31

CHAPTER III.

THE CASE OF MISS ELISABETH V. R.¹⁾

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 symp-
toms 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 inter-
fered 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 com-
plained 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 pres-
sure 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

¹⁾Breuer u. Freud, Studien ueber Hysterie, 1895, Case V.

32

pronounced over the thighs. The motor power of the legs was
not diminished, the reflexes were of average intensity and all
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 ac-
companied 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 domina-
tion 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 cannot
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 under-
stood 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 at-
tention 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,

33

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 sen-
sitiveness 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 consis-
tency 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 sys-
tematic massage and faradization of the sensitive muscles without
regard to the pain produced, and in order to remain in communi-
cation 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.

34

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 ardu-
ous that ever befell my lot, and the difficulty of giving an account
of this work ranks well with the obstacles that had to be over-
come. 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 him-
self 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 inter-
est shown in her, the understanding which we foreshadow, the
hope of recovery extended to her, all these will induce the pa-
tient to give up her secrets. With Miss Elisabeth it seemed
probable to me right from the very beginning that she was con-
scious 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.”¹⁾

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

¹⁾It will be shown that, notwithstanding, I erred.

35

lacking. Later I penetrated into the deeper strata of memory by
using for those locations hypnotic investigation or a similar tech-
nique. 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 hynotic 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 condi-
tions. 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 inter-
course 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 tend-
encies 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 indiffer-
ence with which she treated her mother and older sister, as will

36

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 over-
looked 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 mat-
ter 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 consist-
ing 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 con-
centrate her entire devotion and care on the surviving mother.
At the end of the mourning year the eldest sister married a tal-
ented and ambitious man of notable position, who by his mental
capacity seemed to be destined for a great future, but who, how-
ever, 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

37

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’ treat-
ment in a dark room, in which Elisabeth participated. Follow-
ing this an operation proved necessary and the excitement con-
nected with this occurred at the same time that the first brother-
in-
law made preparations to move. Finally the operation, skil-
fully 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 under-
gone 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, mani-
fested 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 be-
came “fatigued” and then “caught cold.”

38

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 at the thoughts caused by
her death and the changes which it caused. The sister had suc-
cumbed 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, there-
after 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 re-
linquish the child, the only legacy of the deceased, to the two
ladies, he for the first time gave them the opportunity of accus-

39

ing 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 men, 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 com-
posed 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 ex-
plained 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 impres-
sions and bodily pains which she accidentally perceived simul-
taneously, 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 inten-

40

sive 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 mali-
cious glance, I could perhaps recall the words which old Mr. v. R.
was wont to utter concerning his favorite daughter: “She is fre-
quently 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 treat-
ment, the case of Miss Elisabeth v. R. would have been quite
unimportant for the theory of hysteria. Nevertheless, I con-
tinued my analysis because I felt sure that an understanding of
the causation as well as the determination of the hysterical symp-
toms 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 con-
nected.

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 con-
sciousness 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 though of an evening in which a young man had

41

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 hav-
ing 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, ex-
change 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 re-
solved to wait for him.

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 con-
sented 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 condi-
tion 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.

42

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 incompatability 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 aggrevating 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.²

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 torment-
ing 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 atten-
tion. 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

²Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June,
1894.

43

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 re-
sulting from this, namely, that the analysis pointed to a con-
version 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.³

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 more 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 pain-
ful 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 con-
trolled 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

³I can neither exclude nor prove that this pain, especially of the thighs,
was of a neurasthenic nature.

44

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 hith-
erto 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 fluctua-
tions 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 incon-
siderate 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 motive 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 mono-symptomatic. I
found, for example, that the right leg became painful during
our hypnosis when we dealt with memories relating to the nurs-
ing 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 impres-
sion relating to the second half of the history. My attention
having been called to that by this constant behavior I went further

45

in my investigations and gained the impression that perhaps de
tailization 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 ex
amination 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 ques
tions 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 impression according to their occur
rence, 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 direc
tion 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 her bore the
painful zones; namely, the legs. We could then easily under
stand the connection between the astasia-
abasia and the first scene
of conversion in this history.

46

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 ques-
tioned 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-
painful to her.

