Selected papers on hysteria and other psychoneuroses · Sigmund Freud
CHAPTER III. THE CASE OF MISS ELISABETH V. R.
With the serious illness of her father, and the necessity of her nursing him their relations became less frequent. The evening which she at first recalled marked the height of her feeling, but even then there was no exchange of ideas between them on the subject. It was only at the urging of her family that she consented to leave the sick bed that evening and go to an affair where she was to meet him. She wished to hasten home early but was forced to remain, only yielding on his promising to accompany her home. At no time had she entertained such a tender regard for him as during this walk, but after returning home at a late hour in this blissful state and finding the condition of her father aggravated she bitterly reproached herself for having sacrificed so much time for her own amusement. It was the last time that she left her sick father for a whole evening; her friend she saw but seldom after this. After the death of her father he seemed to hold himself aloof out of respect for her sorrow and then business affairs drew him into other spheres. Gradually she came to the realization that his interest in her was suppressed by other feelings and that he was lost to her. This failure of her first love pained her as often as she thought of it.
In this relationship and in the scene caused by it, I was to seek the causation of the first hysterical pain. A conflict, or a state of incompatibility arose through the contrast between the happiness which she had not at that time denied herself and the sad condition in which she found her father upon her arrival home. As a result of this conflict the erotic presentations were repressed from the associations, and the affect connected with them was made use of in aggravating or reviving a simultaneously (or somewhat previously) existing physical pain. It was therefore the mechanism of a conversion for the purpose of defense as I have shown circumstantially in another place.[17] To be sure, we have room here for all kinds of observations. I must assert that I was unsuccessful in demonstrating from her memory that the conversion took place in the moment of her returning home. I therefore investigated for similar experiences which might have occurred while she was nursing her father, and I evoked a number of scenes, among which was one during which she had to jump out of bed with bare feet in a cold room to respond to the repeated calls of her father. I was inclined to attribute to this moment a certain significance, for in addition to complaining of pain in her legs she also complained of tormenting sensations of coldness. Nevertheless, here, too I could not with certainty lay hold of the scene which could be indicated as the scene of conversion. This led me to admit that there was here some gap, when I recalled the fact that the hysterical pains in the legs were really not present at the time she nursed her father. From her memory she recalled only a single attack of pain lasting a few days to which at that time she paid no attention. I then directed my attention to the first appearance of the pains. In this respect I was successful in awakening a perfect memory.
They came on just at the time of a relative’s visit whom she could not receive because she was ill in bed, and who had the misfortune to find her ill in bed on another occasion two years later. But the search for the psychic motive of these first pains failed as often as repeated. I believed that I could assume that these first pains were due to a slight rheumatic attack and really had no psychic basis, and I also discovered that this organic trouble was the model for the later hysterical imitation, at all events that it occurred before the scene of being accompanied home. That these mild organic pains could continue for some time without her paying much attention to them is quite possible when we consider the nature of the disease. The obscurity resulting from this, namely, that the analysis pointed to a conversion of psychic excitement into bodily pain at a time when such pain was certainly not perceived and not recalled—this problem I hope to be able to solve in later considerations and by other examples.[18]
With the discovery of the motive for the first conversion we began a second more fruitful period of the treatment. In the first place very soon afterward the patient surprised me with the statement that she now knew why the pains always radiated from that definite location on the right thigh and were most painful there. This is really the place upon which her father’s leg rested every morning while she changed the bandages of his badly swollen leg. That occurred hundreds of times, and strange to say she did not think of this connection until today. She thus gave me the desired explanation of the origin of an atypical hysterogenic zone. Furthermore during our analysis her painful legs always commenced to “join in the discussion.” I mean the following remarkable state of affairs: The patient was as a rule free from pain when we began our work, but as soon as I evoked some recollection by question or by pressure of the head she at first reported some pain usually of a very vivid nature, and then winced and placed her hand on the painful area. This awakened pain remained constant as long as the patient was controlled by the recollection, reaching its height when she was about to utter the essential and critical part of her communication, and disappearing with the last words of the statement. I gradually learned to use this awakened pain as a compass. Whenever she was moody or claimed to have pains I knew that she had not told me everything, and urged a continuation of the confession until the pain was “spoken away.” Then only did I awaken a new recollection.
During this period of ab-reaction, the patient’s condition showed such a striking improvement both somatically and psychically that I used to remark half jokingly that during each treatment I carried away a certain number of pain motives, and that when I had cleaned them all out she would be well. She soon reached a stage during which she had no pain much of the time; she consented to walk a great deal and to give up her hitherto condition of isolation. During the analysis I followed up now the spontaneous fluctuations of her condition and now some fragments of her sorrowful tale which in my opinion I had not sufficiently exhausted. In this work I made some interesting discoveries the principles of which I could later verify in other patients. In the first place it was found that the spontaneous fluctuations never occurred unless provoked associatively by the events of the day. On one occasion she heard of an illness in the circle of her acquaintances which recalled to her a detail in the illness of her father. On another occasion the child of her deceased sister visited her and its resemblance to its mother recalled many painful incidents. On still another occasion it was a letter from her absent sister showing distinctly the influence of the inconsiderate brother-in-law, and this awakened a pain causing the reproduction of a family scene heretofore not reported.
