hysteria assumed the form of the painful abasia. It explained neither the causation nor the determination of the hysteria in question. We could perhaps assume that the patient had formed an association between her psychically painful impressions and bodily pains which she accidentally perceived simultaneously, and that now she made use in her memory of the physical sensation as a symbol for the psychic. What motive she had for this substitution and in what moment this came about remained unexplained. To be sure, these were questions whose nature was not familiar to the physicians. For it was customary to content ones self with the information and to assume that the patient was constitutionally hysterical and that under the intensive pressure of any kind of excitement hysterical symptoms could develop.
Even less than for the explanation did this confession offer for the treatment of the case. One could not conceive what beneficial influence Miss Elisabeth could derive from recounting sad familiar family experiences of the past years to a stranger who could give her in return only moderate sympathy, nor could we perceive any improvement after the confession. During the first period of the treatment the patient never failed to repeat to her physician: I continue to feel ill, I have the same pains as before, and when she accompanied this by a crafty and malicious glance, I could perhaps recall the words which old Mr. v. R. was wont to utter concerning his favorite daughter: She is frequently pert and disputatious, but after all I had to confess that she was right.
Had I given up the patient at this stage of the psychic treatment the case of Miss Elisabeth v. R. would have been quite unimportant for the theory of hysteria. Nevertheless, I continued my analysis because I felt sure that an understanding of the causation as well as the determination of the hysterical symptoms could be gained from the deeper strata of consciousness.
For this purpose the patient should have been put in deep hypnosis. But unhappily I had to realize that all my procedures in that direction could put the patient in no other state of consciousness than that in which she gave me her confession. Still I was very pleased that this time she abstained from triumphantly remonstrating with the words: You see I really do not sleep, I cannot be hypnotized. In such despair I conceived the idea of making use of the trick of pressing the head, the origin of which I have thoroughly discussed in the preceding contribution concerning Miss Lucy. This was done by requesting the patient to unfailingly inform me of what came before her minds eye or passed through her memory at the moment of the pressure. For a long time she was silent, and then admitted that on my pressure she thought of an evening in which a young man had accompanied her home from some social affair. She also thought of the conversation that passed between them, and her feelings on returning home to nurse her father.
With this first mention of the young man a new shaft was opened, the content of which I now gradually brought out. We dealt here rather with a secret, for with the exception of a mutual friend, no one knew anything of the relation and the hopes connected with it. It concerned the son of an old friend who was formerly one of their neighbors. The young man having become an orphan attached himself with great devotion to her father; he was guided in his career by his advice, and this veneration for the father was extended to the ladies of the family. Numerous reminiscences of repeated joint readings, exchange of thoughts and utterances on his side marked the gradual growth of her conviction that he loved and understood her and that a marriage with him would not impose the sacrifice that she feared. Unhappily he was but little older than she and as yet was far from being independent. She however firmly resolved to wait for him.
With the serious illness of her father, and the necessity of her nursing him their relations became less frequent. The evening which she at first recalled marked the height of her feeling but even then there was no exchange of ideas between them on the subject. It was only at the urging of her family that she consented to leave the sick bed that evening and go to an affair where she was to meet him. She wished to hasten home early but was forced to remain, only yielding on his promising to accompany her home. At no time had she entertained such a tender regard for him as during this walk, but after returning home at a late hour in this blissful state and finding the condition of her father aggravated she bitterly reproached herself for having sacrificed so much time for her own amusement. It was the last time that she left her sick father for a whole evening; her friend she saw but seldom after this. After the death of her father he seemed to hold himself aloof out of respect for her sorrow and then business affairs drew him into other spheres. Gradually she came to the realization that his interest in her was suppressed by other feelings and that he was lost to her. This failure of her first love pained her as often as she thought of it.
In this relationship and in the scene caused by it, I was to seek the causation of the first hysterical pain. A conflict, or a state of incompatibility arose through the contrast between the happiness which she had not at that time denied herself and the sad condition in which she found her father upon her arrival home. As a result of this conflict the erotic presentations were repressed from the associations and the affect connected with them was made use of in aggravating or reviving a simultaneously (or somewhat previously) existing physical pain. It was therefore the mechanism of a conversion for the purpose of defense as I have shown circumstantially in another place.2
To be sure, we have room here for all kinds of observations. I must assert that I was unsuccessful in demonstrating from her memory that the conversion took place in the moment of her returning home. I therefore investigated for similar experiences which might have occurred while she was nursing her father, and I evoked a number of scenes, among which was one during which she had to jump out of bed with bare feet in a cold room to respond to the repeated calls of her father. I was inclined to attribute to this moment a certain significance, for in addition to complaining of pain in her legs she also complained of tormenting sensations of coldness. Nevertheless, here too I could not with certainty lay hold of the scene which could be indicated as the scene of conversion. This led me to admit that there was here some gap, when I recalled the fact that the hysterical pains in the legs were really not present at the time she nursed her father. From her memory she recalled only a single attack of pain lasting a few days to which at that time she paid no attention. I then directed my attention to the first appearance of the pains. In this respect I was successful in awakening a perfect memory. They came on just at the time of a relatives visit whom she could not receive because she was ill in bed, and who had the misfortune to find her ill in bed on another occasion two years later. But the search for the psychic motive of these first pains failed as often as repeated. I believed that I could assume that these first pains were due to a slight rheumatic attack and really had no psychic basis, and I also discovered that this organic trouble was the model for the later hysterical imitation, at all events that it occurred before the scene of being accompanied home. That these mild organic pains could continue for some time without her paying much attention to them is quite possible when we consider the nature of the disease. The obscurity resulting from this, namely, that the analysis pointed to a conversion of psychic excitement into bodily pain at a time when such pain was certainly not perceived and not recalledthis problem I hope to be able to solve in later considerations and by other examples.3
With the discovery of the motive for the first conversion we began a second more fruitful period of the treatment. In the first place very soon afterward the patient surprised me with the statement that she now knew why the pains always radiated from that definite location on the right thigh and were most painful there. This is really the place upon which her fathers leg rested every morning while she changed the bandages of his badly swollen leg. That occurred hundreds of times, and strange to say she did not think of this connection until today. She thus gave me the desired explanation of the origin of an atypical hysterogenic zone. Furthermore during our analysis her painful legs always commenced to join in the discussion. I mean the following remarkable state of affairs: The patient was as a rule free from pain when we began our work, but as soon as I evoked some recollection by question or by pressure of the head she at first reported some pain usually of a very vivid nature, and then winced and placed her hand on the painful area. This awakened pain remained constant as long as the patient was controlled by the recollection, reaching its height when she was about to utter the essential and critical part of her communication, and disappearing with the last words of the statement. I gradually learned to use this awakened pain as a compass. Whenever she was moody or claimed to have pains I knew that she had not told me everything, and urged a continuation of the confession until the pain was spoken away. Then only did I awaken a new recollection.
During this period of ab-reaction, the patients condition showed such a striking improvement both somatically and psychically that I used to remark half jokingly that during each treatment I carried away a certain number of pain motives, and that when I had cleaned them all out she would be well. She soon reached a stage during which she had no pain much of the time; she consented to walk a great deal and to give up her hitherto condition of isolation. During the analysis I followed up now the spontaneous fluctuations of her condition and now some fragments of her sorrowful tale which in my opinion I had not sufficiently exhausted. In this work I made some interesting discoveries the principles of which I could later verify in other patients.
