CHAPTER III.

THE CASE OF MISS ELISABETH V. R.

In the fall of 1892 I was requested by a friendly colleague to examine a

young lady who had suffered from pains in her legs for over two years

and who walked badly. He also added that he diagnosed the case as

hysteria, though none of the usual symptoms of the neurosis could be

found. He stated that he knew something of the family and that the last

few years had brought them much misfortune and little pleasure. At first

the father of the patient died, then the mother underwent a serious

operation for the eyes, and soon thereafter a married sister succumbed

to a chronic cardiac affection after childbirth. Our patient had taken

an active part in all the afflictions and in all the nursings of the

sick. I made no further progress into the case after I had seen the

twenty-four-year-old patient for the first time. She seemed intelligent

and psychically normal and her affliction, which interfered with her

social relations and pleasure, she bore with a happy mien, thus vividly

recalling the “belle indifference” of hysterics. She walked with the

upper part of her body bent forward, but without any support; her gait

did not correspond to any known pathological gait and it was in no way

strikingly bad. She complained of severe pains on walking, of early

fatigue in walking as well as standing, and after a brief period she

would seek rest in which the pains became diminished but they by no

means disappeared. The pain was of an indefinite nature—one could assume

it to be a painful fatigue. The seat of the pain was given as a quite

extensive but indefinitely circumscribed location on the superficial

surface of the right thigh. It was from this area that the pains

radiated and where they were of the greatest intensity. Here, too, the

skin and muscles were especially sensitive to pressure and pinching,

while needle pricks were rather indifferently perceived. The same

hyperalgesia of the skin and muscles was demonstrable, not only in this

area, but over almost the entire surface of both legs. The muscles were

perhaps more painful than the skin, but both kinds of pains were

unmistakably most pronounced over the thighs. The motor power of the

legs was not diminished, the reflexes were of average intensity and all

other symptoms were lacking, so that there was no basis for the

assumption of a serious organic affection. The disease developed

gradually during two years and changed considerably in its intensity.

I did not find it easy to determine the diagnosis, but for two reasons I

concluded to agree with my colleague. First, because it was rather

peculiar that such a highly intelligent patient should not be able to

give anything definite about the character of her pains. A patient

suffering from an organic pain, if it is not accompanied by any

nervousness will be able to describe it definitely and calmly; it may

perhaps be lancinating, appearing at certain intervals, extending from

this to that location, and in his opinion it may be evoked by this or

that influence. The neurasthenic describing his pain gives the

impression of being occupied with some difficult mental problem reaching

far beyond his powers. His features are tense and distorted as though

under the domination of a painful affect, his voice becomes shriller, he

struggles for expression, he rejects all designations that the physician

makes for his pains, even though they are undoubtedly afterwards found

as appropriate. He is ostensibly of the opinion that language is too

poor to give expression to his feelings. His sensations are something

unique, they never existed before so that they can not be exhaustively

described. He never tires of constantly adding new details and when he

has to stop he is surely controlled by the impression that he was

unsuccessful in making himself understood to the physician. All this is

due to the fact that his pains absorb his whole attention. In the case

of Miss v. R. we had just the opposite behavior and we had to conclude

from this that she attributed sufficient significance to the pain, but

that her attention was concentrated on something else of which the pains

were the accompanying phenomena, perhaps on thoughts and sensations

which were connected with the pain.

A still greater determination for the conception of the pain must

however, be found in a second moment. If we irritate a painful area in a

patient suffering from an organic disease or neurasthenia his

physiognomy will show a definite expression of discomfort or of physical

pain. Furthermore, the patient winces, refuses to be examined and

assumes a defensive attitude. With Miss v. R. when the hyperalgesic skin

or muscles of her legs were pinched or pressed her face assumed a

peculiar expression approaching nearer pleasure than pain, she cried out

and—I had to think of a pleasurable tickling—her face reddened, she

threw her head backward, closed her eyes, and her body bent backward;

all this was not very distinct but sufficiently marked so that it could

only agree with the conception that her affliction was a hysteria and

that the irritation touched a hysterogenic zone.

Her mien was not in accord with the pain which the pinching of the

muscles and skin were supposed to excite. It probably harmonized better

with the content of the thoughts which were behind the pain and which

were evoked in the patient by irritating that part of the body

associated with them. I have repeatedly observed similar significant

expressions on irritating hyperalgesic zones in unmistakable cases of

hysteria. The other gestures evidently corresponded to the slightest

indications of a hysterical attack.

We could not at that time find any explanation for the unusual

localization of the hysterogenic zone. That the hyperalgesia chiefly

concerned the muscles gave material for reflection. The most frequent

affliction causing the diffuse and local pressure sensitiveness of the

muscles is the rheumatic infiltration of the same, the common chronic

muscular rheumatism about which aptitude to mask nervous affections I

have already spoken. The consistency of the painful muscles in Miss v.

R. did not contradict this assumption, as there were many hard cords in

the muscle masses which seemed to be especially sensitive. There was

probably also an organic change in the muscles, in the assumed sense,

upon which the neurosis rested and which significance was markedly

exaggerated by the neurosis.

The therapy followed out was based on a supposition of a mixed

affection. We recommended the continuation of a systematic massage and

faradization of the sensitive muscles without regard to the pain

produced, and in order to remain in communication with the patient I

undertook the treatment of her legs by means of strong Franklin’s

sparks. To her question whether she should force herself to walk we

answered decidedly in the affirmative.

We thus attained a slight improvement. She particularly liked the

painful shocks of the influence machine and the stronger they were the

more they seemed to suppress her pains. My colleague meanwhile prepared

the soil for the psychic treatment, and when after four weeks of sham

treatment I proposed the same and gave the patient some explanations

concerning the procedures and its effects I found a ready understanding

and only slight resistances.

The work which then began became eventually the most arduous that ever

befell my lot, and the difficulty of giving an account of this work

ranks well with the obstacles that had to be overcome. For a long time,

too, I did not understand the connection between the history of the

disease and the affliction, a thing which should really have been caused

and determined by this row of events.

When one undertakes a cathartic treatment he at first asks himself

whether the patient understands the origin and cause of her suffering.

If that is so one does not need any special technique to cause her to

reproduce the history of her ailment. The interest shown in her, the

understanding which we foreshadow, the hope of recovery extended to her,

all these will induce the patient to give up her secrets. With Miss

Elisabeth it seemed probable to me right from the very beginning that

she was conscious of the reasons for her suffering, that she had only a

secret but no foreign body in consciousness. On looking at her one had

to think of the poet’s words,

“That mask indicates a hidden meaning.”[16]

At first I could thus forego hypnosis, reserving it, however, for future

use if in the course of the confession conditions should arise for which

explanation the memory would not perhaps suffice. Thus in this first

complete analysis of a hysteria which I had undertaken, I reached a

process of treatment which later I raised into a method and employed it

consciously in the process of removing by strata the pathogenic psychic

material which we used to compare with the technique of excavating a

buried city. I at first allowed the patient to relate to me what was

known to her, paying careful attention wherever a connection remained

enigmatical or where a link in the chain of causation seemed to be

lacking. Later I penetrated into the deeper strata of memory by using

for those locations hypnotic investigation or a similar technique. The

presupposition of the whole work was naturally the expectation that a

perfect and sufficient determination could be demonstrated. The means of

the deeper investigation will soon be discussed.

The history which Miss Elisabeth gave was very dull and was woven of

manifold painful experiences. During this recital she was not in a

hypnotic state; I merely asked her to lie down and keep her eyes closed.

I however made no objection if she from time to time opened her eyes,

changed her position or sat up. Whenever she entered more deeply into a

part of her history she seemed to merge spontaneously into a condition

resembling a hypnotic state. She then remained motionless and kept her

eyes firmly closed.

I shall now reproduce the results of the superficial strata of her

memory. As the youngest of three daughters she spent her youth with her

parents, to whom she was devotedly attached, on their estate in Hungary.

Her mother’s health was frequently disturbed by an affliction of her

eyes and also by nervous conditions. It thus happened that she became

especially and devotedly attached to her jovial and broadminded father

who was wont to say that this daughter took the place of both a son and

friend with whom he could exchange his thoughts. As much as the girl

gained in mental stimulation in consequence of this intercourse it did

not escape the father that her psychic constitution deviated from that

ideal which one so much desires to see in a girl. Jocosely he called her

pert and disputatious. He warned her against being too confident in her

judgments, against her tendencies to tell the truth regardlessly to

everybody, and expressed his opinion that she would find it difficult to

get a husband. As a matter of fact she was very discontented with her

girlhood; she was filled with ambitious plans, wishing to study or

obtain a musical education, and revolted at the thought of being forced

to give up her inclination to sacrifice her freedom of judgment on

account of marriage. Meanwhile she was proud of her father, of the

regard and social position of her family, and jealously guarded

everything connected with these matters. The indifference with which she

treated her mother and older sisters, as will be shown, was considered

by her parents to be due to the blunter side of her character.

The age of the girls impelled the family to move into the metropolis,

where for a time Elisabeth enjoyed the richer and gayer life. But then

came the calamity which destroyed the happiness of the home. The father

either concealed or overlooked a chronic cardiac affection, and one day

he was brought home in an unconscious state after the first attack of

edema of the lungs. This was followed by an illness of one and a half

years, during which Elisabeth took the most prominent part in nursing

him. She slept in her father’s room, awoke at night at his call, watched

over him faithfully during the day, and forced herself to appear

cheerful while he went through a hopeless condition with amiable

resignation. The beginning of her affection must have been connected

with this time of her nursing, for she could recall that during the last

half year of this care she had to remain in bed on one occasion for a

day and a half on account of severe pain in the leg. She maintained,

however, that these pains soon passed away and excited neither worry nor

attention. As a matter of fact it was two years after the death of her

father that she began to feel sick and became unable to walk on account

of pain.