Another closely related scene played a part in the connection
of the pain while 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 re-
turned 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

47

Gastein in the evening, spending a sleepless night in the sleeping
car, and being tormented simultaneously by the worries con-
cerning 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, “occupa-
tion” 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 Com-
munication, 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 fore-
ground, it had not produced the abasia, but everything pointed to
the fact that the already existing abasia had in this way under-
gone a considerable reenforcement. 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

48

cooperation and voluntary attention of the patient. At times it
was really surprising how promptly and how infallibly the indi-
vidual 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 dis-
continue the work and to try again, as the day seemed unpro-
pitious. 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 fre-
quently 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 state-
ment was too disagreeable to her. I therefore proceeded as if
I was 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 enter-
tain 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

49

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 tech-
nique. 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 these 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 un-
burdened 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 anal-
ysis, as yet I did not know in what moment and through what
mechanism 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 ques-
tions. My patient immediately arose requesting me to discon-
tinue 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 strength-
ened 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 fol-
lowing the worriment about her mother’s vision and the nursing
of her mother during the time of the operation and her final

50

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 affection-
ately 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 a 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 occu-
pied 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 remi-
niscences, the time in Gastein, the worry connected with the ex-
pectations 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

51

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 begin-
ning. 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 peremp-
torily repeated itself. The thought which flashed like dazzling
lightning through the darkness was, “Now he is free again, and
I can become his wife.”

Of course, now everything was clear. The analyzer’s effort
was richly repaid. The ideas of the “defense” (abwehr)
against an unbearable presentation, the origin of hysterical symp-
toms through conversion of psychic into physical excitement, the
formation of a separate psychic group by an arbitrary act, lead-
ing to the defense–all these were in that moment palpably pre-
sented before my eyes. Thus and thus alone did things happen
here. This girl entertained an affectionate regard for her
brother-in-law against the acceptance of which into her con-
sciousness her whole moral being struggled. She succeeded in
sparing herself the painful consciousness that she was in love
with her sister’s husband by creating for herself instead bodily
pains, and at the moment when this certainty wished to thrust
itself into her consciousness (while she walked with him, during
that morning reverie, in the bath, and before her sister’s bed)
her pains originated by means of a successful conversion into the
somatic. When she came under my care there was already a
complete isolation from her consciousness of the presentation
group referring to this love, else, I believe that she would never

52

have agreed to such a treatment. The resistance which she re-
peatedly brought forth during the reproduction of traumatically
produced scenes really corresponded to the energy with which
the unbearable presentation had been crowded out from the
association.

For the therapeutist there now came a sorry time. The effect
of the resumption of that repressed presentation was a crushing
one for the poor child. When I summed up the whole situation
with these prosaic words: “you were really for a long time in
love with your brother-in-law,” she complained of the most hor-
rible pains at that moment; she made another despairing effort
to reject the explanation, saying that it was not true, that I sug-
gested it to her, it could not be, she was incapable of such base-
ness, and that she would never forgive herself for it. It was
quite easy to prove to her that her own information allowed no
other interpretation, but it took a long time before the two
reasons that I offered for consolation, namely, that one is not
responsible for one’s feelings and that her behavior, her sick-
ness under those circumstances was sufficient proof of her moral
nature—I say it took a long time before these consolations made
an impression on her. I was now forced to pursue more than
one course in order to calm the patient. In the first place I
wished to give her the opportunity to rid herself by ab-reaction
of the material long since accumulated. We investigated the
first impressions of the relations with her brother-in-law, the
beginning of those unconsciously kept affectionate regards. We
found here all those little indications and forebodings which on
a retrospective view showed a fully developed passion. On his
first visit to the house he mistook her for his destined bride and
greeted her before he greeted her older and homely sister. One
evening they entertained each other so vivaciously and seemed to
understand each other so well that the bride interrupted them
with this half serious remark: “You two, indeed, would have
suited each other very nicely.” On another occasion, while in a
gathering who were ignorant of the engagement, the conversa-
tion drifted to the young man, and a young lady indiscreetly re-
marked about a blemish in his shape, a juvenile joint affliction.
The bride herself remained calm while Elisabeth flew into a pas-
sion, and with an ardor which even she herself could not after-

53

THE CASE OF MISS ELISABETH R.

ward understand she defended the straight form of her future
brother-in-law. While we worked our way through these remi-
niscences, it became clear to Elisabeth that her affection for her
brother-in-law had slumbered in her for a long time, perhaps
since the beginning of their relations, and had concealed itself
so long under the mask of a mere kinsmanlike affection as only
her very delicate family feeling would allow.

