The study of Mrs. Cäcilie M. gave me the opportunity to gather a collection of such symbolizations. A whole series of physical sensations which were otherwise looked upon as organically determined were of a psychic origin, or at least furnished with a psychic interpretation. A certain number of her experiences were accompanied by a piercing sensation in the region of the heart (“I felt a stitch in my heart”). The piercing headache of hysteria was undoubtedly, in her case, to be interpreted as thought pains (“something sticks in my head”), and it disappeared each time when the problem in question was solved. The sensation of the hysterical aura in the throat, when it manifested itself during an aggravation, ran parallel with the thought, “I have to swallow that.” There was a whole series of parallel running sensations and ideas in which it was now the sensation evoking the idea as an interpretation and now the idea which produced the sensation by symbolization, and not seldom it remained obscure which was the primary element of the two.
In no other patient was I able to find such a prolific application of symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual and of a special artistic temperament whose highly developed sense for form manifested itself in very beautiful poems. I maintain, however, that if a hysteria creates through symbolization a somatic sensation for the emotionally accentuated presentation, it is due less to individual and arbitrary things than one supposes. When during an offending harangue she takes literally such phrases as “stitch in the heart” or “slap in the face,” and perceives them as real occurrences she practices no facetious misuse but only revives the sensations to which this phrase thanks its existence. For how does it happen that in speaking of an aggrieved person we use such expressions as “he experienced a ‘stitch in his heart,’” if the mortification was not actually accompanied by a precordial sensation that could be so interpreted and recognized? Is it not probable that the phrase “to swallow something” applied to an unreturned insult really originates from the sensation of innervation appearing in the pharynx when one forces back his speech thus preventing a reaction to the insult? All these sensations and innervations belong to the “expression of the emotions,” which as Darwin taught us, originally consisted of sensible and expedient actions; at present most of them may be so weakened that their expression in speech seems to us like a figurative transformation, but very probably all this was once meant literally, and hysteria is justified in reconstructing the original literal sense for its stronger innervation. Indeed, perhaps it is improper to say that it creates such sensations through symbolization, perhaps it has not taken the usage of speech as a model, but both originated from a common source.[[26]]
CHAPTER IV.
The Psychotherapy of Hysteria.
In our “Preliminary Communication” we have stated that while investigating the etiology of hysterical symptoms we have also discovered a therapeutic method which we consider of practical significance. “We found, at first to our very greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeeded in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process giving free play to the affect” (p. [4]).
We furthermore attempted to explain how our psychotherapeutic method acts. “It does away with the effects of the original not ab-reacted to ideas by affording an outlet to the suppressed affect through speech. It brings it into associative correction by drawing it into normal consciousness (in mild hypnosis), or it is done away with through the physician’s suggestion just as happens in somnambulism with amnesia” (p. [13]).
Although the essential features of this method have been enumerated in the preceding pages, a repetition is unavoidable, and I shall now attempt to show connectedly how far reaching this method is, its superiority over others, its technique, and its difficulties.
I.
I, for my part, may state that I can adhere to the “Preliminary Communication,” but I must confess that after continuous occupation for years with the problems therein touched, I was confronted with new views, as a result of which the former material underwent at least a partial change in grouping and conception. It would be unjust to impute too much of the responsibility for this development to my honored friend, J. Breuer. I therefore take the weight of responsibility upon myself.
In attempting to use Breuer’s method of treating hysterical symptoms in a great number of patients by investigation and ab-reaction in hypnosis, I encountered two obstacles, the pursuit of which led me to change the technique as well as the conception. (1) Not all persons were hypnotizable who undoubtedly showed hysterical symptoms, and in whom there most probably existed the same psychic mechanism. (2) I had to question what essentially characterizes hysteria, and in what it differs from other neuroses.
How I overcame the first difficulty, and what it taught me, I will show later. I will first state what position I have taken in my daily practice towards the second problem. It is very difficult to examine a case of neurosis before it has been subjected to a thorough analysis, such as would result only through the application of Breuer’s method. But before we have such a thorough knowledge we are obliged to decide upon the diagnosis and kind of treatment. Hence the only thing remaining for me was to select such cases for the cathartic method which could, for the time being, be diagnosed as hysteria, and which showed some or many stigmata, or the characteristic symptoms of hysteria. Yet it sometimes happened that in spite of the diagnosis of hysteria the therapeutic results were very poor, and even the analysis revealed nothing of importance. At other times I attempted to treat cases which no one took for hysteria by Breuer’s method, and I found that I could influence them, and even cure them. Such, for example, was my experience with obsessions, the real obsessions of Westphal’s type, cases which did not show a single feature of hysteria. Thus the psychic mechanism revealed in the “Preliminary Communication” could not be pathognomonic of hysteria. Nor could I for the sake of this mechanism throw so many neuroses into the same pot with hysteria. From all the investigated doubts I finally seized upon a plan to treat all the other neuroses in question just like hysteria, to investigate the etiology and the form of psychic mechanisms, and to leave the diagnosis of hysteria to be dependent upon the result of this investigation.