The gap which the father left in the life of this family consisting of

four women, the social solitude, the cessation of so many relations

which promised stimulation and pleasure, the increased infirmity of the

mother, all these clouded the mood of our patient, but simultaneously

stimulated a warm desire that the family might soon find a substitute

for the lost happiness and urged her to concentrate her entire devotion

and care on the surviving mother. At the end of the mourning year the

eldest sister married a talented and ambitious man of notable position,

who by his mental capacity seemed to be destined for a great future, but

who, however, very soon developed a morbid sensitiveness and egotistic

perseveration of moods, and dared to show his disregard for the old lady

in the family circle. That was more than Elisabeth could endure. She

felt herself called upon to take up the fight against her brother-in-law

whenever he gave occasion for it, while the other women took lightly the

outburst of his excited temperament. To her it was a painful

disillusionment to find that the reconstruction of the old family

happiness experienced such a disturbance. She could not forgive her

married sister because with feminine docility she strove to avoid

espousing her cause. Thus a whole series of scenes remained in

Elisabeth’s memory to which were attached a number of partially uttered

grievances against her first brother-in-law. But what she reproached him

most for was the fact that for the sake of a promotion in view he moved

with his small family to a distant city in Austria and thus increased

the lonesomeness of her mother. On this occasion Elisabeth distinctly

felt her inability and helplessness to afford her mother a substitute

for the lost happiness, and the impossibility of following out the

resolution made at the death of her father.

The marriage of the second sister seemed to promise more for the future

of the family. The second brother-in-law, although not of the same

mental calibre as the first, was a man after the heart of delicate

ladies, and his behavior reconciled Elisabeth to the matrimonial

institution and to the thought of the sacrifice connected with it. What

is more the second couple remained near her mother, and the child of

this brother-in-law and the second sister became Elisabeth’s pet.

Unfortunately the year during which the child was born was clouded by

another event. The visual affliction of the mother demanded many weeks’

treatment in a dark room, in which Elisabeth participated. Following

this an operation proved necessary and the excitement connected with

this occurred at the same time that the first brother-in-law made

preparations to move. Finally the operation, skilfully performed, proved

successful, and the three families met at a summer resort. There

Elisabeth, exhausted by the worries of the past months, had the first

opportunity to recuperate from the effects of the suffering and anxiety

that the family had undergone since the death of her father.

But during the time spent at this resort Elisabeth was attacked by the

pain and weakness. Afterwards, the pains, which had become noticeable

for a short while some time previously, manifested themselves severely

for the first time after taking a warm bath at a small watering place.

In connection with this it was thought that a long walk, really a walk

of half a day, a few days, previously, had some connection with the

onset of the pains. This readily produced the impression that Elisabeth

at first became “fatigued” and then “caught cold.”

From this time on Elisabeth became the patient in the family. Following

the advice of the physician she spent the rest of the summer in the

watering place at Gastein, whither she went with her mother, but not

without having a new worriment to think about. The second sister was

again pregnant and information as to her condition was quite

unfavorable, so that Elisabeth could hardly decide to take the journey

to Gastein. After barely two weeks at Gastein both mother and sister

were recalled as the patient at home did not feel well.

An agonizing journey, which for Elisabeth was a mixture of pain and

anxious expectations, was followed by certain signs at the home railroad

station which forebode the worst, and then on entering the chamber of

the patient they were confronted with the reality—that they arrived too

late to take leave of the dying one.

Elisabeth not only suffered from the loss of this sister whom she dearly

loved but was also grieved by the thoughts caused by her death and the

changes which it caused. The sister had succumbed to heart trouble which

was aggravated by the pregnancy.

She then conceived the thought that the heart trouble was the paternal

inheritance. It was then recalled that in her early childhood the

deceased went through an attack of chorea with a slight heart affection.

The family then blamed themselves and the physicians for permitting the

marriage. They could not spare reproaches to the unfortunate widower for

impairing the health of his wife by two successive pregnancies without

any pause. The sad thought that this happiness should terminate thus,

after the rare conditions for a happy marriage had been found,

thereafter constantly occupied Elisabeth’s mind. Moreover, she again saw

everything fail that she had planned for her mother. The widowed

brother-in-law was inconsolable and withdrew from his wife’s family. It

seemed that his own family from whom he was estranged during his short

and happy married life took advantage of the opportunity to again draw

him into their own circle. There was no way of maintaining the former

union; to live together with the mother-in-law was improper out of

regard for the unmarried sister-in-law, and inasmuch as he refused to

relinquish the child, the only legacy of the deceased, to the two

ladies, he for the first time gave them the opportunity of accusing him

of heartlessness. Finally, and that was not the least painful thing,

Elisabeth received some indefinite information concerning a disagreement

between the two brothers-in-law, the occasion for which she could only

surmise. It seemed as if the widower made some requests concerning

financial matters which the other brother-in-law considered

unjustifiable, and thought, that in view of the recent sorrow of his

mother, it was nothing but an evil extortion. This then was the history

of the young woman of ambitious and loving disposition. Resentful of her

fate, embittered over the failures of her little plans to restore the

lustre of the home; of her beloved ones, some being dead, some away, and

some estranged— without any inclination to seek refuge in the love of a

strange man, she lived thus for a year and a half nursing her mother and

her pains, separated from almost, all social intercourse.

If we forget the greater sufferings and place ourselves in this girl’s

position, we can but extend to Miss Elisabeth our hearty sympathy. But

what is the physician’s interest in this sorrowful tale; what is its

relation to her painful and her weak gait; what outlook is there for

explaining and curing this case by the knowledge which we perhaps

obtained from these psychic traumas?

For the physician this confession of the patient signified at first a

great disappointment, for to be sure it was a history composed of banal

mental shocks from which we could neither explain why the patient became

afflicted with hysteria nor how the hysteria assumed the form of the

painful abasia. It explained neither the causation nor the determination

of the hysteria in question. We could perhaps assume that the patient

had formed an association between her psychically painful impressions

and bodily pains which she accidentally perceived simultaneously, and

that now she made use in her memory of the physical sensation as a

symbol for the psychic. What motive she had for this substitution and in

what moment this came about remained unexplained. To be sure, these were

questions whose nature was not familiar to the physicians. For it was

customary to content one’s self with the information and to assume that

the patient was constitutionally hysterical and that under the intensive

pressure of any kind of excitement hysterical symptoms could develop.

Even less than for the explanation did this confession offer for the

treatment of the case. One could not conceive what beneficial influence

Miss Elisabeth could derive from recounting sad familiar family

experiences of the past years to a stranger who could give her in return

only moderate sympathy, nor could we perceive any improvement after the

confession. During the first period of the treatment the patient never

failed to repeat to her physician: “I continue to feel ill, I have the

same pains as before,” and when she accompanied this by a crafty and

malicious glance, I could perhaps recall the words which old Mr. v. R.

was wont to utter concerning his favorite daughter: “She is frequently

pert and disputatious,” but after all I had to confess that she was

right.

Had I given up the patient at this stage of the psychic treatment the

case of Miss Elisabeth v. R. would have been quite unimportant for the

theory of hysteria. Nevertheless, I continued my analysis because I felt

sure that an understanding of the causation as well as the determination

of the hysterical symptoms could be gained from the deeper strata of

consciousness.

I therefore decided to put the direct question to the broadened

consciousness of the patient, in order to find out with what psychic

impression the origin of the pain in the legs was connected.

For this purpose the patient should have been put in deep hypnosis. But

unhappily I had to realize that all my procedures in that direction

could put the patient in no other state of consciousness than that in

which she gave me her confession. Still I was very pleased that this

time she abstained from triumphantly remonstrating with the words: “You

see, I really do not sleep, I cannot be hypnotized.” In such despair I

conceived the idea of making use of the trick of pressing the head, the

origin of which I have thoroughly discussed in the preceding

contribution concerning Miss Lucy. This was done by requesting the

patient to unfailingly inform me of what came before her mind’s eye or

passed through her memory at the moment of the pressure. For a long time

she was silent, and then admitted that on my pressure she thought of an

evening in which a young man had accompanied her home from some social

affair. She also thought of the conversation that passed between them,

and her feelings on returning home to nurse her father.

With this first mention of the young man a new shaft was opened, the

content of which I now gradually brought out. We dealt here rather with

a secret, for with the exception of a mutual friend, no one knew

anything of the relation and the hopes connected with it. It concerned

the son of an old friend who was formerly one of their neighbors. The

young man having become an orphan attached himself with great devotion

to her father; he was guided in his career by his advice, and this

veneration for the father was extended to the ladies of the family.

Numerous reminiscences of repeated joint readings, exchange of thoughts

and utterances on his side marked the gradual growth of her conviction

that he loved and understood her and that a marriage with him would not

impose the sacrifice that she feared. Unhappily he was but little older

than she and as yet was far from being independent. She however firmly

resolved to wait for him.

