Selected papers on hysteria and other psychoneuroses · Sigmund Freud
CHAPTER III. THE CASE OF MISS ELISABETH V. R.
In the fall of 1892 I was requested by a friendly colleague to examine a young lady who had suffered from pains in her legs for over two years and who walked badly. He also added that he diagnosed the case as hysteria, though none of the usual symptoms of the neurosis could be found. He stated that he knew something of the family and that the last few years had brought them much misfortune and little pleasure. At first the father of the patient died, then the mother underwent a serious operation for the eyes, and soon thereafter a married sister succumbed to a chronic cardiac affection after childbirth. Our patient had taken an active part in all the afflictions and in all the nursings of the sick. I made no further progress into the case after I had seen the twenty-four-year-old patient for the first time. She seemed intelligent and psychically normal and her affliction, which interfered with her social relations and pleasure, she bore with a happy mien, thus vividly recalling the “belle indifference” of hysterics. She walked with the upper part of her body bent forward, but without any support; her gait did not correspond to any known pathological gait and it was in no way strikingly bad.
She complained of severe pains on walking, of early fatigue in walking as well as standing, and after a brief period she would seek rest in which the pains became diminished but they by no means disappeared. The pain was of an indefinite nature—one could assume it to be a painful fatigue. The seat of the pain was given as a quite extensive but indefinitely circumscribed location on the superficial surface of the right thigh. It was from this area that the pains radiated and where they were of the greatest intensity. Here, too, the skin and muscles were especially sensitive to pressure and pinching, while needle pricks were rather indifferently perceived. The same hyperalgesia of the skin and muscles was demonstrable, not only in this area, but over almost the entire surface of both legs. The muscles were perhaps more painful than the skin, but both kinds of pains were unmistakably most pronounced over the thighs. The motor power of the legs was not diminished, the reflexes were of average intensity and all other symptoms were lacking, so that there was no basis for the assumption of a serious organic affection. The disease developed gradually during two years and changed considerably in its intensity.
I did not find it easy to determine the diagnosis, but for two reasons I concluded to agree with my colleague. First, because it was rather peculiar that such a highly intelligent patient should not be able to give anything definite about the character of her pains. A patient suffering from an organic pain, if it is not accompanied by any nervousness will be able to describe it definitely and calmly; it may perhaps be lancinating, appearing at certain intervals, extending from this to that location, and in his opinion it may be evoked by this or that influence. The neurasthenic describing his pain gives the impression of being occupied with some difficult mental problem reaching far beyond his powers. His features are tense and distorted as though under the domination of a painful affect, his voice becomes shriller, he struggles for expression, he rejects all designations that the physician makes for his pains, even though they are undoubtedly afterwards found as appropriate. He is ostensibly of the opinion that language is too poor to give expression to his feelings. His sensations are something unique, they never existed before so that they can not be exhaustively described. He never tires of constantly adding new details and when he has to stop he is surely controlled by the impression that he was unsuccessful in making himself understood to the physician. All this is due to the fact that his pains absorb his whole attention. In the case of Miss v. R. we had just the opposite behavior and we had to conclude from this that she attributed sufficient significance to the pain, but that her attention was concentrated on something else of which the pains were the accompanying phenomena, perhaps on thoughts and sensations which were connected with the pain.
A still greater determination for the conception of the pain must however, be found in a second moment. If we irritate a painful area in a patient suffering from an organic disease or neurasthenia his physiognomy will show a definite expression of discomfort or of physical pain. Furthermore, the patient winces, refuses to be examined and assumes a defensive attitude. With Miss v. R. when the hyperalgesic skin or muscles of her legs were pinched or pressed her face assumed a peculiar expression approaching nearer pleasure than pain, she cried out and—I had to think of a pleasurable tickling—her face reddened, she threw her head backward, closed her eyes, and her body bent backward; all this was not very distinct but sufficiently marked so that it could only agree with the conception that her affliction was a hysteria and that the irritation touched a hysterogenic zone. Her mien was not in accord with the pain which the pinching of the muscles and skin were supposed to excite. It probably harmonized better with the content of the thoughts which were behind the pain and which were evoked in the patient by irritating that part of the body associated with them. I have repeatedly observed similar significant expressions on irritating hyperalgesic zones in unmistakable cases of hysteria. The other gestures evidently corresponded to the slightest indications of a hysterical attack.
