14

CHAPTER II

CASE HISTORIES

OBSERVATION I. MISS ANNA O. (BREUER)

Miss Anna O. was twenty-one years old when she became ill in 1880.
She was considerably burdened by her heredity; there were some
psychoses in her large family. Her parents were nervous, but healthy.
Up to the onset of the disease, the patient showed no sign of nervousness,
not even during pubescence. She had a keen, intuitive intellect, a craving
for psychic fodder, which she did not, however, receive after she left
school. She was endowed with a sensitiveness for poetry and fantasy,
which was, however, controlled by a very strong and critical mind. The
latter made her also completely unsuggestible. Only arguments, no
assertions had any influence upon her. Her will was energetic, impene-
trable and persevering, sometimes mounting to selfishness; it relinquished
its aim only out of kindness and for the sake of others.

To the essential features of her character may be added sympathetic
kindness. The care and provision for some poor or sick person furnished
her an excellent outlet even during her own illness, for she was gratifying
a strong impulse. Her moods always showed a slight tendency to an
excess of merriment or sadness, which made her more or less tempera-
mental. The sexual element in her make-up was astonishingly unde-
veloped. The patient, whose life became as transparent to me as seldom
happens in the case of one person to another, never experienced any love,
and in the whole mass of hallucinations, which characterized her disease,
this element of the psychic life never appeared.

With her puritanically-minded family, this girl of overflowing mental
vitality led a most monotonous existence, although she probably exag-
gerated it to an excessive degree for her illness. She systematically
nurtured day-dreaming, which she called her “private theater.” While
she was seemingly in touch with the persons of her environment, she in
reality lived in the realm of fairyland; but when she was addressed, she
always responded so that no one had any inkling of it. This psychic
activity was carried on contemporaneously with her household duties, which
she accomplished faultlessly. Later I shall show how readily this habitual
dreaminess of her healthy state merged into the pathological.

The course of the disease may be divided into the following vaguely
defined phases:

(A) The latent incubation, which lasted from the middle of July until
the tenth of December, 1880. This phase, which in most cases escapes us,
afforded us here such perfect insight that for that very reason I do not

15

CASE HISTORIES

wish to underestimate its pathological interest. I will discuss later this
part of the history.

(B) The manifest disease showed the following peculiar symptoms:
Paraphasia, convergent strabismus, definite disturbances of hearing,
paralyses and contractures which were complete in the right upper and
in the two lower extremities, and incomplete in the left upper extremity
and paralysis of the muscles of the neck. The contracture of the right-
sided extremities gradually disappeared. During this period the patient
began to show signs of improvement, which suddenly stopped in April
through a severe psychic trauma, the death of her father, which was
followed by:

(C) A period of continuous somnambulism alternating with normal
states, a series of symptoms which continued until December, 1880.

(D) A gradual disappearance of these states and phenomena, which
continued until June, 1882.

In July, 1880, the patient’s father, whom she loved passionately,
developed a peripleuritic abscess, which did not yield to treatment, and
ended in his death in April, 1881. I was, therefore, not surprised that
she gradually became reduced in health. No one, perhaps not even the
patient, herself, knew what was taking place in her. Her condition
gradually grew worse, she became very weak, anemic, and evinced a
disgust for nourishment, so that despite her marked reluctance, it was
found necessary to take her away from the sick man. The main reason
for this step was a very intensive cough about which I was first consulted.
I found that she had a typical nervous cough. Soon, there also developed
a striking need for rest, distinctly noticeable in the afternoon hours,
which merged in the evening into a sleep-
like state, followed by strong
excitement.

In the beginning of December she developed convergent strabismus.
An ophthalmologist diagnosed this (mistakenly) as a paresis of the
abducent muscles. From the eleventh of December until the first of April
the patient remained bedridden.

In rapid succession there seemingly developed a series of new and
severe disturbances.

Left-
sided occipital pain; convergent strabismus (diplopia), which
was markedly aggravated through excitement. She complained that the
wall was falling over (obliquus affection). Profound analyzable visual
disturbances, paresis of the anterior muscles of the throat, to the extent
that the head could finally be moved only if the patient pressed it back-
ward between her raised shoulders and then moved her whole back.
Contractures and anesthesia of the right upper extremity, and somewhat
later of the right lower extremity. These, too, were entirely extended,
adducted, and rotated inwardly. Later, the same affection appeared in
the left lower extremity, and lastly in the left arm, in which, however,
the fingers remained slightly movable. Both shoulder joints, too, were
not altogether rigid. The maximum contracture concerned the muscles
of the upper arm, and even later when the anesthesia could be more

16

STUDIES IN HYSTERIA

precisely tested, the elbow region proved to be most anesthetic. In the
beginning of the disease the anesthesia test was not properly given because
the patient developed anxiety and refused her coöperation.

It was in this condition that I took the patient under treatment, and I
soon became convinced that we were confronted with a severe psychic
alteration. There were two entirely separate states of consciousness,
which alternated very frequently and spontaneously, moving further apart
during the course of the disease. In one of them she knew her environ-
ment, was sad and anxious, but relatively normal; in the other, she hal-
lucinated, was “naughty”—i.e., she scolded, threw the pillows at people
whenever and to what extent her contractures enabled her to, and tore
with her movable fingers the buttons from the covers and underwear, etc.
If anything had been changed in the room during this phase, if someone
entered, or went out, she then complained that she was lacking in time,
and observed the gap in the lapse of her conscious ideas. As this was
disputed wherever possible, or when an effort was made to calm her when
she complained that she was going crazy, there followed after each pillow
throwing and similar behavior, the additional complaints of all the things
that were done to her, and of the disorder in which she was left, etc.

