Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

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.