This ab-reaction benefited her much, but I was able to give
her still more relief by taking a friendly interest in her present
state of affairs. With this object in view I sought an interview
with Mrs. V. R., whom I found to be an intelligent and refined
lady, whose courage to face life, however, was somewhat lessened
through the last misfortune. From her I learned that the ac-
cusation of rude extortion which the older brother-in-law had
brought against the widower, and which was so painful to Elisa-
beth, had to be retracted on closer investigation. The character
of the young man remained untarnished; it was merely a misun-
derstanding, an easily conceived difference of opinion concerning
the valuation of money that could arise between the merchant,
to whom money is only a working tool, and the official—that is
all there was to this seemingly so painful incident. I begged the
mother to give Elisabeth all explanations that she might hereafter
need, and to offer her in the future that opportunity for unbur-
dening her mind to which I had accustomed her.

Naturally I was also anxious to know what chance there was
for the fulfillment of the girl’s present conscious wish. Here
things were less favorable! The mother stated that for some
time she had had an inkling of Elisabeth’s affections for her
brother-in-law; of course she did not know that it existed during
the lifetime of her sister. Whoever saw them both in friendly
intercourse—of late, to be sure, only seldom—could entertain no
doubt of the girl’s anxiety to please him. However, neither she,
her mother, nor the advisers of the family showed any particular
inclination to bring about a matrimonial union between the two.
The health of the young man had not been very good and had
received a setback through the death of his beloved wife, and it
was not at all certain that he had sufficiently recovered from the
shock to enter into a new matrimony. It was quite probable that
this was the reason for his reserve, perhaps also because he was

54

not sure of his position, and wished to avoid all obvious gossip.
With such a reserve on both sides the solution for which Elisa-
beth was yearning was likely to fail.

I informed the girl of everything that I had heard from her
mother and had the satisfaction of seeing her benefited by the
explanation concerning the money affair. On the other hand, I
expected her to bear calmly the uncertainties of her future which
could not be set aside. The advancing summer compelled us to
bring the treatment to an end. She now felt better, and since
we had discussed the causes to which the pain could be traced she
no longer complained of pain. We both felt that the work was
done, although I thought that the ab-reaction of the suppressed
love was really not as complete as it should have been. I re-
garded her as cured and urged her to continue independently
the solution after the way had been cleared, to which she agreed.
She left with her mother for a summer resort where they were
to join the older sister and her family.

I still have something more to report about the further course
of Miss Elisabeth v. R.’s disease. A few weeks after our part-
ing I received a despairing letter from her mother informing me
that at the first attempt to draw Elisabeth into a conversation
about her love affairs she became very excited and refused to
talk, and since then had suffered from violent pains. She was
very indignant at my having betrayed her confidence and was
perfectly inaccessible, so that the treatment seemed a complete
failure. She wished to know what was to be done, for of me
she would hear nothing. I made no reply. It was to be expected
that after she was relieved from my discipline she would make
another attempt to reject her mother’s interference and return to
her inaccessibility. I was, however, quite certain that everything
would adjust itself and that my efforts had not been in vain.
Two months later they returned to Vienna and the colleague to
whom I was grateful for the case informed me that Elisabeth
was perfectly well, and that her behavior was normal although
occasionally she had slight pains. Since then she has repeatedly
sent me similar messages, each time promising to visit me, which
she has never done. This is quite characteristic of the personal
relationship formed during such treatment. My colleague then

55

assured me that she could be cured. The relation of
the brother-
in-law to the family underwent no change.

In the spring of 1894 I was informed that she would be present
at a private ball to which I could gain access. I did not let the
opportunity escape me and saw my former patient gliding along
in a rapid dance. Since then, following her own inclination, she
has married a stranger.

EPICRISIS.