These absences had already been noticed when she was still out of
bed. She suddenly stopped in the middle of a sentence, repeated the
last words, and after a brief period she went on. Little by little this took
on the described dimensions and at the peak of the disease, when the
contractures had also affected the left side, she was only half way normal
for a very short period during the day. But even the moments of rela-
tively clear consciousness were encroached upon by the disturbance. The
most rapid changes of her mood went to extremes, from very transitory
cheerfulness to deep feelings of anxiety, obstinate opposition to all thera-
peutic measures, and anxious hallucinations of black snakes for which she
mistook her hair and laces, etc. At the same time she kept exhorting
herself not to be so stupid, that this was only her hair, etc. In very clear
moments she complained of the deep darkness in her head, that she could
not think, that she was going blind and deaf, and that she had two egos,
her real and an evil one, which forced her to evil things, etc.

During the afternoons she remained in a state of somnolence, which
continued until about an hour after sunset. She then awoke and com-
plained that something was tormenting her, or rather she always repeated
the infinitive, “to torment, to torment.”

For simultaneously with the development of the contractures there
appeared a deep, functional disorganization of her speech. At first, it
was noticed that she missed words; gradually, when this increased her
language was devoid of all grammar, all syntax, to the extent that the
whole conjugation of verbs was wrong. Most of the time she utilized an
infinitive formed out of a weak past participle, and she never used any
articles. In the further course of this development she missed words
almost continuously, and searched for them laboriously in four or five
languages, so that one could hardly understand her. In her effort to

17

write she used in the beginning the same jargon until she was altogether
prevented from writing by her contractures. There then followed two
weeks of complete mutism. Continuous effort to speak elicited no sound.
Here, the psychic mechanism of the disturbance became clarified for the
first time. I felt that she was very annoyed over something and decided
not to talk about it. When I guessed this and forced her to talk about
it, the inhibition, which formerly made every expression impossible,
disappeared.

This occurred contemporaneously with the return of motion in the
left-sided extremities. In March, 1881, the paraphasia disappeared, but
she now spoke only English, seemingly without knowing it, and quarreled
with her nurse, who naturally did not understand her. And not until a
few months later could I convince her that she spoke English. Yet, she
herself understood her German-
speaking environment. In periods of
great anxiety she stopped speaking altogether, or she mixed together many
idioms. During her best and most lucid hours she spoke either French or
Italian. Between those periods and those during which she spoke
English, there was a complete amnesia. The strabismus then diminished
and finally appeared only during violent excitement. She was also able
to carry her head normally. On the first of April she left her bed for the
first time.

Her father, whom she idolized and whom she saw only rarely during
her illness, died on April 5th. This was the most severe psychic trauma
which could have happened to her. She then showed violent excitement,
which was followed by a deep stupor, lasting for about two days, from
which she awoke in a very alienated state. At first she was very much
quieter, and her feeling of anxiety was essentially diminished. The con-
tractures of both arms continued, likewise the not very deep anesthesia
of the limbs. She also showed a high degree of narrowing of the visual
field. From a bouquet which gave her much pleasure she could see only
one flower. She also complained that she could not recognize people.
Formerly, she could recognize faces without willful effort, now she had
to repeat at this very troublesome “recognizing work” that “The nose
is this way,” or “The hair is that way; hence it must be so and so.” All
human beings appeared to her like wax figures without any relationships
to herself. The presence of some of her relatives was very painful to
her, and this “negativistic instinct” grew progressively. If anyone,
whom she otherwise liked, entered the room, she recognized him, but
after a short time she sank back into her brooding and the person in
question no longer existed for her. She always recognized me, whenever
I entered her room; she always felt my presence and remained cheerful
as long as I talked to her, until the sudden encroachments of the hal-
lucinatory “absences.”

She spoke only English and understood nothing that was told her in
German. The people about her were forced to speak English, and even
the nurse managed in some way to make herself understood. She read

18

only French or Italian and if she happened to read aloud to somebody,
she translated it by sight into excellent English with surprising fluency.

She then began to write again, but in a peculiar manner. She wrote
with her left hand, or she used printed, antique lettering, which she had
collected into an alphabet from her Shakespeare.

If she took the smallest amount of nourishment, she later refused food
altogether, but she allowed herself to be fed by me, so that her nutrition
rapidly improved. But bread she always refused to eat. After being
fed, she never omitted washing her mouth, and did this also if for some
reason she did not eat. This indicated how absent-minded this act was.

The afternoon somnolence and the deep stupor around sunset con-
tinued. During these periods if she expressed herself at all, she was
lucid, calm, and cheerful. I shall have to take this up again later with
greater detail.

This relatively tolerable state did not last long. About ten days after
her father died, a consultant was called in whom she ignored as com-
pletely as all strangers, while I demonstrated to him her peculiarities.
When I requested her to read aloud in English from a French book, she
said laughingly, “This is like an examination.” The strange physician
interjected some remarks and made efforts to make himself noticeable,
but in vain. It was a real “negative hallucination,” which has so often
been reproduced experimentally since then. He finally succeeded in
attracting her attention by blowing smoke into her face. She then sud-
denly saw a stranger, rushed to the door, grabbed the key, but fell to the
floor unconscious. This was followed by a short outburst of anger, and
then by a severe attack of anxiety, which I could calm only with a great
deal of effort. Unfortunately, I had to leave the city the same evening,
and when I returned after many days, I found that the patient’s condition
was markedly aggravated. Throughout the whole time she was entirely
absentminded and full of anxiety. Her hallucinatory absences were
filled with terrifying images of skulls and skeletons. As she lived
through these things and dramatized them partially in speech, the people
around her could understand most of the content of her hallucinations.
In the afternoon she remained somnolent, and at sunset in a deep hypnosis,
for which she coined in English the name of “clouds.” If she was then
able to relate the hallucinations of the day, she awoke lucidly, feeling
calm and cheerful and soon got busy with drawing or writing, which con-
tinued throughout the night in a perfectly rational manner. She went to
sleep at four o’clock, and the next morning the scene of the previous day
was repeated. The contrast between the irresponsible girl, harassed by
hallucinations during the day, and the perfectly clear girl at night, was
most remarkable.

