Freud - Complete Works (25 page)

   This information reminded me that
her first hysterical symptom, the vomiting, had passed away; the
anxiety attack remained and acquired a fresh content. Accordingly,
what we were dealing with was a hysteria which had to a
considerable extent been abreacted. And in fact she had reported
her discovery to her aunt soon after it happened.

   ‘Did you tell your aunt the
other stories-about his making advances to you?’

   ‘Yes. Not at once, but
later on, when there was already talk of a divorce. My aunt said:
"We’ll keep that in reserve. If he causes trouble in the
Court, we’ll say that too."'

   I can well understand that it
should have been precisely this last period - when there were more
and more agitating scenes in the house and when her own state
ceased to interest her aunt, who was entirely occupied with the
dispute - that it should have been this period of accumulation and
retention that left her the legacy of the mnemic symbol.

   I hope this girl, whose sexual
sensibility had been injured at such an early age, derived some
benefit from our conversation. I have not seen her since.

Studies On Hysteria

119

DISCUSSION

   If someone were to assert that
the present case history is not so much an analysed case of
hysteria as a case solved by guessing, I should have nothing to say
against him. It is true that the patient agreed that what I
interpolated into her story was probably true; but she was not in a
position to recognize it as something she had experienced. I
believe it would have required hypnosis to bring that about.
Assuming that my guesses were correct, I will now attempt to fit
the case into the schematic picture of an ‘acquired’
hysteria on the lines suggested by Case 3. It seems plausible,
then, to compare the two sets of erotic experiences with
‘traumatic’ moments and the scene of discovering the
couple with an ‘auxiliary’ moment. The similarity lies
in the fact that in the former experiences an element of
consciousness was created which was excluded from the
thought-activity of the ego and remained, as it were, in storage,
while in the latter scene a new impression forcibly brought about
an associative connection between this separated group and the ego.
On the other hand there are dissimilarities which cannot be
overlooked. The cause of the isolation was not, as in Case 3, an
act of will on the part of the ego but
ignorance
on the part
of the ego, which was not yet capable of coping with sexual
experiences. In this respect the case of Katharina is typical. In
every analysis of a case of hysteria based on sexual traumas we
find that impressions from the pre-sexual period which produced no
effect on the child attain traumatic power at a later date as
memories, when the girl or married woman has acquired an
understanding of sexual life. The splitting-off of psychical groups
may be said to be a normal process in adolescent development; and
it is easy to see that their later reception into the ego affords
frequent opportunities for psychical disturbances. Moreover, I
should like at this point to express a doubt as to whether a
splitting of consciousness due to ignorance is really different
from one due to conscious rejection, and whether even adolescents
do not possess sexual knowledge far oftener than is supposed or
than they themselves believe.

Studies On Hysteria

120

   A further distinction in the
psychical mechanism of this case lies in the fact that the scene of
discovery, which we have described as ‘auxiliary’,
deserves equally to be called ‘traumatic’. It was
operative on account of its own content and not merely as something
that revived previous traumatic experiences. It combined the
characteristics of an ‘auxiliary’ and a
‘traumatic’ moment. There seems no reason, however, why
this coincidence should lead us to abandon a conceptual separation
which in other cases corresponds also to a separation in time.
Another peculiarity of Katharina’s case, which, incidentally,
has long been familiar to us, is seen in the circumstance that the
conversion, the production of the hysterical phenomena, did not
occur immediately after the trauma but after an interval of
incubation. Charcot liked to describe this interval as the
‘period of psychical working-out’
[
élaboration
].

   The anxiety from which Katharina
suffered in her attacks was a hysterical one; that is, it was a
reproduction of the anxiety which had appeared in connection with
each of the sexual traumas. I shall not here comment on the fact
which I have found regularly present in a very large number of
cases - namely that a mere suspicion of sexual relations calls up
the affect of anxiety in virginal individuals.¹

  
¹
(
Footnote added
1924:) I venture
after the lapse of so many years to lift the veil of discretion and
reveal the fact that Katharina was not the niece but the daughter
of the landlady. The girl fell ill, therefore, as a result of
sexual attempts on the part of her own father. Distortions like the
one which I introduced in the present instance should be altogether
avoided in reporting a case history. From the point of view of
understanding the case, a distortion of this kind is not, of
course, a matter of such indifference as would be shifting the
scene from one mountain to another.

Studies On Hysteria

121

CASE
5

FRÄULEIN ELISABETH VON R.
 
(Freud)

In the autumn of 1892 I was asked by a doctor
I knew to examine a young lady who had been suffering for more than
two years from pains in her legs and who had difficulties in
walking. When making this request he added that he thought the case
was one of hysteria, though there was no trace of the usual
indications of that neurosis. He told me that he knew the family
slightly and that during the last few years it had met with many
misfortunes and not much happiness. First the patient’s
father had died, then her mother had had to undergo a serious
eye-operation and soon afterwards a married sister had succumbed to
a heart-affection of long standing after a confinement. In all
these troubles and in all the sick-nursing involved, the largest
share had fallen to our patient.

