96

standing of her sexual life. The splitting-off of psychic groups is,
as it were, a normal process in the development of adolescence, and
it is quite comprehensible that their later reception into the ego
offers advantageous occasions for psychic disturbances. Moreover, I
wish to give expression in this place to a doubt: whether the split-
ting of consciousness through ignorance is really different from the
one through conscious rejection, and whether adolescents do not
frequently possess more sexual knowledge than one supposes or than
they, themselves, believe.

A further deviation in the psychic mechanism of this case lies
in the fact that the scene of the discovery, which we have designated
as “auxiliary,” deserves also the name, “traumatic.” It exerted
influences through its own content, and not just through the awaken-
ing of the preceding traumatic experience; it unites the characters
of an “auxiliary” and a “traumatic” factor. However, I see no
reason for giving up in this coincidence an abstract separation, which
in other cases corresponds also to a temporal separation. Another
peculiarity of Katharina’s case, which was, however, known for some
time, is shown in the fact that in the conversion the production of
the hysterical phenomena did not immediately follow the trauma, but
only after an interval of incubation. Charcot had a predilection for
calling this interval the “period of psychic elaboration.”

The anxiety which Katharina showed in her attacks was hys-
terical, i.e., it was a reproduction of that anxiety, which appeared
at each of the sexual traumas. I am also desisting here from eluci-
dating the process which I have recognized regularly and pertinently
in an unusually large number of cases; namely, that the mere
presentiment of sexual relations in virginal persons, evokes an affect
of anxiety.

OBSERVATION V. MISS ELISABETH V. R. (FREUD)

In the fall of 1892 I was requested by a friendly colleague to examine
a young lady who had been suffering from pains in her legs for over two
years, so that she walked badly. He also added to his request that he had
diagnosed the case as hysteria, though none of the usual symptoms of the
neurosis could be found. He stated that he knew very little of the family,
but that the last few years had brought them much misfortune and little
pleasure. First the patient’s father died, then the mother underwent a
serious operation on her eyes, and soon thereafter a married sister
succumbed to a chronic cardiac affection following childbirth. Our
patient had taken an active part in all the afflictions, especially in the
nursing of the sick.

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CASE HISTORIES

I made no further progress in the case after I had seen the twenty-
four year old patient for the first time. She seemed intelligent and
psychically normal, and bore her affliction with a cheerful 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
walk did not correspond to any known pathological gait, and it was in no
way strikingly bad. She complained only of severe pains and of early
fatigue in walking as well as standing, so that after a brief period she
had to seek rest in which the pains diminished, but by no means disap-
peared. The pain was of an indefinite nature—one could assume it to be
a painful fatigue. The seat of the pain was quite extensive, but indefi-
nitely circumscribed on the superficial surface of the right thigh. It was
from this area that the pains radiated and were of the greatest intensity.
Here, too, the skin and muscles were especially sensitive to pressure and
pinching, while needle pricks were rather indifferently perceived. The
same hyperalgesia of the skin and muscles was demonstrable not only in
this area, but over almost the entire surface of both legs. The muscles
were perhaps more painful than the skin, but both kinds of pains were
unmistakably most pronounced over the thighs. The motor power of the
legs was not diminished, the reflexes were of average intensity, and as all
other symptoms were lacking, 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
strange that such a highly intelligent patient should not be able to give
anything definite about the character of her pains. A patient suffering
from an organic pain, if it is not accompanied by any nervousness, will
be able to describe it definitely and calmly; it may perhaps be lancinating,
appear at certain intervals, and extend from this to that location, or in
his opinion it may be evoked by this or that influence. The neurasthenic³³
in describing his pain gives the impression as being occupied with some
difficult mental problem, something far beyond his powers. His features
are tense and distorted as though under the domination of a painful affect,
his voice becomes shriller, he struggles for expression, he rejects all
designations that the physician makes for his pains, even though they are
undoubtedly afterwards found to be correct. He is ostensibly of the
opinion that language is too poor to give expression to his feelings.
These sensations are something unique, they never existed before, so that
they cannot be exhaustively described. It is for this reason that he never
tires of constantly adding new details, and when he has to stop, he is
distinctly controlled by the impression that he was unsuccessful in making
himself understood to the physician. All this is due to the fact that his
pains absorb his whole attention. In the case of Miss v. R. we had just
the opposite behavior and we had to conclude from this that she attributed
sufficient significance to the pain, but that her attention was concentrated

³³A hypochondriac afflicted with anxiety neurosis.

98

on something else of which the pains were only the accompanying phe-
nomena, perhaps on thoughts and sensations which were connected with
pain.

A still greater determination for the conception of the pain must,
however, be found in a second factor. If we irritate a painful area in a
patient suffering from an organic disease or neurasthenia, his physiog-
nomy will show a definite expression of discomfort or of physical pain,
the patient winces, refuses to be examined, and assumes a defensive atti-
tude. But if anyone pinched or pressed Miss v. R.’s hyperalgesic skin
or muscles of her legs, her face assumed a peculiar expression approach-
ing nearer pleasure than pain, she cried out and—I had to think of a
perhaps pleasurable tickling—her face reddened, she threw her head back-
ward, 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 con-
ception that her affliction was a hysteria and that the irritation touched a
hysterogenic zone.

Her mien was not adequate to the pain, which the pinching of the
muscles and skin were supposed to excite. It probably harmonized better
with the contents of the thoughts which were behind the pain and which
were evoked in the patient through a stimulation of those parts of the
body associated with them. I have repeatedly observed similar significant
expression from stimulation of hyperalgesic zones in unmistakable cases
of hysteria. The other gestures evidently corresponded to the slightest
suggestion of an hysterical attack.

We could not at that time find any explanation for the unusual locali-
zation of the hysterogenic zone. That the hyperalgesia chiefly concerned
the muscles, gave material for reflection. The most frequent affliction
which could produce diffuse and local pressure sensitiveness of the muscles
is rheumatic infiltration, or the common chronic muscular rheumatism,
concerning which aptitude to mask nervous ailments I have spoken. The
consistency of the painful muscles in Miss v. R. did not contradict this
assumption, as there were many hard cords in the muscle masses, which
seemed to be especially sensitive. There was probably also an organic
change in the muscles, in the assumed sense, upon which the neurosis
leaned, and the significance of which was markedly exaggerated by the
neurosis.

The therapeutic procedure was, therefore, based on the assumption of
a mixed affection. We recommended systematic massage and faradization
of the sensitive muscles regardless of the pain it produced, and in order
to remain in contact with the patient, I treated her legs by means of strong
Franklin sparks. To her question whether she should force herself to
walk, we answered decidedly in the affirmative.

We thus attained a slight improvement. She particularly liked the
painful shocks of the “influence machine,” and the stronger they were,
the more they seemed to remove her pains. My colleague, meanwhile,
prepared the soil for the psychic treatment, and when after four weeks
of this sham treatment, I proposed it and explained to the patient the

99

procedures and its effects, I found a ready understanding and only a slight
resistance.

The work which I then began, turned out to be the most arduous
undertaking that ever fell to my lot, and the difficulty of giving an account
of this work ranks well with the obstacles that had to be overcome. For
a long time, too, I did not understand the connection between the history
of the disease and the affliction, which should really have been caused and
determined by this series of events.