I was not always a psychotherapist but like other neuropath-
ologists I was educated to the use of focal diagnosis and electrical
prognosis, so that even I myself am struck by the fact that the
histories of the diseases which I write read like novels and, as it
were, dispense with the serious features of the scientific character.
Yet I must console myself with the fact that the nature of the
subject is apparently more responsible for this issue than my own
predilection. Focal diagnosis and electrical reactions are really
not important in the study of hysteria, whereas a detailed discus-
sion of the psychic processes, as one is wont to receive it from
the poet, and the application of a few psychological formulæ,
allows one to gain an insight into the course of events of hysteria.
Such histories should be considered like psychiatrical ones, but
they have the advantage over the latter in the fact that they give
the intimate connection between the history of the disease and the
morbid symptoms, a thing for which we still look in vain in the
biographies of other psychoses.

With the description of the treatment I endeavored to inter-
weave the explanations which I gave about the case of Miss
Elisabeth v. R. and it will perhaps be superfluous to summarize
here the essential features. I have discussed the character of the
patient and the features which repeat themselves in so many
hysterics, and which we really can not consider as degenerative.
I mentioned the talent, the ambition, the moral sensitiveness, the
immense yearning for love which found its gratification in the
family, the independence of her nature reaching beyond the
womanly ideal which manifested itself largely by obstinacy, readi-
ness for fight, and inaccessibility. According to the information
of my colleague no hereditary taints could be shown on either
side of the family. Her mother, to be sure, suffered for years

56

from some indefinite neurotic depression, but her brothers and
sisters, her father and his family belonged to the even-tempered
and not to the nervous. There was no serious case of neuro-
psychosis in the nearest relatives.

This nature was acted upon by painful emotions, the foremost
of which was the debilitating influence of a long attendance upon
her beloved sick father.

That nursing of the sick plays such a significant rôle in the
histories of hysterias has its good reasons. A number of
effective moments which are found here are quite obvious,
namely, the disturbance of the physical health through inter-
rupted sleep, neglect of nourishment, and the reaction of a con-
stantly gnawing worriment on the vegetative functions; but the
most important factor, however, is, in my estimation, to be found
elsewhere. He whose mind is occupied with the hundred differ-
ent tasks of nursing which succeed each other continuously for
weeks and months, becomes accustomed, on the one hand, to sup-
press all signs of his own emotions, and on the other, his attention
is soon turned away from his own impressions because he has
neither the time nor strength to do them justice. Thus the nurse
accumulates for himself an overabundance of affective impres-
sions which he barely perceived clearly enough; at any rate they
were not awakened by ab-reaction, that is he creates for himself
the material for a retention hysteria. If the patient recovers
these impressions naturally become reduced in value, but if he
dies and the period of mourning comes during which only that
which refers to the deceased seems of value, the impressions
waiting for discharge appear in turn, and after a brief pause of
exhaustion the hysteria, the germ of which originated during the
nursing, bursts forth.

The same subsequent discharge of traumas accumulated during
nursing is occasionally encountered where the general impression
of the disease does not ensue, and yet the mechanism of hysteria
can be noticed. Thus, I knew a highly gifted but slightly
nervous lady whose whole personality suggests the hysteric
though she never became a burden to the doctor and was never
obliged to interrupt the exercise of her duties. This lady had
nursed three or four of her beloved ones until their death, caus-
ing her each time complete physical exhaustion, yet these sad

57

THE CASE OF MISS ELISABETH R.

duties never made her ill. However, shortly after the death of
the patient she began the work of reproduction, bringing again
to her view the scenes of the disease and death. Each day—one
might say at her leisure—she went over again every impression,
crying and consoling herself. Such adjustment she passed through
daily in conjunction with her usual duties, without, however, con-
fusing the two activities. Everything passed before her chrono-
logically. Whether the memory work of one day precisely corre-
sponded to a day of the past I am unable to say. I presume that
it depended on the leisure which was allowed to her by the cur-
rent affairs of the household.

