Her tendency to auto-hypnotic
absences
was from now on established. On the morning after
the night I have described, while she was waiting for the
surgeon’s arrival, she fell into such a fit of abstraction
that he finally arrived in the room without her having heard his
approach. Her persistent anxiety interfered with her eating and
gradually led to intense feelings of nausea. Apart from this,
indeed, each of her hysterical symptoms arose during an affect. It
is not quite certain whether in every case a momentary state of
absence
was involved, but this seems probable in view of the
fact that in her waking state the patient was totally unaware of
what had been going on.
Some of her symptoms, however,
seem not to have emerged in her
absences
but merely in an
affect during her waking life; but if so, they recurred in just the
same way. Thus we were able to trace back all of her different
disturbances of vision to different, more or less clearly
determining causes. For instance, on one occasion, when she was
sitting by her father’s bedside with tears in her eyes, he
suddenly asked her what time it was. She could not see clearly; she
made a great effort, and brought her watch near to her eyes. The
face of the watch now seemed very big - thus accounting for her
macropsia and convergent squint. Or again, she tried hard to
suppress her tears so that the sick man should not see them.
Studies On Hysteria
39
A dispute, in the course of which
she suppressed a rejoinder, caused a spasm of the glottis, and this
was repeated on every similar occasion.
She lost the power of speech
(
a
) as a result of fear, after her first hallucination at
night, (
b
) after having suppressed a remark another time (by
active inhibition), (
c
) after having been unjustly blamed
for something and (
d
) on every analogous occasion (when she
felt mortified). She began coughing for the first time when once,
as she was sitting at her father’s bedside, she heard the
sound of dance music coming from a neighbouring house, felt a
sudden wish to be there, and was overcome with self-reproaches.
Thereafter, throughout the whole length of her illness she reacted
to any markedly rhythmical music with a
tussis nervosa
.
I cannot feel much regret that
the incompleteness of my notes makes it impossible for me to
enumerate all the occasions on which her various hysterical
symptoms appeared. She herself told me them in every single case,
with the one exception I have mentioned; and, as I have already
said, each symptom disappeared after she had described its first
occurrence.
In this way, too, the whole
illness was brought to a close. The patient herself had formed a
strong determination that the whole treatment should be finished by
the anniversary of the day on which she was moved into the country.
At the beginning of June, accordingly, she entered into the
‘talking cure’ with the greatest energy. On the last
day - by the help of re-arranging the room so as to resemble her
father’s sickroom - she reproduced the terrifying
hallucination which I have described above and which constituted
the root of her whole illness. During the original scene she had
only been able to think and pray in English; but immediately after
its reproduction she was able to speak German. She was moreover
free from the innumerable disturbances which she had previously
exhibited. After this she left Vienna and travelled for a while;
but it was a considerable time before she regained her mental
balance entirely. Since then she has enjoyed complete health.
Studies On Hysteria
40
Although I have suppressed a
large number of quite interesting details, this case history of
Anna O. has grown bulkier than would seem to be required for a
hysterical illness that was not in itself of an unusual character.
It was, however, impossible to describe the case without entering
into details, and its features seem to me of sufficient importance
to excuse this extensive report. In just the same way, the eggs of
the echinoderm are important in embryology, not because the sea
urchin is a particularly interesting animal but because the
protoplasm of its eggs is transparent and because what we observe
in them thus throws light on the probable course of events in eggs
whose protoplasm is opaque. The interest of the present case seems
to me above all to reside in the extreme clarity and
intelligibility of its pathogenesis.
There were two psychical
characteristics present in the girl while she was still completely
healthy which acted as predisposing causes for her subsequent
hysterical illness:
(1) Her monotonous family life
and the absence of adequate intellectual occupation left her with
an unemployed surplus of mental liveliness and energy, and this
found an outlet in the constant activity of her imagination.
(2) This led to a habit of
day-dreaming (her ‘private theatre’), which laid the
foundations for a dissociation of her mental personality.