When one undertakes a cathartic treatment, he at first asks himself
whether the patient understands the origin and cause of her suffering.
If that is so, one does not need any special technique to cause her to
reproduce the history of her ailment. The interest shown in her, the
understanding which we fore-
shadow, the hope of recovery extended to
her, all these induce the patient to give up her secrets. In the case of
Miss Elisabeth, it seemed probable right from the very beginning that
she was conscious of the reasons for her suffering, that she had only a
secret but no foreign body in consciousness. On looking at her one had
to think of the poet’s words, “That mask indicates a hidden meaning.”³⁴

At first I could, therefore, dispense with hypnosis, reserving it, how-
ever, for future use should conditions arise in the course of the confession
for which explanation the memory would not suffice. Thus, in this first
complete analysis of an hysteria which I had under-
taken I attained a
process of treatment which I later raised to a method and intentionally
used as a process of clearing stratum by stratum the pathogenic psychic
material, which we were pleased to compare with the technique of exca-
vating a buried city. At first I let the patient relate what was known to
her, paying careful attention wherever a connection remained enigmati-
cal, or where a link in the chain of causation seemed to be lacking. Later
I penetrated into the deeper strata of memory by using for those locations
hypnotic investigations or a similar technique. The presupposition of the
whole work was naturally based on the expectation that a perfect and
sufficient determination could be demonstrated. The methods of the
deeper investigation will soon be discussed.

The history which Miss Elisabeth gave was quite dull and was woven
of manifold painful experiences. During this recital she was not in a
hypnotic state; I merely asked her to lie down and keep her eyes closed.
I, however, made no objection if from time to time she opened her eyes,
changed her position, or sat up. Whenever she entered more deeply into
a part of her history, she seemed to lapse 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 most superficial stratum 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 the eyes, as well as by a nervous ailment. It thus happened that she

³⁴It will be shown that I was, nevertheless, mistaken.

100

became especially and devotedly attached to her jovial and broadminded
father, who was wont to say that his daughter took the place of both a
son and friend with whom he could exchange thoughts. As much as the
girl gained in mental stimulation in consequence of this intercourse, it
did not escape the father that her psychic constitution deviated from that
ideal which one so much desires to see in a girl. Jocosely he called her
“pert and disputatious.” He warned her against being too confident in
her judgments, against her tendencies to tell the truth regardless of every-
body, 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 girl-
hood; she was filled with ambitious plans, she wished to study or to
obtain a musical education, and revolted at the thought of being forced
to give up her ambitions and sacrifice her freedom of judgment for the
sake of marriage. Meanwhile, she was proud of her father, of the regard
and social position of her family, and jealously guarded everything con-
nected with these matters. The indifference with which she treated her
mother and older sisters, as will be shown, was considered by her parents
to be due to the blunter side of her character.

The age of the girls impelled the family to move into the metropolis,
where for a time Elisabeth enjoyed a richer and gayer social life. But
then came the calamity which destroyed the happiness of the home. The
father either concealed or overlooked a chronic cardiac affection, and one
day he was brought home in an unconscious state after the first attack
of œdema 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 resig-
nation. The beginning of her affection must have been connected with
this period 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 her right leg. She maintained, how-
ever, that these pains soon passed away and excited neither worry nor
attention. As a matter of fact, it was not before two years after the death
of her father that she began to feel sick and unable to walk on account
of pain.

The void which her father left in the life of this family consisting of
four women, the social solitude, the cessation of so many relations which
promised stimulation and pleasure, the increased infirmity of the mother,
all these beclouded the patient’s emotional attitude, but simultaneously
aroused a warm desire that the family might soon find a substitute for
the lost happiness, and impelled her to concentrate her entire devotion and
care on the surviving mother. At the end of the year of mourning the
eldest sister married a talented and ambitious man of notable position,
who seemed to have been destined for a great future by virtue of his
mentality, but who, however, soon developed a morbid sensitiveness and
egotistic perseveration of moods, and dared to show his disregard for

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CASE HISTORIES

the old lady in the family circle. That was more than Elisabeth could
endure. She felt it her duty to take up the cudgels against her brother-
in-law whenever he gave occasion for it, whereas the other women took
lightly the outburst of his excited temperament. She felt it a painful
disillusionment that the reconstruction of the old family happiness could
be impeded by such a disturbance, and she could not forgive her married
sister because, due to feminine docility, the latter firmly avoided espousing
either cause. Thus, a whole series of scenes remained in Elisabeth’s
memory, which were connected with a number of partially unuttered
grievances against her first brother-in-law. But her greatest grievance
against him was the fact that for the sake of a prospective promotion he
moved his small family to a distant city in Austria, and thus helped to
increase her mother’s isolation. On this occasion Elisabeth distinctly
felt her inability and helplessness to afford her mother a substitute for
her lost happiness, as well as the impossibility of following out the
resolution she made on the occasion of her father’s death.

The marriage of the second sister seemed more promising for the
future welfare of the family. The second brother-in-law, although not
of the same mental caliber as the first, was a man after the heart of
delicate ladies, and his behavior reconciled Elisabeth to the institution of
marriage and to the sacrifices it entailed. What is more, the second
couple remained near her mother, and the child of this brother-in-law
and the second sister became Elisabeth’s pet. Unfortunately, the year
during which the child was born was clouded by another event. The
visual affliction of the mother demanded many weeks’ treatment in a dark
room, in which Elisabeth participated. Following this, an operation
proved necessary and the excitement connected with this occurred at the
same time as the first brother-in-law made preparations to move. Finally,
the operation, having been skillfully 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 to which the family had been
subjected since the death of her father.

But just during this sojourn in the summer resort, Elisabeth became
ill with pain and weakness. These pains, which had been noticeable for
a short while some time previously, manifested themselves severely for
the first time after taking a warm bath at a small spa. A long walk,
actually half a day’s hike a few days previously, was thought to have had
some connection with the onset of the pains, so that it was quite easy to
gain the impression that Elisabeth at first became “fatigued,” and then
“caught cold.”

From now on Elisabeth became the patient in the family. Following
the advice of the physician, she spent the rest of the summer in Bad
Gastein, whither she went with her mother, but not without having a new
worriment to think about. The second sister was again pregnant, and
the information as to her condition was quite unfavorable, so that
Elisabeth could hardly decide to take the journey to Gastein. After barely

102

two weeks at Gastein both mother and sister were recalled because things
were not well with the patient at home.

An agonizing journey, which for Elisabeth was full of pain and
anxious expectations, was followed by certain signs at the railroad station
which forbode the worst, and then, on entering the sick room, they were
confronted with the reality—that they had 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 almost as much from the thoughts instigated by her
death, and from the changes which it entailed. The sister had suc-
cumbed to heart trouble, which was aggravated by the pregnancy.

The idea then came to her mind that heart trouble was the paternal
inheritance of the family. It was then recalled that in her early girlhood
the deceased went through an attack of chorea with a slight heart affec-
tion. The members of the family then blamed themselves and the physi-
cians for permitting the marriage, and they could not help reproaching the
unfortunate widower for endangering his wife’s health through two
successive pregnancies without any pause. The sad thought that after
the rare conditions for a happy marriage had been found, that this
happiness should have terminated in this way, constantly occupied
Elisabeth’s mind. Moreover, she again saw everything go to pieces that
she had planned for her mother. The widowed brother-in-law was incon-
solable 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 draw him back into their own
circle. There was no way of maintaining the former union; out of regard
for his unmarried sister-in-law, it would have seemed improper to live
together with his mother-in-law, and as he refused to relinquish his child,
the only legacy of the deceased, to the two ladies, they accused him for
the first time of heartlessness. Finally, and this was not the least painful,
Elisabeth received some definite information concerning a disagreement
between the two brothers-in-law, the cause of which she could only
surmise. It seemed that the widower made some financial demands,
which the other brother-in-law considered unjustifiable; indeed, in view
of the mother’s recent sorrow, he could only designate it as a wicked
extortion. This then was the history of the ambitious and lovable young
woman. Resentful of her fate, embittered over the failure of her little
plans to restore the family luster; of those dear to her, some were dead,
some away, and some estranged—without any inclination to seek refuge
in the love of a strange man, she lived thus for a year and a half away
from almost all social relations nursing her mother and her pains.

