On being visited by Miss Lucy R. two days after the last analysis I had to ask her what pleasant things happened to her. She looked as though transformed, she smiled and held her head aloft. For a moment I thought that after all I probably mistook the conditions and that the governess of the children had now become the bride of the master. But she soon dissipated all my suppositions, saying, “Nothing new happened. You really do not know me. You have always seen me while I was sick and depressed. I am otherwise always cheerful. On awaking yesterday morning my burden was gone and since then I feel well.”—“What do you think of your chances in the house?”—“I am perfectly clear about that. I know that I have none, and I am not going to be unhappy about it.”—“Will you now be able to get along with the others in the house?”—“I believe so, because most of the trouble was due to my sensitiveness.”—“Do you still love the master?”—“Certainly I love him, but that does not bother me much. One can think and feel as one wishes.”
I now examined her nose and found that the pain and the reflex sensations had almost completely reappeared. She could distinguish odors, but she was uncertain when they were very intense. What part the nasal trouble played in the anosmia I must leave undecided.
The whole treatment extended over a period of nine weeks. Four months later I accidentally met the patient at one of our summer resorts—she was cheerful and stated that her health continued to be good.
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.