Sigmund Freud (1856–1939). Selected Papers on Hysteria and Other Psychoneuroses. 1912.
Chapter II. The Case of Miss Lucy R.
T
This young lady visited me from time to time during my office hours—she was a governess in the family of a factory superintendent living in the suburbs of Vienna. She was an English lady of rather delicate constitution, anemic, and with the exception of her nasal trouble was in good health. Her first statements concurred with those of her physician. She suffered from depression and lassitude, and was tormented by subjective sensations of smell. Of hysterical signs, she showed a quite distinct general analgesia without tactile impairment, the fields of vision showed no narrowing on coarse testing with the hand, the nasal mucous membrane was totally analgesic and reflexless, tactile sensation was absent, and the perception of this organ was abolished for specific as well as for other stimuli, such as ammonia or acetic acid. The purulent nasal catarrh was then in a state of improvement.
On first attempting to understand this case the subjective sensations of smell had to be taken as recurrent hallucinations interpreting persistent hysterical symptoms. The depression was perhaps the affect belonging to the trauma and there must have been an episode during which the present subjective sensations were objective. This episode must have been the trauma, the symbols of which recurred in memory as sensations of smell. Perhaps it would be more correct to consider the recurring hallucinations of smell with the accompanying depression as equivalents of hysterical attacks. The nature of recurrent hallucinations really makes them unfit to take the part of continuous symptoms, and this really did not occur in this rudimentarily developed case. On the other hand it was absolutely to be expected that the subjective sensations of smell would show such a specialization as to be able to correspond in its origin to a very definite and real object.
This expectation was soon fulfilled, for on being asked what odor troubled her most she stated that it was an odor of burned pastry. I could then assume that the odor of burned pastry really occurred in the traumatic event. It is quite unusual to select sensations of smell as memory symbols of traumas, but it is quite obvious why these were here selected. She was afflicted with purulent rhinitis, hence the nose and its perceptions were in the foreground of her attention. All I knew about the life of the patient was that she took care of two children whose mother died a few years ago from a grave and acute disease.
As a starting point of the analysis I decided to use the “odor of burned pastry.” I will now relate the history of this analysis. It could have occurred under more favorable conditions, but as a matter of fact what should have taken place in one session was extended over a number of them. She could only visit me during my office hours, during which I could devote to her but little of my time. One single conversation had to be extended for over a week as her duties did not permit her to come to me often from such a distance, so that the conversation was frequently broken off and resumed at the next session.
On attempting to hypnotize Miss Lucy R. she did not merge into the somnambulic state. I therefore was obliged to forego somnambulism and the analysis was made while she was in a state not perhaps differing much from the normal.
I feel obliged to express myself more fully about the point of the technique of my procedure. While visiting the Nancy clinics in 1889 I heard Dr. Liébeault, the old master of hypnotism, say, “Yes, if we had the means to put everybody into the somnambulic state, hypnotism would then be the most powerful therapeutic agent.” In Bernheim’s clinic it almost seemed that such an art really existed and that it could be learned from Bernheim. But as soon as I tried to practice it on my own patients I noticed that at least my powers were quite limited in this respect. Whenever a patient did not merge into the somnambulistic state after one to three attempts I possessed no means to force him into it. However, the percentage of somnambulists in my experience were far below that claimed by Bernheim.
Thus I had my choice, either to forbear using the cathartic method in most of the cases suitable for it, or to venture the attempt without somnambulism by using hypnotic influence in light or even doubtful cases. It made no difference of what degree (following the accepted scales of hypnotism) the hypnotism was which did not correspond to somnambulism, for every direction of suggestibility is independent of the other and nothing is prejudicial towards the evocation of catalepsy, automatic movements and similar phenomena for the purpose of facilitating the awakening of forgotten recollections. I soon relinquished the habit of deciding the degree of hypnotism, as in a great number of cases it incited the patients’ resistance, and clouded the confidence which I needed for the more important psychic work. Moreover, in mild grades of hypnotism I soon tired of hearing, after the assurance and command, “You will sleep, sleep now!” such protests as, “But, Doctor, I am not sleeping.” I was then forced to bring in the very delicate distinction, saying, “I do not mean the usual sleep, I mean the hypnotic,—you see, you are hypnotized, you cannot open your eyes”; or, “I really don’t want you to sleep.” I, myself, am convinced that many of my colleagues using psychotherapy know how to get out of such difficulties more skilfully than I; they can proceed differently. I, however, believe that if through the use of a word one can so frequently become embarrassed, it is better to avoid the word and the embarrassment. Wherever the first attempt did not produce either somnambulism or a degree of hypnotism with pronounced bodily changes, I dropped the hypnosis and demanded only “concentration,” I ordered the patient to lie on his back and close his eyes as a means of reaching this “concentration.” With little effort I obtained as profound a degree of hypnotism as was possible.