In the first place it was found that the spontaneous fluctuations never occurred unless provoked associatively by the events of the day. On one occasion she heard of an illness in the circle of her acquaintances which recalled to her a detail in the illness of her father. On another occasion the child of her deceased sister visited her and its resemblance to its mother recalled many painful incidents. On still another occasion it was a letter from her absent sister showing distinctly the influence of the inconsiderate brother-in-law, and this awakened a pain causing the reproduction of a family scene heretofore not reported.
As she never reproduced the same pain motives twice we were justified in the expectation that the stock would in time become exhausted. I never prevented her from merging into a situation tending to evoke new memories which had not as yet come to the surface. Thus for example I sent her to the grave of her sister, or I urged her to go in society where she was apt to meet her youthful friend who happened to be in the city.
In this manner I obtained an insight into the mode of origin of a hysteria which could be designated as mono-symptomatic. I found, for example, that the right leg became painful during our hypnosis when we dealt with memories relating to the nursing of her father, to her young friend, and to other memories occurring during the first period of the pathogenic term; while the pain in the left leg came on as soon as I evoked the memory of her lost sister, of both brothers-in-law, in brief of any impression relating to the second half of the history. My attention having been called to that by this constant behavior I went further in my investigations and gained the impression that perhaps detailization went still further and that every new psychic cause of painful feeling might have some connection with a differently located painful area in the legs. The original painful location on the right thigh referred to the nursing of her father, and as the result of new traumas the painful area then grew by apposition so that strictly speaking we had here not one single physical symptom connected with a multiform psychic memory complex but a multiplicity of similar symptoms which on superficial examination seemed to be fused into one. To be sure I have not followed out the demarcations of the individual psychic causes corresponding to the pain zones for I found that the patients attention was turned away from these relations.
Notwithstanding this I directed further interest to the mode of construction of the whole symptom-complex of the abasia upon this painful zone, and with this view in mind I asked such questions as this: What is the origin of the pains in walking and standing, or on lying? She answered these questions partially uninfluenced, partially under the pressure of my hand. We thus obtained two results. In the first place she grouped all scenes connected with painful impressions according to their occurrence, sitting, standing, etc. Thus, for example, she stood at the door when her father was brought home with his cardiac attack and in her fright remained as though rooted to the spot. To this first quotation fright while standing she connected more recollections up to the overwhelming scene when she again stood as if pinned near the death bed of her sister. The whole chain of reminiscences should justify the connection of the pain with standing up, and could also serve as an association proof, only one had to bear in mind the fact that in all these occasions we must demonstrate another moment which had served to direct the attentionand as a further result the conversionjust on the standing, walking, sitting, etc. The explanation for this direction of attention could hardly be sought in other connections than in the fact that walking, standing, and lying are connected with capabilities and conditions of those members which here bore the painful zones; namely, the legs. We could then easily understand the connection between the astasia-abasia and the first scene of conversion in this history.
Among the scenes which in consequence of this review had made the walking painful one which referred to a walk she had taken in company, at the watering place, which apparently lasted too long, stood out most prominently. The deeper circumstances of this occurrence revealed themselves only hesitatingly and left many a riddle unsolved. She was in an especially good humor and gladly joined the circle of friendly persons; it was a lovely day, not too warm, her mother remained at home; her older sister had already departed, the younger one felt indisposed but did not wish to mar her pleasure. The husband of the second sister at first declared that he would remain at home with his wife, but finally went along for her (Elisabeths) sake. This scene seemed to have a great deal to do with the first appearance of the pains, for she recalled that she returned home from the walk very fatigued and with severe pains, she could not however say definitely whether she had perceived the pains before this. I took for granted that if she had suffered any pain she would have hardly resolved to enter upon this long walk. On being questioned whence the pains originated on this walk she answered rather indefinitely saying that the contrast between her solitude and the married happiness of her sick sister, of which she was constantly reminded by the behavior of her brother-in-law, was painful to her.
Another closely related scene played a part in the connection of the pain with sitting. It was a few days later, her sister and brother-in-law had already departed and she found herself in an excitable longing mood. She arose in the morning and ascended a small hill which they were wont to visit together and which afforded the only pretty view. There she sat down on a stone bench giving free play to her thoughts. Her thoughts again concerned her lonesomeness, the fate of her family, and she now frankly admitted that she entertained the eager wish to become as happy as her sister. After this mornings meditation she returned home with severe pains. In the evening of the same day she took the bath, after which the pains definitely appeared and continued persistently.
We could further ascertain with great certainty that the pains on walking and standing diminished in the beginning on lying down. Only after hearing of her sisters illness and on leaving Gastein in the evening, spending a sleepless night in the sleeping car, and being tormented simultaneously by the worries concerning her sister and violent pains, it was only then that the pains appeared for the first time while she was lying down, and throughout that time lying down was even more painful than walking or standing.
Thus the painful sphere grew by apposition first because every new pathogenically affecting theme occupied a new region of the legs, second, every one of the impressionable scenes left a trace because it produced a lasting, always more cumulative, occupation of the different functions of the legs, thus connecting these functions with the sensations of pain. There was unmistakably, however, still a third mechanism which furthered the production of astasia-abasia. When the patient finished the recitation of a whole series of events with the plaint that she then perceived pain in standing alone, and when in another series referring to the unfortunate attempt of bringing about new conditions in the family she was not tired of repeating that the painful in that was the feeling of her helplessness, the sensation that she could make no headway, I had to admit that her reflections influenced the formation of the abasia, and had to assume that she directly sought a symbolic expression for her painfully accentuated thoughts and had found it in the aggravation of her pains. That somatic symptoms of hysteria could originate through such symbolization we have already asserted in our Preliminary Communication, and in the epicrisis to this history. I will give some examples of conclusive evidence. In Miss Elisabeth v. R. the psychic mechanism of the symbolization was not in the foreground, it had not produced the abasia, but everything pointed to the fact that the already existing abasia had in this way undergone a considerable reenforcement. Accordingly this abasia as I met it in the stage of development was not only to be compared to a psychically associative paralysis of function but also to a symbolic paralysis of function.
Before I continue with the history of my patient I will add something about her behavior during the second period of the treatment. Throughout this whole analysis I made use of the method of evoking pictures and ideas by pressing the head, a method therefore, which would be inapplicable without the full cooperation and voluntary attention of the patient. At times it was really surprising how promptly and how infallibly the individual scenes belonging to one theme succeeded each other in chronological order. It was as if she read from a long picture book the pages of which passed in review before her eyes. At other times there seemed to be inhibitions, of what kind I could not at that time surmise. When I exerted some pressure she maintained that nothing came into her mind. I repeated the pressure and told her to wait, but still nothing would come. At first when such obstinacy manifested itself I determined to discontinue the work and to try again, as the day seemed unpropitious. Two observations, however, caused me to change my procedure. Firstly, because such failure of this method only occurred when I found Elisabeth cheerful and free from pain and never when she had a bad day; secondly, because she frequently made assertions of seeing nothing after the lapse of a long pause during which her tense and occupied mind betrayed to me some psychic process within. I therefore decided to assume that the method had never failed, that under the pressure of my hands Elisabeth had each time perceived some idea or had seen some picture but that she was not always ready to inform me of it and attempted to repress the thing evoked. I could thing of two motives for such concealment; either Elisabeth subjected the idea that came to her mind to a criticism to which she was not entitled, thinking it not sufficiently important and unfit as an answer to the question, or she feared to say it because that statement was too disagreeable to her. I therefore proceeded as if I were perfectly convinced of the reliability of my technique. Whenever she asserted that nothing came into her mind, I did not let that pass. I assured her that something must have come to her but that perhaps she was not attentive enough, that I was quite willing to repeat the pressure. I also told her not to entertain any doubts concerning the correctness of the idea presenting itself to her mind, that that was not any of her concern; that it was her duty to remain perfectly objective and to tell whatever came into her mind, be it suitable or not, and I ended by saying that I knew well that something did come which she concealed from me and that as long as she would continue to do so she would not get rid of her pains. After such urging I found that there was really no pressure that remained unsuccessful. I then had to assume that I correctly recognized the state of affairs, and indeed I won through this analysis perfect confidence in my technique. It often happened that only after the third pressure did she make a statement then added Why I could have told you that the first timeIndeed why did you not say itI thought that it was not correct: or I thought that I could avoid it, but it recurred each time. During this difficult work I began to attach a profounder significance to the resistance which the patient showed in the reproduction of her recollections, and I carefully compared these occasions in which it was especially striking.