If one could forget greater suffering, and wished to read one’s self
into the psychic life of a girl, one could hardly deny Miss Elisabeth a
sincere human sympathy. But what about the physician’s interest in this
sorrowful tale and its relation to her painful and weak gait; what about
the prospects of explaining and curing this case by the knowledge which
we may perhaps obtain from these psychic traumas?

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CASE HISTORIES

For the physician the confession of this patient was at first a great
disappointment. For, to be sure, it was a history composed of banal
mental shocks, from which we could neither explain why the patient
became afflicted with hysteria, nor how the hysteria assumed the form
of the painful abasia. It explained neither the causation nor the deter-
mination 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 simultaneously,
and that now she utilized in her memory the physical sensation as a
symbol for the psychic. What motives she had for this substitution and
in what moment this came about remained unexplained. To be sure,
these were questions, whose nature was not hitherto familiar to physi-
cians. For it was customary to content one’s self with the information
that the patient was constitutionally hysterical, and that under the
intensive pressure of any kind of excitement she could develop hysterical
symptoms.

This confession offered even less for the explanation than for the
treatment of the case. One could not conceive what beneficial influence
Miss Elisabeth could derive from recounting sad, familiar family experi-
ences of the past years to a stranger, who could give her in return only
moderate sympathy, nor could one observe any improvement after the
confession. During the first period of the treatment the patient never
failed to repeat to her physician: “I continue to feel ill, I have the same
pains as before,” and when she accompanied this by a crafty and malicious
glance, I could perhaps recall the words which old Mr. v. R. was wont
to say about his favorite daughter: “She is frequently pert and dispu-
tatious,” but after all I had to confess that she was right.

Had I given up the patient at this stage of the psychic treatment, the
case of Miss Elisabeth v. R. would have been of no importance whatever
for the theory of hysteria. But I continued my analysis because I felt
sure that an understanding of the causation, as well as the determination
of the hysterical symptoms could be gained from the deeper strata of
consciousness.

I, therefore, decided to put the direct question to the broadened con-
sciousness of the patient as to what psychic impression was connected
with the origin of the pain in the legs.

For this purpose the patient should have been put into deep hypnosis.
But fortunately I was forced to realize that all my procedures in that
direction could not put the patient in any other state of consciousness
than that in which she gave me her confession. Still, I was very pleased
that this time she abstained from triumphantly remonstrating with the
words: “You see I really do not sleep. I cannot be hypnotized.” In
such despair I conceived the idea of making use of the trick of pressing
the head, the origin of which I have thoroughly discussed in the preceding
observation of Miss Lucie. This was done by requesting the patient to
unfailingly inform me of whatever appeared before her mind’s eye or
flashed through her memory at the moment of the pressure. She was

104

silent for a long time, and then admitted that on my pressure she thought
of an evening in which a young man had accompanied her home from
some social affair, of the conversation that passed between them, and of
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 then gradually brought out. We dealt here rather
with a secret, for with the exception of a mutual friend, no one knew
anything of the relationship and the hopes connected with it. It concerned
the son of an old friendly family, who formerly lived in the neighborhood.

The young man, being an orphan, attached himself with great devotion
to her father, who guided him in his career, and this veneration for the
father was naturally extended to the ladies of the family. Numerous
reminiscences of joint readings, exchange of views, and remarks which
had been repeated to her, marked the gradual growth of her conviction
that he loved and understood her, and that a marriage with him would
not impose upon her the sacrifice that she feared. Unhappily, he was
only slightly older than she, and as yet far from independent. She, how-
ever, firmly resolved to wait for him.

With the serious illness of her father, and the necessity of nursing
him, these relations became less frequent. The evening, which she
recalled first, really marked the height of her feelings, but even then there
was no exchange of ideas between them on the subject. It was only at
the urging of her family that she consented to leave the sick bed that
evening and attend the social affair, where she was to meet him. She
wished to hasten home early, but she was forced to remain, and only
yielded 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 con-
dition of her father aggravated, she bitterly reproached herself for having
sacrificed so much for her own amusement. It was the last time that she
left her sick father for a whole evening, and thereafter she saw her friend
only rarely. After the death of her father he seemed to hold himself
aloof out of respect for her sorrow, and business affairs later took him
to other regions. Gradually, she came to the realization that his interest
in her was suppressed by other feelings and that he was lost to her. This
failure of her first love pained her as often as she thought of it.

In this relationship and in the above mentioned scene to which it led,
I had to seek the causation of the first hysterical pain. A conflict, or a
state of incompatibility arose through the contrast between the happiness
which she had not at that time denied herself, and the sad condition in
which she found her father upon her arrival home. As a result of this
conflict, the erotic ideas were repressed from the associations and the
affect connected with them was utilized in aggravating or reviving a
simultaneously (or somewhat previously) existing physical pain. It-
was, thus, the mechanism of a conversion for the purpose of defense, as I have
shown circumstantially in another place.³⁵

³⁵ Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894.

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CASE HISTORIES

To be sure, we have room here for all kinds of observations. I must
stress the fact that I did not succeed in demonstrating from her memory
that the conversion took place at the time of her returning home. I,
therefore, investigated for similar experiences which might have occurred
while she was nursing her father, and I evoked a number of scenes, among
which was one during which she had to jump out of bed with bare feet
in a cold room to respond to the repeated calls of her father. I was
inclined to attribute to this moment a certain significance, for in addition
to complaining of pain in her legs, she also complained of tormenting
sensations of coldness. Nevertheless, here, too, I could not with cer-
tainty lay hold of the scene which could be designated as the scene of con-
version. This led me to admit that there was some gap in the explanation
until I recalled that the hysterical pains in the legs were really not present
at the time she nursed her father. From her memory she recalled only
a single attack of pain lasting a few days, to which at that time she paid
no attention. I then directed my attention to the first appearance of the
pains. Here I was successful in awakening a definite memory. Just at
that time a relative visited her; she could not receive him because she
was ill in bed, and he had the misfortune to find her ill on another occa-
sion two years later. But the search for the psychic motive of these first
pains failed as often as it was 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 could also discover that this organic trouble
was the model for the later hysterical imitation, at all events that it
occurred before the scene of being accompanied home. That these mild
organic pains should have continued for some time without her paying
much attention to them was quite possible when we consider the nature
of the situation. The obscurity resulting from this, namely, that the
analysis pointed to a conversion of psychic excitement into bodily pain
at a time when such pain was certainly not perceived and not recalled—
this problem I hope to be able to solve in later considerations and by other
examples.³⁶

With the discovery of the motive for the first conversion we began a
second more fruitful period of the treatment. In the first place, very soon
afterward the patient surprised me with the statement that she now
knew why the pains always radiated from that definite location on the
right thigh, and were most painful there. This was the exact 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 for the origin of an atypical
hysterogenic zone. Furthermore, during our analysis her painful legs
always “joined 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

³⁶I can neither exclude nor prove that this pain, especially of the thighs,
was of a neurasthenic nature.