Aside from this “subsequent tear” which attached itself to
these deaths at short intervals, this lady periodically observed
annual anniversaries representing the time of the various catas-
trophies, and here her vivid visual reproduction and her affective
manifestations followed faithfully the date. Thus, for example,
I found her in tears, and on sympathetic inquiry as to what oc-
curred that day, she half irritably remarked, “Nothing on that
day except that Professor N. was again here and gave us to under-
stand that things were hopeless—at that time I had no time to
cry.” She referred to the last illness of her husband who died
three years before. It would have been very interesting to know
whether she always repeated the same scene on these recurring
anniversaries, or whether as a I suppose in the interest of my
theory other details presented themselves each time for ab-
reaction. I was, however, unable to find anything definite about
that; the wise and courageous woman was ashamed of the inten-
sity with which those reminiscences acted upon her.⁴

⁴To my surprise I once discovered that such subse-
quent ab-reaction—through other impressions than nursing—may form the content of an
otherwise enigmatic neurosis. It was the case of a pretty girl of nineteen,
Miss Matilda H., whom I first saw with an incomplete paralysis of the
legs and months afterward I was again called because her character had
changed. She was depressed and tired of living, entertaining lack of
consideration for her mother, and was irritable and inapproachable. The
whole picture of the patient did not seem to me to be that of an ordinary
melancholia. She could easily be put into a somnambulic state, and I
made use of this peculiarity to impart to her each time commands and
suggestions to which she listened in her profound sleep and responded
with profuse tears, but which, however, caused but little change in her
condition. One day while hypnotized she became talkative and informed

58

I again repeat that this woman was not sick, that subsequent
ab-
reaction, despite all resemblance, is still not a hysterical
process; one may ask why, after one nursing there results a
hysteria and after another none. It cannot lie in personal pre-
disposition, for the lady that I have in mind showed it very
remarkably.

I now return to Miss Elisabeth v. R. While nursing her
father there occurred for the first time an hysterical symptom in
the form of a pain in a definite location on the right thigh. The
mechanism of this symptom is fully explained on an analytical
basis. It occurred in a moment during which the ideas of her
duties towards her sick father came into conflict with the content
of her erotic yearning which she then entertained. Under vivid
self reproach she decided in favor of the former and created
for herself the hysterical pain. According to the conception ex-
plained by the theory of conversion in hysteria, the process could
be described as follows: She repressed the erotic idea from her
consciousness and changed the sum of the affect into somatic sen-
sations of pain. Whether this first conflict occurred only once,
or repeated itself is not clear. The latter is more probable.
Quite a similar conflict–of a higher moral significance, and even
me that the reason for her depression was the breaking of her betrothal
many months before. She stated that on closer acquaintance with her
fiance the things displeasing to her and her mother became more and
more evident. On the other hand, the material advantages of the engage-
ment were too tangible to make the decision of a rupture easy, thus, both
of them hesitated for a long time. She then merged into a condition of
indecision in which she allowed everything to pass apathetically and
finally her mother pronounced for her the decisive “no.” Shortly after,
she awoke as from a dream and began to occupy herself fervently with
the thoughts about the broken betrothal, she began to weigh the pros and
cons, a process which she continued for some time. At present she con-
tinues to live in that time of doubt, and entertains daily the moods and
the thoughts which would have been appropriate for that day. The
irritability against her mother could only be explained if we took into
consideration the circumstances that existed on that decisive day. Next
to this thought activity she found her present life a mere phantom just
like a dream. I did not again succeed in getting the girl to talk–I con-
tinued my exhortations during deep somnambulism. I saw her each time
burst out into tears without however receiving any answer from her. But
one day, it was near the anniversary of the engagement, the whole state
of depression disappeared. This was attributed to my great hypnotic cure.

59

THE CASE OF MISS ELISABETH R.

better demonstrated by the analysis-
repeated itself after years
and led to the aggravation of the same pain and to its dissemina-
tion beyond its original limits. Again, it was an erotic idea which
came into conflict with all her moral conceptions, for her affection
for her brother-in-law, both during the life and after the death
of her sister, and the thought that she should yearn just for this
man, was to her very disagreeable. This analysis gives detailed
information about this conflict which represents the pivotal point
in the history of her malady. The patient’s affection for her
brother-in-law might have begun to germinate long ago, but in
favor of its development was the physical exhaustion through
the recent nursing, and her moral exhaustion through years of
disillusionment which then began to break down her reserve and
she confessed to herself the need of the love of a man. During
a friendly intercourse continuing for weeks (in the summer re-
sort) this erotic inclination reached its full development simul-
taneously with the pain. The analysis shows a special psychic
condition of the patient at that time, which in connection with her
inclination and the pain, seems to afford an understanding of the
process in the sense of the conversion theory.