I now come to the description of the third period of our treatment. The patient felt better, she was psychically unburdened and more capable, but the pains were manifestly not removed, reappearing from time to time with the old severity. The imperfect cure went hand in hand with the imperfect analysis, as yet I did not know in what moment and through what mechanisms the pains originated. During the reproduction of the most manifold scenes of the second period and the observation of the patients resistance towards the reproduction, I formed a definite suspicion which I did not then dare to use as a basis for my action. An accidental observation turned the issue. While working with the patient one day I heard the steps of a man in the adjacent room and a rather pleasant voice asking some questions. My patient immediately arose requesting me to discontinue the treatment for the day because she heard her brother-in-law who just arrived asking for her. Before this disturbance she was free from pains but thereafter she betrayed by her mien and gait the sudden appearance of violent pains. This strengthened my suspicion and I decided to elicit the decisive explanation.
I questioned her concerning the circumstances and causes of the first appearance of the pains. Her thoughts were directed to the summer resort in that watering place where she had been before taking the journey to Gastein. A number of scenes were reproduced which had already been treated less exhaustively. They recalled her frame of mind at that time, the exhaustion following the worriment about her mothers vision and the nursing of her mother during the time of the operation and her final despair at being unable as a lonesome girl to enjoy life or to accomplish anything in life. Until then she felt strong enough to dispense with the help of a man, but now she was controlled by a feeling of her womanly weakness, a yearning for love in which, to put it in her own words, her obdurate self began to soften. In such humor the happy marriage of her younger sister made the profoundest impression on her. She thought how affectionately he cared for her, how they understood each other with a mere glance, and how sure they seemed to be of each other. It was truly regrettable that the second pregnancy followed so quickly the first and her sister knew that this was the cause of her suffering but how willingly she endured it and all because he was the cause of it. The brother-in-law did not at first wish to participate in the walk which was so intimately connected with Elisabeths pain; he preferred to remain home with his sick wife, but the latter urged him with a glance to go because she thought that would give Elisabeth pleasure. Elisabeth remained with him throughout the whole walk; they spoke about the most varied and intimate things; she found herself in a thorough accord with all he said, and she became overwhelmed with the desire to possess a man like him. This was followed by a scene a few days later, when, on the morning after their departure, she visited the point commanding the beautiful view which had been their favorite walk. There she seated herself upon a stone and again dreamed of her sisters happiness and of a man like her brother-in-law who could engage her affections. When she arose she had pains which again disappeared, and only in the afternoon after having taken the warm bath did they reappear, remaining ever since. I attempted to investigate the thoughts which occupied her mind while taking the bath, but all I could obtain was that the bath house recalled her absent sister because she had lived in the same house.
For some time the state of affairs was clear to me. Absorbed in painfully sweet recollections she was wholly unconscious of the drift of her thoughts and continued to reproduce her reminiscences, the time in Gastein, the worry connected with the expectations of the letter, finally the information of her sisters illness, the long wait until the evening when she could first leave Gastein, the journey with its tormenting uncertainties during a sleepless nightall these moments were accompanied by a violent aggravation of the pain. I asked her if during the journey she thought of the sad possibility which she afterward found realized. She answered that she carefully avoided the thought but that in her opinion her mother expected the worst from the very beginning. This was followed by the reminiscences of her arrival in Viennathe impressions which she received from the relatives at the station, the short journey from Vienna to the neighboring summer resort where her sister lived, the arrival in the evening, the hasty walk through the garden to the door of the little garden paviliona silence in the house, the oppressive darkness, the fact of not having been received by the brother-in-law. She then recalled standing before the bed seeing the deceased, and in the moment of the awful certainty that the beloved sister had died without having taken leave of them and without having her last days eased through their nursingin that very moment another thought flashed through Elisabeths brain which now peremptorily repeated itself. The thought which flashed like dazzling lightning through the darkness was, Now he is free again, and I can become his wife.
Of course, now everything was clear. The analyzers effort was richly repaid. The ideas of the defense (abwehr) against an unbearable presentation, the origin of hysterical symptoms through conversion of psychic into physical excitement, the formation of a separate psychic group by an arbitrary act, leading to the defenseall these were in that moment palpably presented before my eyes. Thus and thus alone did things happen here. This girl entertained an affectionate regard for her brother-in-law against the acceptance of which into her consciousness her whole moral being struggled. She succeeded in sparing herself the painful consciousness that she was in love with her sisters husband by creating for herself instead bodily pains, and at the moment when this certainty wished to thrust itself into her consciousness (while she walked with him, during that morning reverie, in the bath, and before her sisters bed) her pains originated by means of a successful conversion into the somatic. When she came under my care there was already a complete isolation from her consciousness of the presentation group referring to this love, else, I believe that she would never have agreed to such a treatment. The resistance which she repeatedly brought forth during the reproduction of traumatically produced scenes really corresponded to the energy with which the unbearable presentation had been crowded out from the association.
For the therapeutist there now came a sorry time. The effect of the resumption of that repressed presentation was a crushing one for the poor child. When I summed up the whole situation with these prosaic words: you were really for a long time in love with your brother-in-law, she complained of the most horrible pains at that moment; she made another despairing effort to reject the explanation, saying that it was not true, that I suggested it to her, it could not be, she was incapable of such baseness, and that she would never forgive herself for it. It was quite easy to prove to her that her own information allowed no other interpretation, but it took a long time before the two reasons that I offered for consolation, namely, that one is not responsible for ones feelings and that her behavior, her sickness under those circumstances was sufficient proof of her moral natureI say it took a long time before these consolations made an impression on her. I was now forced to pursue more than one course in order to calm the patient. In the first place I wished to give her the opportunity to rid herself by ab-reaction of the material long since accumulated. We investigated the first impressions of the relations with her brother-in-law, the beginning of those unconsciously kept affectionate regards. We found here all those little indications and forebodings which on a retrospective view showed a fully developed passion. On his first visit to the house he mistook her for his destined bride and greeted her before he greeted her older and homely sister. One evening they entertained each other so vivaciously and seemed to understand each other so well that the bride interrupted them with this half serious remark: You two, indeed, would have suited each other very nicely. On another occasion while in a gathering who were ignorant of the engagement the conversation drifted to the young man, and a young lady indiscreetly remarked about a blemish in his shape, a juvenile joint affliction. The bride herself remained calm while Elisabeth flew into a passion, and with an ardor which even she herself could not afterward understand she defended the straight form of her future brother-in-law. While we worked our way through these reminiscences it became clear to Elisabeth that her affection for her brother-in-law had slumbered in her for a long time, perhaps since the beginning of their relations, and had concealed itself so long under the mask of a mere kinsmanlike affection as only her very delicate family feeling would allow.