Despite the nocturnal euphoria, the psychic state became more and
more aggravated. She showed intense suicidal impulses, which were
quite dangerous because she lived on the third floor. It was for this
reason that contrary to her will, the patient was removed to the country,
to a suburb of Vienna, on June 7, 1881. I never threatened to take her

19

away from home, but somehow she expected and feared it. This occasion,
too, showed how the affect of anxiety dominated the psychic disturbance.
Just as she merged into a period of calmness after the death of her father,
now, too, she quieted down after the feared expectation had taken place.
To be sure, this did not take place until after a disturbance of three days
and three nights, which followed immediately her removal to the country.
During this period she remained sleepless, took no nourishment, and was
full of suicidal ideas (not so dangerous in the garden). She also broke
windows, etc., and evinced hallucinations without absences, which she
differentiated well from the others. Finally, however, she became quiet,
took nourishment from the nurses, and was even willing to take chloral
in the evening.

Before I proceed with the description of the further course, I will
have to return and describe a peculiarity of the case, which I have thus
far only cursorily indicated.

We had already noticed that hitherto the course of the disease was
characterized by the fact that every afternoon the patient lapsed into a
somnolent state, which changed to a deeper sleep about sunset (clouds).
(This periodicity can be explained quite plausibly through the nursing
situation, to which she had been subjected for many months. During the
night she held vigils at her sick father’s bedside or remained in her bed
listening, full of anxiety, until the morning. In the afternoons she lay
down for a short rest, as is the case with most nurses. It was this type of
nocturnal vigilance and afternoon napping that was probably misplaced
into her own disease and continued after her sleep had long ago changed
into a hypnotic state.) The stupor lasted about an hour, when she became
restless and tossed around in bed and repeated the words, “to torment, to
torment,” always with her eyes closed. On the other hand, it was noticed
that in her day absences she seemingly developed some situation or story,
the nature of which was detected through some words which she mur-
mured. But it so happened, first accidentally, later intentionally, that
someone near her uttered such a catch-word while the patient complained
of torments. She immediately took it up and began to depict a situation,
or relate a story. In the beginning haltingly, in her paraphasic jargon,
but the further she went, the more fluent she became until in the end she
spoke a clear German. (During the first period, before she completely
adopted English speech.) The stories which were always sad were in
part very pretty; they were in the style of Andersen’s “Picture-
without Pictures,” and were probably modeled on them. The beginning
and the central point of the situation mostly dealt with a girl sitting, full
of anxiety, near a patient. But quite different motives were also dilated
upon. A few moments after finishing the story, she woke up and was
apparently calm, or as she called it, “comfy” (comfortable). During
the night she again became restless, and in the morning after a two hours’
sleep she was apparently again in the midst of another set of ideas. If
she sometimes could not tell me the story in the nocturnal hypnosis, there

20

was no nocturnal restfulness; to bring this about, she had to tell me two
stories on the following day.

The essential elements of the described manifestations, the accumula-
tion and fusion of her ‘absences’ into nocturnal autohypnosis, the effec-
tiveness of the fantastic products as a psychic stimulus, as well as the
alleviation and removal of the tense state through talking in the
hypnosis—all these remained constant throughout the whole year and a
half of observation.

Following the death of her father, the stories naturally became more
tragic, but only with the aggravation of her psychic state, which followed
the above related violent breaking through of her somnambulism, did the
nocturnal recitals lose the character of more or less free, poetic creations,
and change into a series of frightful and terrifying hallucinations, which
one could already infer during the day from the patient’s behavior. But
I have already described how completely her psyche was freed after,
having been tortured by anxiety and terror, she reproduced the experi-
ences of these terrifying pictures.

In the country, where I could not see the patient daily, the situation
developed in the following manner: I came in the evening when I knew
that she was in a state of hypnosis, and I took away from her the whole
supply of fantasms which she had collected since my last visit. In order
to obtain good results this had to be accomplished very thoroughly. Fol-
lowing this, she was quite tranquil and the next day she was very pleasant,
docile, industrious and cheerful. The following day she was always
more moody, peevish and unpleasant; all of which became more marked
on the third day. In this state of mind it was not always easy even in
hypnosis to induce her to express herself, for which procedure she
invented the good and serious name of “talking-
cure,” and humorously
referred to it as “chimney-
sweeping.” She knew that after expressing
herself, she would lose all her peevishness and “energy,” yet whenever
(after a long pause) she was in an angry mood she refused to talk, so
that I had to extort it from her through urging and begging, as well as
through some tricks, such as reciting to her a stereotyped introductory
formula of her stories. But she never spoke until after she had carefully
touched my hands and had become convinced of my identity. During
the nights when rest could not be obtained through expression, one had
to make use of chloral. I tried this a number of times before, but I had
to give her 5 grams per dose, and sleep was preceded by a sort of intoxi-
cation, which lasted an hour. In my presence she was cheerful, but when
I was away, there appeared a most uncomfortable, anxious state of excite-
ment (incidentally, the deep intoxication just mentioned made no change
in the contractures). I could have omitted the narcotic because the
talking, if it did not bring sleep, at least produced calm. In the country,
however, the nights were so intolerable between the hypnotic alleviations,
that we had to resort to chloral. Gradually, however, she did not need
so much of it.