With the serious illness of her father, and the necessity of her nursing

him their relations became less frequent. The evening which she at first

recalled marked the height of her feeling, but even then there was no

exchange of ideas between them on the subject. It was only at the urging

of her family that she consented to leave the sick bed that evening and

go to an affair where she was to meet him. She wished to hasten home

early but was forced to remain, only yielding on his promising to

accompany her home. At no time had she entertained such a tender regard

for him as during this walk, but after returning home at a late hour in

this blissful state and finding the condition of her father aggravated

she bitterly reproached herself for having sacrificed so much time for

her own amusement. It was the last time that she left her sick father

for a whole evening; her friend she saw but seldom after this. After the

death of her father he seemed to hold himself aloof out of respect for

her sorrow and then business affairs drew him into other spheres.

Gradually she came to the realization that his interest in her was

suppressed by other feelings and that he was lost to her. This failure

of her first love pained her as often as she thought of it.

In this relationship and in the scene caused by it, I was to seek the

causation of the first hysterical pain. A conflict, or a state of

incompatibility arose through the contrast between the happiness which

she had not at that time denied herself and the sad condition in which

she found her father upon her arrival home. As a result of this conflict

the erotic presentations were repressed from the associations, and the

affect connected with them was made use of in aggravating or reviving a

simultaneously (or somewhat previously) existing physical pain. It was

therefore the mechanism of a conversion for the purpose of defense as I

have shown circumstantially in another place.[17]

To be sure, we have room here for all kinds of observations. I must

assert that I was unsuccessful in demonstrating from her memory that the

conversion took place in the moment of her returning home. I therefore

investigated for similar experiences which might have occurred while she

was nursing her father, and I evoked a number of scenes, among which was

one during which she had to jump out of bed with bare feet in a cold

room to respond to the repeated calls of her father. I was inclined to

attribute to this moment a certain significance, for in addition to

complaining of pain in her legs she also complained of tormenting

sensations of coldness. Nevertheless, here, too I could not with

certainty lay hold of the scene which could be indicated as the scene of

conversion. This led me to admit that there was here some gap, when I

recalled the fact that the hysterical pains in the legs were really not

present at the time she nursed her father. From her memory she recalled

only a single attack of pain lasting a few days to which at that time

she paid no attention. I then directed my attention to the first

appearance of the pains. In this respect I was successful in awakening a

perfect memory. They came on just at the time of a relative’s visit whom

she could not receive because she was ill in bed, and who had the

misfortune to find her ill in bed on another occasion two years later.

But the search for the psychic motive of these first pains failed as

often as repeated. I believed that I could assume that these first pains

were due to a slight rheumatic attack and really had no psychic basis,

and I also discovered that this organic trouble was the model for the

later hysterical imitation, at all events that it occurred before the

scene of being accompanied home. That these mild organic pains could

continue for some time without her paying much attention to them is

quite possible when we consider the nature of the disease. The obscurity

resulting from this, namely, that the analysis pointed to a conversion

of psychic excitement into bodily pain at a time when such pain was

certainly not perceived and not recalled—this problem I hope to be able

to solve in later considerations and by other examples.[18]

With the discovery of the motive for the first conversion we began a

second more fruitful period of the treatment. In the first place very

soon afterward the patient surprised me with the statement that she now

knew why the pains always radiated from that definite location on the

right thigh and were most painful there. This is really the place upon

which her father’s leg rested every morning while she changed the

bandages of his badly swollen leg. That occurred hundreds of times, and

strange to say she did not think of this connection until today. She

thus gave me the desired explanation of the origin of an atypical

hysterogenic zone. Furthermore during our analysis her painful legs

always commenced to “join in the discussion.” I mean the following

remarkable state of affairs: The patient was as a rule free from pain

when we began our work, but as soon as I evoked some recollection by

question or by pressure of the head she at first reported some pain

usually of a very vivid nature, and then winced and placed her hand on

the painful area. This awakened pain remained constant as long as the

patient was controlled by the recollection, reaching its height when she

was about to utter the essential and critical part of her communication,

and disappearing with the last words of the statement. I gradually

learned to use this awakened pain as a compass. Whenever she was moody

or claimed to have pains I knew that she had not told me everything, and

urged a continuation of the confession until the pain was “spoken away.”

Then only did I awaken a new recollection.

During this period of ab-reaction, the patient’s condition showed such a

striking improvement both somatically and psychically that I used to

remark half jokingly that during each treatment I carried away a certain

number of pain motives, and that when I had cleaned them all out she

would be well. She soon reached a stage during which she had no pain

much of the time; she consented to walk a great deal and to give up her

hitherto condition of isolation. During the analysis I followed up now

the spontaneous fluctuations of her condition and now some fragments of

her sorrowful tale which in my opinion I had not sufficiently exhausted.

In this work I made some interesting discoveries the principles of which

I could later verify in other patients.

In the first place it was found that the spontaneous fluctuations never

occurred unless provoked associatively by the events of the day. On one

occasion she heard of an illness in the circle of her acquaintances

which recalled to her a detail in the illness of her father. On another

occasion the child of her deceased sister visited her and its

resemblance to its mother recalled many painful incidents. On still

another occasion it was a letter from her absent sister showing

distinctly the influence of the inconsiderate brother-in-law, and this

awakened a pain causing the reproduction of a family scene heretofore

not reported.

As she never reproduced the same pain motives twice we were justified in

the expectation that the stock would in time become exhausted. I never

prevented her from merging into a situation tending to evoke new

memories which had not as yet come to the surface. Thus for example I

sent her to the grave of her sister, or I urged her to go in society

where she was apt to meet her youthful friend who happened to be in the

city.

In this manner I obtained an insight into the mode of origin of a

hysteria which could be designated as monosymptomatic. I found, for

example, that the right leg became painful during our hypnosis when we

dealt with memories relating to the nursing of her father, to her young

friend, and to other memories occurring during the first period of the

pathogenic term; while the pain in the left leg came on as soon as I

evoked the memory of her lost sister, of both brothers-in-law, in brief

of any impression relating to the second half of the history. My

attention having been called to that by this constant behavior I went

further in my investigations and gained the impression that perhaps

detailization went still further and that every new psychic cause of

painful feeling might have some connection with a differently located

painful area in the legs. The original painful location on the right

thigh referred to the nursing of her father, and as the result of new

traumas the painful area then grew by apposition so that strictly

speaking we had here not one single physical symptom connected with a

multiform psychic memory complex but a multiplicity of similar symptoms

which on superficial examination seemed to be fused into one. To be sure

I have not followed out the demarcations of the individual psychic

causes corresponding to the pain zones for I found that the patient’s

attention was turned away from these relations.

Notwithstanding this I directed further interest to the mode of

construction of the whole symptom-complex of the abasia upon this

painful zone, and with this view in mind I asked such questions as this:

“What is the origin of the pains in walking and standing, or on lying?”

She answered these questions partially uninfluenced, partially under the

pressure of my hand. We thus obtained two results. In the first place

she grouped all scenes connected with painful impressions according to

their occurrence, sitting, standing, etc. Thus, for example, she stood

at the door when her father was brought home with his cardiac attack and

in her fright remained as though rooted to the spot. To this first

quotation “fright while standing” she connected more recollections up to

the overwhelming scene when she again stood as if pinned near the death

bed of her sister. The whole chain of reminiscences should justify the

connection of the pain with standing up, and could also serve as an

association proof, only one had to bear in mind the fact that in all

these occasions we must demonstrate another moment which had served to

direct the attention—and as a further result the conversion—just on the

standing, walking, sitting, etc. The explanation for this direction of

attention could hardly be sought in other connections than in the fact

that walking, standing, and lying are connected with capabilities and

conditions of those members which here bore the painful zones; namely,

the legs. We could then easily understand the connection between the

astasia-abasia and the first scene of conversion in this history.

Among the scenes which in consequence of this review had made the

walking painful one which referred to a walk she had taken in company,

at the watering place, which apparently lasted too long, stood out most

prominently. The deeper circumstances of this occurrence revealed

themselves only hesitatingly and left many a riddle unsolved. She was in

an especially good humor and gladly joined the circle of friendly

persons; it was a lovely day, not too warm, her mother remained at home;

her older sister had already departed, the younger one felt indisposed

but did not wish to mar her pleasure. The husband of the second sister

at first declared that he would remain at home with his wife, but

finally went along for her (Elisabeth’s) sake. This scene seemed to have

a great deal to do with the first appearance of the pains, for she

recalled that she returned home from the walk very fatigued and with

severe pains, she could not however say definitely whether she had

perceived the pains before this. I took for granted that if she had

suffered any pain she would have hardly resolved to enter upon this long

walk. On being questioned whence the pains originated on this walk she

answered rather indefinitely saying that the contrast between her

solitude and the married happiness of her sick sister, of which she was

constantly reminded by the behavior of her brother-in-law, was painful

to her.

Another closely related scene played a part in the connection of the

pain with sitting. It was a few days later, her sister and

brother-in-law had already departed and she found herself in an

excitable longing mood. She arose in the morning and ascended a small

hill which they were wont to visit together and which afforded the only

pretty view. There she sat down on a stone bench giving free play to her

thoughts. Her thoughts again concerned her lonesomeness, the fate of her

family, and she now frankly admitted that she entertained the eager wish

to become as happy as her sister. After this morning’s meditation she

returned home with severe pains. In the evening of the same day she took

the bath, after which the pains definitely appeared and continued

persistently.

We could further ascertain with great certainty that the pains on

walking and standing diminished in the beginning on lying down. Only

after hearing of her sister’s illness and on leaving Gastein in the

evening, spending a sleepless night in the sleeping car, and being

tormented simultaneously by the worries concerning her sister and

violent pains, it was only then that the pains appeared for the first

time while she was lying down, and throughout that time lying down was

even more painful than walking or standing.

