Freud - Complete Works (32 page)

Studies On Hysteria

158

   Stated in terms of the conversion
theory, this incontrovertible fact of the summation of traumas and
of the preliminary latency of symptoms tells us that conversion can
result equally from fresh symptoms and from recollected ones. This
hypothesis completely explains the apparent contradiction that we
observed between the events of Fräulein Elisabeth von
R.’s illness and her analysis. There is no doubt that the
continued existence in consciousness of ideas whose affect has not
been dealt with can be tolerated by healthy individuals up to a
great amount. The view which I have just been putting forward does
no more than bring the behaviour of hysterical people nearer to
that of healthy ones. What we are concerned with is clearly a
quantitative factor - the question of how much affective tension of
this kind an organism can tolerate. Even a hysteric can retain a
certain amount of affect that has not been dealt with; if, owing to
the occurrence of similar provoking causes, that amount is
increased by summation to a point beyond the subject’s
tolerance, the impetus to conversion is given. Thus when we say
that the construction of hysterical symptoms can proceed on the
strength of recollected affects as well as fresh ones, we shall not
be making any unfamiliar assertion, but stating something that is
almost accepted as a postulate.

   I have now discussed the motives
and mechanism of this case of hysteria; it remains for me to
consider how precisely the hysterical symptom was determined. Why
was it that the patient’s mental pain came to be represented
by pains in the legs rather than elsewhere? The circumstances
indicate that this somatic pain was not
created
by the
neurosis but merely used, increased and maintained by it. I may add
at once that I have found a similar state of things in almost all
the instances of hysterical pains into which I have been able to
obtain an insight. There had always been a genuine,
organically-founded pain present at the start. It is the commonest
and most widespread human pains that seem to be most often chosen
to play a part in hysteria: in particular, the periosteal and
neuralgic pains accompanying dental disease, the headaches that
arise from so many different sources and, not less often, the
rheumatic muscular pains that are so often unrecognized. In the
same way I attribute an organic foundation to Fräulein
Elisabeth von R.’s first attack of pain which occurred as far
back as while she was nursing her father. I obtained no result when
I tried to discover a psychical cause for it - and I am inclined, I
must confess, to attribute a power of differential diagnosis to my
method of evoking concealed memories, provided it is carefully
handled. This pain, which was rheumatic in its origin,¹ then
became a mnemic symbol of her painful psychical excitations; and
this happened, so far as I can see, for more than one reason. The
first and no doubt the most important of these reasons was that the
pain was present in her consciousness at about the same time as the
excitations. In the second place, it was connected, or could be
connected, along a number of lines with the ideas in her mind at
the time. The pain, indeed, may actually have been a consequence,
though only a remote one, of the period of nursing - of the lack of
exercise and reduced diet that her duties as a sick-nurse entailed.
But the girl had no clear knowledge of this. More importance should
probably be attached to the fact that she must have felt the pain
during that time at significant moments, for instance, when she
sprang out of bed in the cold of winter in response to a call from
her father. But what must have had a positively decisive influence
on the direction taken by the conversion was another line of
associative connection: the fact that on a long succession of days
one of her painful legs came into contact with her father’s
swollen leg while his bandages were being changed. The area of her
right leg which was marked out by this contact remained thereafter
the focus of her pains and the point from which they radiated. It
formed an artificial hysterogenic zone whose origin could in the
present case be clearly observed.

   If anyone feels astonished at
this associative connection between physical pain and psychical
affect, on the ground of its being of such a multiple and
artificial character, I should reply that this feeling is as little
justified as astonishment at the fact that it is the rich people
who own the most money. Where there are no such numerous
connections a hysterical symptom will not, in fact, be formed; for
conversion will find no path open to it. And I can affirm that the
example of Fräulein Elisabeth von R, was among the simpler
ones as regards its determination. I have had the most tangled
threads to unravel, especially in the case of Frau Cäcilie
M.

  
¹
It may, however, have been of a
spinal-neurasthenic sort.

Studies On Hysteria

159

   I have already discussed in the
case history the way in which the patient’s astasia-abasia
was built up on these pains, after a particular path had been
opened up for the conversion. In that passage, however, I also
expressed my view that the patient had created, or increased, her
functional disorder by means of symbolization, that she had found
in the astasia-abasia a somatic expression for her lack of an
independent position and her inability to make any alteration in
her circumstances, and that such phrases as ‘not being able
to take a single step forward’, ‘not having anything to
lean upon’, served as the bridge for this fresh act of
conversion.

   I shall try to support this view
by other examples. Conversion on the basis of simultaneity, where
there is also an associative link, seems to make the smallest
demands on a hysterical disposition; conversion by symbolization,
on the other hand, seems to call for the presence of a higher
degree of hysterical modification. This could be observed in the
case of Fräulein Elisabeth, but only in the later stage of her
hysteria. The best examples of symbolization that I have seen
occurred in Frau Cäcilie M., whose case I might describe as my
most severe and instructive one. I have already explained that a
detailed report of her illness is unfortunately impossible.