The persistent somnambulism remained away, but in its place there

21

continued an alternation of two states of consciousness. In the middle
of her talk, she hallucinated, ran away, attempted to climb a tree, and
similar actions. If one held her firmly, she continued the conversation
after the shortest period in fragmentary sentences, without noticing what
happened between. But in the hypnosis all these hallucinations appeared
later in her recital.

On the whole her condition improved, her nourishment was good, she
permitted herself to be fed by the nurse through the mouth, but she asked
only for bread, which she, however, refused as soon as it touched her
lips. The contracture paresis of the limbs diminished perceptibly. She
also displayed proper judgment and marked attachment for the con-
sultant, my friend, Dr. B., who paid her regular visits. A Newfoundland
dog, which she received as a present, and to which she became pas-
sionately attached, was of great help to her. When this pet once attacked
a cat, it was wonderful to see how this weak girl grabbed a whip in her
left hand and forcefully belabored the animal with it in order to rescue
the victim. Later, she took care of some poor, sick people, which was also
very beneficial to her.

The clearest demonstration that the ideational complexes produced in
the “absences” of the “condition seconde” leave a pathogenic and
exciting effect, and that they can be resolved through talking in a state
of hypnosis, I received on my return from a vacation of many weeks.
During this period no “talking cures” had taken place, for it was not
possible to persuade the patient to tell her stories to anyone else, not even
to Dr. B. with whom she now entertained a cordial relationship. I found
her in a sad moral state, she was indolent, disobedient, moody, and even
irritable. During the evening recitations it came to light that her fan-
tastic poetic vein was apparently becoming exhausted. She reproduced
more and more stories about her hallucinations and something of what
had angered her during the past days. She developed everything fantas-
tically, but more in the form of fantastic formulas than constructed poems.
But no tolerable state occurred until after I made her come to the city
for a week, and wrested from her every evening from three to five stories.
When this was finished, everything which had accumulated during the
weeks of my absence was worked up. And only then was the former
rhythm of her psychic behavior reëstablished, so that on the first day
following such an expression she was loving and cheerful, on the second
day more irritable and disagreeable, and on the third day distinctly
antagonistic. Her moral state represented a function of the time passed
since her last recital, because every spontaneous product of her fantasy
and every occurrence perceived by the morbid part of her psyche continued
as a psychic stimulus until it was reported in the hypnosis, and its effect
thereby abrogated.

When the patient returned to the city in the fall (to a different resi-
dence than the one in which she became ill) her condition was tolerable
both physically and mentally, inasmuch as only very few events, actually
only important ones, were elaborated into psychic stimuli. I hoped for

22

a continuous and progressive improvement if the permanent burdening
of her psyche through new stimuli could be prevented by a regular thera-
peutic expression. At first, I was disappointed. In December her psychic
condition became markedly worse. She was again excited, sadly
depressed, irritable, and rarely had “a whole good day,” even if nothing
demonstrable “stuck” in her. Towards the end of December during
the Christmas holidays she was particularly restless. Throughout the
whole week she talked every evening, but told nothing new except
fantasms which she elaborated day after day, during the holidays of 1880,
while under the spell of strong anxiety affects. After the completion of
this series there was a great alleviation.

It was now a year since she had lost her father and had become bed-
ridden. From now on the condition became crystallized and systematized
in a very peculiar manner. The two states of consciousness, which always
alternated so that from morning until night the absences increased in
frequency and finally developed into the condition seconde, which alone
continued during the night—these two states differed not just as formerly
through the fact that in the one (first) she was normal, and in the second
alienated, but she lived in the one (first) just like in the winter of 1880–
1881, and everything that happened later was fully forgotten therein.
Only the awareness of her father’s death still seemed to persist most of
the time. The reliving of the past year occurred so intensively that she
hallucinated her former room in her present home. When she wanted to
go to the door, she ran to the oven, which now stood at the window, but
in the old residence it was near the door. This change from one state
into the other succeeded spontaneously, but it could, however, be called
forth with the greatest ease by some sensory impression, which vividly
recalled the former year. It was sufficient to show her an orange (the
principal nourishment during the first period of her illness) to throw her
back from the year 1882 to the year 1881. This reliving of the past year
did not proceed in a general and indefinite manner, but she relived day
by day the past winter. I could not have surmised this if she had not
talked out daily in the evening hypnosis what had excited her in 1881 on
the same day, and if the underlying facts had not been corroborated
with unimpeachable correctness through her mother’s secret diary from
the year 1881. This reliving of the past year continued until the definite
termination of the disease in July, 1882.

At the same time, it was very interesting also to see how these revived
psychic stimuli, exerted their more normal effect from the second into the
first state. Thus, it happened that the patient told me laughingly in the
morning that she did not know why she was angry at me. Thanks to the
diary, I knew what the whole thing was about, and it was also confirmed
in the evening hypnosis. In the year 1881 on the same evening I had
annoyed the patient very much. She said that something was wrong with
her eyes, that she saw the wrong colors, that although she knew her dress
was brown, she saw it blue. It was soon shown that she could distinguish
all colors correctly on the test paper, but that the disturbance showed

23

CASE HISTORIES

itself only on the material of her dress. The reason for this was that in
the year 1881 on the same day she was very much occupied with a night-
gown for her father, which was made of the same material, but dyed blue.
At the same time there was also a very distinct anticipatory effect of these
emerging stories, inasmuch as the disturbance of the normal state had
already appeared before, whereas the memory itself gradually came up
in the condition seconde.