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STUDIES IN HYSTERIA

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 domi-
nated by the recollection, reaching its height when she was about to utter
the essential and critical part of her communication, and disappeared
with the last words of the statement. I gradually learned to use this
awakened pain as a compass. Whenever she became mute, but still
claimed to have pains, I knew that she had not told me everything, and
urged her to continue the confession until the pain was “spoken away.”
Then only did I awaken a new recollection.

During this period of “abreaction” the patient’s condition showed
such a striking improvement both somatically and psychically that I used
to remark half jokingly that during each treatment I carried away a
certain number of pain motives, and that when I had cleaned them all out,
she would be well. She soon reached a stage during which she had no
pain most of the time; she consented to walk a great deal and to give up
her hitherto self-imposed isolation. During the analysis I followed up,
now the spontaneous fluctuations of her condition, and now some frag-
ments of her sorrowful tale, which I felt was not sufficiently exhausted.
In this work I made some interesting discoveries, the principles of which
I could later verify in other patients.

In the first place, it was found that the spontaneous fluctuations never
occurred unless provoked associatively by the events of the day. On one
occasion she heard of an illness in the circle of her acquaintances, which
recalled to her a detail in the illness of her father. On another occasion
the child of her deceased sister visited her and its resemblance to its
mother recalled many painful incidents. On still another occasion it was
a letter from her absent sister showing distinctly the influence of the
inconsiderate brother-in-law, and this awakened a pain, which made her
crave to relate a family scene not reported before.

As she never reproduced the same pain motives twice, we seemed to
be justified in the expectation that the stock would in time become
exhausted, and I did not in any way prevent her from getting into situ-
ations conducive to evoking new memories, which had not yet come to
the surface. Thus, for example, I asked her to visit 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 nursing of her father, to her young
friend, and to other things which occurred during the first part of the
pathogenic period; while the pain in the left leg appeared as soon as I
evoked the memory of her lost sister, of both brothers-in-law, in brief, of
any impression relating to the second half of the history. My attention
having been called to this by this constant behavior, I went further in
my investigations and gained the impression that the detailization went

107

perhaps still further and that every new psychic cause of painful feeling
might have some connection with a differently located pain 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 multiform psychic memory com-
plexes, but a multiplicity of similar symptoms which on superficial exam-
ination 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.

But my interest was further directed to the mode of construction of
the whole symptom-complex, of the abasia, upon this painful zone, and
with this view in mind, I asked such questions as this: “What is the
origin of the pains in walking, standing, or 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 the
scenes connected with painful impressions according to their occurrence,
sitting, standing, etc. Thus, for example, she stood at the door when
her father was brought home with his cardiac attack, and in her fright
remained as though rooted to the spot. To this first quotation, “fright
while standing,” she connected more recollections up to the overwhelming
scene when she again stood as if pinned near the death bed of her sister.
The whole chain of reminiscences should justify the connection of the
pains with the standing up and could also serve as an association proof,
except that one must be mindful of the fact that in all these events another
factor must be demonstrated, that which had directed the attention—and
consequently the conversion—precisely, to the standing (walking, sitting,
etc.). The explanation for this direction of attention could hardly be
sought in other connections than in the fact that walking, standing, and
lying are connected with functions and conditions of those members which
here 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.

Among the scenes which, according to this review, had made the
walking painful, one became most prominent. It referred to a walk she
had taken in large company at the watering place, which apparently lasted
too long. The deeper circumstances of this occurrence revealed them-
selves 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

108

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 hardly have resolved to enter upon this long walk. On being
questioned whence the pains originated on this walk, she answered rather
indefinitely that the contrast between her solitude and the married happi-
ness of her sick sister, of which she was constantly reminded by the
behavior of her brother-in-law, was painful to her.

Another scene closely related to the former as regards to time played
a part in connection with the pains on sitting. It was a few days later,
her sister and brother-in-law had already departed and she found
herself in a tense and longing mood. She arose in the morning and
ascended to the top of a small hill which they were frequently wont to
visit together, and which afforded a very pretty view. There she sat
down on a stone bench and gave free play to her thoughts. Her thoughts
again revolved on her lonesomeness, the fate of her family, and she now
frankly admitted that she entertained the eager wish to become as happy
as her sister. After this morning’s meditation, she returned home with
severe pains. In the evening of the same day she took the bath, after
which the pains definitely appeared and continued persistently.

We could further ascertain with great certainty that the pains on
walking and standing diminished in the beginning on lying down. Only
after she heard of her sister’s illness and left Gastein in the evening,
spending a sleepless night in the sleeping car, tormented simultaneously
by worrying over her sister and by 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.

In this way 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 lasting, always more cumulative cathexes³⁷ 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 on “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 part of it was
the feeling of her helplessness, the sensation that she “could make no
headway.” I then had to think that her reflections, too, influenced the
formation of the abasia, and I had to assume that she directly sought a
symbolic expression for her painfully accentuated thoughts and had found
it in the aggravation of her pains. That somatic symptoms of hysteria
could originate through such symbolization we have already asserted in
our preliminary communication, and I shall give some examples of con-
clusive evidence in the epicrisis to this history. In Miss Elisabeth v. R.

³⁷ v.s.

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CASE HISTORIES

the psychic mechanism of the symbolization was not in the foreground,
it had not produced the abasia, but everything pointed to the fact that the
already existing abasia had in this way undergone a considerable reën-
forcement. Accordingly, this abasia as I encountered it in the stage of
development, could not only 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. Through-
out this whole analysis I made use of the method of evoking pictures and
ideas by pressing her head, a method, therefore, which would be inappli-
cable without the full coöperation and voluntary attention of the patient.
At times her behavior left nothing to be desired, and at such periods it
was really surprising how promptly and how infallibly the individual
scenes belonging to one theme succeeded each other in chronological
order. It was as if she read from a large picture book, the pages of which
passed in review before her eyes. At other times there seemed to be
inhibitions, the nature of which I could not at that time surmise. When
I applied 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 discon-
tinue the work and to try again later, as the day seemed unpropitious.
Two observations, however, caused me to change my procedure. Firstly,
because such failure of this method occurred only when I found Elisabeth
cheerful and free from pain and never when she had a bad day; secondly,
because she frequently made assertions of seeing nothing after the lapse
of a long pause during which her tense and absorbed mind betrayed to
me some inner psychic process. I, therefore, decided to assume that the
method 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 impart it to me and attempted to suppress
what was conjured up. I could think of two motives for such conceal- ment; either Elisabeth subjected the idea that came to her mind to an
unjustified criticism thinking it not sufficiently important or 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 were
perfectly convinced of the reliability of my technique. Whenever she
asserted that nothing came into her mind, I did not let that pass. I
assured her that something must have come to her, but that perhaps she
was not attentive enough, that I was quite willing to repeat the pressure.
I also told her not to entertain any doubts concerning the correctness of
the idea which presented itself to 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. Through such urging I came to the
realization that no pressure remained unsuccessful. I then had to assume
that I correctly recognized the state of affairs, and indeed, I won perfect
confidence in my technique through this analysis. It often happened that

110

she did not make a statement until after the third pressure, and then
added, “Why I could have told you that the first time.”—“Indeed, why
did you not say it?”—“I thought that is 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 ³⁸
which the patient showed in the reproduction of her recollections, and I
carefully noted 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 unburdened and less restrained
in her behavior, but the pains were manifestly not removed, and reappeared
from time to time with the old severity. The imperfect cure went hand in
hand with the imperfect analysis; as yet, I did not know in what moment
and through what mechanisms the pains originated. During the repro-
duction of the most manifold scenes of the second period and the observa-
tion of the patient’s resistance towards the reproduction, I had a definite
suspicion which I did not dare use as a basis for my action. An acci-
dental observation turned the issue. While working with the patient one
day, I heard the steps of a man in the adjacent room and a rather pleasant
voice asking some questions. My patient immediately arose requesting
me to discontinue the treatment for the day because she heard her brother-
in-law, who had just arrived, asking for her. Before this disturbance she
was free from pains, but now she betrayed by her mien and gait the
sudden appearance of violent pains. This strengthened my suspicion and
I decided to elicit the decisive explanation.

