Freud - Complete Works (33 page)

   This seems at first to be a
striking and even a comic example of the genesis of hysterical
symptoms through symbolization by means of a verbal expression.
Closer examination of the circumstances, however, favours another
view of the case. The patient had been suffering at the time from
pains in the feet generally, and it was on their account that she
had been confined to bed so long. All that could be claimed on
behalf of symbolization was that the fear which overcame the
patient, as she took her first steps, picked out from among all the
pains that were troubling her at the time the one particular pain
which was symbolically appropriate, the pain in her right heel, and
developed it into a psychical pain and gave it special
persistence.

   In these examples the mechanism
of symbolization seems to be reduced to secondary importance, as is
no doubt the general rule. But I have examples at my disposal which
seem to prove the genesis of hysterical symptoms through
symbolization alone. The following is one of the best, and relates
once more to Frau Cäcilie. When a girl of fifteen, she was
lying in bed, under the watchful eye of her strict grandmother. The
girl suddenly gave a cry; she had felt a penetrating pain in her
forehead between her eyes, which lasted for weeks. During the
analysis of this pain, which was reproduced after nearly thirty
years, she told me that her grandmother had given her a look so
‘piercing’ that it had gone right into her brain. (She
had been afraid that the old woman was viewing her with suspicion.)
As she told me this thought she broke into a loud laugh, and the
pain once more disappeared. In this instance I can detect nothing
other than the mechanism of symbolization, which has its place, in
some sense, midway between autosuggestion and conversion.

   My observation of Frau
Cäcilie M. gave me an opportunity of making a regular
collection of symbolizations of this kind. A whole set of physical
sensations which would ordinarily be regarded as organically
determined were in her case of psychical origin or at least
possessed a psychical meaning. A particular series of experiences
of hers were accompanied by a stabbing sensation in the region of
the heart (meaning ‘it stabbed me to the heart’). The
pain that occurs in hysteria of nails being driven into the head
was without any doubt to be explained in her case as a pain related
to thinking. ( ‘Something’s come into my head.’)
Pains of this kind were always cleared up as soon as the problems
involved were cleared up. Running parallel to the sensation of a
hysterical ‘aura’ in the throat, when that feeling
appeared after an insult, was the thought ‘I shall have to
swallow this’. She had a whole quantity of sensations and
ideas running parallel with each other. Sometimes the sensation
would call up the idea to explain it, sometimes the idea would
create the sensation by means of symbolization, and not
infrequently it had to be left an open question which of the two
elements had been the primary one.

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   I have not found such an
extensive use of symbolization in any other patient. It is true
that Frau Cäcilie M. was a woman who possessed quite unusual
gifts, particularly artistic ones, and whose highly developed sense
of form was revealed in some poems of great perfection. It is my
opinion, however, that when a hysteric creates a somatic expression
for an emotionally coloured idea by symbolization, this depends
less than one would imagine on personal or voluntary factors. In
taking a verbal expression literally and in feeling the ‘stab
in the heart’ or the ‘slap in the face’ after
some slighting remark as a real event, the hysteric is not taking
liberties with words, but is simply reviving once more the
sensations to which the verbal expression owes its justification.
How has it come about that we speak of someone who has been
slighted as being ‘stabbed to the heart’ unless the
slight had in fact been accompanied by a precordial sensation which
could suitably be described in that phrase and unless it was
identifiable by that sensation? What could be more probable than
that the figure of speech ‘swallowing something’, which
we use in talking of an insult to which no rejoinder has been made,
did in fact originate from the innervatory sensations which arise
in the pharynx when we refrain from speaking and prevent ourselves
from reacting to the insult? All these sensations and innervations
belong to the field of ‘The Expression of the
Emotions’, which, as Darwin has taught us, consists of
actions which originally had a meaning and served a purpose. These
may now for the most part have become so much weakened that the
expression of them in words seems to us only to be a figurative
picture of them, whereas in all probability the description was
once meant literally; and hysteria is right in restoring the
original meaning of the words in depicting its unusually strong
innervations. Indeed, it is perhaps wrong to say that hysteria
creates these sensations by symbolization. It may be that it does
not take linguistic usage as its model at all, but that both
hysteria and linguistic usage alike draw their material from a
common source.¹

