Freud - Complete Works (42 page)

Studies On Hysteria

215

   I have spoken above (
p. 208 f.
) of a patient whose psychical
functioning always stood in inverse ratio to the vividness of her
unconscious ideas. The diminution of her conscious thinking was
based partly, but only partly, on a peculiar kind of abstraction.
After each of her momentary ‘
absences
’ - and
these were constantly occurring - she did not know what she had
thought of in the course of it. She oscillated between her
'
conditions primes
’ and
‘
secondes
’, between the conscious and the
unconscious ideational complexes. But it was not only on that
account that her psychical functioning was reduced, nor on account
of the affect which dominated her from the unconscious. While she
was in this state her waking thought was without energy, her
judgement was childish and she seemed, as I have said, positively
imbecile. I believe that this was due to the fact that waking
thought has less energy at its disposal if a great amount of
psychical excitation is appropriated by the unconscious.

   If this state of things is not
merely temporary, if the split-off mind is in a
constant
state of excitation, as it was with Janet’s hemi-anaesthetic
patients - in whom, moreover, all the sensations in no less than
one half of the body were perceived only by the unconscious mind -
if this is the case, so little cerebral functioning is left over
for waking thought that the weakness of mind which Janet describes
and regards as innate is fully accounted for. There are only very
few people of whom it could be said, as of Uhland’s Bertrand
de Born, that they never need more than half their mind. Such a
reduction in their psychical energy does make the majority of
people weak-minded.

   This weakness of mind caused by a
splitting of the psyche seems also to be a basis of a momentous
characteristic of some hysterical patients - their suggestibility.
(I say ‘some’, since it is certain that among
hysterical patients are to be found people of the soundest and most
critical judgement as well.)

Studies On Hysteria

216

   By suggestibility we understand,
in the first instance, only an inability to criticize ideas and
complexes of ideas (judgements) which emerge in the subject’s
own consciousness or are introduced into it from outside through
the spoken word or through reading. All criticism of ideas like
these which come freshly into consciousness is based on the fact
that they awaken other ideas by association and amongst them some
that are irreconcilable with the fresh ones. The resistance to
these latter is thus dependent on the store of antagonistic ideas
in potential consciousness, and the strength of the resistance
corresponds to the ratio between the vividness of the fresh ideas
and that of those aroused from memory. Even in normal intellects
this ratio is very various. What we describe as an intellectual
temperament depends on it to a great extent. A
‘sanguine’ man is always delighted by new people and
things, and this is no doubt so because the intensity of his mnemic
images is less in comparison with that of new impressions than it
is in a quieter, ‘phlegmatic’ man. In pathological
states the preponderance of fresh ideas and the lack of resistance
to them increases in proportion to the fewness of the mnemic images
aroused - that is, in proportion to the weakness and poorness of
their associative powers. This is already what happens in sleep and
dreams, in hypnosis and whenever there is a reduction in mental
energy, so long as this does not also reduce the vividness of the
fresh ideas.

   The unconscious, split-off mind
in hysteria is pre-eminently suggestible on account of the poverty
and incompleteness of its ideational content. But the
suggestibility of the conscious mind, too, in some hysterical
patients seems to be based on this. They are excitable from their
innate disposition; in them, fresh ideas are very vivid. In
contrast to this, their intellectual activity proper, their
associative function, is reduced, because only a part of their
psychical energy is at the disposal of their waking thought, owing
to a splitting-off of an ‘unconscious’. As a result of
this their power of resistance both to auto- and allo-suggestions
is diminished and sometimes abolished. The suggestibility of their
will
also seems to be due to this alone. On the other hand,
hallucinatory
suggestibility, which promptly changes every
idea of a sense-perception into an actual perception, demands, like
all hallucinations, an abnormal degree of excitability of the
perceptual organ and cannot be traced back solely to a splitting of
the mind.

Studies On Hysteria

217

(6)  INNATE DISPOSITION - DEVELOPMENT
OF HYSTERIA

   At almost every stage of these
discussions I have been obliged to recognize that most of the
phenomena which we have been endeavouring to understand can be
based, among other things, on an innate idiosyncracy. This defies
any explanation that seeks to go beyond a mere statement of the
facts. But the
capacity to acquire
hysteria is also
undoubtedly linked with an idiosyncracy of the person concerned,
and an attempt to define it more accurately will perhaps not be
entirely unprofitable.

   I have explained above why I
cannot accept Janet’s view that the disposition to hysteria
is based on innate psychical weakness. The medical practitioner
who, in his capacity as family doctor, observes the members of
hysterical families of all ages will certainly be inclined to
regard this disposition as lying in an excess rather than in a
defect. Adolescents who are later to become hysterical are for the
most part lively, gifted and full of intellectual interests before
they fall ill. Their energy of will is often remarkable. They
include girls who get out of bed at night so as secretly to carry
on some study that their parents have forbidden from fear of their
overworking. The capacity for forming sound judgements is certainly
not more abundant in them than in other people; but it is rare to
find in them simple, dull intellectual inertia and stupidity. The
overflowing productivity of their minds has led one of my friends
to assert that hysterics are the flower of mankind, as sterile, no
doubt, but as beautiful as double flowers.

   Their liveliness and
restlessness, their craving for sensations and mental activity,
their intolerance of monotony and boredom, may be formulated thus:
they are among those people whose nervous system while it is at
rest liberates excess of excitation which requires to be made use
of (
cf. p. 175
). During
development at puberty, and in consequence of it, this original
excess is supplemented by the powerful increase in excitation which
arises from the awakening of sexuality, from the sex glands. From
then on there is a surplus quantity of free nervous energy
available for the production of pathological phenomena.