I therefore questioned her again 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
making the journey to Gastein. A number of scenes were reproduced
which had already been treated less exhaustively. They recalled her
frame of mind at that time, the exhaustion following the worriment about
her mother’s vision, and the nursing of her mother during the time of the
operation, and her final despair at being unable as a lonesome girl to enjoy
or accomplish anything in life. Until then she felt strong enough
to dispense with the help of a man, but now she was overcome 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 of how affectionately he cared for her, how they under-
stood each other by a mere glance, and how sure they seemed to be of
each other. It was truly regrettable that the second pregnancy followed
so closely upon the first, 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;

³⁸ The mechanisms of resistance, which the author now counts among the
great pillars of psychoanalytic technique, are mentioned here for the first
time. [Translator.]

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CASE HISTORIES

he preferred to remain home with his sick wife, but the latter urged him
with a glance to go because she thought that it would give Elisabeth
pleasure. Elisabeth remained with him throughout the whole walk;
they spoke about the most varied and intimate things; she found herself
in thorough accord with all he said, and she became overwhelmed with
a desire to possess a man like him. This was followed by a scene a
few days later, when, on the morning after their departure, she visited
the point commanding the beautiful view which had been their favorite
walk. There she seated herself upon a stone and again dreamed of her
sister’s happiness and of a man like her brother-
in-
law who could engage
her affections. When she arose, she had pains which again disappeared,
and only in the afternoon after having taken the warm bath did they
reappear, remaining ever since. I attempted to investigate the thoughts
which occupied her mind while taking the bath, but all I could obtain
was that the bathroom recalled her absent sister because she had lived in
the same house.

For some time the state of affairs must have been clear to me. The
patient seemed absorbed in painfully-
sweet recollections, so that she was
wholly unconscious of the drift of her thoughts and continued to reproduce
her reminiscences. She spoke of the time in Gastein, the worry connected
with the expectations of the letter, finally the information of her sister’s
illness, the long wait until the evening when she could finally leave Gastein,
the journey with its tormenting uncertainties during a sleepless night—
all these moments were accompanied by a violent aggravation of the pain.
I asked her if during the journey she thought of the sad possibility which
she afterward found realized. She answered that she carefully avoided
the thought, but that in her opinion her mother expected the worst from
the very beginning. This was followed by the reminiscences of her
arrival in Vienna—the impressions which she received from the relatives
at the station, the short journey from Vienna to the neighboring summer
resort where her sister lived, the arrival in the evening, the hasty walk
through the garden to the door of the little garden pavilion—a silence in
the house, the oppressive darkness, the fact of not having been received
by the brother-
in-
law. She then recalled standing before the bed seeing
the deceased, and in the moment of the awful certainty that the beloved
sister had died without having taken leave of them and without having
her last days eased through their nursing—in that very moment another
thought flashed through Elisabeth’s brain, which now peremptorily
repeated itself. The thought, which flashed like dazzling lightning
through the darkness, was, “Now he is free again, and I can become
his wife.”

Of course, now everything was clear. The analyst’s effort was richly
repaid. The ideas of “defense” against an unbearable idea, the origin
of hysterical symptoms through conversion of psychic into physical
excitement, the formation of a separate psychic group by an act of the
will, which led to the defense—all these were in that moment palpably
presented before my eyes. Thus, and thus alone did things happen here.

112

This girl entertained an affectionate regard for her brother-in-law, against
the acceptance of which into her consciousness 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 through a successful conversion into the somatic. At the time
she came under my care the isolation from her awareness of the group of
ideas referring to this love affair had already been accomplished, else I
believe that she would never have agreed to this mode of treatment. The
resistance with which she repeatedly opposed the reproduction of the
traumatically effective scenes really corresponded to the energy with
which the unbearable idea had been crowded out from the associations.
For the therapist there now came a sorry time. The effect of the
resumption of that repressed idea was crushing 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 horrible pains; she made another despairing effort to reject
the explanation, saying that it was not true, that I suggested it to her, it
could not be, she was incapable of such baseness, 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 sickness
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 alleviate
the patient. In the first place, I wished to give her the opportunity to rid
herself by abreaction of the material long since accumulated. We investi-
gated 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 retrospection
showed a fully developed passion. In his first visit to the house he mis-
took her for his destined bride and greeted her before he greeted her
older and more 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 at a
social gathering where none knew of the engagement, the conversation
drifted to the young man, and a young lady indiscreetly remarked about
a blemish in his figure, a juvenile joint affliction. The bride herself
remained calm while Elisabeth flew into a passion, and with an ardor
which even she herself could not afterwards understand defended the
straight form of her future brother-in-law. While we worked our way
through these reminiscences, it became clear to Elisabeth that her affec-

113

CASE HISTORIES

tion 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 abreaction 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 impaired through the last misfortunes. From
her I learned that the accusation of rude extortion, which the older
brother-in-law had brought against the widower, and which was so
painful to Elisabeth, had to be retracted on closer investigation. The
character of the young man remained untarnished; it was merely a mis-
understanding, 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 unburdening 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 had existed during the lifetime of her sister. Whoever saw them
both in friendly intercourse-
of late, to be sure, only seldom-
could enter
tain no doubt of the girl’s anxiety to please him. However, neither she,
the mother, nor the advisers of the family showed any particular inclina-
tion 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 marriage. It
was quite probable that this was the reason for his reserve, perhaps also
because he was not sure of his position and wished to avoid all obvious
gossip. With such a reserve on both sides the solution for which
Elisabeth 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 explana-
tion con-
cerning the money affair. On the other hand, I urged her to bear calmly
the uncertainties of her future which could not be dismissed. The
advancing summer forced 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
had been finished, although I felt that the abreaction of the suppressed
love was really not as complete as it should have been. I regarded her
as cured and urged her to continue independently the solution after the
way had been cleared for it, to which she agreed. She left with her

114

STUDIES IN HYSTERIA

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 parting 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 had
been relieved from my discipline she would make another attempt to
reject her mother’s interference and return to her reserve. I was, how-
ever, 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 assured me that she could be
considered cured. The relation of the brother-in-law to the family had
not changed.

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 married a stranger.

Epicrisis

I have not always been a psychotherapist, but like other neuro-
pathologists I was educated to methods of focal diagnoses and elec-
trical prognosis, so that even I myself am struck by the fact that the
case histories which I am writing 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 discussion of the psychic
processes, as one is wont to hear 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 case histories should be con-
sidered like psychiatrical ones, but they have the advantage over the
latter in the fact that they give the intimate connection between the

115

history of the disease and the morbid symptoms, a thing for which
we are still looking in vain in the histories of other psychoses.³⁹

With the description of the treatment I endeavored to interweave
the explanations which I gave about the case of Miss Elisabeth v. R.,
and it will perhaps not be superfluous to summarize here the essen-
tial features. I have discussed the character of the patient and the
features which repeat themselves in so many hysterics, and which we
really cannot 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 in obstinacy, pugnaciousness, and shut-
in-ness. 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 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 type. There was no serious case of psychosis in
any near relatives.

