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[ Sigmund Freud on Anna O. Case ]

Dr. Breuer's patient was a girl of twenty-one, of high intellectual gifts. Her illness lasted for over two years, and in the course of it she developed a series of physical and  psychological disturbances which decidedly deserved to be taken seriously. She suffered from a rigid paralysis, accompanied by loss of sensation, of both extremities on the  right side of her body; and the same trouble from time to time affected her on her left side. Her eye movements were disturbed and her power of vision was subject to numerous  restrictions. She had difficulties over the posture of

Anna O.
Bertha Pappenheim,
alias Anna O.,
the famous patient who inspired the psychoanalytic
talking cure while in treatment with Dr. Breuer
her head; she had a severe nervous cough. She had an aversion to taking nourishment, and on one occasion she was for  several weeks unable to drink in spite of a tormenting thirst. Her powers of speech were reduced, even to the point of her being unable to speak or  understand her native language. Finally, she was subject to conditions of 'absence',(1) of confusion, of delirium, and of alteration of her whole personality, to which we shall have presently to turn our attention.

When you hear such an enumeration of symptoms, you will be inclined to think it safe to assume, even though you are not doctors, that what we have  before us is a severe illness, probably affecting the brain, that it offers small prospect of recovery and will probably lead to the patient's early decease.  You must be prepared to learn from the doctors, however, that, in a number of cases which display severe symptoms such as these, it is justifiable to take  a different and a far more favourable view. If a picture of this kind is presented by a young patient of the female sex, whose vital internal organs  (heart, kidneys, etc.) are shown on objective examination to be normal, but who has been subjected to violent emotional shocks - if, moreover, her  various symptoms differ in certain matters of detail from what would have been expected - then doctors are not inclined to take the case too seriously.  They decide that what they have before them is not an organic disease of the brain, but the enigmatic condition which, from the time of ancient Greek medicine, has been known as 'hysteria' and which has the power of  producing illusory pictures of a whole number of serious diseases. They consider that there is then no risk to life but that a return to health - even a  complete one - is probable. It is not always quite easy to distinguish a hysteria like this from a severe organic illness. There is no need for us to  know, however, how a differential diagnosis of that kind is made; it will suffice to have an assurance that the case of Breuer's patient was precisely  of a kind in which no competent physician could fail to make a diagnosis of hysteria. And here we may quote from the report of the patient's illness the  further fact that it made its appearance at a time when she was nursing her father, of whom she was devotedly fond, through the grave illness which led  to his death, and that, as a result of her own illness, she was obliged to give up nursing him.

[...] Dr. Breuer's attitude towards his patient deserved no such reproach.  He gave her both sympathy and interest, even though, to begin with, he did not know how to help her. It seems likely that she herself made his task  easier by the admirable qualities of intellect and character to which he has testified in her case history. Soon, moreover, his benevolent scrutiny showed him the means of bringing her a first instalment of help.

It was observed that, while the patient was in her states of 'absence (altered personality accompanied by confusion), she was in the habit of muttering a  few words to herself which seemed as though they arose from some train of thought that was occupying her mind. The doctor, after getting a report of  these words, used to put her into a kind of hypnosis and then repeat them to her so as to induce her to use them as a starting point. The patient complied  with the plan, and in this way reproduced in his presence the mental creations which had been occupying her mind during the 'absences' and which had betrayed their existence by the fragmentary words which she had  uttered. They were profoundly melancholy phantasies - 'day dreams' we should call them - sometimes characterized by poetic beauty, and their starting-point was as a rule the position of a girl at her father's sick-bed.  When she had related a number of these phantasies, she was as if set free, and she was brought back to normal mental life. The improvement in her  condition, which would last for several hours, would be succeeded next day by a further attack of 'absence'; and this in turn would be removed in the same way by getting her to put into words her freshly constructed  phantasies. It was impossible to escape the conclusion that the alteration in her mental state which was expressed in the 'absences' was a result of the  stimulus proceeding from these highly emotional phantasies. The patient herself, who, strange to say, could at this time only speak and understand  English, christened this novel kind of treatment the 'talking cure'(2) or used to refer to it jokingly as 'chimney sweeping'.(2)