  
¹
In states in which mental alteration goes
deeper, we clearly also find a symbolic version in concrete images
and sensations of more artificial turns of speech. Frau
Cäcilie M. passed through a period during which she
transformed every thought she had into a hallucination, the
explanation of which often called for much ingenuity. She
complained to me at that time of being troubled by a hallucination
that her two doctors - Breuer and I - were hanging on two trees
next each other in the garden. The hallucination disappeared after
the analysis had brought out the following explanation. The evening
before, Breuer had refused to give her a drug she had asked for.
She had then set her hopes on me but had found me equally
hard-hearted. She was furious with us over this, and in her anger
she thought to herself: ‘There’s nothing to choose
between the two of them; one’s the
pendant
[match] of
the other.’

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164

III

THEORETICAL

(BREUER)

Studies On Hysteria

165

III

THEORETICAL

(BREUER)

In the ‘Preliminary Communication’
which introduces this work we laid down the conclusions to which we
were led by our observations, and I think that I can stand by them
in the main. But the ‘Preliminary Communication’ is so
short and concise that for the most part it was only possible in it
to hint at our views. Now, therefore, that the case histories have
brought forward evidence in support of our conclusions it may be
permissible to state them at greater length. Even here, there is,
of course, no question of dealing with the
whole
field of
hysteria. But we may give a somewhat closer and clearer account
(with some added reservations, no doubt) of those points for which
insufficient evidence was adduced or which were not given enough
prominence in the ‘Preliminary Communication’.

   In what follows little mention
will be made of the brain and none whatever of molecules. Psychical
processes will be dealt with in the language of psychology; and,
indeed, it cannot possibly be otherwise. If instead of
‘idea’ we chose to speak of ‘excitation of the
cortex’, the latter term would only have any meaning for us
in so far as we recognized an old friend under that cloak and
tacitly reinstated the ‘idea’. For while ideas are
constant objects of our experience and are familiar to us in all
their shades of meaning, ‘cortical excitations’ are on
the contrary rather in the nature of a postulate, objects which we
hope to be able to identify in the future. The substitution of one
term for another would seem to be no more than a pointless
disguise. Accordingly, I may perhaps be forgiven if I make almost
exclusive use of psychological terms.

   There is another point for which
I must ask in advance for the reader’s indulgence. When a
science is making rapid advances, thoughts which were first
expressed by single individuals quickly become common property.
Thus no one who attempts to put forward to-day his views on
hysteria and its psychical basis can avoid repeating a great
quantity of other people’s thoughts which are in the act of
passing from personal into general possession. It is scarcely
possible always to be certain who first gave them utterance, and
there is always a danger of regarding as a product of one’s
own what has already been said by someone else. I hope, therefore,
that I may be excused if few quotations are found in this
discussion and if no strict distinction is made between what is my
own and what originates elsewhere. Originality is claimed for very
little of what will be found in the following pages.

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(1)  ARE ALL HYSTERICAL PHENOMENA
IDEOGENIC?

   In our ‘Preliminary
Communication’ we discussed the psychical mechanism of
‘hysterical phenomena’, not of ‘hysteria’,
because we did not wish to claim that this psychical mechanism or
the psychical theory of hysterical symptoms in general has
unlimited validity. We are not of the opinion that all the
phenomena of hysteria come about in the manner described by us in
that paper, nor do we believe that they are all ideogenic, that is,
determined by ideas. In this we differ from Moebius, who in 1888
proposed to define as hysterical all pathological phenomena that
are caused by ideas. This statement was later elucidated to the
effect that only a part of the pathological phenomena correspond in
their content to the ideas that cause them - those phenomena,
namely, that are produced by allo- or auto-suggestion, as, for
instance, when the idea of not being able to move one’s arm
causes a paralysis of it; while another part of the hysterical
phenomena, though caused by ideas, do not correspond to them in
their content - as, for instance, when in one of our patients a
paralysis of the arm was caused by the sight of snake-like
objects.