Nevertheless a dissociation of this degree is still within the
bounds of normality. Reveries and reflections during a more or less
mechanical occupation do not in themselves imply a pathological
splitting of consciousness, since if they are interrupted - if, for
instance, the subject is spoken to - the normal unity of
consciousness is restored; nor, presumably, is any amnesia present.
In the case of Anna O., however, this habit prepared the ground
upon which the affect of anxiety and dread was able to establish
itself in the way I have described, when once that affect had
transformed the patient’s habitual day-dreaming into a
hallucinatory
absence
. It is remarkable how completely the
earliest manifestation of her illness in its beginnings already
exhibited its main characteristics, which afterwards remained
unchanged for almost two years. These comprised the existence of a
second state of consciousness which first emerged as a temporary
absence
and later became organized into a ‘
double
conscience
’; an inhibition of speech, determined by the
affect of anxiety, which found a chance discharge in the English
verses; later on, paraphasia and loss of her mother-tongue, which
was replaced by excellent English; and lastly the accidental
paralysis of her right arm, due to pressure, which later developed
into a contractural paresis and anaesthesia on her right side. The
mechanism by which this latter affection came into being agreed
entirely with Charcot’s theory of traumatic hysteria - a
slight trauma occurring during a state of hypnosis.
Studies On Hysteria
41
But whereas the paralysis
experimentally provoked by Charcot in his patients became
stabilized immediately, and whereas the paralysis caused in
sufferers from traumatic neuroses by a severe traumatic shock sets
in at once, the nervous system of this girl put up a successful
resistance for four months. Her contracture, as well as the other
disturbances which accompanied it set in only during the short
absences
in her
condition seconde
, and left her
during her normal state in full control of her body and possession
of her senses; so that nothing was noticed either by herself or by
those around her, though it is true that the attention of the
latter was centred upon the patient’s sick father and was
consequently diverted from her.
Since, however, her absences with
their total amnesia and accompanying hysterical phenomena grew more
and more frequent from the time of her first hallucinatory
auto-hypnosis, the opportunities multiplied for the formation of
new symptoms of the same kind, and those that had already been
formed became more strongly entrenched by frequent repetition. In
addition to this, it gradually came about that any sudden
distressing affect would have the same result as an
absence
(though, indeed, it is possible that such affects actually
caused
a temporary
absence
in every case); chance
coincidences set up pathological associations and sensory or motor
disturbances, which thenceforward appeared along with the affect.
But hitherto this only occurred for fleeting moments. Before the
patient took permanently to her bed she had already developed the
whole assemblage of hysterical phenomena, without anyone knowing
it. It was only after the patient had broken down completely owing
to exhaustion brought about by lack of nourishment, insomnia and
constant anxiety, and only after she had begun to pass more time in
her
condition seconde
than in her normal state, that the
hysterical phenomena extended to the latter as well and changed
from intermittent acute symptoms into chronic ones.
Studies On Hysteria
42
The question now arises how far
the patient’s statements are to be trusted and whether the
occasions and mode of origin of the phenomena were really as she
represented them. So far as the more important and fundamental
events are concerned, the trustworthiness of her account seems to
me to be beyond question. As regards the symptoms disappearing
after being ‘talked away’, I cannot use this as
evidence; it may very well be explained by suggestion. But I always
found the patient entirely truthful and trustworthy. The things she
told me were intimately bound up with what was most sacred to her.
Whatever could be checked by other people was fully confirmed. Even
the most highly gifted girl would be incapable of concocting a
tissue of data with such a degree of internal consistency as was
exhibited in the history of this case. It cannot be disputed,
however, that precisely her consistency may have led her (in
perfectly good faith) to assign to some of her symptoms a
precipitating cause which they did not in fact possess. But this
suspicion, too, I consider unjustified. The very insignificance of
so many of those causes, the irrational character of so many of the
connections involved, argue in favour of their reality. The patient
could not understand how it was that dance music made her cough;
such a construction is too meaningless to have been deliberate. (It
seemed very likely to me, incidentally, that each of her twinges of
conscience brought on one of her regular spasms of the glottis and
that the motor impulses which she felt - for she was very fond of
dancing - transformed the spasm into a
tussis nervosa
.)
