Freud - Complete Works (20 page)

   I must make one further remark
before bringing Frau von N.’s case history to a close. Dr.
Breuer and I knew her pretty well and for a fairly long time, and
we used to smile when we compared her character with the picture of
the hysterical psyche which can be traced from early times through
the writings and the opinions of medical men. We had learnt from
our observations on Frau Cäcilie M. that hysteria of the
severest type can exist in conjunction with gifts of the richest
and most original kind - a conclusion which is, in any case, made
plain beyond a doubt in the biographies of women eminent in history
and literature. In the same way Frau Emmy von N. gave us an example
of how hysteria is compatible with an unblemished character and a
well-governed mode of life. The woman we came to know was an
admirable one. The moral seriousness with which she viewed her
duties, her intelligence and energy, which were no less than a
man’s, and her high degree of education and love of truth
impressed both of us greatly; while her benevolent care for the
welfare of all her dependants, her humility of mind and the
refinement of her manners revealed her qualities as a true lady as
well. To describe such a woman as a ‘degenerate’ would
be to distort the meaning of that word out of all recognition. We
should do well to distinguish between the concepts of
‘disposition’ and ‘degeneracy’ as applied
to people; otherwise we shall find ourselves forced to admit that
humanity owes a large proportion of its great achievements to the
efforts of ‘degenerates’.

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94

   I must confess, too, that I can
see no sign in Frau von N.’s history of the ‘psychical
inefficiency’ to which Janet attributes the genesis of
hysteria. According to him the hysterical disposition consists in
an abnormal restriction of the field of consciousness (due to
hereditary degeneracy) which results in a disregard of whole groups
of ideas and, later, to a disintegration of the ego and the
organization of secondary personalities. If this were so, what
remains of the ego after the withdrawal of the
hysterically-organized psychical groups would necessarily also be
less efficient than a normal ego; and in fact, according to Janet,
the ego in hysteria is afflicted by psychical stigmata, condemned
to mono-ideism and incapable of the volitional acts of ordinary
life. Janet, I think, has made the mistake here of promoting what
are after-effects of changes in consciousness due to hysteria to
the rank of primary determinants of hysteria. The subject is one
that deserves further consideration elsewhere; but in Frau non N.
there was no sign of any such inefficiency. During the times of her
worst states she was and remained capable of playing her part in
the management of a large industrial business, of keeping a
constant eye on the education of her children, of carrying on her
correspondence with prominent people in the intellectual world - in
short, of fulfilling her obligations well enough for the fact of
her illness to remain concealed. I am inclined to believe, then,
that all this involved a considerable
excess
of efficiency,
which could perhaps not be kept up in the long run and was bound to
lead to exhaustion - to a secondary ‘
misére
psychologique
’ [‘psychological
impoverishment’]. It seems likely that disturbances of this
kind in her efficiency were beginning to make themselves felt at
the time when I first saw her; but however that may be, severe
hysteria had been present for many years before the appearance of
the symptoms of exhaustion.¹

  
¹
[
Footnote added
1924:] I am aware
that no analyst can read this case history to-day without a smile
of pity. But it should be borne in mind that this was the first
case in which I employed the cathartic procedure to a large extent.
For this reason I shall leave the report in its original form. I
shall not bring forward any of the criticisms which can so easily
be made on it to-day, nor shall I attempt to fill in any of the
numerous gaps in it. I will only add two things: what I afterwards
discovered about the immediate aetiology of the illness and what I
heard of its subsequent course.

  
When, as I have mentioned, I spent a few days as Frau Emmy’s
guest in her country house, there was a stranger present at one of
the meals who clearly tried to make himself agreeable. After his
departure my hostess asked me how I had liked him and added as it
were in passing: ‘Only imagine, the man wants to marry
me!’ When I took this in connection with some other remarks
which she had made, but to which I had not paid sufficient
attention, I was led to conclude that she was longing at that time
to be married again but found an obstacle to the realization of her
purpose in the existence of her two daughters, who were the
heiresses of their father’s fortune.

   A
few years later at a Scientific Congress I met a prominent
physician from Frau Emmy’s part of the country. I asked him
if he was acquainted with the lady and knew anything of her
condition. Yes, he said, he knew her, and had himself given her
hypnotic treatment. She had gone through the same performance with
him - and with many other doctors - as she had with me. Her
condition had become very bad; she had rewarded his hypnotic
treatment of her by making a remarkable recovery, but had then
suddenly quarrelled with him, left him, and once more set her
illness going to its full extent. It was a genuine instance of the
‘compulsion to repeat’.

   It
was not for another quarter of a century that I once more had news
of Frau Emmy. Her elder daughter - the one of whom I had earlier
made such an unfavourable prognosis - approached me with a request
for a report on her mother’s mental condition on the strength
of my former treatment of her. She was intending to take legal
proceedings against her mother, whom she represented as a cruel and
ruthless tyrant. It seems that she had broken off relations with
both her children and refused to assist them in their financial
difficulties. The daughter who wrote to me had obtained a
doctor’s degree and was married.

Studies On Hysteria

95

CASE
3

MISS LUCY R., AGE 30  
(Freud)

At the end of the year 1892 a colleague of my
acquaintance referred a young lady to me who was being treated by
him for chronically recurrent suppurative rhinitis. It subsequently
turned out that the obstinate persistence of her trouble was due to
caries of the ethmoid bone. Latterly she had complained of some new
symptoms which the well-informed physician was no longer able to
attribute to a local affection. She had entirely lost her sense of
smell and was almost continuously pursued by one or two subjective
olfactory sensations. She found these most distressing. She was,
moreover, in low spirits and fatigued, and she complained of
heaviness in the head, diminished appetite and loss of
efficiency.

