Conversion on the basis of coincidence in otherwise existing associative connections seems to exert the slightest claims on the hysterical predisposition; on the other hand conversion through symbolization seems to require a higher grade of hysterical modification, a fact also demonstrated in Miss Elisabeth in the later stages of her hysteria. The prettiest examples of symbolization I have observed in Mrs. Cäcilie M.,[[24]] whom I can call my most difficult and most instructive case. I have already mentioned that this history does not unfortunately lend itself to detailed reproduction.
Among other things Mrs. Cäcilie also suffered from a most violent facial neuralgia which appeared suddenly two or three times during the year and persisted for from five to ten days, resisting every remedy, and ceased as if cut off. It limited itself to the second and third branches of the trigeminus, and as there was undoubtedly an excess of urates in the urine, and as a not very “clear acute rheumatism” played a certain part in the patient’s history it was reasonable to assume that we dealt with a gouty neuralgia. This opinion was also shared by the consulting physicians who saw every attack. The neuralgia was treated with the methods in vogue, such as electric pencilling, alkaline waters and purgatives, but it always remained uninfluenced until it was convenient to make room for another symptom. In former years—the neuralgia was fifteen years old—the teeth were accused of preserving it and were condemned to extraction, and one fine morning under narcosis the execution of seven of the culprits took place. That did not run so smoothly as the teeth were so firm that most of the roots were left behind. This cruel operation was followed by neither temporary nor permanent relief. At that time the neuralgia raged for months. Even while under my care whenever she had neuralgia the dentist was called and he always declared he found diseased roots. He commenced to get ready for such work but usually he was soon interrupted, for the neuralgia suddenly ceased and with it the desire for the dentist. During the intervals the teeth did not ache at all. One day just while another attack was raging I put the patient into a hypnotic condition and placed an energetic interdiction on the pains, and from that moment they ceased. I then began to doubt the genuineness of this neuralgia.
About a year after this hypnotic remedial success the condition of Mrs. Cäcilie M. took a new and surprising turn. There suddenly appeared other states than those that had been characteristic of the last years, but after some reflection the patient declared that all these conditions had existed in her before and were really scattered over the long period of her disease (thirty years). Indeed a surprising abundance of hysterical incidents were unrolled which the patient was able to localize correctly in the past and soon the frequently very entangled thought connections which determined the sequence of these incidents became recognizable. It was like a series of pictures with an explanatory text. Pitres, on describing his délire ecmnésique must have had in mind a similar case. The way such a hysterical condition belonging to the past was reproduced was most remarkable. In the first place while the patient was in the best of condition there appeared a pathological mood of special coloring which was regularly mistaken by the patient and was referred to a banal occurrence of the last hours. This increasing obnubilation of consciousness was followed by hysterical symptoms, such as hallucinations, pains, convulsions, and long declamations, and finally an event of the past attached itself to this hallucinatory manifestation which could explain the initial mood and determine the occasional symptoms. With this last part of the attack lucidity returned, the ailments disappeared as if by magic and good health again existed—until the next attack which was half a day later. Usually I was called at the height of this condition. I produced hypnosis, evoked a reproduction of the traumatic events, and by artificial aid I curtailed the attack. Having gone through with the patient many hundreds of such cycles, I obtained the most instructive explanations concerning the determinants of hysterical symptoms. The joint observation with Breuer of this remarkable case was also the chief motive for the publication of our “Preliminary Communication.”
In this connection it finally came to the reproduction of the facial neuralgia which I myself had still treated as actual attacks. I was desirous of knowing whether we would find here a psychic causation. When I attempted to evoke the traumatic scene, the patient soon imagined herself in a period during which she felt marked psychic sensitiveness against her husband. She related a conversation with him and a remark that he made which aggravated her very much. She then suddenly grasped her cheek, crying aloud with pain, and said, “That was like a slap in the face”—with this both the attack and the pain came to an end. There is no doubt that here, too, we dealt with a symbolization. She had felt as if she really received a slap in the face. Now everybody will ask how the sensation of “a slap in the face” can lead to the manifestations of a trigeminal neuralgia, to its limiting itself to the second and third branch, and to its being aggravated on opening the mouth and mastication (not by talking!).
The following day the neuralgia reappeared, but this time it could be solved by the reproduction of another scene the content of which equally showed a supposed insult. This process continued for nine days; from the result it seemed that for years, aggravations, especially through words, produced new attacks of this facial neuralgia by way of symbolization.
But finally we also succeeded in reproducing the first attack of the neuralgia which occurred more than fifteen years before. Here there was no symbolization but a conversion through coincidence. It was a painful sight which recalled to her mind a reproach and this caused her to repress another series of thoughts. We have here, then, a case of conflict and defense, and the origin of the neuralgia in this moment could not be explained if we do not wish to assume that she then suffered from slight toothache or facial pains, a thing not improbable, as she was then in the first months of pregnancy.
The result of the explanation showed that this neuralgia became the mark of a definite psychic excitement through the usual road of conversion but that afterward it could be awakened through associative reminiscences of thoughts and symbolic conversions. It was really the same procedure as encountered in Miss Elisabeth v. R.
I will now introduce another example which will illustrate the efficacy of symbolization under other determinants. On one occasion Mrs. Cäcilie M. was tormented by a violent pain in her right heel, experiencing stinging sensations which made walking impossible. The analysis conducted us to a time when the patient was in a foreign institution. For eight days she lay in her room, and for the first time the house physician was to take her to the dining room. The pain came on while the patient took the physician’s arm on leaving the room. It disappeared during the reproduction of this scene while she remarked that at that time she feared lest she would not make the “proper impression” on this strange society[[25]] (“rechte Auftreten”).
This seems a striking, almost comical example for the origin of hysterical symptoms through symbolization by means of an expression of speech. But a closer investigation of the circumstances of that moment will favor another conception. The patient at that time suffered from pain in her feet on account of which she remained in bed, and we can only assume that the fear which obsessed her on taking the first steps produced from the simultaneously existing pains the one symbolically appropriate symptom in the right heel so as to form it into a psychic algia and to particularly fit it for long duration.
Notwithstanding the fact that the mechanism of symbolization in these examples seems to be crowded to second rank, that which certainly corresponds to the rule, I have still other examples at my disposal which seem to demonstrate the origin of hysterical symptoms through symbolization only. One of the best is the following example which again refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed watched by her austere grandmother. The girl suddenly cried out complaining of having perceived a pain in the forehead between the eyes which thereafter continued for weeks. On analyzing this pain, which was reproduced after almost thirty years, she stated that her grandmother gazed at her so “piercingly” that it seemed as if her look penetrated deeply into her brain. She was really afraid of being looked upon suspiciously by this old lady. On reproducing this thought she burst into loud laughter and the pain ceased. Here I find nothing other than the mechanism of symbolization which in a way stands midway between the mechanism of auto-suggestion and that of conversion.