Studies On Hysteria
45
Nevertheless, though her two
states were thus sharply separated, not only did the secondary
state intrude into the first one, but - and this was at all events
frequently true, and even when she was in a very bad condition - a
clear-sighted and calm observer sat, as she put it, in a corner of
her brain and looked on at all the mad business. This persistence
of clear thinking while the psychosis was actually going on found
expression in a very curious way. At a time when, after the
hysterical phenomena had ceased, the patient was passing through a
temporary depression, she brought up a number of childish fears and
self-reproaches, and among them the idea that she had not been ill
at all and that the whole business had been simulated. Similar
observations, as we know, have frequently been made. When a
disorder of this kind has cleared up and the two states of
consciousness have once more become merged into one, the patients,
looking back to the past, see themselves as the single undivided
personality which was aware of all the nonsense; they think they
could have prevented it if they had wanted to, and thus they feel
as though they had done all the mischief deliberately. - It should
be added that this normal thinking which persisted during the
secondary state must have fluctuated enormously in its amount and
must very often have been completely absent.
I have already described the
astonishing fact that from beginning to end of the illness all the
stimuli arising from the secondary state, together with their
consequences, were permanently removed by being given verbal
utterance in hypnosis, and I have only to add an assurance that
this was not an invention of mine which I imposed on the patient by
suggestion. It took me completely by surprise, and not until
symptoms had been got rid of in this way in a whole series of
instances did I develop a therapeutic technique out of it.
The final cure of the hysteria
deserves a few more words. It was accompanied, as I have already
said, by considerable disturbances and a deterioration in the
patient’s mental condition. I had a very strong impression
that the numerous products of her secondary state which had been
quiescent were now forcing their way into consciousness; and though
in the first instance they were being remembered only in her
secondary state, they were nevertheless burdening and disturbing
her normal one. It remains to be seen whether it may not be that
the same origin is to be traced in other cases in which a chronic
hysteria terminates in a psychosis.
Studies On Hysteria
46
CASE
2
FRAU EMMY VON N., AGE 40, FROM
LIVONIA
(Freud)
On May 1, 1889, I took on the case of a lady
of about forty years of age, whose symptoms and personality
interested me so greatly that I devoted a large part of my time to
her and determined to do all I could for her recovery. She was a
hysteric and could be put into a state of somnambulism with the
greatest ease; and when I became aware of this I decided that I
would make use of Breuer’s technique of investigation under
hypnosis, which I had come to know from the account he had given me
of the successful treatment of his first patient. This was my first
attempt at handling that therapeutic method. I was still far from
having mastered it; in fact I did not carry the analysis of the
symptoms far enough nor pursue it systematically enough. I shall
perhaps be able best to give a picture of the patient’s
condition and my medical procedure by reproducing the notes which I
made each evening during the first three weeks of the treatment.
Wherever later experience has brought me a better understanding, I
shall embody it in footnotes and interpolated comments.
May 1, 1889
. - This lady,
when I first saw her, was lying on a sofa with her head resting on
a leather cushion. She still looked young and had finely-cut
features, full of character. Her fact bore a strained and painful
expression, her eyelids were drawn together and her eyes cast down;
there was a heavy frown or her forehead and the naso-labial folds
were deep. She spoke in a low voice as though with difficulty and
her speech was from time to time subject to spastic interruptions
amounting to a stammer. She kept her fingers, which exhibited a
ceaseless agitation resembling athetosis, tightly clasped together.
There were frequent convulsive tic-like movements of her face and
the muscles of her neck, during which some of them, especially the
right sterno-cleido-mastoid, stood out prominently. Furthermore she
frequently interrupted her remarks by producing a curious
‘clacking’ sound from her mouth which defies
imitation.¹
¹
This ‘clacking’ was made up of
a number of sounds. Colleagues of mine with sporting experience
told me, on hearing it, that its final notes resembled the call of
a capercaillie.
Studies On Hysteria
47
What she told me was perfectly
coherent and revealed an unusual degree of education and
intelligence. This made it seem all the more strange when every two
or three minutes she suddenly broke off, contorted her face into an
expression of horror and disgust, stretched out her hand towards
me, spreading and crooking her fingers, and exclaimed, in a changed
voice, charged with anxiety: ‘Keep still! - Don’t say
anything! - Don’t touch me!’ She was probably under the
influence of some recurrent hallucination of a horrifying kind and
was keeping the intruding material at bay with this formula.¹
These interpolations came to an end with equal suddenness and the
patient took up what she had been saying, without pursuing her
momentary excitement any further, and without explaining or
apologizing for her behaviour - probably, therefore, without
herself having noticed the interpolation.²
I learned what follows of her
circumstances. Her family came from Central Germany, but had been
settled for two generations in the Baltic Provinces of Russia,
where it possessed large estates. She was one of fourteen children,
of which she herself in the thirteenth. Only four of them survive.
She was brought up carefully, but under strict discipline by an
over-energetic and severe mother. When she was twenty-three she
married an extremely gifted and able man who had made a high
position for himself as an industrialist on a large scale, but was
much older than she was. After a short marriage he died of a
stroke. To this event, together with the task of bringing up her
two daughters, now sixteen and fourteen years old, who were often
ailing and suffered from nervous troubles, she attributed her own
illness. Since her husband’s death, fourteen years ago, she
had been constantly ill with varying degrees of severity. Four
years ago her condition was temporarily improved by a course of
massage combined with electric baths. Apart from this, all her
efforts to regain her health have been unsuccessful. She has
travelled a great deal and has many lively interests. She lives at
present in a country seat on the Baltic near a large town. For
several months she has once more been very ill, suffering from
depression and insomnia, and tormented with pains; she went to
Abbazia in the vain hope of improvement, and for the last six weeks
has been in Vienna, up till now in the care of a physician of
outstanding merit.
