Autobiographical note 73 страница

Nevertheless, it would be wrong to suppose that dreams and their interpretation occupy such a prominent position in all psycho-analyses as they do in this example.

While the case history before us seems particularly favoured as regards the utilization of dreams, in other respects it has turned out poorer than I could have wished. But its shortcomings are connected with the very circumstances which have made its publication possible. As I have already said, I should not have known how to deal with the material involved in the history of a treatment which had lasted, perhaps, for a whole year. The present history, which covers only three months could be recollected and reviewed; but its results remain incomplete in more than one respect. The treatment was not carried through to its appointed end, but was broken off at the patient’s own wish when it had reached a certain point. At that time some of the problems of the case had not even been attacked and others had only been imperfectly elucidated; whereas, if the work had been continued, we should no doubt have obtained the fullest possible enlightenment upon every particular of the case. In the following pages, therefore, I can present only a fragment of an analysis.

Readers who are familiar with the technique of analysis as it was expounded in the Studies on Hysteria will perhaps be surprised that it should not have been possible in three months to find a complete solution at least for those of the symptoms which were taken in hand. This will become intelligible when I explain that since the date of the Studies psycho-analytic technique has been completely revolutionized. At that time the work of analysis started out from the symptoms, and aimed at clearing them up one after the other. Since then I have abandoned that technique, because I found it totally inadequate for dealing with the finer structure of a neurosis. I now let the patient himself choose the subject of the day’s work, and in that way I start out from whatever surface his unconscious happens to be presenting to his notice at the moment. But on this plan everything that has to do with the clearing-up of a particular symptom emerges piecemeal, woven into various contexts, and distributed over widely separated periods of time. In spite of this apparent disadvantage, the new technique is far superior to the old, and indeed there can be no doubt that it is the only possible one.

In face of the incompleteness of my analytic results, I had no choice but to follow the example of those discoverers whose good fortune it is to bring to the light of day after their long burial the priceless though mutilated relics of antiquity. I have restored what is missing, taking the best models known to me from other analyses; but, like a conscientious archaeologist, have not omitted to mention in each case where the authentic parts end and my constructions begin.

There is another kind of incompleteness which I myself have intentionally introduced. I have as a rule not reproduced the process of interpretation to which the patient’s associations and communications had to be subjected, but only the results of that process. Apart from the dreams, therefore, the technique of the analytic work has been revealed in only a very few places. My object in this case history was to demonstrate the intimate structure of a neurotic disorder and the determination of its symptoms; and it would have led to nothing but hopeless confusion if I had tried to complete the other task at the same time. Before the technical rules, most of which have been arrived at empirically, could be properly laid down, it would be necessary to collect material from the histories of a large number of treatments. Nevertheless, the degree of shortening produced by the omission of the technique is not to be exaggerated in this particular case. Precisely that portion of the technical work which is the most difficult never came into question with the patient; for the factor of ‘transference’, which is considered at the end of the case history, did not come up for discussion during the short treatment.

For a third kind of incompleteness in this report neither the patient nor the author is responsible. It is, on the contrary, obvious that a single case history, even if it were complete and open to no doubt, cannot provide an answer to all the questions arising out of the problem of hysteria. It cannot give an insight into all the types of this disorder, into all the forms of internal structure of the neurosis, into all the possible kinds of relation between the mental and the somatic which are to be found in hysteria. It is not fair to expect from a single case more than it can offer. And any one who has hitherto been unwilling to believe that a psychosexual aetiology holds good generally and without exception for hysteria is scarcely likely to be convinced of the fact by taking stock of a single case history. He would do better to suspend his judgement until his own work has earned him the right to a conviction.¹

¹ [Footnote added 1923:] The treatment described in this paper was broken off on December 31st, 1899. [1900] My account of it was written during the two weeks immediately following, but was not published until 1905. It is not to be expected that after more than twenty years of uninterrupted work I should see nothing to alter in my view of such a case and in my presentment of it; but it would obviously be absurd to bring the case history ‘up to date’ by means of emendations and additions. In all essentials, therefore, I have left it as it was, and in the text I have merely corrected a few oversights and inaccuracies to which my excellent English translators, Mr. and Mrs. James Strachey, have directed my attention. Such critical remarks as I have thought it permissible to add I have incorporated in these additional notes: so that the reader will be justified in assuming that I still hold to the opinions expressed in the text unless he finds them contradicted in the footnotes. The problem of medical discretion which I have discussed in this preface does not touch the remaining case histories contained in this volume; for three of them were published with the express assent of the patients (or rather, as regards little Hans, with that of his father), while in the fourth case (that of Schreber) the subject of the analysis was not actually a person but a book produced by him. In Dora’s case the secret was kept until this year. I had long been out of touch with her, but a short while ago I heard that she had recently fallen ill again from other causes, and had confided to her physician that she had been analysed by me when she was a girl. This disclosure made it easy for my well-informed colleague to recognize her as the Dora of 1899. No fair judge of analytic therapy will make it a reproach that the three months’ treatment she received at that time effected no more than the relief of her current conflict and was unable to give her protection against subsequent illnesses.