But inasmuch as I forebore using somnambulism, I perhaps robbed myself of a preliminary stipulation without which the cathartic method seems inapplicable. For it is based on the fact that in the altered state of consciousness the patients have at their disposal such recollections and recognize such connections which do not apparently exist in their normal conscious state. Wherever the somnambulic broadening of consciousness lacks there must also be an absence of the possibility of bringing about a causal relation which the patient cannot give to the doctor as something known to him, and it is just the pathogenic recollections “which are lacking from the memory of the patients in their usual psychic states or only exist in a most condensed state” (preliminary communication).
My memory helped me out of this embarrassment. I, myself, saw Bernheim adduce proof that the recollections of somnambulism are only manifestly forgotten in the waking state and can be readily reproduced by slight urging accompanied by hand pressure which is supposed to mark another conscious state. He, for instance, imparted to a somnambulist the negative hallucination that he was no more present, and then attempted to make himself noticeable to her by the most manifold and regardless attacks, but was unsuccessful. After the patient was awakened he asked her what he did to her during the time that she thought he was not there. She replied very much astonished, that she knew nothing, but he did not give in, insisting that she would recall everything; and placed his hand on her forehead so that she should recall things, and behold, she finally related all that she did not apparently perceive in the somnambulic state and about which she ostensibly knew nothing in the waking state.
This astonishing and instructive experiment was my model. I decided to proceed on the supposition that my patients knew everything that was of any pathogenic significance, and that all that was necessary was to force them to impart it. When I reached a point where to the question “Since when have you this symptom?” or, “Where does it come from?” I receive the answer, “I really don’t know this,” I proceeded as follows: I placed my hand on the patient’s forehead or took her head between my hands and said, “Under the pressure of my hand it will come into your mind. In the moment that I stop the pressure you will see something before you, or something will pass through your mind which you must note. It is that which we are seeking. Well, what have you seen or what came into your mind?”
On applying this method for the first time (it was not in the case of Miss Lucy R.) I was surprised to find just what I wanted, and I may say that it has since hardly ever failed me, it always showed me the way to proceed in my investigations and enabled me to conclude all such analyses without somnambulism. Gradually I became so bold that when a patient would answer, “I see nothing,” or “Nothing came into my mind,” I insisted that it was impossible. They probably had the right thought but did not believe it and repudiated it. I would repeat the procedure as often as they wished, and every time they saw the same thing. Indeed, I was always right; the patients had not as yet learned to let their criticism rest. They repudiated the emerging recollection or fancy because they considered it as a useless intruding disturbance, but after they imparted it, it was always shown that it was the right one. Occasionally after forcing a communication by pressing the head three or four times I got such answer as, “Yes, I was aware of it the first time, but did not wish to say it,” or “I hoped that it would not be this.”
By this method it was far more laborious to broaden the alleged narrowed consciousness than by investigating in the somnambulic state, and it made me independent of somnambulism and afforded me an insight into the motives which are frequently decisive for the “forgetting” of recollections. I am in position to assert that this forgetting is often intentional and desired. It is always only manifestly successful.
It appeared to me even more remarkable that apparently long forgotten numbers and dates can be reproduced by a similar process, thus proving an unexpected faithfulness of memory.
The insignificant choice which one has in searching for numbers and dates especially allows us to take to our aid the familiar axiom of the theory of aphasia, namely, that recognition is a slighter accomplishment of memory than spontaneous recollection.