I place reliance on the opinion that the patient’s affection for
her brother-in-law, intensive as it was, was not clearly known to
her except on certain rare occasion and then only momentarily.
If that were not so she would have become conscious of the in-
consistency between this fondness and her moral ideas and would
have had to endure the same mental agony which I saw her suffer
after the analysis. Her reminiscences gave us no information
concerning such suffering. These she spared herself and as a
result the love itself did not become clear to her. At that time,
as well as during the analysis, her love for her brother-in-law
existed in the form of a foreign body in her consciousness with-
out entering into any relationship with her other ideation. In
reference to this love there existed the peculiar condition of
knowing and simultaneously not knowing, it was the condition
of the split-off psychic group. When we assert that this love was
not “clearly known” to her we mean exactly what we say. We
do not mean a lower quality or a lesser degree of consciousness,
but a separation of the free associative thinking process from the
rest of ideation.

60

How does it come about that such an intensively accentuated
presentation group should be kept so isolated? As a rule the
rôle played by an idea in the association really increases with the
sum of its affect.

This question can be answered if we bear in mind two facts
which we can make use of as a safeguard: (1) That the hysterical
pains originated simultaneously with the formation of these sepa-
rate psychic groups, (2) that the patient exerted great resistance
against the attempt to bring about the association between the
separate psychic groups and the rest of the content of conscious-
ness, and when the union was finally effected she perceived ex-
cessive psychic pain. Our conception of hysteria brings together
these two moments with the fact of the splitting of consciousness,
for (2) contains the indication for the motive for the splitting
of consciousness, while (1) shows the mechanism of the same.
The motive was that of defense, it was the striving of the whole
ego to agree with this presentation group and the mechanism was
that of conversion, that is, instead of psychic pains which she
spared herself there appeared physical pains. Thus a transfor-
mation occurred through which pain the patient had escaped an
unbearable psychic state, though it was at the cost of a psychic
anomaly in the form of a splitting of consciousness and a physical
suffering, pains, upon which an astasia-abasia was constructed.

To be sure I can give no instruction as to how one can bring
about such a conversion. It is not apparently done as one inten-
tionally does an arbitrary action, it is a process which is executed
in the individual under the impulse of the motive of defense if an
adaptation for it exists in his organization or is brought about
by temporary modification.

One has the right to attack the theory more closely by asking
what it is that is transformed into physical pains. The cautious
reply will be something out of which psychic pains could have and
should have been formed. If we wish to venture further and
attempt a kind of algebraic formulation of the presentation mech-
anism we may attribute to the presentation complex of this un-
consciously remaining love a certain amount of affect and desig-
nate the latter quantity as the thing converted. Direct deduction
of this conception would be the fact that the “unconscious love”
has through such conversion forfeited so much of its intensity

61

that it was reduced to a weak idea. Its existence as a separate
psychic group would only be made possible through such weak-
ening. Yet this present case is not suitable to afford us any
clearness in this delicate matter. It probably corresponds to an
imperfect conversion only. From other cases it seems quite
probable that perfect conversions also occur and that in these the
unbearable idea actually becomes repressed as only an idea of
very little intensity could be repressed. After an associative
union has been consummated the patients assure us that since
the origin of the hysterical symptoms their unbearable thoughts
never occupied their minds.