   In giving this definition,
Moebius is not merely proposing a modification in nomenclature and
suggesting that in future we should only describe as hysterical
those pathological phenomena which are ideogenic (determined by
ideas); what he thinks is that all hysterical symptoms are
ideogenic. ‘Since ideas are very frequently the cause of
hysterical phenomena, I believe that they always are.’ He
terms this an inference by analogy. I prefer to call it a
generalization, the justification for which must first be
tested.

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   Before any discussion of the
subject, we must obviously decide what we understand by hysteria. I
regard hysteria as a clinical picture which has been empirically
discovered and is based on observation, in just the same way as
tubercular pulmonary phthisis. Clinical pictures of this kind that
have been arrived at empirically are made more precise, deeper and
clearer by the progress of our knowledge; but they ought not to be
and cannot be disrupted by it. Aetiological research has shown that
the various constituent processes of pulmonary phthisis have
various causes: the tubercle is due to
bacillus Kochii
, and
the disintegration of tissue, the formation of cavities and the
septic fever are due to other microbes. In spite of this,
tubercular phthisis remains a clinical unity and it would be wrong
to break it up by attributing to it only the ‘specifically
tubercular’ modifications of tissue caused by Koch’s
bacillus and by detaching the other modifications from it. In the
same way hysteria must remain a clinical unity even if it turns out
that its phenomena are determined by various causes, and that some
of them are brought about by a psychical mechanism and others
without it.

   It is my conviction that this is
in fact so; only a part of the phenomena of hysteria are ideogenic,
and the definition put forward by Moebius tears in half the
clinical unity of hysteria, and indeed the unity of one and the
same symptom in the same patient.

   We should be drawing an inference
completely analogous to Moebius’s ‘inference by
analogy’ if we were to say that because ideas and perceptions
very often give rise to erections we may assume that they alone
ever do so and that peripheral stimuli set this vasomotor process
in action only by a roundabout path through the psyche. We know
that this inference would be false, yet it is based on at least as
many facts as Moebius’s assertion about hysteria. In
conformity with our experience of a large number of physiological
processes, such as the secretion of saliva or tears, changes in the
action of the heart, etc., it is possible and plausible to assume
that one and the same process may be set in motion equally by ideas
and by peripheral and other non-psychical stimuli. The contrary
would need to be proved and we are very far short of that. Indeed,
it seems certain that many phenomena which are described as
hysterical are not caused by ideas alone.

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   Let us consider an everyday
instance. A woman may, when ever an affect arises, produce on her
neck, breast and face an erythema appearing first in blotches and
then becoming confluent. This is determined by ideas and therefore
according to Moebius is a hysterical phenomenon. But this same
erythema appears, though over a less extensive area, when the skin
is irritated or touched, etc. This would
not
be hysterical.
Thus a phenomenon which is undoubtedly a complete unity would of
one occasion be hysterical and on another occasion not. It may of
course be questioned whether this phenomenon, the erethism of the
vasomotors, should be regarded as a specifically hysterical one or
whether it should not be more properly looked upon simply as
‘nervous’. But on Moebius’s view the breaking up
of the unity would necessarily result in any case and the
affectively-determined erythema would alone be called
hysterical.

   This applies in exactly the same
way to the hysterical pain which are of so much practical
importance. No doubt these are often determined directly by ideas.
They are ‘hallucinations of pain’. If we examine these
rather more closely it appears that the fact of an idea being very
vivid is not enough to produce them but that there must be a
special abnormal condition of the apparatuses concerned with the
conduction and sensation of pain, just as in the case of affective
erythema an abnormal excitability of the vasomotors must be
present. The phrase ‘hallucinations of pain’
undoubtedly gives the most pregnant description of the nature of
these neuralgias, but it compels us too, to carry over to them the
views that we have formed of hallucinations in general. A detailed
discussion of these views would not be in place here. I subscribe
to the opinion that ‘ideas’, mnemic images pure and
simple, without any excitation of the perceptual apparatus, never,
even at their greatest vividness and intensity, attain the
character of objective existence which is the mark of
hallucinations.¹

