Freud - Complete Works (28 page)

Studies On Hysteria

136

   I did, however, turn my attention
to the way in which the whole symptomatic complex of abasia might
have been built up upon these painful zones, and in that connection
I asked her various questions, such as what was the origin of her
pains in walking? in standing? and in lying down? Some of these
questions she answered spontaneously, some under the pressure of my
hand. Two things emerged from this. In the first place she divided
all the scenes with painful impressions attached to them into
groups for me, according as she had experienced them while she was
sitting or standing, and so on. For instance, she was
standing
by a door when her father was brought home with his
heart attack, and in her fright she stood stock still as though she
was rooted to the ground. She went on to add a number of other
memories to this first example of fright while she was standing,
till she came to the fearful scene in which once again she
stood
, as though spellbound, by her sister’s
death-bed. This whole chain of memories might be expected to show
that there was a legitimate connection between her pains and
standing up; and it might indeed be accepted as evidence of an
association. But we must bear in mind that another factor must be
proved to be present in all these events, one which directed her
attention precisely to her standing (or, as the case may be, to her
walking, sitting, etc.) and consequently led to conversion. The
explanation of her attention taking this direction can scarcely be
looked for elsewhere than in the circumstance that walking,
standing and lying are functions and states of those parts of her
body which in her case comprised the painful zones, namely, her
legs. It was therefore easy in the present case to understand the
connection between the astasia-abasia and the first occurrence of
conversion.

Studies On Hysteria

137

   Among the episodes which,
according to this catalogue, seemed to have made
walking
painful, one received special prominence: a walk which she had
taken at the health resort in the company of a number of other
people and which was supposed to have been too long. The details of
this episode only emerged with hesitation and left several riddles
unsolved. She had been in a particularly yielding mood, and eagerly
joined her party of friends. It was a fine day, not too hot. Her
mother stopped at home and her elder sister had already gone away.
Her younger sister felt unwell, but did not want to spoil her
enjoyment; the brother-in-law began by saying that he would stay
with his wife, but afterwards decided to join the party on
Elisabeth’s account. This scene seemed to have had a great
deal to do with the first appearance of the pains, for she
remembered being very tired and suffering from violent pain when
she returned from the walk. She said, however, that she was not
certain whether she had already noticed the pains before this. I
pointed out to her that she was unlikely to have undertaken such a
long walk if she had had any considerable pains. I asked her what
it was in the walk that might have brought on the pain and she gave
me the somewhat obscure reply that the contrast between her own
loneliness and her sick sister’s married happiness (which her
brother-in-law’s behaviour kept constantly before her eyes)
had been painful to her.

   Another scene, which was very
close to the former one in time, played a part in linking the pains
with
sitting
. It was a few days later. Her sister and
brother-in-law had already left the place. She found herself in a
restless, yearning mood. She rose early in the morning and climbed
a small hill to a spot which they had often been to together and
which afforded a lovely view. She sat down there on a stone bench
and gave herself up to her thoughts. These were once again
concerned with her loneliness and the fate of her family; and this
time she openly confessed to a burning wish that she might be as
happy as her sister. She returned from this morning meditation with
violent pains, and that same evening had the bath after which the
pains made their final and permanent appearance.

Studies On Hysteria

138

   It was further shown without any
doubt that her pain in walking and standing used, to begin with, to
be allayed when she was
lying down
. The pains were not
linked to lying down as well until, after hearing the news of her
sister’s illness, she travelled back from Gastein and was
tormented during the night alike by worry about her sister and by
raging pains, as she lay, sleepless, stretched out in the railway
carriage. And for quite a time after this, lying down was actually
more painful to her than walking or standing.

   In this way, firstly, the painful
region had been extended by the addition of adjacent areas: every
fresh theme which had a pathogenic effect had cathected a new
region in the legs; secondly, each of the scenes which made a
powerful impression on her had left a trace behind it, bringing
about lasting and constantly accumulating cathexis of the various
functions of the legs, a linking of these functions with her
feelings of pain. But a third mechanism had unmistakably been
involved in the building up of her astasia-abasia. The patient
ended her description of a whole series of episodes by complaining
that they had made the fact of her ‘standing alone’
painful to her. In another series of episodes, which comprised her
unsuccessful attempts to establish a new life for her family, she
was never tired of repeating that what was painful about them had
been her feeling of helplessness, the feeling that she could not
‘take a single step forward’. In view of this, I was
forced to suppose that among the influences that went to the
building up of her abasia, these reflections of hers played a part;
I could not help thinking that the patient had done nothing more
nor less than look for a
symbolic
expression of her painful
thoughts and that she had found it in the intensification of her
sufferings. The fact that somatic symptoms of hysteria can be
brought about by symbolization of this kind was already asserted in
our ‘Preliminary Communication’. In the Discussion on
the present case I shall bring forward two or three conclusive
instances of this. This psychical mechanism of symbolization did
not play a prominent part with Fräulein Elisabeth von R. It
did not
create
her abasia. But everything goes to show that
the abasia which was already present received considerable
reinforcement in this way. Accordingly, this abasia, at the stage
of development at which I came across it, was to be equated not
only with a functional paralysis based on psychical associations
but also with one based on symbolization.