Hence to a patient who is unable to recall in what year, month or day a certain event took place, enumerate the years during which it might have occurred as well as the names of the twelve months and the thirty-one days of the month, and assure him that at the right number or name his eyes will open themselves or that he will feel which number is the correct one. In most cases the patients really decide on a definite date and frequently enough (as in the case of Mrs. Cäcilie N.) it could be ascertained from existing notes of that time that the date was correctly recognized. At other times and in different patients it was shown from the connection of the recollected facts that the dates thus found were incontestable. A patient, for instance, after a date was found by enumerating for her the dates, remarked, “This is my father’s birthday,” and added “Of course I expected this episode [about which we spoke] because it was my father’s birthday.”
I can only slightly touch upon this theme. The conclusion which I wished to draw from all these experiences is that the pathogenic important experiences with all their concomitant circumstances are faithfully retained in memory, even where they seem forgotten, as when the patient seems unable to recall them.
After this long but unavoidable digression I now return to the history of Miss Lucy R. As aforesaid, she did not merge into somnambulism when an attempt was made to hypnotize her, but lay calmly in a degree of mild suggestibility, her eyes constantly closed, the features immobile, the limbs without motion. I asked her whether she remembered on what occasion the smell perception of burned pastry originated.—“Oh, yes, I know it well. It was about two months ago, two days before my birthday. I was with the children (two girls) in the school room playing and teaching them to cook, when a letter just left by the letter carrier was brought in. From its postmark and handwriting I recognized it as one sent to me by my mother from Glasgow and I wished to open it and read it. The children then came running over, pulled the letter out of my hand and exclaimed, ‘No you must not read it now, it is probably a congratulatory letter for your birthday and we will keep it for you until then.’ While the children were thus playing there was a sudden diffusion of an intense odor. The children forgot the pastry which they were cooking and it became burned. Since then I have been troubled by this odor, it is really always present but is more marked during excitement.”
“Do you see this scene distinctly before you?”—“As clearly as I experienced it.”—“What was there in it that so excited you?”—“I was touched by the affection which the children displayed towards me.”—“But weren’t they always so affectionate?”—“Yes, but I just got the letter from my mother.”—“I can’t understand in what way the affection of the little ones and the letter from the mother contrasted, a thing which you appear to intimate.”—“I had the intention of going to my mother and my heart became heavy at the thought of leaving those dear children.”—“What is the matter with your mother? Was she so lonesome that she wanted you, or was she sick just then and you expected some news?”—“No, she is delicate but not really sick, and has a companion with her.”—“Why then were you obliged to leave the children?”—“This house had become unbearable to me. The housekeeper, the cook, and the French maid seemed to be under the impression that I was too proud for my position. They united in intriguing against me and told the grandfather of the children all sorts of things about me, and when I complained to both gentlemen I did not receive the support which I expected. I then tendered my resignation to the master (father of the children) but he was very friendly, asking me to reconsider it for two weeks before taking any definite steps. It was while I was in that state of indecision that the incident occurred. I thought that I would leave the house but have remained.”—“Aside from the attachment of the children is there anything particular which attracts you to them?”—“Yes, my mother is distantly related to their mother and when the latter was on her death bed I promised her to do my utmost in caring for the children, that I would not forsake them, and be a mother to them, and this promise I broke when offering my resignation.”
The analysis of the subjective sensation of smell seemed completed. It was once objective and intimately connected with an experience, a small scene, in which contrary affects conflicted, sorrow at forsaking the children, and the mortification which despite all urged her to this decision. Her mother’s letter naturally recalled the motives of this decision because she thought of returning to her mother. The conflict of the affects raised this moment to a trauma and the sensation of smell which was connected with it remained as its symbol. The only thing to be explained was the fact that out of all the sensory perceptions of that scene, the perception of smell was selected as the symbol, but I was already prepared to use the chronic nasal affliction as an explanation. On being directly questioned she stated that just at that time she suffered from a severe coryza and could scarcely smell anything but in her excitement she perceived the odor of burned pastry, it penetrated the organically motived anosmia.
