Freud - Complete Works (27 page)

   As far as the physician was
concerned, the patient’s confession was at first sight a
great disappointment. It was a case history made up of commonplace
emotional upheavals, and there was nothing about it to explain why
it was particularly from hysteria that she fell ill or why her
hysteria took the particular form of a painful abasia. It threw
light neither on the causes nor the specific determination of her
hysteria. We might perhaps suppose that the patient had formed an
association between her painful mental impressions and the bodily
pains which she happened to be experiencing at the same time, and
that now, in her life of memories, the was using her physical
feelings as a symbol of her mental ones. But it remained
unexplained what her motives might have been for making a
substitution of this kind and at what moment it had taken place.
These, incidentally, were not the kind of questions that physicians
were in the habit of raising. We were usually content with the
statement that the patient was constitutionally a hysteric, liable
to develop hysterical symptoms under the pressure of intense
excitations
of whatever kind
.

   Her confession seemed to offer
even less help towards the cure of her illness than it did towards
its explanation. It was not easy to see what beneficent influence
Fräulein Elisabeth could derive from recapitulating the tale
of her sufferings of recent years - with which all the members of
her family were so familiar - to a stranger who received it with
only a moderate sympathy. Nor was there any sign of the confession
producing a curative effect of this kind. During this first period
of her treatment she never failed to repeat that she was still
feeling ill and that her pains were as bad as ever; and, when she
looked at me as the said this with a sly look of satisfaction at my
discomfiture, I could not help being reminded of old Herr von
R.’s judgement about his favourite daughter - that she was
often ‘cheeky’ and ‘ill-behaved’. But I was
obliged to admit that she was in the right.

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131

   If I had stopped the
patient’s psychical treatment at this stage, the case of
Fräulein Elisabeth von R. would clearly have thrown no light
on the theory of hysteria. But I continued my analysis because I
firmly expected that deeper levels of her consciousness would yield
an understanding both of the causes and the specific determinants
of the hysterical symptoms. I therefore decided to put a direct
question to the patient in an enlarged state of consciousness and
to ask her what psychical impression it had been to which the first
emergence of pains in her legs had been attached.

   With this end in view I proposed
to put the patient into a deep hypnosis. But, unfortunately, I
could not help observing that my procedure failed to put her into
any state other than the one in which she had made her recital. I
was glad enough that on this occasion she refrained from
triumphantly protesting: ‘I’m not asleep, you know; I
can’t be hypnotized.’ In this extremity the idea
occurred to me of resorting to the device of applying pressure to
the head, the origin of which I have described in full in the case
history of Miss Lucy. I carried this out by instructing the patient
to report to me faithfully whatever appeared before her inner eye
or passed through her memory at the moment of the pressure. She
remained silent for a long time and then, on my insistence,
admitted that she had thought of an evening on which a young man
had seen her home after a party, of the conversation that had taken
place between them and of the feelings with which she had returned
home to her father’s sick-bed.

   This first mention of the young
man opened up a new vein of ideas the contents of which I now
gradually extracted. It was a question here of a secret, for she
had initiated no one, apart from a common friend, into her
relations with the young man and the hopes attached to them. He was
the son of a family with which they had long been on friendly terms
and who lived near their former estate. The young man, who was
himself an orphan, was devotedly attached to her father and
followed his advice in pursuing his career. He had extended his
admiration for her father to the ladies of the family. Numerous
recollections of reading together, of exchanging ideas, and of
remarks made by him which were repeated to her by other people,
bore witness to the gradual growth in her of a conviction that he
loved her and understood her and that marriage with him would not
involve the sacrifices on her part which she dreaded from marriage
in general. Unluckily, he was scarcely any older than herself and
was still far from being self-supporting. But she was firmly
determined to wait for him.

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   After her father had fallen
seriously ill and she had been so much taken up with looking after
him, her meetings with her friend became more and more rare. The
evening which she had first remembered represented what had
actually been the climax of her feeling; but even then there had
been no
éclaircissement
between them. On that
occasion she had allowed herself to be persuaded, by the insistence
of her family and of her father himself, to go to a party at which
she was likely to meet him. She had wanted to hurry home early but
had been pressed to stay and had given way when he promised to see
her home. She had never had such warm feelings towards him as while
he was accompanying her that evening. But when she arrived home
late in this blissful frame of mind, she found her father was worse
and reproached herself most bitterly for having sacrificed so much
time to her own enjoyment. This was the last time she left her sick
father for a whole evening. She seldom met her friend after this.
After her father’s death the young man seemed to keep away
from her out of respect for her sorrow. The course of his life then
took him in other directions. She had to familiarize herself by
degrees with the thought that his interest in her had been
displaced by others and that she had lost him. But this
disappointment in her first love still hurt her whenever she
thought of him.

   It was therefore in this
relationship and in the scene described above in which it
culminated that I could look for the causes of her first hysterical
pains. The contrast between the blissful feelings she had allowed
herself to enjoy on that occasion and the worsening of her
father’s state which had met her on her return home
constituted a conflict, a situation of incompatibility. The outcome
of this conflict was that the erotic idea was repressed from
association and the affect attaching to that idea was used to
intensify or revive a physical pain which was present
simultaneously or shortly before. Thus it was an instance of the
mechanism of conversion for the purpose of defence, which I have
described in detail elsewhere.