Accordingly, in my view the patient’s statements were
entirely trustworthy and corresponded to the facts.
Studies On Hysteria
43
And now we must consider how far
it is justifiable to suppose that hysteria is produced in an
analogous way in other patients, and that the process is similar
where no such clearly distinct
condition seconde
has become
organized. I may advance in support of this view the fact that in
the present case, too, the story of the development of the illness
would have remained completely unknown alike to the patient and the
physician if it had not been for her peculiarity of remembering
things in hypnosis, as I have described, and of relating what she
remembered. While she was in her waking state she knew nothing of
all this. Thus it is impossible to arrive at what is happening in
other cases from an examination of the patients while in a waking
state, for with the best will in the world they can give one no
information. And I have already pointed out how little those
surrounding the present patient were able to observe of what was
going on. Accordingly, it would only be possible to discover the
state of affairs in other patients by means of some such procedure
as was provided in the case of Anna O. by her auto-hypnoses.
Provisionally we can only express the view that trains of events
similar to those here described occur more commonly than our
ignorance of the pathogenic mechanism concerned has led us to
suppose.
When the patient had become
confined to her bed, and her consciousness was constantly
oscillating between her normal and her ‘secondary’
state, the whole host of hysterical symptoms, which had arisen
separately and had hitherto been latent, became manifest, as we
have already seen, as chronic symptoms. There was now added to
these a new group of phenomena which seemed to have had a different
origin: the paralytic contractures of her left extremities and the
paresis of the muscles raising her head. I distinguish them from
the other phenomena because when once they had disappeared they
never returned, even in the briefest or mildest form or during the
concluding and recuperative phase, when all the other symptoms
became active again after having been in abeyance for some time. In
the same way, they never came up in the hypnotic analyses and were
not traced back to emotional or imaginative sources. I am therefore
inclined to think that their appearance was not due to the same
psychical process as was that of the other symptoms, but is to be
attributed to a secondary extension of that unknown condition which
constitutes the somatic foundation of hysterical phenomena.
Studies On Hysteria
44
Throughout the entire illness her
two states of consciousness persisted side by side: the primary one
in which she was quite normal psychically, and the secondary one
which may well be likened to a dream in view of its wealth of
imaginative products and hallucinations, its large gaps of memory
and the lack of inhibition and control in its associations. In this
secondary state the patient was in a condition of alienation. The
fact that the patient’s mental condition was entirely
dependent on the intrusion of this secondary state into the normal
one seems to throw considerable light on at least one class of
hysterical psychosis. Every one of her hypnoses in the evening
afforded evidence that the patient was entirely clear and
well-ordered in her mind and normal as regards her feeling and
volition so long as none of the products of her secondary state was
acting as a stimulus ‘in the unconscious’. The
extremely marked psychosis which appeared whenever there was any
considerable interval in this unburdening process showed the degree
to which those products influenced the psychical events of her
‘normal’ state. It is hard to avoid expressing the
situation by saying that the patient was split into two
personalities of which one was mentally normal and the other
insane. The sharp division between the two states in the present
patient only exhibits more clearly, in my opinion, what has given
rise to a number of unexplained problems in many other hysterical
patients. It was especially noticeable in Anna O. how much the
products of her ‘bad self’, as she herself called it,
affected her moral habit of mind. If these products had not been
continually disposed of, we should have been faced by a hysteric of
the malicious type - refractory, lazy, disagreeable and
ill-natured; but, as it was, after the removal of those stimuli her
true character, which was the opposite of all these, always
reappeared at once.