The evening hypnosis was also richly burdened thereby, as she had
to relate not only the fantasms of fresh productions, but also the expres-
sions of “vexations” of 1881. (The fantasms of 1881 I had fortunately
already removed at that time.) Thus, the amount of work to be accom-
plished between the patient and the physician increased enormously
through a third series of individual disturbances, which also had to be
accomplished in this manner. The psychic events of the incubation period
of the disease, from July until December, 1880, which produced the sum
total of hysterical phenomena, had to be “talked out,” and with it the
symptoms disappeared.

It was a great surprise to me, when for the first time, and accidentally,
a disturbance, which had existed for a long time, disappeared in the
evening hypnosis through an unprovoked conversation. In that summer
there was a period of intensive heat, and the patient suffered very much
of thirst, for without any apparent reason, she suddenly found it impos-
sible to drink. She took the longed for glass of water in her hand, but
as it touched her lips, she pushed it away like a hydrophobic. At the
same time she was apparently, for a few seconds in an “absent” state.
To alleviate this torturing thirst she lived exclusively on fruits, melons,
and similar things. After this had continued for about six weeks, she
spoke about her English governess, whom she did not like, and then
related with all signs of disgust how she once entered her room and saw
her little dog, that disgusting animal, drink out of a glass. She said
nothing because she wanted to be polite. After she gave energetic
expression to her strangled anger, she asked for a drink, and without
any inhibition drank a great deal of water, awaking from the hypnosis
with the glass at her lips. With this the disturbance disappeared forever.
In the same way many peculiar and persistent habits disappeared after
their causative experiences were related. However, it was a great step
forward when the first persistent contracture of the right leg, though now
slightly diminished, disappeared in the same way. It was these experi-
ences, namely, that the hysterical phenomena disappeared in the hypnosis,
as soon as she reproduced the events which caused the symptom that gave
origin to a therapeutic technical procedure which in logical sequence
and systematic procedure left nothing to be desired. Every single symp-
tom of this complicated, morbid picture was separately taken up, and the
various occasions during which it appeared were related in reverse order,
beginning with the days before the patient became bedridden, and back-
ward to the time of its first appearance. When this was related, the
symptom was thereby permanently removed.

24

STUDIES IN HYSTERIA

In this manner she “related away” the contractures, the paralyses,
the anesthesias, the various disturbances of sight and hearing, the
neuralgias, coughs, trembling, and other symptoms, and finally also the
disturbances of speech. Thus, in the disturbances of vision the following
symptoms were separately removed: convergent strabismus with diplopia,
the deviation of the two eyes to the right so that the extended hand always
grasped the object towards the left, the narrowing of the field of vision,
central amblyopia, makropsia, the sight of a skull in place of her father’s
head, and the inability to read. Only a few phenomena, which developed
during the patient’s invalidism, as the extension of the contracture
paralysis to the left side, which probably had no psychic causation, were
inaccessible to analysis.

To abbreviate the situation, by seeking to evoke directly in her
memory the first occasion of a symptom, turned out to be quite imprac-
tical. She could not find it and became confused, and such attempts pro-
ceeded even more slowly than when she was allowed to “wind off” back-
wards the thread of the memory, slowly but surely. But as the evening
hypnosis proceeded rather slowly, because the patient became fatigued
and distracted from the “talking out” of the other two series, and also
because the recollections required time to develop their full vividness, the
following procedure developed: I visited her in the morning and hypno-
tized her (we followed empirically very simple hypnotic procedures), and
asked her to tell me under mental concentration her thoughts concerning
the symptom just reacted, in order to find out the causes which gave
origin to it. The patient then described in rapid succession, in short
phrases, these external causes, which I wrote down. In the evening
hypnosis, she then related in considerable detail all the events which I
had noted of the series. An example will show, with what exhaustive
thoroughness, in every sense of the word, this was actually done. It
always happened that the patient did not hear when I talked to her. This
transient “not hearing” was differentiated in the following manner:

(a) Not hearing, that someone entered while in a state of distraction.
She gave 108 detailed cases of it, mentioning persons and circumstances,
and often also dates. The first person whom she did not hear entering
was her father.

(b) Not understanding when many persons spoke. This occurred 27
times. The first time it was again her father and an acquaintance.

(c) Not hearing, when alone, when she was directly addressed; 50
times. The origin of it: when her father in vain asked her for wine.

(d) Becoming deaf from being shaken (as, for example, in a vehicle,
etc.), 15 times. The origin: when her younger brother shook her in
anger, when he caught her at night listening at the door of the sickroom.

(e) Becoming deaf from fright of a noise, 37 times. The origin of
it was when her father had a choking attack from swallowing the wrong
way.

(f) Becoming deaf in deep ‘absences,’ 12 times.

25

(g) Becoming deaf through long listening, so that when she was then
addressed she could not hear, 54 times.

To be sure, all of these processes are for the most part identical,
insofar that they can be traced to distraction, “absences,” or to an affect
of fright. But in the memory of the patient they were so distinctly
separated that if she ever made a mistake in the order of their appearance,
they had to be corrected and put in the right order, otherwise, she got
stuck in her recital. The interest and significance which she imparted to
the communicated events and the precision of her recitals left no room
for inventions. Many of these events were of a purely subjective nature
and could, therefore, not be controlled, the accompanying circumstances of
the others could very well be recalled by persons of her environment.