I THE CLINICAL PICTURE

In my Interpretation of Dreams, published in 1900, I showed that dreams in general can be interpreted, and that after the work of interpretation has been completed they can be replaced by perfectly correctly constructed thoughts which can be assigned a recognizable position in the chain of mental events. I wish to give an example in the following pages of the only practical application of which the art of interpreting dreams seems to admit. I have already mentioned in my book¹ how it was that I came upon the problem of dreams. The problem crossed my path as I was endeavouring to cure psychoneuroses by means of a particular psychotherapeutic method. For, among their other mental experiences, my patients told me their dreams, and these dreams seemed to call for insertion in the long thread of connections which spun itself out between a symptom of the disease and a pathogenic idea. At that time I learnt how to translate the language of dreams into the forms of expression of our own thought-language, which can be understood without further help. And I may add that this knowledge is essential for the psycho-analyst; for the dream is one of the roads along which consciousness can be reached by the psychical material which, on account of the opposition aroused by its content, his been cut off from consciousness and repressed, and has thus become pathogenic. The dream, in short, is one of the détours by which repression can be evaded; it is one of the principal means employed by what is known as the indirect method of representation in the mind. The following fragment from the history of the treatment of a hysterical girl is intended to show the way in which the interpretation of dreams plays a part in the work of analysis. It will at the same time give me a first opportunity of publishing at sufficient length to prevent further misunderstanding some of my views upon the psychical processes of hysteria and upon its organic determinants. I need no longer apologize on the score of length, since it is now agreed that the exacting demands which hysteria makes upon physician and investigator can be met only by the most sympathetic spirit of inquiry and not by an attitude of superiority and contempt. For,

Nicht kunst und Wissenschaft allein,

Geduld will bei dem Werke sein!²

¹ The Interpretation of Dreams, Chapter II.

² [ Not Art and Science serve, alone;

Patience must in the work be shown.]8 If I were to begin by giving a full and consistent case history, it would place the reader in a very different situation from that of the medical observer. The reports of the patient’s relatives - in the present case I was given one by the eighteen-year-old girl’s father - usually afford a very indistinct picture of the course of the illness. I begin the treatment, indeed, by asking the patient to give me the whole story of his life and illness, but even so the information I receive is never enough to let me see my way about the case. This first account may be compared to an unnavigable river whose stream is at one moment choked by masses of rock and at another divided and lost among shallows and sandbanks. I cannot help wondering how it is that the authorities can produce such smooth and precise histories in cases of hysteria. As a matter of fact the patients are incapable of giving such reports about themselves. They can, indeed, give the physician plenty of coherent information about this or that period of their lives; but it is sure to be followed by another period as to which their communications run dry, leaving gaps unfilled, and riddles unanswered; and then again will come yet another period which will remain totally obscure and unilluminated by even a single piece of serviceable information. The connections - even the ostensible ones - are for the most part incoherent, and the sequence of different events is uncertain. Even during the course of their story patients will repeatedly correct a particular or a date, and then perhaps, after wavering for some time, return to their first version. The patients’ inability to give an ordered history of their life in so far as it coincides with the history of their illness is not merely characteristic of the neurosis.¹ It also possesses great theoretical significance. For this inability has the following grounds. In the first place, patients consciously and intentionally keep back part of what they ought to tell - things that are perfectly we known to them - because they have not got over their feelings of timidity and shame (or discretion, where what they say concerns other people); this is the share taken by conscious disingenuousness. In the second place, part of the anamnestic knowledge, which the patients have at their disposal at other times, disappears while they are actually telling their story, but without their making any deliberate reservations: the share taken by unconscious disingenuousness. In the third place, there are invariably true amnesias - gaps in the memory into which not only old recollections but even quite recent ones have fallen - and paramnesias, formed secondarily so as to fill in those gaps.² When the events themselves have been kept in mind, the purpose underlying the amnesias can be fulfilled just as surely by destroying a connection, and a connection is most surely broken by altering the chronological order of events. The latter always proves to be the most vulnerable element in the store of memory and the one which is most easily subject to repression. Again we meet with many recollections that are in what might be described as the first stage of repression, and these we find surrounded with doubts. At a later period the doubts would be replaced by a loss or a falsification of memory.³