This ab-reaction benefited her much, but I was able to give her still more relief by taking a friendly interest in her present state of affairs. With this object in view I sought an interview with Mrs. v. R. whom I found to be an intelligent and refined lady whose courage to face life, however, was somewhat lessened through the last misfortune. From her I learned that the accusation of rude extortion which the older brother-in-law had brought against the widower, and which was so painful to Elisabeth, had to be retracted on closer investigation. The character of the young man remained untarnished; it was merely a misunderstanding, an easily conceived difference of opinion concerning the valuation of money that could arise between the merchant, to whom money is only a working tool, and the officialthat is all there was to this seemingly so painful incident. I begged the mother to give Elisabeth all explanations that she might hereafter need, and to offer her in the future that opportunity for unburdening her mind to which I had accustomed her.
Naturally I was also anxious to know what chance there was for the fulfillment of the girls present conscious wish. Here things were less favorable! The mother stated that for some time she had had an inkling of Elisabeths affections for her brother-in-law; of course she did not know that it existed during the lifetime of her sister. Whoever saw them both in friendly intercourseof late, to be sure, only seldomcould entertain no doubt of the girls anxiety to please him. However, neither she, her mother, nor the advisers of the family showed any particular inclination to bring about a matrimonial union between the two. The health of the young man had not been very good and had received a setback through the death of his beloved wife, and it was not at all certain that he had sufficiently recovered from the shock to enter into a new matrimony. It was quite probable that this was the reason for his reserve, perhaps also because he was not sure of his position, and wished to avoid all obvious gossip. With such a reserve on both sides the solution for which Elisabeth was yearning was likely to fail.
I informed the girl of everything that I had heard from her mother and had the satisfaction of seeing her benefited by the explanation concerning the money affair. On the other hand, I expected her to bear calmly the uncertainties of her future which could not be set aside. The advancing summer compelled us to bring the treatment to an end. She now felt better, and since we had discussed the causes to which the pain could be traced she no longer complained of pain. We both felt that the work was done, although I thought that the ab-reaction of the suppressed love was really not as complete as it should have been. I regarded her as cured and urged her to continue independently the solution after the way had been cleared, to which she agreed. She left with her mother for a summer resort where they were to join the older sister and her family.
I still have something more to report about the further course of Miss Elisabeth v. R.s disease. A few weeks after our parting I received a despairing letter from her mother informing me that at the first attempt to draw Elisabeth into a conversation about her love affairs she became very excited and refused to talk, and since then had suffered from violent pains. She was very indignant at my having betrayed her confidence and was perfectly inaccessible, so that the treatment seemed a complete failure. She wished to know what was to be done, for of me she would hear nothing. I made no reply. It was to be expected that after she was relieved from my discipline she would make another attempt to reject her mothers interference and return to her inaccessibility. I was, however, quite certain that everything would adjust itself and that my efforts had not been in vain. Two months later they returned to Vienna and the colleague to whom I was grateful for the case informed me that Elisabeth was perfectly well, and that her behavior was normal although occasionally she had slight pains. Since then she has repeatedly sent me similar messages, each time promising to visit me, which she has never done. This is quite characteristic of the personal relationship formed during such treatment. My colleague then assured me that she could be considered cured. The relation of the brother-in-law to the family underwent no change.
In the spring of 1894 I was informed that she would be present at a private ball to which I could gain access. I did not let the opportunity escape me and saw my former patient gliding along in a rapid dance. Since then, following her own inclination, she has married a stranger.
I was not always a psychotherapist but like other neuropathologists I was educated to the use of focal diagnosis and electrical prognosis, so that even I myself am struck by the fact that the histories of the diseases which I write read like novels and, as it were, dispense with the serious features of the scientific character. Yet I must console myself with the fact that the nature of the subject is apparently more responsible for this issue than my own predilection. Focal diagnosis and electrical reactions are really not important in the study of hysteria, whereas a detailed discussion of the psychic processes, as one is wont to receive it from the poet, and the application of a few psychological formulæ, allows one to gain an insight into the course of events of hysteria. Such histories should be considered like psychiatrical ones, but they have the advantage over the latter in the fact that they give the intimate connection between the history of the disease and the morbid symptoms, a thing for which we still look in vain in the biographies of other psychoses.
With the description of the treatment I endeavored to interweave the explanations which I gave about the case of Miss Elisabeth v. R. and it will perhaps be superfluous to summarize here the essential features. I have discussed the character of the patient and the features which repeat themselves in so many hysterics, and which we really can not consider as degenerative. I mentioned the talent, the ambition, the moral sensitiveness, the immense yearning for love which found its gratification in the family, the independence of her nature reaching beyond the womanly ideal which manifested itself largely by obstinacy, readiness for fight, and inaccessibility. According to the information of my colleague no hereditary taints could be shown on either side of the family. Her mother, to be sure, suffered for years from some indefinite neurotic depression, but her brothers and sisters, her father and his family belonged to the even-tempered and not to the nervous. There was no serious case of neuropsychosis in the nearest relatives.
That nursing of the sick plays such a significant rôle in the histories of hysterias has its good reasons. A number of effective moments which are found here are quite obvious, namely, the disturbance of the physical health through interrupted sleep, neglect of nourishment, and the reaction of a constantly gnawing worriment on the vegetative functions; but the most important factor, however, is, in my estimation, to be found elsewhere. He whose mind is occupied with the hundred different tasks of nursing which succeed each other continuously for weeks and months, becomes accustomed, on the one hand, to suppress all signs of his own emotions, and on the other, his attention is soon turned away from his own impressions because he has neither the time nor strength to do them justice. Thus the nurse accumulates for himself an overabundance of affective impressions which he barely perceived clearly enough; at any rate they were not weakened by ab-reaction, that is, he creates for himself the material for a retention hysteria. If the patient recovers these impressions naturally become reduced in value, but if he dies and the period of mourning comes during which only that which refers to the deceased seems of value, the impressions waiting for discharge appear in turn, and after a brief pause of exhaustion the hysteria, the germ of which originated during the nursing, bursts forth.
The same subsequent discharge of traumas accumulated during nursing is occasionally encountered where the general impression of the disease does not ensue, and yet the mechanism of hysteria can be noticed. Thus, I know a highly gifted but slightly nervous lady whose whole personality suggests the hysteric though she never became a burden to the doctor and was never obliged to interrupt the exercise of her duties. This lady had nursed three or four of her beloved ones until their death, causing her each time complete physical exhaustion, yet these sad duties never made her ill. However, shortly after the death of the patient she began the work of reproduction, bringing again to her view the scenes of the disease and death. Each dayone might say at her leisureshe went over again every impression, crying and consoling herself. Such adjustment she passed through daily in conjunction with her usual duties, without, however, confusing the two activities. Everything passed before her chronologically. Whether the memory work of one day precisely corresponded to a day of the past I am unable to say. I presume that it depended on the leisure which was allowed to her by the current affairs of the household.
Aside from this subsequent tear which attached itself to these deaths at short intervals, this lady periodically observed annual anniversaries representing the time of the various catastrophies, and here her vivid visual reproduction and her affective manifestations followed faithfully the date. Thus, for example, I found her in tears, and on sympathetic inquiry as to what occurred that day, she half irritably remarked, Nothing on that day except that Professor N. was again here and gave us to understand that things were hopelessat that time I had no time to cry. She referred to the last illness of her husband who died three years before. It would have been very interesting to know whether she always repeated the same scenes on these recurring anniversaries, or whether as I suppose in the interest of my theory other details presented themselves each time for ab-reaction. I was, however, unable to find anything definite about that; the wise and courageous woman was ashamed of the intensity with which those reminiscences acted upon her.4
I again repeat that this woman was not sick, that subsequent ab-reaction, despite all resemblance, is still not a hysterical process; one may ask why, after one nursing there results a hysteria and after another none. It cannot lie in personal predisposition, for the lady that I have in mind showed it very remarkably.