Thus the painful sphere grew by apposition first because every new

pathogenically affecting theme occupied a new region of the legs,

second, every one of the impressionable scenes left a trace because it

produced a lasting, always more cumulative, “occupation” of the

different functions of the legs, thus connecting these functions with

the sensations of pain. There was unmistakably, however, still a third

mechanism which furthered the production of astasia-abasia. When the

patient finished the recitation of a whole series of events with the

plaint that she then perceived pain in “standing alone,” and when in

another series referring to the unfortunate attempt of bringing about

new conditions in the family she was not tired of repeating that the

painful in that was the feeling of her helplessness, the sensation that

she “could make no headway,” I had to admit that her reflections

influenced the formation of the abasia, and had to assume that she

directly sought a symbolic expression for her painfully accentuated

thoughts and had found it in the aggravation of her pains. That somatic

symptoms of hysteria could originate through such symbolization we have

already asserted in our Preliminary Communication, and in the epicrisis

to this history. I will give some examples of conclusive evidence. In

Miss Elisabeth v. R. the psychic mechanism of the symbolization was not

in the foreground, it had not produced the abasia, but everything

pointed to the fact that the already existing abasia had in this way

undergone a considerable reinforcement. Accordingly this abasia as I met

it in the stage of development was not only to be compared to a

psychically associative paralysis of function but also to a symbolic

paralysis of function.

Before I continue with the history of my patient I will add something

about her behavior during the second period of the treatment. Throughout

this whole analysis I made use of the method of evoking pictures and

ideas by pressing the head, a method therefore, which would be

inapplicable without the full cooperation and voluntary attention of the

patient. At times it was really surprising how promptly and how

infallibly the individual scenes belonging to one theme succeeded each

other in chronological order. It was as if she read from a long picture

book the pages of which passed in review before her eyes. At other times

there seemed to be inhibitions, of what kind I could not at that time

surmise. When I exerted some pressure she maintained that nothing came

into her mind. I repeated the pressure and told her to wait, but still

nothing would come. At first when such obstinacy manifested itself I

determined to discontinue the work and to try again, as the day seemed

unpropitious. Two observations, however, caused me to change my

procedure. Firstly, because such failure of this method only occurred

when I found Elisabeth cheerful and free from pain and never when she

had a bad day; secondly, because she frequently made assertions of

seeing nothing after the lapse of a long pause during which her tense

and occupied mind betrayed to me some psychic process within. I

therefore decided to assume that the method had never failed, that under

the pressure of my hands Elisabeth had each time perceived some idea or

had seen some picture but that she was not always ready to inform me of

it and attempted to repress the thing evoked. I could think of two

motives for such concealment; either Elisabeth subjected the idea that

came to her mind to a criticism to which she was not entitled, thinking

it not sufficiently important and unfit as an answer to the question, or

she feared to say it because that statement was too disagreeable to her.

I therefore proceeded as if I were perfectly convinced of the

reliability of my technique. Whenever she asserted that nothing came

into her mind, I did not let that pass. I assured her that something

must have come to her but that perhaps she was not attentive enough,

that I was quite willing to repeat the pressure. I also told her not to

entertain any doubts concerning the correctness of the idea presenting

itself to her mind, that that was not any of her concern; that it was

her duty to remain perfectly objective and to tell whatever came into

her mind, be it suitable or not, and I ended by saying that I knew well

that something did come which she concealed from me and that as long as

she would continue to do so she would not get rid of her pains. After

such urging I found that there was really no pressure that remained

unsuccessful. I then had to assume that I correctly recognized the state

of affairs, and indeed I won through this analysis perfect confidence in

my technique. It often happened that only after the third pressure did

she make a statement then added “Why I could have told you that the

first time”—“Indeed why did you not say it”—“I thought that it was not

correct:” or “I thought that I could avoid it, but it recurred each

time.” During this difficult work I began to attach a profounder

significance to the resistance which the patient showed in the

reproduction of her recollections, and I carefully compared those

occasions in which it was especially striking.

I now come to the description of the third period of our treatment. The

patient felt better, she was psychically unburdened and more capable,

but the pains were manifestly not removed, reappearing from time to time

with the old severity. The imperfect cure went hand in hand with the

imperfect analysis, as yet I did not know in what moment and through

what mechanisms the pains originated. During the reproduction of the

most manifold scenes of the second period and the observation of the

patient’s resistance towards the reproduction, I formed a definite

suspicion which I did not then dare to use as a basis for my action. An

accidental observation turned the issue. While working with the patient

one day I heard the steps of a man in the adjacent room and a rather

pleasant voice asking some questions. My patient immediately arose

requesting me to discontinue the treatment for the day because she heard

her brother-in-law who just arrived asking for her. Before this

disturbance she was free from pains, but thereafter she betrayed by her

mien and gait the sudden appearance of violent pains. This strengthened

my suspicion and I decided to elicit the decisive explanation.

I questioned her concerning the circumstances and causes of the first

appearance of the pains. Her thoughts were directed to the summer resort

in that watering place where she had been before taking the journey to

Gastein. A number of scenes were reproduced which had already been

treated less exhaustively. They recalled her frame of mind at that time,

the exhaustion following the worriment about her mother’s vision and the

nursing of her mother during the time of the operation and her final

despair at being unable as a lonesome girl to enjoy life or to

accomplish anything in life. Until then she felt strong enough to

dispense with the help of a man, but now she was controlled by a feeling

of her womanly weakness, a yearning for love in which, to put it in her

own words, “her obdurate self began to soften.” In such humor the happy

marriage of her younger sister made the profoundest impression on her.

She thought how affectionately he cared for her, how they understood

each other with a mere glance, and how sure they seemed to be of each

other. It was truly regrettable that the second pregnancy followed so

quickly the first and her sister knew that this was the cause of her

suffering but how willingly she endured it and all because he was the

cause of it. The brother-in-law did not at first wish to participate in

the walk which was so intimately connected with Elisabeth’s pain; he

preferred to remain home with his sick wife, but the latter urged him

with a glance to go because she thought that would give Elisabeth

pleasure. Elisabeth remained with him throughout the whole walk; they

spoke about the most varied and intimate things; she found herself in

thorough accord with all he said, and she became overwhelmed with the

desire to possess a man like him. This was followed by a scene a few

days later, when, on the morning after their departure, she visited the

point commanding the beautiful view which had been their favorite walk.

There she seated herself upon a stone and again dreamed of her sister’s

happiness and of a man like her brother-in-law who could engage her

affections. When she arose she had pains which again disappeared, and

only in the afternoon after having taken the warm bath did they

reappear, remaining ever since. I attempted to investigate the thoughts

which occupied her mind while taking the bath, but all I could obtain

was that the bath house recalled her absent sister because she had lived

in the same house.

For some time the state of affairs was clear to me. Absorbed in

painfully sweet recollections she was wholly unconscious of the drift of

her thoughts and continued to reproduce her reminiscences, the time in

Gastein, the worry connected with the expectations of the letter,

finally the information of her sister’s illness, the long wait until the

evening when she could first leave Gastein, the journey with its

tormenting uncertainties during a sleepless night—all these moments were

accompanied by a violent aggravation of the pain. I asked her if during

the journey she thought of the sad possibility which she afterward found

realized. She answered that she carefully avoided the thought but that

in her opinion her mother expected the worst from the very beginning.

This was followed by the reminiscences of her arrival in Vienna—the

impressions which she received from the relatives at the station, the

short journey from Vienna to the neighboring summer resort where her

sister lived, the arrival in the evening, the hasty walk through the

garden to the door of the little garden pavilion—a silence in the house,

the oppressive darkness, the fact of not having been received by the

brother-in-law. She then recalled standing before the bed seeing the

deceased, and in the moment of the awful certainty that the beloved

sister had died without having taken leave of them and without having

her last days eased through their nursing—in that very moment another

thought flashed through Elisabeth’s brain which now peremptorily

repeated itself. The thought which flashed like dazzling lightning

through the darkness was, “Now he is free again, and I can become his

wife.”

Of course, now everything was clear. The analyzer’s effort was richly

repaid. The ideas of the “defense” (abwehr) against an unbearable

presentation, the origin of hysterical symptoms through conversion of

psychic into physical excitement, the formation of a separate psychic

group by an arbitrary act, leading to the defense—all these were in that

moment palpably presented before my eyes. Thus and thus alone did things

happen here. This girl entertained an affectionate regard for her

brother-in-law against the acceptance of which into her consciousness

her whole moral being struggled. She succeeded in sparing herself the

painful consciousness that she was in love with her sister’s husband by

creating for herself instead bodily pains, and in the moment when this

certainty wished to thrust itself into her consciousness (while she

walked with him, during that morning reverie, in the bath, and before

her sister’s bed) her pains originated by means of a successful

conversion into the somatic. When she came under my care there was

already a complete isolation from her consciousness of the presentation

group referring to this love, else, I believe that she would never have

agreed to such a treatment. The resistance which she repeatedly brought

forth during the reproduction of traumatically produced scenes really

corresponded to the energy with which the unbearable presentation had

been crowded out from the association.