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133

   A number of comments might of
course be made at this point. I must emphasize the fact that I did
not succeed in establishing from her memory that the conversion
took place at the moment of her return home. I therefore looked
about for similar experiences during the time she was nursing her
father and elicited a number of them. Among these, special
prominence attached, on account of their frequent occurrence, to
scenes in which, at her father’s call, she had jumped out of
bed with bare feet in a cold room. I was inclined to attribute some
importance to these factors, since in addition to complaining about
the pain in her legs she also complained of tormenting sensations
of cold. Nevertheless, even here I was unable to get hold of any
scene which it was possible to identify as that at which the
conversion had occurred. I was inclined for this reason to think
that there was a gap in the explanation at this point, until I
recollected that the hysterical pains in the legs had in fact not
made their appearance during the period when she was nursing her
father. She only remembered a single attack of pain, which had only
lasted a day or two and had not attracted her attention. I now
directed my enquiries to this first appearance of the pains. I
succeeded in reviving the patient’s memory of it with
certainty. At that very time a relative had visited them and she
had been unable to receive him, owing to being laid up in bed. This
same man had been unlucky enough, when he visited them again two
years later, to find her in bed once more. But in spite of repeated
attempts we failed to trace any psychical cause for the first
pains. I thought it safe to assume that they had in fact appeared
without any psychical cause and were a mild rheumatic affection;
and I was able to establish that this organic disorder, which was
the model copied in her later hysteria, had in any case to be dated
before the scene of her being accompanied back from the party. From
the nature of things it is nevertheless possible that these pains,
being of organic origin, may have persisted for some time to a
mitigated degree without being very noticeable. The obscurity due
to the fact that the analysis pointed to the occurrence of a
conversion of psychical excitation into physical pain though that
pain was certainly not perceived at the time in question or
remembered afterwards - this is a problem which I hope to be able
to solve later on the basis of further considerations and later
examples.¹

  
¹
I cannot exclude the possibility, though I
cannot establish the fact, that these pains, which chiefly affected
the thighs, were of a
neurasthenic
nature.

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134

   The discovery of the reason for
the first conversion opened a second, fruitful period of the
treatment. The patient surprised me soon afterwards by announcing
that she now knew why it was that the pains always radiated from
that particular area of the right thigh and were at their most
painful there: it was in this place that her father used to rest
his leg every morning, while she renewed the bandage round it, for
it was badly swollen. This must have happened a good hundred times,
yet she had not noticed the connection till now. In this way she
gave me the explanation that I needed of the emergence of what was
an atypical hysterogenic zone. Further, her painful legs began to
‘join in the conversation’ during our analyses. What I
have in mind is the following remarkable fact. As a rule the
patient was free from pain when we started work. If, then, by a
question or by pressure upon her head I called up a memory, a
sensation of pain would make its first appearance, and this was
usually so sharp that the patient would give a start and put her
hand to the painful spot. The pain that was thus aroused would
persist so long as she was under the influence of the memory; it
would reach its climax when she was in the act of telling me the
essential and decisive part of what she had to communicate, and
with the last word of this it would disappear. I came in time to
use such pains as a compass to guide me; if she stopped talking but
admitted that she still had a pain, I knew that she had not told me
everything, and insisted on her continuing her story till the pain
had been talked away. Not until then did I arouse a fresh
memory.

   During this period of
‘abreaction’ the patient’s condition, both
physical and mental, made such a striking improvement that I used
to say, only half jokingly, that I was taking away a certain amount
of her motives for pain every time and that when I had cleared them
all away she would be well. She soon got to the point of being
without pain most of the time; she allowed herself to be persuaded
to walk about a great deal and to give up her former isolation. In
the course of the analysis I sometimes followed the spontaneous
fluctuations in her condition; and I sometimes followed my own
estimate of the situation when I considered that I had not
completely exhausted some portion of the story of her illness.

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135

   During this work I made some
interesting observations, whose lessons I subsequently found
confirmed in treating other patients. As regards the spontaneous
fluctuations, in the first place, I found that in fact none had
occurred which had not been provoked by association with some
contemporary event. On one occasion she had heard of an illness of
one of her acquaintances which reminded her of a detail of her
father’s illness; another time her dead sister’s child
had been on a visit to them, and its likeness to its mother had
stirred up her feelings of grief; and yet another time a letter
from her distant sister showed clear evidence of her unfeeling
brother-in-law’s influence and gave rise to a pain which
required her to produce the story of a family scene which she had
not yet told me about. Since she never brought up the same
precipitating cause of a pain twice over, it seemed that we were
justified in supposing that we should in this way exhaust the stock
of them; and I therefore did not hesitate to get her into
situations which were calculated to bring up fresh memories which
had not yet reached the surface. For instance, I sent her to visit
her sister’s grave, and I encouraged her to go to a party at
which she might once more come across the friend of her youth.

   In the next place, I obtained
some insight into the manner of origin of what might be described
as a ‘monosymptomatic’ hysteria. For I found that her
right
leg became painful under hypnosis when the discussion
turned on her nursing her sick father, on her relations with the
friend of her youth or on other events falling within the first
period of her pathogenic experiences; on the other hand, the pain
made its appearance in her other,
left
, leg as soon as I
stirred up a memory relating to her dead sister or her two
brothers-in-law - in short, to an impression from the second half
of the story of her illness. Having thus had my attention aroused
by the regularity of this relation, I carried my investigation
further and formed an impression that this differentiation went
still further and that every fresh psychical determinant of painful
sensations had become attached to some fresh spot in the painful
area of her legs. The original painful spot in her right thigh had
related to her nursing her father; the area of pain had extended
from this spot to neighbouring regions as a result of fresh
traumas. Here, therefore, what we were dealing with was not
strictly speaking a
single
physical symptom, linked with a
variety of mnemic complexes in the mind, but a number of similar
symptoms which appeared, on a superficial view, to be merged into
one symptom. But I did not pursue further the delimitation of zones
of pain corresponding to different psychical determinants, since I
found that the patient’s attention was directed away from
this subject.