I now return to Miss Elisabeth v. R. While nursing her father there occurred for the first time an hysterical symptom in the form of a pain in a definite location on the right thigh. The mechanism of this symptom is fully explained on an analytical basis. It occurred in a moment during which the ideas of her duties towards her sick father came into conflict with the content of her erotic yearning which she then entertained. Under vivid self reproach she decided in favor of the former and created for herself the hysterical pain. According to the conception explained by the theory of conversion in hysteria, the process could be described as follows: She repressed the erotic idea from her consciousness and changed the sum of the affect into somatic sensations of pain. Whether this first conflict occurred only once, or repeated itself is not clear. The latter is more probable. Quite a similar conflictof a higher moral significance, and even better demonstrated by the analysisrepeated itself after years and led to the aggravation of the same pain and to its dissemination beyond its original limits. Again, it was an erotic idea which came into conflict with all her moral conceptions, for her affection for her brother-in-law, both during the life and after the death of her sister, and the thought that she should yearn just for this man, was to her very disagreeable. This analysis gives detailed information about this conflict which represents the pivotal point in the history of her malady. The patients affection for her brother-in-law might have begun to germinate long ago, but in favor of its development was the physical exhaustion through the recent nursing, and her moral exhaustion through years of disillusionment which then began to break down her reserve and she confessed to herself the need of the love of a man. During a friendly intercourse continuing for weeks (in the summer resort) this erotic inclination reached its full development simultaneously with the pain. The analysis shows a special psychic condition of the patient at that time, which in connection with her inclination and the pain, seems to afford an understanding of the process in the sense of the conversion theory.
I place reliance on the opinion that the patients affection for her brother-in-law, intensive as it was, was not clearly known to her except on certain rare occasions and then only momentarily. If that were not so she would have become conscious of the inconsistency between this fondness and her moral ideas and would have had to endure the same mental agony which I saw her suffer after the analysis. Her reminiscences gave us no information concerning such suffering. These she spared herself and as a result the love itself did not become clear to her. At that time, as well as during the analysis, her love for her brother-in-law existed in the form of a foreign body in her consciousness without entering into any relationship with her other ideation. In reference to this love there existed the peculiar condition of knowing and simultaneously not knowing, it was the condition of the split-off psychic group. When we assert that this love was not clearly known to her we mean exactly what we say. We do not mean a lower quality or a lesser degree of consciousness, but a separation of the free associative thinking process from the rest of ideation.
How does it come about that such an intensively accentuated presentation group should be kept so isolated? As a rule the rôle played by an idea in the association really increases with the sum of its affect.
This question can be answered if we bear in mind two facts which we can make use of as a safeguard: (1) That the hysterical pains originated simultaneously with the formation of these separate psychic groups, (2) that the patient exerted great resistance against the attempt to bring about the association between the separate psychic groups and the rest of the content of consciousness, and when the union was finally effected she perceived excessive psychic pain. Our conception of hysteria brings together these two moments with the fact of the splitting of consciousness, for (2) contains the indication for the motive for the splitting of consciousness while (1) shows the mechanism of the same. The motive was that of defense, it was the striving of the whole ego to agree with this presentation group and the mechanism was that of conversion, that is, instead of psychic pains which she spared herself there appeared physical pains. Thus a transformation occurred through which pain the patient had escaped an unbearable psychic state, though it was at the cost of a psychic anomaly in the form of a splitting of consciousness and a physical suffering, pains, upon which an astasia-abasia was constructed.
To be sure I can give no instruction as to how one can bring about such a conversion. It is not apparently done as one intentionally does an arbitrary action, it is a process which is executed in the individual under the impulse of the motive of defense if an adaptation for it exists in his organization or is brought about by temporary modification.
One has the right to attack the theory more closely by asking what it is that is transformed into physical pains. The cautious reply will be something out of which psychic pains could have and should have been formed. If we wish to venture further and attempt a kind of algebraic formulation of the presentation mechanism we may attribute to the presentation complex of this unconsciously remaining love a certain amount of affect and designate the latter quantity as the thing converted. Direct deduction of this conception would be the fact that the unconscious love has through such conversion forfeited so much of its intensity that it was reduced to a weak idea. Its existence as a separate psychic group would only be made possible through such weakening. Yet this present case is not suitable to afford us any clearness in this delicate matter. It probably corresponds to an imperfect conversion only. From other cases it seems quite probable that perfect conversions also occur and that in these the unbearable idea actually becomes repressed as only an idea of very little intensity could be repressed. After an associative union has been consummated the patients assure us that since the origin of the hysterical symptoms their unbearable thoughts never occupied their minds.
I have stated above that on certain occasions, though only transitorily, the patient consciously recognized the love for her brother-in-law. Such a moment occurred when for example, at the death bed of her sister the thought flashed through her mind, Now he is free and I can become his wife. I must discuss the significance of these moments for the conception of the whole neurosis. However, I think that the assumption of a defense hysteria (abwehr hysterie) includes the requisite that at least one such moment has already occurred. For consciousness does not know in advance when such an unbearable idea will present itself. The unbearable idea which with its appendix is later excluded for the formation of a separate psychic group must have been originally in the mind, otherwise no conflict would have resulted leading to its exclusion.5 Just such moments should be designated as traumatic. It is in them that the conversion takes place which results in the splitting of consciousness and the hysterical symptoms. Everything tends to show that in Miss Elisabeth v. R. there were a number of such moments (the scenes of the walking, morning meditation, bath, and at the bed of her sister) and perhaps new moments of this kind occurred during the treatment. The multiplicity of such traumatic moments is made possible by the fact that an experience similar to the one which at first initiated the unbearable idea, introduces new emotions to the separated psychic groups and thus transitorily abolishes the success of the conversion. The ego is forced to occupy itself with this suddenly enforced and lighted-up idea, and then to restore the former state by means of new conversions. Miss Elisabeth, who was in constant relation with her brother-in-law, must have been particularly exposed to the appearance of new traumas.
I must now occupy myself with the point which I have designated as a difficulty for the understanding of the aforementioned history. On the analytical basis I assume that the first conversion took place in the patient while she nursed her father, at the time when her duties as nurse came into conflict with her erotic yearnings, and that this process was the prototype for the later ones which led to the outbreak of the disease in the Alpine watering place. But then we have it from the patients statement that at the time of nursing and the period following which I designated as the first period she had not suffered at all from the pains and weakness. To be sure, during the illness of her father she was once bedridden for a few days with pains in her legs, but it is doubtful whether this attack already belonged to the hysteria. A causal relation between these first pains and any psychic impressions could not be demonstrated by analysis; it is possible, even probable, that at that time we dealt with a common rheumatic muscular pain. Even if we should assume that this first attack of pain was the result of a hysterical conversion in consequence of the rejection of the erotic thoughts then existing, the fact nevertheless remains that the pains disappeared after a few days, so that the patient actually behaved differently than she did during the analysis. During the reproduction of the so called first period all her statements concerning the illness and death of her father, the impressions relating to her first brother-in-law, etc., all these were accompanied by manifestations of pain, while at the time she really experienced these impressions she perceived no pains. Is this not a contradiction tending to considerably diminish the confidence in the explanatory value of such an analysis?