Her nature was influenced 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
factors, which one finds here, are quite obvious; thus, the disturbance
of the physical health through interrupted sleep, neglect of nourish-
ment, and the reaction of a constantly gnawing worriment on the
vegetative functions. The most important factor, however, is in
my estimation to be found elsewhere. He whose mind is occupied
with the hundred different tasks of nursing which succeed each other
continuously for weeks and months, gets into the habit, on the one
hand, of suppressing all signs of his own emotions, and on the other
hand, his attention is soon turned away from his own impressions
because he has neither the time nor the strength to do them justice.
Thus, the nurse accumulates in himself an overabundance of affective
impressions which he or she barely perceives clearly enough; at any
rate, they are not dissipated by abreaction; that is, he or she creates
for himself the material for a retention hysteria. If the patient³⁹

³⁹This situation no longer obtains in present-day psychiatry. Beginning
with the Zurich School under the stimulation of Bleuler the descriptive
psychiatry of Kraepelin long ago gave way to the interpretative psychiatry of
the present.

116

recovers, these impressions naturally lose their value, but if he dies
and one goes into a period of mourning 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 fact of subsequent adjustment to traumas accumulated
during nursing is occasionally also encountered where the general
impression of being sick does not ensue, but where the mechanism of
hysteria, nevertheless, can be noticed. Thus, I have known a highly
gifted but slightly nervous lady whose whole personality suggests the
hysteric, yet she never became a burden to the doctor and was never
forced to interrupt the exercise of her duties. This lady had nursed
three or four of her dear ones until they died, which caused her each
time a complete physical exhaustion, yet these sad duties have never
made her sick. However, shortly after the death of the patient she
begins her work of reproduction in which she reviews the scenes of
the disease, and of the death. Each day—one might say, at her
leisure—she goes over again every impression, crying over it, and
consoling herself. Such adjustment continues through her daily
occupations without any confusion of the two activities. Everything
passes before her chronologically. Whether the memory work of one
day precisely corresponded to a day of the past, I am unable to say.
I presume that it depends on the leisure which is left to her by the
current affairs of the household.

Aside from this “after crying,” which follows these demises after
short intervals, this lady periodically observed the anniversaries of
the various catastrophes, and here her vivid visual reproductions
and her affective manifestations follow faithfully the dates. Thus,
for example, I found her in tears, and on sympathetic inquiry as to
what occurred on that day, she half irritably remarked, “Nothing on
that day except that Professor N. was again here and gave us to
understand 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 scenes on these recurring anniversaries,
or whether, as I suppose, in the interest of my theory, other details
presented themselves each time for abreaction. I was, however,
unable to find anything definite about this; the wise and courageous

117

CASE HISTORIES

woman was ashamed of the intensity with which those reminiscences
acted upon her.⁴⁰

I repeat that this woman was not sick and that subsequent
abreaction, 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 the personal predisposition, for the
lady whom I have here in mind showed it in the most prolific manner.

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 analytic 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 explained 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

⁴⁰To my surprise, I once discovered that such subsequent abreaction–
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 later I
was again called because her character had changed. She was depressed and
tired of living, lacked all 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 me that the reason
for her depression was the breaking of her betrothal many months before. She
stated that on closer acquaintance with her fiancé the things displeasing to her
and her mother became more and more evident in him. On the other hand,
the material advantages of the engagement were too tangible to make the
decision of a rupture easy; thus, both of them hesitated for a long time. She
passed apathetically and finally her mother pronounced for her the decisive “no.”
Shortly afterwards 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. She continued
to live in that time of doubt, and entertained daily the moods and the thoughts,
which would have been appropriate for that day. The irritability against her
mother could only be explained by circumstances that existed at that time.
Next to this mental 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 continued
my exhortations during deep somnambulism. I saw her each time burst 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 dis-
appeared. This was attributed to the success of my great hypnotic cure.

118

affect into somatic sensations 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 better demonstrated by the analysis—repeated itself after
years and led to the aggravation of the same pain and to its dissemi-
nation 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
very disagreeable to her. 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 from the recent nursing, and her moral
exhaustion from years of disillusionment, which then began to break
down her reserve, and caused her to confess to herself the need of
the love of a man. During a relationship which extended over weeks
(in that summer resort) this erotic desire attained full development
simultaneously with the pain, and analysis shows that during that
time the patient was in a special psychic state, which in conjunction
with the desire and pain, seems to afford an understanding of the
process in the sense of the conversion theory.

I must place reliance on the statement that the patient’s affection
for her brother-in-law, intensive as it was, was not clearly known to
her except on certain rare occasions, and then only momentarily. If
that were not so, she would have become conscious of the incompati-
bility between this desire and her moral ideas, and would have had
to endure the same mental agonies which I saw her suffer after our
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 without 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 mental process from the rest
of the ideational content.

119

How did it happen that such an intensively accentuated group of
ideas could be kept so isolated? For generally the rôle of an idea in
the association actually increases with the size of its affect.

This question can be answered if we take into account two facts
which we can use as if proven: (1) That the hysterical pain orig-
inated simultaneously with the formation of these separate 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 consciousness, and when the
union was, nevertheless, effected, she felt excessive psychic pain.
Our conception of hysteria brings together these two factors with the
fact of the splitting of consciousness, by asserting that (2) contains
the indication of the motive for the splitting of consciousness, while
(1) shows the mechanism of the same. The motive was that of
defense, or the striving of the whole ego to get into harmony with this
ideation group, and the mechanism was that of conversion; that is,
instead of psychic pains which she spared herself, there appeared
physical pains. A transformation was thus initiated, which resulted
in a gain insofar as the patient had escaped an unbearable psychic
state; to be sure, this gain was obtained at the cost of a psychic
anomaly, a splitting of consciousness and physical suffering, the pains,
upon which an astasia-abasia was constructed.

To be sure, I can give no directions as to how one can produce in
himself such a conversion. Apparently it is not done as one inten-
tionally performs an arbitrary action; it is a process which takes
place in a person under the impulse of the motive of defense, if he
has a tendency for it in his organization, or if it is brought about by
temporary modification.

One has the right to examine the theory more closely and ask:
“What is it then that becomes transformed into physical pains?”
The cautious reply will be: “Something out of which psychic pains
could have and should have been formed.” If one wishes to venture
further and attempt a kind of algebraic formulation of the ideational
mechanism, one might perhaps attribute to the ideational complex
of this desire (which remained unconscious) a certain amount of
affect and designate the latter quality as the thing converted. A
direct deduction of this conception would be that through such con-
version the “unconscious love” forfeits so much of its intensity that
it becomes reduced to a weak idea, and its existence as a separate
psychic group could be possible only through this weaken-
ing. How-

120

ever, the present case is not capable of throwing light on this delicate
matter. It probably corresponds only to an imperfect conversion.
From other cases it seems quite probable that there are also perfect
conversions, 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 reëstablished, the patients assure
us that since the origin of the hysterical symptoms their unbearable
ideas had never occupied their minds.

I have stated above that on certain occasions, though only transi-
torily, the patient consciously recognized the love for her brother-in-
law. Such a moment occurred when, for example, at the deathbed
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 in the assumption of a “defense hysteria” there is already
the requisite that at least one such moment should have occurred.
For consciousness really does not know in advance when such an
unbearable idea will present itself. For the unbearable idea, which
is later excluded with its appendage for the formation of a separate
psychic group, must have been originally in the mental activity, else
there would have been no conflict to lead to its exclusion.⁴¹ Just such
moments should be designated as “traumatic.” It is in them that
the conversion takes place, and results in the splitting of con-
sciousness and the hysterical symptoms. Everything tends to show
that in Miss Elisabeth v. R. there were a number of such moments
(the scenes of the walking, morning meditation, bath, and at the
bedside of her sister), and perhaps new moments of this kind
also occurred during the treatment. The multiplicity of such
traumatic moments is made possible by the fact that an experience
similar to the one which first initiated the unbearable idea, introduces
new emotions to the separated psychic groups and thus transitorily
abolishes the success of the conversion. The ego is forced to occupy
itself with this suddenly reënforced and flared-up idea, and must later
restore the former state through 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. A case
whose traumatic history had been finished in the past would have
been more desirable for this discussion.