As she never reproduced the same pain motives twice we were justified in the expectation that the stock would in time become exhausted. I never prevented her from merging into a situation tending to evoke new memories which had not as yet come to the surface. Thus for example I sent her to the grave of her sister, or I urged her to go in society where she was apt to meet her youthful friend who happened to be in the city. In this manner I obtained an insight into the mode of origin of a hysteria which could be designated as monosymptomatic. I found, for example, that the right leg became painful during our hypnosis when we dealt with memories relating to the nursing of her father, to her young friend, and to other memories occurring during the first period of the pathogenic term; while the pain in the left leg came on as soon as I evoked the memory of her lost sister, of both brothers-in-law, in brief of any impression relating to the second half of the history. My attention having been called to that by this constant behavior I went further in my investigations and gained the impression that perhaps detailization went still further and that every new psychic cause of painful feeling might have some connection with a differently located painful area in the legs. The original painful location on the right thigh referred to the nursing of her father, and as the result of new traumas the painful area then grew by apposition so that strictly speaking we had here not one single physical symptom connected with a multiform psychic memory complex but a multiplicity of similar symptoms which on superficial examination seemed to be fused into one. To be sure I have not followed out the demarcations of the individual psychic causes corresponding to the pain zones for I found that the patient’s attention was turned away from these relations.
Notwithstanding this I directed further interest to the mode of construction of the whole symptom-complex of the abasia upon this painful zone, and with this view in mind I asked such questions as this: “What is the origin of the pains in walking and standing, or on lying?” She answered these questions partially uninfluenced, partially under the pressure of my hand. We thus obtained two results. In the first place she grouped all scenes connected with painful impressions according to their occurrence, sitting, standing, etc. Thus, for example, she stood at the door when her father was brought home with his cardiac attack and in her fright remained as though rooted to the spot. To this first quotation “fright while standing” she connected more recollections up to the overwhelming scene when she again stood as if pinned near the death bed of her sister. The whole chain of reminiscences should justify the connection of the pain with standing up, and could also serve as an association proof, only one had to bear in mind the fact that in all these occasions we must demonstrate another moment which had served to direct the attention—and as a further result the conversion—just on the standing, walking, sitting, etc. The explanation for this direction of attention could hardly be sought in other connections than in the fact that walking, standing, and lying are connected with capabilities and conditions of those members which here bore the painful zones; namely, the legs. We could then easily understand the connection between the astasia-abasia and the first scene of conversion in this history.
Among the scenes which in consequence of this review had made the walking painful one which referred to a walk she had taken in company, at the watering place, which apparently lasted too long, stood out most prominently. The deeper circumstances of this occurrence revealed themselves only hesitatingly and left many a riddle unsolved. She was in an especially good humor and gladly joined the circle of friendly persons; it was a lovely day, not too warm, her mother remained at home; her older sister had already departed, the younger one felt indisposed but did not wish to mar her pleasure. The husband of the second sister at first declared that he would remain at home with his wife, but finally went along for her (Elisabeth’s) sake. This scene seemed to have a great deal to do with the first appearance of the pains, for she recalled that she returned home from the walk very fatigued and with severe pains, she could not however say definitely whether she had perceived the pains before this. I took for granted that if she had suffered any pain she would have hardly resolved to enter upon this long walk. On being questioned whence the pains originated on this walk she answered rather indefinitely saying that the contrast between her solitude and the married happiness of her sick sister, of which she was constantly reminded by the behavior of her brother-in-law, was painful to her.
Another closely related scene played a part in the connection of the pain with sitting. It was a few days later, her sister and brother-in-law had already departed and she found herself in an excitable longing mood. She arose in the morning and ascended a small hill which they were wont to visit together and which afforded the only pretty view. There she sat down on a stone bench giving free play to her thoughts. Her thoughts again concerned her lonesomeness, the fate of her family, and she now frankly admitted that she entertained the eager wish to become as happy as her sister. After this morning’s meditation she returned home with severe pains. In the evening of the same day she took the bath, after which the pains definitely appeared and continued persistently. We could further ascertain with great certainty that the pains on walking and standing diminished in the beginning on lying down. Only after hearing of her sister’s illness and on leaving Gastein in the evening, spending a sleepless night in the sleeping car, and being tormented simultaneously by the worries concerning her sister and violent pains, it was only then that the pains appeared for the first time while she was lying down, and throughout that time lying down was even more painful than walking or standing.
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.”
Text from Project Gutenberg, public domain in the United States.