Freud - Complete Works (241 page)

Fragment Of An Analysis Of A Case Of Hysteria

1364

   No doubt this case history, as I
have so far outlined it, does not upon the whole seem worth
recording. It is merely a case of ‘
petite
hystérie
’ with the commonest of all somatic and
mental symptoms: dyspnoea,
tussis nervosa
, aphonia, and
possibly migraines, together with depression, hysterical
unsociability, and a
taedium vitae
which was probably not
entirely genuine. More interesting cases of hysteria have no doubt
been published, and they have very often been more carefully
described; for nothing will be found in the following pages on the
subject of stigmata of cutaneous sensibility, limitation of the
visual field, or similar matters. I may venture to remark, however,
that all such collections of the strange and wonderful phenomena of
hysteria have but slightly advanced our knowledge of a disease
which still remains as great a puzzle as ever. What is wanted is
precisely an elucidation of the
commonest
cases and of their
most frequent and typical symptoms. I should have been very well
satisfied if the circumstances had allowed me to give a complete
elucidation of this case of
petite hystérie
. And my
experiences with other patients leave me in ho doubt that my
analytic method would have enabled me to do so.

   In 1896, shortly after the
appearance of my
Studies on Hysteria
(written in conjunction
with Dr. J. Breuer, 1895), I asked an eminent fellow-specialist for
his opinion on the psychological theory of hysteria put forward in
that work. He bluntly replied that he considered it an
unjustifiable generalization of conclusions which might hold good
for a few cases. Since then I have seen an abundance of cases of
hysteria, and I have been occupied with each case for a number of
days, weeks, or years. In not a single one of them have I failed to
discover the psychological determinants which were postulated in
the
Studies
, namely, a psychical trauma, a conflict of
affects, and an additional factor which I brought forward in later
publications - a disturbance in the sphere of sexuality. It is of
course not to be expected that the patient will come to meet the
physician half-way with material which has become pathogenic for
the very reason of its efforts to lie concealed; nor must the
enquirer rest content with the first ‘No’ that crosses
his path.¹

  
¹
Here is an instance of this. Another
physician in Vienna, whose conviction of the unimportance of sexual
factors in hysteria has probably been very much strengthened by
such experiences as this, was consulted in the case of a
fourteen-year-old girl who suffered from dangerous hysterical
vomiting. He made up his mind to ask her the painful question
whether by any chance she had ever had a love-affair with a man.
‘No!’ answered the child, no doubt with well-affected
astonishment; and then repeated to her mother in her irreverent
way: ‘Only fancy! the old stupid asked me if I was in
love!’ She afterwards came to me for treatment, and proved -
though not during our very first conversation, to be sure - to have
been a masturbator for many years, with a considerable leucorrhoeal
discharge (which had a close bearing on her vomiting). She had
finally broken herself of the habit, but was tormented in her
abstinence by the most acute sense of guilt, so that she looked
upon every misfortune that befell her family as a divine punishment
for her transgression. Besides this, she was under the influence of
the romance of an unmarried aunt, whose pregnancy (a second
determinant for her vomiting) was supposed to have been happily
hidden from her. The girl was looked upon as a ‘mere
child,’ but she turned out to be initiated into all the
essentials of sexual relations.

Fragment Of An Analysis Of A Case Of Hysteria

1365

   In Dora’s case, thanks to
her father’s shrewdness which I have remarked upon more than
once already, there was no need for me to look about for the points
of contact between the circumstances of the patient’s life
and her illness, at all events in its most recent form. Her father
told me that he and his family while they were at B-- had formed an
intimate friendship with a married couple who had been settled
there for several years. Frau K. had nursed him during his long
illness, and had in that way, he said, earned a title to his
undying gratitude. Herr K. had always been most kind to Dora. He
had gone walks with her when he was there, and had made her small
presents; but no one had thought any harm of that. Dora had taken
the greatest care of the K.’s two little children, and been
almost a mother to them. When Dora and her father had come to see
me two years before in the summer, they had been just on their way
to stop with Herr and Frau K., who were spending the summer on one
of our lakes in the Alps. Dora was to have spent several weeks at
the K.’s, while her father had intended to return home after
a few days. During that time Herr K. had been staying there as
well. As her father was preparing for his departure the girl had
suddenly declared with the greatest determination that she was
going with him, and she had in fact put her decision into effect.
It was not until some days later that she had thrown any light upon
her strange behaviour. She had then told her mother - intending
that what she said should be passed on to her father - that Herr K.
had had the audacity to make her a proposal while they were on a
walk after a trip upon the lake. Herr K. had been called to account
by her father and uncle on the next occasion of their meeting, but
he had denied in the most emphatic terms having on his side made
any advances which could have been open to such a construction. He
had then proceeded to throw suspicion upon the girl, saying that he
had heard from Frau K. that she took no interest in anything but
sexual matters, and that she used to read Mantegazza’s
Physiology of Love
and books of that sort in their house on
the lake. It was most likely, he had added, that she had been
over-excited by such reading and had merely ‘fancied’
the whole scene she had described.