⁴¹It is different in a hypnoid hysteria. Here the content of the separate
psychic groups may never have been in the ego consciousness.

121

I must now occupy myself with the point which I have designated
as a difficulty for the understanding of this case history. On the
analytical basis I assumed that the first conversion took place in the
patient while she nursed her father, at the time when her duties as a
nurse came into conflict with her erotic yearnings, and that this
process was the model for the later ones which led to the outbreak
of the disease in the Alpine spa. But, according to the patient’s state-
ment she had not at all suffered from any pains and weakness at the
time of the nursing, and the period following it, which I designated
as the “first period.” 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 impressions
could not be demonstrated by analysis; it is possible, even probable,
that at that time we dealt with a common rheumatic muscular pain.
But if we should assume that this first attack of pain was the result
of an hysterical conversion in consequence of the rejection of erotic
thoughts which then existed, the fact, nevertheless, remains that the
pains disappeared after a few days, so, that the patient actually
behaved differently than she seemed to show during the analysis.
During the reproduction of the so-
called first period, all her state-
ments 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 felt no pains. Is this not a contradiction which
is likely 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 sub-
sequently, that is, in the second period when the patient reproduced
these impressions in her mind. The conversion did not follow the
fresh impressions, but the memories of the same. I even believe that
such a process is not at all unusual in hysteria and regularly partici-
pates in creating hysterical symptoms. Nevertheless, as such an
assertion does not seem plausible, I shall attempt to make it more
credible by citing other experiences.

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

122

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 efforts to educate herself as a singer, complained
that her beautiful voice did not obey her in certain notes. She felt
choking and tightening sensations in the throat, so that the tones
sounded strained, and her teacher could, therefore, not yet permit
her to appear in public. Although this imperfection affected only her
middle notes, it could not be explained on the basis of a defect of her
vocal organs, for at times this disturbance did not show itself and
her teacher was very pleased with her, but at other times, the slightest
excitement, seemingly without any provocation, evoked the choking
sensation, and prevented free expansion of the voice. It was not
difficult to recognize in this annoying sensation an hysterical con-
version. Whether there was really a contracture of certain muscles
of the vocal chords could not be verified.⁴² In the hypnotic analysis,
which I undertook with this girl, I found out the following concerning
her vicissitudes and the ailments occasioned through them. She
became an orphan at an early age and was brought up by her aunt,
who had many children, and she had to share the life of a most
unfortunate family existence. The husband of this aunt, seemingly
a pathological personality, abused his wife and children in the most
brutal manner, and what especially pained her was his unconcealed
sexual preference for the servant and nurse girls in the house. This
became even more obnoxious as the children grew older. When her
aunt died, Rosalia became the protectress of the orphaned children
who were harassed by their father. She took her duties 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 provoking accusation, she perceived a scratching

⁴²I had under observation another case in which a contracture of the
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
rehearsing in Rome, in great excitement, she suddenly perceived the sensation
of being unable to close her opened mouth and sank fainting to the floor. The
physician, who was called, closed her jaws forcibly, but since that time the
patient had been 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 apparently had been over for some
time, for massage in a light hypnosis sufficed to open her mouth widely. The
lady has since then sung in public.

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CASE HISTORIES

in her throat, the tightening 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 pos-
sibility of making herself independent in order to escape the excite-
ment and painful impressions which were daily occurrences in her
uncle’s house. An efficient music teacher took an unselfish interest
in her, assuring her that her voice entitled her to choose the profes-
sion 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 vocal organs
during singing. The apparatus of which she should have had free
control was filled with the remnants of innervation from those
numerous scenes of suppressed excitement. Since then she has left
her uncle’s house and has 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 reproduction
of all the exciting impressions and by subsequent abreaction. 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 treat-
ment 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 with friendliness,
but just for that reason she incurred the displeasure 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 becom-
ing 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 that she,
for instance, did not dare to sing or play the piano when her aunt
was within hearing distance, and carefully avoided either singing or
playing anything for her aged uncle—her mother’s brother—when-
ever her aunt was home. While I was endeavoring to efface the
traces of the old excitements, new ones originated through these

124

relations with her hosts, 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 prickling
sensation in the fingertips, which had manifested itself every few
hours since the day before, and forced her to make very peculiar
jerky movements. I could not see the attack; otherwise, I would
have guessed the cause from seeing the motions of the fingers, but I
immediately endeavored to trace through hypnotic analysis the causa-
tion of this symptom (it was really a minor hysterical attack). As
the whole thing existed only for a short time, I hoped to be able to
explain it and quickly remove it. To my surprise, she reproduced
without any hesitation in chronological order a whole row of scenes
beginning in her early childhood. All these had perhaps the same
characteristics in the fact that she had suffered an injustice without
defense, something which could make her fingers jerk; for example,
scenes like the one of being forced to hold out her hand in school
while the teacher struck it with a ruler. But they were all banal
causes, to which I would have gladly opposed the right to enter into
the etiology of hysterical symptoms. It was different, however, with
one scene of her early girlhood, which was connected with the others.
The bad uncle who suffered from rheumatism asked her to massage
his back. She did not dare refuse him. He was in bed while she was
doing it and he suddenly threw off the covers, jumped up, and
attempted to grab her and throw her down. She naturally stopped
the massage and in a moment escaped and locked herself in 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 in 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 which she
experienced 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 ond 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

125

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 con-
tinuous jerking, as if one literally and figuratively would reject some-
thing like throwing away a sheet of music or rejecting an unreason-
able demand.

She was quite positive in her assurance that she did not perceive
the symptom before, that it was not caused by the scenes previously
related. Was there anything else to be assumed except that the scene
experienced yesterday had in the first place awakened the recollection
of a former similar content, and that it then developed into a memory
symbol for the whole group of recollections? The conversion was
on the one hand furnished with newly experienced affects, and 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.⁴³ In some of these 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 trauma
and became fixed. Yet, no real distinction can be made between
those of temporary appearance and those which remained entirely
latent causations. 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 coöpera-
tion of the former motives could not be dispensed with, and for the
solution of which it required a consideration of all the motives.
Translating this into the language of conversion theory, this unde-
niable fact of the summation of 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 seems to exist in
the history and analysis of Miss Elisabeth v. R.

For there is no question that normal persons continue to carry
in their consciousness a large number of ideas with unadjusted affects.
The assertion which I have just defended merely approximates the
behavior of hysteria to that of the normal. It is apparently reduced to

⁴³ Compare here the nice examples of Mrs. Emmy in Case History II.

126

a quantitative factor; it is simply a question of how many such affec-
tive strains an organization can endure. Even an 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 indi-
vidual’s endurance, the impetus for conversion is formed. It is, there-
fore, no singular theory, but almost a postulate to say that the forma-
tion of hysterical symptoms 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 have
been selected to represent the psychic pains? The circumstances 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 organically founded pain. It
is always the most common, the most widespread pain of humanity
that seem to be most frequently called upon to play a part in hysteria.
Among the most common are the periosteal and the neuralgic pains
of the teeth, headaches 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 organi-
cally 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
memories, if they are carefully applied. This original rheumatic
pain ⁴⁴ became the memory symbol for her painful psychic excite-
ments, 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 content of that time. At
all events, it was perhaps a remote consequence of the nursing, of
her want of exercise, and of the poor nutrition entailed by her duties.
But this hardly became clear to the patient, and what is more impor-
tant is that she had to perceive it during important 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

⁴⁴But perhaps spinal neurasthenic?