I have stated above that on certain occasions, though only
transitorily, the patient consciously recognized the love for her
brother-
in-law. Such a moment occurred when for example, at
the death bed of her sister the thought flashed through her mind,
“Now he is free and I can become his wife.” I must discuss
the significance of these moments for the conception of the whole
neurosis. However, I think that the assumption of a defense
hysteria (abwehr hysterie) includes the requisite that at least one
such moment has already occurred. For consciousness does not
know in advance when such an unbearable idea will present itself.
The unbearable idea which with its appendix is later excluded
for the formation of a separate psychic group must have been
originally in the mind, otherwise no conflict would have resulted
leading to its exclusion.⁵ Just such moments should be desig-
nated as “traumatic.” It is in them that the conversion takes
place which results in the splitting of consciousness and the hys-
terical symptoms. Everything tends to show that in Miss Elisa-
beth v. R. there were a number of such moments (the scenes
of the walking, morning meditation, bath, and at the bed of her
sister) and perhaps new moments of this kind occurred during
the treatment. The multiplicity of such traumatic moments is
made possible by the fact that an experience similar to the one
which at first initiated the unbearable idea, introduces new emo-
tions to the separated psychic groups and thus transitorily abol-
ishes the success of the conversion. The ego is forced to occupy
itself with this suddenly enforced and lighted-up idea, and then

⁵It is different in a hypnoid hysteria. Here the content of the separate
psychic groups may never have been in the ego consciousness.

62

to restore the former state by means of new conversions. Miss
Elisabeth, who was in constant relation with her brother-in-law,
must have been particularly exposed to the appearance of new
traumas.

I must now occupy myself with the point which I have desig-
nated as a difficulty for the understanding of the aforementioned
history. On the analytical basis I assume that the first conversion
took place in the patient while she nursed her father, at the time
when her duties as nurse came into conflict with her erotic yearn-
ings, and that this process was the prototype for the later ones
which led to the outbreak of the disease in the Alpine watering
place. But then we have it from the patient’s statement that at
the time of nursing and the period following which I designated
as the “first period” she had not suffered at all from the pains
and weakness. To be sure, during the illness of her father she
was once bedridden for a few days with pains in her legs, but it
is doubtful whether this attack already belonged to the hysteria.
A causal relation between these first pains and any psychic im-
pressions could not be demonstrated by analysis; it is possible,
even probable, that at that time we dealt with a common rheumatic
muscular pain. Even if we should assume that this first attack
of pain was the result of a hysterical conversion in consequence
of the rejection of the erotic thoughts then existing, the fact
nevertheless remains that the pains disappeared after a few days,
so that the patient actually behaved differently than she did during
the analysis. During the reproduction of the so called first period
all her statements concerning the illness and death of her father,
the impressions relating to her first brother-in-law, etc., all these
were accompanied by manifestations of pain, while at the time
she really experienced these impressions she perceived no pains.
Is this not a contradiction tending to diminish considerably the
confidence in the explanatory value of such an analysis?

I believe that I can explain the contradiction by assuming
that the pains—the product of the conversion—did not originate
while the patient experienced the impressions during the first
period, but subsequently, that is, in the second period, when the
patient reproduced these impressions in her mind. The con-
version did not follow the fresh impressions but the memories
of them. I even believe that such a process is not at all unusual

63

in hysteria and regularly participate in creating hysterical symp-
toms. Nevertheless, as such an assertion does not seem plaus-
ible I shall attempt to make it more credible by citing other
experiences.

It once happened to me during a similar analysis that a new
hysterical symptom was formed during the treatment so that I
could attempt its removal on the day after its origin.

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 imperfec-
tion 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 provo-
cation, evoked the choking sensation, and prevented free expan-
sion of the voice. It was not difficult to recognize in this an-
noying sensation an hysterical conversion. Whether there really
appeared a contracture of certain muscles of the vocal chords I
have not verified.⁶ In the hypnotic analysis which I undertook
with this girl I found out the following concerning her vicissi-
tudes 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

⁶I had under observation another case in which a
masseters made it impossible for the artist to sing. The young lady in
question through painful experiences in the family was forced to go on
the stage. While in Rome rehearsing, in great excitement she suddenly
sank fainting to the floor. The physician who was called closed her jaws
forcibly, but the patient since that time was unable to open her jaws more
than a finger’s breadth and had to give up her newly chosen profession.
When she came under my care many years later, the motives for that
excitement were apparently over for some time, for massage in a light
hypnosis sufficed to open her mouth widely. The lady has since sung
in public.