Fragment Of An Analysis Of A Case Of Hysteria

1366

   ‘I have no doubt’,
continued her father, ‘that this incident is responsible for
Dora’s depression and irritability and suicidal ideas. She
keeps pressing me to break off relations with Herr K. and more
particularly with Frau K., whom she used positively to worship
formerly. But that I cannot do. For, to begin with, I myself
believe that Dora’s tale of the man’s immoral
suggestions is a phantasy that has forced its way into her mind;
and besides, I am bound to Frau K. by ties of honourable friendship
and I do not wish to cause her pain. The poor woman is most unhappy
with her husband, of whom, by the way, I have no very high opinion.
She herself has suffered a great deal with her nerves, and I am her
only support. With my state of health I need scarcely assure you
that there is nothing wrong in our relations. We are just two poor
wretches who give one another what comfort we can by an exchange of
friendly sympathy. You know already that I get nothing out of my
own wife. But Dora, who inherits my obstinacy, cannot be moved from
her hatred of the K.’s. She had her last attack after a
conversation in which she had again pressed me to break with them.
Please try and bring her to reason.’

   Her father’s words did not
always quite tally with this pronouncement; for on other occasions
he tried to put the chief blame for Dora’s impossible
behaviour on her mother whose peculiarities made the house
unbearable for every one. But I had resolved from the first to
suspend my judgement of the true state of affairs till I had heard
the other side as well.

Fragment Of An Analysis Of A Case Of Hysteria

1367

   The experience with Herr K. - his
making love to her and the insult to her honour which was
involved - seems to provide in Dora’s case the psychical
trauma which Breuer and I declared long ago to be the indispensable
prerequisite for the production of a hysterical disorder. But this
new case also presents all the difficulties which have since led me
to go beyond that theory,¹ besides an additional difficulty of
a special kind. For, as so often happens in histories of cases of
hysteria, the trauma that we know of as having occurred in the
patient’s past life is insufficient to explain or to
determine the
particular character
of the symptoms; we
should understand just as much or just as little of the whole
business if the result of the trauma had been symptoms quite other
than
tussis nervosa
, aphonia, depression, and
taedium
vitae
. But there is the further consideration that some of
these symptoms (the cough and the loss of voice) had been produced
by the patient years before the time of the trauma, and that their
earliest appearances belong to her childhood, since they occurred
in her eighth year. If, therefore, the trauma theory is not to be
abandoned, we must go back to her childhood and look about there
for any influences or impressions which might have had an effect
analogous to that of a trauma. Moreover, it deserves to be remarked
that in the investigation even of cases in which the first symptoms
had not already set in childhood I have been driven to trace back
the patients’ life history to their earliest years.²

  
¹
I have gone beyond that theory, but I have
not abandoned it; that is to say, I do not to-day consider the
theory incorrect, but incomplete. All that I have abandoned is the
emphasis laid upon the so-called ‘hypnoid state’, which
was supposed to be occasioned in the patient by the trauma, and to
be the foundation for all the psychologically abnormal events which
followed. If, where a piece of joint work is in question, it is
legitimate to make a subsequent division of property, I should like
to take this opportunity of stating that the hypothesis of
‘hypnoid states’ - which many reviewers were inclined
to regard as the central portion of our work - sprang entirely from
the initiative of Breuer. I regard the use of such a term as
superfluous and misleading, because it interrupts the continuity of
the problem as to the nature of the psychological process
accompanying the formation of hysterical symptoms.

  
² Cf. my paper on ‘The Aetiology of Hysteria’
(1896
c
).

Fragment Of An Analysis Of A Case Of Hysteria

1368

   When the first difficulties of
the treatment had been overcome, Dora told me of an earlier episode
with Herr K., which was even better calculated to act as a sexual
trauma. She was fourteen years old at the time. Herr K. had made an
arrangement with her and his wife that they should meet him one
afternoon at his place of business in the principal square of B--
so as to have a view of a church festival. He persuaded his wife,
however, to stay at home, and sent away his clerks, so that he was
alone when the girl arrived. When the time for the procession
approached, he asked the girl to wait for him at the door which
opened on to the staircase leading to the upper story, while he
pulled down the outside shutters. He then came back, and, instead
of going out by the open door, suddenly clasped the girl to him and
pressed a kiss upon her lips. This was surely just the situation to
call up a distinct feeling of sexual excitement in a girl of
fourteen who had never before been approached. But Dora had at that
moment a violent feeling of disgust, tore herself free from the
man, and hurried past him to the staircase and from there to the
street door. She nevertheless continued to meet Herr K. Neither of
them ever mentioned the little scene; and according to her account
Dora kept it a secret till her confession during the treatment. For
some time afterwards, however, she avoided being alone with Herr K.
The K.’s had just made plans for an expedition which was to
last for some days and on which Dora was to have accompanied them.
After the scene of the kiss she refused to join the party, without
giving any reason.

   In this scene - second in order
of mention, but first in order of time - the behaviour of this
child of fourteen was already entirely and completely hysterical. I
should without question consider a person hysterical in whom an
occasion for sexual excitement elicited feelings that were
preponderantly or exclusively unpleasurable; and I should do so
whether or no the person were capable of producing somatic
symptoms. The elucidation of the mechanism of this
reversal of
affect
is one of the most important and at the same time one of
the most difficult problems in the psychology of the neuroses. In
my own judgement I am still some way from having achieved this end;
and I may add that within the limits of the present paper I shall
be able to bring forward only a part of such knowledge on the
subject as I do possess.

Fragment Of An Analysis Of A Case Of Hysteria

1369

   In order to particularize
Dora’s case it is not enough merely to draw attention to the
reversal of affect; there has also been a
displacement
of sensation. Instead of the genital sensation which would
certainly have been felt by a healthy girl in such
circumstances,¹ Dora was overcome by the unpleasurable feeling
which is proper to the tract of mucous membrane at the entrance to
the alimentary canal - that is by disgust. The stimulation of her
lips by the kiss was no doubt of importance in localizing the
feeling at that particular place; but I think I can also recognize
another factor in operation.²