Studies On Hysteria

139

   Before I resume my account of the
case I will add a few words on the patient’s behaviour during
this second phase of the treatment. Throughout the analysis I made
use of the technique of bringing out pictures and ideas by means of
pressing on the patient’s head, a method, that is, which
would be unworkable without the patient’s full co-operation
and willing attention. Sometimes, indeed, her behaviour fulfilled
my highest expectations, and during such periods it was surprising
with what promptitude the different scenes relating to a given
theme emerged in a strictly chronological order. It was as though
she were reading a lengthy book of pictures, whose pages were being
turned over before her eyes. At other times there seemed to be
impediments of whose nature I had no suspicion then. When I pressed
her head she would maintain that nothing occurred to her. I would
repeat my pressure and tell her to wait, but still nothing
appeared. The first few times when this recalcitrance exhibited
itself I allowed myself to be led into breaking off the work: it
was an unfavourable day; we would try another time. Two
observations, however, decided me to alter my attitude. I noticed,
in the first place, that the method failed in this way only when I
found Elisabeth in a cheerful state and free from pain, never when
she was feeling badly. In the second place, that she often made
such assertions as that she saw nothing, after she had allowed a
long interval to pass during which her tense and preoccupied
expression of face nevertheless betrayed the fact that a mental
process was taking place in her. I resolved, therefore, to adopt
the hypothesis that the procedure never failed: that on every
occasion under the pressure of my hand some idea occurred to
Elisabeth or some picture came before her eyes, but that she was
not always prepared to communicate it to me, and tried to suppress
once more what had been conjured up. I could think of two motives
for this concealment. Either she was applying criticism to the
idea, which she had no right to do, on the ground of its not being
important enough or of its being an irrelevant reply to the
question she had been asked; or she hesitated to produce it because
she found it too disagreeable to tell. I therefore proceeded as
though I was completely convinced of the trustworthiness of my
technique. I no longer accepted her declaration that nothing had
occurred to her, but assured her that something
must
have
occurred to her. Perhaps, I said, she had not been sufficiently
attentive, in which case I should be glad to repeat my pressure. Or
perhaps she thought that her idea was not the right one. This, I
told her, was not her affair; she was under an obligation to remain
completely objective and say what had come into her head, whether
it was appropriate or not. Finally I declared that I knew very well
that something
had
occurred to her and that she was
concealing it from me; but she would never be free of her pains so
long as she concealed anything. By thus insisting, I brought it
about that from that time forward my pressure on her head never
failed in its effect. I could not but conclude that I had formed a
correct opinion of the state of affairs, and I derived from this
analysis a literally unqualified reliance on my technique. It often
happened that it was not until I had pressed her head three times
that she produced a piece of information; but she herself would
remark afterwards: ‘I could have said it to you the first
time.’ - ‘And why didn’t you?’ - ‘I
thought it wasn’t what was wanted’, or ‘I thought
I could avoid it, but it came back each time.’ In the course
of this difficult work I began to attach a deeper significance to
the resistance offered by the patient in the reproduction of her
memories and to make a careful collection of the occasions on which
it was particularly marked.

Studies On Hysteria

140

  I have now arrived at the third period
of the treatment. The patient was better. She had been mentally
relieved and was now capable of successful effort. But her pains
had manifestly, not been removed; they recurred from time to time,
and with all their old severity. This incomplete therapeutic result
corresponded to an incompleteness in the analysis. I still did not
know exactly at what moment and by what mechanism the pains had
originated. During the reproduction of the great variety of scenes
in the second period and while I was observing the patient’s
resistance to telling me about them, I had formed a particular
suspicion. I did not venture yet, however, to adopt it as the basis
of my further action. But a chance occurrence decided the matter.
One day while I was working with the patient, I heard a man’s
footsteps in the next room and a pleasant voice which seemed to be
asking some question. My patient thereupon got up and asked that we
might break off for the day: she had heard her brother-in-law
arrive and enquire for her. Up to that point she had been free from
pain, but after the interruption her facial expression and gait
betrayed the sudden emergence of severe pains. My suspicion was
strengthened by this and I determined to precipitate the decisive
explanation.

   I therefore questioned her about
the causes and circumstances of the first appearance of the pains.
By way of answer her thoughts turned towards her summer visit to
the health resort before her journey to Gastein, and a number of
scenes turned up once more which had not been treated very
completely. She recalled her state of feeling at the time, her
exhaustion after her anxieties about her mother’s eyesight
and after having nursed her at the time of her operation, and her
final despair of a lonely girl like her being able to get any
enjoyment out of life or achieve anything in it. Till then she had
thought herself strong enough to be able to do without the help of
a man; but she was now overcome by a sense of her weakness as a
woman and by a longing for love in which, to quote her own words,
her frozen nature began to melt. In this mood she was deeply
affected by her second sister’s happy marriage - by seeing
with what touching care he looked after her, how they understood
each other at a single glance and how sure they seemed to be of
each other. It was no doubt to be regretted that the second
pregnancy followed so soon after the first, and her sister knew
that this was the reason of her illness; but how willingly she bore
it because he was its cause. On the occasion of the walk which was
so intimately connected with Elisabeth’s pains, her
brother-in-law had at first been unwilling to join in it and had
wanted to stay by his sick wife. She, however, persuaded him with a
look to go with them, because she thought it would give Elisabeth
pleasure. Elisabeth remained in his company all through the walk.
They discussed every kind of subject, among them the most intimate
ones. She found herself in complete agreement with everything he
said, and a desire to have a husband like him became very strong in
her. Then, a few days later, came the scene on the morning after
the departure of her sister and brother-in-law when she made her
way to the place with a view, which had been a favourite object of
their walks. There she sat down and dreamt once again of enjoying
such happiness as her sister’s and of finding a husband who
would know how to capture her heart like this brother-in-law of
hers. She was in pain when she stood up, but it passed off once
more. It was not until the afternoon, when she had had the warm
bath, that the pains broke out, and she was never again free from
them. I tried to discover what thoughts were occupying her mind
while she was having the bath; but I learnt only that the
bath-house had reminded her of the members of her family who had
gone away, because that was the building in which they had
stayed.