For the therapeutist there now came a sorry time. The effect of the

resumption of that repressed presentation was a crushing one for the

poor child. When I summed up the whole situation with these prosaic

words: “you were really for a long time in love with your

brother-in-law,” she complained of the most horrible pains at that

moment; she made another despairing effort to reject the explanation,

saying that it was not true, that I suggested it to her, it could not

be, she was incapable of such baseness, and that she would never forgive

herself for it. It was quite easy to prove to her that her own

information allowed no other interpretation, but it took a long time

before the two reasons that I offered for consolation, namely, that one

is not responsible for one’s feelings and that her behavior, her

sickness under those circumstances was sufficient proof of her moral

nature—I say it took a long time before these consolations made an

impression on her. I was now forced to pursue more than one course in

order to calm the patient. In the first place I wished to give her the

opportunity to rid herself by ab-reaction of the material long since

accumulated. We investigated the first impressions of the relations with

her brother-in-law, the beginning of those unconsciously kept

affectionate regards. We found here all those little indications and

forebodings which on a retrospective view showed a fully developed

passion. On his first visit to the house he mistook her for his destined

bride and greeted her before he greeted her older and homely sister. One

evening they entertained each other so vivaciously and seemed to

understand each other so well that the bride interrupted them with this

half serious remark: “You two, indeed, would have suited each other very

nicely.” On another occasion while in a gathering who were ignorant of

the engagement the conversation drifted to the young man, and a young

lady indiscreetly remarked about a blemish in his shape, a juvenile

joint affliction. The bride herself remained calm while Elisabeth flew

into a passion, and with an ardor which even she herself could not

afterward understand she defended the straight form of her future

brother-in-law. While we worked our way through these reminiscences it

became clear to Elisabeth that her affection for her brother-in-law had

slumbered in her for a long time, perhaps since the beginning of their

relations, and had concealed itself so long under the mask of a mere

kinsmanlike affection as only her very delicate family feeling would

allow.

This ab-reaction benefited her much but I was able to give her still

more relief by taking a friendly interest in her present state of

affairs. With this object in view I sought an interview with Mrs. v. R.

whom I found to be an intelligent and refined lady whose courage to face

life, however, was somewhat lessened through the last misfortune. From

her I learned that the accusation of rude extortion which the older

brother-in-law had brought against the widower, and which was so painful

to Elisabeth, had to be retracted on closer investigation. The character

of the young man remained untarnished, it was merely a misunderstanding,

an easily conceived difference of opinion concerning the valuation of

money that could arise between the merchant, to whom money is only a

working tool, and the official—that is all there was to this seemingly

so painful incident. I begged the mother to give Elisabeth all

explanations that she might hereafter need, and to offer her in the

future that opportunity for unburdening her mind to which I had

accustomed her.

Naturally I was also anxious to know what chance there was for the

fulfilment of the girl’s present conscious wish. Here things were less

favorable! The mother stated that for some time she had had an inkling

of Elisabeth’s affection for her brother-in-law, of course she did not

know that it existed during the lifetime of her sister. Whoever saw them

both in friendly intercourse—of late, to be sure, only seldom—could

entertain no doubt of the girl’s anxiety to please him. However, neither

she, her mother, nor the advisers of the family showed any particular

inclination to bring about a matrimonial union between the two. The

health of the young man had not been very good and had received a

setback through the death of his beloved wife, and it was not at all

certain that he had sufficiently recovered from the shock to enter into

a new matrimony. It was quite probable that this was the reason for his

reserve, perhaps also because he was not sure of his position, and

wished to avoid all obvious gossip. With such a reserve on both sides

the solution for which Elisabeth was yearning was likely to fail.

I informed the girl of everything that I had heard from her mother and

had the satisfaction of seeing her benefited by the explanation

concerning the money affair. On the other hand, I expected her to bear

calmly the uncertainties of her future which could not be set aside. The

advancing summer compelled us to bring the treatment to an end. She now

felt better, and since we had discussed the causes to which the pain

could be traced she no longer complained of pain. We both felt that the

work was done, although I thought that the ab-reaction of the suppressed

love was really not as complete as it should have been. I regarded her

as cured and urged her to continue independently the solution after the

way had been cleared, to which she agreed. She left with her mother for

a summer resort where they were to join the older sister and her family.

I still have something more to report about the further course of Miss

Elisabeth v. R.’s disease. A few weeks after our parting I received a

despairing letter from her mother informing me that at the first attempt

to draw Elisabeth into a conversation about her love affairs she became

very excited and refused to talk, and since then had suffered from

violent pains. She was very indignant at my having betrayed her

confidence and was perfectly inaccessible so that the treatment seemed a

complete failure. She wished to know what was to be done, for of me she

would hear nothing. I made no reply. It was to be expected that after

she was relieved from my discipline she would make another attempt to

reject her mother’s interference and return to her inaccessibility. I

was, however, quite certain that everything would adjust itself and that

my efforts had not been in vain. Two months later they returned to

Vienna and the colleague to whom I was grateful for the case informed me

that Elisabeth was perfectly well, and that her behavior was normal

although occasionally she had slight pains. Since then she has

repeatedly sent me similar messages, each time promising to visit me,

which she has never done. This is quite characteristic of the personal

relationship formed during such treatment. My colleague then assured me

that she could be considered cured. The relation of the brother-in-law

to the family underwent no change.

In the spring of 1894 I was informed that she would be present at a

private ball to which I could gain access. I did not let the opportunity

escape me and saw my former patient gliding along in a rapid dance.

Since then, following her own inclination, she has married a stranger.

EPICRISIS.

I was not always a psychotherapist but like other neuropathologists I

was educated to the use of focal diagnosis and electrical prognosis so

that even I myself am struck by the fact that the histories of the

diseases which I write read like novels and, as it were, dispense with

the serious features of the scientific character. Yet I must console

myself with the fact that the nature of the subject is apparently more

responsible for this issue than my own predilection. Focal diagnosis and

electrical reactions are really not important in the study of hysteria,

whereas a detailed discussion of the psychic processes, as one is wont

to receive it from the poet, and the application of a few psychological

formulæ, allows one to gain an insight into the course of events of

hysteria. Such histories should be considered like psychiatrical ones,

but they have the advantage over the latter in the fact that they give

the intimate connection between the history of the disease and the

morbid symptoms, a thing for which we still look in vain in the

biographies of other psychoses.

With the description of the treatment I endeavored to interweave the

explanations which I gave about the case of Miss Elisabeth v. R. and it

will perhaps be superfluous to summarize here the essential features. I

have discussed the character of the patient and the features which

repeat themselves in so many hysterics, and which we really can not

consider as degenerative. I mentioned the talent, the ambition, the

moral sensitiveness, the immense yearning for love which found its

gratification in the family, the independence of her nature reaching

beyond the womanly ideal which manifested itself largely by obstinacy,

readiness for fight, and inaccessibility. According to the information

of my colleague no hereditary taints could be shown on either side of

the family. Her mother, to be sure, suffered for years from some

indefinite neurotic depression, but her brothers and sisters, her father

and his family belonged to the even-tempered and not to the nervous.

There was no serious case of neuropsychosis in the nearest relatives.

This nature was acted upon by painful emotions, the foremost of which

was the debilitating influence of a long attendance upon her beloved

sick father.

That nursing of the sick plays such a significant rôle in the histories

of hysterias has its good reasons. A number of effective moments which

are found here are quite obvious, namely, the disturbance of the

physical health through interrupted sleep, neglect of nourishment, and

the reaction of a constantly gnawing worriment on the vegetative

functions; but the most important factor, however, is, in my estimation,

to be found elsewhere. He whose mind is occupied with the hundred

different tasks of nursing which succeed each other continuously for

weeks and months, becomes accustomed, on the one hand, to suppress all

signs of his own emotions, and on the other, his attention is soon

turned away from his own impressions because he has neither the time nor

strength to do them justice. Thus the nurse accumulates for himself an

over abundance of affective impressions which he barely perceived

clearly enough, at any rate they were not weakened by ab-reaction, that

is, he creates for himself the material for a retention hysteria. If the

patient recovers these impressions naturally become reduced in value,

but if he dies and the period of mourning comes during which only that

which refers to the deceased seems of value, the impressions waiting for

discharge appear in turn, and after a brief pause of exhaustion the

hysteria, the germ of which originated during the nursing, bursts forth.

The same subsequent discharge of traumas accumulated during nursing is

occasionally encountered where the general impression of the disease

does not ensue, and yet the mechanism of hysteria can be noticed. Thus,

I know a highly gifted but slightly nervous lady whose whole personality

suggests the hysteric though she never became a burden to the doctor and

was never obliged to interrupt the exercise of her duties. This lady had

nursed three or four of her beloved ones until their death, causing her

each time complete physical exhaustion, yet these sad duties never made

her ill. However, shortly after the death of the patient she began the

work of reproduction, bringing again to her view the scenes of the

disease and death. Each day—one might say at her leisure—she went over

again every impression, crying and consoling herself. Such adjustment

she passed through daily in conjunction with her usual duties, without,

however confusing the two activities. Everything passed before her

chronologically. Whether the memory work of one day precisely

corresponded to a day of the past I am unable to say. I presume that it

depended on the leisure which was allowed to her by the current affairs

of the household.

Aside from this “subsequent tear” which attached itself to these deaths

at short intervals, this lady periodically observed annual anniversaries

representing the time of the various catastrophes, and here her vivid

visual reproduction and her affective manifestations followed faithfully

the date. Thus, for example, I found her in tears, and on sympathetic

inquiry as to what occurred that day, she half irritably remarked,

“Nothing on that day except that Professor N. was again here and gave us

to understand that things were hopeless—at that time I had no time to

cry.” She referred to the last illness of her husband who died three

years before. It would have been very interesting to know whether she

always repeated the same scenes on these recurring anniversaries, or

whether as I suppose in the interest of my theory other details

presented themselves each time for ab-reaction. I was however, unable to

find anything definite about that; the wise and courageous woman was

ashamed of the intensity with which those reminiscences acted upon

her.[19]

I again repeat that this woman was not sick, that subsequent

ab-reaction, despite all resemblance, is still not a hysterical process;

one may ask why, after one nursing there results a hysteria and after

another none. It cannot lie in personal predisposition for the lady that

I have in mind showed it very remarkably.