   The young lady, who was living as
a governess in the house of the managing director of a factory in
Outer Vienna, came to visit me from time to time in my consulting
hours. She was an Englishwoman. She had a delicate constitution,
with a poor pigmentation, but was in good health apart from her
nasal affection. Her first statements confirmed what the physician
had told me. She was suffering from depression and fatigue and was
tormented by subjective sensations of smell. As regards hysterical
symptoms, she showed a fairly definite general analgesia, with no
loss of tactile sensibility, and a rough examination (with the
hand) revealed no restriction of the visual field. The interior of
her nose was completely analgesic and without reflexes; she was
sensitive to tactile pressure there, but the perception proper to
it as a sense-organ was absent, alike for specific stimuli and for
others (e.g. ammonia or acetic acid). The purulent nasal catarrh
was just then in a phase of improvement.

   In our first attempts at making
the illness intelligible it was necessary to interpret the
subjective olfactory sensations, since they were recurrent
hallucinations, as chronic hysterical symptoms. Her depression
might perhaps be the affect attaching to the trauma, and is should
be possible to find an experience in which these smells, which had
now become subjective, had been objective. This experience must
have been the trauma which the recurring sensations of smell
symbolized in memory. It might be more correct to regard the
recurrent olfactory hallucinations, together with the depression
which accompanied them, as equivalents of a hysterical
attack
. The nature of recurrent hallucinations makes them
unsuitable in point of fact for playing the part of
chronic
symptoms. But this question did not really arise in a case like
this which showed only a rudimentary development. It was essential,
however, that the subjective sensations of smell should have had a
specialized origin of a sort which would admit of their being
derived from some quite particular real object.

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96

   This expectation was promptly
fulfilled. When I asked her what the smell was by which she was
most constantly troubled she answered: ‘A smell of burnt
pudding.’ Thus I only needed to assume that a smell of burnt
pudding had actually occurred in the experience which had operated
as a trauma. It is very unusual, no doubt, for olfactory sensations
to be chosen as mnemic symbols of traumas, but it was not difficult
to account for this choice. The patient was suffering from
suppurative rhinitis and consequently her attention was especially
focused on her nose and nasal sensations. What I knew of the
circumstances of the patient’s life was limited to the fact
that the two children whom she was looking after had no mother; she
had died some years earlier of an acute illness.

   I therefore decided to make the
smell of burnt pudding the starting-point of the analysis. I will
describe the course of this analysis as it might have taken place
under favourable conditions. In fact, what should have been a
single session spread over several. This was because the patient
could only visit me in my consulting hours, when I could only
devote a short time to her. Moreover, a single discussion of this
sort used to extend over more than a week, since her duties would
not allow her to make the long journey from the factory to my house
very often. We used therefore to break our conversation off short
and take up the thread at the same place next time.

   Miss Lucy R. did not fall into a
state of somnambulism when I tried to hypnotize her. I therefore
did without somnambulism and conducted her whole analysis while she
was in a state which may in fact have differed very little from a
normal one.

Studies On Hysteria

97

   I shall have to go into this
point of my technical procedure in greater detail. When, in 1889, I
visited the Nancy clinics, I heard Dr. Liébeault, the
doyen
of hypnotism, say: ‘If only we had the means of
putting every patient into a state of somnambulism, hypnotic
therapy would be the most powerful of all.’ In
Bernheim’s clinic it almost seemed as though such an art
really existed and as though it might be possible to learn it from
Bernheim. But as soon as I tried to practise this art on my own
patients, I discovered that
my
powers at least were subject
to severe limits, and that if somnambulism were not brought about
in a patient at the first three attempts I had no means of inducing
it. The percentage of cases amenable to somnambulism was very much
lower in my experience than what Bernheim reported.

   I was accordingly faced with the
choice of either abandoning the cathartic method in most of the
cases which might have been suitable for it, or of venturing on the
experiment of employing that method without somnambulism and where
the hypnotic influence was light or even where its existence was
doubtful. It seemed to me a matter of indifference what degree of
hypnosis - according to one or other of the scales that have been
proposed for measuring it - was reached by this non somnambulistic
state; for, as we know, each of the various forms taken by
suggestibility is in any case independent of the others, and the
bringing about of catalepsy, automatic movements, and so on, does
not work either for or against what I required for my purposes,
namely that the awakening of forgotten memories should be made
easier. Moreover, I soon dropped the practice of making tests to
show the degree of hypnosis reached, since in quite a number of
cases this roused the patients’ resistance and shook their
confidence in me, which I needed for carrying out the more
important psychical work. Furthermore, I soon began to tire of
issuing assurances and commands such as: ‘You are going to
sleep! . . . sleep!’ and of hearing the
patient, as so often happened when the degree of hypnosis was
light, remonstrate with me: ‘But, doctor, I’m
not
asleep’, and of then having to make highly
ticklish distinctions: ‘I don’t mean ordinary sleep; I
mean hypnosis. As you see, you are hypnotized, you can’t open
your eyes’, etc., ‘and in any case, there’s no
need for you to go to sleep’, and so on. I feel sure that
many other physicians who practise psychotherapy can get out of
such difficulties with more skill than I can. If so, they may adopt
some procedure other than mine. It seems to me, however, that if
one can reckon with such frequency on finding oneself in an
embarrassing situation through the use of a particular word, one
will be wise to avoid both the word and the embarrassment. When,
therefore, my first attempt did not lead either to somnambulism or
to a degree of hypnosis involving marked physical changes, I
ostensibly dropped hypnosis, and only asked for
‘concentration’; and I ordered the patient to lie down
and deliberately shut his eyes as a means of achieving this
‘concentration’. It is possible that in this way I
obtained with only a slight effort the deepest degree of hypnosis
that could be reached in the particular case.