Here, too, everything proceeded as was regularly observed when a
symptom was “talked away”; the latter appeared with heightened
intensity while it was related. Thus, during the analysis of the “not
hearing,” the patient was so deaf that now and then we could only under-
stand each other through writing. The first cause was regularly some
sort of fright, which she experienced while nursing her father, some
neglect on her part, or something similar.

The recollections did not always run smoothly. Sometimes the patient
had to exert enormous effort. Once the whole process was stopped for a
time because a memory could not come to the surface. It concerned an
hallucination, which was very terrifying to the patient. She saw a skull
on her father while she was nursing him. She and some of the people
about her recalled that once while she was still seemingly healthy, she
paid a visit to one of her relatives and when she opened the door, she fell
unconscious. In order to overcome this impediment, she now paid them
another visit, and again fell unconscious on entering the room. In the
evening hypnosis the impediment was overcome, it turned out that as
she entered the room, she noticed a pale face in a mirror hanging across
the door, but it was not her face, but that of her father with a skull—we
have often observed that the fear of a memory, as in this case, inhibited its
emergence, and it had to be forced out by the patient, or by the physician.

The following show among other things how strong the inner logic
of the states was. As already noted, during this period, that is during the
year 1881, the patient was always at night in her condition seconde. Once
she awoke in the night and insisted that she had again been taken away
from home, and got into a very bad state of excitement, which alarmed
the whole household. The reason for this was simple. The previous
night her visual disturbances were made to disappear through her
“talking cure,” and to be sure, also in the condition seconde. When she
awoke at night, she found herself in a room unfamiliar to her, for the
family had changed their residence since the spring of 1881. These very
disagreeable incidents were prevented at her request, when I closed her
eyes in the evening with the suggestion that she would not be able to
open them until I would myself open them in the morning. Only once

26

STUDIES IN HYSTERIA

more was this disturbance repeated, when the patient wept in her dream
and awakened with her eyes open.

As these tedious analyses of the symptoms referred to the summer
months of 1880, during which her illness developed, I gained a full under-
standing into the incubation and the pathogenesis of this hysteria, which
I will now briefly discuss.

In July, 1880, the patient’s father was very sick while in the country,
suffering from a sub-pleural abscess. Anna shared the nursing with her
mother. She awoke once in the night with great anxiety about her very
feverish patient; she was full of tension because a surgeon was expected
from Vienna to operate on him. The mother was away for a short time,
and Anna sat near the sickbed holding her right arm over the back of the
chair. She sank into a state of day-dreaming, and saw how a black snake
came out of the wall towards the patient, as if to bite him. (It is quite
probable that on the lawn near the house there were some snakes, which
at some previous time frightened this girl, and gave the memory for the
hallucinations.) She wanted to drive away the reptile, but felt as if
paralyzed. The right arm, which was hanging over the back of the chair,
was “asleep” and was anesthetic and paralyzed, and as she looked at it,
the fingers changed into small snakes with skulls (nails). It is probable
that she made an effort to ward off the snake with her paralyzed arm,
and thereby established the association of an anesthesia and paralysis with
the snake hallucination. When the latter disappeared, she wished to
pray in her anxiety, but the words refused to come. She could not talk
at all until she finally remembered an English nursery rhyme, and only in
this language could she continue to think and pray.

The blast of the locomotive, which announced the expected physician,
interrupted this spookiness. But the following day as she wished to take
a hoop out of the bush, into which it was thrown during play, a bent twig
again evoked the snake hallucination. But this, as well as the contrac-
tures, appeared only in the short “absences” which, beginning with that
night, became more frequent. (The contractures did not, however,
become stabilized before December, when the patient had a thorough
breakdown and could no longer leave her bed.) On an occasion which
I have not noted and which I cannot recall, a contracture of the arm
joined that of the right leg.

The tendency to autohypnotic absences was not established. On the
day following that night, while waiting for the surgeon, she sank into
such a deep absentmindedness, that the latter finally stood in her room
and she never heard him enter. The constant feeling of anxiety pre-
vented her from eating and gradually produced an intense disgust. With
this exception all her individual, hysterical symptoms originated during
an affect. It is not quite clear whether a complete momentary “absence”
always appeared with it, but it is probable because the patient knew
nothing of this whole connection while awake.

However, some symptoms did not seem to have originated during an
“absence,” but in an affect during the waking state; but they repeated

27

CASE HISTORIES

themselves in the same manner. Thus, the various visual disturbances
were traced to more or less individual, clearly determined causes, e.g.,
while sitting at the sickbed with tears in her eyes, she was suddenly
asked by her father what time it was. She saw indistinctly and had to
exert herself to direct the watch near her eyes, so that the face of the
watch appeared to her very large (makropsia and convergent strabismus),
or she exerted a great deal of effort to suppress the tears, in order that her
sick father should not see them.

A quarrel, in which she suppressed the answer caused a contracture
of the glottis, which repeated itself on every similar occasion.

Speech was impeded (a) by anxiety, since the first nocturnal hal-
lucination, (b) since she again had to suppress utterances (active inhi-
bition), (c) since she was once unjustly scolded, and (d) in all analogous
situations (aggravations).

The cough appeared for the first time while the patient kept a vigil
at her father’s bed and heard dance music coming from a neighboring
house. She conceived a wish to be there, which was immediately fol-
lowed by self-reproaches. Since that time she had reacted with a nervous
cough throughout her whole illness, whenever she heard very rhythmic
music.