I believe that I can explain the contradiction by assuming that the painsthe product of the conversiondid not originate while the patient experienced the impressions during the first period, but subsequently, that is, in the second period when the patient reproduced these impressions in her mind. The conversion did not follow the fresh impressions but the memories of them. I even believe that such a process is not at all unusual in hysteria and regularly participates in creating hysterical symptoms. Nevertheless, as such an assertion does not seem plausible I shall attempt to make it more credible by citing other experiences.
Miss Rosalia H., twenty-three years old, who for a number of years made great effort to educate herself as a singer, complained that her beautiful voice did not obey her in certain notes. There appeared choking and tightening sensations in the throat so that the tones sounded strained, and her teacher could therefore not allow her to appear in public. Although this imperfection affected only her middle notes it could not be explained to be due to a defect of her vocal organs, for at times this disturbance was absent and her teacher was very pleased with her, but at other times the slightest excitement, seemingly without any provocation, evoked the choking sensation, and prevented free expansion of the voice. It was not difficult to recognize in this annoying sensation an hysterical conversion. Whether there really appeared a contracture of certain muscles of the vocal chords I have not verified.6 In the hypnotic analysis which I undertook with this girl I found out the following concerning her vicissitudes and her ailments occasioned through them. She became an orphan at an early age and was brought up at the house of an aunt who had many children of her own, and she thus shared the life of a most unfortunate family. The husband of this aunt, seemingly a pathological personality, abused his wife and children in the most brutal manner and especially pained her by his sexual preference for the servant girl in the house. This became even more obnoxious as the children grew older. When the aunt died Rosalia became the protectress of the orphaned children who were harassed by their father. She took her duties seriously, fought through all conflicts and had to exert her greatest efforts to suppress the manifestations of her contempt for her uncle. It was then that the choking sensation in her throat originated. Whenever she was compelled to swallow an affront, whenever she had to remain silent on hearing a provoking accusation she perceived a scratching in her throat, the tightening and failure of her voice; in brief she had all the localized sensations in her larynx and pharynx which now disturbed her in singing. It was conceivable that she sought the possibility of making herself independent in order to escape the excitement and painful impressions which were daily occurrences in her uncles house. An efficient music teacher took an unselfish interest in her, assuring her that her voice entitled her to choose the profession of singing. She began secretly to take lessons of him and because she often went for her lessons with the choking sensation in her throat following some violent scene in the house, a connection was formed between the singing and the hysterical paresthesia for which a way was prepared by the sensitiveness of the organ during singing. The apparatus of which she should have had free control was filled with the remnants of innervation after those numerous scenes of repressed excitement. Since then she has left the house of her uncle, having moved to another city so as to be away from the family, but her ailments were not benefited by it. No other hysterical symptoms were discovered in this pretty and unusually bright girl.
I endeavored to cure this retention-hysteria by a reproduction of all the exciting impressions and by subsequent ab-reaction. I afforded her the opportunity of railing against her uncle in long speeches and of telling him the bare truth to his face, etc. The treatment benefited her, but unfortunately she lived here under quite unfavorable conditions. She had no luck with her relatives. She was the guest of another uncle who treated her with friendliness, but just for that reason she incurred the displeasure of her aunt. The latter believed that her husband evinced too marked an interest in his niece and made it a point of opposing the girls stay in Vienna. She herself in her youth was obliged to relinquish a desire of becoming an artist and was now jealous of her niece because she had the opportunity to develop her talent not considering that it was not mere desire but a wish to become independent which led her niece to take this step. Rosalia felt so uncomfortable in the house that she for instance, did not dare to sing or play the piano when her aunt was within hearing distance, and carefully avoided either singing or playing anything for her aged unclebrother of her motherwhenever her aunt was home. While I was endeavoring to efface the traces of the old excitements, new ones originated through these relations with her host and finally interfered with the success of my treatment and prematurely interrupted the cure.
One day the patient came to me with a new symptom hardly twenty-four hours old. She complained of a disagreeable prickling sensation in the fingertips which had manifested itself every few hours since the day before and forced her to make very peculiar jerky movements with the fingers. I could not see the attack, otherwise I would have guessed its meaning on seeing the finger movements but I immediately endeavored to trace through hypnotic analysis the causation of this symptom (it was really a minor hysterical attack). As the whole thing only existed for a short time I hoped to be able to explain it and quickly remove it. To my surprise without any hesitation she reproduced in chronological order a whole row of scenes beginning in her early childhood. All these had perhaps the same characteristics in the fact that she had suffered an injustice without defense, something which could make her fingers jerk, for example, scenes like the one of being forced to hold out her hand in school while her teacher struck it with a ruler. But they were all banal causes the right of which to enter into the etiology of an hysterical symptom I have already opposed. It was different, however, with one scene of her early girlhood which was connected with the others. The bad uncle who suffered from rheumatism asked her to massage his back. She did not dare refuse him. He was in bed while she was doing it and suddenly threw off the covers, jumped up, attempting to get hold of her and throw her down. Naturally she stopped the massage and in a moment escaped and locked herself within her own room. She evidently did not like to recall this experience and could not say whether she had seen anything when the man suddenly exposed himself. The sensations of the fingers could be explained as due to the suppressed impulse to punish him, or it might simply have originated from the fact that she was at that time massaging him. Only after this scene did she begin to talk about the one experienced yesterday after which the sensitiveness and jerkiness of the fingers appeared as a recurring memory symbol. The uncle with whom she now lived begged her to play something for him. She sat at the piano and accompanied herself singing, believing that her aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up, closed the piano, and flung away the sheet of music. We can guess what memories came to her mind, and the train of thought which she tried to ward off at that moment, for the exasperation brought on by the unjust accusation should have really urged her to leave the house, but on account of her illness she was forced to remain in Vienna and had no other shelter. The movement of the fingers which I saw during the reproduction of this scene resembled a continuous jerking, as if one literally and figuratively would reject something like throwing away a sheet of music or rejecting an unreasonable demand.
She was quite positive in her assurance that she did not perceive the symptom before, that it was not caused by the scenes previously related. Was there anything else to be assumed except that the scene experienced yesterday had in the first place awakened the recollection of a former similar content and that then the formation of a memory symbol for the whole group of recollections took place? The conversion was on the one hand furnished with newly experienced affects, on the other with recollected affects.
When we consider this state of affairs we must admit that in the origin of hysterical symptoms such a process is the rule rather than the exception. Whenever I seek for the determinants of such states I frequently find not a single but a group of similar traumatic motives. In some cases it could be ascertained that this particular symptom had already existed for a short time after the first trauma and then subsided, but reappeared after the next trauma and become fixed. Yet no real distinction can be made between the temporary appearance and the latency after the first motives. In a large majority of cases it was also found that the first traumas had left no symptoms, while a later trauma of the same kind produced a symptom for the origin of which the cooperation of the former motives could not be dispensed with and for the solution of which it really required a consideration of all the motives. Translating this into the language of the conversion theory we will say that this undeniable fact of the summation of the traumas and the erstwhile latency of the symptoms simply means that the conversion can be brought about from a fresh as well as from a remembered affect, and this assumption fully explains the contradiction which seems to exist in the history and analysis of Miss Elisabeth v. R.
There is no question that normal persons carry in their consciousness in considerable numbers the continuation of ideas with unadjusted affects. The theory which I just asserted merely approximates the behavior of hysteria to the normal. It is apparently reduced to a quantitative moment; it is simply a question of how many such affective strains an organization can endure. Even a hysterical person will be able to retain a certain amount in an unadjusted state, but if through a summation of similar motives it increases beyond the individuals endurance, the impetus for conversion is formed. It is therefore no singular theory but almost a postulate to say that the formation of hysterical symptoms may also be brought about at the cost of recollected affects.
