Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

Epicrisis.

I would not underestimate the aforesaid case even though it only represents a young and light hysteria presenting but few symptoms. Moreover, it seems to me instructive that even such a slight neurotic affliction requires so many psychic determinants, and on a more exhaustive consideration of this history I am tempted to put it down as an illustration of that form of hysteria which even persons not burdened by heredity may acquire if their experiences favor it. It should be well noted that I do not speak of a hysteria which may be independent of all predisposition; such form does not probably exist, but we speak of such a predisposition only after the person became hysterical, as nothing pointed to it before this. A neuropathic disposition as commonly understood is something different. It is determined even before the disease by a number of hereditary burdens, or a sum of individual psychic abnormalities. As far as I know none of these moments could be demonstrated in the case of Miss Lucy R. Her hysteria could therefore be called acquired and presupposes nothing except probably a very marked susceptibility to acquire hysteria, a characteristic about which we know hardly anything. The chief importance in such cases lies in the nature of the trauma, to be sure in connection with the reaction of the person to the trauma. It is an indispensable condition for the acquirement of hysteria that there should arise a relation of incompatibility between the ego and some of its approaching presentations. I hope to be able to show in another place how a variety of neurotic disturbances originate from the different procedures which the “ego” pursues in order to free itself from that incompatibility. The hysterical form of defence, for which a special adaptation is required, consists in converting the excitement into physical innervation. The gain brought about by this process is the crowding out of the unbearable presentation from the ego consciousness, which then contains instead the physical reminiscences produced by conversion—in our case the subjective sensation of smell—and suffers from the affect which is more or less distinctly adherent to these reminiscences. The situation thus produced is no longer changeable, for changing and conversion annihilate the conflict which helped towards the adjustment of the affect. Thus the mechanism producing hysteria corresponds on the one hand to an act of moral faint heartedness, on the other hand it presents itself as a protective arrangement at the command of the ego. There are many cases in which it must be admitted that the defense of the increased excitement through the production of hysteria may actually have been most expedient, but more frequently one will naturally come to the conclusion that a greater measure of moral courage would have been an advantage to the individual.

Accordingly the real traumatic moment is that, in which the conflict thrusts itself upon the ego and the latter decides to banish it. Such banishment does not annihilate the opposing presentation but merely crowds it into the unconscious. This process, occurring for the first time, forms a nucleus and point of crystallization for the formation of a new psychic group separated from the ego, around which, in the course of time, everything collects in accord with the opposing presentation. The splitting of consciousness in such cases of acquired hysteria is thus a desired and intentional one, and is often initiated by at least one arbitrary act. But literally, something different happens than the individual expects, he would wish to eliminate a presentation as though it never came to pass but only succeeds in isolating it psychically.

The traumatic moment in the history of our patient corresponds to the scene created by the master on account of the kissing of the children. For the time being this scene remained without any palpable effects, perhaps it initiated the depression and sensitiveness, but I leave this open;—the hysterical symptoms, however, commenced later in moments which can be designated as “auxiliary,” and which may be characterized by the fact that in them there is a simultaneous flowing together of both separated groups just as in the broadened somnambulic consciousness. The first of these moments in which the conversion took place in Miss Lucy R., was the scene at the table when the chief accountant attempted to kiss the children. The traumatic memory helped along, and she acted as though she had not entirely banished her attachment for her master. In other cases we find that these different moments come together and the conversion occurs directly under the influence of the trauma.

The second auxiliary moment repeated almost precisely the mechanism of the first. A strong impression transitorily reestablished the unity of consciousness and the conversion takes the same route opened to it in the first. It is interesting to note that the symptom occurring second concealed the first so that it could not be distinctly perceived until the second was eliminated. The reversal of the succession of events to which also the analysis must be adapted seems to me quite remarkable. In a whole series of cases I found that the symptoms which came later covered the first, and only the last thing in the analysis contained the key to the whole.

The therapy here consisted in forcing the union of the dissociated psychic groups with the ego consciousness. It is remarkable that the success did not run parallel with the accomplished work, the cure resulted suddenly only after the last part was accomplished.

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 nature—one 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 hyperalgesic skin or muscles of her legs were pinched or pressed her face assumed a peculiar expression approaching nearer pleasure than pain, she cried out and—I had to think of a pleasurable tickling—her 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 hyperalgesic 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 Franklin’s 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 poet’s words,

“That mask indicates a hidden meaning.”[^[16]]

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 mother’s 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 father’s 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 affection 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 Elisabeth’s 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 Elisabeth’s 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 reality—that 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 Elisabeth’s 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 wife’s 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 estranged— without 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 girl’s position, we can but extend to Miss Elisabeth our hearty sympathy. But what is the physician’s 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 one’s 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.

I therefore decided to put the direct question to the broadened consciousness of the patient, in order to find out with what psychic impression the origin of the pain in the legs was connected.

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 mind’s 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.[^[17]]

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 relative’s 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 recalled—this problem I hope to be able to solve in later considerations and by other examples.[^[18]]

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 father’s 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 patient’s 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 monosymptomatic. 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 patient’s 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 attention—and as a further result the conversion—just 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 (Elisabeth’s) 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 morning’s 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 sister’s 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 reinforcement. 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 think 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 time”—“Indeed why did you not say it”—“I 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 those 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 patient’s 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 mother’s 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 Elisabeth’s 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 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 sister’s 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 sister’s illness, the long wait until the evening when she could first leave Gastein, the journey with its tormenting uncertainties during a sleepless night—all 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 Vienna—the 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 pavilion—a 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 nursing—in that very moment another thought flashed through Elisabeth’s 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 analyzer’s 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 defense—all 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 sister’s husband by creating for herself instead bodily pains, and in 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 sister’s 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 one’s feelings and that her behavior, her sickness under those circumstances was sufficient proof of her moral nature—I 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 official—that 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 fulfilment of the girl’s present conscious wish. Here things were less favorable! The mother stated that for some time she had had an inkling of Elisabeth’s affection 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 intercourse—of late, to be sure, only seldom—could entertain no doubt of the girl’s 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 mother’s 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.