I now return to Miss Elisabeth v. R. While nursing her father there

occurred for the first time an hysterical symptom in the form of a pain

in a definite location on the right thigh. The mechanism of this symptom

is fully explained on an analytical basis. It occurred in a moment

during which the ideas of her duties towards her sick father came into

conflict with the content of her erotic yearning which she then

entertained. Under vivid self reproach she decided in favor of the

former and created for herself the hysterical pain. According to the

conception explained by the theory of conversion in hysteria, the

process could be described as follows: She repressed the erotic idea

from her consciousness and changed the sum of the affect into somatic

sensations of pain. Whether this first conflict occurred only once, or

repeated itself is not clear. The latter is more probable. Quite a

similar conflict—of a higher moral significance, and even better

demonstrated by the analysis—repeated itself after years and led to the

aggravation of the same pain and to its dissemination beyond its

original limits. Again, it was an erotic idea which came into conflict

with all her moral conceptions, for her affection for her

brother-in-law, both during the life and after the death of her sister,

and the thought that she should yearn just for this man, was to her very

disagreeable. This analysis gives detailed information about this

conflict which represents the pivotal point in the history of her

malady. The patient’s affection for her brother-in-law might have begun

to germinate long ago, but in favor of its development was the physical

exhaustion through the recent nursing, and her moral exhaustion through

years of disillusionment which then began to break down her reserve and

she confessed to herself the need of the love of a man. During a

friendly intercourse continuing for weeks (in the summer resort) this

erotic inclination reached its full development simultaneously with the

pain. The analysis shows a special psychic condition of the patient at

that time, which in connection with her inclination and the pain, seems

to afford an understanding of the process in the sense of the conversion

theory.

I place reliance on the opinion that the patient’s affection for her

brother-in-law, intensive as it was, was not clearly known to her except

on certain rare occasions and then only momentarily. If that were not so

she would have become conscious of the inconsistency between this

fondness and her moral ideas and would have had to endure the same

mental agony which I saw her suffer after the analysis. Her

reminiscences gave us no information concerning such suffering. These

she spared herself and as a result the love itself did not become clear

to her. At that time, as well as during the analysis, her love for her

brother-in-law existed in the form of a foreign body in her

consciousness without entering into any relationship with her other

ideation. In reference to this love there existed the peculiar condition

of knowing and simultaneously not knowing, it was the condition of the

split off psychic group. When we assert that this love was not “clearly

known” to her we mean exactly what we say. We do not mean a lower

quality or a lesser degree of consciousness, but a separation of the

free associative thinking process from the rest of ideation.

How does it come about that such an intensively accentuated presentation

group should be kept so isolated? As a rule the rôle played by an idea

in the association really increases with the sum of its affect.

This question can be answered if we bear in mind two facts which we can

make use of as a safeguard: (1) That the hysterical pains originated

simultaneously with the formation of these separate psychic groups, (2)

that the patient exerted great resistance against the attempt to bring

about the association between the separate psychic groups and the rest

of the content of consciousness, and when the union was finally effected

she perceived excessive psychic pain. Our conception of hysteria brings

together these two moments with the fact of the splitting of

consciousness, for (2) contains the indication for the motive for the

splitting of consciousness while (1) shows the mechanism of the same.

The motive was that of defense, it was the striving of the whole ego to

agree with this presentation group and the mechanism was that of

conversion, that is, instead of psychic pains which she spared herself

there appeared physical pains. Thus a transformation occurred through

which gain the patient had escaped an unbearable psychic state, though

it was at the cost of a psychic anomaly in the form of a splitting of

consciousness and a physical suffering, pains, upon which an

astasia-abasia was constructed.

To be sure I can give no instruction as to how one can bring about such

a conversion. It is not apparently done as one intentionally does an

arbitrary action, it is a process which is executed in the individual

under the impulse of the motive of defense if an adaptation for it

exists in his organization or is brought about by temporary

modification.

One has the right to attack the theory more closely by asking what it is

that is transformed into physical pains. The cautious reply will be

something out of which psychic pains could have and should have been

formed. If we wish to venture further and attempt a kind of algebraic

formulation of the presentation mechanism we may attribute to the

presentation complex of this unconsciously remaining love a certain

amount of affect and designate the latter quantity as the thing

converted. Direct deduction of this conception would be the fact that

the “unconscious love” has through such conversion forfeited so much of

its intensity that it was reduced to a weak idea. Its existence as a

separate psychic group would only be made possible through such

weakening. Yet this present case is not suitable to afford us any

clearness in this delicate matter. It probably corresponds to an

imperfect conversion only. From other cases it seems quite probable that

perfect conversions also occur and that in these the unbearable idea

actually becomes repressed as only an idea of very little intensity

could be repressed. After an associative union has been consummated the

patients assure us that since the origin of the hysterical symptoms

their unbearable thoughts never occupied their minds.

I have stated above that on certain occasions, though only transitorily,

the patient consciously recognized the love for her brother-in-law. Such

a moment occurred when for example, at the death bed of her sister the

thought flashed through her mind, “Now he is free and I can become his

wife.” I must discuss the significance of these moments for the

conception of the whole neurosis. However, I think that the assumption

of a defense hysteria (abwehr hysterie) includes the requisite that at

least one such moment has already occurred. For consciousness does not

know in advance when such an unbearable idea will present itself. The

unbearable idea which with its appendix is later excluded for the

formation of a separate psychic group must have been originally in the

mind, otherwise no conflict would have resulted leading to its

exclusion.[20] Just such moments should be designated as “traumatic.” It

is in them that the conversion takes place which results in the

splitting of consciousness and the hysterical symptoms. Everything tends

to show that in Miss Elisabeth v. R. there were a number of such moments

(the scenes of the walking, morning meditation, bath, and at the bed of

her sister) and perhaps new moments of this kind occurred during the

treatment. The multiplicity of such traumatic moments is made possible

by the fact that an experience similar to the one which at first

initiated the unbearable idea, introduces new emotions to the separated

psychic groups and thus transitorily abolishes the success of the

conversion. The ego is forced to occupy itself with this suddenly

enforced and lighted-up idea, and then to restore the former state by

means of new conversions. Miss Elisabeth who was in constant relation

with her brother-in-law must have been particularly exposed to the

appearance of new traumas.

I must now occupy myself with the point which I have designated as a

difficulty for the understanding of the afore mentioned history. On the

analytical basis I assume that the first conversion took place in the

patient while she nursed her father, at the time when her duties as

nurse came into conflict with her erotic yearnings, and that this

process was the prototype for the later ones which led to the outbreak

of the disease in the Alpine watering place. But then we have it from

the patient’s statement that at the time of nursing and the period

following which I designated as the “first period” she had not suffered

at all from the pains and weakness. To be sure, during the illness of

her father she was once bedridden for a few days with pains in her legs,

but it is doubtful whether this attack already belonged to the hysteria.

A causal relation between these first pains and any psychic impressions

could not be demonstrated by analysis; it is possible, even probable,

that at that time we dealt with a common rheumatic muscular pain. Even

if we should assume that this first attack of pain was the result of a

hysterical conversion in consequence of the rejection of the erotic

thoughts then existing, the fact nevertheless remains that the pains

disappeared after a few days so that the patient actually behaved

differently than she did during the analysis. During the reproduction of

the so called first period all her statements concerning the illness and

death of her father, the impressions relating to her first

brother-in-law, etc., all these were accompanied by manifestations of

pain, while at the time she really experienced these impressions she

perceived no pains. Is this not a contradiction tending to considerably

diminish the confidence in the explanatory value of such an analysis?

I believe that I can explain the contradiction by assuming that the

pains—the product of the conversion—did not originate while the patient

experienced the impressions during the first period, but subsequently,

that is in the second period when the patient reproduced these

impressions in her mind. The conversion did not follow the fresh

impressions but the memories of them. I even believe that such a process

is not at all unusual in hysteria and regularly participates in creating

hysterical symptoms. Nevertheless, as such an assertion does not seem

plausible I shall attempt to make it more credible by citing other

experiences.

It once happened to me during a similar analysis that a new hysterical

symptom was formed during the treatment so that I could attempt its

removal on the day after its origin.

I will describe the essential features of the history of this patient.

They are simple but not without interest.

Miss Rosalia H., twenty-three years old, who for a number of years made

great effort to educate herself as a singer, complained that her

beautiful voice did not obey her in certain notes. There appeared

choking and tightening sensations in the throat so that the tones

sounded strained, and her teacher could therefore not allow her to

appear in public. Although this imperfection affected only her middle

notes it could not be explained to be due to a defect of her vocal

organs, for at times this disturbance was absent and her teacher was

very pleased with her, but at other times the slightest excitement,

seemingly without any provocation, evoked the choking sensation, and

prevented free expansion of the voice. It was not difficult to recognize

in this annoying sensation an hysterical conversion. Whether there

really appeared a contracture of certain muscles of the vocal chords I

have not verified.[21] In the hypnotic analysis which I undertook with

this girl I found out the following concerning her vicissitudes and her

ailments occasioned through them. She became an orphan at an early age

and was brought up at the house of an aunt who had many children of her

own, and she thus shared the life of a most unfortunate family. The

husband of this aunt, seemingly a pathological personality, abused his

wife and children in the most brutal manner and especially pained her by

his sexual preference for the servant girl in the house. This became

even more obnoxious as the children grew older. When the aunt died

Rosalia became the protectress of the orphaned children who were

harassed by their father. She took her duties seriously, fought through

all conflicts and had to exert her greatest efforts to suppress the

manifestations of her contempt for her uncle. It was then that the

choking sensation in her throat originated. Whenever she was compelled

to swallow an affront, whenever she had to remain silent on hearing a

provoking accusation she perceived a scratching in her throat, the

tightening and failure of her voice, in brief she had all the localized

sensations in her larynx and pharynx which now disturbed her in singing.