I have now occupied myself with the motive and mechanism of this case of hysteria, it still remains to discuss the determination of the hysterical symptoms. Why should just the pains in the legs be selected to represent the psychic pains? The circumstances of the case point to the fact that this somatic pain was not created by the neurosis but was merely utilized, aggravated, and retained by it. I will add that in most of the cases of hysterical algias into which I have been able to gain an insight the conditions were similar, that is, there was to begin with always a real organically founded pain. It is always the most common, the most widespread pains of humanity that seem to be most frequently called upon to play a part in hysteria. Among the most common are the periosteal and neuralgic pains of the teeth, headaches which originate from so many different sources, and not in a lesser degree the so often mistaken rheumatic pains of the muscles. The first attack of pain which Miss Elisabeth v. R. had while she nursed her father, I consider to have been organically determined, for I received no information when I investigated for its psychic motive, and I admit that I am inclined to attribute differential diagnostic significance to my methods of evoking hidden memories if they are carefully applied. This original rheumatic pain7 became in the patient the memory symbol for her painful psychic emotions, and as far as I can see, for more than one reason. First and principally because it existed in consciousness almost simultaneously with the other excitements, and second because it was or could be connected in many ways with the ideation of that time. At all events it was perhaps a remote consequence of the nursing, of her want of exercise, and the poor nutrition entailed by her duties as nurse. But this hardly became clear to the patient, and what is more important is the fact that she had to perceive it during significant moments of the nursing, as for example, when she jumped out of bed in the cold room to respond to her fathers call. Even more decisive for the direction taken by the conversion must have been the other manner of associative connection, namely, the fact that for many days one of her painful legs came in contact with the swollen leg of her father during the changing of bandages. The location on the right leg distinguished by this contact remained henceforth the focus and starting point of the pains, an artificial hysterogenic zone the origin of which can be plainly seen in this case.
If any one should be surprised at the associative connection between physical pain and psychic affect, thinking it to be too manifold and artificial, I should answer that such surprise is just as unfair as to be surprised over the fact that just the richest in the world possess most money. Where prolific connections do not exist there is naturally no formation of hysterical symptoms, and conversion does not find its way. I can also state that in reference to determinations the case of Miss Elisabeth v. R. belongs to the simpler ones. In the case of Mrs. Cäcilie M. particularly, I had to solve the most intricate knots of this kind.8
I have already discussed in the history of the case how the astasia-abasia of our patient was built up on those pains after the conversion had taken definite direction. But there, too, I have expressed the opinion that the patient has created or aggravated the disturbance of function through symbolization. For her dependence and helplessness to change anything in the circumstances she found a somatic expression in the astasia-abasia, and the expressions to make no headway, to have no support, etc., formed the bridge for this new act of conversion. I will endeavor to support this conception by other examples.
Conversion on the basis of coincidence in otherwise existing associative connections seems to exert the slightest claims on the hysterical predisposition; on the other hand conversion through symbolization seems to require a higher grade of hysterical modification, a fact also demonstrated in Miss Elisabeth in the later stages of her hysteria. The prettiest examples of symbolization I have observed in Mrs. Cäcilie M.,9 whom I can call my most difficult and most instructive case. I have already mentioned that this history does not unfortunately lend itself to detailed reproduction.
Among other things Mrs. Cäcilie also suffered from a most violent facial neuralgia which appeared suddenly two or three times during the year and persisted for from five to ten days, resisting every remedy, and ceased as if cut off. It limited itself to the second and third branches of the trigeminus, and as there was undoubtedly an excess of urates in the urine, and as a not very clear acute rheumatism played a certain part in the patients history it was reasonable to assume that we dealt with a gouty neuralgia. This opinion was also shared by the consulting physicians who saw every attack. The neuralgia was treated with the methods in vogue, such as electric penciling, alkaline waters and purgatives, but it always remained uninfluenced until it was convenient to make room for another symptom. In former yearsthe neuralgia was fifteen years oldthe teeth were accused of preserving it and were condemned to extraction, and one fine morning under narcosis the execution of seven of the culprits took place. That did not run so smoothly as the teeth were so firm that most of the roots were left behind. This cruel operation was followed by neither temporary nor permanent relief. At that time the neuralgia raged for months. Even while under my care whenever she had neuralgia the dentist was called and he always declared he found diseased roots. He commenced to get ready for such work but usually he was soon interrupted, for the neuralgia suddenly ceased and with it the desire for the dentist. During the intervals the teeth did not ache at all. One day just while another attack was raging I put the patient into a hypnotic condition and placed an energetic interdiction on the pains, and from that moment they ceased. I then began to doubt the genuineness of this neuralgia.
About a year after this hypnotic remedial success the condition of Mrs. Cäcilie M. took a new and surprising turn. There suddenly appeared other states than those that had been characteristic of the last years, but after some reflection the patient declared that all these conditions had existed in her before and were really scattered over the long period of her disease (thirty years). Indeed a surprising abundance of hysterical incidents were unrolled which the patient was able to localize correctly in the past and soon the frequently very entangled thought connections which determined the sequence of these incidents became recognizable. It was like a series of pictures with an explanatory text. Pitres, on describing his délire ecmnésique, must have had in mind a similar case. The way such a hysterical condition belonging to the past was reproduced was most remarkable. In the first place while the patient was in the best of condition there appeared a pathological mood of special coloring which was regularly mistaken by the patient and was referred to a banal occurrence of the last hours. This increasing obnubilation of consciousness was followed by hysterical symptoms, such as hallucinations, pains, convulsions, and long declamations, and finally an event of the past attached itself to this hallucinatory manifestation which could explain the initial mood and determine the occasional symptoms. With this last part of the attack lucidity returned, the ailments disappeared as if by magic and good health again existeduntil the next attack which was half a day later. Usually I was called at the height of this condition. I produced hypnosis, evoked a reproduction of the traumatic events, and by artificial aid I curtailed the attack. Having gone through with the patient many hundreds of such cycles, I obtained the most instructive explanations concerning the determinants of hysterical symptoms. The joint observation with Breuer of this remarkable case was also the chief motive for the publication of our Preliminary Communication.
In this connection it finally came to the reproduction of the facial neuralgia which I myself had still treated as actual attacks. I was desirous of knowing whether we would find here a psychic causation. When I attempted to evoke the traumatic scene, the patient soon imagined herself in a period during which she felt marked psychic sensitiveness against her husband. She related a conversation with him and a remark that he made which aggravated her very much. She then suddenly grasped her cheek, crying aloud with pain, and said, That was like a slap in the facewith this both the attack and the pain came to an end. There is no doubt that here, too, we dealt with a symbolization. She had felt as if she really received a slap in the face. Now everybody will ask how the sensation of a slap in the face can lead to the manifestations of a trigeminal neuralgia, to its limiting itself to the second and third branch, and to its being aggravated on opening the mouth and mastication (not by talking!).
The following day the neuralgia reappeared, but this time it could be solved by the reproduction of another scene the content of which equally showed a supposed insult. This process continued for nine days; from the result it seemed that for years, aggravations, especially through words, produced new attacks of this facial neuralgia by way of symbolization.
But finally we also succeeded in reproducing the first attack of the neuralgia which occurred more than fifteen years before. Here there was no symbolization but a conversion through coincidence. It was a painful sight which recalled to her mind a reproach and this caused her to repress another series of thoughts. We have here, then, a case of conflict and defense, and the origin of the neuralgia in this moment could not be explained if we do not wish to assume that she then suffered from slight toothache or facial pains, a thing not improbable, as she was then in the first months of pregnancy.