   But in order for these phenomena
to appear in the form of hysterical symptoms there must evidently
also be another, specific idiosyncracy in the individual concerned.
For after all, the great majority of lively and excitable people do
not become hysterical. I was only able, above, to describe this
idiosyncracy in the vague and unenlightening phrase,
‘abnormal excitability of the nervous system’. But it
may be possible to go further and say that this abnormality lies in
the fact that in such people the excitation of the central organ
can flow into the sensory nervous apparatuses which are normally
accessible only to peripheral stimuli, as well as into the nervous
apparatuses of the vegetative organs which are isolated from the
central nervous system by powerful resistances. It may be that this
idea of there being a surplus of excitation constantly present
which has access to the sensory, vasomotor and visceral apparatuses
already accounts for some pathological phenomena.

Studies On Hysteria

218

   In people of this kind, as soon
as their attention is forcibly concentrated on some part of the
body, what Exner speaks of as the ‘facilitation of
attention’ in the sensory path of conduction concerned
exceeds the normal amount. The free, floating excitation is, as it
were, diverted into this path, and a local hyperalgesia is
produced. As a result, every pain, however caused, reaches maximum
intensity, every ailment is ‘fearful’ and
‘unbearable’. Further, whereas in normal people a
quantity of excitation, after cathecting a sensory path, always
leaves it again, this is not so in these cases. That quantity,
moreover, not only remains behind but is constantly increased by
the influx of fresh excitations. A slight injury to a joint thus
leads to arthralgia, and the painful sensations due to ovarian
swelling lead to chronic ovarian neuralgia; and since the nervous
apparatuses of the circulation are more accessible to cerebral
influence than in normal people, we find nervous palpitation of the
heart, a tendency to fainting, proneness to excessive blushing and
turning pale, and so on.

   However, it is not only in regard
to
central
influences that the peripheral nervous
apparatuses are more easily excitable. They also react in an
excessive and perverse fashion to appropriate, functional stimuli.
Palpitations follow from moderate effort no less than from
emotional excitement, and the vasomotor nerves cause the arteries
to contract (‘dead fingers’), apart from any psychical
influence. And just as a slight injury leaves behind an arthralgia,
a short attack of bronchitis is followed by nervous asthma, and
indigestion by frequent cardiac pains. We must accordingly
recognize that accessibility to sums of excitation of central
origin is no more than a special case of general abnormal
excitability,¹ even though it is the most important one from
the point of view of our present topic.

  
¹
Oppenheim’s ‘instability of the
molecules’.

Studies On Hysteria

219

   It seems to me, therefore, that
the old ‘reflex theory’ of these symptoms, which would
perhaps be better described simply as ‘nervous’ ones
but which form part of the empirical clinical picture of hysteria,
should not be completely rejected. The vomiting, which of course
accompanies the dilatation of the uterus in pregnancy, may, where
there is abnormal excitability quite well be set going in a reflex
manner by trivial uterine stimuli, or perhaps even by the periodic
changes in size of the ovaries. We are acquainted with so many
remote effects resulting from organic changes, so many strange
instances of ‘referred pain’, that we cannot reject the
possibility that a host of nervous symptoms which are sometimes
determined psychically may in other cases be remote effects of
reflex action. Indeed, I venture to put forward the highly unmodern
heresy that even motor weakness in a leg may sometimes be
determined by a genital affection, not psychically, but by direct
reflex action. I think we shall do well not to insist too much on
the exclusiveness of our new discoveries or to seek to apply them
in all cases.

   Other forms of abnormal sensory
excitability still escape our understanding completely: general
analgesia, for instance anaesthetic areas, real restriction of the
field of vision, and so on. It is possible and perhaps probable
that further observations will prove the psychical origin of one or
other of these stigmata and so explain the symptom; but this has
not yet happened (for I do not venture to generalize the findings
presented by our first case history), and I do not think it is
justifiable to presume that this is their origin before it has been
properly traced.

   On the other hand the
idiosyncracy of the nervous system and of the mind which we have
been discussing seems to explain one or two very familiar
properties of many hysterical patients. The surplus of excitation
which is liberated by their nervous system when in a state of rest
determines their incapacity to tolerate a monotonous life and
boredom - their craving for sensations which drives them, after the
onset of their illness, to interrupt the monotony of their invalid
life by all kinds of ‘incidents’, of which the most
prominent are from the nature of things pathological phenomena.
They are often supported in this by autosuggestion. They are led
further and further along this road by their need for being ill, a
remarkable trait which is as pathognomonic for hysteria as is
fear
of being ill for hypochondria. I know a hysterical
woman who inflicted on herself injuries which were often quite
severe, merely for her own use and without those about her or her
physician learning of them. If she did nothing else she used to
play all kinds of tricks while she was alone in her room simply to
prove to herself that she was not normal. For she had in fact a
distinct feeling of not being well and could not discharge her
duties satisfactorily, and she tried to justify herself in her own
eyes by actions such as these. Another patient, a very sick woman
suffering from pathological conscientiousness and full of distrust
of herself, felt every hysterical phenomenon as something guilty,
because, she said, she need not have had it if she had really
wanted not to. When a paresis of her legs was wrongly diagnosed as
a disease of the spine she felt it as an immense relief, and when
she was told that it was ‘only nervous’ and would pass
off, that was enough to bring on severe pangs of conscience. The
need to be ill arises from the patient’s desire to convince
herself and other people of the reality of her illness. When this
need is further associated to the distress caused by the monotony
of a sick-room, the inclination to produce more and more new
symptoms is developed to its fullest.