Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

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.