   My first interview with this
young woman of twenty-four years of age did not help me to make
much further progress in understanding the case. She seemed
intelligent and mentally normal and bore her troubles, which
interfered with her social life and pleasures, with a cheerful air
- the
belle indifférence
of a hysteric, I could not
help thinking. She walked with the upper part of her body bent
forward, but without making use of any support. Her gait was not of
any recognized pathological type, and moreover was by no means
strikingly bad. All that was apparent was that she complained of
great pain in walking and of being quickly overcome by fatigue both
in walking and in standing, and that after a short time she had to
rest, which lessened the pains but did not do away with them
altogether. The pain was of an indefinite character; I gathered
that it was something in the nature of a painful fatigue. A fairly
large, ill defined area of the anterior surface of the right thigh
was indicated as the focus of the pains, from which they most often
radiated and where they reached their greatest intensity. In this
area the skin and muscles were also particularly sensitive to
pressure and pinching (though the prick of a needle was, if
anything, met with a certain amount of unconcern). This
hyperalgesia of the skin and muscles was not restricted to this
area but could be observed more or less over the whole of both
legs. The muscles were perhaps even more sensitive to pain than the
skin; but there could be no question that the thighs were the parts
most sensitive to both these kinds of pain. The motor power of the
legs could not be described as small, and the reflexes were of
medium strength. There were no other symptoms, so that there was no
ground for suspecting the presence of any serious organic
affection. The disorder had developed gradually during the previous
two years and varied greatly in intensity.

Studies On Hysteria

122

   I did not find it easy to arrive
at a diagnosis, but I decided for two reasons to assent to the one
proposed by my colleague, viz. that it was a case of hysteria. In
the first place I was struck by the indefiniteness of all the
descriptions of the character of her pains given me by the patient,
who was nevertheless a highly intelligent person. A patient
suffering from organic pains will, unless he is neurotic in
addition, describe them definitely and calmly. He will say, for
instance, that they are shooting pains, that they occur at certain
intervals, that they extend from this place to that and that they
seem to him to be brought on by one thing or another. Again, when a
neurasthenic¹ describes his pains, he gives an impression of
being engaged on a difficult intellectual task to which his
strength is quite unequal. His features are strained and distorted
as though under the influence of a distressing affect. His voice
grows more shrill and he struggles to find a means of expression.
He rejects any description of his pains proposed by the physician,
even though it may turn out afterwards to have been unquestionably
apt. He is clearly of opinion that language is too poor to find
words for his sensations and that those sensations are something
unique and previously unknown, of which it would be quite
impossible to give an exhaustive description. For this reason he
never tires of constantly adding fresh details, and when he is
obliged to break off he is sure to be left with the conviction that
he has not succeeded in making himself understood by the physician.
All this is because his pains have attracted his whole attention to
themselves. Fräulein von R. behaved in quite an opposite way;
and we are driven to conclude that, since she nevertheless attached
sufficient importance to her symptoms, her attention must be
dwelling on something else, of which the pains were only an
accessory phenomenon - probably on thoughts and feelings,
therefore, which were connected with them.

  
¹
(A hypochondriac or a person affected with
anxiety neurosis.)

Studies On Hysteria

123

   But there is a second factor
which is even more decisively in favour of this view of the pains.
If one stimulates an area sensitive to pain in someone with an
organic illness or in a neurasthenic, the patient’s face
takes on an expression of discomfort or physical pain. Moreover he
flinches and draws back from the examination and resists it. In the
case of Fräulein von R., however, if one pressed or pinched
the hyperalgesic skin and muscles of her legs, her face assumed a
peculiar expression, which was one of pleasure rather than pain.
She cried out - and I could not help thinking that it was as though
she was having a voluptuous tickling sensation - her face flushed,
she threw back her head and shut her eyes and her body bent
backwards. None of this was very exaggerated but it was distinctly
noticeable, and it could only be reconciled with the view that her
disorder was hysterical, and that the stimulation had touched upon
a hysterogenic zone.

   Her expression of face did not
fit in with the pain which was ostensibly set up by the pinching of
her muscles and skin; it was probably more in harmony with the
subject-matter of the thoughts which lay concealed behind the pain
and which had been aroused in her by the stimulation of the parts
of the body associated with those thoughts. I had repeatedly
observed expressions of similar significance in undoubted cases of
hysteria, when a stimulus was applied to their hyperalgesic zones.
Her other gestures were evidently very slight hints of a hysterical
attack.

   To begin with there was no
explanation of the unusual localization of her hysterogenic zone.
The fact that the hyperalgesia mainly affected the muscles also
gave food for thought. The disorder which is most usually
responsible for diffuse and local sensitivity to pressure in the
muscles is a rheumatic infiltration of those muscles - common
chronic muscular rheumatism. I have already spoken of its tendency
to simulate nervous affections. This possibility was not
contradicted by the consistency of the patient’s hyperalgic
muscles. There were numerous hard fibres in the muscular substance,
and these seemed especially sensitive. Thus it was probable that an
organic change in the muscles of the kind indicated was present and
that the neurosis attached itself to this and made it seem of
exaggerated importance.

Studies On Hysteria

124

   Treatment proceeded on the
assumption that the disorder was of this mixed kind. We recommended
the continuation of systematic kneading and faradization of the
sensitive muscles, regardless of the resulting pain, and I reserved
to myself treatment of her legs with high tension electric
currents, in order to be able to keep in touch with her. Her
question whether she should force herself to walk was answered with
a decided ‘yes’.

   In this way we brought about a
slight improvement. In particular, she seemed to take quite a
liking to the painful shocks produced by the high tension
apparatus, and the stronger these were the more they seemed to push
her own pains into the background. In the meantime my colleague was
preparing the ground for psychical treatment, and when, after four
weeks of my pretence treatment, I proposed the other method and
gave her some account of the procedure and mode of operation, I met
with quick understanding and little resistance.