It was conceivable that she sought the possibility of making herself

independent in order to escape the excitement and painful impressions

which were daily occurrences in her uncle’s house. An efficient music

teacher took an unselfish interest in her, assuring her that her voice

entitled her to choose the profession of singing. She began secretly to

take lessons of him and because she often went for her lessons with the

choking sensation in her throat following some violent scene in the

house, a connection was formed between the singing and the hysterical

paresthesia for which a way was prepared by the sensitiveness of the

organ during singing. The apparatus of which she should have had free

control was filled with the remnants of innervation after those numerous

scenes of repressed excitement. Since then she has left the house of her

uncle, having moved to another city so as to be away from the family,

but her ailments were not benefited by it. No other hysterical symptoms

were discovered in this pretty and unusually bright girl.

I endeavored to cure this “retention hysteria” by a reproduction of all

the exciting impressions and by subsequent ab-reaction. I afforded her

the opportunity of railing against her uncle in long speeches and of

telling him the bare truth to his face, etc. The treatment benefited

her, but unfortunately she lived here under quite unfavorable

conditions. She had no luck with her relatives. She was the guest of

another uncle who treated her with friendliness, but just for that

reason she incurred the displeasure of her aunt. The latter believed

that her husband evinced too marked an interest in his niece and made it

a point of opposing the girl’s stay in Vienna. She herself in her youth

was obliged to relinquish a desire of becoming an artist and was now

jealous of her niece because she had the opportunity to develop her

talent not considering that it was not mere desire but a wish to become

independent which led her niece to take this step. Rosalia felt so

uncomfortable in the house that she for instance, did not dare to sing

or play the piano when her aunt was within hearing distance, and

carefully avoided either singing or playing anything for her aged

uncle—brother of her mother—whenever her aunt was home. While I was

endeavoring to efface the traces of the old excitements, new ones

originated through these relations with her host and finally interfered

with the success of my treatment and prematurely interrupted the cure.

One day the patient came to me with a new symptom hardly twenty-four

hours old. She complained of a disagreeable prickling sensation in the

fingertips which had manifested itself every few hours since the day

before and forced her to make very peculiar jerky movements with the

fingers. I could not see the attack, otherwise I would have guessed its

meaning on seeing the finger movements but I immediately endeavored to

trace through hypnotic analysis the causation of this symptom (it was

really a minor hysterical attack). As the whole thing only existed for a

short time I hoped to be able to explain it and quickly remove it. To my

surprise without any hesitation she reproduced in chronological order a

whole row of scenes beginning in her early childhood. All these had

perhaps the same characteristics in the fact that she had suffered an

injustice without defense, something which could make her fingers jerk,

for example, scenes like the one of being forced to hold out her hand in

school while her teacher struck it with a ruler. But they were all banal

causes the right of which to enter into the etiology of an hysterical

symptom I have already opposed. It was different, however, with one

scene of her early girlhood which was connected with the others. The bad

uncle who suffered from rheumatism asked her to massage his back. She

did not dare refuse him. He was in bed while she was doing it and

suddenly threw off the covers, jumped up, attempting to get hold of her

and throw her down. Naturally she stopped the massage and in a moment

escaped and locked herself within her own room. She evidently did not

like to recall this experience and could not say whether she had seen

anything when the man suddenly exposed himself. The sensations of the

fingers could be explained as due to the suppressed impulse to punish

him, or it might simply have originated from the fact that she was at

that time massaging him. Only after this scene did she begin to talk

about the one experienced yesterday after which the sensitiveness and

jerkiness of the fingers appeared as a recurring memory symbol. The

uncle with whom she now lived begged her to play something for him. She

sat at the piano and accompanied herself singing, believing that her

aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up,

closed the piano, and flung away the sheet of music. We can guess what

memories came to her mind, and the train of thought which she tried to

ward off at that moment, for the exasperation brought on by the unjust

accusation should have really urged her to leave the house, but on

account of her illness she was forced to remain in Vienna and had no

other shelter. The movement of the fingers which I saw during the

reproduction of this scene resembled a continuous jerking as if one

literally and figuratively would reject something like throwing away a

sheet of music or rejecting an unreasonable demand.

She was quite positive in her assurance that she did not perceive the

symptom before, that it was not caused by the scenes previously related.

Was there anything else to be assumed except that the scene experienced

yesterday had in the first place awakened the recollection of a former

similar content and that then the formation of a memory symbol for the

whole group of recollections took place? The conversion was on the one

hand furnished with newly experienced affects, on the other with

recollected affects.

When we consider this state of affairs we must admit that in the origin

of hysterical symptoms such a process is the rule rather than the

exception. Whenever I seek for the determinants of such states I

frequently find not a single but a group of similar traumatic motives.

In some cases it could be ascertained that this particular symptom had

already existed for a short time after the first trauma and then

subsided, but reappeared after the next trauma and become fixed. Yet no

real distinction can be made between the temporary appearance and the

latency after the first motives. In a large majority of cases it was

also found that the first traumas had left no symptoms, while a later

trauma of the same kind produced a symptom for the origin of which the

cooperation of the former motives could not be dispensed with and for

the solution of which it really required a consideration of all the

motives. Translating this into the language of the conversion theory we

will say that this undeniable fact of the summation of the traumas and

the erstwhile latency of the symptoms simply means that the conversion

can be brought about from a fresh as well as from a remembered affect,

and this assumption fully explains the contradiction which seems to

exist in the history and analysis of Miss Elisabeth v. R.

There is no question that normal persons carry in their consciousness in

considerable numbers the continuation of ideas with unadjusted affects.

The theory which I just asserted merely approximates the behavior of

hysteria to the normal. It is apparently reduced to a quantitative

moment; it is simply a question of how many such affective strains an

organization can endure. Even a hysterical person will be able to retain

a certain amount in an unadjusted state, but if through a summation of

similar motives it increases beyond the individual’s endurance, the

impetus for conversion is formed. It is therefore no singular theory but

almost a postulate to say that the formation of hysterical symptoms may

also be brought about at the cost of recollected affects.

I have now occupied myself with the motive and mechanism of this case of

hysteria, it still remains to discuss the determination of the

hysterical symptoms. Why should just the pains in the legs be selected

to represent the psychic pains? The circumstances of the case point to

the fact that this somatic pain was not created by the neurosis but was

merely utilized, aggravated, and retained by it. I will add that in most

of the cases of hysterical algias into which I have been able to gain an

insight the conditions were similar, that is, there was to begin with

always a real organically founded pain. It is always the most common,

the most widespread pains of humanity that seem to be most frequently

called upon to play a part in hysteria. Among the most common are the

periosteal and neuralgic pains of the teeth, headaches which originate

from so many different sources, and not in a lesser degree the so often

mistaken rheumatic pains of the muscles. The first attack of pain which

Miss Elisabeth v. R. had while she nursed her father, I consider to have

been organically determined, for I received no information when I

investigated for its psychic motive, and I admit that I am inclined to

attribute differential diagnostic significance to my methods of evoking

hidden memories if they are carefully applied. This original rheumatic

pain[22] became in the patient the memory symbol for her painful psychic

emotions, and as far as I can see, for more than one reason. First and

principally because it existed in consciousness almost simultaneously

with the other excitements, and second because it was or could be

connected in many ways with the ideation of that time. At all events it

was perhaps a remote consequence of the nursing, of her want of

exercise, and the poor nutrition entailed by her duties as nurse. But

this hardly became clear to the patient and what is more important is

the fact that she had to perceive it during significant moments of the

nursing, as for example, when she jumped out of bed in the cold room to

respond to her father’s call. Even more decisive for the direction taken

by the conversion must have been the other manner of associative

connection, namely, the fact that for many days one of her painful legs

came in contact with the swollen leg of her father during the changing

of bandages. The location on the right leg distinguished by this contact

remained henceforth the focus and starting point of the pains, an

artificial hysterogenic zone the origin of which can be plainly seen in

this case.

If any one should be surprised at the associative connection between

physical pain and psychic affect, thinking it to be too manifold and

artificial, I should answer that such surprise is just as unfair as to

be surprised over the fact “that just the richest in the world possess

most money.” Where prolific connections do not exist there is naturally

no formation of hysterical symptoms, and conversion does not find its

way. I can also state that in reference to determinations the case of

Miss Elisabeth v. R. belongs to the simpler ones. In the case of Mrs.

Cäcilie M.[23] particularly, I had to solve the most intricate knots of

this kind.

I have already discussed in the history of the case how the

astasia-abasia of our patient was built up on those pains after the

conversion had taken definite direction. But there, too, I have

expressed the opinion that the patient has created or aggravated the

disturbance of function through symbolization. For her dependence and

helplessness to change anything in the circumstances she found a somatic

expression in the astasia-abasia, and the expressions “to make no

headway,” “to have no support,” etc., formed the bridge for this new act

of conversion. I will endeavor to support this conception by other

examples.