As plausible as this sounded it did not satisfy me; there seemed to be something lacking. There was no acceptable reason wherefore this series of excitements and this conflict of affects should have led to hysteria. Why did it not all remain on a normal psychological basis? In other words, what justified the conversion under discussion? Why did she not recall the scenes themselves instead of the sensations connected with them which she preferred as symbols for her recollection? Such questions might seem superfluous and impertinent when dealing with old hysterias in whom the mechanism of conversion was habitual, but this girl first acquired hysteria through this trauma, or at least through this slight distress.
From the analysis of similar cases I already knew that where hysteria is to be newly acquired one psychic determinant is indispensable; namely, that some presentation must intentionally be repressed from consciousness and excluded from associative elaboration.
In this intentional repression I also find the reason for the conversion of the sum of excitement, be it partial or total. The sum of excitement which is not to enter into psychic association more readily finds the wrong road to bodily innervation. The reason for the repression itself could only be a disagreeable feeling, the incompatibility of one of the repressible ideas with the ruling presentation-mass of the ego. The repressed presentation then avenges itself by becoming pathogenic.
From this I concluded that Miss Lucy R. merged into that moment of hysterical conversion, which must have been under the determinations of that trauma which she intentionally left in the darkness and which she took pains to forget. On considering her attachment for the children and her sensitiveness towards the other persons of the household, there remained but one interpretation which I was bold enough to impart to her. I told her that I did not believe that all these things were simply due to her affection for the children, but that I thought that she was rather in love with her master, perhaps unwittingly, that she really nurtured the hope of taking the place of the mother, and it was for that reason that she became so sensitive towards the servants with whom she had lived peacefully for years. She feared lest they would notice something of her hope and scoff at her.
She answered in her laconic manner: “Yes, I believe it is so.”—“But if you knew that you were in love with the master, why did you not tell me so?”—“But I did not know it, or rather, I did not wish to know it. I wished to crowd it out of my mind, never to think of it, and of late I have been successful.”
“Why did you not wish to admit it to yourself? Were you ashamed because you loved a man?”—“O, no, I am not unreasonably prudish; one is certainly not responsible for one’s own feelings. I only felt chagrined because it was my employer in whose service I was and in whose house I lived, and toward whom I could not feel as independent as towards another. What is more, I am a poor girl and he is a rich man of a prominent family, and if anybody should have had any inkling about my feelings they would have ridiculed me.”
After this I encountered no resistances in elucidating the origin of this affection. She told me that the first years of her life in that house were passed uneventfully. She fulfilled her duties without thinking about unrealizable wishes. One day, however, the serious, and very busy and hitherto very reserved master, engaged her in conversation about the exigencies of rearing the children. He became milder and more cordial than usual, he told her how much he counted on her in the bringing up of his orphaned children, and looked at her rather peculiarly. It was in this moment that she began to love him, and gladly occupied herself with the pleasing hopes which she conceived during that conversation. However, as this was not followed by anything else, and despite her waiting and persevering no other confidential heart-to-heart talk followed, she decided to crowd it out of her mind. She quite agreed with me that the look in connection with the conversation was probably intended for the memory of his deceased wife. She was also perfectly convinced that her love was hopeless.
After this conversation I expected a decided change in her condition but for a time it did not take place. She continued depressed and moody—a course of hydrotherapy which I ordered for her at the same time refreshed her somewhat mornings. The odor of burned pastry did not entirely disappear; though it became rarer and feebler it appeared only, as she said, when she was very much excited.
The continuation of this memory symbol led me to believe that besides the principal scene it represented many smaller side traumas and I therefore investigated everything that might have been in any way connected with the scene of the burned pastry. We thus passed through the theme of family friction, the behavior of the grandfather and others, and with that the sensation of burned odor gradually disappeared. Just then there was a lengthy interruption occasioned by a new nasal affliction which led to the discovery of the caries of the ethmoid.
On her return she informed me that she received many Christmas presents from both gentlemen as well as from the household servants, as if they were trying to appease her and wipe away the recollection of the conflicts of the last months. These frank advances made no impression on her.
On questioning her on another occasion about the odor of burned pastry she stated that it had entirely disappeared, but instead she was now bothered by another and similar odor like the smoke of a cigar. This odor really existed before; it was only concealed by the odor of the pastry but now appeared by itself.