¹ Another physician once sent his sister to me for psychotherapeutic treatment, telling me that she had for years been treated without success for hysteria (pains and defective gait). The short account which he gave me seemed quite consistent with the diagnosis. In my first hour with the patient I got her to tell me her history herself. When the story came out perfectly clearly and connectedly in spite of the remarkable events it dealt with, I told myself that the case could not be one of hysteria, and immediately instituted a careful physical examination. This led to the diagnosis of a not very advanced state of tabes, which was later treated with Hg injections (Ol. cinereum) by Professor Lang with markedly beneficial results.

² Amnesias and paramnesias stand in a complementary relation to each other. When there are large gaps in the memory there will be few mistakes in it. And conversely, paramnesias can at a first glance completely conceal the presence of amnesias.

³ If a patient exhibits doubts in the course of his narrative, an empirical rule teaches us to disregard such expressions of his judgement entirely. If the narrative wavers between two versions, we should incline to regard the first one as correct and the second as a product of repression.

That this state of affairs should exist in regard to the memories relating to the history of the illness is a necessary correlate of the symptoms and one which is theoretically requisite. In the further course of the treatment the patient supplies the facts which, though he had known them all along, had been kept back by him or had not occurred to his mind. The paramnesias prove untenable, and the gaps in his memory are filled in. It is only towards the end of the treatment that we have before us all intelligible, consistent, and unbroken case history. Whereas the practical aim of the treatment is to remove all possible symptoms and to replace them by conscious thoughts, we may regard it as a second and theoretical aim to repair all the damages to the patient’s memory. These two aims are coincident. When one is reached, so is the other; and the same path leads to them both.

It follows from the nature of the facts which form the material of psycho-analysis that we are obliged to pay as much attention in our case histories to the purely human and social circumstances of our patients as to the somatic data and the symptoms of the disorder. Above all, our interest will be directed towards their family circumstances - and not only, as will be seen later, for the purpose of enquiring into their heredity.0 The family circle of the eighteen-year-old girl who is the subject of this paper included, besides herself, her two parents and a brother who was one and a half years her senior. Her father was the dominating figure in this circle, owing to his intelligence and his character as much as to the circumstances of his life. It was those circumstances which provided the framework for the history of the patient’s childhood and illness. At the time at which I began the girl’s treatment her father was in his late forties, a man of rather unusual activity and talents, a large manufacturer in very comfortable circumstances. His daughter was most tenderly attached to him, and for that reason her critical powers, which developed early, took all the more offence at many of his actions and peculiarities.

Her affection for him was still further increased by the many severe illnesses which he had been through since her sixth year. At that time he had fallen ill with tuberculosis and the family had consequently moved to a small town in a good climate situated in one of our southern provinces. There his lung trouble rapidly improved; but, on account of the precautions which were still considered necessary, both parents and children continued for the next ten years or so to reside chiefly in this spot, which I shall call B--. When her father’s health was good, he used at times to be away, on visits to his factories. During the hottest part of the summer the family used to move to a health resort in the hills.

When the girl was about ten years old, her father had to go through a course of treatment in a darkened room on account of a detached retina. As a result of this misfortune his vision was permanently impaired. His gravest illness occurred some two years later. It took the form of a confusional attack, followed by symptoms of paralysis and slight mental disturbances. A friend of his (who plays a part in the story with which we shall be concerned later on) persuaded him, while his condition had scarcely improved, to travel to Vienna with his physician and come to me for advice. I hesitated for some time as to whether I ought not to regard the case as one of tabo-paralysis, but I finally decided upon a diagnosis of a diffuse vascular affection; and since the patient admitted having had a specific infection before his marriage, I prescribed an energetic course of anti-luetic treatment, as a result of which all the remaining disturbances passed off. It is no doubt owing to this fortunate intervention of mine that four years later he brought his daughter, who had meanwhile grown unmistakably neurotic, and introduced her to me, and that after another two years he handed her over to me for psychotherapeutic treatment.