I do not regret very much that the incompleteness of my notes makes
it impossible to trace back here all hysterical symptoms to their causes.
The patient did this in all of them with the one exception mentioned,
and every symptom, as was stated, disappeared after the first cause
was related.

In this way the whole hysteria came to an end. The patient, how-
ever, made a firm resolution that everything must be finished on the
anniversary of her transfer to the country. In the beginning of June,
she, therefore, exercised the “talking cure” with zealous energy. On
the last day, with the additional help of arranging the room like her
father’s nursing room, she reproduced the above-related hallucinations,
which were at the root of her whole disease, and in which she could
think and pray only in English. Immediately thereafter she spoke
German, and was then free from all the numberless individual disturb-
ances which she formerly presented. She then left Vienna for a vaca-
tion, but it took considerable time before her psychic equilibrium was
restored. She has since then enjoyed perfect health.

As much as I have suppressed of the interesting material of
Anna A.’s case history, it, nevertheless, became more voluminous
than a, not in itself unusual, hysterical disease seems to merit. But
the description of this case was impossible without entering into
its details, and the peculiarities of the same seem to me of such great
importance that one might excuse the detailed history. For the eggs
of the echinodermata are not important to embryology just because

28

the sea urchin is such an interesting animal, but because their pro-
toplasm is transparent, and, therefore, warrants the conclusion that
what can be seen in them also takes place in eggs with opaque
protoplasm.

It seems to me that the interest of this case lies above all in its
far-reaching transparency and the explicableness of its pathogenesis.

As a predisposition for the hysterical disease, we find in this
still perfectly healthy girl two psychic pictures:
(1) The monotonous family existence without a corresponding
psychic labor for the unused excess of psychic activity and energy,
which disburdened itself through continuous work of her phantasy and
(2) The habitual day-dreaming (“private theater”) shows
what laid the foundation for the dissociation of the psychic person-
ality. At all events, even this is still within normal limits. Dreaming,
as well as meditation during a more or less mechanical occupation,
does not in itself condition a pathological splitting of consciousness,
because every disturbance therein, as for example, every call,
reëstablishes its normal unity, nor is it followed by any amnesia.
Yet, in Anna O this day-dreaming created the soil upon which
the anxiety and the affective expectation established themselves
in the manner described, after it had transformed the habitual dream-
ing into an hallucinatory “absence.” It is remarkable that the main
features which continued almost constantly throughout two years
were already perfect during the first manifestations of the onset of
the disease. Thus, it already shows the existence of two states of
consciousness, which at first appeared as a transitory “absence”
and later became organized into a “double conscience,” the speech
inhibition, which was conditioned by the affect of anxiety, plus the
accidental disburdening from the English nursery rhyme; later the
paraphasia, the loss of the mother tongue, which was replaced by
an excellent English, and finally, the accidental pressure paralysis of
the right arm, which later developed into a right-sided contracture
paralysis and anesthesia. The mechanism of the origin of this last
affection corresponds perfectly to Charcot’s theory of traumatic
hysteria; that is, the existence of a hypnotic state, in which there
occurs a slight trauma.

But, whereas in the patients in whom Charcot produced experi-
mentally the hysterical paralysis, this soon became stabilized, and
in those carriers of traumatic neuroses who are shocked by a severe
fright-trauma the neurosis appears immediately, the nervous system

29

CASE HISTORIES

of our young girl offered successful resistance throughout four
months. The contracture, as well as the other disturbances which
gradually joined it, appeared only during the momentary “absences,”
in the condition seconde, and left the patient during the normal
state in full possession of her body and her senses, to the extent
that neither she herself knew anything about it, nor did those about
her see anything, especially as they were distracted by centering
their attention on their very sick father.

But, inasmuch as since that first hallucinatory auto-hypnosis the
“absences” with complete amnesia and accompanying hysterical
phenomena kept on accumulating, the occasions for the formation
of such new symptoms increased and fortified those already formed
through more frequent repetitions. It was due to this that gradually
every painful and sudden affect behaved exactly as the “absences”
(when it did not perhaps always produce momentary absences).
Accidental coincidents formed pathological associations in the form
of sensory or motor disturbances, which thereafter appeared simul-
taneously with the affect. But they were always only momentary
and transitory. Before the patient became bedridden, she had already
developed a very large collection of hysterical phenomena, and nobody
knew anything about it. But only after the patient broke down
completely as a result of extreme weakness, inanition, insomnia, and
the steady anxiety-affect, to the extent that she remained longer in
the condition seconde than in the normal state—only then did the
hysterical phenomena encroach also upon the latter and change from
attack-like manifestations into chronic symptoms.

The question must now be asked, to what extent the statements
of the patient were reliable, and whether the phenomena were really
determined by the mode of origin and causation described by her.
As far as the more important and more fundamental processes are
concerned, the trustworthiness of the report, as far as I am con-
cerned, is beyond question. I do not refer here to the question of
the disappearance of the symptoms after they were “related away,”
they could quite readily be explained by suggestion. However, I
always found the patient perfectly truthful and trustworthy. The
subjects related were intimately connected with those things that
were most sacred to her, and whatever was accessible to control
through others was perfectly corroborated. Even the most talented
girl would not be in any position to build up a system of statements,
which would contain such a perfect inner logic, as given in the

30

description of the history of the development of her illness. But
one cannot, however, deny that in her logical conclusion she might
have (to the best of her belief) attributed a causation to some symp-
toms which did not really exist. But I do not even think that this
assumption is correct. The lack of significance of so many causes,
the irrationality of so many connections speak directly for their
reality. Thus, the patient could not understand how dance music
could have ever made her cough. As an intentional fabrication this
would be senseless. To be sure, I could imagine that a conscience
scruple could cause a contraction of the glottis, and the motor
impulse, which this girl, so fond of dancing, experienced, could have
changed the contraction of the glottis into a nervous cough. I, there-
fore, consider the patient’s statements as perfectly trustworthy and
truthful.