127

CASE HISTORIES

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 the bandages. The location on the right leg
distinguished by this contact henceforth remained the focus and
starting point of the pains; it was an artificial hysterogenic zone, the
origin of which can be plainly seen in this case.

If anyone 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 people in the world pos-
sess most of the money.” Where prolific connections do not exist,
there is naturally no formation of hysterical symptoms, and conver-
sion does not find its way. I can also state that in reference to deter-
minations the case of Miss Elisabeth v. R. belongs to the simpler ones.
In the case of Mrs. Cecilia M. particularly, I had to solve the most
intricate knots of this kind.

I have already discussed in the case history how the astasia-
abasia of our patient was built up on those pains after a definite path
was opened to the conversion. But, there, too, I have expressed the
opinion that the patient created or aggravated the disturbance of
function through symbolization. For her dependence and helpless-
ness to change anything in the circumstances she found a somatic
expression in the astasia-abasia, and the expressions “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 asso-
ciative connections seems to exert the least claims on the hysterical
predisposition; on the other hand, conversion through symbolization
seems to require a higher grade of hysterical modification, a fact also
demonstrated in Miss Elisabeth in the later stages of her hysteria.
The nicest examples of symbolization I have observed in Mrs.
Cecilia M., whom I can call my most difficult and most instructive
case. I have already mentioned that unfortunately this case history
does not lend itself to detailed reproduction.

Among other things Mrs. Cecilia 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 then ceased as if cut off. It limited itself to the

128

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” played a certain part in the patient’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 by the methods in
vogue, such as electric penciling, alkaline waters and purgatives, but
it always remained uninfluenced until it found it 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.⁴⁵ This did not run so
smoothly, as the teeth were so firm that most of the roots were left
behind. This cruel operation 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
started to get ready for an extraction, but usually he was soon inter-
rupted, 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
genuineness of this neuralgia.

About a year after this hypnotic remedial success, the condition
of Mrs. Cecilia M. took a new and surprising turn. There suddenly
appeared other states than those that had been characteristic of the
last years, but after some reflection the patient declared that all these
conditions had existed 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
mental connections, which determined the sequence of these inci-
dents, 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 an hysterical con-
dition belonging to the past was reproduced was most remarkable.

⁴⁵It is remarkable how history repeats itself. Lest there should be some
misunderstanding, I wish to remind the reader that the above was written in
1893, and the theory of focal infection especially of the teeth was brought out
as something new in psychiatry only about ten years ago. [Translator.]

129

In the first place, while the patient was in the best of condition, there
appeared a pathological mood of special coloring, which was regularly
mistaken 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, con-
vulsions, 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 symptoms 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 induced hypnosis, evoked a reproduction of the
traumatic events, and by artificial aid I curtailed the attack. Having
gone through with the patient many hundreds of such cycles, I
obtained the most instructive explanations concerning the deter-
minants 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 also came to the reproduction of the
facial neuralgias, 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 annoyed
her very much. She then suddenly grasped her cheek, crying 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 manifestation of a trigeminal neuralgia, to its limiting itself to
the second and third branches, and to its being aggravated on opening
the mouth, and on mastication (not on 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 continued for nine
days, and from the result it seemed that for years irritations, especially
through words, produced new attacks of this facial neuralgia by way
of symbolization.

130

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 coincidence.
It was a painful sight which recalled to her mind a reproach, and
this caused her to repress another series of thoughts. We had here,
then, a case of conflict and defense, and the origin of the neuralgia
in this moment could not be further explained if we did not wish to
assume that she suffered at that time from slight toothache or facial
pains, a thing not improbable, as she was then in the first months of
pregnancy.

The result of the explanation showed that this neuralgia became
the mark of a definite psychic excitement through the usual road of
conversion, but that it could be awakened later through associative
accusations from mental life and symbolic conversions. It was really
the same procedure as we encountered in Miss Elisabeth v. R.

I will now introduce another example which will illustrate the
efficacy of symbolization under other determinants. On one occasion
Mrs. Cecilia M. was tormented by a violent pain in her right heel,
she had stinging sensations on every step, which made walking impos-
sible. The analysis conducted us to a time when the patient was in a
foreign sanitarium. For eight days she kept to 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 physician’s
arm on leaving the room. It disappeared during the reproduction
of this scene while she remarked at at that time she feared lest she
would not make the “proper impression” on this strange society⁴⁶
(“rechte Auftreten” equals ‘proper stepping’).

This seems a striking, almost comical example for the origin of
hysterical symptoms through symbolization by means of a verbal
expression. But closer investigation of the circumstances of that
moment favors another conception. The patient suffered at that
time from actual pains 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, in order
to form it into a psychic algia and to assist it to maintain itself for
a long time.

Notwithstanding the fact that the mechanism of symbolization in
these examples seems to be pushed into second rank, which certainly

⁴⁶The literal translation of Auftreten is “to press down by treading.”

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CASE HISTORIES

agrees with 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. Cecilia 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 thereafter continued for weeks. On analyzing this
pain, which was reproduced after almost thirty years, she stated that
her grandmother gazed at her so “piercingly” that it seemed as if
her look 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. Cecilia M. gave me the opportunity to gather
a collection of such symbolizations. A whole series of physical sen-
sations, which were otherwise looked upon as organically determined,
were of psychic origin, or at least lent themselves to psychic inter-
pretation. A certain number of her experiences were accompanied
by a piercing sensation in the region of the heart (“I felt a stitch
in my heart”). The piercing headache of hysteria was undoubtedly,
in her case, to be interpreted as a mental pain (“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 annoyance, 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 of the two elements was the primary one.

In no other patient was I able to find such a prolific application
of symbolization. To be sure, Mrs. Cecilia M. was quite an unusual
person, of a special artistic temperament, whose highly developed
sense of form manifested itself in producing very beautiful poems.
I maintain, however, that if an hysteric creates through symbolization
a somatic sensation for an emotionally accentuated idea, 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 occur-
 

132

rences, she practices no facetious misuse, but only revives the sen-
sations to which these phrases owe their existence. For how does
it happen that in speaking of an aggrieved person we use such expres-
sions as “he experienced a ‘stitch in his heart’,” if the mortification
was not actually accompanied by a precordial sensation that could
be so interpreted and recognized? Is it not probable that the phrase,
“to swallow something,” applied to an unreturned insult, really
originates from the sensation of innervation appearing in the pharynx
when one forces back his speech, thus preventing a reaction to the
insult? All these sensations and innervations belong to the
“expression of the emotions,” which, as Darwin taught us, originally
consisted of sensible and expedient actions; at present most of them
may be so weakened that their verbal expression seems to us like a
figurative transformation, but very probably all this was once meant
literally, and hysteria is justified in reconstructing the original literal
sense for its stronger innervation. Indeed, perhaps it is improper to
say that it creates such sensations through symbolization, perhaps it
has not taken the usage of speech as a model, but like it draws it from
a common source.⁴⁷

⁴⁷In conditions of profounder psychic changes we apparently find a symbolic
stamp of the more artificial usage of language in the form of emblematic
pictures and sensations. There was a time in Mrs. Cecilia 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!”