I had in the meantime also made the acquaintance in Vienna of a sister of his, who was a little older than himself. She gave clear evidence of a severe form of psychoneurosis without any characteristically hysterical symptoms. After a life which had been weighed down by an unhappy marriage, she died of a marasmus which made rapid advances and the symptoms of which were, as a matter of fact, never fully cleared up. An elder brother of the girl’s father, whom I once happened to meet, was a hypochondriacal bachelor.

The sympathies of the girl herself, who, as I have said, became my patient at the age of eighteen, had always been with the father’s side of the family, and ever since she had fallen ill she had taken as her model the aunt who has just been mentioned. There could be no doubt, too, that it was from her father’s family that she had derived not only her natural gifts and her intellectual precocity but also the predisposition to her illness. I never made her mother’s acquaintance. From the accounts given me by the girl and her father I was led to imagine her as an uncultivated woman and above all as a foolish one, who had concentrated all her interests upon domestic affairs, especially since her husband’s illness and the estrangement to which it led. She presented the picture, in fact, of what might be called the ‘housewife’s psychosis’. She had no understanding of her children’s more active interests, and was occupied all day long in cleaning the house with its furniture and utensils and in keeping them clean - to such an extent as to make it almost impossible to use or enjoy them. This condition, traces of which are to be found often enough in normal housewives, inevitably reminds one of forms of obsessional washing and other kinds of obsessional cleanliness. But such women (and this applied to the patient’s mother) are entirely without insight into their illness, so that one essential characteristic of an ‘obsessional neurosis’ is lacking. The relations between the girl and her mother had been unfriendly for years. The daughter looked down on her mother and used to criticize her mercilessly, and she had withdrawn completely from her influence.¹

¹ I do not, it is true, adopt the position that heredity is the only aetiological factor in hysteria. But, on the other hand - and I say this with particular reference to some of my earlier publications, e.g. ‘Heredity and the Aetiology of the Neuroses’ (1896n), in which I combated that view - I do not wish to give an impression of underestimating the importance of heredity in the aetiology of hysteria or of asserting that it can be dispensed with. In the case of the present patient the information I have given about her father and his brother and sister indicates a sufficiently heavy taint; and, indeed, if the view is taken that pathological conditions such as her mother’s must also imply a hereditary predisposition, the patient’s heredity may be regarded as a convergent one. To my mind, however, there is another factor which is of more significance in the girl’s hereditary or, properly speaking, constitutional predisposition. I have mentioned that her father had contracted syphilis before his marriage. Now a strikingly high percentage of the patients whom I have treated psycho-analytically come of fathers who have suffered from tabes or general paralysis. In consequence of the novelty of my therapeutic method, I see only the severest cases, which have already been under treatment for years without any success. In accordance with the Erb-Fournier theory, tabes or general paralysis in the male parent may be regarded as evidence of an earlier luetic infection; and indeed I was able to obtain direct confirmation of such an infection in a number of cases. In the most recent discussion on the offspring of syphilitic parents (Thirteenth International Medical Congress, held in Paris, August 2nd to 9th, 1900: papers by Finger, Tarnowsky, Jullien, etc.), I find no mention of the conclusion to which I have been driven by my experience as a neuro-pathologist - namely, that syphilis in the male parent is a very relevant factor in the aetiology of the neuropathic constitution of children.

During the girl’s earlier years, her only brother (her elder by a year and a half) had been the model which her ambitions had striven to follow. But in the last few years the relations between the brother and sister had grown more distant. The young man used to try so far as he could to keep out of the family disputes; but when he was obliged to take sides he would support his mother. So that the usual sexual attraction had drawn together the father and daughter on the one side and the mother and son on the other.

The patient, to whom I shall in future give the name of ‘Dora’, had even at the age of eight begun to develop neurotic symptoms. She became subject at that time to chronic dyspnoea with occasional accesses in which the symptom was very much aggravated. The first onset occurred after a short expedition in the mountains and was accordingly put down to over-exertion. In the course of six months, during which she was made to rest and was carefully looked after, this condition gradually passed off. The family doctor seems to have had not a moment’s hesitation in diagnosing the disorder as purely nervous and in excluding any organic cause for the dyspnoea; but he evidently considered this diagnosis compatible with the aetiology of over-exertion.¹