The result of the explanation showed that this neuralgia became the mark of a definite psychic excitement through the usual road of conversion but that afterward it could be awakened through associative reminiscences of thoughts and symbolic conversions. It was really the same procedure as encountered in Miss Elisabeth v. R.
I will now introduce another example which will illustrate the efficacy of symbolization under other determinants. On one occasion Mrs. Cäcilie M. was tormented by a violent pain in her right heel, experiencing stinging sensations which made walking impossible. The analysis conducted us to a time when the patient was in a foreign institution. For eight days she lay in her room, and for the first time the house physician was to take her to the dining room. The pain came on while the patient took the physicians arm on leaving the room. It disappeared during the reproduction of this scene while she remarked that at that time she feared lest she would not make the proper impression on this strange society10 (rechte Auftreten).
This seems a striking, almost comical example for the origin of hysterical symptoms through symbolization by means of an expression of speech. But a closer investigation of the circumstances of that moment will favor another conception. The patient at that time suffered from pain in her feet on account of which she remained in bed, and we can only assume that the fear which obsessed her on taking the first steps produced from the simultaneously existing pains the one symbolically appropriate symptom in the right heel so as to form it into a psychic algia and to particularly fit it for long duration.
Notwithstanding the fact that the mechanism of symbolization in these examples seems to be crowded to second rank, that which certainly corresponds to the rule, I have still other examples at my disposal which seem to demonstrate the origin of hysterical symptoms through symbolization only. One of the best is the following example which again refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed watched by her austere grandmother. The girl suddenly cried out complaining of having perceived a pain in the forehead between the eyes which thereafter continued for weeks. On analyzing this pain, which was reproduced after almost thirty years, she stated that her grandmother gazed at her so piercingly that it seemed as if her look penetrated deeply into her brain. She was really afraid of being looked upon suspiciously by this old lady. On reproducing this thought she burst into loud laughter and the pain ceased. Here I find nothing other than the mechanism of symbolization which in a way stands midway between the mechanism of auto-suggestion and that of conversion.
The study of Mrs. Cäcilie M. gave me the opportunity to gather a collection of such symbolizations. A whole series of physical sensations which were otherwise looked upon as organically determined were of a psychic origin, or at least furnished with a psychic interpretation. A certain number of her experiences were accompanied by a piercing sensation in the region of the heart (I felt a stitch in my heart). The piercing headache of hysteria was undoubtedly, in her case, to be interpreted as thought pains (something sticks in my head), and it disappeared each time when the problem in question was solved. The sensation of the hysterical aura in the throat, when it manifested itself during an aggravation, ran parallel with the thought, I have to swallow that. There was a whole series of parallel running sensations and ideas in which it was now the sensation evoking the idea as an interpretation and now the idea which produced the sensation by symbolization, and not seldom it remained obscure which was the primary element of the two.
In no other patient was I able to find such a prolific application of symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual and of a special artistic temperament whose highly developed sense for form manifested itself in very beautiful poems. I maintain, however that if a hysteria creates through symbolization a somatic sensation for the emotionally accentuated presentation, it is due less to individual and arbitrary things than one supposes. When during an offending harangue she takes literally such phrases as stitch in the heart or slap in the face, and perceives them as real occurrences she practices no facetious misuse but only revives the sensations to which this phrase thanks its existence. For how does it happen that in speaking of an aggrieved person we use such expressions as he experienced a stitch in his heart, if the mortification was not actually accompanied by a precordial sensation that could be so interpreted and recognized? Is it not probable that the phrase to swallow something applied to an unreturned insult really originates from the sensation of innervation appearing in the pharynx when one forces back his speech, thus preventing a reaction to the insult? All these sensations and innervations belong to the expression of the emotions, which as Darwin taught us, originally consisted of sensible and expedient actions; at present most of them may be so weakened that their expression in speech seems to us like a figurative transformation, but very probably all this was once meant literally, and hysteria is justified in reconstructing the original literal sense for its stronger innervation. Indeed, perhaps it is improper to say that it creates such sensations through symbolization, perhaps it has not taken the usage of speech as a model, but both originated from a common source.11
Note 1. It will be shown that, notwithstanding, I erred. [back]
Note 2. Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894. [back]
Note 3. I can neither exclude nor prove that this pain, especially of the thighs, was of a neurasthenic nature. [back]
Note 4. To my surprise I once discovered that such subsequent ab-reactionthrough other impressions than nursingmay form the content of an otherwise enigmatic neurosis. It was the case of a pretty girl of nineteen, Miss Matilda H., whom I first saw with an incomplete paralysis of the legs and months afterward I was again called because her character had changed. She was depressed and tired of living, entertaining lack of consideration for her mother, and was irritable and inapproachable. The whole picture of the patient did not seem to me to be that of an ordinary melancholia. She could easily be put into a somnambulic state, and I made use of this peculiarity to impart to her each time commands and suggestions to which she listened in her profound sleep and responded with profuse tears, but which, however, caused but little change in her condition. One day while hypnotized she became talkative and informed me that the reason for her depression was the breaking of her betrothal many months before. She stated that on closer acquaintance with her fiance the things displeasing to her and her mother became more and more evident. On the other hand, the material advantages of the engagement were too tangible to make the decision of a rupture easy, thus, both of them hesitated for a long time. She then merged into a condition of indecision in which she allowed everything to pass apathetically and finally her mother pronounced for her the decisive no. Shortly after, she awoke as from a dream and began to occupy herself fervently with the thoughts about the broken betrothal, she began to weigh the pros and cons, a process which she continued for some time. At present she continues to live in that time of doubt, and entertains daily the moods and the thoughts which would have been appropriate for that day. The consideration the circumstances that existed on that decisive day. Next to this thought activity she found her present life a mere phantom just irritability against her mother could only be explained if we took into like a dream. I did not again succeed in getting the girl to talkI continued my exhortations during deep somnambulism. I saw her each time burst into tears without however receiving any answer from her. But one day, it was near the anniversary of the engagement, the whole state of depression disappeared. This was attributed to my great hypnotic cure. [back]
Note 5. It is different in a hypnoid hysteria. Here the content of the separate psychic groups may never have been in the ego consciousness. [back]
Note 6. I had under my observation another case in which a contracture of the masseters made it impossible for the artist to sing. The young lady in question through painful experiences in the family was forced to go on the stage. While in Rome rehearsing, in great excitement she suddenly perceived the sensation of being unable to close her opened mouth and sank fainting to the floor. The physician who was called closed her jaws forcibly, but the patient since that time was unable to open her jaws more than a fingers breadth and had to give up her newly chosen profession. When she came under my care many years later, the motives for that excitement were apparently over for some time, for massage in a light hypnosis sufficed to open her mouth widely. The lady has since sung in public. [back]
Note 10. The literal translation of Auftreten is to press down by treading. [back]
Note 11. In conditions of profounder psychic changes we apparently find a symbolic stamp (mark) of the more artificial usage of language in the form of emblematic pictures and sensations. There was a time in Mrs. Cäcilie M. during which every thought was changed into an hallucination, and which solution frequently afforded great humor. She at that time complained to me of being troubled by the hallucination that both her physicians, Breuer and I, were hanged in the garden on two nearby trees. The hallucination disappeared after the analysis revealed the following origin: The evening before Breuer refused her request for a certain drug. She then placed her hopes on me but found me just as inflexible. She was angry at both of us, and in her affect she thought, They are worthy of each other, the one is a pendant of the other! [back]