64

the life of a most unfortunate family. The husband of this aunt,
seemingly a pathological personality, abused his wife and chil-
dren in the most brutal manner and especially pained her by his
sexual preference for the servant girl in the house. This be-
came 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 du-
ties 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 provok-
ing accusation she perceived a scratching in her throat, the tight-
ening 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 in-
terest 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 or 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 reproduc-
tion of all the exciting impressions and by subsequent ab-reac-
tion. 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

65

with friendliness, but just for that reason she incurred the dis-
pleasure 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 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 prick-
ling 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 ex-
isted for a short time I hoped to be able to explain it and quickly
remove it. To my surprise without any hesitation she repro-
duced in chronological order a whole row of scenes beginning in
her early childhood. All these had perhaps the same charac-
teristics in the fact that she had suffered an injustice without
defense, something which could make her fingers jerk, for exam-
ple, 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 con-
nected with the others. The bad uncle, who suffered from rheu-
matism, 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

66

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 expe-
rienced 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,
Rosalia 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
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 per-
ceive the symptom before, that it was not caused by the scene
previously related. Was there anything else to be assumed ex-
cept 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

67

trauma and became 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 co-
operation 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 conver-
sion 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 seem to exist in the history and
analysis of Miss Elisabeth v. R.

There is no question that normal persons carry in their con-
sciousness 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 appar-
ently 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 symp-
toms 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 circum-
stances 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 organ-
ically 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

68

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 memo-
ries if they are carefully applied. This original rheumatic pain⁷
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 symp-
toms, 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.⁸
particularly, I had to solve the most intricate knots of this kind.

⁷ But perhaps spinal neurasthenic?

⁸ See Studien über Hysterie, p. 57, footnote.

69

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 aggra-
vated the disturbance of functions through symbolization. For
her dependence and helplessness to change anything in the cir-
cumstances she found a somatic expression in the astasia-abasia,
and the expression “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.

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 modi-
fication, 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.,⁹⁾ 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”¹⁾ played a certain part in the pa-
tient’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 penciling, 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 opera-
tion

⁹⁾l. c.

¹⁾l. c.

70

tion 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 gen-
uineness of this neuralgia.

About a year after this hypnotic remedial success the condition
of Mrs. Cäcilie M. took a new and surprising turn. There sud-
denly appeared other states than those that had been charac-
teristic 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 connec-
tions 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 belong-
ing 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 mis-
taken 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

71

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 aggra-
vated her very much. She then suddenly grasped her cheek, cry-
ing 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 every-
body 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 con-
tinued 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 coin-
cidence. 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
month of pregnancy.

The result of the explanation showed that this neuralgia be-
came the mark of a definite psychic excitement through the usual

72

road of conversion but that afterward it could be awakened
through associative reminiscences of thoughts and symbolic con-
versions. 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 occa-
sion Mrs. Cäcilie M. was tormented by a violent pain in her right
heel, experiencing stinging sensations which made walking im-
possible. 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 phy-
sician’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 society¹⁰⁾ (“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 circum-
stances 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 there-
after continued for weeks. On analyzing this pain, which was
reproduced after almost thirty years, she stated that her grand-
mother gazed at her so “piercingly” that it seemed as if her look

¹⁰⁾The literal translation of Auftreten is to press down by treading.

73

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.

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 deter-
mined were of a psychic origin, or at least furnished with a psychic
interpretation. A certain number of her experiences were accom-
panied 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 applica-
tion 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 beau-
tiful 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

74

“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 reac-
tion 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 recon-
structing the original literal sense for its stronger innervation.
Indeed, perhaps it is improper to say that it creates such sensa-
tions through symbolization, perhaps it has not taken the usage of
speech as a model, but both originated from a common source.¹⁾

In conditions of profounder psychic changes we apparently find a
symbolic stamp (mark) of the more artificial usage of language in the
form of emblematic pictures and sensations. There was a time in Mrs.
Cäcilie M. during which every thought was changed into an hallucination,
and which solution frequently afforded great humor. She at that time
complained to me of being troubled by the hallucination that both her
physicians, Breuer and I, were hanged in the garden on two nearby trees.
The hallucination disappeared after the analysis revealed the following
origin: The evening before Breuer refused her request for a certain
drug. She then placed her hopes on me but found me just as inflexible.
She was angry at both of us, and in her affect she thought, “They are
worthy of each other, the one is a pendant of the other!”