It soon emerged, as though by chance, that this process of sweeping the  mind clean could accomplish more than the merely temporary relief of her ever-recurring mental confusion. It was actually possible to bring about the  disappearance of the painful symptoms of her illness, if she could be brought to remember under hypnosis, with an accompanying expression of affect, on  what occasion and in what connection the symptom had first appeared. 'It was in the summer during a period of extreme heat, and the patient was  suffering very badly from thirst; for, without being able to account for it in any way, she suddenly found it impossible to drink. She would take up the  glass of water that she longed for, but as soon as it touched her lips she would push it away like someone suffering from hydrophobia. As she did  this, she was obviously in an absence for a couple of seconds. She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst. This had  lasted for some six weeks, when one day during hypnosis she grumbled about her English "lady-companion", whom she did not care for, and went  on to describe, with every sign of disgust, how she had once gone into this lady's room and how her little dog - horrid creature! - had drunk out of a  glass there. The patient had said nothing, as she had wanted to be polite. After giving further energetic expression to the anger she had held back, she  asked for something to drink, drank a large quantity of water without any difficulty, and awoke from her hypnosis with the glass at her lips; and thereupon the disturbance vanished, never to return.'(3)

[...] No doubt you will now ask me for some further instances of the causation of hysterical symptoms besides the one I have already given you  of a fear of water produced by disgust at a dog drinking out of a glass. But if I am to keep to my programme I shall have to restrict myself to very few  examples. In regard to the patient's disturbances of vision, for instance, Breuer describes how they were traced back to occasions such as one on  which, 'when she was sitting by her father's bedside with tears in her eyes, he suddenly asked her what time it was. She could not see clearly; she made  a great effort, and brought her watch near to her eyes. The face of the watch now seemed very big - thus accounting for her macropsia and convergent  squint. Or again, she tried hard to suppress her tears so that the sick man should not see them.' Moreover, all of the pathogenic impressions came  from the period during which she was helping to nurse her sick father. 'She once woke up during the night in great anxiety about the patient, who was in  a high fever; and she was under the strain of expecting the arrival of a surgeon from Vienna who was to operate. Her mother had gone away for a short time and Anna was sitting at the bedside with her right arm over the  back of her chair. She fell into a waking dream and saw a black snake coming towards the sick man from the wall to bite him. (It is most likely that  there were in fact snakes in the field behind the house and that these had previously given the girl a fright; they would thus have provided the material  for her hallucination.) She tried to keep the snake off, but it was as though she was paralysed. Her right arm, over the back of the chair, had gone to  sleep, and had become anaesthetic and paretic; and when she looked at it the fingers turned into little snakes with death's heads (the nails). (It seems  probable that she had tried to use her paralysed right hand to drive off the snake and that its anaesthesia and paralysis has consequently become  associated with the hallucination of the snake.) When the snake vanished, in her terror she tried to pray. But language failed her: she could find no tongue  in which to speak, till at last she thought of some children's verses in English and then found herself able to think and pray in that language.'(4) When the  patient had recollected this scene in hypnosis, the rigid paralysis of her left arm, which had persisted since the beginning of her illness, disappeared, and the treatment was brought to an end.

When, some years later, I began to employ Breuer's method of examination and treatment on patients of my own, my experiences agreed entirely with  his. A lady, aged about forty, suffered from a tic consisting of a peculiar 'clacking' sound which she produced whenever she was excited, or sometimes for no visible reason. It had its origin in two experiences, whose  common element lay in the fact that at the moment of their occurrence she had formed a determination not to make any noise, and in the fact that on  both these occasions a kind of counter-will led her to break the silence with this same sound. On the first of these occasions one of her children had been  ill, and, when she had at last with great difficulty succeeded in getting it off to sleep, she had said to herself that she must keep absolutely still so as not to  wake it. On the other occasion, while she was driving with her two children in a thunderstorm, the horses had bolted and she had carefully tried to avoid  making any noise for fear of frightening them even more.(5) I give you this one example out of a number of others which are reported in the Studies on Hysteria.(6)

[...] Ladies and Gentlemen, if I may be allowed to generalize - which is unavoidable in so condensed an account as this - I should like to formulate what we have learned so far as follows: our hysterical patients suffer from reminiscences. Their symptoms are residues and mnemic symbols of particular  (traumatic) experiences. (From Sigmund Freud: Five Lectures on Psychoanalysis.)

Notes:
1. The French term.
2. In English in the original.
3. Studies on Hysteria.
4. Studies on Hysteria.
5. Studies on Hysteria.
6. Extracts from that volume, together with some later writings of mine on hysteria, are now to be had in an English translation prepared by Dr. A. A.  Brill of New York.

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