We could not at that time find any explanation for the unusual localization of the hysterogenic zone. That the hyperalgesia chiefly concerned the muscles gave material for reflection. The most frequent affliction causing the diffuse and local pressure sensitiveness of the muscles is the rheumatic infiltration of the same, the common chronic muscular rheumatism about which aptitude to mask nervous affections I have already spoken. The consistency of the painful muscles in Miss v. R. did not contradict this assumption, as there were many hard cords in the muscle masses which seemed to be especially sensitive. There was probably also an organic change in the muscles, in the assumed sense, upon which the neurosis rested and which significance was markedly exaggerated by the neurosis. The therapy followed out was based on a supposition of a mixed affection. We recommended the continuation of a systematic massage and faradization of the sensitive muscles without regard to the pain produced, and in order to remain in communication with the patient I undertook the treatment of her legs by means of strong Franklin’s sparks. To her question whether she should force herself to walk we answered decidedly in the affirmative. We thus attained a slight improvement. She particularly liked the painful shocks of the influence machine and the stronger they were the more they seemed to suppress her pains. My colleague meanwhile prepared the soil for the psychic treatment, and when after four weeks of sham treatment I proposed the same and gave the patient some explanations concerning the procedures and its effects I found a ready understanding and only slight resistances.
The work which then began became eventually the most arduous that ever befell my lot, and the difficulty of giving an account of this work ranks well with the obstacles that had to be overcome. For a long time, too, I did not understand the connection between the history of the disease and the affliction, a thing which should really have been caused and determined by this row of events. When one undertakes a cathartic treatment he at first asks himself whether the patient understands the origin and cause of her suffering. If that is so one does not need any special technique to cause her to reproduce the history of her ailment. The interest shown in her, the understanding which we foreshadow, the hope of recovery extended to her, all these will induce the patient to give up her secrets. With Miss Elisabeth it seemed probable to me right from the very beginning that she was conscious of the reasons for her suffering, that she had only a secret but no foreign body in consciousness. On looking at her one had to think of the poet’s words, “That mask indicates a hidden meaning.”[16]
At first I could thus forego hypnosis, reserving it, however, for future use if in the course of the confession conditions should arise for which explanation the memory would not perhaps suffice. Thus in this first complete analysis of a hysteria which I had undertaken, I reached a process of treatment which later I raised into a method and employed it consciously in the process of removing by strata the pathogenic psychic material which we used to compare with the technique of excavating a buried city. I at first allowed the patient to relate to me what was known to her, paying careful attention wherever a connection remained enigmatical or where a link in the chain of causation seemed to be lacking. Later I penetrated into the deeper strata of memory by using for those locations hypnotic investigation or a similar technique. The presupposition of the whole work was naturally the expectation that a perfect and sufficient determination could be demonstrated. The means of the deeper investigation will soon be discussed. The history which Miss Elisabeth gave was very dull and was woven of manifold painful experiences. During this recital she was not in a hypnotic state; I merely asked her to lie down and keep her eyes closed. I however made no objection if she from time to time opened her eyes, changed her position or sat up. Whenever she entered more deeply into a part of her history she seemed to merge spontaneously into a condition resembling a hypnotic state. She then remained motionless and kept her eyes firmly closed.
I shall now reproduce the results of the superficial strata of her memory. As the youngest of three daughters she spent her youth with her parents, to whom she was devotedly attached, on their estate in Hungary. Her mother’s health was frequently disturbed by an affliction of her eyes and also by nervous conditions. It thus happened that she became especially and devotedly attached to her jovial and broadminded father who was wont to say that this daughter took the place of both a son and friend with whom he could exchange his thoughts. As much as the girl gained in mental stimulation in consequence of this intercourse it did not escape the father that her psychic constitution deviated from that ideal which one so much desires to see in a girl. Jocosely he called her pert and disputatious. He warned her against being too confident in her judgments, against her tendencies to tell the truth regardlessly to everybody, and expressed his opinion that she would find it difficult to get a husband. As a matter of fact she was very discontented with her girlhood; she was filled with ambitious plans, wishing to study or obtain a musical education, and revolted at the thought of being forced to give up her inclination to sacrifice her freedom of judgment on account of marriage. Meanwhile she was proud of her father, of the regard and social position of her family, and jealously guarded everything connected with these matters. The indifference with which she treated her mother and older sisters, as will be shown, was considered by her parents to be due to the blunter side of her character.
