Studies On Hysteria
22
This girl, who was bubbling over
with intellectual vitality: led an extremely monotonous existence
in her puritanically-minded family. She embellished her life in a
manner which probably influenced her decisively in the direction of
her illness, by indulging in systematic day-dreaming, which she
described as her ‘private theatre’. While everyone
thought she was attending, she was living through fairy tales in
her imagination; but she was always on the spot when she was spoken
to, so that no one was aware of it. She pursued this activity
almost continuously while she was engaged on her household duties,
which she discharged unexceptionably. I shall presently have to
describe the way in which this habitual day-dreaming while she was
well passed over into illness without a break.
The course of the illness fell
into several clearly separable phases:
(A) Latent incubation. From the
middle of July, 1880, till about December 10. This phase of an
illness is usually hidden from us; but in this case, owing to its
peculiar character, it was completely accessible; and this in
itself lends no small pathological interest to the history, I shall
describe this phase presently.
(B) The manifest illness. A
psychosis of a peculiar kind, paraphasia, a convergent squint,
severe disturbances of vision, paralyses (in the form of
contractures), complete in the right upper and both lower
extremities, partial in the left upper extremity, paresis of the
neck muscles. A gradual reduction of the contracture to the
right-hand extremities. Some improvement, interrupted by a severe
psychical trauma (the death of the patient’s father) in
April, after which there followed
(C) A period of persisting
somnambulism, subsequently alternating with more normal states. A
number of chronic symptoms persisted till December, 1881.
(D) Gradual cessation of the
pathological states and symptoms up to June, 1882.
Studies On Hysteria
23
In July, 1880, the
patient’s father, of whom she was passionately fond, fell ill
of a peripleuritic abscess which failed to clear up to which he
succumbed in April, 1881. During the first months of the illness
Anna devoted her whole energy to nursing her father, and no one was
much surprised when by degrees her own health greatly deteriorated.
No one, perhaps not even the patient herself, knew what was
happening to her; but eventually the state of weakness, anaemia and
distaste for food became so bad that to her great sorrow she was no
longer allowed to continue nursing the patient. The immediate cause
of this was a very severe cough, on account of which I examined her
for the first time. It was a typical
tussis nervosa
. She
soon began to display a marked craving for rest during the
afternoon, followed in the evening by a sleep-like state and
afterwards a highly excited condition.
At the beginning of December a
convergent squint appeared. An ophthalmic surgeon explained this
(mistakenly) as being due to paresis of one abducens. On December
11 the patient took to her bed and remained there until April
1.
There developed in rapid
succession a series of severe disturbances which were
apparently
quite new: left-sided occipital headache;
convergent squint (diplopia), markedly increased by excitement;
complaints that the walls of the room seemed to be falling over
(affection of the obliquus); disturbances of vision which it was
hard to analyse; paresis of the muscles of the front of the neck,
so that finally the patient could only move her head by pressing it
backwards between her raised shoulders and moving her whole back;
contracture and anaesthesia of the right upper, and, after a time,
of the right lower extremity. The latter was fully extended,
adducted and rotated inwards. Later the same symptom appeared in
the left lower extremity and finally in the left arm, of which,
however, the fingers to some extent retained the power of movement.
So, too, there was no complete rigidity in the shoulder-joints. The
contracture reached its maximum in the muscles of the upper arms.
In the same way, the region of the elbows turned out to be the most
affected by anaesthesia when, at a later stage, it became possible
to make a more careful test of this. At the beginning of the
illness the anaesthesia could not be efficiently tested, owing to
the patient’s resistance arising from feelings of
anxiety.
Studies On Hysteria
24
It was while the patient was in
this condition that I under took her treatment, and I at once
recognized the seriousness of the psychical disturbance with which
I had to deal. Two entirely distinct states of consciousness were
present which alternated very frequently and without warning and
which became more and more differentiated in the course of the
illness. In one of these states she recognized her surroundings;
she was melancholy and anxious, but relatively normal. In the other
state she hallucinated and was ‘naughty’ - that is to
say, she was abusive, used to throw the cushions at people, so far
as the contractures at various times allowed, tore buttons off her
bed clothes and linen with those of her fingers which she could
move, and so on. At this stage of her illness if something had been
moved in the room or someone had entered or left it she would
complain of having ‘lost’ some time and would remark
upon the gap in her train of conscious thoughts. Since those about
her tried to deny this and to soothe her when she complained that
she was going mad, she would, after throwing the pillows about,
accuse people of doing things to her and leaving her in a muddle,
etc.
These
‘
absences
’ had already been observed before she
took to her bed; she used then to stop in the middle of a sentence,
repeat her last words and after a short pause go on talking. These
interruptions gradually increased till they reached the dimensions
that have just been described; and during the climax of the
illness, when the contractures had extended to the left side of her
body, it was only for a short time during the day that she was to
any degree normal. But the disturbances invaded even her moments of
relatively clear consciousness. There were extremely rapid changes
of mood leading to excessive but quite temporary high spirits, and
at other times severe anxiety, stubborn opposition to every
therapeutic effort and frightening hallucinations of black snakes,
which was how she saw her hair, ribbons and similar things. At the
same time she kept on telling herself not to be so silly: what she
was seeing was really only her hair, etc. At moments when her mind
was quite clear she would complain of the profound darkness in her
head, of not being able to think, of becoming blind and deaf, of
having two selves, a real one and an evil one which forced her to
behave badly, and so on.