Conversion on the basis of coincidence in otherwise existing associative

connections seems to exert the slightest claims on the hysterical

predisposition; on the other hand conversion through symbolization seems

to require a higher grade of hysterical modification, a fact also

demonstrated in Miss Elisabeth in the later stages of her hysteria. The

prettiest examples of symbolization I have observed in Mrs. Cäcilie

M.,[24] whom I can call my most difficult and most instructive case. I

have already mentioned that this history does not unfortunately lend

itself to detailed reproduction.

Among other things Mrs. Cäcilie also suffered from a most violent facial

neuralgia which appeared suddenly two or three times during the year and

persisted for from five to ten days, resisting every remedy, and ceased

as if cut off. It limited itself to the second and third branches of the

trigeminus, and as there was undoubtedly an excess of urates in the

urine, and as a not very “clear acute rheumatism” played a certain part

in the patient’s history it was reasonable to assume that we dealt with

a gouty neuralgia. This opinion was also shared by the consulting

physicians who saw every attack. The neuralgia was treated with the

methods in vogue, such as electric pencilling, alkaline waters and

purgatives, but it always remained uninfluenced until it was convenient

to make room for another symptom. In former years—the neuralgia was

fifteen years old—the teeth were accused of preserving it and were

condemned to extraction, and one fine morning under narcosis the

execution of seven of the culprits took place. That did not run so

smoothly as the teeth were so firm that most of the roots were left

behind. This cruel operation was followed by neither temporary nor

permanent relief. At that time the neuralgia raged for months. Even

while under my care whenever she had neuralgia the dentist was called

and he always declared he found diseased roots. He commenced to get

ready for such work but usually he was soon interrupted, for the

neuralgia suddenly ceased and with it the desire for the dentist. During

the intervals the teeth did not ache at all. One day just while another

attack was raging I put the patient into a hypnotic condition and placed

an energetic interdiction on the pains, and from that moment they

ceased. I then began to doubt the genuineness of this neuralgia.

About a year after this hypnotic remedial success the condition of Mrs.

Cäcilie M. took a new and surprising turn. There suddenly appeared other

states than those that had been characteristic of the last years, but

after some reflection the patient declared that all these conditions had

existed in her before and were really scattered over the long period of

her disease (thirty years). Indeed a surprising abundance of hysterical

incidents were unrolled which the patient was able to localize correctly

in the past and soon the frequently very entangled thought connections

which determined the sequence of these incidents became recognizable. It

was like a series of pictures with an explanatory text. Pitres, on

describing his délire ecmnésique must have had in mind a similar case.

The way such a hysterical condition belonging to the past was reproduced

was most remarkable. In the first place while the patient was in the

best of condition there appeared a pathological mood of special coloring

which was regularly mistaken by the patient and was referred to a banal

occurrence of the last hours. This increasing obnubilation of

consciousness was followed by hysterical symptoms, such as

hallucinations, pains, convulsions, and long declamations, and finally

an event of the past attached itself to this hallucinatory manifestation

which could explain the initial mood and determine the occasional

symptoms. With this last part of the attack lucidity returned, the

ailments disappeared as if by magic and good health again existed—until

the next attack which was half a day later. Usually I was called at the

height of this condition. I produced hypnosis, evoked a reproduction of

the traumatic events, and by artificial aid I curtailed the attack.

Having gone through with the patient many hundreds of such cycles, I

obtained the most instructive explanations concerning the determinants

of hysterical symptoms. The joint observation with Breuer of this

remarkable case was also the chief motive for the publication of our

“Preliminary Communication.”

In this connection it finally came to the reproduction of the facial

neuralgia which I myself had still treated as actual attacks. I was

desirous of knowing whether we would find here a psychic causation. When

I attempted to evoke the traumatic scene, the patient soon imagined

herself in a period during which she felt marked psychic sensitiveness

against her husband. She related a conversation with him and a remark

that he made which aggravated her very much. She then suddenly grasped

her cheek, crying aloud with pain, and said, “That was like a slap in

the face”—with this both the attack and the pain came to an end. There

is no doubt that here, too, we dealt with a symbolization. She had felt

as if she really received a slap in the face. Now everybody will ask how

the sensation of “a slap in the face” can lead to the manifestations of

a trigeminal neuralgia, to its limiting itself to the second and third

branch, and to its being aggravated on opening the mouth and mastication

(not by talking!).

The following day the neuralgia reappeared, but this time it could be

solved by the reproduction of another scene the content of which equally

showed a supposed insult. This process continued for nine days; from the

result it seemed that for years, aggravations, especially through words,

produced new attacks of this facial neuralgia by way of symbolization.

But finally we also succeeded in reproducing the first attack of the

neuralgia which occurred more than fifteen years before. Here there was

no symbolization but a conversion through coincidence. It was a painful

sight which recalled to her mind a reproach and this caused her to

repress another series of thoughts. We have here, then, a case of

conflict and defense, and the origin of the neuralgia in this moment

could not be explained if we do not wish to assume that she then

suffered from slight toothache or facial pains, a thing not improbable,

as she was then in the first months of pregnancy.

The result of the explanation showed that this neuralgia became the mark

of a definite psychic excitement through the usual road of conversion

but that afterward it could be awakened through associative

reminiscences of thoughts and symbolic conversions. It was really the

same procedure as encountered in Miss Elisabeth v. R.

I will now introduce another example which will illustrate the efficacy

of symbolization under other determinants. On one occasion Mrs. Cäcilie

M. was tormented by a violent pain in her right heel, experiencing

stinging sensations which made walking impossible. The analysis

conducted us to a time when the patient was in a foreign institution.

For eight days she lay in her room, and for the first time the house

physician was to take her to the dining room. The pain came on while the

patient took the physician’s arm on leaving the room. It disappeared

during the reproduction of this scene while she remarked that at that

time she feared lest she would not make the “proper impression” on this

strange society[25] (“rechte Auftreten”).

This seems a striking, almost comical example for the origin of

hysterical symptoms through symbolization by means of an expression of

speech. But a closer investigation of the circumstances of that moment

will favor another conception. The patient at that time suffered from

pain in her feet on account of which she remained in bed, and we can

only assume that the fear which obsessed her on taking the first steps

produced from the simultaneously existing pains the one symbolically

appropriate symptom in the right heel so as to form it into a psychic

algia and to particularly fit it for long duration.

Notwithstanding the fact that the mechanism of symbolization in these

examples seems to be crowded to second rank, that which certainly

corresponds to the rule, I have still other examples at my disposal

which seem to demonstrate the origin of hysterical symptoms through

symbolization only. One of the best is the following example which again

refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed

watched by her austere grandmother. The girl suddenly cried out

complaining of having perceived a pain in the forehead between the eyes

which thereafter continued for weeks. On analyzing this pain, which was

reproduced after almost thirty years, she stated that her grandmother

gazed at her so “piercingly” that it seemed as if her look penetrated

deeply into her brain. She was really afraid of being looked upon

suspiciously by this old lady. On reproducing this thought she burst

into loud laughter and the pain ceased. Here I find nothing other than

the mechanism of symbolization which in a way stands midway between the

mechanism of auto-suggestion and that of conversion.

The study of Mrs. Cäcilie M. gave me the opportunity to gather a

collection of such symbolizations. A whole series of physical sensations

which were otherwise looked upon as organically determined were of a

psychic origin, or at least furnished with a psychic interpretation. A

certain number of her experiences were accompanied by a piercing

sensation in the region of the heart (“I felt a stitch in my heart”).

The piercing headache of hysteria was undoubtedly, in her case, to be

interpreted as thought pains (“something sticks in my head”), and it

disappeared each time when the problem in question was solved. The

sensation of the hysterical aura in the throat, when it manifested

itself during an aggravation, ran parallel with the thought, “I have to

swallow that.” There was a whole series of parallel running sensations

and ideas in which it was now the sensation evoking the idea as an

interpretation and now the idea which produced the sensation by

symbolization, and not seldom it remained obscure which was the primary

element of the two.

In no other patient was I able to find such a prolific application of

symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual

and of a special artistic temperament whose highly developed sense for

form manifested itself in very beautiful poems. I maintain, however,

that if a hysteria creates through symbolization a somatic sensation for

the emotionally accentuated presentation, it is due less to individual

and arbitrary things than one supposes. When during an offending

harangue she takes literally such phrases as “stitch in the heart” or

“slap in the face,” and perceives them as real occurrences she practices

no facetious misuse but only revives the sensations to which this phrase

thanks its existence. For how does it happen that in speaking of an

aggrieved person we use such expressions as “he experienced a ‘stitch in

his heart,’” if the mortification was not actually accompanied by a

precordial sensation that could be so interpreted and recognized? Is it

not probable that the phrase “to swallow something” applied to an

unreturned insult really originates from the sensation of innervation

appearing in the pharynx when one forces back his speech thus preventing

a reaction to the insult? All these sensations and innervations belong

to the “expression of the emotions,” which as Darwin taught us,

originally consisted of sensible and expedient actions; at present most

of them may be so weakened that their expression in speech seems to us

like a figurative transformation, but very probably all this was once

meant literally, and hysteria is justified in reconstructing the

original literal sense for its stronger innervation. Indeed, perhaps it

is improper to say that it creates such sensations through

symbolization, perhaps it has not taken the usage of speech as a model,

but both originated from a common source.[26]