  
¹
This perceptual apparatus, including the
sensory areas of the cortex, must be different from the organ which
stores up and reproduces sense-impressions in the form of mnemic
images. For the basic essential of the function of the perceptual
apparatus is that its
status quo ante
should be capable of
being restored with the greatest possible rapidity; otherwise no
proper further perception could take place. The essential of
memory, on the other hand, is that no such restoration should occur
but that every perception should create changes that are permanent.
It is impossible for one and the same organ to fulfil these two
contradictory conditions. The mirror of a reflecting telescope
cannot at the same time be a photographic plate. I am in agreement
with Meynert, in the sense of believing, as I have said, that what
gives hallucinations their objective character is an excitation of
the perceptual apparatus (though I do not agree with him when he
speaks of an excitation of the subcortical centres). If the
perceptual organ is excited by a mnemic image, we must suppose that
that organ’s excitability has been changed in an abnormal
direction, and that this change is what makes hallucination
possible.

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   This applies to sensory
hallucinations and still more to hallucinations of pain. For it
does not seem possible for a healthy person to endow the memory of
a physical pain with even the degree of vividness, the distant
approximation to the real sensation, which can, after all, be
attained by optical and acoustic mnemic images. Even in the normal
hallucinatory state of healthy people which occurs in sleep there
are never, I believe, dreams of pain unless a real sensation of
pain is present. This ‘retrogressive’ excitation,
emanating from the organ of memory and acting on the perceptual
apparatus by means of ideas, is therefore in the normal course of
things still more difficult in the case of pain than in that of
visual or auditory sensations. Since hallucinations of pain arise
so easily in hysteria, we must posit an abnormal excitability of
the apparatus concerned with sensations of pain.

   This excitability makes its
appearance not only under the spur of ideas but of peripheral
stimuli in just the same way as the erethism of the vasomotors
which we discussed above.

   It is a matter of daily
observation to find that in people with normal nerves peripheral
pains are brought on by pathological processes, not in themselves
painful, in other organs. Thus headaches arise from relatively
insignificant changes in the nose or neighbouring cavities, and
again, neuralgias of the intercostal and brachial nerves from the
heart, etc. If the abnormal excitability, which we have been
obliged to postulate as a necessary condition of hallucinations of
pain, is present in a patient, that excitability is also at the
disposal, so to speak, of the irradiations that I have just
mentioned. The irradiations that occur also in non-neurotic people
are made more intense, and irradiations are formed of a sort which,
it is true, we only find in neurotic patients but which are based
on the same mechanism as the others. Thus, ovarian neuralgia
depends, I believe, on states of the genital apparatus. That its
causes are psychical would have to be proved, and this is not
achieved by showing that that particular kind of pain, like any
other, can be produced under hypnosis as a hallucination, or that
its cause can be psychical. Like erythema or one of the normal
secretions, it arises both from psychical and from purely somatic
causes. Are we to describe only the first kind as hysterical -
cases which we know have a psychical origin? If so, the commonly
observed cases of ovarian neuralgia would have to be excluded from
the hysterical syndrome, and this will hardly do.

   If a slight injury to a joint is
gradually followed by a severe arthralgia, no doubt the process
involves a psychical element viz. a concentration of attention on
the injured part, which intensifies the excitability of the nerve
tracts concerned. But this can hardly be expressed by saying that
the hyperalgesia has been caused by ideas.

   The same is true of the
pathological
diminution
of sensation. It is quite unproved
and improbable that general analgesia or analgesia of individual
parts of the body unaccompanied by anaesthesia is caused by ideas.
And even if the discoveries of Binet and Janet were to be fully
confirmed to the effect that hemi-anaesthesia is determined by a
peculiar psychical condition, by a splitting of the psyche, the
phenomenon would be a psychogenic but not an ideogenic one, and
therefore, according to Moebius, should not be termed
hysterical.