Studies On Hysteria
25
In the afternoons she would fall
into a somnolent state which lasted till about an hour after
sunset. She would then wake up and complain that something was
tormenting her - or rather, she would keep repeating in the
impersonal form ‘tormenting, tormenting’. For alongside
of the development of the contractures there appeared a deep-going
functional disorganization of her speech. It first became
noticeable that she was at a loss to find words, and this
difficulty gradually increased. Later she lost her command of
grammar and syntax; she no longer conjugated verbs, and eventually
she used only infinitives, for the most part incorrectly formed
from weak past participles; and she omitted both the definite and
indefinite article. In the process of time she became almost
completely deprived of words. She put them together laboriously out
of four or five languages and became almost unintelligible. When
she tried to write (until her contractures entirely prevented her
doing so) she employed the same jargon. For two weeks she became
completely dumb and in spite of making great and continuous efforts
to speak she was unable to say a syllable. And now for the first
time the psychical mechanism of the disorder became clear. As I
knew, she had felt very much offended over something and had
determined not to speak about it. When I guessed this and obliged
her to talk about it, the inhibition, which had made any other kind
of utterance impossible as well, disappeared.
This change coincided with a
return of the power of movement to the extremities of the left side
of her body, in March, 1881. Her paraphasia receded; but
thenceforward she spoke only in English - apparently, however,
without knowing that she was doing so. She had disputes with her
nurse who was, of course, unable to understand her. It was only
some months later that I was able to convince her that she was
talking English. Nevertheless, she herself could still understand
the people about her who talked German. Only in moments of extreme
anxiety did her power of speech desert her entirely, or else she
would use a mixture of all sorts of languages. At times when she
was at her very best and most free, she talked French and Italian.
There was complete amnesia between these times and those at which
she talked English. At this point, too, her squint began to
diminish and made its appearance only at moments of great
excitement. She was once again able to support her head. On the
first of April she got up for the first time.
Studies On Hysteria
26
On the fifth of April her adored
father died. During her illness she had seen him very rarely and
for short periods. This was the most severe psychical trauma that
she could possibly have experienced. A violent outburst of
excitement was succeeded by profound stupor which lasted about two
days and from which she emerged in a greatly changed state. At
first she was far quieter and her feelings of anxiety were much
diminished. The contracture of her right arm and leg persisted as
well as their anaesthesia, though this was not deep. There was a
high degree of restriction of the field of vision: in a bunch of
flowers which gave her much pleasure she could only see one flower
at a time. She complained of not being able to recognize people.
Normally, she said, she had been able to recognize faces without
having to make any deliberate effort; now she was obliged to do
laborious ‘recognizing work’¹ and had to say to
herself ‘this person’s nose is such-and-such, his hair
is such-and-such, so he must be so-and-so’. All the people
she saw seemed like wax figures without any connection with her.
She found the presence of some of her close relatives very
distressing and this negative attitude grew continually stronger If
someone whom she was ordinarily pleased to see came into the room,
she would recognize him and would be aware of things for a short
time, but would soon sink back into her own broodings and her
visitor was blotted out. I was the only person whom she always
recognized when I came in; so long as I was talking to her she was
always in contact with things and lively, except for the sudden
interruptions caused by one of her hallucinatory
‘
absences
’.
She now spoke only English and
could not understand what was said to her in German. Those about
her were obliged to talk to her in English; even the nurse learned
to make herself to some extent understood in this way. She was,
however, able to read French and Italian. If she had to read one of
these aloud, what she produced, with extraordinary fluency, was an
admirable extempore English translation.
She began writing again, but in a
peculiar fashion. She wrote with her left hand, the less stiff one,
and she used Roman printed letters, copying the alphabet from her
edition of Shakespeare.
She had eaten extremely little
previously, but now she refused nourishment altogether. However,
she allowed me to feed her, so that she very soon began to take
more food. But she never consented to eat bread. After her meal she
invariably rinsed out her mouth and even did so if, for any reason,
she had not eaten anything - which shows how absent-minded she was
about such things.
¹
[In English in the original.]
Studies On Hysteria
27
Her somnolent states in the
afternoon and her deep sleep after sunset persisted. If, after
this, she had talked herself out (I shall have to explain what is
meant by this later) she was clear in mind, calm and cheerful.
This comparatively tolerable
state did not last long. Some ten days after her father’s
death a consultant was brought in, whom, like all strangers, she
completely ignored while I demonstrated all her peculiarities to
him. ‘That’s like an examination,’¹ she
said, laughing, when I got her to read a French text aloud in
English. The other physician intervened in the conversation and
tried to attract her attention, but in vain. It was a genuine
‘negative hallucination’ of the kind which has since so
often been produced experimentally. In the end he succeeded in
breaking through it by blowing smoke in her face. She suddenly saw
a stranger before her, rushed to the door to take away the key and
fell unconscious to the ground. There followed a short fit of anger
and then a severe attack of anxiety which I had great difficulty in
calming down. Unluckily I had to leave Vienna that evening, and
when I came back several days later I found the patient much worse.
She had gone entirely without food the whole time, was full of
anxiety and her hallucinatory
absences
were filled with
terrifying figures, death’s heads and skeletons. Since she
acted these things through as though she was experiencing them and
in part put them into words, the people around her became aware to
a great extent of the content of these hallucinations.