   Frau Cäcilie suffered among
other things from an extremely violent facial neuralgia which
appeared suddenly two or three times a year, lasted for from five
to ten days, resisted any kind of treatment and then ceased
abruptly. It was limited to the second and third branches of one
trigeminal, and since an abnormal excretion of urates was
undoubtedly present and a not quite clearly defined ‘acute
rheumatism’ played some part in the patient’s history,
a diagnosis of gouty neuralgia was plausible enough. This diagnosis
was confirmed by the different consultants who were called in at
each attack. Treatment of the usual kind was ordered: the electric
brush, alkaline water, purges; but each time the neuralgia remained
unaffected until it chose to give place to another symptom. Earlier
in her life - the neuralgia was fifteen years old - her teeth were
accused of being responsible for it. They were condemned to
extraction, and one fine day, under narcosis, the sentence was
carried out on seven of the criminals. This was not such an easy
matter; her teeth were so firmly attached that the roots of most of
them had to be left behind. This cruel operation had no result,
either temporary or permanent. At that time the neuralgia raged for
months on end. Even at the time of my treatment, at each attack of
neuralgia the dentist was called in. On each occasion he diagnosed
the presence of diseased roots and began to get to work on them;
but as a rule he was soon interrupted. For the neuralgia would
suddenly cease, and at the same time the demand for the
dentist’s services. During the interval her teeth did not
ache at all. One day, when an attack was raging once more, the
patient got me to give her hypnotic treatment. I laid a very
energetic prohibition on her pains, and from that moment they
ceased. I began at that time to harbour doubts of the genuineness
of the neuralgia.

Studies On Hysteria

160

   About a year after this
successful hypnotic treatment Frau Cäcilie’s illness
took a new and surprising turn. She suddenly developed new
pathological states, different from those that had characterized
the last few years. But after some reflection the patient declared
that she had had all of them before at various times during the
course of her long illness, which had lasted for thirty years.
There now developed a really surprising wealth of hysterical
attacks which the patient was able to assign to their right place
in her past. And soon, too, it was possible to follow the often
highly involved trains of thought that determined the order in
which these attacks occurred. They were like a series of pictures
with explanatory texts. Pitres must have had something of the sort
in mind in putting forward his description of what he termed
‘
délire ecmnésique
’. It was most
remarkable to see the way in which a hysterical state of this kind
belonging to the past was reproduced. There first came on, while
the patient was in the best of health, a pathological mood with a
particular colouring which she regularly misunderstood and
attributed to some commonplace event of the last few hours. Then,
to the accompaniment of an increasing clouding of consciousness,
there followed hysterical symptoms: hallucinations, pains, spasms
and long declamatory speeches. Finally, these were succeeded by the
emergence in a hallucinatory form of an experience from the past
which made it possible to explain her initial mood and what had
determined the symptoms of her present attack. With this last piece
of the attack her clarity of mind returned. Her troubles
disappeared as though by magic and she felt well once again - till
the next attack, half a day later. As a rule I was sent for at the
climax of the attack, induced a state of hypnosis, called up the
reproduction of the traumatic experience and hastened the end of
the attack by artificial means. Since I assisted at several
hundreds of such cycles with the patient, I gained the most
instructive information on the way in which hysterical symptoms are
determined. Indeed, it was the study of this remarkable case,
jointly with Breuer, that led directly to the publication of our
‘Preliminary Communication’.

Studies On Hysteria

161

   In this phase of the work we came
at last to the reproduction of her facial neuralgia, which I myself
had treated when it appeared in contemporary attacks. I was curious
to discover whether this, too, would turn out to have a psychical
cause. When I began to call up the traumatic scene, the patient saw
herself back in a period of great mental irritability towards her
husband. She described a conversation which she had had with him
and a remark of his which she had felt as a bitter insult. Suddenly
she put her hand to her cheek, gave a loud cry of pain and said:
‘It was like a slap in the face.’ With this her pain
and her attack were both at an end.

   There is no doubt that what had
happened had been a symbolization. She had felt as though she had
actually been given a slap in the face. Everyone will immediately
ask how it was that the sensation of a ‘slap in the
face’ came to take on the outward forms of a trigeminal
neuralgia, why it was restricted to the second and third branches,
and why it was made worse by opening the mouth and chewing -
though, incidentally, not by talking.

   Next day the neuralgia was back
again. But this time it was cleared up by the reproduction of
another
scene, the content of which was once again a
supposed insult. Things went on like this for nine days. It seemed
to be the case that for years insults, and particularly spoken
ones, had, through symbolization, brought on fresh attacks of her
facial neuralgia.

   But ultimately we were able to
make our way back to her first attack of neuralgia, more than
fifteen years earlier. Here there was no symbolization but a
conversion through simultaneity. She saw a painful sight which was
accompanied by feelings of self-reproach, and this led her to force
back another set of thoughts. Thus it was a case of conflict and
defence. The generation of the neuralgia at that moment was only
explicable on the assumption that she was suffering at the time
from slight toothache or pains in the face, and this was not
improbable, since she was just then in the early months of her
first pregnancy.

Studies On Hysteria

162

   Thus the explanation turned out
to be that this neuralgia had come to be indicative of a particular
psychical excitation by the usual method of conversion, but that
afterwards it could be set going through associative reverberations
from her mental life, or symbolic conversion. In fact, the same
behaviour that we found in Fräulein Elisabeth von R.

   I will give a second example
which demonstrates the action of symbolization under other
conditions. At a particular period, Frau Cäcilie was afflicted
with a violent pain in her right heel - a shooting pain at every
step she took, which made walking impossible. Analysis led us in
connection with this to a time when the patient had been in a
sanatorium abroad. She had spent a week in bed and was going to be
taken down to the common dining-room for the first time by the
house physician. The pain came on at the moment when she took his
arm to leave the room with him; it disappeared during the
reproduction of the scene, when the patient told me she had been
afraid at the time that she might not ‘find herself on a
right footing’ with these strangers.