The age of the girls impelled the family to move into the metropolis, where for a time Elisabeth enjoyed the richer and gayer life. But then came the calamity which destroyed the happiness of the home. The father either concealed or overlooked a chronic cardiac affection, and one day he was brought home in an unconscious state after the first attack of edema of the lungs. This was followed by an illness of one and a half years, during which Elisabeth took the most prominent part in nursing him. She slept in her father’s room, awoke at night at his call, watched over him faithfully during the day, and forced herself to appear cheerful while he went through a hopeless condition with amiable resignation. The beginning of her affection must have been connected with this time of her nursing, for she could recall that during the last half year of this care she had to remain in bed on one occasion for a day and a half on account of severe pain in the leg. She maintained, however, that these pains soon passed away and excited neither worry nor attention. As a matter of fact it was two years after the death of her father that she began to feel sick and became unable to walk on account of pain.
The gap which the father left in the life of this family consisting of four women, the social solitude, the cessation of so many relations which promised stimulation and pleasure, the increased infirmity of the mother, all these clouded the mood of our patient, but simultaneously stimulated a warm desire that the family might soon find a substitute for the lost happiness and urged her to concentrate her entire devotion and care on the surviving mother. At the end of the mourning year the eldest sister married a talented and ambitious man of notable position, who by his mental capacity seemed to be destined for a great future, but who, however, very soon developed a morbid sensitiveness and egotistic perseveration of moods, and dared to show his disregard for the old lady in the family circle. That was more than Elisabeth could endure. She felt herself called upon to take up the fight against her brother-in-law whenever he gave occasion for it, while the other women took lightly the outburst of his excited temperament. To her it was a painful disillusionment to find that the reconstruction of the old family happiness experienced such a disturbance. She could not forgive her married sister because with feminine docility she strove to avoid espousing her cause. Thus a whole series of scenes remained in Elisabeth’s memory to which were attached a number of partially uttered grievances against her first brother-in-law. But what she reproached him most for was the fact that for the sake of a promotion in view he moved with his small family to a distant city in Austria and thus increased the lonesomeness of her mother. On this occasion Elisabeth distinctly felt her inability and helplessness to afford her mother a substitute for the lost happiness, and the impossibility of following out the resolution made at the death of her father.
The marriage of the second sister seemed to promise more for the future of the family. The second brother-in-law, although not of the same mental calibre as the first, was a man after the heart of delicate ladies, and his behavior reconciled Elisabeth to the matrimonial institution and to the thought of the sacrifice connected with it. What is more the second couple remained near her mother, and the child of this brother-in-law and the second sister became Elisabeth’s pet. Unfortunately the year during which the child was born was clouded by another event. The visual affliction of the mother demanded many weeks’ treatment in a dark room, in which Elisabeth participated. Following this an operation proved necessary and the excitement connected with this occurred at the same time that the first brother-in-law made preparations to move. Finally the operation, skilfully performed, proved successful, and the three families met at a summer resort. There Elisabeth, exhausted by the worries of the past months, had the first opportunity to recuperate from the effects of the suffering and anxiety that the family had undergone since the death of her father. But during the time spent at this resort Elisabeth was attacked by the pain and weakness. Afterwards, the pains, which had become noticeable for a short while some time previously, manifested themselves severely for the first time after taking a warm bath at a small watering place. In connection with this it was thought that a long walk, really a walk of half a day, a few days, previously, had some connection with the onset of the pains. This readily produced the impression that Elisabeth at first became “fatigued” and then “caught cold.”
From this time on Elisabeth became the patient in the family. Following the advice of the physician she spent the rest of the summer in the watering place at Gastein, whither she went with her mother, but not without having a new worriment to think about. The second sister was again pregnant and information as to her condition was quite unfavorable, so that Elisabeth could hardly decide to take the journey to Gastein. After barely two weeks at Gastein both mother and sister were recalled as the patient at home did not feel well. An agonizing journey, which for Elisabeth was a mixture of pain and anxious expectations, was followed by certain signs at the home railroad station which forebode the worst, and then on entering the chamber of the patient they were confronted with the reality—that they arrived too late to take leave of the dying one. Elisabeth not only suffered from the loss of this sister whom she dearly loved but was also grieved by the thoughts caused by her death and the changes which it caused. The sister had succumbed to heart trouble which was aggravated by the pregnancy.