I suggested that she should
separate from the two girls, who had their governess, and go into a
nursing home, where I could see her every day. This she agreed to
without raising the slightest objection.
¹
These words did in fact represent a
protective formula, and this will be explained later on. Since then
I have come across similar protective formulas in a melancholic
woman who endeavoured by their means to control her tormenting
thoughts - wishes that something bad might happen to her husband
and her mother, blasphemies, etc.
²
What we had here was a hysterical delirium
which alternated with normal consciousness, just as a true tic
intrudes into a voluntary movement without interfering with it and
without being mixed up with it.
Studies On Hysteria
48
On the evening of
May 2
I
visited her in the nursing home. I noticed that she started
violently whenever the door opened unexpectedly. I therefore
arranged that the nurses and the house physicians, when they
visited her, should give a loud knock at her door and not enter
till she had told them to come in. But even so, she still made a
grimace and gave a jump every time anyone entered.
Her chief complaint to-day was of
sensations of cold and pain in her left leg which proceeded from
her back above the iliac crest. I ordered her to be given warm
baths and I shall massage her whole body twice a day.
She is an excellent subject for
hypnotism. I had only to hold up a finger in front of her and order
her to go to sleep, and she sank back with a dazed and confused
look. I suggested that she should sleep well, that all her symptoms
should get better, and so on. She heard all this with closed eyes
but with unmistakably concentrated attention; and her features
gradually relaxed and took on a peaceful appearance. After this
first hypnosis she retained a dim memory of my words; but already
at the second there was complete somnambulism (with amnesia). I had
warned her that I proposed to hypnotize her, to which she raised no
difficulty. She has not previously been hypnotized, but it is safe
to suppose that she has read about hypnotism, though I cannot tell
what notions she may have about the hypnotic state.¹
This treatment by warm baths,
massage twice a day and hypnotic suggestion was continued for the
next few days. She slept well, got visibly better, and passed most
of the day lying quietly in bed. She was not forbidden to see her
children, to read, or to deal with her correspondence.
¹
Every time she woke from hypnosis she
looked about her for a moment in a confused way, let her eyes fall
on me, seemed to have come to her senses, put on her glasses, which
she took off before going to sleep, and then became quite lively
and on the spot. Although in the course of the treatment (which
lasted for seven weeks in this first year and eight in the second)
we discussed every sort of subject, and although I put her to sleep
twice almost every day, she never made any comment to me about the
hypnosis or asked me a single question about it; and in her waking
state she seemed, so far as possible, to ignore the fact that she
was undergoing hypnotic treatment.
Studies On Hysteria
49
May 8, morning
. - She
entertained me, in an apparently quite normal state, with gruesome
stories about animals. She had read in the
Frankfurter
Zeitung
, which lay on the table in front of her, a story of how
an apprentice had tied up a boy and put a white mouse into his
mouth. The boy had died of fright. Dr. K. had told her that he had
sent a whole case of white rats to Tiflis. As she told me this she
demonstrated every sign of horror. She clenched and unclenched her
hand several times. ‘Keep still! - Don’t say anything!
- Don’t touch me! - Supposing a creature like that was in the
bed!’ (She shuddered.) ‘Only think, when it’s
unpacked! There’s a dead rat in among them - one that’s
been gn-aw-aw-ed at!’
During the hypnosis I tried to
disperse these animal hallucinations. While she was asleep I picked
up the
Frankfurter Zeitung
. I found the anecdote about the
boy being maltreated, but without any reference to mice or rats. So
she had introduced these from her delirium while she was reading.
(I told her in the evening of our conversation about the white
mice. She knew nothing of it, was very much astonished and laughed
heartily.¹)
¹
A sudden interpolation like this of a
delirium into a waking state was not uncommon with her and was
often repeated later in my presence. She used to complain that in
conversation she often gave the most absurd answers, so that people
did not understand her. On the occasion when I first visited her I
asked her how old she was and she answered quite seriously:
‘I am a woman dating from last century.’ Some weeks
later she explained to me she had been thinking at the time in her
delirium of a beautiful old cupboard which, as a connoisseur of old
furniture, she had bought in the course of her travels. It was to
this cupboard that her answer had referred when my question about
her age raised the topic of dates.
Studies On Hysteria
50
During the afternoon she had what
she called a ‘neck cramp’,¹ which, however, as she
said, ‘only lasted a short time - a couple of
hours’.
Evening
. - I requested
her, under hypnosis, to talk, which, after some effort, she
succeeded in doing. She spoke softly and reflected for a moment
each time before answering. Her expression altered according to the
subject of her remarks, and grew calm as soon as my suggestion had
put an end to the impression made upon her by what she was saying.
I asked her why it was that she was so easily frightened, and she
answered: ‘It has to do with memories of my earliest
youth.’ ‘When?’ ‘First when I was five
years old and my brothers and sisters often threw dead animals at
me. That was when I had my first fainting fit and spasms. But my
aunt said it was disgraceful and that I ought not to have attacks
like that, and so they stopped. Then I was frightened again when I
was seven and I unexpectedly saw my sister in her coffin; and again
when I was eight and my brother terrified me so often by dressing
up in sheets like a ghost; and again when I was nine and I saw my
aunt in her coffin and her jaw suddenly dropped.’