I was not very much pleased with the success of my treatment. What occurred here is what a mere symptomatic treatment is generally blamed for, namely, that it removes one symptom only to make room for another. Nevertheless, I immediately set forth to remove this new memory symbol by analysis.
This time I did not know whence this subjective sensation of smell originated, nor on what important occasion it was objective. On being questioned she said, “They constantly smoke at home, I really don’t know whether the smell which I feel has any particular significance.” I then proposed that she should try to recall things under the pressure of my hands. I have already mentioned that her recollections were plastically vivid, that she was a “visual.” Indeed under the pressure of my hands a picture came into her mind—at first only slowly and fragmentarily. It was the dining room of the house in which she waited with the children for the arrival of the gentlemen from the factory for dinner.—“Now we are all at the table, the gentlemen, the French maid, the housekeeper, the children and I. It is the same as usual.”—“Just keep on looking at that picture. It will soon become developed and specialized.”—“Yes, there is a guest, the chief accountant, an old gentleman who loves the children like his own grandchildren, but he dines with us so frequently that it is nothing unusual.”—“Just have patience, keep on looking at the picture, something will certainly happen.”—“Nothing happens. We leave the table, the children take leave and go with us up to the second floor as usual.”—“Well?”—“It really is something unusual, I now recognize the scene. As the children take leave the chief accountant attempts to kiss them, but my master jumps up and shouts at him, ‘Don’t kiss the children!’ I then experienced a stitch in the heart, and as the gentlemen were smoking, this odor remained in my memory.”
This, therefore, was the second, deeper seated scene causing the trauma and leaving the memory symbol. But why was this scene so effective? I then asked her which scene happened first, this one or the one with the burned pastry?—“The last scene happened first by almost two months.”—“Why did you feel the stitch at the father’s interference? The reproof was not meant for you.”—“It was really not right to rebuke an old gentleman in such manner who was a dear friend and a guest; it could have been said quietly.”—“Then you were really affected by your master’s impetuosity? Were you perhaps ashamed of him, or have you thought, ‘If he could become so impetuous to an old friend guest over such a trifle, how would he act towards me if I were his wife?’”—“No, that is not it.”—“But still it was about his impetuosity?”—“Yes, about the kissing of the children; he never liked that.” Under the pressure of my hands there emerged a still older scene which was the real effective trauma and which bestowed on the scene with the chief accountant the traumatic effectivity.
A few months before a lady friend visited the house and on leaving kissed both children on the lips. The father, who was present, controlled himself and said nothing to the lady, but when she left he was very angry at the unfortunate governess. He said that he held her responsible for this kissing; that it was her duty not to tolerate it; that she was neglecting her duties in allowing such things, and that if it ever happened again he would entrust the education of his children to some one else. This occurred while she believed herself loved and waited for a repetition of that serious and friendly talk. This episode shattered all her hopes. She thought: “If he can upbraid and threaten me on account of such a trifle, of which I am entirely innocent, I must have been mistaken, he never entertained any tenderer feelings towards me, else he would have been considerate.”—It was evidently this painful scene that came to her as the father reprimanded the chief accountant for attempting to kiss the children.
On being visited by Miss Lucy R. two days after the last analysis I had to ask her what pleasant things happened to her. She looked as though transformed, she smiled and held her head aloft. For a moment I thought that after all I probably mistook the conditions and that the governess of the children had now become the bride of the master. But she soon dissipated all my suppositions, saying, “Nothing new happened. You really do not know me. You have always seen me while I was sick and depressed. I am otherwise always cheerful. On awaking yesterday morning my burden was gone and since then I feel well.”—“What do you think of your chances in the house?”—“I am perfectly clear about that. I know that I have none, and I am not going to be unhappy about it.”—“Will you now be able to get along with the others in the house?”—“I believe so, because most of the trouble was due to my sensitiveness.”—“Do you still love the master?”—“Certainly I love him, but that does not bother me much. One can think and feel as one wishes.”
I now examined her nose and found that the pain and the reflex sensations had almost completely reappeared. She could distinguish odors, but she was uncertain when they were very intense. What part the nasal trouble played in the anosmia I must leave undecided.