She then conceived the thought that the heart trouble was the paternal inheritance. It was then recalled that in her early childhood the deceased went through an attack of chorea with a slight heart affection. The family then blamed themselves and the physicians for permitting the marriage. They could not spare reproaches to the unfortunate widower for impairing the health of his wife by two successive pregnancies without any pause. The sad thought that this happiness should terminate thus, after the rare conditions for a happy marriage had been found, thereafter constantly occupied Elisabeth’s mind. Moreover, she again saw everything fail that she had planned for her mother. The widowed brother-in-law was inconsolable and withdrew from his wife’s family. It seemed that his own family from whom he was estranged during his short and happy married life took advantage of the opportunity to again draw him into their own circle. There was no way of maintaining the former union; to live together with the mother-in-law was improper out of regard for the unmarried sister-in-law, and inasmuch as he refused to relinquish the child, the only legacy of the deceased, to the two ladies, he for the first time gave them the opportunity of accusing him of heartlessness. Finally, and that was not the least painful thing, Elisabeth received some indefinite information concerning a disagreement between the two brothers-in-law, the occasion for which she could only surmise. It seemed as if the widower made some requests concerning financial matters which the other brother-in-law considered unjustifiable, and thought, that in view of the recent sorrow of his mother, it was nothing but an evil extortion. This then was the history of the young woman of ambitious and loving disposition. Resentful of her fate, embittered over the failures of her little plans to restore the lustre of the home; of her beloved ones, some being dead, some away, and some estranged— without any inclination to seek refuge in the love of a strange man, she lived thus for a year and a half nursing her mother and her pains, separated from almost, all social intercourse.
If we forget the greater sufferings and place ourselves in this girl’s position, we can but extend to Miss Elisabeth our hearty sympathy. But what is the physician’s interest in this sorrowful tale; what is its relation to her painful and her weak gait; what outlook is there for explaining and curing this case by the knowledge which we perhaps obtained from these psychic traumas? For the physician this confession of the patient signified at first a great disappointment, for to be sure it was a history composed of banal mental shocks from which we could neither explain why the patient became afflicted with hysteria nor how the hysteria assumed the form of the painful abasia. It explained neither the causation nor the determination of the hysteria in question. We could perhaps assume that the patient had formed an association between her psychically painful impressions and bodily pains which she accidentally perceived simultaneously, and that now she made use in her memory of the physical sensation as a symbol for the psychic. What motive she had for this substitution and in what moment this came about remained unexplained. To be sure, these were questions whose nature was not familiar to the physicians. For it was customary to content one’s self with the information and to assume that the patient was constitutionally hysterical and that under the intensive pressure of any kind of excitement hysterical symptoms could develop.
Even less than for the explanation did this confession offer for the treatment of the case. One could not conceive what beneficial influence Miss Elisabeth could derive from recounting sad familiar family experiences of the past years to a stranger who could give her in return only moderate sympathy, nor could we perceive any improvement after the confession. During the first period of the treatment the patient never failed to repeat to her physician: “I continue to feel ill, I have the same pains as before,” and when she accompanied this by a crafty and malicious glance, I could perhaps recall the words which old Mr. v. R. was wont to utter concerning his favorite daughter: “She is frequently pert and disputatious,” but after all I had to confess that she was right. Had I given up the patient at this stage of the psychic treatment the case of Miss Elisabeth v. R. would have been quite unimportant for the theory of hysteria. Nevertheless, I continued my analysis because I felt sure that an understanding of the causation as well as the determination of the hysterical symptoms could be gained from the deeper strata of consciousness. I therefore decided to put the direct question to the broadened consciousness of the patient, in order to find out with what psychic impression the origin of the pain in the legs was connected.
For this purpose the patient should have been put in deep hypnosis. But unhappily I had to realize that all my procedures in that direction could put the patient in no other state of consciousness than that in which she gave me her confession. Still I was very pleased that this time she abstained from triumphantly remonstrating with the words: “You see, I really do not sleep, I cannot be hypnotized.” In such despair I conceived the idea of making use of the trick of pressing the head, the origin of which I have thoroughly discussed in the preceding contribution concerning Miss Lucy. This was done by requesting the patient to unfailingly inform me of what came before her mind’s eye or passed through her memory at the moment of the pressure. For a long time she was silent, and then admitted that on my pressure she thought of an evening in which a young man had accompanied her home from some social affair. She also thought of the conversation that passed between them, and her feelings on returning home to nurse her father.
With this first mention of the young man a new shaft was opened, the content of which I now gradually brought out. We dealt here rather with a secret, for with the exception of a mutual friend, no one knew anything of the relation and the hopes connected with it. It concerned the son of an old friend who was formerly one of their neighbors. The young man having become an orphan attached himself with great devotion to her father; he was guided in his career by his advice, and this veneration for the father was extended to the ladies of the family. Numerous reminiscences of repeated joint readings, exchange of thoughts and utterances on his side marked the gradual growth of her conviction that he loved and understood her and that a marriage with him would not impose the sacrifice that she feared. Unhappily he was but little older than she and as yet was far from being independent. She however firmly resolved to wait for him.
Text from Project Gutenberg, public domain in the United States.