To what extent are we justified in the assumption, that this
hysteria is analogous also to the development of hysteria in other
patients, or that something similar appears also where there is no
such clearly split organization as a “condition seconde”? In this
respect I would like to point out that the whole history of the onset
of the disease would have remained totally unknown to our patient,
as well as to the physicians, if she had not possessed the above
described peculiarity of recalling in hypnosis and of relating what
she recalled. During the waking state she knew nothing of all this.
What the state of affairs is in other cases cannot, therefore, be
surmised from the examinations of wakeful persons, for with the
best of intentions they can give no information. And how little the
people around her observed all these processes I have already
described. What the state of affairs is in other patients could,
therefore, only be recognized through a procedure similar to the one
furnished by hypnosis in Anna O. Above all, the only assumption
that appears justified is that similar processes may occur more fre-
quently than our lack of knowledge of the pathogenic mechanisms
leads us to assume.

When the patient had become bedridden and her consciousness
constantly oscillated between the normal and the “second” state,
the army of hysterical symptoms, which originated singly and were
latent until they manifested themselves as chronic symptoms, was
joined by a new group of symptoms which seemed to have had a
different origin. I refer to the contracture paralysis of the left-sided
extremities and the paralysis of the muscles of the head. I separate

31

CASE HISTORIES

them from other phenomena because once they had disappeared,
they never reappeared either in any form of attack, or in any sort
of intimation during the conclusion of the phase of recovery when
all the other symptoms usually became revived, even after they
had been dormant for a long time. This also tallies with the fact
that they never appeared in the hypnotic analysis, and were never
brought back through affective or fantastic causes. I, therefore,
would believe that they did not owe their existence to the same psy-
chic processes as the other symptoms, but to the secondary extension
of that unknown state, which forms the somatic foundation of
hysterical phenomena.

During the whole course of the disease, the two states of con-
sciousness existed side by side, the first, in which the patient was
psychically normal, and the second, which we can readily compare
with the dream, as far as it concerns the richness in fantasies, hal-
lucinations, large gaps of memory, lack of inhibitions, and lack of
control of encroaching thoughts. In this second state the patient
seemed alienated. It appears to me that I have obtained a good
insight into the nature of at least one kind of hysterical psychosis,
and that is, that the psychic state of the patient was thoroughly
dependent on the diffusion of this second state into the normal one.
Every evening hypnosis furnished proof, that the patient was per-
fectly clear, organized, and normal in her feelings and volition, if
no product of the second state acted as a stimulus in her “uncon-
scious.” The flourishing psychosis during every larger pause of this
disburdening procedure, proved directly in what measure these
products influenced the psychic process of the normal state. It is
hard to avoid the expression that the patient was separated into
two personalities, of which one was psychically normal and the other
psychotic. I believe that the sharp distinction of the two states in
our patient only clarifies a behavior which is an enigma in many
other hysterical causes. In Anna O. it was very striking how the
products of the “evil ego,” as the patient, herself, called it, influenced
her moral habits. If they had not been continuously removed, she
would have been an hysteric of the malicious type, obstinate, lazy,
hateful, and irritable, whereas after the removal of these stimuli,
her true character always came to the surface, which was exactly
the reverse of the one just described.

But no matter how distinctly the two states were separated, the
“second state” not only mixed with the first, but as the patient

32

expressed it, that at least frequently even during her worst states
“there sat a keen and quiet observer somewhere in a little corner
of the brain, who watched this crazy stuff.” This continuous exist-
ence of clear thinking during the predominance of the psychosis
produced a very remarkable expression. When after the end of the
hysterical phenomena, the patient merged into a transitory depres-
sion, she alleged among other childish fears and self-reproaches, that
she was not sick and that everything was only simulated. Similar
things had apparently occurred many times.

After the disease has run its course and the two states of con-
sciousness have fused together, the patients then regard themselves
on retrospection, as uncured personalities, who have known all this
nonsense. And they believe that they could have prevented every-
thing if they had wanted to, that is, that they have intentionally
produced this nuisance. This persistence of normal thinking during
the second state might have fluctuated very much quantitatively, or
might not have existed most of the time.

The surprising fact that from the beginning to the end of the
disease all stimuli originating from the second state, as well as their
results, had been removed through talking in the hypnotic state I
have already described. I have nothing to add except the assurance
that it was not a discovery of mine, which I have suggested to the
patient, but that I was most surprised by it, and only after a series
of spontaneous adjustments took place, there developed from it a
therapeutic technique.

A few words should also be said about the final recovery from the
hysteria. It proceeded in the manner described, under considerable
disturbance of the patient and with an aggravation of her psychic
state. One had the distinct impression that a large number of prod-
ucts of the second state, hitherto dormant, now forced themselves
into consciousness, that they were recalled even though at first again
in the condition seconde, but that they burdened and disturbed the
normal state. One will have to take into consideration the question
whether a psychosis with which a chronic hysteria ends up has not
the same origin also in other cases.

OBSERVATION II. MRS. EMMY VON N. (FREUD)

On the first of May, 1889, I became physician to a woman of about
forty years of age, whose suffering, as well as her personality, inspired
me with so much interest that I devoted to her a large part of my
time and made it my task to cure her. She was hysterical, and as I