Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

Epicrisis.

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.

This nature was acted upon by painful emotions, the foremost of which was the debilitating influence of a long attendance upon her beloved sick father.

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 over abundance 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 day—one might say at her leisure—she 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 catastrophes, 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 hopeless—at 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.[^[19]]

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 conflict—of a higher moral significance, and even better demonstrated by the analysis—repeated 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 patient’s 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 patient’s 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 gain 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.[^[20]] 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 afore mentioned 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 patient’s 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 pains—the product of the conversion—did 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.

It once happened to me during a similar analysis that a new hysterical symptom was formed during the treatment so that I could attempt its removal on the day after its origin.

I will describe the essential features of the history of this patient. They are simple but not without interest.

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.[^[21]] 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 uncle’s 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 girl’s 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 uncle—brother of her mother—whenever 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 individual’s 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 pain[^[22]] 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 father’s 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.[^[23]] particularly, I had to solve the most intricate knots of this kind.

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.,[^[24]] 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 patient’s 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 pencilling, alkaline waters and purgatives, but it always remained uninfluenced until it was convenient to make room for another symptom. In former years—the neuralgia was fifteen years old—the 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 existed—until 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 face”—with 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 physician’s 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 society[^[25]] (“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.[^[26]]

CHAPTER IV.
The Psychotherapy of Hysteria.

In our “Preliminary Communication” we have stated that while investigating the etiology of hysterical symptoms we have also discovered a therapeutic method which we consider of practical significance. “We found, at first to our very greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeeded in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process giving free play to the affect” (p. [4]).

We furthermore attempted to explain how our psychotherapeutic method acts. “It does away with the effects of the original not ab-reacted to ideas by affording an outlet to the suppressed affect through speech. It brings it into associative correction by drawing it into normal consciousness (in mild hypnosis), or it is done away with through the physician’s suggestion just as happens in somnambulism with amnesia” (p. [13]).

Although the essential features of this method have been enumerated in the preceding pages, a repetition is unavoidable, and I shall now attempt to show connectedly how far reaching this method is, its superiority over others, its technique, and its difficulties.