The whole treatment extended over a period of nine weeks. Four months later I accidentally met the patient at one of our summer resorts—she was cheerful and stated that her health continued to be good.
I would not underestimate the aforesaid case even though it only represents a young and light hysteria presenting but few symptoms. Moreover, it seems to me instructive that even such a slight neurotic affliction requires so many psychic determinants, and on a more exhaustive consideration of this history I am tempted to put it down as an illustration of that form of hysteria which even persons not burdened by heredity may acquire if their experiences favor it. It should be well noted that I do not speak of a hysteria which may be independent of all predisposition; such form does not probably exist, but we speak of such a predisposition only after the person became hysterical, as nothing pointed to it before this. A neuropathic disposition as commonly understood is something different. It is determined even before the disease by a number of hereditary burdens, or a sum of individual psychic abnormalities. As far as I know none of these moments could be demonstrated in the case of Miss Lucy R. Her hysteria could therefore be called acquired and presupposes nothing except probably a very marked susceptibility to acquire hysteria, a characteristic about which we know hardly anything. The chief importance in such cases lies in the nature of the trauma, to be sure in connection with the reaction of the person to the trauma. It is an indispensable condition for the acquirement of hysteria that there should arise a relation of incompatibility between the ego and some of its approaching presentations. I hope to be able to show in another place how a variety of neurotic disturbances originate from the different procedures which the “ego” pursues in order to free itself from that incompatibility. The hysterical form of defence, for which a special adaptation is required, consists in converting the excitement into physical innervation. The gain brought about by this process is the crowding out of the unbearable presentation from the ego consciousness, which then contains instead the physical reminiscences produced by conversion—in our case the subjective sensation of smell—and suffers from the affect which is more or less distinctly adherent to these reminiscences. The situation thus produced is no longer changeable, for changing and conversion annihilate the conflict which helped towards the adjustment of the affect. Thus the mechanism producing hysteria corresponds on the one hand to an act of moral faint heartedness; on the other hand it presents itself as a protective arrangement at the command of the ego. There are many cases in which it must be admitted that the defense of the increased excitement through the production of hysteria may actually have been most expedient, but more frequently one will naturally come to the conclusion that a greater measure of moral courage would have been an advantage to the individual.
Accordingly the real traumatic moment is that in which the conflict thrusts itself upon the ego and the latter decides to banish it. Such banishment does not annihilate the opposing presentation but merely crowds it into the unconscious. This process, occurring for the first time, forms a nucleus and point of crystallization for the formation of a new psychic group separated from the ego, around which, in the course of time, everything collects in accord with the opposing presentation. The splitting of consciousness in such cases of acquired hysteria is thus a desired and intentional one, and is often initiated by at least one arbitrary act. But literally, something different happens than the individual expects, he would wish to eliminate a presentation as though it never came to pass but only succeeds in isolating it psychically.
The traumatic moment in the history of our patient corresponds to the scene created by the master on account of the kissing of the children. For the time being this scene remained without any palpable effects; perhaps it initiated the depression and sensitiveness, but I leave this open;—the hysterical symptoms, however, commenced later in moments which can be designated as “auxiliary,” and which may be characterized by the fact that in them there is a simultaneous flowing together of both separated groups just as in the broadened somnambulic consciousness. The first of these moments in which the conversion took place in Miss Lucy R., was the scene at the table when the chief accountant attempted to kiss the children. The traumatic memory helped along, and she acted as though she had not entirely banished her attachment for her master. In other cases we find that these different moments come together and the conversion occurs directly under the influence of the trauma.
The second auxiliary moment repeated almost precisely the mechanism of the first. A strong impression transitorily re-established the unity of consciousness and the conversion takes the same route opened to it in the first. It is interesting to note that the symptom occurring second concealed the first so that it could not be distinctly perceived until the second was eliminated. The reversal of the succession of events to which also the analysis must be adapted seems to me quite remarkable. In a whole series of cases I found that the symptoms which came later covered the first, and only the last thing in the analysis contained the key to the whole.
The therapy here consisted in forcing the union of the dissociated psychic groups with the ego consciousness. It is remarkable that the success did not run parallel with the accomplished work, the cure resulted suddenly only after the last part was accomplished.