The little girl went through the usual infectious diseases of childhood without suffering any lasting damage. As she herself told me - and her words were intended to convey a deeper meaning - her brother was as a rule the first to start the illness and used to have it very slightly, and she would then follow suit with a severe form of it. When she was about twelve she began to suffer from unilateral headaches in the nature of a migraine, and from attacks of nervous coughing. At first these two symptoms always appeared together, but they became separated later on and ran different courses. The migraine grew rarer, and by the time she was sixteen she had quite got over it. But attacks of tussis nervosa, which had no doubt been started by a common catarrh, continued to occur over the whole period. When, at the age of eighteen, she came to me for treatment, she was again coughing in a characteristic manner. The number of these attacks could not be determined; but they lasted from three to five weeks, and on one occasion for several months. The most troublesome symptom during the first half of an attack of this kind, at all events in the last few years, used to be a complete loss of voice. The diagnosis that this was once more a nervous complaint had been established long since; but the various methods of treatment which are usual, including hydrotherapy and the local application of electricity, had produced no result. It was in such circumstances as these that the child had developed into a mature young woman of very independent judgement, who had grown accustomed to laugh at the efforts of doctors, and in the end to renounce their help entirely. Moreover, she had always been against calling in medical advice, though she had no personal objection to her family doctor. Every proposal to consult a new physician aroused her resistance, and it was only her father’s authority which induced her to come to me at all.

I first saw her when she was sixteen, in the early summer. She was suffering from a cough and from hoarseness, and even at that time I proposed giving her psychological treatment. My proposal was not adopted, since the attack in question, like the others, passed off spontaneously, though it had lasted unusually long. During the next winter she came and stayed in Vienna with her uncle and his daughters after the death of the aunt of whom she had been so fond. There she fell ill of a feverish disorder which was diagnosed at the time as appendicitis.² In the following autumn, since her father’s health seemed to justify the step, the family left the health-resort of B--- for good and all. They first moved to the town where her father’s factory was situated, and then, scarcely a year later, settled permanently in Vienna.

¹ The probable precipitating cause of this first illness will be discussed later on.

² On this point see the analysis of the second dream.3

Dora was by that time in the first bloom of youth - a girl of intelligent and engaging looks. But she was a source of heavy trials for her parents. Low spirits and an alteration in her character had now become the main features of her illness. She was clearly satisfied neither with herself nor with her family; her attitude towards her father was unfriendly, and she was on very bad terms with her mother, who was bent upon drawing her into taking a share in the work of the house. She tried to avoid social intercourse, and employed herself - so far as she was allowed to by the fatigue and lack of concentration of which she complained - with attending lectures for women and with carrying on more or less serious studies. One day her parents were thrown into a state of great alarm by finding on the girl’s writing-desk, or inside it, a letter in which she took leave of them because, as she said, she could no longer endure her life.¹ Her father, indeed, being a man of some perspicacity, guessed that the girl had no serious suicidal intentions. But he was none the less very much shaken; and when one day, after a slight passage of words between him and his daughter, she had a first attack of loss of consciousness² - an event which was subsequently covered by an amnesia - it was determined, in spite of her reluctance, that she should come to me for treatment.

¹ As I have already explained, the treatment of the case, and consequently my insight into the complex of events composing it, remained fragmentary. There are therefore many questions to which I have no solution to offer, or in which I can only rely upon hints and conjectures. This affair of the letter came up in the course of one of our sessions, and the girl showed signs of astonishment. ‘How on earth’, he asked, ‘did they find the letter? It was shut up in my desk.’ But since she knew that her parents had read this draft of a farewell letter, I conclude that she had herself arranged for it to fall into their hands.

² The attack was, I believe, accompanied by convulsions and delirious states. But since this event was not reached by the analysis either, I have no trustworthy recollections on the subject to fall back upon.4 No doubt this case history, as I have so far outlined it, does not upon the whole seem worth recording. It is merely a case of ‘petite hystérie’ with the commonest of all somatic and mental symptoms: dyspnoea, tussis nervosa, aphonia, and possibly migraines, together with depression, hysterical unsociability, and a taedium vitae which was probably not entirely genuine. More interesting cases of hysteria have no doubt been published, and they have very often been more carefully described; for nothing will be found in the following pages on the subject of stigmata of cutaneous sensibility, limitation of the visual field, or similar matters. I may venture to remark, however, that all such collections of the strange and wonderful phenomena of hysteria have but slightly advanced our knowledge of a disease which still remains as great a puzzle as ever. What is wanted is precisely an elucidation of the commonest cases and of their most frequent and typical symptoms. I should have been very well satisfied if the circumstances had allowed me to give a complete elucidation of this case of petite hystérie. And my experiences with other patients leave me in ho doubt that my analytic method would have enabled me to do so.

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